M. C. Parker

Postoperative adhesions: Ten-year follow-up of 12,584 patients undergoing lower abdominal surgery

PURPOSE: Postoperative adhesions are a significant problem after colorectal surgery. However, the basic epidemiology and clinical burden are unknown. The Surgical and Clinical Adhesions Research Study has investigated the scale of the problem in a population of 5 million. METHODS: Validated data from the Scottish National Health Service Medical Record Linkage Database were used to define a cohort of 12,584 patients undergoing open lower abdominal surgery in 1986. Readmissions for potential adhesion-related disease in the subsequent ten years were analyzed. The methodology was conservative in interpreting adhesion-related disease. RESULTS: In the study cohort 32.6 percent of patients were readmitted a mean of 2.2 times in the subsequent ten years for a potential adhesion-related problem. Although 25.4 percent of readmissions were in the first postoperative year, they continued steadily throughout the study period. After open lower abdominal surgery 7.3 percent (643) of readmissions (8,861) were directly related to adhesions. This varied according to operation site: colon (7.1 percent), rectum (8.8 percent), and small intestine (7.6 percent). The readmission rate was assessed to provide an indicator of relative risk of adhesion-related problems after initial surgery. The overall average rate of readmissions was 70.4 per 100 initial operations, with 5.1 directly related to adhesions. This rose to 116.4 and 116.5, respectively, after colonic or rectal surgery—with 8.2 and 10.3 directly related to adhesions. CONCLUSIONS: There is a high relative risk of adhesion-related problems after open lower abdominal surgery and a correspondingly high workload associated with these readmissions. This is influenced by the initial site of surgery, colon and rectum having both the greatest impact on workload and highest relative risk of directly adhesion-related problems. The study provides sound justification for improved adhesion prevention strategies.

The SCAR‐3 study: 5‐year adhesion‐related readmission risk following lower abdominal surgical procedures

Objectiveu2002 The Surgical and Clinical Adhesions Research (SCAR) and SCAR‐2 studies demonstrated that the burden of adhesions following lower abdominal surgery is considerable and appears to remain unchanged despite advances in strategies to prevent adhesions. In this study, we assessed the adhesion‐related readmission risk directly associated with common lower abdominal surgical procedures, taking into account the effect of previous surgery, demography and concomitant disease.

Adhesions and Colorectal Surgery – Call for Action

Mounting evidence highlights that adhesions are now the most frequent complication of abdominopelvic surgery, yet many surgeons are still not aware of the extent of the problem and its serious consequences. While many patients go through life without apparent problems, adhesions are the major cause of small bowel obstruction and a leading cause of infertility and chronic pelvic pain in women. Moreover, adhesions complicate future abdominal surgery with important associated morbidity and expense and a considerable risk of mortality.

Self-expanding metallic stents in the treatment of benign colorectal disease: indications and outcomes

Objectiveu2002 The use of stents for benign colorectal obstruction is considered controversial because of a lack of data and perceived high failure and complication rates. The aim of this study was to evaluate the indications and outcomes following stent placement for benign colorectal disease in a UK district general hospital and to review the published literature.

Colorectal surgery: the risk and burden of adhesion-related complications.

Objectivesu2003 Adhesions are associated with serious medical complications. This study examines the real‐time burden of adhesion‐related readmissions following colorectal surgery and assesses the impact of previous surgery on adhesion‐related outcomes.

Comparison of short- and long-term outcomes following either insertion of self-expanding metallic stents or emergency surgery in malignant large bowel obstruction

