JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 25, Number 1, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/lap.2014.0228
Laparoscopy for Small Bowel Obstruction in Children—An Update Hanna Alemayehu, MD, Bryan David, Amita A. Desai, MD, Corey W. Iqbal, MD, and Shawn D. St. Peter, MD
Abstract
Introduction: We evaluated the current role of minimally invasive surgery (MIS) in children with small bowel obstruction (SBO) at our institution. Subjects and Methods: A retrospective review of patients undergoing MIS for acute SBO was performed from 2008 to 2013. The study population was compared with a historical control including patients from 2001 to 2008. Results: There were 71 patients who met inclusion criteria; 35 were male, and 36 were female. Sixty-two children underwent laparoscopy for their first episode of SBO, and 12 underwent laparoscopy for recurrent SBO, accounting for 74 episodes of SBO managed with MIS. The most common etiology of SBO was adhesions (n = 40). Laparoscopy and laparoscopic-assisted procedures were associated with shorter nasogastric tube decompression (1.4 – 2 days [P < .001] and 1.5 – 2.7 days [P = .002], respectively) and time to regular diet (3.9 – 4 days [P = .002] and 4.6 – 2.8 days [P = .024], respectively) compared with those converted to laparotomy (5.1 – 4.9 days of nasogastric tube decompressions and 8 – 4.7 days to regular diet). There was no difference in postoperative morbidity comparing laparoscopy (11%), laparoscopic-assisted (5%), and laparoscopic converted to open procedures (18%) (P = .48). Conclusions: Laparoscopy continues to be a safe diagnostic and therapeutic tool in the management of pediatric SBO.
Introduction
Subjects and Methods
D
After Institutional Review Board approval was obtained, a retrospective review of patients under 18 years of age undergoing laparoscopy for the management of acute SBOs was performed from 2008 to 2013. Acute SBO was defined as patients presenting with signs and symptoms of bowel obstruction with an acute onset, supported by radiographic evidence of SBO. Patients with chronic obstruction, colonic obstruction, known intestinal dysmotility, or acute ileocolic intussusception were excluded. Patients with inflammatory bowel strictures were included only if they presented acutely. MIS was defined as a completely laparoscopic procedure, a laparoscopic-assisted procedure, or a laparoscopic procedure converted to the open procedure. A laparoscopic-assisted procedure was defined as a procedure with both the diagnosis and the adhesiolysis performed laparoscopically, and the therapeutic part of the procedure was performed by a small extension of the umbilical incision with exteriorization of the select segment of bowel requiring definitive intervention,
uring the dawn of minimally invasive surgery (MIS), laparoscopy was considered an unfeasible approach for acute small bowel obstruction (SBO), because of bowel distension, which limits visualization and increases the potential for enteric injuries with laparoscopic graspers.1,2 As the experience with laparoscopy grew, surgeons became more comfortable with approaching many abdominal emergencies, including acute SBO, with laparoscopy.3–10 Laparoscopy has also been shown to be feasible to treat bowel obstructions in the pediatric population, although the literature is sparse.11–14 We previously reviewed our institutional experience with laparoscopic management of SBO in children,11 wherein we documented that laparoscopy for SBO in children can be safe and effective with a reasonable rate of completion without conversion. The purpose of this study was to evaluate the evolution of laparoscopy for these patients and to compare our current outcomes with the historical control.
The Children’s Mercy Hospital, Kansas City, Missouri.
73
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ALEMAYEHU ET AL.
Table 1. Patient Characteristics by Operative Approach
Age (years) Weight (kg) Time (months) between previous surgery and SBO Number of abdominal surgeries prior to MIS for SBO
Laparoscopic (n = 37)
Laparoscopic-assisted (n = 20)
Converted to open (n = 17)
P valuea
10.8 (5.2) 38.4 (20.4) 26.4 (43.4)
10.0 (5.8) 36.3 (21.1) 20.8 (62.3)
9.0 (6.7) 30.4 (21.3) 42.4 (76.3)
.559 .425 .5
1.5 (0.9)
1.3 (0.9)
1.2 (0.4)
.406
Data are mean (standard deviation) values. a Obtained using analysis of variance testing with post hoc analysis. MIS, minimally invasive surgery; SBO, small bowel obstruction.
