Introduction: In western countries, around 20% of surgical emergencies are related to acute small bowel obstruction. Over 60% of all cases of small bowel blockage are primarily caused by post-operative adhesions. Aims: Monitoring and contrasting the care style with the symptoms in the same group of individuals who have had prior surgery. Materials & Methods: This Cross Sectional (Observational) study was conducted on 60 patients, at Bapuji Hospital and Chigateri General Hospital, from the department of General Surgery, JJM Medical College, Davangere. The study period was from January 2021 to August 2022. Result: The abdominal pain is the most common symptom present in 96.6% cases (58 patients). 66.6% cases (40 patients) had Vomiting. 58.3% (35 patients) and 66.6% of cases (40 patients) had abdominal distension and Constipation or obstipation respectively. Fever was there in 36.66% cases (22 patients), but it is significant if this symptom is present the management is surgical approach. Conclusion: The most frequent reason for small bowel blockage is adhesion. The most typical signs of adhesive small intestinal obstruction are vomiting and abdominal discomfort. However, surgical intervention decision-making is less sensitive.
In western countries, around 20% of surgical emergencies are related to acute small bowel obstruction. Over 60% of all cases of small bowel blockage are primarily caused by post-operative adhesions. [1] Adhesions will result from any abdominal procedure that causes a peritoneal rupture. A number of surgical procedures, including cholecystectomy, hysterectomy, appendectomy, colorectal, and LSCS operations, are frequently linked to ASBO. Intra-abdominal adhesions are frequently caused by radiation enteritis, foreign material, infections, acute and chronic inflammatory conditions. However, these reasons pale in comparison to small bowel obstruction following surgery. 1–10% of appendicectomies, 6% of open cholecystelectomies, 10–25% of intestinal procedures, and 17–25% of colorectal surgeries result in ASBO occurrences.
Adhesions following a laparotomy are unavoidable. Local fibrin is produced and degraded in response to any cause of peritoneal irritation. Yet adhesions result from this. Numerous therapies, such as limiting gauze contact, using appropriate surgical procedures, and cleaning the peritoneal cavity with saline, are being tested to prevent the development of adhesions.
There are two approaches to managing an adhesive small bowel obstruction: nonoperative and operative. Computed Tomography, biochemical testing, and clinical evaluation form the basis of management. The degree of symptoms and indicators associated with small bowel obstruction varies from patient to patient and is influenced by a variety of circumstances, including the kind of prior surgery the patient has had.
The purpose of this research is to classify the patient for conservative and surgical care by analyzing the symptoms and indicators. Additionally, to monitor patients who have received both surgical and non-operative care in order to watch for return of symptoms associated with SBO, such as stomach discomfort and the potential for hospitalization
This Cross Sectional (Observational) study was conducted on 60 patients, at Bapuji Hospital and Chigateri General Hospital, from the department of General Surgery, JJM Medical College, Davangere. The study period was from January 2021 to August 2022.
SOURCE OF DATA: This study was conducted in the department of General Surgery at Bapuji Hospital and Chigateri General Hospital attached to JJM Medical College, Davangere
STUDY PERIOD: January 2021 to August 2022.
SAMPLE SIZE: 60 patients
METHOD OF DATA COLLECTION:
60 patients who came with symptoms suggestive of Small Bowel Obstruction with previous surgeries were considered. Patients underwent detailed clinical examination and investigations after obtaining consent. When Adhesive small bowel obstruction was identified the details of management were recorded.
Patients were analysed for:
Inclusion criteria:
Exclusion criteria:
Statistical Analysis:
For statistical analysis, data were initially entered into a Microsoft Excel spreadsheet and then analyzed using SPSS (version 27.0; SPSS Inc., Chicago, IL, USA) and GraphPad Prism (version 5). Numerical variables were summarized using means and standard deviations, while categorical variables were described with counts and percentages. Two-sample t-tests, which compare the means of independent or unpaired samples, were used to assess differences between groups. Paired t-tests, which account for the correlation between paired observations, offer greater power than unpaired tests. Chi-square tests (χ² tests) were employed to evaluate hypotheses where the sampling distribution of the test statistic follows a chi-squared distribution under the null hypothesis; Pearson's chi-squared test is often referred to simply as the chi-squared test. For comparisons of unpaired proportions, either the chi-square test or Fisher’s exact test was used, depending on the context. To perform t-tests, the relevant formulae for test statistics, which either exactly follow or closely approximate a t-distribution under the null hypothesis, were applied, with specific degrees of freedom indicated for each test. P-values were determined from Student's t-distribution tables. A p-value ≤ 0.05 was considered statistically significant, leading to the rejection of the null hypothesis in favour of the alternative hypothesis.
