Adhesive small bowel obstruction: aspects on epidemiology, treatment, costs and prevention

Abstract: Small bowel obstruction (SBO) is a common and sometimes life-threatening clinical condition, usually caused by post-operative adhesions. The aims of this thesis were to investigate the outcome after SBO surgery (Paper I), cost of SBO surgery including follow-up (Paper II), incidence of SBO after colorectal cancer (CRC) surgery (Paper III), and to assess the safety of using the adhesion preventing substance icodextrin in CRC surgery (Paper IV).Paper I, a population-based retrospective study on all patients operated for adhesive SBO (n=402) in the Uppsala and Gävleborg counties between 2007 and 2012. The SBO mechanism was a fibrous band in 56%. Complications and reoperations were recorded in 48% and 10% of patients, respectively. Complications, ICU care and early mortality were associated with age and ASA class. Seventy two patients had a recurrence of SBO, 26 of whom were re-operated. Previous laparotomies, diffuse adhesions, and complicated surgery (bowel injury, longer operation times and bleeding) were predictors of recurrent SBO. Paper II used the same cohort as in Paper I with an extended follow-up (8 years in median). Mean total cost estimates per patients were €40,467 during the study period. Diffuse adhesions and complications were associated with increased costs for SBO in a multivariable analysis (p<0.001).Paper III is a population-based register study based on all CRC cancer patients in Sweden 2007–2017. Among 33,632 CRC patients operated for stage I–III disease, the 5-year cumulative incidence was 7.6% for SBO and 2.2% for SBO surgery. In 198,649 matched CRC-free comparators the corresponding incidences were 0.6% and 0.2%, respectively. Open surgery and radiotherapy were associated with an increased incidence of SBO and SBO surgery. Paper IV is an interim analysis regarding morbidity and mortality, of a randomized controlled multicenter study assessing whether the adhesion preventing substance icodextrin can reduce the risk of postoperative SBO in stage I–III CRC patients. Randomization, to standard treatment with or without icodextrin, was blinded to the authors. Demographic data and overall complications were similar in the groups. Mortality, ICU care, anastomotic leaks and reoperations did not differ.