Incidence of small bowel obstruction after laparoscopic and open colon resection

The American Journal of Surgery (2011) 201, 411 415 Midwest Surgical Association Incidence of small bowel obstruction after laparoscopic and open colon resection Melissa Alvarez-Downing, M.D. a, Zachary Klaassen, M.D. a,b, Robert Orringer, M.D., F.A.C.S. a, Mark Gilder, M.D., F.A.C.S. a, Debra Tarantino, M.D., F.A.C.S. a, Ronald S. Chamberlain, M.D., M.P.A., F.A.C.S. a,b,c, * a Department of Surgery, Saint Barnabas Medical Center, Suite 1172, 94 Old Short Hills Road, Livingston, NJ 07039, USA; b St. George s University School of Medicine, Grenada, West Indies, USA; c Department of Surgery, University of Medicine, Dentistry of New Jersey, Newark, NJ, USA KEYWORDS: Small bowel obstruction; Colorectal resection; Laparoscopic surgery; Adhesion Abstract BACKGROUND: Small bowel obstruction (SBO) is responsible for more than 1 billion dollars in health care costs yearly in the United States. We sought to evaluate whether laparoscopic colorectal surgery resulted in a decreased incidence of SBO within the first year of surgical resection compared with open surgery. METHODS: From January 2003 to December 2008, 339 patients underwent open (open colorectal resection [OPEN]) colorectal resection and 448 patients underwent laparoscopic (laparoscopic colorectal resection [LAP]) colorectal resection. Hospital admissions up to 1 year after the initial resection identified patients admitted for the management of SBO, ileus, or nausea and vomiting. RESULTS: During the 1st year after surgery, 6 patients in the OPEN group developed SBO, and 5 patients in the LAP group developed SBO. The overall frequency of SBO for the OPEN group was 1.8% and 1.1% for the LAP group (P.5461). CONCLUSIONS: Although advantages such as quicker postoperative recovery and decreased hospital stay have been attributed to laparoscopic surgery, no difference in the incidence of SBO within the 1st year of surgery was found compared with open colorectal surgery. 2011 Elsevier Inc. All rights reserved. Small bowel obstruction (SBO) is responsible for more than 1 million inpatient hospital days and over 1 billion dollars in health care costs yearly in the United States. 1 Intra-abdominal adhesions form in 95% 2 of patients undergoing open abdominal surgery and are the cause of approximately 70% of SBO. 3 Colorectal surgery has been considered an area of considerable risk for developing postoperative SBO because in part of the frequent need * Corresponding author: Tel.: 1-973-322-5195; fax: 1-973-322-2471. E-mail address: rchamberlain@sbhcs.com Manuscript received June 15, 2010; revised manuscript September 8, 2010 for pelvic dissection 4 with documented SBO rates as high as 10%. 5 Since the introduction of laparoscopic surgery to treat both benign and malignant colorectal diseases, numerous authors have shown safe and equivalent resection and postoperative outcomes using the laparoscopic approach. 6 Furthermore, the introduction of hand-assisted laparoscopic resection to shorten operative times has further diversified a surgeon s options when performing resection. Whether laparoscopic resection results in decreased tissue manipulation, decreased adhesion formation, or specifically a decreased incidence of SBO remains unclear. Duepree et al 3 evaluated the incidence of SBO in 716 patients undergoing 0002-9610/$ - see front matter 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2010.09.015

412 The American Journal of Surgery, Vol 201, No 3, March 2011 either laparoscopic or open colorectal resection. The authors reported a significantly lower incidence of admission for SBO in the laparoscopic group (1.9%) compared with the open resection group (6.1%); however, there was no significant difference between the groups in regards to the incidence of SBO requiring surgical intervention. 3 In the current study, we analyzed a 5-year period of colorectal resections that included predominantly open surgery at the beginning of the study and primarily laparoscopic resection at the end of the study period. We sought to evaluate if laparoscopic colorectal surgery resulted in a decreased incidence of admission and treatment of SBO within the first year of surgical resection compared with an open approach. Methods A retrospective analysis of all consecutive patients, with or without a previous history of abdominal surgery, undergoing elective open (open colorectal resection [OPEN]), laparoscopic, or hand-assisted laparoscopic (laparoscopic colorectal resection [LAP]) colon resection