Mini-invasive treatment in children with small-bowel obstruction (review)

Abstract

Introduction. Mechanical obstruction of the small bowel is a common problem for the adult and pediatic surgeons around the world. Small-bowel obstruction requiring more than 300,000 operation per year with the annual costs of $2.8 billion. In children, the acute small-bowel obstruction is a quite common cause of hospital admission, which required the urgent surgery. The development of small-bowel obstruction caused by the various reasons, but most frequently by the adhesions that accompanied all types of surgery. Laparotomy remains the main method of treatment children with the smallbowel obstruction. The applying of mini-invasive methods for the treatment of small-bowel obstruction is still controversial and do not widely accepted among surgeons.

The aim of the study was to generalize the causes of the adhesive processes and the experience of laparoscopic interventions in patients with small-bowel obstruction.

Material and methods. A literature search was performed using PubMed, Cochrane, and Medline databases dealt with laparoscopic treatment of smallbowel obstruction. The next key words were used for the search: small-bowel obstruction, adhesive intestinal obstruction, children, laparoscopy and laparoscopic adhesiolysis. Some limitations were used for this search which are as follows: clinical trials, randomized controlled trials, multicenter retro- and prospective trials, and experts opinion; conference abstracts were excluded due to the limited data.

Discussion. Among various etiologic agents, e.g. intussusception, volvulus, incarcerated internal hernia, the adhesion process is the leading cause of the small-bowel obstruction. The adhesion formation is nearly inevitable consequence of surgery. Adhesive small-bowel obstruction can develop after any surgical interventions, but its frequency strongly depends on children’s age and type of initial operation. The incidence rate of small-bowel obstruction in newborns ranges from 2.3% to 19.5% (6.2% on average), while in children over one year of age – from 0.1% to 14% (4.7% on average). The difference in the incidence rate between neonates and infants / children may reflect the different pathologies and procedures, as well as physiological pecularities and repair processes. Laparotomy regarding as the standard surgical intervention is accompanied by the damage of visceral peritoneum that creates the susceptibility in 10% – 30% of patients for even more adhesions, and, as the consequence, the disease recurrence and the necessity of re-operations. Despite the above-mentioned, the open adhesiolysis continues to be the most often approach to treatment in adults and children. During the dawn of mini-invasive surgery, laparoscopy was considered an unsuitable approach to small-bowel obstruction due to the dilated loops that significantly reduced the visualization and increased the risk of its iatrogenic injury. Since the first succesful laparoscopic adhesiolysis (D.F. Bastug, 1991) was performed, it was gradually acceped by adult surgeons and later by pediatric surgeons. Based on the consensus conference guidelines (2012), the only absolute exclusion criteria for laparoscopic adhesiolysis are those related to true contraindications to pneumoperitoneum, such as hemodynamic instability or cardiopulmonary impairment. All other contraindications are relative and should be judged on a case-to-case basis, depending on the laparoscopic experience of the surgeon. The open Hasson technique or special optical trocar is strongly recommended for the induction of pneumoperitoneum and the first trocar entry. The applying of 10- or 5-mm equipments more suitable due to the lower risk of the intestine injury. The literature data about the operative time of the open and laparoscopic approaches have the inconsistent results – some of surgeons indicate the shorter operative time during the laparoscopy and others, on the contrary, report about the reduced mean operative time of the laparotomy vs laparoscopy, or that the duration of these interventions is similar. The incidence rate of convertion during laparoscopic adhesiolysis ranges from 7% to 73% that dependes on surgeon experience in laparoscopic surgery. The incidence rate of adhesive obstruction recurrence was less after laparoscopic approach compared with the conventional laparotomy. Besides the well-known advantages of laparoscopy (such as better cosmetic effect, reduction of postoperative pain, and shorter period of hospitalization), laparoscopic adhesiolysis associates with the lower probability of the recurrence of adhesive obstruction, shorter time of the renewal of the first bowel motility, and the less postoperative morbidity.

Conclusions. The postoperative adhesion is the most often etiology of the small-bowel obstruction in children, but the other etiology is not excluded. The laparoscopic adhesiolysis may be the alternative approach to the conventional laparotomy providing the appropriate skills in laparoscopy. The laparoscopic adhesiolysis is characterized by the lower rates of severe postoperative complications compared with the open approach.