Application Of Long Intestinal Tube Splinting For Adhesive Small Bowel Obstruction

The high incidence and recurrent nature of adhesive small bowel obstruction(ASBO)places a significant burden on our health care system worldwide.The economic impact from adhesion-related complications such as intestinal obstructions on the US healthcare system continues its astronomical rise with estimates from 1994 at $1.3 billion dollars to over $5.0 billion dollars in 2005.Abdominal surgery is the major cause for ASBO with an incidence of 3%.The recurrence rate is high in ASBO patients no matter conservative or surgical treatment is performed.The recurrence rate of ASBO after surgery varies from 15.9%to 46%.A great deal of studies has been dedicated in attempts to prevent recurrent ASBO.However,there is no method has been proved to be safe and efficient.The long intestinal tube "stent" method of splinting is a method to prevent obstruction with encouraging adhesions to form in an orderly pattern.It has been reported that tube splinting has a recurrence rate of ASBO varying from 0%to 14.3%.The indication which was used for tube splinting by most surgeons is multiple and matted adhesions.However,it is a subjective and indefinite index.Each surgeon has different criterion about "multiple matted adhesions".Whether or not the tube splinting was performed completely depended on operator’s decision.It makes it very difficult to define a control group.Consequently,tube splinting has not been proved to prevent recurrent ASBO though it has lower recurrence rate compared with simple enterolysis.Currently,the placement of long intestinal tube through gastrostomy,jejunostomy,and nose was used by most surgeons.However,it has a high complication rate varying from 14%to 42.9%.How to decrease complication rate of tube splinting is always debated.The placement of tube via lower digestive tract is another choice for splinting small bowel.Because it was hardly mentioned in previous reports,we do not whether it has lower complication rate compared with anterograde tube splinting.Abdominal cocoon(AC)is a rare cause of intestinal obstruction,which is characterized by the encasement of the small bowel by a fibrocollagenic cocoon and widespread adhesions between loops of intestine.The incidence of adhesive small bowel obstruction(ASBO)after surgery is high.The treatment for AC is debated because there was no persuasive therapeutic result with large number of patients and long term follow-up.Long intestinal tube splinting allows loops of the intestine to adhere permanently to each other in an orderly pattern and some authors considered that it could aggravate intestine adhesions and make it difficulty for a second surgery if obstruction recurs with increased risk of intestinal injury and conglutination.In absence of study about the degree of adhesions after placement of the tube,we could not to judge this opinion.The purposes of this study are to resolve these questions:(1)investigate the efficiency of tube splinting for preventing recurrent ASBO by survival analysis.(2)compare complication rate between anterograde tube splinting and retrograde tube splinting.(3)assess the efficiency of tube splinting for reducing recurrence in AC patients by comparing the recurrence rate of ASBO between the patients who received simple enterolysis and tube splinting.(4)induce animal model of dense intestinal adhesions and assess the influence of tube splinting on postoperative intestine adhesions.Chapterl Application of retrograde long intestinal tube splinting for adhesive small bowel obstructionPart1 Estimation of the efficiency of long intestinal tube splinting for preventing recurrent adhesive small bowel obstructionObjective:After operated adhesive small bowel obstruction(ASBO),the recurrence rate is very high.Long intestinal tube splinting was reported to have low recurrence rates of ASBO.In absence of control group,tube splinting has not been proved to decrease recurrent ASBO.The aim of this study is to estimate its efficiency for preventing recurrent ASBO by survival analysis.Methods:A retrospective analysis was performed on all patients who underwent operation for postoperative ASBO between December 2001 and 2008 at our unit.Recurrent ASBO was identified by long term follow-up.Risk factors of recurrence were analyzed in the patients who did not receive tube splinting.According to the risk factors,all patients,including the patients who received tube splinting or not,were divided into high-risk recurrence group and low-risk recurrence group.The efficiency of tube splinting for reducing recurrence in each group was investigated,respectively.Results:There were 1071 patients experienced surgery for postoperative ASBO.Of them,162 patients experienced tube splinting.The median follow-up was 75 ± 22.9 months(from 2 to 135 months).The recurrence rate of ASBO was 5.5%in the patients who did not receive tube splinting,and 8%in the patients received tube splinting.The risk of recurrent ASBO increased in the patients with amount of perioperative blood loss>300ml.In high-risk recurrence group,tube splinting could reduce recurrent ASBO[P=0.045;HR=0.3(0.1-0.9)].In low-risk recurrence group,tube splinting had no influence on recurrence[P=0.91;HR= 1.1(0.2-6.0)].Conclusions:Long intestinal tube splinting could prevent recurrence of ASBO only in the patients with high risk of recurrence.For other ASBO patients,it has no efficiency.Chapterl Application of retrograde long intestinal tube splinting for adhesive small