Population Level Analysis of Adhesive Small Bowel Obstruction: Sustained Advantage of a Laparoscopic Approach.

Objective: The objective of this study was to determine the effects of open versus laparoscopic surgery on the development of adhesive small bowel obstruction (aSBO). Summary Background Data: aSBO is a significant contributor to short and long-term postoperative morbidity. Laparoscopy has demonstrated a protective effect in colorectal surgery, but these effects have not been generalized to other abdominal procedures. Methods: Population level California state data (1995-2010) was analyzed. We identified patients who underwent Roux-en-Y gastric bypass (RYGB), cholecystectomy, partial colectomy, appendectomy, and hysterectomy. The primary outcome was aSBO. Clinical, patient, and hospital characteristics were assessed using Kaplan-Meir methodology and Cox regression analysis adjusting for demographics, comorbidities, and operative approach. Results: We included 1,612,629 patients with a median follow-up of 6.3 years. The 5-year incidence rate of aSBO was higher after open surgery compared with laparoscopic surgery for each procedure (RYGB 2.1% vs. 1.5%,P< 0.001; cholecystectomy 2.2% vs. 0.65%,P< 0.001; partial colectomy 5.5% vs. 2.8%,P< 0.001; appendectomy 0.58% vs. 0.35%,P< 0.001; and hysterectomy 0.89% vs. 0.54%,P< 0.001). The period of greatest risk for aSBO formation was within the first 2-years. In multivariate analysis, an open approach was associated with an increased risk of aSBO for each procedure [RYGB hazard ratio (HR) 1.24,P< 0.001; cholecystectomy HR 1.89,P< 0.001; partial colectomy HR 1.49,P< 0.001; appendectomy HR 1.45,P< 0.001; and hysterectomy HR 1.16,P< 0.001). Conclusions: Laparoscopy is associated with a significant and sustained reduction in the rate of aSBO. The period of greatest risk for aSBO is within the first 2 years after surgery.