Laparoscopic vs Open Surgical Management of Adhesive Bowel Obstruction in Children: A Retrospective Study Comparing the Outcomes at a Tertiary Care Center for Pediatric Surgery

INTRODUCTION

Postoperative adhesions are an inevitable outcome of abdominal surgery in both adult and pediatric populations. Up to 90–95% of adult patients develop intra-abdominal adhesions following a laparotomy.^1,2 Incidence of postoperative adhesive bowel obstruction in children has been reported in the range of 1–5% although it varies according to primary pathology and type of operation performed.^3–6 Adhesive bowel obstruction can occur anytime from the early postoperative period after the index operation to many decades later. The management of adhesive bowel obstruction continues to evolve in both adult and pediatric patients. Open laparotomy is widely accepted as the standard approach for patients with adhesive bowel obstruction in whom conservative treatment fails. In recent times, laparoscopic approach has become a widely accepted treatment modality for adhesive small bowel obstruction in adults because of its advantages like less pain, fast recovery and reduced morbidity.⁷ Following its successful use in adult population, laparoscopic surgery has been increasingly used for the treatment of adhesive small bowel obstruction in children with good outcome.^8–10

Although advanced laparoscopic surgery is now commonly available in the majority of tertiary pediatric centers for the treatment of both urgent and elective cases still data on the laparoscopic treatment of bowel obstruction due to adhesions are scarce. The purpose of this study was to report our institutional experience comparing outcomes in patients with adhesive bowel obstruction treated by laparoscopic adhesiolysis and open laparotomy.

MATERIALS AND METHODS

This retrospective study was conducted in the Department of Pediatric Surgery at Ibn Sina Hospital of Kuwait. This is a Tertiary Care Center for Pediatric Surgery dealing with all routine and emergency cases in pediatric surgery from newborn period till 12 years of age. In this study, charts of all the patients who were admitted with diagnosis of adhesive bowel obstruction from January 2007 to September 2017 were reviewed and analyzed. During first half of study period (January 2007–August 2012). All the patients who needed surgical intervention were managed by open laparotomy. In the second half of the study period (September 2012–September 2017), laparoscopic management was adopted and laparoscopic adhesiolysis was performed for these cases by the consultant pediatric surgeon who is well-versed with advanced laparoscopy. Adhesiolysis was performed by blunt and sharp dissection using bipolar diathermy in open laparotomy cases while in laparoscopic cases mostly sharp dissection was performed using laparoscopic scissors or laparoscopic energy device for thick bands. Children who were successfully managed with conservative treatment without any surgical intervention were excluded from this study. Also, the cases where the laparoscopic procedure was converted into an open laparotomy were excluded from the study. Demographic data of all the patients with diagnosis of adhesive intestinal obstruction were obtained. Details of primary pathology and surgical procedure, time between previous surgery and penetration, the duration of adhesiolysis surgery, intraoperative findings and techniques, need for total parenteral nutrition, duration of hospital stay, and complications were recorded for both the open and laparoscopic groups. After discharge from the hospital, all the patients were followed up for a minimum period of 1 year. Statistical analysis was carried out comparing open and laparoscopic group and significance was devised using paired t-test. p %3C; 0.05 was considered statistically significant.

RESULTS

Seventytwo of 80 children with adhesive bowel obstruction needed surgical intervention. These children aged between 2 months and 132 months (mean = 53.88 ± 37.58). There were 43 men and 29 women. All of these 72 children had undergone at least one surgical procedure before they had presented with adhesive bowel obstruction. Previous surgical procedures done on these children are shown in Figure 1. They include colostomy or ileostomy closure after anorectal malformation (five), Hirschsprung’s disease (three cases), necrotizing enterocolitis (five cases), meconium ileus (three cases), appendicectomy (six cases), Meckel’s diverticulum (three cases), intussusception (four cases), Ladd’s procedure for malrotation (four cases), congenital diaphragmatic hernia (four cases), Nissen fundoplication (three cases), and six cases of intra-abdominal benign or malignant masses (ganglioneuroma 1, hepatoblastoma 1, Wilms tumor 1, mesenteric cyst 1, ovarian cyst 1, and one retroperitoneal cyst). In the open laparotomy group, mean age in months (51.83 ± 38.92) and weight in kilograms (19.58 ± 13.24) was not significantly different from laparoscopic group where mean age in months and weight in kilograms was 56.19 ± 35.79 and 17.50 ± 8.49, respectively. Mean duration since previous surgery in open laparotomy group was 20 months while in laparoscopic group it was 28 months. Average operative time was 138 minutes in laparotomy group and 122 minutes in laparoscopic group. Intraoperative findings were similar in both the groups. Transitional zone due to adhesive band or bands between proximal dilated and distal collapsed small intestine was observed in all patients in both open and laparoscopy group. In open laparotomy group, three patients (7.1%) had single obstructing band while multiple obstructing bands between the bowel loops and abdominal scar were seen in 39 (92.8%). Four patients (16.4%) in the laparoscopic group had a single thick obstructing band (Fig. 2) while in 22 (84.6%) of the laparoscopic group patients had multiple adhesive bands with scar and bowel loops (Fig. 3). During adhesiolysis in open surgery, serosal tears were reported in 20 patients and two of them needed intraoperative blood transfusion. None in laparoscopic group had this complication. In 35% (15) of laparoscopic cases, it was required to resect a segment of small intestine because it was of doubtful viability. No bowel resection and anastomosis was needed in laparoscopic group. In one case which was managed by open laparotomy left dome of diaphragm was injured while separating dense adhesions with diaphragmatic dome. It was repaired with interrupted nonabsorbable stiches. One case in each open and laparoscopic group developed postoperative pneumonia, which was managed chest physiotherapy and antibiotics. Wound complications like seroma and infection occurred in six cases in open laparotomy group. There were no wound-related complications in laparoscopic group. Thus, overall rate of intraoperative and postoperative complications was significantly higher in open laparotomy group (p = 0.000). Children in laparoscopic group were fed on postoperative day 2–4 (mean = 2.58) and no total parenteral nutrition was required for any patient in this group. While in open laparotomy group oral feeds were delayed until day 5–9 (mean = 5.9) and total parenteral nutrition was required in many (36) of these cases length of hospital stay in laparoscopic group (range = 3–8 days, mean = 5.5 days) was significantly shorter (p ≤ 0.05) than open laparotomy group (range = 6–27 days, mean = 11.3 days). Thus, over all postoperative recovery was better in the laparoscopic group (Table 1). After discharge, all patients were followed in outpatient department for any symptom or recurrence of adhesions for a minimum period of 12 months. Patients operated by open laparotomy follow-up for a period of 12–84 months and laparoscopic group patents were followed up from 12 months to 60 months after adhesiolysis. None of the patients in either group developed recurrence after surgery.

