Risk factors for post-colectomy adhesive small bowel obstruction

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1 Original article Acta Medica Academica 2016;45(2): DOI: /ama Risk factors for ost-colectomy adhesive small bowel obstruction Edin Husarić 1, Šefik Hasukić 1, Nešad Hotić 1, Amir Halilbašić 1, Senada Husarić 2, Ismar Hasukić 2 1 Dearment of Surgery, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina, 2 Dearment of Gastroenterology, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina Corresondence: ehusaric@hotmail.com Tel.: Fax.: Received: 14 January 2016 Acceted: 6 Aril 2016 Key words: Small bowel Obstruction Colorectal cancer. Objective. The urose of this study was to assess the risk factors for adhesive small bowel obstruction (SBO) following colectomy for colorectal cancer. Patients and methods. In this retrosective study we analyzed 284 atients who underwent surgery for colorectal cancer at the Deartment of Surgery University Clinical Center Tuzla in the eriod from 1 st January 2009 until 31 st December All atients underwent oen colectomy. The length of follow u was from 6 months to 6 years (median follow u 3 years and 6 months). The study included all atients who underwent surgery due to colon cancer. The study excluded atients with ostoerative small bowel obstruction after colon cancer surgery with different comorbidities. Results. In the analyzed samle of 284 atients, a small bowel obstruction occurred in 13.7% atients after surgery for colon cancer. The highest correlation of risk factors and the occurrence of ostoerative small bowel obstruction after colectomy for colorectal cancer in multivariate regression analysis was found to be for Tumor-Node-Metastasis 3 (or =3.680), and ostoerative comlications (or =30.683). Conclusions. Postoerative SBO have many causes, but in this study the highest risk factors were the Tumor-Node-Metastasis 3, and ostoerative comlications. Introduction Postoerative abdominal adhesions are associated with significant morbidity and mortality, lacing a substantial burden on healthcare systems worldwide. It is estimated that in 93%-100% of atients undergoing transabdominal surgery, the oeration results in ostoerative adhesions. These widesread adhesions differ from atient to atient, deending on the tye of surgery and ossible ostoerative comlications (1). Small bowel obstruction (SBO) is caused mainly by ostoerative adhesions (more than 75% of all cases) (2-6), and is a common ostoerative morbidity of colectomy for colorectal cancer (7). It leads to markedly lower atient quality of life, longer hosital stays and increased hositalization costs (8). Postoerative SBO is one of the major concerns in surgery, and the aearance of early ostoerative SBO symtoms is a serious issue because it affects the longterm rognosis of atients with colorectal cancer. Patients with clinical deterioration or with a CT scan evoking strangulated SBO need urgent surgery (9-10). Patients undergoing surgical management for SBO had a reduced risk of recurrence requiring hositalization, as well as SBO symtoms, as comared to those Coyright 2016 by the Academy of Sciences and Arts of Bosnia and Herzegovina. 121