Table-1 : Symptom Analysis
Symptoms |
Number of patients |
Abdominal Pain |
58 |
Vomit |
40 |
Abdominal Distension |
35 |
Constipation/obstipation |
40 |
Fever |
22 |
Table-2 : Analysis of previous surgeries
PREVIOUS SURGERY |
NUMBER OF PATIENTS |
Open Appendicectomy |
22 |
Previous LSCS |
20 |
Previous Perforation Repair |
7 |
Tubectomy |
4 |
Abdominal Hysterectomy |
3 |
Open Strictureplasty |
2 |
Open LPJ |
1 |
Open Salpingo-oophorectomy (SA OOP) |
1 |
Table-3: Analysis of Previous Surgeries in Males
Table-4: Analysis of Previous Surgeries in Females
The abdominal pain is the most common symptom present in 96.6% cases (58 patients). 66.6% cases (40 patients) had Vomiting. 58.3% (35 patients) and 66.6% of cases (40 patients) had Abdominal distension and Constipation or obstipation respectively.
Fever was there in 36.66% cases (22 patients), but it is significant if this symptom is present the management is surgical approach.
The various previous surgeries for which the patient attended the hospital with symptoms suggestive of adhesive small bowel obstruction. According to this study, the previous history of Open Appendicectomy (22 patients) is the most common cause followed by Previous LSCS (20 patients) which constitutes 36% and 33% respectively of the cause for adhesive small bowel obstruction. The other surgeries which led to adhesions includes 7 perforation surgeries, 4 tubectomies, 3 abdominal hysterectomies, 2 strictureplasty, 1 Open LPJ and 1 salphingo-oophorectomy.
In males’ previous history of Open Appendicectomy and previous history of Perforation surgeries are the two most common causes which led to adhesion formation. These two account for more than 90% (Graph -5) of the previous surgeries in males.
The previous LSCS surgeries are the most common causes which led to adhesion formation in Females, which accounts for 57% of the causes for adhesion. The next common surgeries in the females are Open Appendicectomy and Open Tubectomy, which accounts for 14% and 11% respectively.
There are fewer patients with ASBO in the age ranges of 18–25 and older than 65. When it comes to adhesive small intestinal obstruction, there is no discernible gender difference (Graph-2).
Even though sticky small intestinal obstruction frequently manifests as abdominal pain, abdominal discomfort is a sign of many other abdominal disorders. This study shows that while abdominal pain is more specific (100%) in identifying the ailment, it is less sensitive (34.48%) in helping choose the best course of surgical care.
In 583.33 percent of cases, there is abdominal distention. This symptom is dependable. The five "Fs" of abdominal distension are fat, fluid, feces, fetal, and flatus. Flatus and fluid buildup are the result of adhesion blockage. In the event of an adhesive small intestinal blockage, this symptom becomes dependable. Abdominal distension also happens with colonic blockage; however, it is dependable. With surgical therapy, the abdominal distension had a 54.28% sensitivity and a 96% specificity.
According to this study, 36% of adhesion development cases were caused by a prior appendicectomy. LSCS accounts for 33% of adhesion formation, which is the other main reason. In younger age groups, both of these illnesses are more prevalent. In the study conducted by Raphael P H Meier et al [2], history of Previous Appendicectomy is the major cause for Adhesive Small Bowel Obstruction, the next major cause being the surgeries for Colorectal Malignant lesions. Previous malignant surgeries were excluded in our study.
In the current study, hysterectomy accounts for 5% of the causes of ASBO. Additional factors in this research that contributed to the development of adhesions were LPJ, tubectomy, strychnoplasty, salphingo-oophorectomy, and prior perforation procedures.