such as stricturoplasty or resection. In contrast, a laparoscopic converted to an open procedure was defined as an attempt at diagnosis and/or adhesiolysis laparoscopically that was abandoned secondary to lack of visbility or working space, requiring conversion to laparotomy to complete the diagnosis, adhesiolysis, or further definitive intervention. Data were collected, and both descriptive and comparative analyses were performed. Comparative data were analyzed using analysis of variance testing with Tukey’s post hoc analysis for multiple group comparisons of continuous variables. Student’s t test was used for two-group comparisons for continuous variables, and chi-squared test with Yates’s correction, or Fisher’s exact test where appropriate, was used for discrete variables. The current study population was compared with a historical control including patients from 2001 to 200811; patients included in the current study were excluded from the historical control. All values reported as mean – standard deviation values.
inability to adequately mobilize bowel (n = 1), and completion of secondary procedure (Hartman’s reversal, n = 1). Postoperatively, the mean number of days of nasogastric tube decompression was 2.2 – 3.4 days, mean time to a regular diet was 5.0 – 4.2 days, and mean postoperative duration of stay was 9.6 – 19.1 days. Analysis of variance testing showed a difference between groups in terms of nasogastric tube decompression and time to regular diet (Table 3). Tukey’s post hoc test showed that completely laparoscopic and laparoscopic-assisted procedures were similar and were associated with a shorter time of nasogastric tube decompression and time to regular diet than the procedures necessitating conversion to an open procedure (Table 4). However, postoperative hospital duration of stay was similar in all groups. There were eight postoperative complications: intraabdominal abscess (n = 3), anastomotic stricture (n = 2), anastomotic leak (n = 1), bowel obstruction (n = 1), and respiratory failure (n = 1). Discussion
Results
There were 71 patients who were managed with MIS for SBO during the study period, of which 35 were male and 36 were female. There were 62 initial episodes of SBO and 12 recurrent SBOs, accounting for 74 episodes of SBO approach laparoscopically. The mean age at operation was 10.2 – 5.8 years, with a mean weight of 36.0 – 20.4 kg, and 55.3% (n = 42) of these had had previous abdominal surgery, with a mean of 1.4 – 0.7 surgeries prior to the operation in this study. The mean time from a previous operation to current presentation was 28.6 – 48.1 months. SBOs were managed completely laparoscopically 50% (n = 37) of the time, 27% (n = 20) with laparoscopic-assisted procedures, and 23% (n = 17) with conversion to open procedures. Patient characteristics were similar in all three operative approaches (Table 1). The most common etiology of SBO was adhesions (n = 39), with other causes shown in Table 2. The most common procedure performed was adhesiolysis only (n = 28), followed by bowel resection with primary anastomosis (n = 19), appendectomy (n = 6), Meckel’s diverticulectomy (n = 5), bowel resection with ostomy formation (n = 4), and other miscellaneous procedures (n = 12). Reasons for conversion included the lack of adequate visualization or working space due to dense adhesions (n = 12), lack of adequate visualization or working space due to significantly dilated bowel (n = 1), inability to diagnose etiology of obstruction (n = 1), enterotomy with trocar placement (n = 1),
SBO remains a significant source of morbidity and healthcare expenditure.4 Initial concerns about the use of laparoscopy in the treatment of SBO have been refuted by several studies that have shown MIS to be safe and effective in select patients.2,7–9 Some adult studies have even suggested reductions in postoperative morbidity, mortality, length of stay, and costs in patients undergoing laparoscopy for adhesive SBO.4,10 Laparoscopy for SBO in children has been less well studied, but the literature does indicate safety and efficacy in the pediatric population as well.11,12,14 In our current institutional experience it is clear that laparoscopy for SBO in children remains an effective approach as about 70% of the patients avoided a laparotomy. This translated to a shorter time of postoperative nasogastric tube decompression
Table 2. Etiology of Small Bowel Obstruction Etiology Adhesions Inflammatory bowel disease Other Perforated appendicitis Meckel’s diverticulum Volvulus Anastamotic stricture Internal hernia
Number (%) 39 10 8 5 5 3 2 2
(52) (13) (11) (7) (7) (4) (3) (3)
LAPAROSCOPY FOR SMALL BOWEL OBSTRUCTION IN CHILDREN
75
Table 3. Outcomes by Operative Approach Laparoscopic (n = 37)
Laparoscopic-assisted (n = 20)
Converted to open (n = 17)
P valuea
1.4 (2.0)
1.5 (2.7)
5.1 (4.9)
< .001b
3.9 (4.0) 5.7 (12.1) 10.8 (4)
4.6 (2.8) 9.9 (18.5) 5 (1)
8 (4.65) 17.8 (28.6) 17.6 (3)
Mean (SD) time (days) of postoperative nasogastric tube Mean (SD) time (days) to regular diet Mean (SD) duration (days) of stay Postoperative complication rate [n (%)]
.002b .095 .48
a
Obtained using analysis of variance testing with post hoc analysis. Indicates significant difference. SD, standard deviation.
