This article has been cited by other articles in PMC. Abstract Objective To determine the incidence of small bowel obstruction SBO , to identify risk factors for its development, and to determine the most common sites of adhesions causing SBO in patients undergoing ileal pouch—anal anastomosis IPAA.
SBO was based on clinical, radiologic, and surgical findings. Early SBO was defined as a hospital stay greater than 10 or 14 days because of delayed bowel function, or need for reoperation or readmission for SBO within 30 days. Fifty-four patients had more than one SBO. The cumulative risk of SBO was 8. The need for surgery for SBO was 0.
A multivariate analysis showed that when only late SBOs were considered, performance of a diverting ileostomy and pouch reconstruction both led to a significantly higher risk of SBO. Thus, strategies that reduce the risk of adhesions are warranted in this group of patients to improve patient outcome and decrease healthcare costs. Postoperative adhesions form as a result of trauma to the peritoneum and the ensuing biochemical and cellular response that occurs in an attempt to repair the peritoneal surface.
Not only do they cause a considerable number of complications and deaths, but the healthcare costs required to deal with these issues are also considerable. Patients who undergo IPAA may be at particularly high risk for the development of SBO because of the combined abdominal and pelvic dissection, the need for multiple operations, and possibly a higher septic complication rate than that of less complex procedures. Further, changes in surgical technique have been made and the impact of these modifications has not been assessed.
Thus, the purposes of this study were to determine the magnitude of the risk of SBO after IPAA in a large cohort of patients followed up prospectively, to identify perioperative risk factors that increase the likelihood of postoperative SBO, to identify the frequency that surgical intervention will be required to treat SBO, and to determine the specific locations of adhesions that most frequently cause SBO.
Knowledge of the magnitude of the risk of SBO and of the particular sites of adhesions causing obstruction is necessary to evaluate the need for and optimization of strategies to prevent postoperative adhesions and SBO. All data regarding the surgery and follow-up were collected prospectively. In addition, a mailed questionnaire was sent to all patients in case additional admissions for SBO occurred at other hospitals.
Discharge summaries and operative reports from outside hospitals were obtained to verify information reported on the questionnaires. In all patients in whom SBO developed, charts were reviewed to determine the cause, management, and outcome.
For those who required laparotomy, the operative note was reviewed to determine the cause of obstruction. Data were collected for age, sex, preoperative diagnosis, whether colectomy was performed before or in conjunction with the pelvic pouch, use of a diverting ileostomy at the time of IPAA construction, anastomotic leakage, need for pouch reconstruction, and the occurrence of early or late SBO.
The diagnosis of SBO was based on the history, physical examination, and abdominal radiographic findings. Early SBO was defined as a postoperative hospital stay greater than 14 days after the IPAA, or 10 days after closure of ileostomy, because of delayed bowel function, when no other cause for delayed bowel function could be identified; or if a patient was readmitted or required reoperation for an obstruction occurring within 30 days of the surgery.
Late obstructions were those occurring more than 30 days after the pelvic pouch procedure or ileostomy closure. Data are presented as proportions or means plus or minus standard deviation. Differences were tested using chi-square or Student t test. Probability values for each variable in the model were calculated from the Wald chi-square test. Factors analyzed included prior subtotal colectomy, use of a diverting-loop ileostomy, occurrence of an anastomotic leak pouch or ileoanal , and the need for pouch reconstruction.
Pouch reconstruction was defined as combined abdominal and perineal approach with or without construction of a new pouch. A loop ileostomy was always performed in conjunction with the procedure. Their demographic and clinical details are shown in Table 1.
Most of the patients had ulcerative colitis, about half had their colectomy performed before the IPAA, and approximately two thirds had a diverting-loop ileostomy. Sixteen patients died during follow-up; no deaths were related to SBO. Ninety-six patients were lost to follow-up before , and data on these patients were included until the date of their last admission or follow-up visit.
The mean follow-up of the cohort was 8. Early SBO occurred in patients and accounted for Of these, only eight 5. The cause was adhesions in six and internal hernia or volvulus in two. A total of episodes of late SBO occurred in patients average 1.
Of these, 72 Adhesions were the cause of the SBO in 65 The risk of SBO was 8. The need for surgical intervention was 0. Open in a separate window Figure 1. Overall risk of small bowel obstruction and risk of need for surgical treatment of small bowel obstruction after IPAA. Forty-four of these occurred after closure of the ileostomy. Thus, 90 of Open in a separate window Figure 2. Risk of small bowel obstruction, excluding all early obstructions, after IPAA.