The impact of laparoscopy on emergency surgery for adhesional small bowel obstruction: prospective single centre cohort study

Abstract

Introduction Laparoscopic adhesiolysis is increasingly being used to treat adhesional small bowel obstruction (ASBO) as it has been associated with reduced postoperative length of stay (LOS) and faster recovery. However, concerns regarding limited working space, iatrogenic bowel injury and failure to relieve the obstruction have limited its uptake. This study reports our centre’s experience of adopting laparoscopy as the standard operative approach. Methods A single-centre prospective cohort study was performed incorporating local data from the National Emergency Laparotomy Audit Database; January 2015 to December 2019. All patients undergoing surgery for ASBO were included. Patient demographic, operative and inhospital outcomes data were compared between different surgical approaches. Linear regression analysis was performed for LOS. Results A total of 299 cases were identified. Overall, 76.3% of cases were started laparoscopically and 52.2% were completed successfully. Patients treated laparoscopically had lower Portsmouth – Physiological and Operative Severity Score for the enuMeration of Mortality and morbidity (P-POSSUM) predicted mortality (median 2.1 (interquartile range (IQR) 1.3–5.0) vs 5.7 (IQR 2.0–12.4), p=<0.001) and shorter postoperative LOS compared with open (median 4.2 days (IQR 2.5–8.2) vs 11.3 days (IQR 7.3–16.6), p=0.000). Inhospital mortality was lower in the laparoscopic group (2 vs 7 deaths, p=<0.001). In regression analysis, laparoscopic surgery was found to have the strongest association with postoperative LOS (β −8.51 (−13.87 to −3.16) p=0.002) compared with open surgery. Conclusions Laparoscopy is a safe and feasible approach for adhesiolysis in the majority of patients with ASBO. It is associated with reduced LOS with no impact on complications or mortality.

P‐POSSUM and the NELA Score Overpredict Mortality for Laparoscopic Emergency Bowel Surgery: An Analysis of the NELA Database

“…The LaCeS randomised feasibility study demonstrated that emergency laparoscopic colorectal surgery is safe but was only designed to inform a future trial [30]. Other registry-based studies investigating adhesiolysis, perforated peptic ulcer repairs and colorectal resections have reported improved outcomes with laparoscopy but are restricted by their observational nature [31][32][33]. It does make intuitive sense that the reduced post-operative pain and physiological burden conferred by minimally invasive surgery could translate to a survival advantage, in the high-risk patients This study is of course limited by its observational nature and the potential for selection bias that comes with it.…”

Frailty associated with poor outcomes after emergency laparotomy

“…Papers have shown patients undergoing laparoscopic vs open approach for adhesional SBO and perforated peptic ulcers have significantly better outcomes, with lower complication rates and mortality. 22,23 An analysis of the NELA database in 2022 showed riskadjusted mortality for emergency bowel surgery is lower for laparoscopy compared with open surgery, and that the P-POSSUM and NELA scores overpredict mortality for laparoscopic emergency abdominal operations. 24 Based on our results, as well as the current literature available, it is acceptable to conclude that laparoscopy is associated with improved perioperative outcome in the acute abdomen and it would be considered reasonable to attempt a minimally invasive approach, where clinically feasible, for emergency laparotomy patients.…”