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recent year, 948,000 hospital days of care were required for treatment of
SBO.6 The same study suggests that Medicare alone is paying $3.2 billion
per year for treatment of SBO, and currently there are 117 hospitalizations
per 100,000 people for treatment of bowel obstruction.6 In several
countries in Europe, the medical costs for SBO were greater than the costs
for gastric cancer and almost as much as for colon cancer.7,8 Although
initial studies suggested that the increased role of minimally invasive
surgery did not appear to have significantly reduced the incidence of
adhesive SBO, more recent studies suggests that SBO incidence is lower
in patients who undergo a minimally invasive procedure. Clearly, given
the magnitude of this problem, finding a prevention for or cure of this
costly and frustrating complication should be a priority for American
medicine.
Etiology of SBO
Any discussion of SBO mandates a discussion of adhesions and the role
they play in the disease. Although adhesions rarely lead to obstruction of
the large bowel, they account for more than 70% of all SBOs.2 A review
of the literature regarding the etiology of SBO confirms that in the United
States, adhesions constitute the major source of SBO by a large mar-
gin9-12 (Table 2). Other causes of SBO include hernia (most common
cause of SBO in undeveloped countries), cancer, inflammatory bowel
Curr Probl Surg, November 2012 643
TABLE 3. Lexicon of small bowel obstruction
Less serious More serious
Partial Complete
Low grade High grade
Simple Closed loop
Low High
Ileus Mechanical
Chronic Acute
Intrinsic Extrinsic
FIG 4. Generalized peritoneal inflammatory response associated with injury. Note the rise and time
course for fibrin and mesothelial cells. (Reprinted with kind permission of Springer Science⫹Business
Media from DiZerega GS, ed. Peritoneal Surgery. New York: Springer-Verlag, 2000.)
and the injury may include exposure to intestinal contents. The healing
attempt begins with the formation, through coagulation, of a fibrin-
rich exudate through which mesothelial cells can migrate and accom-
plish reepithelialization.
648 Curr Probl Surg, November 2012
FIG 5. Biochemical events associated with peritoneal injury and possible adhesion formation. tPA,
tissue plasminogen activator; PAI, plasminogen activator inhibitor; uPA, urokinase plasminogen
activator. (Reprinted with permission from Attard and MacLean.13)
There is sound logic behind the use of such agents, although their effective-
ness has been somewhat limited. Reports in the literature describe the
effective use of a large number of pharmacological agents in experimental
animal studies.25 However, few agents progress to clinical trials.
Several compounds in the laboratory have been noted to decrease adhe-
sions by interfering with fibrin deposition: nonsteroidal anti-inflammatory
drugs (NSAIDs), heparin, and corticosteroids. NSAID action targets prosta-
glandin synthesis, decreasing the inflammatory response from the start.26
Heparin acts directly on the coagulation cascade by inhibiting the internal
pathway of the coagulation cascade by acting on factor Xa and thrombin via
antithrombin. Corticosteroids may also have potential to inhibit adhesion
formation via immune modulation, but studies have not been able to
demonstrate this convincingly.27 Drugs that alter the inflammatory response
following operation have been most studied. The drugs include steroids and
the NSAIDs. The balance between adhesion reduction and acceptable
systemic side effects, such as bleeding and impaired wound healing has been
difficult to overcome for these agents. Therapeutic anticoagulation to prevent
fibrin deposition or the use of streptokinase to promote fibrinolysis has not
had a significant effect on adhesion reduction in animal studies, and again
there is the concern for the risk of postoperative bleeding. The results from
studies using streptokinase and urokinase have been equivocal or even
harmful in some studies.13
For a thorough review of the status of pharmacological strategies for
adhesion prevention, we recommend recent articles by Attard and
Maclean13; and Lauder and colleagues.,25 Obviously, a pharmacologic
agent that would reduce inflammation and optimize fibrinolysis postop-
eratively without causing bleeding or impairing wound healing would be
an ideal candidate for adhesion prevention.18
Laparoscopic vs. Open Surgery and Adhesions
Surgeons who perform laparoscopic surgery appreciate and recognize
that adhesion formation is less after laparoscopic procedures, such as
cholecystectomy and hernia repair, than after the same procedures performed
Curr Probl Surg, November 2012 651
as open operations. This is believed to be so because there is less damage to
the peritoneum— both parietal and visceral—and less handling of the tissue
with laparoscopy. Gutt and colleagues, general surgeons, wrote about this
in 2004.28 They reviewed the published literature on this topic and found
15 reports to evaluate from 1987 to 2001: 3 clinical and 12 experimental.
