| Abstract|| |
Background: Adhesive small bowel obstruction (ASBO) is a feared complication after abdominal operations in both children and adults. The optimal management of ASBO in the pediatric population is debated. The aim of the present study was to examine the safety and effectiveness of non-operative management in ASBO. Patients and Methods: A retrospective review of 33 patients who were admitted for ASBO over a 5-year period was carried out. Follow-up data were available for 29 patients. Demographic, clinical, and operative details and outcomes were collected for these patients. Data analysis was done with SPSS version 15.0. P ≤ 0.05 was regarded as significant. Results: Out of 618 abdominal surgeries within the 5-year period, 34 admissions were recorded from 29 patients at the follow-up period of 1-28 months. There were 19 boys (65.5%). The median age of patients was 4.5 years. Typhoid intestinal perforation (n = 7), intussusception (n = 6), intestinal malrotation (n = 5), and appendicitis (n = 4) were the major indications for a prior abdominal surgery leading to ASBO. Twenty-five patients (73.5%) developed SBO due to adhesions within the first year of the primary procedure. Of the 34 patients admitted with ASBO, 18 (53%) underwent operative intervention and 16 (47%) were successfully managed non-operatively. There were no differences in sex (P = 0.24), initial procedure (P = 0.12), age, duration of symptoms, and time to re-admission between the patients who responded to non-operative management and those who underwent operative intervention. However, the length of hospital stay was significantly shorter in the non-operative group (P < 0.0001). Five (14.7%) patients had small bowel resection. A 43-day-old child who initially underwent Ladd's procedure died within 15 h of re-admission while being prepared for surgery, accounting for the only mortality (3.4%). Conclusion: Non-operative management is still a safe and preferred approach in selected patients with ASBO. However, 53% eventually required surgery.
Keywords: Adhesive small bowel obstruction, children, non-operative management
|How to cite this article:|
Nasir AA, Abdur-Rahman LO, Bamigbola KT, Oyinloye AO, Abdulraheem NT, Adeniran JO. Is non-operative management still justified in the treatment of adhesive small bowel obstruction in children?. Afr J Paediatr Surg 2013;10:259-64
|How to cite this URL:|
Nasir AA, Abdur-Rahman LO, Bamigbola KT, Oyinloye AO, Abdulraheem NT, Adeniran JO. Is non-operative management still justified in the treatment of adhesive small bowel obstruction in children?. Afr J Paediatr Surg [serial online] 2013 [cited 2019 Dec 6];10:259-64. Available from: http://www.afrjpaedsurg.org/text.asp?2013/10/3/259/120908
This paper was presented at the 11th Annual scientific
conference of Association of Paediatric Surgeon of
Nigeria, Ibadan in September 2012
| Introduction|| |
Postoperative adhesion formation is a complex interaction of cellular components involved in inflammation and tissue repair. The current hypothesis is that manipulation of the serosal surfaces and exposure to non-organic materials disrupts the mesothelium, resulting in a local inflammatory response, with an influx of fibroblasts which facilitates the creation of fibrin-based adhesions. ,
Postoperative adhesions are almost inevitable after most abdominal surgeries. The severity and extent of adhesions are variable and continue to impose significant morbidity on children after abdominal surgery. The major consequence to the child requiring re-admission for adhesive small bowel obstruction (ASBO) is the high risk of relaparotomy and its attendant morbidities and complications. ,
The exact incidence of adhesive intestinal obstruction in children is not known, but has been reported to vary from 1.1% to 8.3%, ,, most occurring within the first year after surgery. ,, Because of their age, children have a longer lifetime risk for development of adhesion-related complications when compared with adults.
The reported success of non-operative management varies widely from 0% to 63%. ,,, The relatively high rate of operation may partially reflect unease with protracted trials of conservative management among pediatric surgeons.
Many authors recommended that there was no role for conservative management in infancy and childhood. , Such assertions have been refuted with the reporting of successful non-operative management. However, the optimal management of ASBO in the pediatric population is continuously debated in literature and served as an impetus for the current study.