2 Acta Medica Academica 2016;45: with conservative treatment (11). Acute SBO is still considered by many a relative contraindication for laaroscoy. However, laaroscoy is a feasible and effective treatment for acute SBO with accetable morbidity but laarotomy remains the standard aroach (12). This study was designed to evaluate the risk factors for ostoerative SBO after colectomy for colorectal cancer from our database, which contains 284 colectomy cases over 5 years. Patients and methods From January 1 st 2009 to December 31 st 2014 (6 years) at the Deartment of Surgery, University Clinical Centre, Tuzla, 284 atients underwent surgery for colorectal cancer (213 males, and 71 females). This retrosective study included all atients who underwent surgery for colorectal cancer. The study excluded atients under 40 years, atients with inflammatory bowel disease, abdominal abscess and associated abdominal cancer. The factors studied regarding adhesive ostoerative SBO were as follows: age, gender, American Society of Anesthesiologists (ASA) score, oeration time, elased time from the latest oeration, the resence of foreign material and intra-abdominal drain, tumor size and location, oerative rocedures, Tumor-Node Metastasis stage, the urgency of the surgery, alication of radiation and/or chemotheray, and ostoerative surgical and medical comlications. Data collected through a re-established questionnaire were included. Patients were divided in two grous. The SBO grou (39 atients), were the atients who underwent surgery one or more times due to ostoerative SMO. The non SMO grou (245 atients) were atients who underwent surgery due to colorectal cancer without clinical signs of ostoerative SMO. All atients underwent oen colectomy surgery. The duration of follow u ranged from 6 months to 6 years (median follow u: 3 years and 6 months). We treated atients with subocclusion interference conservatively, and we treated atients surgically who had clear clinical and radiological signs of intestinal obstruction. This is usually erformed by adhesiolysis, but in two cases we had to erform resection of the small intestine due to intestinal obstruction. Adhesions as the cause of ostoerative small bowel obstruction were detected by clinical and radiological examinations and intraoeratively. Statistical analysis Statistical analysis was done using the biomedical alication software MedCalc 12.3 statistical software. Categorical variables were analyzed by the χ2-test, the χ2-test contingency, and by comaring roortions and the odds ratio (OR) for each variable, with 95% confidence intervals (CI). Nonarametric correlation by Searman was used to test the significant relationshis between the variables. Utilizing univariate and multivariate logistic regression analysis, the level of imact of certain variables on the resence of a ostoerative small bowel obstruction caused by adhesion was tested. The difference between samles was considered significant if <0.05. Results In the analyzed samle of 284 atients, small bowel obstruction after surgery for colorectal cancer was found in 39 atients. The majority of atients in the SBO grou (56.4%), were over 60 years of age, and in the non SMO grou the majority of atients were years of age. There were similar ercentages of male and female atients in both study grous. An ASA score of III was most common in atients in the SMO grou, that is in 74.3%. The number of revious surgi- 122

3 Edin Husarić et al.: Post-colectomy small bowel obstruction Table 1 Preoerative characteristics of atients with colectomy for colorectal cancer Grous Characteristic SMO n (%) non SMO n (%) Age (year) (43) 208 (84) >60 22 (56) 34 (13) Gender Male 30 (76) 183 (74) Female 9 (19) 62 (25) ASA score II 10 (25) 143 (58) III 20 (51) 93 (38) IV 9 (23) 9 (3) No. of revious rocedures 1 32 (82) 215 (87) 2 5 (12) 30 (12) (5) 0 (0.0) SBO=Small bowel obstruction. cal rocedures was about the same for both grous of atients (Table 1). A median laarotomy was the only access in both grous of atients. Oeration time exceeded three hours in 69.2% atients in the SMO grou, and in 69% atients in the non SMO grou the oeration time was less than 3 hours. Intra-abdominal drains and foreign material were resent in all atients in both grous. The most common surgical rocedure in both grous was Miles oeration, followed by anterior rectal resection, Hartmann s rocedure and left hemicolectomy. TNM stage 3 colorectal tumors were found in 76.5% in the SMO grou, and in 53.9% in the non SMO grou. TNM stage 2 was significantly more reresented in atients in the non SMO grou (37.1%), in relation to the SMO grou (12.8%) (Table 2). On the basis of the analysis of the reoerative and intraoerative risk factors for ostoerative small bowel obstruction after colectomy due to colorectal cancer, it was determined that the following arameters significantly increased the likelihood of ostoerative small bowel obstruction caused by adhesions: ostoerative comlications (OR: 38.3), TNM 3 (OR: 7.94), oerating time (OR: 5.0), and age grou (OR: 0.126). Male gender, ASA score 3, emergency surgery, the alication of radiation and/or chemotheray and tumor location did not significantly increase the likelihood of the occurrence of ostoerative obstruction of the small bowel in atients after colectomy for colorectal cancer (Table 3). By multivariate regression analysis of reoerative and intraoerative risk factors for ostoerative small bowel obstruction after colectomy for colorectal cancer, we found that TNM 3 (OR-30.68) and ostoerative comlications (OR-3.68) are the best redictive risk factors for ostoerative small bowel obstruction (Table 4). 123