In the 3 clinical studies, adhesions following laparoscopy were less than
after open surgery in comparable groups of patients. Lundorff and
colleagues evaluated adhesions at the operative site after open and
laparoscopic operation for ectopic tubal pregnancy in 73 women.29 The
authors found significantly fewer adhesions at the operative site in the
laparoscopic group. Milingos and colleagues found similar results in
patients who had surgical adhesiolysis for infertility.30 A third study
compared adhesion formation between the liver bed, the omentum, and
the duodenum after open or laparoscopic cholecystectomy.31 After open
cholecystectomy, all patients (100%) had thick extensive adhesions to the
operative site vs. 44% of patients after laparoscopic cholecystectomy, and
these adhesions were loose and easy to separate. In this analysis of the
data, the authors concluded that laparoscopic surgery is associated with a
reduction in the formation of adhesions after abdominal operations in all
clinical and most experimental studies.
An update of the current role of the topical gels and the membrane
barriers for the surgeon to use in the operating room will not be given
here; it is the subject of the last section in this monograph.
ments, sepsis, organ failure, and drug and medication toxicity each can
contribute to an ileus. Many drugs affect the sympathetic and parasym-
pathetic innervation of the gut and thus motility. The opiates, calcium
channel blockers, psychotropic drugs, and pain medicines are common
contributors to ileus. It is important to remember that in the surgical
patient, unrecognized or untreated infection either in the abdomen or the
chest is often a cause of prolonged ileus.45
Distinguishing mechanical SBO from ileus is best assisted by radio-
graphic examinations. First, the plain films will demonstrate whether an
obstruction is present. The CT scans of the abdomen and pelvis with oral
contrast show where the obstruction is and what the lesion is. When ileus
is present, there is no focal point of obstruction; gas and liquid are seen
throughout the small bowel and colon. There is no transition zone as one
Curr Probl Surg, November 2012 659
sees with SBO with dilated bowel upstream and decompressed bowel
distally. An added benefit of the CT scan is that it images the entire
abdomen and its contents and can identify other causes for the ileus and
abdominal distention, such as an abscess, diverticulitis, or pancreatitis,
which is really the patient’s problem.
Fortunately, today we have very good imaging techniques to help us
evaluate the bowel and its neighboring organs. When the gut is not working,
we have total parenteral nutrition (TPN) and good critical care units to
support the patient until the underlying conditions can be treated.
Small Bowel vs. Large Bowel Obstruction. With the assistance of
high-quality body imaging techniques, it is usually possible for the
surgeon to distinguish SBO from a large bowel obstruction (LBO). Yet,
there is some overlap in the signs and symptoms that can make this
distinction a challenge when one first sees the patient in the office or the
emergency department.
The symptoms of SBO are abdominal distention, crampy abdominal pain,
nausea, vomiting, and constipation. Vomiting, bilious or feculent, is com-
mon, whereas this is a later event in colonic obstruction. Paroxysms of
abdominal pain occurring at 4-10-minute intervals are typical.
Large bowel obstructions, usually from colon cancer or strictures from
diverticulitis, are seldom acute; there is usually a several-day to several-week
history of constipation and change in bowel habits. Mid abdominal pain and
abdominal distention are the 2 most consistent signs. Blood in the stool and
anemia are strongly suggestive of carcinoma. Per rectal examination, an
empty rectal vault is suggestive of a proximal colon obstruction, and blood on
the examining finger indicates a distal lesion. Diarrhea may be present as a
function of liquid stool passing around the obstructing lesion. The abdomen
is distended and tympanic as with the SBO. Cascading bowel sounds and
borborygmus are often present, whereas high-pitched bowel sounds are heard
only if there is superimposed SBO. Patients with LBO are likely to be more
elderly than the SBO group of patients.
