Post-Appendectomy Bowel Obstruction Paige Mallette November 4, 2010

J.O. 8 yo M 10 days s/p laparoscopic appendectomy for complicated appendicitis Post-operatively, slow to take PO and ambulate Discharged home on POD #6 with oral antibiotics Presents to ED with acutely worsening abdominal pain and emesis Last bowel movement on the day of presentation No fevers/chills

CT Abdomen:

After NG decompression - continued abdominal distension

Post-operative bowel obstruction after appendectomy 1 Records of 1684 children over 15 year period reviewed –1371 non-perforated appendicitis 954 laparoscopic 417 open –313 perforated appendicitis 221 laparoscopic 92 open Inclusion criteria: –Diagnosis verified by operative findings Exclusion criteria: –Prior abdominal procedure

Incidence of post-operative bowel obstruction (2.2% overall) –Laparoscopic: 1.9% (N = 14) –Open: 4.51% (N = 23) –p < Time interval between surgery and post-operative intestinal obstruction –Laparoscopic: 4.1 months –Open: 9.7 months –p = Post-operative bowel obstruction after appendectomy 1

Incidence in non-perforated appendicitis –Laparoscopic: 1.04% –Open: 3.35% –p = Incidence in perforated appendicitis –Laparoscopic: 1.8% –Open: 9.78% –p = Post-operative bowel obstruction after appendectomy 1

Adhesive small bowel obstruction 2 All appendectomies over a 7-year period reviewed –Laparoscopic: 628 –Open: 477 –Age and gender distribution similar 378 perforated 8 admitted for SBO (0.7%) –7/8 were perforated –Laparoscopic: 1 (0.2%) –Open: 7 (1.5%) –P = 0.01

Small bowel obstruction after open appendectomy 3 Historical review of 245,400 patients who underwent open appendectomy Cumulated risk of small bowel obstruction –Control population (matched based on age, sex & township) 0.003% at 1 year 0.21% at 30 years –Open appendectomy population After 4 weeks: 0.41% After 1 year: 0.635% (200-fold increase) After 30 years: 1.3% (6-fold increase)

Higher risk if perforated or if normal appendix Slightly lower risk in women age Risk of dying from small bowel obstruction after open appendectomy: –6 per 1 million person years –2.6 times higher than that of controls Small bowel obstruction after open appendectomy 3

Who needs an operation? 4 Review of 100 patients with SBO Independent predictors of need for operative exploration (p < 0.05) –Intraperitoneal free fluid –Mesenteric edema –Lack of “small bowel feces sign” –History of vomiting Combination of all 4 –96% sensitivity & 90% PPV

Who needs an operation? 4 Group 1 (Op) –Obstructing neoplasm –Vomiting –Free intraperitoneal fluid –Mesenteric vascular engorgement –Thickened small intestine wall Group 2 (Non-Op) –Adhesive disease –History of prior abdominal surgery –Prior hospitalization for SBO –+ feces sign

Who needs an operation? 4

References 1.Kaselas C, Molinaro F, Lacreuse I, Becmeur F. Postoperative bowel obstruction after laparoscopic and open appendectomy in children: a 15-year experience. J Ped Surg. 2009;4: Tsao K, et al. Adhesive small bowel obstruction after appendectomy in children: comparison between the laparoscopic and open approach. J Ped Surg. 2007;42: Andersson R. Small bowel obstruction after appendicectomy. Brit J Surg. 2001;88: Zielinski M, et al. Small bowel obstruction – who needs an operation? A multivariate prediction model. World J Surg. 2010;34: