Can the Laparoscopic Approach for Adhesive Small Bowel Obstruction be Used in Octogenarians? An Observational Study Using ACS NSQIP.

BACKGROUND: With the population of octogenarians projected to increase fourfold by 2050, we sought to compare outcomes of laparoscopic versus open approach in octogenarians requiring surgery for adhesive small bowel obstruction (SBO). METHODS/MATERIALS AND METHODS: Using 2006-2015 American College of Surgeons National Surgical Quality Improvement Project, we identified patients aged ≥80 y who underwent emergency surgery within 1 d of admission for SBO. Risk variables of interest included age, sex, race, body mass index, preoperative sepsis, and American Society of Anesthesiologists (ASA) classification. Outcomes included length of stay, mortality, and pneumonia. Univariable and multivariable analyses were performed. RESULTS: Eight hundred fifty-six patients were identified. Six hundred ninety-nine (81.7%) underwent laparotomy; 157 (18.3%) underwent laparoscopy. Twenty-four (15.3%) of laparoscopic cases were converted. There was no difference between the open and laparoscopic groups in age, and race, preoperative albumin, or preoperative sepsis. The open group had higher rates of totally dependent functional status, congestive heart failure, chronic obstructive pulmonary disease, and higher ASA class. There was no difference in operative time. Laparoscopy was associated with shorter length of stay. The open approach showed higher rates of postoperative pneumonia, myocardial infarct, and mortality. Multivariable analysis showed increased age, functional status, preoperative albumin, and ASA class associated with mortality. The operative approach was not associated with mortality. Postoperative pneumonia was associated with male sex and open approach. CONCLUSIONS: Age, preoperative functional status, low preoperative albumin, and ASA classes IV and V were associated with mortality, while the open approach and male sex were associated with postoperative pneumonia. Octogenarians who present with SBO due to adhesive disease may benefit from an initial laparoscopic exploration. Further prospective studies are warranted.

Laparoscopic adhesiolysis for acute small bowel obstruction: systematic review and pooled analysis.

BACKGROUND: Adhesional small bowel obstruction (SBO) occurs in 14-17% of patients within 2 years of open colorectal or general surgery. The aim of this pooled analysis is to compare the safety and efficacy of laparoscopic versus open treatment of SBO. METHODS: An electronic search of Embase, Medline, Web of Science, and Cochrane databases was performed. Weighted mean differences (WMDs) were calculated for the effect size of laparoscopic surgery on continuous variables, and pooled odds ratios (PORs) were calculated for discrete variables. RESULTS: There were eleven non-randomized comparative studies included this review. Laparoscopic surgery was associated with a significant reduction in mortality (POR = 0.31; 95% CI 0.16-0.61; P = 0.0008), overall morbidity (POR = 0.34; 95 % CI 0.27-0.78; P < 0.0001), pneumonia (POR = 0.31; 95% CI 0.20-0.49; P < 0.0001), wound infection (POR = 0.29; 95% CI 0.12-0.70; P = 0.005), and length of hospital stay (WMD = -7.11; 95 % CI -8.47 to -5.75; P < 0.0001). The rates of bowel injury and reoperation were not significantly different between the two groups. Operative time was significantly longer in the laparoscopic group (WMD = 72.31; 95% CI 60.96-83.67; P < 0.0001). CONCLUSION: Laparoscopic surgery for treatment of adhesional SBO improves clinical outcomes and can be performed safely in selected cases with similar rates of bowel injury and reoperation to open surgery. Large scale randomized controlled trials are needed to validate the findings of this pooled analysis of non-randomized data.

Laparotomy for small-bowel obstruction: first choice or last resort for adhesiolysis? A laparoscopic approach for small-bowel obstruction reduces 30-day complications.