The aim of the present study was to examine the safety and effectiveness of non-operative management in ASBO.
| Patients and Methods|| |
All infants and children who underwent a laparotomy between January 2007 and December 2011 at University of Ilorin Teaching Hospital were retrospectively reviewed. Medical records and operative records of each patient were reviewed for age at diagnosis of adhesive intestinal obstruction, sex, age at initial operation, time interval from the initial operation to the development of adhesive intestinal obstruction, type of initial operation, duration of symptoms, type of treatment, and outcome. The diagnosis of adhesive intestinal obstruction was based on a history of previous abdominal surgery, presentation with abdominal pain, vomiting, and abdominal distension, failure to pass flatus or stool, and the presence of dilated bowel loops with multiple air/fluid levels on supine and erect abdominal radiographs. Initial treatment in all patients consisted of resuscitation with intravenous fluids and correction of electrolyte imbalances, nil by mouth, nasogastric decompression, vital sign, and 12-hourly abdominal girth monitoring.
Patients who did not respond to the conservative treatment were explored. The clinical impression of the attending surgeon, presence of localized abdominal tenderness, feculent or increasing nasogastric output, and/or evidence of complete intestinal obstruction that is persisting or free peritoneal air were considered the indications for surgery. In cases of spontaneous resolution, the time of first oral intake in the course of tolerating full diet was considered the point of resolution.
Data were analyzed using SPSS version 15.0 (SPSS Corp., Chicago IL, USA). Variables were compared using Chi-square, Fisher's exact test, or Mann-Whitney test, as appropriate. P ≤ 0.05 was regarded as significant. Data were expressed as median (interquartile range).
| Results|| |
Out of 618 abdominal surgeries within the 5-year period, 34 admissions were recorded from 29 patients at the follow-up period of 1-28 months, giving an incidence of 4.7%. There were 19 boys (65.5%). The median age of patients was 4.5 years (3 months-15 years). Typhoid intestinal perforation (n = 7), intussusception (n = 6), intestinal malrotation (n = 5), and appendicitis (n = 4) were the major indications for a prior abdominal surgery leading to ASBO [Table 1]. The rate of small bowel obstruction from adhesion was higher with intestinal malrotation (42%; 5 out of 12) and intussusceptions (10.7%; 6 out of 56) [Table 1].
Twenty patients (58.8%) developed obstruction within 3 months, and 25 patients (73.5%) developed ASBO due to adhesions within the first year of the primary procedure. Of 34 patients admitted with ASBO, 18 (53%) underwent operative intervention and 16 (47%) were successfully managed non-operatively. Among the patients managed non-operatively, resolution of symptoms was observed within 48 h in 6 (37.5%) patients, in 3-5 days in 4 (25%) patients, after 5 days in 2 (12.5%) patients, and there was no documentation in 4 (25%) patients. There were no differences in sex (P = 0.24), initial procedure (P = 0.12), age (1825 vs. 1095 days, P = 0.96), duration of symptoms (1 vs. 2 days, P = 0.32), and time to re-admission (275 vs. 95 days, P = 0.49) between the patients who responded to non-operative management and those who underwent operative intervention [Table 2]. However, the length of hospital stay was significantly shorter in the non-operative group (5 vs. 13 days, P < 0.0001).
|Table 2: Comparison of clinical parameters (non-operative vs. operative)|
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The type of adhesions found intraoperatively varied between single band in 8 (23.5%) patients, multiple adhesions in 8 (23.5%) patients, and dense adhesions in 1 (39%) patient. Five (14.7%) patients had small bowel resection (SBR), of which four were due to bowel ischemia. There was no significant difference in age (7 vs. 2.5 years, P = 0.26), pulse on admission (110 vs. 128, P = 0.20 beats/min), temperature (37.0 vs. 37.4°C, P = 0.08), WBC count on admission (6.5 vs. 6.6, P = 1), and length of hospital stay (15.5 vs. 13.0 days, P = 0.95) between those with strangulation of bowel at operation and those with viable bowel [Table 3]. The duration of symptoms was shorter in cases of strangulation (1 vs. 3 days), but the difference was not statistically significant [Table 3]. Complication following re-exploration for ASBO included surgical site infections (n = 4), wound dehiscence (n = 2), prolonged ileus (n = 1), anemia (n = 1), and pneumonia (n = 1). A 43-day-old child who initially underwent Ladd's procedure died within 15 h of re-admission while being prepared for surgery, accounting for the only mortality (3.4%).
