Jean-Jacques Duron

The aim of the present study was to determine the cumulative incidence and the risk factors of recurrence in patients operated on for an adhesive postoperative small bowel obstruction (SBO). Postoperative intraperitoneal adhesions, or bands, resulting from any type of abdominal surgery, are the main cause of adhesive postoperative small bowel obstructions, which represent a life-long issue. Recurrences after operated adhesive postoperative SBO are a threatening potentiality for patients and a difficult problem facing any surgeon. Today the cumulative incidence and the risk factors of recurrence have been retrospectively reported but have never been prospectively evaluated in a multicenter study. From January 1997 to January 2002, we enrolled 286 patients operated on for an adhesive postoperative SBO in a prospective multicenter trial. A systematic follow-up was carried out and ended in April 2003. Studied factors for recurrent adhesive postoperative SBO were as follows: age, gender, ASA status, number and sites of previous operations, previous operation for adhesive postoperative SBO, elapsed time from the latest operation, surgical approach, number and type of obstructive structures, site and mechanism of obstruction, final operations, and postoperative surgical and medical complications. They were analyzed using Kaplan-Meier method. A Cox regression model was used to determine the independent risk factor of recurrence. The median follow-up was 41 months (range, 1-75 months). The cumulative incidence of overall recurrence was 15.9%, and for surgically managed recurrence 5.8%. In multivariate analysis, the risk factors for the overall recurrences were age <40 years (hazard ratio [HR], 2.97; confidence interval [CI], 1.48-5.94), adhesion or matted adhesion (HR, 3.79; CI, 1.84-7.78) and, for the surgically managed: adhesions or matted adhesions (HR, 3.64; CI, 1.12-11.84), and postoperative surgical complications (HR, 5.63; CI, 1.73-18.28). Operated adhesive postoperative SBO is a clinical entity with a high recurrence rate and specific risk factors of recurrences. Thus, the patients operated on for adhesive postoperative SBO may be candidates for the preventive use of anti-adhesion agents, particularly when a risk factor of recurrence is present.

Small Bowel obstruction due to post-operative adhesions is a common problem in a general surgical practice. Any laparotomy initiates the lifelong risk of this complication. Mortality rates have improved dramatically in the last three decades. The basic evaluation and treatment of small bowel obstruction is well defined but many individual strategies may result from the variety of clinical presentations and from techniques and equipment available to a local surgical practice. Recent advances in surgical techniques and preventive strategies may improve overall results. Results will remain linked to the continuous aging of the populations of Western countries.

Postoperative peritoneal bands and adhesions are very common and may occur after any surgical procedure within the peritoneal cavity. Certain factors have been shown to contribute to their formation. The abdominal surgeon should take account of these factors in his daily practice; a reasoned and preventive surgical approach and the use of techniques and products with proven clinical efficacity are to be recommended. This should permit the surgeon to simplify and minimize post surgical work and to diminish the incidence and complications of adhesions in both the immediate and long-term post-operative periods such as post-surgical pain syndromes, mechanical bowel obstruction, and adhesive peritonitis complicating reinterventional surgery.

Acute intestinal obstruction comprises a vast clinical entity characterized by the items of the obstruction syndrome. It encompasses numerous etiologies, and in Western countries adhesions are currently the main cause. The work up of this urgent surgical condition must above all be clinical, even though new techniques will probably improve their diagnosis and treatment (CT scan, stent). These new technologies still have to be documented and validated. Likewise, the laparoscopic approach of acute intestinal obstruction has to be prudent. The overall mortality of this urgent condition is still high, more than 10% of the patients.

Consumption of surgical gloves in progressing constantly. All proposed products do not have the same qualities in terms of protection, comfort, and safety for the surgeon, the surgical team and the patient. Latex is the basic material used to manufacture surgical gloves even if it does raise the problem of side-effects and requires use of starch powder for lubrification. The surgeon should be aware of the different products and participate in choosing this indispensable tool. There is a general and advisable trend to using non-powdered gloves.