INTRODUCTION: Small-bowel obstruction (SBO) requiring adhesiolysis is a frequent and costly problem in the United States with limited evidence regarding the most effective and safest surgical management. This study examines whether patients treated with laparoscopy for SBO have better 30-day surgical outcomes than their counterparts undergoing open procedures. METHODS: Patients with a diagnosis of adhesive SBO were selected from the ACS National Surgical Quality Improvement Program database from 2005 to 2010. Cases were classified as either laparoscopic or open adhesiolysis groups using Common Procedural Terminology codes. Chi square and Student's t test were used to compare patient and surgical characteristics with 30-day outcomes, including major complications, incisional complications, and mortality. Factors with p < 0.1 were included in the multivariable logistic regression for each outcome. A propensity score analysis for probability of being a laparoscopic case was used to address residual selection bias. A two-sided p value <0.05 was considered significant. RESULTS: Of the 9,619 SBO included in the analysis, 14.9 % adhesiolysis procedures were performed laparoscopically. Patients undergoing laparoscopic procedures had shorter mean operative times (77.2 vs. 94.2 min, p < 0.0001) and decreased postoperative length of stay (4.7 vs. 9.9 days, p < 0.0001). After controlling for comorbidities and surgical factors, patients having laparoscopic adhesiolysis were less likely to develop major complications [odds ratio (OR) = 0.7, 95 % confidence interval (CI) 0.58-0.85, p < 0.0001] and incisional complications (OR = 0.22, 95 % CI 0.15-0.33, p < 0.0001). The 30-day mortality was 1.3 % in the laparoscopic group versus 4.7 % in the open group (OR = 0.55, 95 % CI 0.33-0.85, p = 0.024). CONCLUSIONS: Laparoscopic adhesiolysis requires a specific skill set and may not be appropriate in all patients. Notwithstanding this, the laparoscopic approach demonstrates a benefit in 30-day morbidity and mortality even after controlling for preoperative patient characteristics. Given these findings in more than 9,000 patients and consistent rates of SBO requiring surgical intervention in the United States, increasing the use of laparoscopy could be a feasible way of to decrease costs and improving outcomes in this population.

Early operation is associated with a survival benefit for patients with adhesive bowel obstruction.

OBJECTIVE: To evaluate the effect of surgical delay on the outcomes of patients with adhesive small bowel obstruction (ASBO). BACKGROUND: It is generally accepted that patients with uncomplicated ASBO failing nonoperative management should be operated on within 5 days. However, the optimal time of operation within this 5-day period is unknown. METHODS: Patients requiring surgery for ASBO were identified from the National Surgical Quality Improvement Program database. Linear regression was performed to evaluate the impact of incremental surgical delay in mortality and complications. The study population was stratified by time to intervention (24-hour intervals), and logistic regression was performed to adjust for premorbid conditions and presentation physiology. The outcomes included 30-day mortality and infectious complications. RESULTS: A total of 4163 patients underwent laparotomy for ASBO. Mortality and complications increased significantly with operative delay. Delay of 24 hours or more was associated with significantly higher mortality: 6.5% vs 3.0%; adjusted odds ratio (AOR) [95% confidence interval (CI), 1.58 (1.12-2.24)]; P = 0.009. The delayed operation group (≥24 hours) also had significantly higher rates of surgical site infections [12.9% vs 10.0%; AOR (95% CI), 1.33 (1.08-1.62); P = 0.007], pneumonia (7.9% vs 5.2%; AOR (95% CI), 1.36 (1.04-1.78); P = 0.025], sepsis [7.6% vs 5.1%; AOR (95% CI), 1.45 (1.10-1.90); P = 0.007], and septic shock [6.2% vs 3.5%; AOR (95% CI), 1.47 (1.07-2.02); P = 0.018]. Early operation was associated with significantly shorter hospital stay [8.4 ± 8.3 vs 14.4±13.5 days; adjusted mean difference (95% CI), -5.2 (-5.9 to -4.4); P<0.001]. CONCLUSIONS: Early operative intervention for patients with ASBO is associated with a significant survival benefit, lower incidence of local and systemic complications, and shorter hospitalization.

Systematic review and meta-analysis of the diagnostic and therapeutic role of water-soluble contrast agent in adhesive small bowel obstruction.