b
and a shorter time to regular diet in those who avoided a laparotomy. As for the selection of patients, after our previous experience was reported, we became much less selective by approaching most patients laparoscopically who present with SBO. This is evident by the fact that we had about 4 cases per year in the historical cohort and 15 cases per year in the contemporary experience. The success rate remained stable despite approaching more patients with laparoscopy; in fact, there was no difference between the current study and our previous experience in terms of nasogastric tube use, duration of hospital stay, morbidity, or rate of conversion to an open procedure. Overall, the outcomes for attempted laparoscopic management of SBO in children in this study are similar to the adult literature. Postoperatively, the mean number of days of nasogastric tube decompression was 2 days, mean time to a regular diet was 5 days, and mean duration of stay was 10 days. Previously published adult studies have shown similar times to initiation of diet, length of stay, and postoperative complication rate.1,3,5,8,15,16 Previously published conversion rates of 0%–73% show wide variability, but are similar to the conversion rate in this study of 23%. A 2001 study in children showed a conversion rate of 33%,14 which is similar to our historical control and our current study. The variability in conversion rate in the adult literature may be due to variations in definition of laparoscopic converted to open procedures and of laparoscopic-assisted procedures. Additionally, in our study, conversion to an open procedure for lack of visibility was due to the dense nature of adhesions, rather than dilated bowel loops. The etiology of bowel obstruction in this study
Table 4. Tukey’s Post Hoc Testing for Outcomes by Operative Approach P value for mean time Of postoperative NGT Laparoscopic versus laparoscopic-assisted Laparoscopic versus converted to open Laparoscopic-assisted versus converted to open a Indicates significant difference. NGT, nasogastric tube.
.993
To regular diet .83
< .001a
.002a
.002a
.024a
population was diverse, although postoperative adhesions accounted for the majority. These two findings emphasize that the effectiveness of laparoscopy may not be easily predicted prior to placing the laparoscope. A comparison of outcomes was also performed by operation approach, namely, laparoscopic, laparoscopic-assisted, and laparoscopic converted to an open procedure. The primary difference between laparoscopic-assisted and laparoscopic converted to open procedures relates to the extent of adhesiolysis performed laparoscopically and the size of the extended incision. In the laparoscopic-assisted approach the adhesiolysis is performed laparoscopically, the etiology of obstruction is diagnosed laparoscopically, and the site of pathology is exteriorized via a small extension of a port site for therapeutic intervention such as stricturoplasty or bowel resection and anastomosis. It can be argued that the difference in operative approach is a semantic one because bowel is exteriorized and handled in both the laparoscopic-assisted and lapaoroscopic converted to open approaches. However, the outcomes data in this study suggest that there is an advantage to the laparoscopic-assisted approach in terms of mean time of postoperative nasogastric tube decompression and of mean time to initiation of a regular diet, with no difference in complication rates. This indicates that some of the advantages of the laparoscopic approach in terms of outcomes are conferred to the patients with laparoscopic-assisted procedures despite the exteriorization of a small segment of bowel. No difference was noted in duration of hospital stay, however. This may be due to the wide ranges in duration of stay seen in each group, with standard deviations of 12–29 days, although the lapaoroscopic procedures tended toward shorter durations of stay. Laparoscopic-assisted procedures for SBO have been described in several studies, but approach-specific outcomes were not evaluated.6–8 This study has several limitations. The use of duration of nasogastric tube decompression as an outcome measure is limited by the inability to determine the correlation of using nasogastric tube decompression and the actual clinical need for continued nasogastric tube decompression. This is further limited by the lack of a specific protocol during the study period regarding clinical markers for removal of the nasogastric tube and initiation of diet. The retrospective nature of the study does not allow us to account for selection bias, surgeon comfort with laparoscopy, indication for operation, or even institutional bias. Therefore conclusions about efficacy of MIS for SBO in children must be made with selection of the appropriate patient in mind. The study population,
76
ALEMAYEHU ET AL.