The progression of symptoms in colonic obstruction depends in part on the
patency of the ileocecal valve. If this valve is incompetent, there is retrograde
decompression of the colon, the onset of symptoms will be gradual, and there
may be some feculent vomiting. Radiologic studies are the most important
diagnostic tools to establish the presence or absence of colonic obstruction
and the location. Plain abdominal radiographs should be obtained first in the
upright (if possible) and supine positions. These will show mild to marked
distention of the colon proximal to the lesion and may show small bowel
distention if the ileocecal valve is incompetent (Fig 9). The plain radiographs
can be diagnostic for cecal volvulus and sigmoid volvulus (Figs 10, 11A and
660 Curr Probl Surg, November 2012
FIG 9. Distended large bowel with competent ileocecal valve in a patient with obstructing rectal
carcinoma. (Reprinted with permission from Jon Lund, http://learncolorectalsurgery.com/#/abdominal-
x-ray/4549818580.)
(⬎95%) that there will be clinical resolution without the need for
operation; otherwise the SBO must be considered complete and operation
should be planned if there are no clinical signs of resolution (Fig 18).
It has been suggested that the oral administration of a small quantity (eg,
100 mL) of gastrograffin can lead to the resolution of SBO. Gastrograffin
is a hyperosmolar liquid that draws water into the bowel lumen, perhaps
improving bowel edema and enhancing contractility. It should be used
cautiously in patients at risk for pulmonary aspiration, as introduction of
the material into the bronchial tree can cause life-threatening pneumoni-
Curr Probl Surg, November 2012 669
FIG 19. Barium small bowel follow-through revealing a tight stricture (arrow) in the terminal ileum in
a patient with partial SBO and known Crohn’s disease.
FIG 21. Internal hernia after gastric bypass with dilated loops of small bowel and classic mesenteric
swirl (arrow).
FIG 23. Typical “bulls eye” (arrow) or “target sign” associated with small bowel intussusception
causing SBO. (Reprinted with permission from James Heilman, MD, http://commons.wikimedia.org/
wiki/File:VolvulusCT.PNG.)
obstruction. This virtually always brings relief to the patient and also
protects against aspiration. Although long tubes with mercury-filled bags
at the end were used in past surgical periods, virtually nobody uses long
tubes today because of the complexity of their management and little
evidence that their efficacy is any greater than standard length NG
tubes.54 In fact, multiple prospective studies show no advantage to using
the longer tubes.
The use of antibiotics in patients with SBO is also somewhat contro-
versial. Although no one argues with the need for preoperative antibiotics
in the patient with bowel obstruction who is going to surgery, there
appears to be little evidence that antibiotic use in the patient with SBO is
indicated, and few practitioners administer antibiotics while patients are
being observed.
The clinical spectrum of SBO varies widely, but the 9 most common
clinical scenarios include (l) complete bowel obstruction, (2) partial
SBO— high grade, (3) partial SBO—low grade, (4) bowel obstruction in
a virgin abdomen, (5) recurrent SBO, (6) bowel obstruction immediately
after operation, (7) bowel obstruction in a patient with known malignancy
or recurrent malignancy, (8) bowel obstruction with a known history of
Crohn’s disease and (9) SBO after gastric bypass (Table 5). A brief
consideration of each of these clinical scenarios is helpful in deciding the
best management course. The actual decision-making process for patients
with SBO is often the most difficult and challenging of any area in
gastrointestinal surgery. The clinician must be very alert and aware as he
or she manages the patient after admission to look for any signs of
improvement or deterioration. Multiple follow-up abdominal radiographs
must be obtained associated with frequent clinical reexaminations to
monitor the progress of the patient.
Patients with complete bowel obstruction merit the closest and most
critical attention. Because of the dangers of incarceration leading to
strangulation as well as closed loop obstructions, patients with complete
676 Curr Probl Surg, November 2012
bowel obstruction demand immediate attention. If a patient presents with
significantly distended bowel, a history of obstipation for the past 12
hours, and no recent improvement, consideration should be given to going
to the operating room immediately. This is particularly true if the patient
has unrelenting pain and the classic tetrad associated with strangulated
bowel, including leukocytosis, fever, tachycardia, and severe abdominal
pain. The dictum that “the sun should never set on a complete bowel
obstruction” is as true today as it was 50 years ago.
Patients presenting with significantly distended bowel and crampy abdom-
inal pain, but who have evidence of gas in the colon and rectum on the
abdominal radiographs as well as a recent history of having passed flatus
(high-grade partial SBO), may be admitted for initial observation. These
patients also require very close vigilance. They should be reexamined on a
regular basis, and repeat abdominal radiographs should be obtained every 8
to 12 hours to see whether the distended bowel is worsening or improving.
