Disease Severity and Cost in Adhesive Small Bowel Obstruction.

BACKGROUND: Adhesive small bowel obstruction (ASBO) severity has been associated with important clinical outcomes. However, the impact of ASBO severity on hospitalization cost is unknown. The American Association for the Surgery of Trauma (AAST) developed an Emergency General Surgery (EGS) disease severity grading system for ASBO. We stratified patients' ASBO severity and captured hospitalization costs hypothesizing that increased disease severity would correlate with greater costs. METHODS: This was a single-center study of hospitalized adult patients with SBO during 2015-2017. Clinical data and estimated total cost (direct + indirect) were abstracted. AAST EGS grades (I-IV) stratified disease severity. Costs were normalized to the median grade I cost. Univariate and multivariate analyses evaluated the relationship between normalized cost and AAST EGS grade, length of hospital and ICU stay, operative time, and Charlson comorbidity index. RESULTS: There were 214 patients; 119 (56%) were female. AAST EGS grades included: I (62%, n = 132), II (23%, n = 49), III (7%, n = 16), and IV (8%, n = 17). Relative to grade I, median normalized cost increased by 1.4-fold for grade II, 1.6-fold for grade III, and 4.3-fold for grade IV disease. No considerable differences in patient comorbidity between grades were observed. Pair-wise comparisons demonstrated that grade I disease cost less than higher grades (corrected p < 0.001). Non-operative management was associated with lower normalized cost compared to operative management (1.1 vs. 4.5, p < 0.0001). In patients who failed non-operative management, normalized cost was increased 7.2-fold. Collectively, the AAST EGS grade correlated well with cost (Spearman's p = 0.7, p < 0.0001). After adjustment for covariates, AAST EGS grade maintained a persistent relationship with cost. CONCLUSION: Increasing ASBO severity is independently associated with greater costs. Efforts to identify and mitigate costs associated with this burdensome disease are warranted. LEVEL OF EVIDENCE: III, economic/decision.

Cost effectiveness analysis of duration of nonoperative management for adhesive bowel obstruction in a developing country.

Background: Adhesive bowel obstruction (ABO) costs billions of dollars in developed countries. Cost is unknown in developing countries. This depends on the type of management and duration of hospital stay. Nonoperative management (NOM) of uncomplicated obstruction is safe for up to 10 days. While it remains cost effective, the most efficient duration of nonoperative management must retain its advantages over operative management. Aim: To describe cost effectiveness of various durations of nonoperative management of adhesive obstruction in a developing country. Method: Over 2 year period, Patients who had uncomplicated adhesive obstruction were observed on trial of nonoperative management. Length of hospital stay and success rate were combined as surrogates for Cost effectiveness analysis of 2 to 5 days and ≥7 days nonoperative management. Results: 41 patients (24(58.5%) females) were eligible. Mean age 38.4 ± 14.7 (range 18-80) years. 31 (75.6%) were first time admissions. The most common previous abdominal operations were for appendix and obstetrics and gynecologic pathologies. Median duration of nonoperative management (dNOM) was 4 days, median LOS was 9 days. Nonoperative management was successful in 53.7% (22 patients). Total estimated direct hospital cost of 41 adhesive bowel obstructions was $133,279. Total personnel charges were $112,142. Mean operative and nonoperative management was $4,914 and $1,814 respectively (p <0.0001). Most of successful nonoperative management was within 5 days. 4 days nonoperative management had the highest cost utility. Conclusion: From this study, without indications for immediate surgical intervention, 4 days nonoperative management is the most cost effective course, after which surgical intervention may be considered if there is no improvement.

Impact of hospital volume on outcomes for laparoscopic adhesiolysis for small bowel obstruction.