4 Acta Medica Academica 2016;45: Table 2 Intraoerative risk factors for small bowel obstruction after colectomy for colorectal cancer Grous Characteristic SMO n (%) non SMO n (%) Oerating time (min) < (30.8) 169 (69.0) > (69.2) 76 (31.0) The resence of foreign material 39 (100) 245 (100) NS The resence of an intra-abdominal drain 39 (100) 245 (100) NS Tumor location Colon 2 (5.1) 49 (20.0) Rectum 37 (94.9) 196 (80.0) Tumor size (cm) >5 19 (48.7) 115 (47.0) <5 20 (51.3) 130 (53.0) Oerative rocedure Miles oeration 15 (38.5) 99 (40.4) Anterior rectal resection 13 (33.3) 108 (44.0) Hartmann s rocedure 9 (23.1) 27 (11.0) Left hemicolectomy 2 (5.1) 11 (4.6) Tumor-Node Metastasis stage II 5 (12.8) 132 (37.1) III 30 (76.5) 91 (53.9) IV 4 (10.3) 22 (9.0) SBO=Small bowel obstruction. Table 3 The robability ratio of reoerative and intraoerative risk factors for ostoerative small bowel obstruction after colectomy for colorectal cancer in univariate analysis Risk factor Grous SMO n non SMO n OR 95% CI The age grou (years) Male sex ASA score Number of revious surgeries The urgency of the surgery Oerating time >3 h Tumor location Colon Rectum Tumor-Node Metastasis Alication of radiation and/or chemotheray Postoerative comlications SBO=Small bowel obstruction. 124

5 Edin Husarić et al.: Post-colectomy small bowel obstruction Table 4 Multivariate regression analysis of reoerative and intraoerative risk factors for ostoerative small bowel obstruction after colectomy for colorectal cancer Risk factor OR 95% CI Number of revious surgery Oerating time >3 h Tumor-Node Metastasis Postoerative comlications Discussion In our study, ostoerative small bowel obstruction caused by adhesions after colectomy for colorectal cancer was determined in 13.7% of atients, and in similar studies, the ercentage of ostoerative adhesions after surgery colon tumors ranged from 5.5% (13) to 9.5% (14-17). In our study, most atients (81.2%) with SMO after colectomy due to colorectal cancer were older than 60 years, as in Manilich s study (18). In the same study, gender was classified as a less significant risk factor for ostoerative adhesions. In our study, the roortion comarison also did not show gender as a risk factor for ostoerative adhesions of the small intestine after colectomy for colorectal cancer (Table 1). The results of similar studies are very contradictory, erhas because few studies have mentioned the role of gender in the develoment of comlications associated with intra-abdominal adhesions. Various factors, other than inflammatory resonses, may lay a role in early ostoerative SBO. In our study, the highest correlation of risk factors and the occurrence of ostoerative small bowel obstruction after colectomy for colorectal cancer was determined in relation to the TNM 3 (OR: 3.68), and ostoerative comlications (OR: ) (Table 4). Those factors are considered to contribute to the increased incidence of SBO. Postoerative comlications were determined as Grade II-Grade IIIb, using the Clavien-Dindo Classification of Surgical Comlications. Early ostoerative SBO reduces atient quality of life and also alters consecutive theraies. For instance, SBO leads to delay in introduction of chemotheray in atients with advanced colorectal cancer. For atients with rectal cancer, which is considered to be a risk factor for ostoerative SBO, attention must be aid to the choice of surgical rocedure, taking oerating time into account. Adhesions are the most common comlication in abdominal surgery, and reresent one of the greatest unsolved roblems of contemorary medicine. Many surgeons are still not aware of this roblem and its serious consequences (19). Limitation of study The limitations of this study are that it is a retrosective study, our samle does not include the grou of atients treated with reventive measures for ostoerative adhesions, and in our study there are no atients treated by laaroscoy-assisted colectomy. We could not measure the mean age or the corresonding disersion measures because we did not take the exact age of the atients, we had already divided the atients into age grous. Conclusion Postoerative small bowel obstruction after colectomy for colorectal cancer is more likely to occur in atients with TNM 3, and in atients who have ostoerative comlications. 125