Patients with partial high-grade SBO should begin to improve within 24 to 48
hours. It is clear that most cases of adhesive SBO that are likely to resolve
will do so within 48 hours. Patients with high-grade obstruction who do not
improve within 24 hours of admission should be taken to the operating room
for exploration. Few other diagnostic studies are indicated, although occa-
sionally a CT scan will confirm the point of obstruction and edema of the
bowel proximal to the obstruction.
The category of patients who have a low-grade partial SBO characteristi-
cally have less abdominal distension and have passed some gas or stool
recently but continue to have crampy abdominal pain and appear to partially
resolve but become symptomatic on liquid or oral intake. With less
distension, less abdominal pain, and radiographs that reveal some improve-
ment in the bowel gas patterns, these patients can be safely watched up to 5-7
days as long as improvement is seen. This group of patients often benefit
from an enteroclysis study to demonstrate the site of obstruction and degree
of luminal narrowing. A contrast study that shows substantial dilation
proximal to the obstruction site and slow passage of contrast through the
obstructed site after 5 days indicates the patient should probably be taken to
the operating room for adhesiolysis. On the other hand, if the patient
continues to improve, distension diminishes, and radiographs reveal resolu-
tion of air-fluid levels, the patient may be cautiously placed back on clear
liquids and advanced to a low-fiber diet as tolerated.
Patients with bowel obstruction and a virgin abdomen virtually always
merit an exploratory laparotomy for either diagnostic purposes or surgical
treatment of the offending etiology. Most commonly, the cause is
incarceration in an abdominal wall hernia (Fig 26), but other causes
Curr Probl Surg, November 2012 677
FIG 26. Cross table lateral radiograph revealing incarcerated umbilical hernia (arrow) in a patient
with a virgin abdomen. (Reprinted with permission from WetPaint, http://wikiradiography.com/
page/Small⫹Bowel⫹Obstruction.)
foreign bodies). All the aforementioned can initially be approached via laparos-
copy.
The most obvious advantages of performing laparoscopy rather than open
surgery for SBO include avoiding laparotomy, and therefore the postlapa-
rotomy recovery, as well as minimizing the postoperative risks of laparoto-
my-related adhesions and ventral hernia. Even if it becomes prudent to
convert to an open operation (cancer-related adhesions or inability to
technically complete the operation laparoscopically), the eventual laparotomy
incision may be limited based on the laparoscopically diagnosed location of
the problem.
An initial laparoscopic approach can allow for access away from the
midline incision to minimize enterotomy of bowel adherent to a previous
midline laparotomy. Even if a later conversion to open surgery is
required, the adhesions might be able to be laparoscopically cleared from
a portion of the midline incision, allowing for safer open access. With the
creation of pneumoperitoneum, the bowel tends to hang from the abdominal
wall, creating natural traction on the adhesive bands. The tented abdominal
wall acts to create countertraction. This effect can be enhanced for adhesions
off the midline by tilting and rotating the table to maximize this effect. In
small condensed spaces, the laparoscope can be brought in close to the tissues
to be lysed, and the magnified view may facilitate better visualization (Fig
30). If localized dense adhesions are encountered that cannot be lysed
Curr Probl Surg, November 2012 685
FIG 30. Excellent view of adhesions seen through the laparoscope. Lysis with “cold” scissors can be
safely done in this setting.
and 60% of all patients who present with an SBO require operation,70,71
and after an operation for lysis of adhesions, the incidence of recurrent
adhesive SBO leading to an operation ranges from 11% to 21%.72,73
Operative procedures to prevent recurrent SBO have been generally
disappointing and only occasionally successful. Suture plication has gener-
ally had poor results and is used by few surgeons today. Somewhat more
successful has been an operatively placed Baker long intestinal tube, which
is passed through the stomach like a Stamm gastrostomy, traverses the entire
length of the small intestine, and reaches the cecum where a 30 mL balloon
is filled with saline to prevent the tube from retracting back into the small
bowel. Obstructive recurrence occurs in 3.3% to 8.0% of patients.74,75
Adhesion Prevention
A voluminous literature on adhesion prevention has been written,
including reviews by Connolly and Ellis76,77 (Table 11, Table 12). In his
review, Ellis suggested that the best way to prevent adhesions was to
minimize trauma during surgery: (1) avoid introduction of foreign
698 Curr Probl Surg, November 2012
TABLE 11. History of attempts to prevent adhesion
1885 Rubbing oil used to prevent adhesions
1886 Saline hydrofloatation described
1892 “Fibrinolysin” (sodium salicylate and thiosinamine) marketed
1902 Gum Arabic used as visceral lubricant
1905 “Cargile” (bovine cecal peritoneum) introduced
1920 Intra-abdominal proteases described
1940 Heparin first studied
1957 “Amfetin” (amniotic fluid) marketed
1994 “Seprafilm” studied in prospective randomized trial
material (talc, etc), (2) leave raw serosal areas open, (3) cover injured
areas with viable tissue, such as omentum, and (4) place omentum behind
the abdominal wall incision. Additional suggestions should include
preventing serosal desiccation with moist lap pads, use of wound
protectors, gentle handling of peritonealized structures, and meticulous
dissection in as small an area as possible.
