Journal of Gastrointestinal Surgery

, Volume 17, Issue 2, pp 288–297 | Cite as

Early Versus Late Adhesiolysis for Adhesive-Related Intestinal Obstruction: A Nationwide Analysis of Inpatient Outcomes

  • Daniel I. Chu
  • Melanie L. Gainsbury
  • Lauren A. Howard
  • Arthur F. Stucchi
  • James M. Becker
2012 SSAT Poster Presentation

Abstract

Background

Classical teaching advocates watchful waiting for 2 days before operating on adhesive-related intestinal obstructions (AIOs). Our aim was to compare the clinical and cost outcomes of early versus late adhesiolysis for AIOs.

Design

Patients undergoing adhesiolysis for AIOs from the 2007 Nationwide Inpatient Sample were stratified to early (≤2 days from admission) vs. late (>2 days) adhesiolysis. The primary outcome was in-hospital mortality and secondary outcomes were post-operative complications (POCs), post-operative length of stay (PLOS), and in-hospital cost.

Results

From 5,443 patients who underwent adhesiolysis for AIOs, 53 and 47 % underwent early and late adhesiolysis, respectively. Late adhesiolysis patients were older (65.0 vs. 60.1 years) and more co-morbid compared to the early group (p < 0.05). After adjustment with propensity score methods, late adhesiolysis patients had no difference in mortality (odds ratio [OR] 0.95, 95%-confidence intervals [CI] 0.67–1.36, p = 0.79) or POCs (OR 1.01, 95%CI 0.89–1.14, p = 0.91) compared to the early group, but had 9.8 % increased PLOS and 41.9 % increased in-hospital cost (p < 0.001).

Conclusions

The 2-day limit of watchful waiting is not associated with increased mortality or POCs for those patients undergoing adhesiolysis for an AIO. Late adhesiolysis, however, was associated with significantly increased PLOS and in-hospital cost compared to early adhesiolysis.

Keywords

Intestinal obstruction Small bowel obstruction Adhesions Adhesiolysis 

Notes

Acknowledgments

We would like to thank Dr. Gheorghe Doros and Denis Rybin, MA from the Biostatistics Consulting Group (BCG) at the Boston University School of Public Health for their guidance and execution of the statistical analysis.

Source of financial support

Robert and Dana Smith Family Foundation and the Smithwick Endowment Fund, Department of Surgery, Boston University School of Medicine.