BACKGROUND: Volume-to-outcome data have been studied in several complex surgical procedures, demonstrating improved outcomes at higher volume centers. Laparoscopic lysis of adhesions (LLOA) for small bowel obstruction (SBO) may result in better outcomes, but there is no information on the learning curve for this potentially complex case. This study evaluates the effect of institutional procedural volume on length of stay (LOS), outcomes, and costs in LLOA for SBOs. MATERIALS AND METHODS: The Nationwide Inpatient Sample data set between 2000 and 2013 was queried for discharges for a diagnosis of SBO involving LLOA in adult patients. Patients with intra-abdominal malignancy and evidence of any other major surgical procedure during hospitalization were excluded. The procedural volume per hospital was calculated over the period, and high-volume hospitals were designated as those performing greater than five LLOA per year. Patient characteristics were described by hospital volume status using stratified cluster sampling tabulation and linear regression methods. LOS, total charges, and costs were reported as means with standard deviation and median values. P < 0.05 was considered significant. RESULTS: A total of 9111 discharges were selected, which was representative of 43,567 weighted discharges nationally between 2000 and 2013. Over the study period, there has been a 450% increase in the number of LLOA performed. High-volume hospitals had significantly shorter LOS (mean: 4.92 ± standard error (SE) 0.13 d; median: 3.6) compared to low-volume hospitals (mean: 5.68 ± 0.06 d; median: 4.5). In multivariate analysis, high-volume status was associated with a decreased LOS of 0.72 d (P < 0.0001) as compared to low-volume status. Other significant predictors for decreased LOS included decreased age, decreased comorbidity, and the absence of small bowel resection. There was no significant association between volume status and total charges in multivariate or univariate models, but high-volume hospitals were associated with lower costs in multivariate models by approximately $984 (P = 0.017). CONCLUSIONS: This study demonstrates that high hospital volume was associated with decreased LOS for LLOA in SBO. Although volume was not associated with differences in total charges, there was a small decrease in hospital costs.

In-hospital costs of an admission for adhesive small bowel obstruction.

BACKGROUND: Previous research on the costs of treatment for ASBO is outdated and often based on reimbursements, rather than true healthcare provider costs of the admission and related interventions. An accurate estimate of the true costs of treatment is necessary to understand the healthcare burden and to model cost-efficacy of adhesion strategies. The aim of this study was to provide an accurate cost estimate of the in-hospital costs for treatment of adhesive small bowel obstruction (ASBO) using micro-costing methods. METHODS: Consecutive patients admitted for ASBO to the Radboud University Medical Center from November 2013 to November 2015 were included. An episode of ASBO was defined as an admission for SBO with operative confirmation of adhesions or after radiological exclusion of other causes for SBO. For the purpose of generalization we used the costs of medication and interventions as provided by the Dutch Healthcare Authority and only if these were not available local hospital costs. We evaluated costs separately for operative and non-operative treatment for ASBO. RESULTS: During the study period 39 admissions for ASBO were eligible for analysis. An operative treatment was required in 19 patients (48.7 %). Mean hospital stay for ASBO with operative treatment was 16.0 ± 11 days versus 4.0 ± 2.0 days for non-operative treatment (P = 0.003). A total of 12 patients developed complications, 2 in the non-operative group (10 %) and 10 in the operative group (52.6 %; P = 0.004). Overall costs for an admission for ASBO with operative treatment were €16 305 (SD €2 513), and for non-operative treatment € 2 277 (SD € 265) (p = <0.001). The highest expenditure with operative treatment for ASBO was made for ward stay (mean €7 856, SD €6 882), OR time (mean €2 6845, SD €1 434), ICU stay (mean €2 183, SD €4 305) and (parenteral) feeding costs (mean €1797, SD €2070). A table with correction coefficient to correct for differences in price levels for goods and services between different countries has been added. CONCLUSION: The in-hospital costs of an admission for ASBO are higher than previously thought. These costs can be used to guide hospital reimbursement policy and for the development of a cost-effective model for the use of adhesion barriers.

Nonoperative management of adhesive small bowel obstruction: what is the break point?

