Background
Methods
Critical appraisal
Level of evidence | Interventional research | Studies concerning diagnostic accuracy | Studies on complications or side effects, etiology, prognosis |
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A1 | Systematic review/meta-analysis of at least 2 independently performed level A2 studies | ||
A2 | Double-blind controlled randomized comparative clinical trial of good study quality with an adequate number of study participants | Diagnostic test compared to reference test; criteria and outcomes defined in advance; assessment of test results by independent observers; independent interpretation of test results; adequate number of consecutive patients enrolled; all patients subjected to both tests | Prospective cohort with sufficient amount of study participants and follow-up, adequately controlled for confounders; selection in follow-up has been successfully excluded |
B | Comparative studies, but without all the features mentioned for level A2 (including patient-control studies, cohort studies) | Diagnostic test compared to reference test, but without all the features mentioned in A2 | Prospective cohort study, but without all the features mentioned for level A2 or retrospective cohort study or case-control study |
C | Noncomparative studies | ||
D | Expert opinion |
Level | Conclusion based on |
A | Systematic review (A1) or at least 2 independent studies with evidence level A2 (“there is evidence that…”) |
B | One study with evidence level A2 or at least 2 independent studies with evidence level B (“it is likely that…”) |
C | One study with evidence level B or level C (“there are indications that…”) |
D | Expert opinion (“the working group recommends…”) |
Level | Recommendation |
I | Strong recommendation |
II | Weak recommendation (suggestion) |
Definitions
Peritoneal adhesions
Adhesive small bowel obstruction
Adhesiolysis
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Seromuscular injury: injury to the visceral peritoneum (serosa) and smooth muscle layer of the bowel. The lumen of the bowel or leakage of bowel contents is not visible.
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Enterotomy: a full thickness injury to the bowel. The mucous layer or lumen of the bowel is visible, or there may be leakage of intestinal contents.
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Delayed diagnosed perforation: bowel injuries made during surgery that initially go unrecognized. Typically, the abdomen is closed at the end of procedure with the bowel injury still in place, causing patients to deteriorate during the postoperative course.
Results
Epidemiology
Classification of adhesions
Grade 0 | No adhesions or insignificant adhesions |
Grade 1 | Adhesions that are filmy and easy to separate by blunt dissection |
Grade 2 | Adhesions where blunt dissection is possible but some sharp dissection necessary, beginning vascularization |
Grade 3 | Lysis of adhesions possible by sharp dissection only, clear vascularization |
Grade 4 | Lysis of adhesions possible by sharp dissection only, organs strongly attached with severe adhesions, damage of organs hardly preventable |
Prevention
Surgical technique
Adhesion barriers
Barrier | Marketed as | Comments |
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Hyaluronate carboxymethylcellulose | Seprafilm® | Solid barrier most suitable for open surgery although laparoscopic placement has been described Studies in both general surgery and gynecological procedures Reduces adhesion formation, as well as the risk for reoperations for adhesive small bowel obstruction (relative risk 0.49, 95% CI 0.28–0.88) |
Oxidized regenerated cellulose | Interceed® | Solid barrier most suitable for open surgery Only studied in gynecological procedures Reduces incidence of adhesion formation relative risk 0.51, 95% CI 0.31–0.86 No studies available on subsequent risk of ASBO This workgroup does not recommend the use of this barrier to prevent ASBO in general surgery |
Icodextrin | Adept® | Liquid barrier, easy to apply in both open and laparoscopic surgery Good safety record in both general surgery and gynecological surgery Reduces recurrence of ASBO following surgery for ASBO in one trial (relative risk 0.20, 95% CI 0.04–0.88) |
Polyethylene glycol | Sprayshield®/Spraygel® | Gel barrier, easy to apply in both open and laparoscopic surgery Reduces adhesion score in both general surgery and gynecological trials Relative few and small studies, impact on long-term adhesion-related complications not described |
Secondary prevention
Approach to the patient with ASBO
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Differentiating between adhesive small bowel obstruction and other causes of bowel obstruction
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Assessing the need for urgent surgical exploration
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Identifying and preventing complications from bowel obstruction
History taking and physical examination
Laboratory tests
Imaging studies
Plain X-rays
Water-soluble contrast studies
CT scans
Ultrasound and MRI
Diagnosis: summary
Level A | Adhesive small bowel obstruction is a leading cause of morbidity, deaths, and healthcare expenditures in emergency surgery. A2 Scott 2016; NELA project team 2016 |
Level B | Adhesive small bowel obstruction causes high morbidity, with average hospital stay of 8 days and 3% in-hospital mortality per episode. Recurrence of adhesive small bowel obstruction is high. Risk for adhesive small bowel obstruction may be somewhat lower after laparoscopic compared to open colorectal surgery, but that results could not be confirmed in randomized trials. A2 ten Broek 2013; Yamada 2016; B Krielen 2016; Foster 2006 |
Level IB | Laparoscopic surgery reduces adhesion formation and might reduce subsequent incidence of ASBO. B Lundorff 1992; ten Broek 2013; Yamada 2016 |
Level IA | Hyaluronate carboxymethylcellulose reduces adhesion formation and the risk of subsequent reoperations of adhesive SBO. The use of this barrier seems cost-effective in open colorectal surgery. A1 ten Broek 2014; A2 Fazio 2006; Park 2009; Kusunoki 205 |
Level IIC | In the absence of signs that require emergent surgical exploration (i.e., peritonitis, strangulation, or bowel ischemia), non-operative management is the treatment strategy of choice. C Fevang 2002; Fevang 2004; Ten Broek 2013; Jeppesen 2016 |
Level IIB | A trial of non-operative management can be continued safely for 72 h. B Keenan 2014; Sakakibara 2007 |
Level IID | Initial evaluation should be complemented with assessment of nutritional status and laboratory tests evaluating at least blood count, lactate, electrolytes, and BUN/Creat
Expert opinion
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Level IIC | Plain X-rays have only limited value in the work-up of patients with small bowel obstruction and are not recommended.
B Maglinte 1996
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Level IB | Optimal diagnostic work-up should include CT scan in the assessment and water soluble oral contrast. In the absence of the need to perform immediate surgery, a follow-up abdominal X-ray should be made after 24 h. If the contrast has reach the colon, this is indicative for resolution of the bowel obstruction. A2 Ceresoli 2016; Branco 2010; Abbas 2005; B Goussous 2013; Zielinski 2011; Zielinski 2010; Daneshmat 1999; Makita 1999; Zalcman 2000 |
Level IIC | Long trilumen naso-intestinal tubes are more efficacious than naso-gastric tubes in non-operative management, but require endoscopic placement.
A2 Chen2012
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Level IIC | Laparoscopic adhesiolyis might reduce morbidity in selected cases of ASBO that require surgery. Results of a randomized trial are awaited. B Sajid 2016; Farinella 2009; Sallinen 2014 |
Level IIB | Adhesion barriers reduce the risk of recurrence for ASBO following operative treatment.
A2 Catena 2012
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Level IIC | Younger patients, and pediatric patients in particular, have higher lifetime risk of developing adhesion-related complications and might therefore benefit most from adhesion prevention. A1 ten Broek 2013; A2 Strik 2016; B Fredriksson 2016 |
Level C | More research is needed to the impact of comorbidities in elderly patients on optimal management of adhesive small bowel obstruction. Patients with diabetes might require more early operative intervention.
B Karamanos 2016
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