Strategies for preventing adhesions have generally fallen into the
categories listed in Table 13. A review of the experimental work done in
each of these areas is appropriate and helpful to understand the difficulty
in solving this clinical conundrum.
Irrigants
As previously mentioned, both normal saline and lactated Ringer’s
solution have been used to fill the peritoneal cavity at the end of a case.
Curr Probl Surg, November 2012 699
The presumption has been that “floating the bowels” would prevent the
injured serosal surfaces from coming in contact with each other, thus
preventing adhesion formation. More than 20 studies have been con-
ducted evaluating “hydroflotation” as a method to reduce adhesions
postoperatively. In the meta-analysis of the aforementioned studies,
Wiseman and colleagues reported that no significant difference was seen
between control and experimental groups.78
Anticoagulants
A large number of studies have been conducted to assess the efficacy of
anticoagulants in preventing adhesive SBO. A number of investigations
have evaluated dextran 70 as a possible antiadhesion irrigant. The
beneficial effects of dextran were observed in several animal studies.
Indeed, 2 prospective clinical studies in humans demonstrated some
efficacy of dextran in preventing pelvic adhesions, which cause infertil-
ity.79,80 However, an equal number of studies have demonstrated no
improvement with dextran,81,82 and because of possible serious side
effects, dextran is not commonly used in adhesion prevention today.
Similarly, intraperitoneal heparin has been extensively studied to
evaluate its potential antiadhesion effect. Initial studies in animals
suggested that intraperitoneal heparin might be effective, but human
studies with heparin were disappointing and were complicated by
bleeding complications.82,83
Anti-Inflammatory Agents
Nonsteroidal anti-inflammatory agents were shown to reduce peritoneal
adhesions in a variety of animal models. However, Nishimura and
colleagues and Holtz demonstrated that ibuprofen had no impact when
given to humans postoperatively.84,85 Generally, NSAIDs have been
unpredictable and erratically effective.
Corticosteroids were shown in animal and humans to reduce postoper-
ative adhesions.86-88 However, intraperitoneal steroids in human studies
have had mixed and unpredictable results in work done by Glucksman
and colleagues and Seitz and colleagues.87,89 In addition, use of steroids
in a postoperative situation is limited by immunosuppression and delayed
wound healing.
Fibrinolytics
Fibrinolytic preparations would intuitively seem like the ideal agents to
prevent postoperative adhesions. Both streptokinase and urokinase have
been shown to have some impact on adhesion formation,90,91 but further
700 Curr Probl Surg, November 2012
studies have been disappointing,92,93 and the surgeon worries about the
impact of such preparations on anastomotic and fascial wound healing.
Recombinant t-PA has been shown to diminish adhesions in animal
models without having a detrimental effect on wound or anastomotic
healing.94,95 However, other studies revealed that adhesions still devel-
oped at the site of colonic anastomoses and ischemic small intestine.96
Clearly, this agent must be studied more thoroughly in humans and holds
some promise as a future antiadhesion agent. Currently, most investiga-
tors agree that the balance between t-PA and t-PA inhibitors (PA-I) holds
the key to successful treatment of obstructive adhesions in the future. Fear
of bleeding, anastomotic disruption, and wound dehiscence have further
limited the use of fibrinolytic agents.
Barriers
The area in which the greatest strides have been made in adhesion
prevention in the past 15 years is that of barriers that separate the various
injured serosal surfaces while they are healing. The concept is simple but
quite effective: placement of a mechanical barrier between the injured
healing serosal surfaces, which persists until all serosal healing has taken
place, will prevent adhesive bowel obstruction. An added advantage of
this approach is that it should have little impact on the normal healing
mechanisms, and if the agent is inert, nonreactive, and absorbable, there
should be little associated morbidity. Several products in membrane form
have been used clinically to obviate adhesions after lower abdominal or
pelvic operations. There are also a few liquid or gel preparations that have
been tested.