however, includes a wide variety of etiologies of SBO and patients with a wide range of ages and weights and indicates that laparoscopy can be used effectively in children with SBO, at the very least as an initial diagnostic tool. Postoperative complications were seen in 8 patients, resulting in a complication rate of 11%, which is similar to the complication rate of 4%–39% documented in the adult literature1,7,16 and 6%–34% in pediatric studies.11,14 This compares favorably with recently described complication rates for open laparotomies for SBOs of 22%.10 In conclusion, laparoscopy is a safe diagnostic and therapeutic tool in the management of pediatric SBOs secondary to a wide variety of etiologies. It can be used effectively as an initial tool of exploration in children with SBO, acknowledging that conversion to an open procedure may be necessary, particularly in patients with dense adhesions limiting visualization and/or working space. Pure laparoscopy and laparoscopic-assisted procedures both have shorter postoperative need for nasogastric tubes and shorter time to introduction of a regular diet, which justifies initial laparoscopy as the preferred approach unless other contraindications exist. Acknowledgments
The authors thank Ashley Sherman, MA, Associate Research Biostatistician in the Department of Research Development and Clinical Investigation at The Children’s Mercy Hospital, Kansas City, MO, for assistance with statistical analysis. Disclosure Statement
No competing financial interests exist. References
1. Strickland P, Lourie DJ, Suddleson EA, et al. Is laparoscopy safe and effective for treatment of acute small-bowel obstructions? Surg Endosc 1999;13:695–698. 2. Agrusa A, Romano G, Di Buono G, et al. Laparoscopic approach in abdominal emergencies: A 5-year experience at a single center. G Chir 2012;33:400–403. 3. Tierris I, Mavrantonis C, Stratoulias C, et al. Laparoscopy for acute small bowel obstruction: Indication or contraindication? Surg Endoc 2011;25:531–535. 4. Mancini GJ, Petroski GF, Lin WC, et al. Nationwide impact of laparoscopic lysis of adhesions in the management of intestinal obstruction in the US. J Am Coll Surg 2008; 207:520–526.
