ADHESIOLYSIS

Postoperative adhesions are almost inevitable after most abdominal surgeries. Postoperative adhesions account for 74% of small bowel Obstructions. The severity and extent of adhesions are, however, variable, and, fortunately, the majority of adhesions do not manifest clinically. However, in the pediatric age group, where adhesive intestinal obstruction is considered to be rare, and, because of this, the treatment is still controversial [1-4]. The outcomes of conservative treatment are variable, and a balance has to be made between this and surgical adhesiolysis which is also known to be complicated by a high rate of adhesion reformation [2,3].

The etiology of adhesion formation remains incompletely understood, and, in spite of advances in surgical techniques, there is little change in the epidemiology of adhesions. This is even so in the era of laparoscopic surgery. Adhesions continue to be mysterious not only in terms of their occurrence but also because of their complications which can occur as early as few days after surgery or remain dormant for several years after the initial procedure. The reason for this variation is not known. The causes predisposing to adhesive intestinal obstruction are also variable, but appendectomy continues to be the commonest cause. Another contributing factor for adhesion formation is multiple operations as in patients with Hirschsprung’s disease who are usually subjected to several operations. This is not related to the original operation but rather to the fact that there was more than one operation. This is specially so if there was infection or contamination. Multiple operations are known to be associated with increased deposition of fibrin which tends to form bridges between adjacent tissues leading to adhesions which can be degraded by the normal fibrinolytic factors. This, however, is not the case always, and surgery, infection, and hypoxia are known to diminish the fibrinolytic activity. The rapid wound healing in children may be the reason for the low incidence of adhesions in children when compared to adults. The exact incidence of adhesive intestinal obstruction in children is not known but has been reported to vary from 2.2% to 8.3% [1].

The treatment of adhesive intestinal obstruction is still controversial. Conservative treatment forms the basis for the management of adhesive intestinal obstruction both in children and adults. In the pediatric age group, the response to this is, however, variable. Early surgical intervention saves the child a great deal of pain and discomfort and allows a quick recovery with early discharge from the hospital. Operative adhesiolysis is, however, known to be associated with a high rate of adhesion reformation as well as the risk of inadvertent enterotomy. The recent advances in minimal invasive surgery with miniaturization of instruments have made it possible for many of the operative procedures to be carried out laparoscopically both in infants and children. This is including laparoscopic adhesiolysis which was shown to be feasible and safe in experienced hands [5].

Not only this but laparoscopy being less invasive and with its widespread use, it is expected to decrease the incidence of adhesive intestinal obstruction.

Suggested Reading:

  1. M. Wilkins and L. Spitz, “Incidence of postoperative adhesion obstruction following neonatal laparotomy,”The British Journal of Surgery, vol. 73, no. 9, pp. 762–764, 1986.
  2. Festen, “Postoperative small bowel obstruction in infants and children,”Annals of Surgery, vol. 196, no. 5, pp. 580–583, 1982.
  3. S. Janik, S. H. Ein, R. M. Filler, et al., “An assessment of the surgical management of adhesive small bowel obstruction in infants and children,”Journal of Pediatric Surgery, vol. 16, no. 3, pp. 225–229, 1981.
  4. Vijay, C. Anindya, P. Bhanu, M. Mohan, and P. L. Rao, “Adhesive small bowel obstruction (ASBO) in children—role of conservative management,”Medical Journal of Malaysia, vol. 60, no. 1, pp. 81–84, 2005.
  5. D. C. van der Zee and N. M. Bax, “Management of adhesive bowel obstruction in children is changed by laparoscopy,” Surgical Endoscopy, vol. 13, no. 9, pp

 

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