between January 2003 and December 2008 was performed. Patients undergoing segmental colectomy (right or left), total colectomy/proctocolectomy, or ileocolectomy were included. All patients had a colorectal resection by 1 of 3 colorectal surgeons with a standard procedure and port placement. All open resections had a vertical midline incision. Patients who underwent laparoscopic or hand-assisted laparoscopic resection had 3 to 5 trocar incisions ranging in size from 5 mm to 12 mm ports. The incision for the hand port was placed infraumbilical in the midline. Any case converted to an open procedure (n 15) was counted as part of the OPEN cohort for the purpose of this study. The data collected included age, sex, index operation, and emergency room visit or hospitalization for SBO. SBO was denoted based on admission codes for nausea and vomiting, ileus, or bowel obstruction. Subsequently, patients were further divided into 2 groups: (1) patients admitted with SBO that resolved with nasogastric decompression and conservative management and (2) patients treated surgically either urgently or because of failed nonoperative management (adhesiolysis or small bowel resection). Data for SBO were collected for 1 year after the initial surgical procedure. All data are presented as mean values with standard deviation calculated using Microsoft Excel (Redmond, WA). Statistical analysis was completed using GraphPad Software (La Jolla, CA), and statistical significance was calculated using the Fisher exact test, with significance defined as P.05. Results From January 2003 to December 2008, a total of 787 patients underwent colorectal resection at our institution. Three hundred thirty-nine patients (43.1%) formed the OPEN cohort, and 448 patients (56.9%) formed the LAP cohort. These patients were analyzed for the incidence of SBO (admission, hospitalization or surgery) in the subsequent 12 months after their colorectal procedure. The mean age in the OPEN group was 68.7 14.8 years versus 64.8 14.6 years in the LAP group (P.002). The male-to-female ratio in the OPEN group was 231 male to 217 and 150 to 189 in the LAP group (P.0440). The most common procedure performed in both groups was segmental colectomy, which included 277 (81.7%) in the OPEN group and 408 (91.1%) in the LAP group. The segmental colectomies consisted of low anterior resection (LAR) (127 OPEN and 203 LAP), right hemicolectomy (104 OPEN and 133 LAP), left hemicolectomy (16 OPEN and 42 LAP), sigmoidectomy (23 OPEN and 19 LAP), transverse colectomy (4 OPEN and 8 LAP), proctectomy (3 OPEN), and cecectomy (3 LAP). The second most common procedure was subtotal colectomy (14 OPEN, 4.1%; 24 LAP, 5.4%) followed by abdominoperineal resection (APR) (22 OPEN, 6.5%; 4 LAP,.9%) and total colectomy (16 OPEN, 4.7%; 9 LAP, 2.0%). In the LAP group, hand-assisted cases accounted for 185 of the 203 (91.1%) LARs, 12 of 133 (9.0%) right hemicolectomies, 3 of 42 (7.1%) left hemicolectomies, 3 of 19 (15.8%) sigmoidectomies, 2 of 24 (8.3%) subtotal colectomies, all 4 (100%) APRs, and 5 of 9 (55.6%) total abdominal colectomies. There were significantly more LAP than OPEN segmental colectomies (P.0002) and significantly more OPEN cases for APR (P.0001), total abdominal colectomy (P.0395), and Hartmann s procedures performed (OPEN vs LAP) (P.0146). There were 15 patients who were seen in the emergency department or admitted to the hospital for nausea, vomiting, paralytic ileus, or obstruction based on ICD codes. Subsequently, radiologic evaluation revealed mechanical SBO in 5 patients (1.1%) in the LAP group (2 hand-assisted laparoscopy cases) and 6 patients (1.8%) in the OPEN group (Fig. 1). Among the LAP group, 3 patients with SBO were treated with conservative management, and 2 required surgical intervention. Among the 6 patients with SBO in the OPEN group, 3 patients were treated conservatively and 3 surgically. Three of 6 patients in the open group (50%) and 2 of 5 patients (40%) in the laparoscopic group with SBO had abdominal surgery before their colorectal procedure, with the most common being an appendectomy. The initial colorectal procedures performed in patients with SBO in the LAP group included 2 total colectomies (1 hand assisted) and 1 hand-assisted LAR, right hemicolectomy, and subtotal colectomy. The colorectal procedures performed for patients with SBO in the OPEN group included 3 right hemicolectomies as well as 1 each for APR, LAR, and sigmoidectomy. The mean age of patients experiencing SBO in the LAP group was 65 18 years versus 68 15 years in the OPEN group (P.05).