5. Ghosheh B, Salemeh JR. Laparoscopic approach to acute small bowel obstruction: Review of 1061 cases. Surg Endosc 2007;21:1945–1949. 6. Liao CH, Liu YY, Chen CC, et al. Single-incision laparoscopic-assisted surgery for small bowel obstruction. J Laparoendosc Adv Surg Tech A 2012;22:957–961. 7. Chowbey PK, Panse R, Sharma A, et al. Elective laparoscopy in diagnosis and treatment of recurrent small bowel obstruction. Surg Laparosc Endosc Percutan Tech 2006;16:416–422. 8. Tsumura H, Ichikawa T, Murakami Y, et al. Laparoscopic adhesiolysis for recurrent post-operative small bowel obstruction. Hepatogastroenterology 2004;51:1058–1061. 9. Borzellino G, Tasselli S, Zerman G, et al. Laparoscopic approach to post-operative adhesive obstruction. Surg Endosc 2004;18:686–690. 10. Kelly KN, Iannuzzi JC, Rickles AS, et al. Laparotomy for small-bowel obstruction: First choice or last resort for adhesiolysis? A laparoscopic approach for small-bowel obstruction reduces 30-day complications. Surg Endosc 2014; 28:65–73. 11. Aguayo P, Fraser JD, Illyas S, et al. Laparoscopic management of small bowel obstruction in children. J Laparoendosc Adv Surg Tech A 2011;21:85–88. 12. Becmeur F, Besson R; GECI. Treatment of small-bowel obstruction by laparoscopy in children multicentric study. Eur J Pediatr Surg 1998;8:343–346. 13. Becmeur F. Laparoscopy and small bowel obstruction in children. Saudi Med J 2003;24(Suppl):S15–S17. 14. Shalaby R, Deskoy A. Laparoscopic approach to small intestinal obstruction in children: A preliminary experience. Surg Laparosc Endosc Percutan Tech 2001;11:301–305. 15. Joseph SP, Simonson M, Edwards C. ‘Let’s just wait in more day’: Impact of timing on surgical outcome in the treatment of adhesion-related small bowel obstruction. Am Surg 2013;79:175–179. 16. Dayton M, Dempsey DT, Larsen GM, et al. New paradigms in the treatment of small bowel obstruction. Curr Probl Surg 2012;49:642–717.
Address correspondence to: Shawn D. St. Peter, MD Pediatric Surgery Training Program Center for Prospective Clinical Trials Department of Surgery Children’s Mercy Hospital 2401 Gillham Road Kansas City, MO 64108 E-mail: [email protected]
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Laparoscopy for Small Bowel Obstruction in Children—An Update Hanna Alemayehu, MD, Bryan David, Amita A. Desai, MD, Corey W. Iqbal, MD, and Shawn D. St. Peter, MD
Abstract
Introduction: We evaluated the current role of minimally invasive surgery (MIS) in children with small bowel obstruction (SBO) at our institution. Subjects and Methods: A retrospective review of patients undergoing MIS for acute SBO was performed from 2008 to 2013. The study population was compared with a historical control including patients from 2001 to 2008. Results: There were 71 patients who met inclusion criteria; 35 were male, and 36 were female. Sixty-two children underwent laparoscopy for their first episode of SBO, and 12 underwent laparoscopy for recurrent SBO, accounting for 74 episodes of SBO managed with MIS. The most common etiology of SBO was adhesions (n = 40). Laparoscopy and laparoscopic-assisted procedures were associated with shorter nasogastric tube decompression (1.4 – 2 days [P < .001] and 1.5 – 2.7 days [P = .002], respectively) and time to regular diet (3.9 – 4 days [P = .002] and 4.6 – 2.8 days [P = .024], respectively) compared with those converted to laparotomy (5.1 – 4.9 days of nasogastric tube decompressions and 8 – 4.7 days to regular diet). There was no difference in postoperative morbidity comparing laparoscopy (11%), laparoscopic-assisted (5%), and laparoscopic converted to open procedures (18%) (P = .48). Conclusions: Laparoscopy continues to be a safe diagnostic and therapeutic tool in the management of pediatric SBO.
Introduction
Subjects and Methods
D
After Institutional Review Board approval was obtained, a retrospective review of patients under 18 years of age undergoing laparoscopy for the management of acute SBOs was performed from 2008 to 2013. Acute SBO was defined as patients presenting with signs and symptoms of bowel obstruction with an acute onset, supported by radiographic evidence of SBO. Patients with chronic obstruction, colonic obstruction, known intestinal dysmotility, or acute ileocolic intussusception were excluded. Patients with inflammatory bowel strictures were included only if they presented acutely. MIS was defined as a completely laparoscopic procedure, a laparoscopic-assisted procedure, or a laparoscopic procedure converted to the open procedure. A laparoscopic-assisted procedure was defined as a procedure with both the diagnosis and the adhesiolysis performed laparoscopically, and the therapeutic part of the procedure was performed by a small extension of the umbilical incision with exteriorization of the select segment of bowel requiring definitive intervention,
uring the dawn of minimally invasive surgery (MIS), laparoscopy was considered an unfeasible approach for acute small bowel obstruction (SBO), because of bowel distension, which limits visualization and increases the potential for enteric injuries with laparoscopic graspers.1,2 As the experience with laparoscopy grew, surgeons became more comfortable with approaching many abdominal emergencies, including acute SBO, with laparoscopy.3–10 Laparoscopy has also been shown to be feasible to treat bowel obstructions in the pediatric population, although the literature is sparse.11–14 We previously reviewed our institutional experience with laparoscopic management of SBO in children,11 wherein we documented that laparoscopy for SBO in children can be safe and effective with a reasonable rate of completion without conversion. The purpose of this study was to evaluate the evolution of laparoscopy for these patients and to compare our current outcomes with the historical control.
