Faculty Bibliography

OBJECTIVE: To determine the efficacy and long-term prognosis for operative versus nonoperative treatment of small-bowel obstruction (SBO) secondary to malignant disease. DESIGN: A chart review. SETTING: A university-affiliated teaching hospital. PATIENTS: The medical records of all patients with malignant disease as the established etiology of their obstruction who presented to the Sir Mortimer B. Davis-Jewish General Hospital, Montreal, between 1986 and 1996 were reviewed. There were 32 patients accounting for 74 admissions. INTERVENTIONS: Selective nonoperative management and exploratory laparotomy, immediate or delayed. MAIN OUTCOME MEASURES: The value of nonoperative management and need for operation. RESULTS: Colorectal and ovarian neoplasms were the principal primary malignant diseases that led to SBO. The median time between diagnosis of the malignant disease and SBO was 1.1 years. At their initial presentation, 80% of patients were treated by operation, but 47% of these patients had an initial trial of nonoperative treatment. Reobstruction occurred in 57% of patients who were operated on compared with 72% of patients who were not. The median time to reobstruction was 17 months for patients who underwent operation compared with 2.5 months for patients who did not. Also, 71% of patients were alive and symptom free 30 days after discharge from operative treatment compared with 52% after nonoperative treatment. Postoperative morbidity was 67%. Mortality was 13%, and 94% of patients eventually died from complications of their primary disease. CONCLUSIONS: SBO secondary to malignant disease usually indicates a grim prognosis. Operative treatment has better outcome than nonoperative management in terms of symptom free interval and reobstruction rates. However, it is marked by high postoperative morbidity. We recommend that, after short trial of nasogastric decompression, patients with obstruction secondary to malignant disease be operated on if clinical factors indicate they they will survive the operation

BACKGROUND: Small bowel obstruction (SBO) is a major cause of morbidity and financial expenditure. The goals of this study were to determine factors predisposing to adhesive SBO, to note the long-term prognosis and recurrence rates for operative and non-operative treatment, to elicit the complication rate of operations and to highlight factors predictive of recurrence. METHODS: The medical records of all patients admitted to one hospital between 1986 and 1996 with the diagnosis of SBO were reviewed retrospectively. This included 410 patients accounting for 675 admissions. RESULTS: The frequency of previous operation by procedure type was colorectal surgery (24 per cent), followed by gynaecological surgery (22 per cent), herniorrhaphy (15 per cent) and appendicectomy (14 per cent). A history of colorectal surgery (odds 2.7) and vertical incisions (odds 2.5) tended to predispose to multiple matted adhesions rather than an obstructive band. At initial admission 36 per cent of patients were treated by means of operation. As the number of admissions increased, the recurrence rate increased while the time interval between admissions decreased. Patients with an adhesive band had a 25 per cent readmission rate, compared with a 49 per cent rate for patients with matted adhesions (P<0.004). At the initial admission 36 per cent of patients were treated surgically. Patients treated without operation had a 34 per cent readmission rate, compared with 32 per cent for those treated surgically (P not significant), a shorter time to readmission (median 0.7 versus 2.0 years; P<0.05), no difference in reoperation rate (14 versus 11 per cent; P not significant) and fewer inpatient days over all admissions (4 versus 12 days; P<0.0001). CONCLUSION: The likelihood of reobstruction increases and the time to reobstruction decreases with increasing number of previous episodes of obstruction. Patients with matted adhesions have a greater recurrence rate than those with band adhesions. Non-operative treatment for adhesions in stable patients results in a shorter hospital stay and similar recurrence and reoperation rates, but a reduced interval to reobstruction when compared with operative treatment

BACKGROUND: Small bowel obstruction (SBO) is a major cause of morbidity and financial expenditure in hospitals around the world. The leading cause of SBO in the western world has become adhesions. The goal of this study was to determine the causes of SBO. METHODS: The medical records of all patients admitted to one hospital between 1986 and 1996 with the diagnosis of SBO were reviewed retrospectively. This included 552 patients accounting for 1,001 admissions. RESULTS: The etiology of SBO was adhesions (74%), Crohn's disease (7%), neoplasia (5%), hernia (2%), radiation (1%), and miscellaneous (11%). Patients with Crohn's disease were younger than patients with other etiologies. Surprisingly, recurrence rates were similar for patients treated operatively as for those treated nonoperatively with the exception in the hernia group where higher recurrence rates were noted for patients initially treated in a nonoperative manner. CONCLUSION: The most common cause of SBO is adhesions followed by Crohn's disease and neoplasia