BACKGROUND: The current management paradigm for recurrent adhesive small bowel obstruction (SBO) is nonoperative. Rates of recurrence differ based on time interval between and number of previous occurrences. Optimal time to intervene has not been determined. METHODS: We constructed a Markov model to evaluate costs and quality of life on a hypothetical cohort of 40-year-old patients after their first episode of medical management for postoperative SBO. We estimated a relative risk reduction of .55 with surgical intervention and a relative risk increase of 2.1, 2.9, and 5.7 after the medical management of the 2nd, 3rd, and 4th SBO. RESULTS: Surgery performed after earlier episodes of SBO was more costly but also more effective. The cost difference between surgery after the 1st SBO recurrence vs the 2nd SBO recurrence was $1,643, with an increase of .135 quality-adjusted life years (QALYs), the incremental cost-effectiveness ratio was $12,170 per QALY. CONCLUSIONS: Surgery after the first episode of SBO provides a small increase in QALY at a small cost since surgical intervention lowers the risk of recurrence.

Impact of Adhesiolysis on Outcome of Colorectal Surgery.

BACKGROUND/AIMS: Adhesiolysis is a frequent part of colorectal surgery, potentially impeding the operation and causing inadvertent bowel injury. Such difficulties might compromise convalescence and oncological quality of resection. The aim of this prospective cohort study was to assess the impact of adhesiolysis on clinical outcomes and histopathological results in colorectal surgery. METHODS: Colorectal procedures were selected from a prospective cohort study of adhesiolysis-related problems. We compared the incidence of bowel injury, morbidity, costs, and the histopathology between patients undergoing elective colorectal surgery with or without adhesiolysis. RESULTS: Two hundred and forty nine colorectal surgeries were analysed. Adhesiolysis was required in 59.0%. The mean adhesiolysis time was 28 min. In the adhesiolysis group, enterotomies occurred in 6.1% and seromuscular injuries in 27.2% compared to 0 and 6.9% respectively in the non-adhesiolysis group (p = 0.012 and p < 0.001). In patients requiring adhesiolysis, 29.9% had major surgery-related complications (MSRC) compared to 15.7% without adhesiolysis (p = 0.007). There were no statistically significant differences regarding inpatient costs and resection margin or number of harvested lymph nodes. CONCLUSIONS: Adhesiolysis during colorectal surgery is related to an increased incidence of iatrogenic bowel injuries and MSRC. Despite the technical challenges associated with adhesiolysis, good histopathological results were obtained in oncological resections.

Epidemiology and Prevention of Postsurgical Adhesions Revisited.

OBJECTIVE: To provide a comprehensive review of recent epidemiologic data on the burden of adhesion-related complications and adhesion prevention. Second, we elaborate on economic considerations for the application of antiadhesion barriers. BACKGROUND: Because the landmark SCAR studies elucidated the impact of adhesions on readmissions for long-term complications of abdominal surgery, adhesions are widely recognized as one of the most common causes for complications after abdominal surgery. Concurrently, interest in adhesion prevention revived and several new antiadhesion barriers were developed. Although these barriers have now been around for more than a decade, adhesion prevention is still seldom applied. METHODS: The first part of this article is a narrative review evaluating the results of recent epidemiological studies on adhesion-related complications and adhesion prevention. In part II, these epidemiological data are translated into a cost model of adhesion-related complications and the potential cost-effectiveness of antiadhesion barriers is explored. RESULTS: New epidemiologic data warrant a shift in our understanding of the socioeconomic burden of adhesion-related complications and the indications for adhesion prevention strategies. Increasing evidence from cohort studies and systematic reviews shows that difficulties during reoperations, rather than small bowel obstructions, account for the majority of adhesion-related morbidity. Laparoscopy and antiadhesion barriers have proven to reduce adhesion formation and related morbidity. The direct health care costs associated with treatment of adhesion-related complications within the first 5 years after surgery are $2350 following open surgery and $970 after laparoscopy. Costs are about 50% higher in fertile-age female patients. Application of an antiadhesion barriers could save between $328 and $680 after open surgery. After laparoscopy, the costs impact ranges from $82 in expenses to $63 of savings. CONCLUSIONS: Adhesions are an important cause for long-term complications in both open and laparoscopic surgery. Adhesiolysis during reoperations seems to impact adhesion-related morbidity most. Routine application of antiadhesion barriers in open surgery is safe and cost-effective. Application of antiadhesion barriers can be cost-effective in selected cases of laparoscopy. More research is needed to develop barriers suitable for laparoscopic use.

