Lower small bowel obstruction rates after laparoscopic colorectal resection

Reuters Health Information: Lower small bowel obstruction rates after laparoscopic colorectal resection

Lower small bowel obstruction rates after laparoscopic colorectal resection

Last Updated: 2015-10-16

By Will Boggs MD

NEW YORK (Reuters Health) - Small bowel obstruction (SBO) rates are lower after laparoscopic colorectal resection than after open resection, according to a population-based database study.

"In addition to some of the better known benefits of a laparoscopic approach, such as shorter length of stay, this study demonstrates that an additional advantage of a laparoscopic approach is a decreased risk of adhesive small bowel obstruction, which is associated with high healthcare utilization, cost, and morbidity for patients," Dr. Christopher T. Aquina from the University of Rochester Medical Center in Rochester, New York, told Reuters Health by email. "Surgeons should try to utilize a laparoscopic approach for colorectal resections whenever feasible."

The study was published online September 29 in Annals of Surgery; just a week later, two randomized clinical trials showing that laparoscopic surgery was no better than, and perhaps inferior to, traditional open surgery for rectal cancer appeared in JAMA (see Reuters Health story of October 6).

Nearly a million inpatient hospital days and more than $2.3 billion in hospital costs each year are attributed to adhesion-related SBO, which can have mortality rates as high as 10%.

Dr. Aquina and colleagues used the New York Department of Health's Statewide Planning and Research Cooperative System (SPARCS) database to compare the rate of SBO between a laparoscopic and an open operative approach for colorectal resection.

During the three years following surgery, 5.3% developed SBO, with a median time to SBO of 251 days, they report.

In both the intention-to-treat (ITT) and the non-ITT analyses, the SBO rate was significantly lower with laparoscopic resection (4.0% and 3.5%, respectively) than with open colorectal resection (5.8% for both analyses).

After controlling for relevant factors and the propensity scores, the open approach was associated with 14% (with ITT) and 34% (with non-ITT) higher rates of SBO, compared with a laparoscopic approach.

Results were similar when the researchers analyzed the rates of operation for SBO: After adjustment, open colorectal resection was associated with 12% (ITT) and 35% (non-ITT) higher rates of operation, compared with laparoscopic colorectal resection.

"While some patients will suffer from their first episode of adhesive small bowel obstruction after three years, most will occur within this time frame," Dr. Aquina said. "However, our study is likely an underestimation of the true small bowel obstruction rate following colorectal surgery due to the limited follow-up period."

"Some of the factors that affect the choice of a laparoscopic versus an open approach include a patient's body habitus, a previous history of abdominal surgery, and the surgeon's training or preference," he explained. "Laparoscopic surgery is more difficult from a technical standpoint in patients with obesity or those with scar tissue from previous surgery. As such, surgeons with more laparoscopic training or experience may be more comfortable and skilled in performing laparoscopic surgery in these patients."

"However," Dr. Aquina said, "while these factors were associated with a lower rate of a laparoscopic approach in our study, most of the patients in our study who underwent an open approach were not obese and did not have previous abdominal surgery, suggesting that underutilization of a laparoscopic approach may be due to individual surgeon preferences."

Dr. Daniel D. Klaristenfeld, a colorectal surgeon from Kaiser Permanente San Diego Medical Center in California, told Reuters Health by email, "Laparoscopic surgery isn't just great in the short term, but also has longer-term advantages. Within a health system like Kaiser Permanente, where we expect to care for our patients for many years to come, laparoscopic surgery continues to have the benefit of preventing hospitalizations, morbidity, and additional operations associated with ventral hernia and small bowel obstructions."

"Most SBOs are going to present within 3-5 years after index surgery," Dr. Klaristenfeld said. "That being said, patients with SBO can present at any time after abdominal operation."

Dr. Klaristenfeld said he would reserve open colorectal resection for "locally advanced disease extending into other structures; ill patient who will not tolerate the pneumoperitoneum necessary for laparoscopic surgery; (and) combined colon and liver resection."

SOURCE: http://bit.ly/1LdETSa

Ann Surg 2015.

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