BACKGROUND: This meta-analysis assessed the diagnostic and therapeutic role of water-soluble contrast agent (WSCA) in adhesive small bowel obstruction (SBO). METHODS: PubMed, Embase and Cochrane databases were searched systematically. The primary outcome in the diagnostic role of WSCA was its ability to predict the need for surgery. In the therapeutic role, the following were evaluated: resolution of SBO without surgery, time from admission to resolution, duration of hospital stay, complications and mortality. To assess the diagnostic role of WSCA, pooled estimates of sensitivity, specificity, positive and negative predictive values, and likelihood ratios were derived. For the therapeutic role of WSCA, weighted odds ratio (OR) and weighted mean difference (WMD) were obtained. RESULTS: Fourteen prospective studies were included. The appearance of contrast in the colon within 4-24 h after administration had a sensitivity of 96 per cent and specificity of 98 per cent in predicting resolution of SBO. WSCA administration was effective in reducing the need for surgery (OR 0.62; P = 0.007) and shortening hospital stay (WMD -1.87 days; P < 0.001) compared with conventional treatment. CONCLUSION: Water-soluble contrast was effective in predicting the need for surgery in patients with adhesive SBO. In addition, it reduced the need for operation and shortened hospital stay.

Management of adhesive small bowel obstruction: A distinct paradigm shift in the United States.

BACKGROUND: Recent studies show that early operative intervention in patients who fail nonoperative management of adhesive small bowel obstruction (ASBO) is associated with improved outcomes. The purpose of this study was to determine the trend in practice pattern and outcomes of patients with ASBO in the United States. METHODS: Data from the National Inpatient Sample data (2003-2013) were extracted for analysis and included patients (age ≥18 years) who were discharged with primary diagnosis codes consistent with ASBO. We analyzed the data to examine changes in mortality and hospital length of stay in addition to any trends in rate and timing of operative interventions. RESULTS: During the study period, 1,930,289 patients were identified with the diagnosis of ASBO. Over the course of the study period, the rate of operative intervention declined (46.10-42.07%, p = 0.003), and the timing between admission and operative intervention was significantly shortened (3.09-2.49 days, p < 0.001). In addition, in-hospital mortality rate decreased significantly (5.29-3.77%, p < 0.001). In the multiple logistic regression analysis, the relative risk of mortality decreased by 5.6% per year (odds ratio, 0.944; 95% confidence interval, 0.937-0.951; p < 0.001). Hospital length of stay decreased from 10.39 to 9.06 days (p < 0.001). CONCLUSION: Over the last decade, fewer patients with ASBO were managed operatively, whereas those requiring an operation underwent one earlier in their hospitalization. Although further studies are warranted, our results suggest that recent changes in practice pattern may have contributed to improved outcomes. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Survival and complication rates in 300 horses undergoing surgical treatment of colic. Part 3: Long-term complications and survival.

REASONS FOR PERFORMING STUDY: Few studies have evaluated long-term survival and complication rates in horses following surgical treatment of colic, making it difficult to offer realistic advice concerning long-term prognosis. OBJECTIVE: To review the complications occurring after discharge from hospital and survival to >12 months after surgery of 300 horses undergoing exploratory laparotomy for acute colic. Pre-, intra- and post operative factors that affected long-term complications and long-term survival were assessed. METHODS: History, clinical findings, surgical findings and procedures and post operative treatments of 300 consecutive surgical colic cases (1994-2001) were reviewed. Long-term follow-up information was retrieved from case records and telephone enquiries from owners. RESULTS: The long-term (>12 months) survival rate for 204 horses discharged after colic surgery and for which follow-up information was available was 84%. The most common complication after discharge was colic, affecting 35.1% of horses following a single laparotomy. Colic was most common in horses that had had small intestinal obstructions, bowel resection or post operative ileus. Abdominal adhesions were most common in horses that presented with severe colic due to strangulation of small intestine. Ventral hernia formation occurred in 8% of horses, and was most common in horses that had had post operative wound drainage or infection. CONCLUSIONS: This study identified various factors that appear to predispose horses to long-term complications after colic surgery. POTENTIAL RELEVANCE: Further evaluation of strategies that might reduce the incidence of such complications are needed; in particular, the value of intraperitoneal heparin should be evaluated, and procedures designed to reduce the rates of wound drainage and infection assessed.