The Children’s Mercy Hospital, Kansas City, Missouri.
73
74
ALEMAYEHU ET AL.
Table 1. Patient Characteristics by Operative Approach
Age (years) Weight (kg) Time (months) between previous surgery and SBO Number of abdominal surgeries prior to MIS for SBO
Laparoscopic (n = 37)
Laparoscopic-assisted (n = 20)
Converted to open (n = 17)
P valuea
10.8 (5.2) 38.4 (20.4) 26.4 (43.4)
10.0 (5.8) 36.3 (21.1) 20.8 (62.3)
9.0 (6.7) 30.4 (21.3) 42.4 (76.3)
.559 .425 .5
1.5 (0.9)
1.3 (0.9)
1.2 (0.4)
.406
Data are mean (standard deviation) values. a Obtained using analysis of variance testing with post hoc analysis. MIS, minimally invasive surgery; SBO, small bowel obstruction.
such as stricturoplasty or resection. In contrast, a laparoscopic converted to an open procedure was defined as an attempt at diagnosis and/or adhesiolysis laparoscopically that was abandoned secondary to lack of visbility or working space, requiring conversion to laparotomy to complete the diagnosis, adhesiolysis, or further definitive intervention. Data were collected, and both descriptive and comparative analyses were performed. Comparative data were analyzed using analysis of variance testing with Tukey’s post hoc analysis for multiple group comparisons of continuous variables. Student’s t test was used for two-group comparisons for continuous variables, and chi-squared test with Yates’s correction, or Fisher’s exact test where appropriate, was used for discrete variables. The current study population was compared with a historical control including patients from 2001 to 200811; patients included in the current study were excluded from the historical control. All values reported as mean – standard deviation values.
inability to adequately mobilize bowel (n = 1), and completion of secondary procedure (Hartman’s reversal, n = 1). Postoperatively, the mean number of days of nasogastric tube decompression was 2.2 – 3.4 days, mean time to a regular diet was 5.0 – 4.2 days, and mean postoperative duration of stay was 9.6 – 19.1 days. Analysis of variance testing showed a difference between groups in terms of nasogastric tube decompression and time to regular diet (Table 3). Tukey’s post hoc test showed that completely laparoscopic and laparoscopic-assisted procedures were similar and were associated with a shorter time of nasogastric tube decompression and time to regular diet than the procedures necessitating conversion to an open procedure (Table 4). However, postoperative hospital duration of stay was similar in all groups. There were eight postoperative complications: intraabdominal abscess (n = 3), anastomotic stricture (n = 2), anastomotic leak (n = 1), bowel obstruction (n = 1), and respiratory failure (n = 1). Discussion
Results
There were 71 patients who were managed with MIS for SBO during the study period, of which 35 were male and 36 were female. There were 62 initial episodes of SBO and 12 recurrent SBOs, accounting for 74 episodes of SBO approach laparoscopically. The mean age at operation was 10.2 – 5.8 years, with a mean weight of 36.0 – 20.4 kg, and 55.3% (n = 42) of these had had previous abdominal surgery, with a mean of 1.4 – 0.7 surgeries prior to the operation in this study. The mean time from a previous operation to current presentation was 28.6 – 48.1 months. SBOs were managed completely laparoscopically 50% (n = 37) of the time, 27% (n = 20) with laparoscopic-assisted procedures, and 23% (n = 17) with conversion to open procedures. Patient characteristics were similar in all three operative approaches (Table 1). The most common etiology of SBO was adhesions (n = 39), with other causes shown in Table 2. The most common procedure performed was adhesiolysis only (n = 28), followed by bowel resection with primary anastomosis (n = 19), appendectomy (n = 6), Meckel’s diverticulectomy (n = 5), bowel resection with ostomy formation (n = 4), and other miscellaneous procedures (n = 12). Reasons for conversion included the lack of adequate visualization or working space due to dense adhesions (n = 12), lack of adequate visualization or working space due to significantly dilated bowel (n = 1), inability to diagnose etiology of obstruction (n = 1), enterotomy with trocar placement (n = 1),
