Laparoscopy Reduces Risk for Small Bowel Obstruction

By Jennifer Garcia
Medscape Medical News

April 16, 2012 — Patients who undergo an open abdominal surgery are at least 4 times more likely to develop small bowel obstruction (SBO) compared with patients who undergo laparoscopic surgery for most abdominal procedures. These are the findings of a population-based retrospective register study published in the April issue of the Archives of Surgery.

Using data from 108,141 patients in the Inpatient Register held by the Swedish National Board of Health and Welfare, the researchers found that the incidence of SBO after surgery ranged from 0.4% to 13.9%, depending on the type of surgery. A multivariate analysis revealed that age, previous abdominal surgery, comorbidity, and surgical technique were risk factors for SBO. Patients who underwent laparoscopic surgeries had the lowest SBO risk among most surgical procedures.

"Small-bowel obstruction is a substantial health care challenge, and correctly identified risk factors can provide improved tools to reduce the risk of SBO after an abdominal surgical procedure," write Eva Angenete, MD, PhD, from the Scandinavian Surgical Outcomes Research Group, Gothenburg, Sweden, and colleagues. "This study shows that, beyond important factors such as age, previous abdominal surgery, and comorbidity, the surgical technique is the most important factor related to SBO," note the authors.

The researchers analyzed surgical records for patients who underwent cholecystectomy, hysterectomy, salpingo-oophorectomy, bowel resection, anterior resection, abdominoperineal resection, rectopexy, appendectomy, and bariatric surgery between January 1, 2002, through December 31, 2004. Age, sex, comorbid conditions, and surgical technique (open vs laparoscopic) were evaluated. Patients with a history of surgery for SBO were excluded from the study.

The main outcome assessed was the development of SBO within 5 years after the index surgery.

The researchers found that bariatric surgery was the only procedure in which the risk for SBO was higher in the laparoscopy group, although the difference was not statistically significant (odds ratio [OR], 0.7 [95% confidence interval (CI), 0.4 - 1.2]; P > .05). Salpingo-oophorectomy was the procedure with the highest risk for SBO after open abdominal surgery (OR, 7.6 [95% CI, 4.4 - 13.1]; P < .001).

Discussing some of the study limitations, the authors note that because the patients' individual medical records were not reviewed, there is a risk that patients with other types of bowel obstruction were included. However, they considered the risk to be equally distributed in all groups. In addition, possible confounding by indication may have occurred because the analyses included comorbidity related to the incidence of SBO in cholecystectomy, bowel resection, and appendectomy but was also related to whether open or laparoscopic surgery was performed. The authors attempted to address this in their categorization of the procedures but note that this will require further study.

"The fact that this study is population based and that the group size is sufficiently large indicate that our results represent an actual difference due to surgical technique," write Dr. Angenete and colleagues. "The safety and the short-term benefits of laparoscopy are already known, and it is possible that laparoscopy should be regarded as the preferred technique in an attempt to further reduce the complications of surgery," conclude the authors.

In an invited commentary, Luke M. Funk, MD, MPH, and Stanley W. Ashley, MD, from the Department of General Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, write: "This finding adds to the body of literature suggesting that laparoscopy decreases the incidence of adhesion related readmissions and has important implications for both the quality and cost of surgical care."

"For payers and health care policy leaders, it suggests that substantial cost savings could be achieved if open surgery were replaced with laparoscopic surgery more often. Given that inpatient expenditures on adhesiolysis-related complications exceed $2 billion annually in the United States, these savings could be substantial," add Dr. Funk and Dr. Ashley.

The study was funded by grants from the Swedish Cancer Foundation, the Swedish Medical Association, the Gothenburg Medical Association, the Assar Gabrielsson Foundation, the Magn Berwall's Foundation, and the Swedish Research Council. The authors and editorialists have disclosed no relevant financial relationships.

Arch Surg. 2012;147:359-365.