Dialysate hyaluronan concentration predicts survival but not peritoneal sclerosis in continuous ambulatory peritoneal dialysis.

Hyaluronan is an important component of extracellular matrix and plays a critical role in early phases of wound healing. Peritoneal mesothelium is a major site of hyaluronan production. Serum hyaluronan concentration has been shown to predict survival in maintenance hemodialysis patients. We hypothesize that mesothelial production of hyaluronan during the stable phase of continuous ambulatory peritoneal dialysis (CAPD) predicts the risk of peritoneal adhesion and mortality. We studied peritoneal dialysate effluent (PDE) hyaluronan levels from 116 stable CAPD patients. They were then followed-up for 3 years. During the follow-up period, there were 196 episodes of peritonitis in 78 patients. Tenckhoff catheter was removed in 31 episodes (15.8%). Tenckhoff catheter was reinserted successfully in 12 cases, and CAPD was resumed. Peritoneal adhesion developed in 16 cases. Three patients died before Tenckhoff catheter reinsertion was attempted. There was no difference in stable-phase PDE hyaluronan levels between patients who developed peritoneal adhesion and those who did not (159 +/- 63 versus 227 +/- 194 microgram/L, P = 0.27). Thirty-three patients died during the study period. Patients who died had significantly higher PDE hyaluronan concentration than survivors (272 +/- 194 versus 170 +/- 105 microgram/L, P < 0.01). Univariate analysis showed that increased PDE hyaluronan level was associated with a shorter patient survival (P < 0.001). There was no association between PDE hyaluronan level and serum albumin, protein nitrogen appearance, and percentage of lean body mass. Multivariate analysis confirmed that PDE hyaluronan level, serum albumin, and diabetic state were independent predictors of survival. We conclude that PDE hyaluronan level during stable phase of CAPD does not predict the risk of postperitonitis adhesion. However, it is a strong independent predictor of survival in CAPD patients.

Prognostic factors in patients with stage I epithelial ovarian cancer.

We analyzed factors predictive of relapse risk in patients with stage I invasive epithelial ovarian cancer: 252 patients from the Princess Margaret Hospital provided a data base for hypothesis generation, and data on 267 patients from the Norwegian Radium Hospital were used for hypothesis testing. The outcomes in most analyses in the two series were very similar, validating the following conclusions. Differentiation (grade) was the most powerful predictor of relapse, followed by dense adherence (which resulted in outcomes equivalent to those in stage II) and, finally, large-volume ascites. When the effects of these three factors were accounted for, then none of the following were prognostic: bilaterality (stage Ib), cyst rupture (stage Ic), capsular penetration (stage Ic), tumor size, histologic subtype, patient age, year of diagnosis, and postoperative therapy. These results allow simplification of stage I substaging, as only differentiation, dense adherence, and large-volume ascites (? peritoneal cytology) need be considered. The 5-year relapse-free rate was 98% in patients with grade 1 tumors in whom both dense adherence and large-volume ascites were absent. These patients are adequately treated by operation alone. Although the relapse risk was high enough in the remaining patients to warrant postoperative treatment, a significant benefit could be shown only for a small subset of patients, namely those with densely adherent tumors treated with abdominopelvic radiotherapy. In grades 2 and 3, none of the therapies used in either series was superior to pelvic radiotherapy or operation alone.

Treatment and outcome of right colon cancers adherent to adjacent organs or the abdominal wall.

