|Year : 2012 | Volume
| Issue : 1 | Page : 18-21
A recommendation for primary operative management for low adhesive bowel obstruction
David O Irabor, Oludolapo O Afuwape
Department of Surgery, Gastrointestinal Surgery Division, University College Hospital, Ibadan, Nigeria
|Date of Web Publication||28-Aug-2012|
David O Irabor
Department of Surgery, UCH Ibadan, PMB 5116, Ibadan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background : Our patients who required surgery for adhesive small bowel obstruction (ASBO) were noticed to have a peculiar association. This link was the type of surgery they had originally, operations in the pelvis or those in which the scars were below the umbilicus. These patients did not improve on conservative management. This study was then undertaken to investigate this trend and to recommend primary surgery for these group of patients, terming them as low ASBO for the purpose of the study.
Aims : (1) To show that majority of patients with low adhesive bowel obstruction do not get better on conservative management. (2) To propose surgical operation as the primary management strategy of patients with low adhesive bowel obstruction.
Settings and Design : The study is set in the gastrointestinal surgery unit of the University College Hospital (UCH) Ibadan. The hospital is located in Ibadan, the most populous city in West Africa with a population of roughly 2.5 million inhabitants. The UCH Ibadan handles more than 90% of all surgical cases in Ibadan.
Materials and Methods : This is a retrospective descriptive study from April 2003 to February 2010 conducted on patients who were admitted on the service of the gastrointestinal surgery unit of the UCH Ibadan, Nigeria, with a diagnosis of ASBO and had surgery for relief of the condition. Admission records, operations registers, and patients' case files were used in sourcing the data. Demographic indices such as age, sex, and type of previous operation were taken into account.
Statistical Analysis : Stata 11.0 statistical software was used.
Results : There were 4 male and 17 female patients giving a male: female ratio of roughly 1:4. Their ages ranged from 23 to 60 years. The global mean age was 40 years. The mean age for males was 31.5 years while for the female patients it was 42 years. Previous surgical operations showed that gynecological operations were in the majority (62%), followed by appendicectomy (24%) and colorectal surgery made up the rest (14%). Statistically, female sex, gynecological operations, and Lanz incisions for appendicectomy increase the chances of having surgery to relieve ASBO.
Conclusions : We propose primary surgical treatment for low ASBO, especially those from gynecological operations and appendicectomy. Conservative management should be reserved as the initial treatment of non-low-level ASBO until other features prove otherwise.
Keywords: Adhesive bowel obstruction, low-level adhesions, operation for adhesions
|How to cite this article:|
Irabor DO, Afuwape OO. A recommendation for primary operative management for low adhesive bowel obstruction. Ann Nigerian Med 2012;6:18-21
| Introduction|| |
All over the world patients who develop adhesive small bowel obstruction (ASBO) pose a great challenge to their caregivers. This stems from the fact that there is no definite "cast-iron" mode of management; patients are managed conservatively until other features indicate a surgical option. In the developing world where financial, material, and personnel resources are at a premium, the sooner one determines which patients with ASBO require surgery, the better. Why allow a patient to exhaust his meager finances on bed fees, intravenous fluids, and other hospital consumables for periods ranging from 5 to 10 days before deciding that surgery after all is indicated? Observation has shown that patients who have had previous surgery for lesions below the umbilicus seem to require surgery to relieve ASBO when developed. This group of patients, for the purpose of this study, will be described as those with "low adhesive obstruction." This study aims to review the current management of ASBO with a view to providing reasonable support for early surgery in patients with low ASBO in a tropical third-world country.
| Materials and Methods|| |
This is a retrospective descriptive study from April 2003 to February 2010, a period of roughly 7 years, on patients who were admitted on the service of the gastrointestinal surgery unit of the University College Hospital (UCH) Ibadan, Nigeria, with a diagnosis of ASBO and had surgery for relief of the condition. The nurses' admissions register on the gastrointestinal surgery ward was used to obtain the hospital numbers of patients who were admitted for adhesive bowel obstruction, subsequently their case files were retrieved from the central records department of the hospital. The operations' register of the gastrointestinal surgery unit was also examined to elicit patients who had definite surgery for adhesive bowel obstruction, after that the medical records department helped to retrieve their case files. Demographic indices such as age, sex, and type of previous operation were taken into account. Variables such as the site of previous surgery, the sex of the patient, and the type of scar the patient had were then subjected to statistical analysis using the Stata 11.0 statistical software to ascertain their influence in determining whether a patient with ASBO will need surgery.
| Results|| |
Fifty-two patients were admitted during that period with a diagnosis of adhesive bowel obstruction, and 21 patients out of this required surgery.
There were 4 male and 17 female patients giving a male:female ratio of roughly 1:4.
Their ages ranged from 23 to 60 years. The global mean age was 40 years. The mean age for males was 31.5 years while for the female patients it was 42 years.
Previous surgical operations showed that gynecological operations were in the majority (62%), followed by appendicectomy (24%) and colorectal surgery made up the rest (14%).
A further look at the individual gynecological cases showed myomectomy (5), hysterectomy (3), Caesarean section (2), salpingectomy (2), and one case of uterine perforation from criminal termination of pregnancy. The time interval between the dates of previous operation to the development of ASBO ranged from 6 days to 20 years. The duration of conservative management before being abandoned for surgery ranged from 1 to 10 days. There was one mortality from septic shock in a 53-year-old female. Statistically, the odds that a given patient with ASBO will require surgery were increased if the patient was of the female sex, had a gynecological operation, and for either sex had an appendicectomy via a Lanz incision.
| Discussion|| |
Low-level adhesive obstruction, for practical purposes and for this study, is defined as that in which the adherent scar occurs below the level of the umbilicus. Such scars may include appendicectomy scars, Pfannenstiel scars, and midline infra-umbilical scars. It also includes ASBO that may occur after pelvic operations such as distal colectomy, abdominoperineal excision of the rectum, myomectomy, and/or hysterectomy.