Small Bowel Obstruction Is a Surgical Disease: Patients with Adhesive Small Bowel Obstruction Requiring Operation Have More Cost-Effective Care When Admitted to a Surgical Service.

BACKGROUND: Adhesive small bowel obstruction (ASBO), although a potential surgical emergency, is increasingly being managed by medical hospitalists due to the likelihood these patients will not require operation. However, the value of care delivered by medical hospitalists to patients with ASBO has not been reported. STUDY DESIGN: We hypothesized that patients admitted to the medical hospitalist service (MHS) for presumed ASBO have increased length of stay (LOS) and charges compared with patients admitted to the surgical service (SS). There were 555 consecutive admissions with presumed ASBO from 2008 to 2012; these were reviewed and grouped according to admitting service and whether an operation was performed. Group medians were compared and multivariate analysis was performed to identify variables independently associated with increased LOS, time to operation (TTO), and charges. RESULTS: Median LOS among patients whose ASBO resolved nonoperatively was similar for those on SS and MHS (2.85 days vs 2.98 days; p = 0.49). In patients without nonoperative resolution of ASBO, those admitted to MHS had longer median LOS when compared with those admitted to SS (9.57 days vs 6.99 days; p = 0.002) and higher median charges ($38,800 vs $30,100; p = 0.025). Patients admitted to MHS who had an operation, had a greater median TTO than operative patients on SS (51.72 hours vs 8.4 hours; p < 0.001). Multivariate analysis did not identify factors independently predictive of increased LOS, TTO, or charges. CONCLUSIONS: Adhesive small bowel obstruction patients are treated in a heterogeneous fashion in our hospital, causing disparate outcomes depending on admitting service when patients undergo operation. Admitting all suspected ASBO patients to SS has the potential to dramatically decrease LOS and reduce waste in those requiring operation, thereby reducing health care expenditures.

Economic Impact of the Use of an Absorbable Adhesion Barrier in Preventing Adhesions Following Open Gynecologic Surgeries.

We used an economic model to assess the impact of using the GYNECARE INTERCEED absorbable adhesion barrier for reducing the incidence of postoperative adhesions in open surgical gynecologic procedures. Caesarean section surgery, hysterectomy, myomectomy, ovarian surgery, tubal surgery, and endometriosis surgery were modeled with and without the use of GYNECARE INTERCEED absorbable adhesion barrier. Incremental GYNECARE INTERCEED absorbable adhesion barrier material costs, medical costs arising from complications, and adhesion-related readmissions were considered. GYNECARE INTERCEED absorbable adhesion barrier use was assumed in 75% of all procedures. The economic impact was reported during a 3-year period from a United States hospital perspective. Assuming 100 gynecologic surgeries of each type and an average of one GYNECARE INTERCEED absorbable adhesion barrier sheet per surgery, a net savings of $540,823 with GYNECARE INTERCEED absorbable adhesion barrier during 3 years is estimated. In addition, GYNECARE INTERCEED absorbable adhesion barrier use resulted in 62 fewer cases of patients developing adhesions. Although the use of GYNECARE INTERCEED absorbable adhesion barrier added $137,250 in material costs, this was completely offset by the reduction in length of stay ($178,766 savings), fewer adhesion-related readmissions ($458,220 savings), and operating room cost ($41,078 savings). Adoption of the GYNECARE INTERCEED absorbable adhesion barrier for appropriate gynecologic surgeries would likely result in significant savings for hospitals, driven primarily by clinical patient benefits in terms of decreased length of stay and adhesion-related readmissions.

Clinical and economic impact of adhesiolysis during repeat cesarean delivery.