bowel obstructionPart2 Comparison of the effects for adhesive small bowel obstruction between retrograde and anterograde long intestinal tube splintingObjective:Adhesive small bowel obstruction(ASBO)is a significant cause of morbidity following abdominal surgery.After simple enterolysis,a significant number of patients will suffer recurrent ASBO.Long intestinal tube splinting is a method accepting that adhesions will form again,and fixing the bowel to ensure a favorable lie,with a low incidence of recurrent ASBO.Anterograde tube splinting is favored by most surgeons.However,the postoperative complications are noteworthy.Tube placement via lower digestive tract was hardly reported in previous reports.The aim of this study is to compare complication rates and recurrence rates of ASBO between retrograde and anterograde tube splinting.Methods:A retrospective analysis was performed on all the patients who had long intestinal tube splinting for postoperative ASBO between December 2001 and 2008 at our unit.Medical records were reviewed.Patients were followed up by telephone to identify recurrent ASBO.Results:There were 162 patients received retrograde long intestinal tube splinting.The overall complication rate was 8%,and the tube related complication rate was 0.6%.The average length of follow-up was 75±28.1 months(from 5 to 131 months).The incidence of recurrent ASBO was 5.4%.Conclusions The results from this retrospective review show that retrograde tube splinting is an effective method for preventing recurrent ASBO,which corresponds well with anterograde tube splinting.Its overall complication rate and tube related complication rate are lower than anterograde tube splinting.Chapterl Application of retrograde long intestinal tube splinting for adhesive small bowel obstructionPart3 Efficency of retrograde long intestinal tube splinting for preventing recurrent adhesive small bowel obstruction in AC patientsObjective:Abdominal cocoon(AC)is a rare cause for small bowel obstruction.Treatment of AC is controversial.The aim of this study is to investigate whether tube splinting could decrease recurrent ASBO.Methods:A retrospective analysis was performed on the patients who underwent operation for AC between December 2001 and 2008 at our unit.Recurrent ASBO was identified by long term follow-up.The efficiency of tube splinting for reducing recurrence was investigated using survival analysis.Results:There were 44 patients underwent surgery for AC.Of them,33 patients received tube splinting.The median follow-up was 79.4±124.8 months(range from 8 to 123 months).The complication rate was 9.1%in simple enterolysis group and 6.1%in tube splinting group(P=0.73).The recurrence rate of ASBO was 6.7%in tube splinting group and 40%in simple enterolysis group(P=0.02).Conclusions:Tube splinting could reduce recurrence of ASBO in AC patients.Placement of long intestinal tube would not increase postoperative complication.Chapter2 Study of the severity of intestine adhesions after long intestinal tube splintingPart1 Establishment of dense intestine adhesions model in pigObjective:Dense adhesions are an independent risk factor of recurrent adhesive small bowel obstruction.Animal study of preventing recurrent small bowel obstruction needs a reliable model.Only simple adhesions could be induced in previous adhesive models.Our purpose is to establish dense intestine adhesions model.Methods:Twelve pigs were divided into two groups.In group 1,terminal ileum was abraded using gauze;in group2,sterile sand paper was used.Fourteen days after the abrasion,another surgery was performed to investigate the severity of adhesions.Fibrosis,degree of adhesions,length of adhesive intestinal,and content of hydroxyproline were used for assess.Results:The animals in group2 had higher content of hydroxyproline and scores of degree of adhesions and fibrosis than in group 1.There was no difference in the score of length of adhesive intestine.Conclusions:Abrasion of intestine using sand paper is a safe and reliable method to induce dense intestine adhesions.Chapter2 Study of the severity of intestine adhesions after long intestinal tube splintingPart2 Influence of long intestinal tube splinting on the severity of intestine adhesionsObjective:Long intestinal tube splinting,which allows loops of intestine to adhere permanently to each other in an orderly pattern,is an effective method for preventing recurrence of adhesive small bowel obstruction.However,there is no study about severity of adhesions after tube splinting.Some authors considered that it would aggravate intestine adhesions and make it difficulty for subsequent surgery.The aim of this study is to investigate the influence of tube splinting on postoperative adhesions.Methods:The dense intestine adhesions were induced in pigs.After 14 days,enterolysis was performed and animals were divided into two groups.Group 1 was control group,and the pigs in group2 underwent tube splinting.Twenty eight days after enterolysis,the severity of adhesions was compared between two groups.Fibrosis,degree of adhesions,length of adhesive intestinal,and content of hydroxyproline were used for assess.Results:Comparison between two groups showed there were no significant differences in the scores of fibrosis,degree of adhesions,and length of adhesive intestine.The content of hydroxyproline in two groups had no difference.Conclusions:The results from this study show that the placement of long intestinal tube would not aggravate adhesions between loops of intestine.