|Table 3: Comparison of clinical parameters (compromised vs. viable bowel)|
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| Discussion|| |
The incidence of adhesive intestinal obstruction in this study was 4.7%, which is similar to 1.1-8.3% reported in pediatric population. ,, Seventy-four percent of ASBO developed within the first years after surgery, consistent with previous reports. ,,
Identifying high-risk procedures for adhesion-related morbidity is of great interest to surgeons as an aid to developing a preventive strategy. The procedure associated with increased risk of ASBO varies in published series. ,,, A 5-year population-based study of 1581 children in Scotland undergoing abdominal surgery reported ileostomy formation and closure to carry the greatest apparent risk for re-admission because of adhesions (25%).  Some series, however, noted appendectomy as the most common procedure in patients re-admitted for ASBO.  This may be a direct consequence of acute appendicitis being one of the most common indications for surgery in children  and may not be necessarily associated with higher rate of adhesion formation. Despite the high incidence of appendectomy in Scotland, Grant et al. reported a low rate of 0.3% adhesion-related re-admission in children who had appendectomy.  Also, in a large population-based study from Sweden, Andersson reported an overall incidence of ASBO after uncomplicated appendicectomy to be 0.97% over 10 years.  In our series, the rate of ASBO following appendicectomy was 4.3%.
In this study, the commonest procedure in children with ASBO was surgery for typhoid intestinal perforation; nonetheless, the rate of adhesion-related re-admission was higher following surgery for intestinal malrotation (42%) and intussusception (10.7%).
Previous studies have reported a high incidence of morbidity associated with operative intervention for malrotation, with a small bowel obstruction incidence ranging from 5.6% to 24%. ,,, The steps of the Ladd's procedure require much handling and manipulation of the bowel with likely damage to the serosal lining of the intestine, which has been implicated in the pathogenesis of adhesion formation.  The adhesions resulting from Ladd's procedure are thought to be advantageous because they are felt to stabilize the bowel in its new position. However, this can be a major cause of morbidity and mortality. ,
ASBO continues to impose significant morbidity on children after abdominal surgery. The major consequence to the child is repeated re-admission and reoperation and its attendant morbidities and complications.  The debate on the optimal management of ASBO in the pediatric population is ongoing.
In a series of 16 children with ASBO studied over an 8-year period, Osifo et al. in Benin, Nigeria reported 100% of children requiring operative intervention.  Al-Salem et al. also reported that 40 (91%) of 44 children required laparotomy in their series.  In both publications, the authors advocated surgical adhesiolysis in children with ASBO.
However, in a large review of 2089 children in the USA admitted with ASBO, operative intervention was performed in 1786 (85.5%) children. The authors recommended that operative intervention should be considered in patients who do not exhibit signs of improvement by the second day after admission to avoid potentially increasing the risk for bowel loss.  In contrast to the above findings, Feigin reported 63% spontaneous resolution of symptoms in 128 children with 174 episodes of postoperative small bowel obstruction; 85% resolved within 48 h of admission.  Vijay et al. also reported a 48.6% response to conservative treatment in a series of 69 children with 74 episodes of adhesive intestinal obstruction. In the present study, spontaneous resolution of symptoms was observed in 47%. This is consistent with previous published reports. ,, Previous studies have reported that infants are significantly more likely to require operative intervention. , Our study suggests no significant difference in age, sex, duration of symptoms, and time to re-admission between the patients who responded to non-operative management and those who underwent surgical intervention. There were significant increases in length of hospital stay and postoperative morbidity of surgical site infection, wound dehiscence, ileus, and pneumonia among the operated cases.