We have come to observe that patients with low-level ASBO do not fare well on the usual "drip and suck" regime of intravenous fluid administration, nasogastric-tube drainage, correction of electrolyte imbalance, prophylactic antibiotic treatment, and regular monitoring of vital signs (pulse, temperature, blood pressure, and respiratory rate). The decompression of the dilated distal jejunum and ileum is really not achievable with a tube nestling in the stomach. Thus, the persistence of kinked, twisted, or compressed gut is maintained by a relentless dilatation of the gut immediately proximal to the site of obstruction.
Other considerations about conservative management revolve around the length of time conservative management should be allowed. Is it okay to continue indefinitely as long as features of strangulation are absent? It is known that not all patients manifest these features early until they develop multiple organ failure because clinical parameters such as continuous abdominal pain, fever, and leucocytosis have not proved to be sensitive, specific, and predictive for bowel strangulation. ,, Can we afford to let that happen? In the developing world, getting a patient to theater for an emergency may take a minimum of 4 hours.
Studies have shown that in one center the patients who had conservative management were observed for a range of 2 to 12 days and most of those who had resolution of their symptoms did that within 1 week while those who eventually required surgery had their periods of conservative management ranging from 1 to 14 days.  In order to reduce this period of uncertainty, several authors have suggested the use of Gastrografin to predict which patients will resolve on conservative management; the consideration being that after instillation of the contrast via nasogastric tube, those patients in whom the contrast appeared in the large bowel after 24 hours are adjudged to have partial obstruction and expected to resolve, but if contrast failed to reach the large bowel within this same period, complete obstruction was the case and laparotomy indicated. ,, The drawback for the applicability of this in a third-world country is the fact that serial X-rays have to be taken (about 4 within the 24 hours) and if a patient is lucky that there are films in the radiology department, electricity supply is stable ensuring that lifts are working and the queue in the X-ray department is not too long, then it may be worthwhile to do this test.
There are some operations that have been shown to have a predisposition for the development of ASBO, and several authors agree that the top four in order of magnitude of presentation include colorectal surgery, gynecological operations, herniorrhaphy, and appendicectomy. , These are the types of operations we would include as being low-level ASBO, and if we look at the patients who have required operative intervention in this study it would seem that our order of magnitude of presentation starts with gynecological operations, then appendicectomy, and lastly with colorectal operations. The mean age of the female patients in this study, at 42 years, supports the period in their lives when gynecological ailments require operations such as myomectomy and hysterectomy while the male patients had appendicectomy which is mainly a condition of young adulthood. Indeed, female gender and previous obstetrics or gynecological operations have been cited as indicators for surgery in ASBO, and women particularly are said to be at risk of strangulating while on admission for ASBO because of delayed laparotomies. ,, Many of these female patients had normal abdominal radiographs in the presence of bowel strangulation,  thus strengthening the need for recommending surgery as first-line management in such patients. A study done in Turkey showed that 62.5% (10 of 16) postappendicectomy ASBO required surgery to relive the obstruction and 50% of those from gastroduodenal operations and colorectal operations, respectively, required surgery.  This study shows a 67% resection rate in the operations performed for the ASBO [Table 1] and the reasons include the presence of already gangrenous bowel, doubtful integrity, and viability of the segment of gut after adhesiolysis (because of multiple serosal tears) and lastly, persistent constriction of a segment after the obstructing fibrous band has been removed. The study also buttresses the unpredictability of the occurrence of ASBO from the original operation, , with our series recording a range between 6 days and 20 years. In a bid to analyze the risk of any of the patients in this study having a particular predisposition to surgical relief of ASBO, we looked at the previous operation, previous indication for surgery (diagnosis), the site of the particular organ involved, and the previous abdominal incision used for the surgery [Table 2]. Observation of this table showed more patients with Lanz and Pfannenstiel scars requiring surgery for relief of ASBO. We then wished to determine whether (a) the anatomical site of the involved organ has any influence, (b) the type of incision used in the previous operation will be a factor, and (c) the preoperative diagnosis influences surgery. Statistical analyses of these data [Table 3] showed significant P values for patients who have had gynecological operations (which is why female sex is also significant) and previous Lanz incision scars for appendicectomy. None of the upper gastrointestinal operations in this study required surgical intervention for ASBO relief. The risk of recurrence of obstruction has also been shown to be significantly lower in patients who have surgical relief of ASBO than those conservatively managed and the latter group was readmitted more rapidly than those treated surgically.  A study from East Africa regarding the challenges faced in managing ASBO patients concluded by stating that inadequate intravenous fluid management and delayed surgical intervention were the major problems faced in their center.  We submit that for some cases, it may seem like overtreating the condition; however, we feel that such operations are not wasted. The advantages, we believe, outweigh the disadvantages; the hospital stay is shorter, the patients' personal expenses are not stretched, and the readmission rate is reduced. One may draw an analogy using emergency appendicectomy for suspected acute appendicitis where a reasonable negative appendicectomy rate is better than the consequences of a ruptured appendix.
| Conclusion|| |
In conclusion, we propose primary surgical treatment for low ASBO especially when it involves an appendicectomy from a Lanz incision and after gynecological operations, with conservative management reserved as the initial treatment of non-low-level ASBO until other features prove otherwise.
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[Table 1], [Table 2], [Table 3]