OBJECTIVE: To estimate adhesiolysis rates at cesarean delivery (CD) and to estimate costs and clinical implications of performing adhesiolysis at repeat CD. DESIGN: Retrospective cohort using secondary data. SETTING: Over 500 acute care hospitals in the USA. POPULATION: Women ≥15 years old with a medical claim for CD between 1 January 2007 and 31 December 2008 who were treated in a hospital that contributed data to the Premier Perspective™ database. METHODS: Using data from hospital discharge records, rates of adhesiolysis at the time of CD were calculated. Among patients with repeat CD, a propensity score was used to create matched cohorts with and without adhesiolysis. Unadjusted rates and means were compared between these cohorts. MAIN OUTCOME MEASURES: Cost, length of stay and selected clinical complications between repeat CD patients with and without adhesiolysis. RESULTS: Adhesiolysis was performed in 0.5% of primary and 6.1% of repeat CD patients. Using propensity scores, 10 261 women who experienced repeat CD with adhesiolysis were matched to 10 261 control women. Hospital cost ($5739 vs. $5448), length of stay (2.97 vs. 2.88 days) and operative time (84.0 vs. 74.2 min) were significantly greater in the adhesiolysis than in the non-adhesiolysis group (p < 0.01 for all comparisons), as was the overall complication rate (6.3 vs. 3.5%). CONCLUSIONS: Adhesiolysis rates were higher in repeat compared with primary CD. Among repeat CD patients, costs and complications were higher in the adhesiolysis group. Reducing adhesion formation after primary CD could reduce cost and complications at the time of repeat CD.

Adhesion reduction agents in gynaecological procedures: can NHS aff ord it? An economic cost efficiency analysis.

We examined the total costs to the National Health Service (NHS, UK) paid to treat adhesion complications and determine the theoretical savings and cost-effectiveness incurred if anti-adhesion agents were adopted. Using Healthcare Resource Groups (HRG) codes, we calculated the costs incurred through Payment by Results (PbR) and then calculated the financial savings that could be realised through the use of anti-adhesion agents. There were 62,186 adhesion-related consultant episodes between 2004 and 2008 encountered within the NHS. If an anti-adhesion agent cost £110 per usage, and can reduce adhesions in 25% of patients undergoing surgery, assuming that 25% of patients were readmitted in the first year after the primary surgery, the financial cost to the health service is, at best, savings of more than £700,000 and at worst, cost neutral to the NHS.

The inpatient burden of abdominal and gynecological adhesiolysis in the US.

BACKGROUND: Adhesions are fibrous bands of scar tissue, often a result of surgery, that form between internal organs and tissues, joining them together abnormally. Postoperative adhesions frequently occur following abdominal surgery, and are associated with a large economic burden. This study examines the inpatient burden of adhesiolysis in the United States (i.e., number and rate of events, cost, length of stay [LOS]). METHODS: Hospital discharge data for patients with primary and secondary adhesiolysis were analyzed using the 2005 Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. Procedures were aggregated by body system. RESULTS: We identified 351,777 adhesiolysis-related hospitalizations: 23.2% for primary and 76.8% for secondary adhesiolysis. The average LOS was 7.8 days for primary adhesiolysis. We found that 967,332 days of care were attributed to adhesiolysis-related procedures, with inpatient expenditures totaling $2.3 billion ($1.4 billion for primary adhesiolysis; $926 million for secondary adhesiolysis). Hospitalizations for adhesiolysis increased steadily by age and were higher for women. Of secondary adhesiolysis procedures, 46.3% involved the female reproductive tract, resulting in 57,005 additional days of care and $220 million in attributable costs. CONCLUSIONS: Adhesiolysis remain an important surgical problem in the United States. Hospitalization for this condition leads to high direct surgical costs, which should be of interest to providers and payers.

Adhesion barriers at cesarean delivery: advertising compared with the evidence.