Fifty-four (4%) of 1284 patients treated for adenocarcinoma of the colon and rectum during a 10-year period ending in 1989 underwent potentially curative resection of right colon lesions found during surgery to be adherent to adjacent organs, abdominal wall, or retroperitoneum. Final pathologic staging was as follows: modified Dukes' class B1 (n = 2), B2 (n = 24), C1 (n = 1), and C2 (n = 27). Thirteen (24%) patients had postoperative complications, including two (3.7%) with sepsis. One patient died after surgery (mortality, 1.9%). Survival rates at 1, 3, and 5 years were 74%, 52%, and 37%, respectively. Only one (11%) of nine patients with pancreatic or duodenal adherence treated with limited resection was free of disease during follow-up. Adjuvant radiation therapy and chemotherapy did not improve survival. Histologic depth of tumor penetration could not be predicted by intraoperative assessment, and therefore radical resection is recommended whenever possible.

Intestinal obstruction.

One hundred severty-one cases of mechanical intestinal obstruction were studied. One hundred fifteen had small bowel obstruction and fifty-six had large bowel obstruction. Adhesion (32.8 per cent), hernia (21.6 per cent), and neoplasm (18.1 per cent) were the cause of obstruction in more than 70 per cent of all cases. More than 40 per cent of patients were older than 60 years and the average age was 52.7. The numbers of males and females were approximately equal. There were twice as many whites as blacks, and the mortality rate was higher among blacks. The overall uncorrected mortality rate was 18.7 per cent. Operation was performed in 105 patients (61.4 per cent), with a postoperative mortality of 19 per cent and corrected postoperative mortality of 4.5 per cent. Contributing factors that were significant were high incidence of metastatic diseases, elderly patients, and delay in admission.

Abdominal surgery in foals: a review of 119 cases (1977-1994).

The case records of 119 young horses (all less than age one year) that underwent an exploratory celiotomy during a 17 year period were examined to determine the surgical findings, short- and long-term outcome, and prevalence of small intestinal disease compared to previous reports in the mature horse. Physical and laboratory values were compared for long-term survivors vs. nonsurvivors and the frequency of post operative intra-abdominal adhesions was determined. The most common cause for exploratory celiotomy was small intestinal strangulation, followed by enteritis and uroperitoneum. Six horses died during surgery, 23 were subjected to euthanasia at the time of surgery due to a grave prognosis, and 17 horses died or were destroyed after surgery, prior to discharge from the hospital; the short-term survival was 61%. Nine horses were lost to follow-up. Forty-one horses survived long-term (at least 6 months after surgery), 15 died or were subjected to euthanasia after discharge for reasons related to the prior abdominal surgery, and 8 died or were destroyed after discharge due to unrelated reasons, making the long-term survival 45%. Fifty-three (45%) of the horses presented as neonates, and 66 (55%) presented age 3-12 months. Uroperitoneum and meconium impaction were the most common disease in the neonate. Intussusception and enteritis were the most common diseases in older foals. The overall prevalence of small intestinal disease was 44%. Significant elevations in packed cell volume, heart rate, nucleated cell counts and total protein in abdominal fluid and rectal temperature were observed in nonsurvivors compared to survivors. Nonsurvivors had significantly decreased serum bicarbonate, chloride, sodium, and venous pH values. There was no evidence that location of the lesion affected long-term survival. Horses with a simple obstruction had a higher survival percentage than those with a strangulating obstruction, and horses that underwent an intestinal resection had a lower long-term survival than those horses undergoing only intestinal manipulation. Nineteen (33%) of the foals examined after the original surgery had evidence of intra-abdominal adhesions. Nine of these (16%) had adhesions that caused a clinical problem.

Retrospective analysis of the results of 151 exploratory laparotomies in horses with gastrointestinal disease.

