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Meta‐analysis of the risk of small bowel obstruction following open or laparoscopic colorectal surgery. BJS 2016; 103: 493-503.

Published: 22nd February 2016

Authors: T. Yamada, K. Okabayashi, H. Hasegawa, M. Tsuruta, J.‐H. Yoo, R. Seishima et al.

Background

One of the potential advantages of laparoscopic compared with open colorectal surgery is a reduction in postoperative bowel obstruction events. Early reports support this proposal, but accumulated evidence is lacking.

Method

A systematic review and meta‐analysis was performed of randomized clinical trials and observational studies by searching the PubMed and Cochrane Library databases from 1990 to August 2015. The primary outcomes were early and late postoperative bowel obstruction following laparoscopic and open colorectal surgery. Both ileus and bowel obstruction were defined as a postoperative bowel obstruction. Subgroup and sensitivity analyses were performed, and a random‐effects model was used to account for the heterogeneity among the studies.

Results

Twenty‐four randomized clinical trials and 88 observational studies were included in the meta‐analysis; 106 studies reported early outcome and 12 late outcome. Collectively, these studies reported on the outcomes of 148 392 patients, of whom 58 133 had laparoscopic surgery and 90 259 open surgery. Compared with open surgery, laparoscopic surgery was associated with reduced rates of early (odds ratio 0·62, 95 per cent c.i. 0·54 to 0·72; P < 0·001) and late (odds ratio 0·61, 0·41 to 0·92; P = 0·019) postoperative bowel obstruction. Weighted mean values for early postoperative bowel obstruction were 8 (95 per cent c.i. 6 to 10) and 5 (3 to 7) per cent for open and laparoscopic surgery respectively, and for late bowel obstruction were 4 (2 to 6) and 3 (1 to 5) per cent respectively.

Conclusion

The reduction in postoperative bowel obstruction demonstrates an advantage of laparoscopic surgery in patients with colorectal disease.

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BJS admin

3 years ago

We congratulate the authors Yamada et al. with their article ‘Meta-analysis of the risk of small bowel obstruction following open or laparoscopic colorectal surgery’ (1). The authors conclude that risk of small bowel obstruction (SBO) is lower after laparoscopic compared to open colorectal. However, some of the key premises of this area of investigation remain unanswered.

When investigating SBO, there is need for more uniform terminology. The authors subdivided bowel obstructions in early and late. Favourable results for laparoscopic surgery were most pronounced for early bowel obstruction, which includes prolonged postoperative ileus. Reduction in post-operative ileus is a well-known benefit of laparoscopic surgery.

The real question is whether laparoscopic surgery reduces the incidence of late bowel obstructions. Adhesions are the most prominent cause of late bowel obstructions. It is often hypothesized that incidence of long-term bowel obstruction in laparoscopic surgery is low compared to open surgery, because laparoscopic surgery induces few adhesions; but strong evidence is lacking. To interpret the results for the comparison of late bowel obstructions in this systematic review, it is important to evaluate how a late SBO was exactly defined in the included articles. Differences in this definition can have major impact on the results. There are 3 main categories of definition of late SBO:
Initially any late post-operative bowel obstruction of which only 60% have bowel obstructions that are truly caused by adhesions (2). Examples for other causes for late SBO after surgery are (recurrence of) tumour, ventral hernia, and internal hernia.
Next adhesive SBO treated conservatively. Although a definitive diagnosis of adhesions requires reoperation, with careful clinical and radiological investigations, 90% accuracy in diagnosis of the adhesive aetiology is feasible.
Lastly there is adhesive SBO, which is treated operatively. This is the gold standard, and the outcome that has most impact on patient morbidity.

For most of the included studies it is not clear exactly what outcome was measured, and during which timeframe. Although significant with the high numbers included, the difference in weighted mean incidences of late bowel obstruction after open and after laparoscopic surgery is small [4% (2 to 6) vs. 3% (1 to 5), respectively]. In the COLOR and CLASSIC trials, which clearly defined their endpoints in a time depended matter, the difference was not significant (3,4).

Although it seems likely that the incidence of adhesive SBO is lower after laparoscopy, the effect is modest. Thus, performing colorectal surgery by laparoscopy is not a complete solution to preventing adhesive SBO; which is one of the leading causes for admissions, death and morbidity in emergency general surgery (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. Yamada T, Okabayashi K, Hasegawa H, Tsuruta M, Yoo JH, Seishima R et al. Meta-analysis of the risk of small bowel obstruction following open or laparoscopic colorectal surgery. Br J Surg 2016; 103: 493-503.
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 meta-analysis. BMJ 2013; 347: f5588.
3. Taylor GW, Jayne DG, Brown SR, Thorpe H, Brown JM, Dewberry SC et al. Adhesions and incisional hernias following laparoscopic versus open surgery for colorectal cancer in the CLASICC trial. Br J Surg 2010; 97: 70-8.
4. Scholin J, Buunen M, Hop W, Bonjer J, Anderberg B, Cuesta M et al. Bowel obstruction after laparoscopic and open colon resection for cancer: results of 5 years of follow-up in a randomized trial. Surg Endosc 2011; 25: 3755-60.
5. Scott JW, Olufajo OA, Brat GA, Rose JA, Zogg CK, Haider AH et al. Use of National Burden to Define Operative Emergency General Surgery. JAMA Surg 2016; 151: e160480.