Cesarean delivery, the most common surgery performed in the United States, is complicated by adhesion formation in 24-73% of cases. Because adhesions have potential sequelae, different synthetic adhesion barriers are currently heavily marketed as a means of reducing adhesion formation resultant from cesarean delivery. However, their use for this purpose has been studied in only two small, nonblinded and nonrandomized trials, both of which were underpowered and subject to bias. Neither demonstrated improvement in meaningful clinical outcomes. In the only cost-effectiveness analysis of adhesion barriers to date, the use of synthetic adhesion barriers was cost-effective only when the subsequent rate of small bowel obstruction was at least 2.4%, a rate far higher than that associated with cesarean delivery. In fact, intra-abdominal adhesions from prior cesarean delivery rarely cause maternal harm and have not been demonstrated to adversely affect perinatal outcome. Based on our review of the available literature, we think the use of adhesion barriers at the time of cesarean delivery would be ill-advised at the present time.

[Prevention of postoperative abdominal adhesions in gynecological surgery. Consensus paper of an Italian gynecologists' task force on adhesions]. / Aderenze addominali postoperatorie e loro prevenzione in chirurgia ginecologica. Documento di consenso si una "task force" di ginecologi italiani sulle aderenze.

Adhesions are the most frequent complication of abdominopelvic surgery, causing important short- and long-term problems, including infertility, chronic pelvic pain and a lifetime risk of small bowel obstruction. They also complicate future surgery with considerable morbidity and expense, and an important mortality risk. They pose serious quality of life issues for many patients with associated social and healthcare costs. Despite advances in surgical techniques, the healthcare burden of adhesion-related complications has not changed in recent years. Adhesiolysis remains the main treatment although adhesions reform in most patients. There is rising evidence, however, that surgeons can take important steps to reduce the impact of adhesions. A task force of Italian gynecologists with a specialist interest in adhesions having reviewed the current evidence on adhesions and considered the opportunities to reduce adhesions in Italy, have approved a collective consensus position. This consensus paper provides a comprehensive overview of adhesions and their consequences and practical proposals for actions that gynecological surgeons in Italy should take. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. They should be adopted particularly in high risk surgery and in patients with adhesiogenic conditions. Patients also need to be better informed of the risks of adhesions.

Unexpected findings on laparoscopy for suspected acute appendicitis: a pro for laparoscopic appendectomy as the standard procedure for acute appendicitis.

PURPOSE: Evaluation of the feasibility, cost-effectiveness, time of surgery, morbidities, and other/additional findings during laparoscopy for suspected appendicitis. METHODS: Prospective evaluation of 148 laparoscopies for suspected acute appendicitis. RESULTS: Laparoscopic appendectomy was safe and cost-effective. No appendiceal stump leaks or wound infections occurred. Of the patients, 4.7% developed intra-abdominal abscesses. Mean time of all procedures was 47 min: 42 min for simple appendectomies (n = 126), 67 min for perforated appendicitis (n = 15), and 75 min for converted procedures (n = 7). Twenty-one of 148 (14.2%) patients had unexpected findings instead of appendicitis: inflamed epiploic appendices (three times), inflammatory disorders of intestine (five times), intestinal adhesions (two times), ovarian cysts (six times: one time with mesenteric lymphadenitis, one time ruptured), tubo-ovarian abscess (one time), tubal necrosis (one time), adnexitis with mesenteric lymphadenitis (one time), and acute cholecystitis (one time). These diagnoses might have been missed during conventional open appendectomy and were, if necessary, treated during laparoscopy. CONCLUSIONS: Laparoscopic appendectomy should be recommended as standard procedure for acute appendicitis.

Adhesions are common and costly after open pouch surgery.