Of 149 horses that underwent 151 exploratory laparotomies for gastrointestinal disorders from September 1987 to May 1991, 107 (72%) were discharged from the hospital: 100 (66%) survived for > 7 months, 94 of which returned to their intended use. Survival rate (64/80) for horses with caecum/large colon obstruction was significantly (P = 0.003) higher than for horses with small intestinal obstruction (33/64). Prolonged surgery was associated with significantly (P < 0.001) lower survival rates than short surgical time. In the large intestine, survival rate (15/29) for strangulated obstructions was significantly (P < 0.001) lower than for simple obstructions (52/58). Generalised septic peritonitis (9 horses) and bowel obstruction associated with adhesions (8 horses) were the most frequent fatal post-operative complications. The rate (6/44) of post-operative adhesions after small intestinal obstruction was significantly (P = 0.006) higher than that (2/68) following large intestinal obstruction. The rate (8/55) of post-operative adhesion formation in horses that required enterotomy/enterectomy was significantly (P = 0.003) higher than that (0/57) in horses that did not require gut wall incisions. Incisional suppuration developed in 42 horses and occurred with a significantly (P = 0.028) higher rate (32/72) after caecum/large colon lesions than after obstruction at other sites, (10/42) but was not associated with known contamination at the time of surgery (P = 0.806).

Adhesion intestinal obstruction in children in northern Nigeria.

In developing countries, reports on adhesion intestinal obstruction in children are scanty. We report 30 children managed for adhesion intestinal obstruction during a 16-year period. The age range was 10 weeks-14 years (median 9 years). There were 24 boys and 6 girls. Postoperative adhesion was the cause in 13 (43%) patients, inflammatory in 11 (37%), and in 5 (17%) no cause could be identified. In one patient, adhesion followed missed ileal perforation from blunt abdominal trauma. Duration of symptoms was 1-21 days (median 4 days). Only four of the 13 patients with postoperative adhesion obstruction were managed conservatively initially, but this failed in all; one was found to have an intestinal perforation at laparotomy. The remaining nine had immediate laparotomy owing to presence of features of strangulation at presentation; two required intestinal resection for gangrene. All other patients had laparotomy soon after resuscitation. The resection rate for gangrene was 13% and 3% required closure of perforations. Postoperatively six (20%) patients developed eight infective complications. There was recurrence in three of 27 (11%) surviving patients within 3 months. Mortality was three (10%). The presentation of adhesion intestinal obstruction in children in northern Nigeria is late and morbidity and mortality are high. Early presentation should improve the outcome.

'Let's just wait one more day': impact of timing on surgical outcome in the treatment of adhesion-related small bowel obstruction.

Controversy exists but most surgeons agree that surgical treatment for failed conservative management of adhesion-related small bowel obstruction (SBO) should be within 48 hours. However, many find themselves delaying definitive treatment in the hopes of resolution. Our aim was to determine what impact timing has on surgical outcomes of SBO. A retrospective review of all consecutive patients surgically treated for adhesion-related SBO was performed from January 2001 to August 2006. Study groups included patients treated emergently (less than 6 hours), expeditiously (6 to 48 hours), and delayed (greater than 48 hours). Laparoscopic, open, and converted treatment types were controlled for as confounding variables using analysis of variance. Outcome measures were return of bowel function after surgery (RBF), length of stay after surgery (LOS), and morbidity. There were 27 emergencies, 30 treated expeditiously, and 34 delayed. Groups were matched in age and gender. RBF after surgery was significantly longer for those delayed in treatment compared with those treated expeditiously (greater than 48 hours = 7.4 days vs less than 6 hours = 7.6 and 6 to 48 hours = 5.4; P < .05) as well as LOS after surgery (greater than 48 hours = 12.3 days vs less than 6 hours = 10.1 and 6 to 48 hours = 7.6; P < 0.05). Patients treated with laparoscopy within 6 to 48 hours had a significantly shorter RBF and LOS than any other combination of timing and treatment. Postoperative morbidity was higher in the delayed group (79%) than the other groups (44% emergent and 40% expeditious) (P < 0.05). There was one death in the delayed group. Delaying surgical treatment beyond 48 hours for SBO is common and results in worse outcomes and longer LOS. Laparoscopic treatment within 48 hours is superior to open treatment.

Laparoscopic versus open adhesiolysis in patients with adhesive small bowel obstruction: a systematic review and meta-analysis.