BackgroundSelf-expanding metallic stents (SEMS) are now regarded as a safe and effective treatment for an acute obstructing colorectal cancer. SEMS insertion is an invasive procedure that could potentially worsen prognosis. This study assessed the short-and long-term outcomes in patients stented for acute large bowel obstruction and in patients who underwent primary emergency surgery.MethodsWe retrospectively identified 19 patients who underwent SEMS insertion and 23 patients who had primary emergency surgery for left-sided large bowel obstruction as the first presentation of colorectal cancer.ResultsThere were no significant differences between the 19 patients in the SEMS group and the 23 patients in the primary emergency surgery group in terms of demographics and tumour location and stage. Stent insertion was successful in 16 patients (84%). One patient died from a stent-related perforation and another had a stoma fashioned for stent migration. Stents were a definitive procedure in 2 patients with advanced disease and acted as a “bridge to surgery” in the remaining 12 patients. Compared to the primary surgery group, there was a trend towards a higher primary anastomosis rate in the SEMS group (p=0.08); there were no significant differences in length of hospital stay, 30-day mortality or complication rates between the groups. Long-term prognosis (estimated 3-year survival) did not differ significantly between the groups (p=0.54); this persisted when only curative resections were considered (p=0.80).ConclusionsPreoperative stent insertion is a safe and effective treatment for large bowel obstruction, and may result in a higher primary anastomosis rate. Stent insertion does not seem to have a deleterious effect on prognosis.

Palliative therapy of colorectal carcinoma: stent or surgery?

“Surgical” palliation of obstructing colorectal carcinomas may involve resection with or without stoma formation, formation of a stoma alone, a colonic bypass procedure, or no procedure at all. Palliative surgical procedures confer a significant morbidity and mortality. Factors associated with increased mortality for colorectal cancer include advancing age of patient, advancing stage of the disease and the necessity for an emergency procedure. Advanced obstructing malignant lesions pose a clinical dilemma as the risks and time of recovery from surgery have to be balanced against providing a dignified quality of remaining life. Self expanding metal stents (SEMS) for acutely obstructing advanced colorectal carcinomas provide a cost effective option that avoids surgery in a usually frail group of patients. They can be inserted under sedation, rapidly decompress the colon and lead to an early return of colonic function. The procedure is carried out endoscopically with radiological assistance to determine a lumen and to confirm adequate stent placement. SEMS are not suitable for low rectal lesions and are more difficult to place in those that traverse colonic flexures. Complications from successful SEMS placement include migration and stent occlusion. The morbidity associated with SEMS is associated with migration or perforation of the colon during placement, pain and less commonly haemorrhage. Despite these problems most patients can be successfully decompressed without further endoscopic or surgical reintervention and allow satisfactory palliation.

Colovesical fistula – Is a surgical approach always justified?

Objectiveu2002 There is a tendency to over investigate patients with colovesical fistula and to advise surgical intervention as the sole course of action. Most patients are elderly and operative intervention often carries a high morbidity and mortality.

Endoscopic alternatives in managing anastomotic strictures of the colon and rectum

BackgroundThe development of anastomotic strictures following colorectal surgery is a frequent problem, but commonly used treatments (e.g. dilatation or revisional surgery) are often ineffective. This study assessed the efficacy of self–expanding metallic stents (SEMS) and endoscopic transanal resection of strictures (ETARS) in managing high–grade benign colorectal anastomotic strictures after the failure of first–line therapies.MethodsAll patients with biopsy–proven benign anastomotic strictures (luminal diameter <7 mm) following colorectal surgery, seen in the period April 1995–October 2004, were treated with either SEMS or ETARS.ResultsIn the study period, we treated 10 patients (7 men) of median age 71 years. Ten ETARS procedures were performed in six patients, with a mean operating time of 42 minutes and a median hospital stay of 1 day. Early complications of ETARS included: re– operation for bleeding, asymptomatic anastomotic perforation and technical failure in an acutely angulated stricture. SEMS were successfully inserted into five patients (including two with failed ETARS) without any early complications. Overall, nine patients have had satisfactory longterm outcomes (median follow–up, 29 months; range, 3–75 months).ConclusionsSEMS and ETARS are simple, safe and effective methods in treating high–grade anastomotic strictures.

Impact of adhesions in colorectal surgery.

The extent of the problem of adhesions is considerable and poses a significant burden on healthcare systems, the workload of surgeons and the lives of patients. This paper reviews the work undertaken and the associated evidence for the impact of adhesions. It considers the various options and strategies to reduce adhesions alongside the fundamental necessity for good surgical technique.