PURPOSE: Open ileal pouch surgery leads to high rates of adhesive small-bowel obstruction (SBO). A laparoscopic approach may reduce these complications. We aimed to review the incidence of adhesive SBO-related complications after open pouch surgery and to model the potential financial impact of a laparoscopic approach purely as an adhesion prevention strategy. MATERIALS AND METHODS: We reviewed cases of open ileal pouch patients kept on a database and examined annually. Case notes were studied for episodes of adhesive SBO requiring admission or reoperation. Similar parameters were studied in a small series undergoing laparoscopic pouch surgery. The financial burden of the open access complications was estimated and potential financial impact of a laparoscopic approach modeled. RESULTS: Two hundred seventy-six patients were followed up after open surgery (median, 6.3; range, 0.2-20.1 years). There were 76 (28%) readmissions (median length of stay, 7.4 days) in 53 patients (19%) and 28 (10%) reoperations (43% within 1 year). Laparoscopic patients required less adhesiolysis at second-stage surgery (0% vs 36%, p < 0.0001) and had less SBO episodes within 12 months of surgery (0% vs 14%, p < 0.0001) than open patients. Modeling a laparoscopic approach cost $1,450 and saved $3,282, thus netting $1,832 per pouch constructed. CONCLUSION: Open ileal pouch surgery results in significant cumulative long-term access-related complications, particularly adhesions. These impose a large medical burden on patients and financial burden on health-care systems, all of which may be recouped by a laparoscopic approach, despite higher theater costs.

Practicalities and costs of adhesions.

In spite of postoperative adhesions being common there appears to be a reluctance to use anti-adhesion products routinely. This article compares the incidence of adhesions with other conditions in order to identify the level of risk. The health economics surrounding adhesion-related disease are described. This combined information may be of help to convince health practitioners of the need to take a more active role in adhesion prevention. The SCAR project has identified the risk of adhesion-related disease. This is compared with published risks of other common clinical situations. An economic model first described by the author in 2002 has been revised with 2006 costs [1]. The SCAR data demonstrates a directly related risk of re-admission in certain groups of 9.4% over 5 years [2]. The frequency of including this fact in the consenting process is low (<15%) [3]. Legal precedent has identified a risk of >2% warrants inclusion in the consent process; failure to do so could be considered negligent [4]. Use of an anti-adhesion product with a cost of 130 euros with an efficacy of 25% in 1 year in the UK could save over 40 million euros over a 10-year period. Adhesion risk is frequent enough to include in consent. Failure to do this and avoidance of treatment, which may reduce adhesions will have major financial consequences on healthcare systems.

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. Studies have shown that despite advances in surgical techniques in recent years, the burden of adhesion-related complications has not changed. Adhesiolysis remains the main treatment even though adhesions reform in most patients. Recent developments in adhesion-reduction strategies and new anti-adhesion agents do, however, offer a realistic possibility of reducing the risk of adhesions forming and potentially improving the clinical outcomes for patients and reducing the associated onward burden to healthcare systems. This paper provides a synopsis of the impact and extent of the problem of adhesions with reference to the wider literature and also consideration of the key note papers presented in this special supplement to Colorectal Disease. It considers the evidence of the risk of adhesions in colorectal surgery and the opportunities and strategies for improvement. The paper acts as a 'call for action' to colorectal surgeons to make prevention of adhesions more of a priority and importantly to inform patients of the risks associated with adhesion-related complications during the consent process.

Long-term follow-up and cost analysis following surgery for small bowel obstruction caused by intra-abdominal adhesions.

BACKGROUND: This study examined the natural course of patients following surgery for small bowel obstruction (SBO) caused by abdominal adhesions. In addition, a cost analysis was performed. METHODS: A retrospective analysis was undertaken of 102 patients who underwent surgery between 1987 and 1992 for intestinal obstruction due to abdominal adhesions. RESULTS: Median follow-up was 14 years. The 102 patients experienced 273 episodes of intestinal obstruction after the index operation, of which 237 involved inpatient readmissions; 47.3 per cent of the episodes resulted in further surgery. Single band adhesions were more common in patients with no previous abdominal surgery (P < 0.001). Some 52.0 per cent of the patients had undergone only one operation for SBO. A mean of 2.7 episodes per patient occurred after the index operation. The cost of adhesion-related problems in this study was 1,588,594 euros or 6702 euros per inpatient episode. CONCLUSION: The readmission rate in a selected cohort of patients with proven intra-abdominal adhesions was higher than reported previously. The annual cost of adhesion-related problems in Sweden was estimated as 39.9-59.5 million euros, and the cost of inpatient readmissions was almost equal to that for gastric cancer.