The relatively high rate of operation may reflect unease with protracted trials of non-operative management among pediatric surgeons. The rationale for early operative intervention for ASBO is to avoid unnecessary bowel resection due to ischemia. Currently, however, there are limited data showing an association between surgical delay and bowel loss. Some studies have even reported no increased risk for complications with delayed surgery. ,,
Feigin et al., however, reported a 31% rate of SBR rate among patients requiring operation.  All cases of SBR occurred in patients operated after 16 h of admission. They proposed 48 h as the point when a decision about surgery should be made, owing to the increasing risk of strangulation and decreasing chance of non-operative resolution. The incidence of small resection due to bowel ischemia in this study was 25% of operated cases, with no significant difference in age, duration of symptoms, time to operation, and length of hospital stay between those with bowel ischemia and those without. The SBR compares with the SBR rate of 16-33% reported by others. ,, However, low SBR rates of 0-9.4% have been documented. , Studies have shown that surgery for postoperative small bowel obstruction is associated with a longer hospital stay, ,, in agreement with the present findings.
Other modalities of managing ASBO, such as use of oral gastrography, are evolving. , Abdelkader et al. successfully used oral administration of gastrografin to complete the conservative management in 8 of 12 (66.6%) patients, thus avoiding surgery and subsequently reducing the hospital stay.  Laparoscopic adhesiolysis for ASBO has also come to the forefront and obviously offers some advantages over laparotomy.  However, long-term results are being awaited.
Pain following abdominal surgery has always been a difficult issue for the surgeons to contend with. Re-admission due to ASBO may just be the "tip of the iceberg" for these patients.  Published literatures have shown the great impact of adhesive ASBO on morbidity and mortality in pediatric population. , Evidence on optimal management of ASBO currently lacks strong support in the pediatric literature. In addition, the greater incidence of relaparotomy in children compared with adults underscores the importance to pediatric surgeons of identifying new methodologies that could prevent the occurrence of postoperative adhesions in children, rather than focusing on its treatment.
Prevention of postoperative adhesions must, therefore, be carried out using a multimodal approach, including a meticulous surgical technique, the use of unpowdered gloves, permanent control of intraoperative temperature and humidity of the bowel, and intra-abdominal rinsing. 
Some of the documented preventive strategies include use of fibrin sealant, intestinal stenting, and hyaluronate-based barrier membrane. The fibrin plication of the small bowel has been proved to avoid recurrent subileus or ileus.  Volkadia et al. reported no recurrence in six children who had intestinal stenting with 10-Fr Ryle's tube at follow-up period of 2-14 years. 
Recently, Inoue et al. also reported a significant reduction in incidence and severity of postoperative adhesions and mean relaparotomy operation time with the use of hyaluronate-based barrier membrane (Seprafilm) in a series of 122 neonates, infants, and children.  More basic research into the mechanisms of adhesiogenesis may be needed to identify new opportunities for therapeutic intervention. Millar also suggested abdominal shaking in early postoperative period as an antidote for postoperative adhesion. 
The limitations of the study design include our inability to identify those patients managed without surgery, who either never presented to our center or were incorrectly diagnosed during their admission. Details about the patients' prehospital course are also lacking. Delay in intervention may be difficult to define because duration of non-operative management begins with the time of admission rather than the time of symptom onset. Furthermore, it is possible that some patients with ASBO who presented initially with varied abdominal symptoms may have been given an alternative primary diagnosis.
| Conclusion|| |
In the absence of any signs of strangulation or radiologic features of complete intestinal obstruction, patients with an adhesive ASBO can be managed safely with non-operative treatment. However, in the absence of any clinical or radiological evidence of resolution, the benefit of avoiding an operation must be carefully weighed against the potentially increased risk of bowel resection with further delay on a case-by-case basis. Further prospective multicenter study is needed to establish optimal management for ASBO in pediatric population.
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Abdulrasheed A Nasir
Division of Paediatric Surgery, Department of Surgery, University of Ilorin Teaching Hospital, PMB 1459, Ilorin
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]