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Adhesive small bowel obstruction after laparotomy during infancy. BJS 2016; 103: 284-289.

Published: 15th December 2015

Authors: F. Fredriksson, R. H. Christofferson, H. E. Lilja

Background

Intra‐abdominal adhesions can cause adhesive small bowel obstruction, chronic abdominal pain and female infertility. Reports on long‐term outcomes following laparotomy during infancy are scarce. The aims of this study were to investigate the incidence of and risk factors for long‐term adhesive small bowel obstruction and associated morbidity after laparotomy during infancy.

Method

Infants who underwent laparotomy between 1976 and 2011 were identified. Data were extracted from medical records and a questionnaire was sent to the patients.

Results

Some 898 of 1185 eligible patients were included, with a median follow‐up time of 14·7 (range 0·0–36·0) years. Median age at first laparotomy was 6 (range 1·0–365·0) days. There were 113 patients (12·6 per cent) with adhesive small bowel obstruction who underwent relaparotomy, 79 (69·9 per cent) occurring during the first 2 years after the initial laparotomy. The highest incidence of small bowel obstruction was found in patients with Hirschsprung's disease (19 of 65, 29 per cent), malrotation (13 of 45, 29 per cent), intestinal atresia (11 of 40, 28 per cent) and necrotizing enterocolitis (16 of 64, 25 per cent). Lengthy duration of surgery (hazard ratio (HR) 1·25, 95 per cent c.i. 1·07 to 1·45), stoma formation (HR 1·72, 1·15 to 2·56) and postoperative complications (HR 1·81, 1·12 to 2·92) were independent risk factors. Chronic abdominal pain was reported in 180 (24·0 per cent) of 750 patients, and 17 (13·8 per cent) of 123 women reported infertility.

Conclusion

The incidence of adhesive small bowel obstruction after laparotomy in infants is high.

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2 Comments

BJS admin

3 years ago

We would like to congratulate the authors Fredriksson et al. with their article ‘Adhesive small bowel obstruction after laparotomy during infancy’ (1). Although the title implicates this article is just about small bowel obstruction, it actually nicely displays the prevalence of other adhesion-related complications (chronic pain and infertility) in this patient group as well. The results are in accordance to the results of our meta-analysis on the incidence of adhesion-related complications. Paediatric patients are among the patients with highest risk of adhesion- related complications following surgery (2).

The only adhesion-related complication not covered in this article is the difficulties during future reoperations. We previously demonstrated in a large prospective cohort that young age is an independent risk factor for requiring future abdominal surgery (3). In our cohort no paediatric patients were included. However, one can easily imagine that paediatric patients have a high life-time risk of requiring abdominal surgery later in adulthood.

While paediatric patients have consistently been shown to be at high risk of developing adhesion-related complications, the question arises, when are surgeons going to take action against adhesions in paediatric surgery? Anti-adhesion barrier have shown to reduce adhesion related risks in adults (4). No trials have been performed in paediatric surgery, but a recent cohort study in paediatric patients showed promising results that were cost-effective (5).

R.P.G. ten Broek
Martijn W.J. Stommel
Chema Strik
H. van Goor

RadboudUMC
P.O.Box 9101
Nijmegen 6500 HB
The Netherlands
Richard.tenbroek@radboudumc.nl

References:
1. Fredriksson F, Christofferson RH, Lilja HE. Adhesive small bowel obstruction after laparotomy during infancy. Br J Surg 2016;103: 284-9.
2. Ten Broek RP, Issa Y, van Santbrink EJ, Bouvy ND, Kruitwagen RF, Jeekel J et al. Burden of adhesions in abdominal and pelvic surgery: systematic review and met-analysis. BMJ 2013; 347: f5588.
3. Strik C, Stommel MW, Schipper LJ, Van GH, Ten Broek RP. Risk factors for future repeat abdominal surgery. Langenbecks Arch Surg 2016 April 13.
4. Ten Broek RP, Stommel MW, Strik C, van Laarhoven CJ, Keus F, van Goor H. Benefits and harms of adhesion barriers for abdominal surgery: a systematic review and meta-analysis. Lancet 2014; 383: 48-59.
5. Inoue M, Uchida K, Otake K, Nagano Y, Ide S, Hashimoto K et al. Efficacy of Seprafilm for preventing adhesive bowel obstruction and cost-benefit analysis in pediatric patients undergoing laparotomy. J Pediatr Surg 2013; 48: 1528-34.