SBO remains a significant source of morbidity and healthcare expenditure.4 Initial concerns about the use of laparoscopy in the treatment of SBO have been refuted by several studies that have shown MIS to be safe and effective in select patients.2,7–9 Some adult studies have even suggested reductions in postoperative morbidity, mortality, length of stay, and costs in patients undergoing laparoscopy for adhesive SBO.4,10 Laparoscopy for SBO in children has been less well studied, but the literature does indicate safety and efficacy in the pediatric population as well.11,12,14 In our current institutional experience it is clear that laparoscopy for SBO in children remains an effective approach as about 70% of the patients avoided a laparotomy. This translated to a shorter time of postoperative nasogastric tube decompression
Table 2. Etiology of Small Bowel Obstruction Etiology Adhesions Inflammatory bowel disease Other Perforated appendicitis Meckel’s diverticulum Volvulus Anastamotic stricture Internal hernia
Number (%) 39 10 8 5 5 3 2 2
(52) (13) (11) (7) (7) (4) (3) (3)
LAPAROSCOPY FOR SMALL BOWEL OBSTRUCTION IN CHILDREN
75
Table 3. Outcomes by Operative Approach Laparoscopic (n = 37)
Laparoscopic-assisted (n = 20)
Converted to open (n = 17)
P valuea
1.4 (2.0)
1.5 (2.7)
5.1 (4.9)
< .001b
3.9 (4.0) 5.7 (12.1) 10.8 (4)
4.6 (2.8) 9.9 (18.5) 5 (1)
8 (4.65) 17.8 (28.6) 17.6 (3)
Mean (SD) time (days) of postoperative nasogastric tube Mean (SD) time (days) to regular diet Mean (SD) duration (days) of stay Postoperative complication rate [n (%)]
.002b .095 .48
a
Obtained using analysis of variance testing with post hoc analysis. Indicates significant difference. SD, standard deviation.
b
and a shorter time to regular diet in those who avoided a laparotomy. As for the selection of patients, after our previous experience was reported, we became much less selective by approaching most patients laparoscopically who present with SBO. This is evident by the fact that we had about 4 cases per year in the historical cohort and 15 cases per year in the contemporary experience. The success rate remained stable despite approaching more patients with laparoscopy; in fact, there was no difference between the current study and our previous experience in terms of nasogastric tube use, duration of hospital stay, morbidity, or rate of conversion to an open procedure. Overall, the outcomes for attempted laparoscopic management of SBO in children in this study are similar to the adult literature. Postoperatively, the mean number of days of nasogastric tube decompression was 2 days, mean time to a regular diet was 5 days, and mean duration of stay was 10 days. Previously published adult studies have shown similar times to initiation of diet, length of stay, and postoperative complication rate.1,3,5,8,15,16 Previously published conversion rates of 0%–73% show wide variability, but are similar to the conversion rate in this study of 23%. A 2001 study in children showed a conversion rate of 33%,14 which is similar to our historical control and our current study. The variability in conversion rate in the adult literature may be due to variations in definition of laparoscopic converted to open procedures and of laparoscopic-assisted procedures. Additionally, in our study, conversion to an open procedure for lack of visibility was due to the dense nature of adhesions, rather than dilated bowel loops. The etiology of bowel obstruction in this study
Table 4. Tukey’s Post Hoc Testing for Outcomes by Operative Approach P value for mean time Of postoperative NGT Laparoscopic versus laparoscopic-assisted Laparoscopic versus converted to open Laparoscopic-assisted versus converted to open a Indicates significant difference. NGT, nasogastric tube.
