Changing patterns and surgical outcomes of small bowel obstruction in the era of minimally invasive surgery for colorectal cancer

Abstract

Introduction: This study aimed to investigate whether the incidence, patterns, and surgical outcomes of small bowel obstruction (SBO) have changed in the era of minimally invasive surgery (MIS) for primary colorectal cancer (CRC). Methods: Consecutive patients who underwent laparotomy for SBO were divided into MIS and traditional open surgery (TOS) groups based on the previous colorectal cancer operation technique used. The MIS group was selected from 1,544 consecutive patients who underwent MIS as a treatment for primary CRCs between 2014 and 2022, while the TOS group was selected from 1,604 consecutive patients who underwent TOS as a treatment for primary CRCs between 2004 and 2013. The demographics, clinicopathological features, and surgical outcomes were compared between the two groups. Results: The SBO incidence in patients who underwent MIS for primary CRC was significantly lower than that in patients who underwent TOS (4.4%, n=68/1544 vs. 9.7%, n=156/1604, P<0.0001). Compared with the TOS group, the MIS group had significantly different (P<0.0001) SBO patterns: adhesion (48.5% vs. 91.7%), internal herniation (23.5% vs. 2.6%), external herniation (11.8% vs. 1.9%), twisted bowel limbs (4.4% vs. 0.6%), ileal volvulus with pelvic floor adhesion (5.9% vs. 1.9%), and nonspecific external compression (5.9% vs. 1.3%). A subset analysis of patients with adhesive SBO (ASBO) showed that the MIS group tended to (P<0.0001) have bands or simple adhesions (75.8%), whereas the TOS group predominantly had matted-type adhesions (59.4%). Furthermore, SBO in the MIS group had an acute (<3 months) or early (3–12 months) onset (64.7%), while that in the TOS group (P<0.0001) had an intermediate or a late onset. When the surgical outcomes of SBO were evaluated, the TOS group had significantly more (P<0.0001) blood loss and longer operation time; however, no significant difference was observed in the surgical morbidity/mortality (Clavien-Dindo classification ≧3, 11.8% vs. 14.1%, P=0.6367), hospitalization, and readmission rates between the two groups. Postoperative follow-up showed that the estimated 3-year (11.37% vs. 18.8%) and 6-year (25.54% vs. 67.4%) recurrence rates of SBO were significantly lower ( P =0.016) in the MIS group than in the TOS group. Conclusions: The wide adoption of MIS to treat primary CRC has led to a lower incidence, altered patterns, and reduced recurrence rates of SBO. Awareness of this new trend will help develop surgical techniques to prevent incomplete restoration of anatomical defects and bowel malalignments specifically associated with MIS for CRC, as well as facilitate timely and appropriate management of SBO complications whenever they occur.