BACKGROUND: The objective of this study was to evaluate whether surgical outcomes differ between laparoscopy versus the open approach for adhesive small bowel obstruction. METHODS: PubMed, MEDLINE, Embase, and the Cochrane Library databases were electronically searched from 1985 to 2010. The study pooled the effects of outcomes of a total of 334 patients enrolled into 4 retrospective comparative studies using meta-analytic methods. RESULTS: Laparoscopic adhesiolysis was associated with a reduced overall complication rate (odds ratio = .42, .25-.70, P < .01), prolonged ileus rate (odds ratio = .28, .10-.73, P = .01) and pulmonary complication rate (odds ratio = .20, .04-.94, P = .04) compared with the open approach. No significant differences were noted for intraoperative injury to bowel rates (odds ratio = 1.93, .76-4.89, P = .17), wound infection rates (odds ratio = .44, .17-1.12, P = .08), and mortality (odds ratio = .81, .12-5.49, P = .83). CONCLUSIONS: Laparoscopic adhesiolysis is advantageous in most of the analyzed outcomes. Laparoscopic treatment of small bowel obstruction is recommended by experienced laparoscopic surgeons in selected patients.

Auto-cross-linked hyaluronic acid gel does not reduce intra-abdominal adhesions or abscess formation in a rat model of peritonitis.

BACKGROUND: Prevention of adhesion and abscess formation would decrease mortality and morbidity after peritonitis. In this study the effect of a new anti-adhesive, auto-cross-linked hyaluronic acid polysaccharide (ACP) gel, on adhesion and abscess formation was studied in a rat peritonitis model. MATERIALS AND METHODS: In experiment 1, bacterial peritonitis was induced in 24 Wistar rats, using a cecal ligation and puncture model. Animals were randomized to receive 4 mL ACP gel (4%) or 4 mL phosphate buffered saline (PBS). After 2 weeks animals were killed and adhesions and abscesses were scored. In experiment 2, 72 rats underwent the same procedure but were randomized to receive 2 mL ACP gel, 4 mL ACP gel, or 4 mL PBS. After 1 and 3 weeks, respectively, half of the animals in each group were killed and adhesions and abscesses were scored. RESULTS: The median total adhesion score was 12 (range, 3-20) in the ACP group and was 9 (range, 6-12) in the PBS group (not significant) in experiment 1. 91% of rats in the ACP group developed abscesses, versus 90% in the control group. There were no significant differences in abscess size or number of abscesses. In experiment 2, total adhesion scores in the 2 mL ACP group, 4 mL ACP group, and PBS group were 4 (range, 2-20), 6 (range, 1-11), and 6 (range, 1-18), respectively, (not significant) after 1 week and 3.5 (range, 1-8), 5 (range, 2-15), and 4 (range, 0-9), respectively, (not significant) after 3 weeks. All rats in the 2 mL ACP group and the PBS group and 83% of the 4 mL ACP group had developed abscesses after 1 week. After 3 weeks these percentages were 80, 75, and 73, respectively. There were no significant differences in size or number of abscesses between groups both after 1 and 3 weeks. CONCLUSION: ACP does not reduce adhesion and abscess formation in a rat peritonitis model.

Incidence of postoperative adhesion obstruction following neonatal laparotomy.

Of 649 neonates undergoing laparotomy in a 10 year period, 54 (8.3 per cent) developed adhesion related intestinal obstruction requiring surgical treatment. In 16 infants the obstruction followed a period of prolonged postoperative ileus, while the remaining 38 had completely recovered from the previous surgical procedure before the development of obstruction. The adhesion obstruction occurred after a single neonatal laparotomy in 35 cases but the remaining 19 had undergone subsequent laparotomies; 75 per cent of the obstructions developed within 6 months and 90 per cent within 1 year of surgery. The highest risk groups were infants undergoing correction of gastroschisis (15.4 per cent) and malrotation (15 per cent). There were nine deaths, two of which were a direct consequence of the adhesion obstruction.