.993
To regular diet .83
< .001a
.002a
.002a
.024a
population was diverse, although postoperative adhesions accounted for the majority. These two findings emphasize that the effectiveness of laparoscopy may not be easily predicted prior to placing the laparoscope. A comparison of outcomes was also performed by operation approach, namely, laparoscopic, laparoscopic-assisted, and laparoscopic converted to an open procedure. The primary difference between laparoscopic-assisted and laparoscopic converted to open procedures relates to the extent of adhesiolysis performed laparoscopically and the size of the extended incision. In the laparoscopic-assisted approach the adhesiolysis is performed laparoscopically, the etiology of obstruction is diagnosed laparoscopically, and the site of pathology is exteriorized via a small extension of a port site for therapeutic intervention such as stricturoplasty or bowel resection and anastomosis. It can be argued that the difference in operative approach is a semantic one because bowel is exteriorized and handled in both the laparoscopic-assisted and lapaoroscopic converted to open approaches. However, the outcomes data in this study suggest that there is an advantage to the laparoscopic-assisted approach in terms of mean time of postoperative nasogastric tube decompression and of mean time to initiation of a regular diet, with no difference in complication rates. This indicates that some of the advantages of the laparoscopic approach in terms of outcomes are conferred to the patients with laparoscopic-assisted procedures despite the exteriorization of a small segment of bowel. No difference was noted in duration of hospital stay, however. This may be due to the wide ranges in duration of stay seen in each group, with standard deviations of 12–29 days, although the lapaoroscopic procedures tended toward shorter durations of stay. Laparoscopic-assisted procedures for SBO have been described in several studies, but approach-specific outcomes were not evaluated.6–8 This study has several limitations. The use of duration of nasogastric tube decompression as an outcome measure is limited by the inability to determine the correlation of using nasogastric tube decompression and the actual clinical need for continued nasogastric tube decompression. This is further limited by the lack of a specific protocol during the study period regarding clinical markers for removal of the nasogastric tube and initiation of diet. The retrospective nature of the study does not allow us to account for selection bias, surgeon comfort with laparoscopy, indication for operation, or even institutional bias. Therefore conclusions about efficacy of MIS for SBO in children must be made with selection of the appropriate patient in mind. The study population,
76
ALEMAYEHU ET AL.
however, includes a wide variety of etiologies of SBO and patients with a wide range of ages and weights and indicates that laparoscopy can be used effectively in children with SBO, at the very least as an initial diagnostic tool. Postoperative complications were seen in 8 patients, resulting in a complication rate of 11%, which is similar to the complication rate of 4%–39% documented in the adult literature1,7,16 and 6%–34% in pediatric studies.11,14 This compares favorably with recently described complication rates for open laparotomies for SBOs of 22%.10 In conclusion, laparoscopy is a safe diagnostic and therapeutic tool in the management of pediatric SBOs secondary to a wide variety of etiologies. It can be used effectively as an initial tool of exploration in children with SBO, acknowledging that conversion to an open procedure may be necessary, particularly in patients with dense adhesions limiting visualization and/or working space. Pure laparoscopy and laparoscopic-assisted procedures both have shorter postoperative need for nasogastric tubes and shorter time to introduction of a regular diet, which justifies initial laparoscopy as the preferred approach unless other contraindications exist. Acknowledgments
The authors thank Ashley Sherman, MA, Associate Research Biostatistician in the Department of Research Development and Clinical Investigation at The Children’s Mercy Hospital, Kansas City, MO, for assistance with statistical analysis. Disclosure Statement
No competing financial interests exist. References
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Address correspondence to: Shawn D. St. Peter, MD Pediatric Surgery Training Program Center for Prospective Clinical Trials Department of Surgery Children’s Mercy Hospital 2401 Gillham Road Kansas City, MO 64108 E-mail: [email protected]
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