Alvarez-Downing et al. Small bowel obstruction 413 Figure 1 The incidence and treatment of SBO for open and laparoscopic colorectal resection. Comments Each year in the United States, SBO is responsible for more than 300,000 hospital admissions, totaling over 1 million inpatient hospital days, and over 1 billion dollars in health care costs for hospitalization and physician services. 1 Intra-abdominal adhesions are the most common cause of SBO in the United States with an estimated frequency of approximately 70%. 7 Autopsy studies by Weibel and Majno 8 reported an incidence of intra-abdominal adhesions of 67% in patients undergoing abdominal surgery, whereas Menzies and Ellis 2 reported an incidence as high as 93%. Studies have estimated the risk of SBO after appendectomy and cholecystectomy at 1% to 10% and 10% to 25% after any intestinal surgery. 7,9 Colon and rectal surgery represents one of the highest risk surgical procedures for developing adhesions and subsequent SBO, and reports have placed the incidence of SBO after colorectal surgery at 15% to 30%. 2,9 Three large studies have analyzed the incidence of SBO after open colorectal procedures. 7,9,10 Nieuwehuijzen et al 9 reported on 234 patients who underwent total or subtotal colectomy between 1985 and 1994 and identified SBO in 18% of patients because of adhesions. Parker et al 10 analyzed 12,584 patients from the Scottish National Health Service medical record linkage database undergoing open lower abdominal surgery in 1986 and found that 643 of 8,861 (7.3%) readmissions were directly related to adhesions. This included 430 patients (66.9%) requiring adhesiolysis (rectum initial site of surgery, 64 patients; colon initial site of surgery, 133 patients) and 197 patients (30.6%) requiring no operative treatment (rectum initial site of surgery, 33 patients; colon initial site of surgery, 58 patients). 10 Beck et al 7 analyzed a random sample of Medicare patients undergoing abdominal surgery in 1993 and found that within 2 years of an open intestinal resection with anastomosis (ICD-9 code 45) 14% of patients (1,057 of 7,393) had obstruction with 2.6% requiring adhesiolysis. In a separate group of 6,765 patients undergoing other operations on the intestine (ICD-9 code 46), 17% of patients had obstruction, and 3.1% required adhesiolysis. Among patients undergoing rectal, rectosigmoid, or perirectal operations (ICD-9 code 48), 15.3% had obstruction, and 5.1% of patients required adhesiolysis within the same 2-year time period. 7 The incidence and risk of SBO after laparoscopic procedures in comparison with laparotomy is undetermined. Reissman et al 11 performed 100 laparoscopic and laparoscopic-assisted colorectal procedures and identified only 1 patient who developed SBO. Rosin et al 12 performed 306 laparoscopic colorectal procedures over 8 years with a mean follow-up of 38 months. In their cohort, 6 patients developed SBO although 2 patients had previous open surgery, resulting in 4 patients (1.3%) with SBO directly related to their previous laparoscopic surgery. Sonoda et al 6 analyzed the incidence of SBO after colorectal resection among 266 patients undergoing hand-assisted laparoscopic surgery (HALS) versus 270 patients undergoing standard laparoscopic surgery (SLS). Patients undergoing HALS resection did not statistically differ from patients who underwent SLS resection in terms of SBO incidence (4.1% vs 7.4%, P.11). The authors concluded that HALS does not lead to a higher incidence of SBO when compared with SLS for resections of the colon and rectum. 6 Duepree et al 3 published the largest study on the incidence of SBO after either laparoscopic bowel resection or open bowel resection. These authors reported on 211 pa-