Hyaluronate/Carboxymethylcellulose
By far, the membrane tested most extensively in adhesion prevention is
a hyaluronic acid/carboxymethylcellulose preparation marketed as Sepra-
film (Genzyme, Cambridge, MA). This somewhat brittle membrane is
absorbed within 7 to 10 days after placement in the abdomen, and
excreted within a month. It has been extensively studied for safety and
efficacy in a number of clinical studies and appears to have very few, if
any, side effects except some questions of a slightly increased risk for
anastomotic leak if wrapped entirely around a fresh anastomosis. A host
of retrospective and prospective randomized studies have been conducted
to ascertain whether it decreases adhesions. The earliest study by Becker
and colleagues was prospective and randomized with adhesion assess-
ment by blinded observers.88 Approximately 175 patients who underwent
ileal-pouch anal anastomosis (IPAA) and protective loop ileostomy were
Curr Probl Surg, November 2012 701
randomized to receive the membrane or not, and adhesion evaluation was
conducted at the second-look laparotomy to close the ileostomy 8 weeks
later. The authors reported significantly fewer and less severe adhesions
in the membrane group.
In a group of patients undergoing rectal surgery who needed an
ileostomy, Tang and colleagues randomized patients who would seek
stoma closure into membrane vs. no membrane groups. At the second
operation, the authors encountered fewer and less severe adhesions in the
membrane group and fewer stoma complications (mean adhesion score
5.81 ⫾ 0.5 vs. 7.82 ⫾ 0.6, P ⬎ 0.05). The authors of both this and the
previous study observed that the dissection was much easier in the membrane
group.97 Similarly Vrijland and colleagues prospectively randomized a
group of 71 patients undergoing a colorectal resection with Hartmanns
into membrane and no-membrane groups. At operation to close the stoma,
a blinded evaluator assessed the field for incidence, severity, and
complications of adhesions. The investigation reported a significant
decrease in severity but not incidence of adhesions (OR, 0.34; 95%
confidence interval, 0.06-1.98).98
A Canadian group led by Cohen in a prospective multicenter trial used
the model of the original group to randomize IPAA patients into
membrane and control groups. The membrane used in this study was
Seprafilm with glycerol added to make the membrane softer, pliable, and
less brittle. Using laparoscopy at the time of ileostomy closure, adhesions
were graded according to incidence and severity. The investigators
reported a significant decrease in incidence and severity in the membrane
group.99 A similar prospective randomized study by Kusunoki and
colleagues was conducted in patients who needed a protective ileostomy
after low anterior resection. During stoma closure, the severity of
adhesions was assessed and found to be significantly reduced in both the
peristomal area and posterior midline. Once again the authors comment
on shorter surgical time and less blood loss.100 Finally, a Cochrane review
conducted by Kumar and colleagues evaluating 6 randomized trials using
Seprafilm revealed that use of the membrane significantly reduced the
extent and incidence of adhesions.101
Although the early studies of Seprafilm were conducted to ascertain the
membrane’s efficacy in reducing adhesions, they were not designed to
assess impact of the membrane on actual SBO. The most important study
in the literature, which truly assessed the impact of the hyaluronate/
carboxymethylcellulose membrane on actual bowel obstruction, was
published in 2006. In a prospective, randomized, multicenter trial
involving 1791 patients, Fazio and colleagues designed the study so that
702 Curr Probl Surg, November 2012
TABLE 14. Efficacy of Seprafilm in reducing small bowel obstruction (SBO)
Incidence of Re-operation Septic
Study Patient SBO (%) for SBO (%) complications
Author Journal type no. (Con vs. Rx) (Con vs. Rx) (Con vs. Rx)
Fazio102 DCR PRCT 1701 12 vs. 12 3.4 vs. 1.8* 3 vs. 4
Salum104 DCR Retro 438 6.1 vs. 4.5 3.9 vs. 1.5 1.1 vs. 3.4
Mottri105 Am Surg Retro 368 14.2 vs. 6.5* 4.4 vs. 1.6 13 vs. 15
Kudo103 Surg Today Retro 51 20 vs. 0* — —
*p ⬍ 0.05.
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