6 Acta Medica Academica 2016;45: What is already known on this subject Small bowel obstruction is caused mainly by ostoerative adhesions (more than 75% of all cases) and is a common ostoerative morbidity of colectomy for colorectal cancer. It leads to markedly lower atient quality of life, longer hosital stays and increased hositalization costs. SBO accounts for as many as 12% to 16% of surgical admissions and more than 300,000 oerations annually in the United States. This reresents more than 2.3 billion dollars in health care exenditures. Peritoneal trauma and inflammation always lead to the formation of acquired adhesions and they may also occur following surgery and exosure to infection or intestinal content, ischemia, irritation or foreign materials. Acute small bowel obstruction is still considered a relative contraindication for laaroscoy. Laarotomy remains the standard aroach. What this study adds In the analyzed samle of 284 atients, small bowel obstruction after surgery for colorectal cancer was found in 39 atients. In our study, the highest correlation of risk factors and the occurrence of ostoerative small bowel obstruction after colectomy for colorectal cancer was determined in relation to TNM 3 (OR-3.68), and ostoerative comlications (OR-30.68). TNM 3 increases the likelihood of the occurrence of SMO by 4, while ostoerative comlications increase the likelihood of the occurrence of SMO 31 times. We believe that the results of our study should be viewed as an overview of the current status and a good basis for future research in alication of different methods to revent ostoerative adhesions and consequent obstruction of the small intestine. Authors contributions: Concetion and design: EH; Acquisition, analysis and interretation of data: AH, NH, ŠH and IH; Drafting the article: SH; Revising it critically for imortant intellectual content: EH, NH, AH and ŠH; Aroved final version of the manuscrit: EH. Conflict of interest: The authors declare that they have no conflict of interest. References 1. Monk J, Berman M, Montz J. Adhesions after extensive gynecologic surgery: clinical significance, etiology, and revention. Am J Obstet Gynecol. 1994;170(5 Pt 1): Lee SY, Park KJ, Ryoo SB, Oh HK, Choe EK, Heo SC. Early ostoerative small bowel obstruction is an indeendent risk factor for subsequent adhesive small bowel obstruction in atients undergoing oen colectomy. World J Surg. 2014;38(11): Oyasiji T, Helton SW. Survey of oinions on oerative management of adhesive small bowel obstruction: laaroscoy versus laarotomy in the state of Connecticut. Surg Endosc. 2011;25(8): Carmichael JC, Mills S. Reoeration for small bowel obstruction how critical is the timing? Clin Colon Rectal Surg. 2006;19(4): Miller G, Boman J, Shrier I, Gordon PH. Etiology of small bowel obstruction. Am J Surg. 2000;180(1): Richards WO, Williams LF Jr. Obstruction of the large and smll intestine. Surg Clin North Am. 1988;68(2): Pickleman J, Lee RM. The management of atients with susected early ostoerative small bowel obstruction. Ann Surg. 1989;210(2): Ellis H, Moran BJ, Thomson JN, Parker MC, Wilson MS, Menzies D, et al. Adhesion-related hosital readmissions after abdominal and elvic surgery: a retrosective cohort study. Lancet. 1999;353(9163): Balthazar EJ. George W. Holmes Lecture. CT of small-bowel obstruction. AJR Am J Roentgenol. 1994;162(2): Donckier V, Closset J, Van Gansbeke D, Zalcman M, Sy M, Houben JJ, et al. Contribution of comuted tomograhy to decision making in the management of adhesive small bowel obstruction. Br J Surg. 1998;85(8): Meier RP, de Saussure WO, Orci LA, Gutzwiller EM, Morel P, Ris F, et al. Clinical outcome in acute small bowel obstruction after surgical or conservative management. World J Surg. 2014;38(12): O Connor DB, Winter DC. The role of laaroscoy in the management of acute small-bowel obstruction: a review of over 2,000 cases. Surg Endosc. 2012;26(1): Park M, Lee Y, Cho B, Yun R, Lee S, Yun H, et al. Sodium hyaluronate-based bioresorbable membrane (sera-film) reduced early ostoerative intestinal obstruction after lower abdominal surgery for colorectal cancer: The reliminary reort. Int J Colorectal Dis. 2009;24(3): Barmaras G, Branco BC, Schnüriger B, Lam L, Inaba K, Demetriades D. The incidence and risk factors of ost-laarotomy adhesive small bowel obstruction. J Gastrointest Surg. 2010;14(10): Jeong WK, Lim SB, Choi HS, Jeong SY. Conservative management of adhesive small bowel obstructions in atients reviously oerated on for rimary colorectal cancer. J Gastrointest Surg. 2008;12: Edna TH, Bjerkeset T. Small bowel obstruction in atients reviously oerated on for colorectal cancer. Eur J Surg. 1998;164(8):

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