Open cholecystectomy, volvulus, intussusception, surgeries for retroperitoneal masses with trans peritoneal approach, open splenectomies, open GJ surgery, obstructed/strangulated hernia, colorectal malignancies, congenital bands, and other surgeries are among the other procedures carried out in our study hospitals that may result in adhesive small bowel obstruction.
According to a review of prior operations, infectious reasons that resulted in surgery are the most frequent cause of adhesion development. An additional aspect that aligns with the global norm is the increased risk of adhesions following pelvic operations.
Gynecological operations account for the majority of adhesion development in females. The tiny sample size of patients who underwent the third and fourth LSCS procedures in this study accounts for the lower frequency of individuals with adhesion in those procedures (perhaps as a result of puerperal sterilization).
Alcohol use is the aetiology of duodenal perforation, which was discovered during the most frequent emergency laparotomy in our community. This study indicates that laparotomy for duodenal perforation is a prevalent source of adhesion development, despite the fact that adhesions are more common following colorectal procedures. The main reason for this is that the majority of colorectal procedures are not included in this study since they were previously performed for malignancies. Ileal perforations and gastric ulcer perforations are the other reasons for laparotomy.
Adhesion development rises with the frequency of procedures performed. Increased pelvic procedures, such as abdominal hysterectomy and prior LSCS, have occurred more often than in past occurrences. Adhesion development increases with the number of pelvic procedures performed.
Graph 11 suggests that conservative therapy will not benefit patients if they do not have symptomatic alleviation in 48–72 hours. The risk of strangulation and related morbidity is present in non-operative care of ASBO, which raises questions about the ideal duration of conservative ASBO management.
In the study conducted by Hajibandeh S. et al [3], the best duration of conservative care and when to operate (early or late) in situations where there is little initial indication of strangulation are still up for debate.
Richard P. G. ten Broek et al [4], according to their research, all ASBO patients should try nonoperative treatment unless there are indications of peritonitis, strangulation, or intestinal ischemia. Although there isn't any data to support the ideal non-operative stay length, the majority of writers and the panel believe that a 72-hour period is suitable and safe. Additionally, they noted in their study that there appears to be a larger risk of bowel injury in surgically treated patients following laparoscopic surgery for ASBO. As a result, patients must be carefully chosen before having laparoscopic surgery.
Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group, by Richard P. G. ten Broek et al [5] the Algorithm for the diagnostic and therapeutic approach to the patient with ASBO is:
In our study, 20% of patients (4 instances) who had surgical therapy had symptoms indicating of recurrence during the follow-up period, whereas 30% of patients (12 cases) who had conservative care had comparable episodes suggestive of recurrence throughout the 5-month follow-up period. Out of 16 instances with recurrence, 12 patients required hospital admission and received conservative care; the other 4 patients were handled on an outpatient basis since they only infrequently had abdominal discomfort.
The main findings of the study conducted by Raphael PH Meier et al [2], indicate that, as compared to patients treated with a conservative strategy, surgical patients had a 50% lower chance of needing to be readmitted to the hospital and a 60% lower chance of experiencing "everyday" SBO symptoms at home.
The current study's findings on the disease's recurrence are consistent with the findings of the previously stated research.
The limitations of the present study are the small sample size and lack of long-term follow-up.
The current available literatures regarding operative and non-operative management of ASBO has the following shortcomings:
The most frequent reason for small bowel blockage is adhesion. The most typical signs of adhesive small intestinal obstruction are vomiting and abdominal discomfort. However, surgical intervention decision-making is less sensitive. High sensitivity (90.90%) and specificity (100%) are found in fever while determining surgical treatment decisions. In contrast to the common causes of adhesive small bowel obstruction in the western population, such as colon surgeries and cholecystectomies, the most common prior surgeries in this cohort that resulted in adhesive small bowel obstruction were appendectomy, LSCS, hollow viscous perforation, and hysterectomy. All patients with ASBO should get a trial of conservative therapy unless there are indications of peritonitis. The current study shown that ASBO recurrence is lower in patients who had surgery. This observational research led to the development of a grading system. This scoring system's sensitivity and specificity have to be demonstrated in research with a suitable sample size.