DISCUSSION

In this retrospective study, we reviewed all cases of adhesive bowel obstruction managed in our department from January 2007 to September 2017. Nonoperative management was started in all children after admission and it was successful in eight of our cases. Initial conservative management is adopted in adult and pediatric practice for management of adhesive bowel obstruction but the success of conservative treatment in children varies between different studies.^11–14 Certain pediatric surgical procedures like ileostomy closure or formation, Ladd’s procedure for malrotation, appendicectomy for perforated appendix and tumor surgery are more prone to adhesion formation.^6,15–17 In our series, ileostomy or colostomy closure after anorectal malformation, Hirschsprung’s disease and necrotizing enterocolitis, appendicectomy for perforated appendix, Meckel’s diverticulectomy, open surgery for intussusception, various tumors and cyst excisions, and Nissen fundoplication were among frequent surgical procedures, which led to the adhesive intestinal obstruction (Fig. 1). Historically, laparotomy with lysis of adhesions has been the conventional management for adhesive small bowel obstruction in children.^18,19 In the adult literature, there have been multiple retrospective publications demonstrating the utility of laparoscopy in the treatment of adhesive small bowel obstruction. They show earlier recovery of bowel function and reduced length of stay and decreased incisional complications. In addition, laparoscopy has the theoretical advantage of reducing additional adhesion formation and thus recurrence.^20,21 There are no randomized, controlled trials in the literature that examine the role of laparoscopy in treating adhesions in children and there are actually few publications that examine the role of laparoscopy in the management of adhesions in children. However, recent review articles and case series advocate laparoscopic management of adhesive bowel obstruction in children.^8–10 At our institute, we have adopted laparoscopic adhesiolysis since 2012. Our conversion rate of 10.3% is lower than 23–30% conversion rate reported by other investigators.^8,22–24 All our laparoscopic adhesiolysis surgeries are performed by an experienced pediatric surgeon who is well versed with advanced laparoscopic skills in children. We always try to keep laparoscopic adhesiolysis as first case in our operation theater in morning hours as far as possible so that operating surgeon can work at ease in comfortable environment. First, trocar is placed by open technique. We lyse adhesion with sharp dissection and energy device was used cautiously to divide thick vascular bands away from the bowel wall. We always run the bowel from duodeno-jejunal junction till ileo-caecal area to make sure we lyse all adhesions and to inspect the bowel for any iatrogenic injury. While comparing intraoperative and postoperative complications in our open laparotomy group and laparoscopic group we observed that serosal tear happened in 20 out of 42 open surgery cases while no such injuries occurred in laparoscopic group. This could be because of the fact that in laparoscopic group adhesions were divided more precisely and always under magnified vision. Serosal tears and subsequent bleeding could be one of the reasons for prolonged ileus in open surgery cases. In 15 (35%) out of 42 cases managed by open laparotomy resection anastomosis of the intestine was done which will definitely delay recovery of intestinal function. Laparoscopic incisions have a lower incidence of wound related complications and this was evident in our study as well where six cases had seroma or wound infection in laparotomy group. There was no wound related complication in laparoscopic group which could be one reason for shorter hospital stay in this group of patients. Lee et al. studied a large, pediatric administrative database to examine the management of adhesive small bowel obstruction and found that laparoscopic treatment was associated with shorter median length of stay (6 vs 8 days), lower postoperative complication rates (5.6% vs 10.4%), and lower mean total hospital costs.²⁵ Although our study has limitations like retrospective nature of the study and small sample size but our results are encouraging to continue laparoscopic management of adhesive bowel obstruction. Results from our study indicate that time to start oral feeds (2.5 vs 5.9 days), length of hospital stay in days (5.5 vs 11.3), and serosal tear rate (0 vs 20), need for resection anastomosis (0 vs 15) were significantly lower (p ≤ 0.05) in laparoscopic group in comparison to open laparotomy group. Thus, we conclude that laparoscopic management of adhesive bowel obstruction in children can be safely carried out by an experienced laparoscopic pediatric surgeon and it is associated with better outcome in form of early starting of oral feeds, shorter length of hospital stay, and less complications in comparison to open laparotomy although more randomized control studies are required to support our observations.

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