References

  1. 1.
    Becker JM, Dayton MT, Fazio VW, Beck DE, Stryker SJ, Wexner SD, Wolff BG, Roberts PL, Smith LE, Sweeney SA, Moore M. Prevention of postoperative abdominal adhesions by a sodium hyaluronate-based bioresorbable membrane: a prospective, randomized, double-blind multicenter study. J Am Coll Surg 1996;183:297–306.PubMedGoogle Scholar
  2. 2.
    Liakakos T, Thomakos N, Fine PM, Dervenis C,Young RL. Peritoneal adhesions: etiology, pathophysiology, and clinical significance. Recent advances in prevention and management. Dig Surg 2001;18:260-273.PubMedCrossRefGoogle Scholar
  3. 3.
    Wiseman DM. Disorders of adhesions or adhesion-related disorder: monolithic entities or part of something bigger—CAPPS? Semin Reprod Med 2008;26:356–368.PubMedCrossRefGoogle Scholar
  4. 4.
    Ray NF, Denton WG, Thamer M, Henderson SC, Perry S. Abdominal adhesiolysis: inpatient care and expenditures in the United States in 1994. J Am Coll Surg 1998;186:1–9.PubMedCrossRefGoogle Scholar
  5. 5.
    Parker MC, Ellis H, Moran BJ, Thompson JN, Wilson MS, Menzies D, McGuire A, Lower AM, Hawthorn RJ, O'Briena F, Buchan S, Crowe AM. Postoperative adhesions: ten-year follow-up of 12,584 patients undergoing lower abdominal surgery. Dis Colon Rectum 2001;44:822–829.PubMedCrossRefGoogle Scholar
  6. 6.
    Duron JJ, Silva NJ, du Montcel ST, Berger A, Muscari F, Hennet H, Veyrieres M, Hay JM. Adhesive postoperative small bowel obstruction: incidence and risk factors of recurrence after surgical treatment: a multicenter prospective study. Ann Surg 2006;244:750–757.PubMedCrossRefGoogle Scholar
  7. 7.
    Landercasper J, Cogbill TH, Merry WH, Stolee RT, Strutt PJ. Long-term outcome after hospitalization for small-bowel obstruction. Arch Surg 1993;128:765–770.PubMedCrossRefGoogle Scholar
  8. 8.
    Fevang BT, Fevang J, Lie SA, Soreide O, Svanes K, Viste A. Long-term prognosis after operation for adhesive small bowel obstruction. Ann Surg 2004;240:193–201.PubMedCrossRefGoogle Scholar
  9. 9.
    Miller G, Boman J, Shrier I, Gordon PH. Small-bowel obstruction secondary to malignant disease: an 11-year audit. Can J Surg 2000;43:353–358.PubMedGoogle Scholar
  10. 10.
    Souba W, Jurkovic G, Kaiser L, Pearce W, Pemberton J, Soper N eds. ACS Surgery Principles and Practice:6th edition. Philadelphia: BC Decker, 2007.Google Scholar
  11. 11.
    Diaz JJ, Jr., Bokhari F, Mowery NT, Acosta JA, Block EF, Bromberg WJ, Collier BR, Cullinane DC, Dwyer KM, Griffen MM, Mayberry JC, Jerome R. Guidelines for management of small bowel obstruction. J Trauma 2008;64:1651–1664.PubMedCrossRefGoogle Scholar
  12. 12.
    Fevang BT, Fevang J, Stangeland L, Soreide O, Svanes K, Viste A. Complications and death after surgical treatment of small bowel obstruction: a 35-year institutional experience. Ann Surg 2000;231:529–537.PubMedCrossRefGoogle Scholar
  13. 13.
    Cameron J ed. Current surgical therapy. Philadelphia: Elsevier Mosby, 2004.Google Scholar
  14. 14.
    Mulholland M, Doherty G, Maier R, Upchurch GJ eds. Greenfield's surgery:scientific principles and practice. Philadelphia: Lipincott, Williams & Wilkins, 2006.Google Scholar
  15. 15.
    Cox MR, Gunn IF, Eastman MC, Hunt RF, Heinz AW. The safety and duration of non-operative treatment for adhesive small bowel obstruction. Aust N Z J Surg 1993;63:367–371.PubMedCrossRefGoogle Scholar
  16. 16.
    Carmichael JC, Mills S. Reoperation for small bowel obstruction—how critical is the timing? Clin Colon Rectal Surg 2006;19:181–187.PubMedCrossRefGoogle Scholar
  17. 17.
    Playforth RH, Holloway JB, Griffen WO, Jr. Mechanical small bowel obstruction: a plea for earlier surgical intervention. Ann Surg 1970;171:783–788.PubMedCrossRefGoogle Scholar
  18. 18.
    Tendler MJ, Cartwright RS. Acute intestinal obstruction- a re-evaluation of therapy; review of thirty-one years at a university hospital; 1923–1953. J La State Med Soc 1956;108:4–10.PubMedGoogle Scholar
  19. 19.
    Zollinger RM, Kinsey DL, Grant GN. Intestinal obstruction. Postgrad Med 1963;33:165–171.PubMedGoogle Scholar
  20. 20.
    Brill S. The mortality of intestinal obstruction: analysis of 124 cases operated upon at the Hospital of the University of Pennsylvania. Ann Surg 1929;89:541-548.PubMedCrossRefGoogle Scholar
  21. 21.
    Anonymous Healthcare Cost and Utilizations Project. HCUP Nationwide Inpatient sample. 2007.Google Scholar
  22. 22.
    Guller U, Hervey S, Purves H, Muhlbaier LH, Peterson ED, Eubanks S, Pietrobon R. Laparoscopic versus open appendectomy: outcomes comparison based on a large administrative database. Ann Surg 2004;239:43–52.PubMedCrossRefGoogle Scholar
  23. 23.
    D'Agostino RB, Jr. Propensity scores in cardiovascular research. Circulation 2007;115:2340–2343.PubMedCrossRefGoogle Scholar
  24. 24.
    Duron JJ, du Montcel ST, Berger A, Muscari F, Hennet H, Veyrieres M, Hay JM. Prevalence and risk factors of mortality and morbidity after operation for adhesive postoperative small bowel obstruction. Am J Surg 2008;195:726–734.PubMedCrossRefGoogle Scholar
  25. 25.
    Seror D, Feigin E, Szold A, Allweis TM, Carmon M, Nissan S, Freund HR. How conservatively can postoperative small bowel obstruction be treated? Am J Surg 1993;165:121–125.PubMedCrossRefGoogle Scholar
  26. 26.
    Tanaka S, Yamamoto T, Kubota D, Matsuyama M, Uenishi T, Kubo S, Ono K. Predictive factors for surgical indication in adhesive small bowel obstruction. Am J Surg 2008;196:23–27.PubMedCrossRefGoogle Scholar
  27. 27.
    Pickleman J, Lee RM. The management of patients with suspected early postoperative small bowel obstruction. Ann Surg 1989;210:216–219.PubMedCrossRefGoogle Scholar
  28. 28.
    Matter I, Khalemsky L, Abrahamson J, Nash E, Sabo E, Eldar S. Does the index operation influence the course and outcome of adhesive intestinal obstruction? Eur J Surg 1997;163:767–772.PubMedGoogle Scholar
  29. 29.
    Lefaivre KA, Macadam SA, Davidson DJ, Gandhi R, Chan H, Broekhuyse HM. Length of stay, mortality, morbidity and delay to surgery in hip fractures. J Bone Joint Surg Br 2009;91:922–927.PubMedCrossRefGoogle Scholar
  30. 30.
    Asbun HJ, Pempinello C, Halasz NA. Small bowel obstruction and its management. Int Surg 1989;74:23–27.PubMedGoogle Scholar
  31. 31.
    Edlich RF, Woods JA. Wangensteen's transformation of the treatment of intestinal obstruction from empiric craft to scientific discipline. J Emerg Med 1997;15:235–241.PubMedCrossRefGoogle Scholar
  32. 32.
    Branco BC, Barmparas G, Schnuriger B, Inaba K, Chan LS, Demetriades D. Systematic review and meta-analysis of the diagnostic and therapeutic role of water-soluble contrast agent in adhesive small bowel obstruction. Br J Surg 2010;97:470–478.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2012

Authors and Affiliations

  • Daniel I. Chu
    • 1
    • 2
  • Melanie L. Gainsbury
    • 1
  • Lauren A. Howard
    • 1
  • Arthur F. Stucchi
    • 1
  • James M. Becker
    • 1
  1. 1.Department of SurgeryBoston University Medical CenterBostonUSA
  2. 2.Department of SurgeryBoston University School of MedicineBostonUSA

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