414 The American Journal of Surgery, Vol 201, No 3, March 2011 Table 1 Recent published studies on the incidence and/or treatment of SBO for laparoscopic colorectal surgery including studies comparing LAP with OPEN Patients (N) Mean age (y) Sex (M:F) SBO incidence (N) (%) P value SBO (conservative treatment) SBO (surgical treatment) (%) Current Study OPEN 339 68.7 150:189 6 (1.8).54 3 (.9%) 3 (.9) 1 LAP 448 64.8 231:217 5 (1.1) 3 (.6%) 2 (.4) 1 Duepree 3 OPEN 505 57.7 255:250 39 (7.7).03 31 (6.1%) 8 (1.6) 2.42 LABR 211 50.8 91:120 7 (3.3) 4 (1.9%) 3 (1.4) 2.71 Rosin 12 LBR 306 63 176:130 6 (2.0) N/A 5 (1.6%) 1 (.3) 3.17 Sonoda 6 Hals 266 56 152:114 11 (4.1).14 5 (1.9%) 6 (2.3) 2 SLS 270 58 127:143 20 (7.4) 7 (2.6%) 13 (4.8) 2.8 Follow-up (y) Previous studies analyzing the incidence of SBO after colorectal surgery show that OPEN and LAP results vary marginally. The results of the current study are in line with previous published studies, reporting that there is minimal advantage to OPEN over LAP procedures. M male; F female; NA not applicable. tients who underwent laparoscopic-assisted bowel resection (LABR) and 505 patients who underwent open bowel resection (OPEN), with a mean follow-up period of 2.71 and 2.42 years, respectively. They reported that SBO requiring conservative treatment was significantly less in the LABR patients (n 4) compared with the OPEN patients (n 31) (P.016). Furthermore, there was no significant difference in surgical intervention for patients with SBO (LABR 3 patients, OPEN 8 patients). 3 The authors concluded that minimally invasive procedures for bowel resection resulted in a significant decrease in the incidence of postoperative SBO. In the current study of 787 patients, including 339 OPEN patients and 448 LAP patients, we identified a 1.8% incidence of SBO within the first year of surgery for OPEN patients and 1.1% for LAP patients (P.05). A 1-year timeframe was chosen because the incidence of SBO after colectomy is well documented ( 25%), with 58% of all SBO occurring within the first year. 10 Of note, this SBO incidence is comparable to results reported by Rosin et al 12 (5 patients treated conservatively, 1.6%; 1 patient treated surgically,.3%) and Sonoda et al 6 (7 patients treated conservatively, 2.6%; 13 patients treated surgically, 4.8%) despite a longer follow-up period (3.17 and 2.8 years, respectively). Acknowledging that our results are in contrast to those of Duepree et al 3 in regards to the incidence of SBO between laparoscopic and open colorectal resection, it is noteworthy that similar to Duepree et al and others 3,6,12 we found no difference in the treatment outcomes or approach to SBO between the laparoscopic and open groups (Table 1). This is the first study to compare the incidence of SBO within the 1st year of surgery for patients undergoing laparoscopic or open colorectal resections. Although laparoscopic surgery has numerous well-documented advantages, laparoscopic colorectal resection did not significantly decrease the incidence of SBO within the 1st year of surgery when compared with patients undergoing open colorectal resection. Interestingly, 60% (n 3) of SBO in LAP patients occurred in patients having a total colectomy. Increased bowel manipulation and dissection associated with a total colectomy may increase a patient s risk of SBO compared with other colorectal resections. However, breaching the peritoneal barrier, even with minimally invasive incisions and laparoscopic intracorporeal manipulation of abdominal organs, predisposes patients to postoperative adhesions and potential SBO that is not unlike traditional open surgery. Although colorectal surgery continues to evolve into a minimally invasive discipline, the difficult clinical issue of postoperative SBO is not ameliorated with laparoscopic colorectal surgery. References 1. Ray NF, Denton WG, Thamer M, et al. Abdominal adhesiolysis: inpatient care and expenditure in the united States in 1994. J Am Coll Surg 1998;186:1 9. 2. Menzies D, Ellis H. Intestinal obstruction from adhesions how big is the problem? Ann R Coll Surg Engl 1990;72:60 3. 3. Duepree HJ, Senagore AJ, Delaney CP, et al. Does means of access affect the incidence of small bowel obstruction and ventral hernia after bowel resection? Laparoscopy versus laparotomy. J Am Coll Surg 2003;197:177 81. 4. Indar AA, Efron JE, Young-Fadok TM. Laparoscopic ilieal pouch-anal anastomosis reduces abdominal and pelvic adhesions. Surg Endosc 2009;23:174 7. 5. Parikh JA, Ko CY, Maggard MA, et al. What is the rate of small bowel obstruction after colectomy? Am Surg 2008;74:1001 5. 6. Sonoda T, Pandey S, Trencheva K, et al. Longterm complications of hand-assisted versus laparoscopic colectomy. J Am Coll Surg 2008; 208:62 6. 7. Beck DE, Opelka FG, Bailey HR, et al. Incidence of small-bowel obstruction and adhesiolysis after open colorectal and general surgery. Dis Colon Rectum 1999;42:241 8. 8. Weibel MA, Majno G. Peritoneal adhesions and their relation to abdominal surgery. Am J Surg 1973;126:345 53.

