J. M. Hyak1, G. A. Campagna1, Z. T. Stone1, B. Johnson1,3, Y. Yu2,3, A. D. Schwartz4, E. H. Rosenfeld2, B. Naik-Mathuria2,3 4Baylor College Of Medicine,Department Of Pediatrics,Houston, TX, USA 1Baylor College Of Medicine,Houston, TX, USA 2Baylor College Of Medicine,Michael E. Debakey Department Of Surgery,Houston, TX, USA 3Texas Children’s Hospital,Department Of Surgery,Houston, TX, USA
Introduction:
Adhesive small bowel obstruction (ASBO) occurs in 1.1-8.3% of pediatric abdominal surgery patients. Our study compared surgical outcomes of non-operative and operative management of adhesive small bowel obstruction in children and assessed the impact of age on surgical management.
Methods:
We retrospectively studied children (age ≤18 years) admitted for ASBO to a tertiary academic children’s hospital from 2011-2015. Children with no prior abdominal surgery, surgery ≤4 weeks prior to admission, and complex medical conditions such as genetic or metabolic diseases were excluded. Patients were stratified by management: early operative (EO; time to surgery ≤12 hours), delayed operative (DO; time to surgery >12 hours) or non-operative (NO; discharged without operation). Rates of perforation and small bowel resection were compared using χ2 test. A receiver operating characteristic (ROC) curve was used to evaluate age as a diagnostic indicator for non-operative management. A p-value <0.05 was considered significant.
Results:
We identified 212 unique patients, comprising 269 total hospitalization, who were admitted for ASBO. Early operation was required in 58/269 (22%), failed non-operative management requiring delayed operation in 83/269 (31%), and successful non-operative management in 128/269 (48%). Mean age at admission (EO 7.7 vs DO 7.8 vs NO 8.7 years, p=0.42) and age at index abdominal surgery (EO 3.0 vs DO 3.3 vs NO 4.2 years, p=0.35) were similar.
Incidence of leukocytosis (EO 47.9% vs DO 62.9% vs NO 51.7%, p=0.206) and fever (EO 16% vs DO 8.9% vs NO 6.7%, p=0.298) did not differ between groups. There was no difference in length of stay between DO and EO (21.7±27.5 vs 18.2±22.2 days, p=0.43). Rate of bowel resection was greater in DO versus EO (27.7% vs 12.1%, p=0.026). However, bowel perforation incidence (DO 15.7% vs EO 10.3%, p=0.36) and length of bowel resected (DO 4.6±11.8 cm vs EO 6.2±25.1 cm, p=0.61) were similar. ROC analysis for age at admission yielded AUC 0.56 (p=0.07, 95% CI 0.495-0.633) for discriminating the need for surgery. Optimal criterion value for age was 1.88 years, representing the greatest accuracy in predicting non-operative management of ASBO, with sensitivity and specificity of 86.5% and 32.1%, respectively. Children ≤2 years of age had a higher operative rate than older children (61% vs. 49%, p=0.06).
Conclusion:
Though most children with ASBO are initially managed non-operatively, over one third fail conservative management, requiring delayed surgery. This results in significantly higher rates of bowel resection. Age alone did not distinguish children requiring operation from those managed non-operatively. However, we found a trend towards higher operative rate in children ≤2 years. Further studies are needed to evaluate risk factors for failing non-operative management as these children may benefit from early surgical intervention to prevent bowel loss.