BJS admin

3 years ago

We would like to thank the authors Ten Broek et al. for their appreciation of our article “Adhesive small bowel obstruction after laparotomy during infancy” (1). It is an important research field as neonates and infants have a long lifetime risk for development of adhesion-related morbidity. Research is still scarce, only including the risk of adhesive small bowel obstruction (ASBO) (2-5). We found that the incidence of ASBO was as high as 12.6% after laparotomy during infancy (1). In addition, patients who underwent surgery due to ASBO had a significantly higher prevalence of both chronic abdominal pain and hospitalization due to abdominal pain. We also identified risk factors for developing ASBO in our study. The awareness of those risk factors may promote changes in surgical practice.

It is obvious that the paediatric population would benefit from anti-adhesion therapies. The barriers oxidized regenerated cellulose (Interceed) and hyaluronate carboxymethylcellulose (Seprafilm) have proved to reduce adhesion formation in clinical trials in adults (6,7). However, they are for various reasons seldom used. In a recent retrospective study, Inoue et al. found that Seprafilm reduced the incidence of ASBO in a paediatric population (8). A combination of more than one anti-adhesive agent may be required to prevent ASBO. Clinical trials in the paediatric population with anti-adhesive therapies approved for clinical use are necessary. In parallel, research into the mechanisms of intra-abdominal adhesion formation is crucial to find the optimal anti-adhesive therapies.

F. Fredriksson
Department of Women’s and Children’s Health
Section of Paediatric Surgery
Uppsala University
SE-751 85 Uppsala
Sweden
fanny.fredriksson@kbh.uu.se

References:
1. Fredriksson F, Christofferson RH, Lilja HE. Adhesive small bowel obstruction after laparotomy during infancy. Br J Surg 2016; 103: 284-9.
2. Wilkins BM, Spitz L. Incidence of postoperative adhesion obstruction following neonatal laparotomy. Br J Surg 1986; 73: 762–764.
3. Choudhry MS, Grant HW. Small bowel obstruction due to adhesions following neonatal laparotomy. Pediatr Surg Int 2006; 22: 729–732.
4. Van Eijck FC, Wijnen RMH, van Goor H. The incidence and morbidity of adhesions after treatment of neonates with gastroschisis and omphalocele: a 30-year review. J Pediatr Surg 2008; 43: 479–483.
5. Young JY, Kim DS, Muratore CS et al. High incidence of postoperative bowel obstruction in newborns and infants. J Pediatr Surg 2007; 42: 962-965.
6. Ten Broek RPG, Stommel MWJ, Strik C, van Laarhoven CJHM, Keus F, van Goor H. Benefits and harms of adhesion barriers for abdominal surgery: a systematic review and meta-analysis. Lancet 2014 Jan 4; 383(9911): 48–59.
7. Kumar S, Wong PF, Leaper DJ. Intra-peritoneal prophylactic agents for preventing adhesions and adhesive intestinal obstruction after non-gynaecological abdominal surgery. Cochrane Database Syst Rev 2009; (1): CD005080.
8. Inoue M, Uchida K, Otake K, Nagano Y, Ide S, Hashimoto K et al. Efficacy of Seprafilm for preventing adhesive bowel obstruction and cost-benefit analysis in pediatric patients undergoing laparotomy. J Pediatr Surg 2013; 48: 1528-34.