Alvarez-Downing et al. Small bowel obstruction 415 9. Nieuwenhuijzen M, Reijnen MM, Kuijpers JH, et al. Small bowel obstruction after total or subtotal colectomy: a 10-year retrospective review. Br J Surg 1998;85:1242 5. 10. Parker MC, Ellis H, Moran BJ, et al. Postoperative adhesions: ten-year follow-up of 12,584 patients undergoing lower abdominal surgery. Dis Colon Rectum 2001;44:822 9. 11. Reissman P, Cohen S, Weiss EG, et al. Laparoscopic colorectal surgery: ascending the learning curve. World J Surg 1996;20:277 81. 12. Rosin D, Zmora O, Hoffman A, et al. Low incidence of adhesionrelated bowel obstruction after laparoscopic colorectal surgery. J Laparoendosc Adv Surg Tech A 2007;17:604 7. Discussion Harry L. Reynolds Jr, M.D. (Cleveland, OH). First, just as laparoscopic techniques have been proposed as useful in decreasing adhesion formation, multiple products have been developed to be used intra-abdominally to prevent adhesions. Were any of the hyaluronic acid-based adhesion prevention products used in either the open laparoscopic or assist cases, and, if so, was this evaluated in the analysis? Second, I noted the authors used hand-assist techniques in a significant number of these patients. Like the authors, I have found hand-assist techniques useful, but I am frequently accused by my partners of performing open surgery when I place a hand in the abdomen. The 2 lap patients who developed bowel obstruction and required surgery were in the hand-assist group. The numbers are small, but do you think there is any significance to the observation that the hand-assist laparoscopic cases with obstruction were operated while the 3 straight laparoscopic cases were managed medically? And, finally, do you plan on carrying out the analysis longer, perhaps breaking out the hand-assist cases as a separate group and seeing if there is a difference that develops over an extended period? Zachary Klaassen, M.D. (Livingston, NJ): To answer your first question, hyaluronic acid film is the prevention product of choice for surgeons at our hospital. Of the 3 surgeons that were involved in the study, 1 routinely uses it. It was not involved in the analysis of the study because of inconsistent numbers between the 3 surgeons. To answer your second question, I probably would include a reference to the Sonota study from 2009, which looked at about 500 patients undergoing hand-assist or standard laparoscopic surgery. There were 20 patients with SBO in the standard laparoscopic group and 11 patients in the hand-assisted group. Roughly 50% in both groups were surgically treated. So, based on our small numbers and their data, I would say that hand-assist does not lead to increased frequency of surgical treatment of SBO. To answer the third question, it would be interesting to extend the study past 2 years and to examine the film issue. Akpofure Peter Ekeh, M.D. (Dayton, OH): Are you certain that all the patients that were operated on had procedures in your hospital? Could they have gone to surrounding hospitals with their complications? And, the second question, did you take into account the possibility that some of these patients may have had previous abdominal surgery, which might bias your incidence of bowel obstruction? Dr. Klaassen: There is no way to be certain if these patients did come back to our hospital or go to another hospital, but we are a community hospital in a suburban New York area, so most of patients would come back to our hospital. To answer your second question, there were 3 patients in the open group and 2 patients in the laparoscopic group who had prior abdominal operations. Christopher P. Brandt, M.D. (Cleveland, OH): In the patients who were treated surgically for SBO, were those operations done laparoscopically or open? And, would it be more likely you could accomplish it laparoscopically in people who had a laparoscopic versus an open procedure? Dr. Klaassen: Of the 5 patients treated surgically, 4 were exploratory laparotomies, and 1 was a diagnostic laparoscopy. I do agree that if a patient initially had a laparoscopic procedure, it would be at least nice to try a diagnostic laparoscopy first.