Laparotomy for small-bowel obstruction: first choice or last resort for adhesiolysis? A laparoscopic approach for small-bowel obstruction reduces 30-day complications.

INTRODUCTION: Small-bowel obstruction (SBO) requiring adhesiolysis is a frequent and costly problem in the United States with limited evidence regarding the most effective and safest surgical management. This study examines whether patients treated with laparoscopy for SBO have better 30-day surgical outcomes than their counterparts undergoing open procedures.

METHODS: Patients with a diagnosis of adhesive SBO were selected from the ACS National Surgical Quality Improvement Program database from 2005 to 2010. Cases were classified as either laparoscopic or open adhesiolysis groups using Common Procedural Terminology codes. Chi square and Student's t test were used to compare patient and surgical characteristics with 30-day outcomes, including major complications, incisional complications, and mortality. Factors with p < 0.1 were included in the multivariable logistic regression for each outcome. A propensity score analysis for probability of being a laparoscopic case was used to address residual selection bias. A two-sided p value <0.05 was considered significant.

RESULTS: Of the 9,619 SBO included in the analysis, 14.9 % adhesiolysis procedures were performed laparoscopically. Patients undergoing laparoscopic procedures had shorter mean operative times (77.2 vs. 94.2 min, p < 0.0001) and decreased postoperative length of stay (4.7 vs. 9.9 days, p < 0.0001). After controlling for comorbidities and surgical factors, patients having laparoscopic adhesiolysis were less likely to develop major complications [odds ratio (OR) = 0.7, 95 % confidence interval (CI) 0.58-0.85, p < 0.0001] and incisional complications (OR = 0.22, 95 % CI 0.15-0.33, p < 0.0001). The 30-day mortality was 1.3 % in the laparoscopic group versus 4.7 % in the open group (OR = 0.55, 95 % CI 0.33-0.85, p = 0.024).

CONCLUSIONS: Laparoscopic adhesiolysis requires a specific skill set and may not be appropriate in all patients. Notwithstanding this, the laparoscopic approach demonstrates a benefit in 30-day morbidity and mortality even after controlling for preoperative patient characteristics. Given these findings in more than 9,000 patients and consistent rates of SBO requiring surgical intervention in the United States, increasing the use of laparoscopy could be a feasible way of to decrease costs and improving outcomes in this population.