Acute Intestinal Obstruction Caused by Gastrointestinal Foreign Bodies in Children: A Comparison of Laparoscopic Treatment and Open Surgery

doi:10.21203/rs.3.rs-4935690/v1

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Acute Intestinal Obstruction Caused by Gastrointestinal Foreign Bodies in Children: A Comparison of Laparoscopic Treatment and Open Surgery

https://doi.org/10.21203/rs.3.rs-4935690/v1

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Objective

This study aims to explore the appropriate surgical treatment method for acute intestinal obstruction caused by gastrointestinal foreign bodies in children through a comparison of clinical characteristics in patients treated via laparoscopic and open surgery.

Methods

This study retrospectively analyzed 12 children with acute intestinal obstruction caused by gastrointestinal foreign bodies treated at Shanghai Children's Hospital and Huzhou Maternity and Child Care Hospital from June 2019 to June 2024. Basic information, treatment methods, and prognoses of the patients were collected. General data, operation time, postoperative fasting time, postoperative hospital stay, and intraoperative and postoperative complications were compared between the two groups. Categorical data were compared using Fisher’s exact test. Normally distributed continuous data were expressed as mean ± standard deviation and analyzed using an independent samples t-test; non-normally distributed data were expressed as M (P25, P75) and analyzed using the non-parametric Mann-Whitney U test.

Results

Six cases underwent laparoscopic transumbilical extended incision, successfully extracting the intestines and removing the foreign bodies without converting to open surgery. Compared to Six cases undergoing traditional open surgery during the same period, the postoperative fasting time and postoperative hospital stay in the laparoscopic group were 4 (5 ± 3.65) days and 5.5 (5 ± 7.5) days, respectively, while in the traditional open surgery group, they were 5 (4.25 ± 6) days and 6 (5 ± 8.6) days, respectively; the differences were statistically significant (P < 0.05). The laparoscopic group had significantly shorter operation time and faster postoperative recovery. The acceptance of the laparoscopic treatment by the families was significantly higher than that of the open surgery treatment.

Conclusion

The method of extracting obstructed intestines and removing foreign bodies via laparoscopic-assisted transumbilical extended incision has advantages over open surgery for treating acute intestinal obstruction caused by gastrointestinal foreign bodies, such as shortening hospital stay and operation time. However, for children with secondary gastrointestinal perforation caused by magnetic foreign bodies, open surgery, due to its broader exploration scope, is more advantageous for detecting occult perforations.

Laparoscopic

Acute Intestinal Obstruction

Gastrointestinal Foreign Bodies

It has been reported that 80–90% of ingested foreign bodies (FBs) can pass through the alimentary tract spontaneously. However, 10–20% of ingested FBs require endoscopic removal, and 1% or less ultimately require surgery [1, 2]. Patients and their families are rarely aware of ingested FBs, which could cause complete intestinal obstruction or even intestinal perforation. Traditionally, surgery for this condition was performed via open laparotomy. However, with the development of laparoscopic techniques and surgical instruments, their application in acute small bowel obstruction has increased and has shown good efficacy [3, 4]. Nevertheless, the optimal surgical approach for acute small bowel obstruction in children requires further clarification [5, 6]. By retrospectively analyzing the clinical characteristics, therapeutic processes, and prognoses of children with acute intestinal obstruction caused by ingested foreign bodies treated with laparoscopic and open surgery, we aim to explore the appropriate surgical treatment for this type of intestinal obstruction.

Population

This study was approved by the Ethics Committee of Shanghai Children's Hospital, and informed consent was obtained from the guardians of all pediatric patients. We collected basic data on 12 cases of acute intestinal obstruction caused by gastrointestinal foreign bodies treated from June 2019 to June 2024 at Shanghai Children's Hospital and Huzhou Maternity and Child Health Care Hospital. We statistically analyzed the operation time, postoperative recovery time to normal diet, hospital stay, incidence of postoperative complications, and follow-up outcomes for both the laparoscopic and open surgery groups to determine the optimal treatment method for such patients.

Inclusion criteria

Inclusion criteria were: 1. No history of abdominal surgery; all children excluded those with hemodynamic instability or combined cardiopulmonary diseases; 2. A confirmed history of foreign body ingestion. Exclusion criteria were: 1. Incomplete clinical data; 2. History of abdominal surgery; 3. Presence of hemodynamic instability or combined cardiopulmonary diseases.

Clinical Manifestations

All children presented with abdominal pain, vomiting, and cessation of gas and stool passage for over 24 hours. After admission, conservative treatment including fasting, gastrointestinal decompression, and intravenous fluids was administered for 12 to 48 hours, but there was no improvement. Repeated upright abdominal X-rays or enhanced CT scans showed no relief or worsening of the intestinal obstruction. (Fig. 1–2)

Surgical Methods

Routine gastrointestinal decompression, catheterization, and endotracheal intubation under general anesthesia were performed preoperatively.

Position and Trocar Placement: The child was placed in a supine position with the waist elevated, and the operating table position was adjusted as needed. After satisfactory anesthesia, the umbilicus was gently lifted to check for adhesions. A 10mm incision was made longitudinally through the umbilicus, pneumoperitoneum was established, maintaining pressure at 8–12 mmHg, and a 10mm trocar was placed to insert a 30° laparoscope. Two 5mm trocars were placed at the McBurney’s point and the opposite McBurney’s point in the lower left abdomen or 2 cm above the pubic symphysis, and pneumoperitoneum was reestablished. A single-port laparoscope was inserted through the umbilicus.

Exploration and Trocar Position Adjustment: The abdominal cavity was explored to determine the site of obstruction, then the positions of the other two trocars were decided, ensuring they could facilitate retrograde exploration of the entire abdominal intestine from the cecum. Using atraumatic bowel clamps, the cecum was located first and the terminal ileum was inspected segment by segment proximally until the stenosis-dilation junction was identified.

Foreign Body Removal: The pneumoperitoneum was deflated, and the umbilical incision was extended longitudinally by about 3cm to exteriorize the intestine. Blood supply to the bowel was checked, the obstructing foreign body was located, the bowel was incised longitudinally along its long axis to remove the foreign body, and the bowel was sutured transversely through all layers to prevent future stenosis.

Reinsertion and Additional Exploration: After reinserting the bowel, if multiple foreign bodies were suspected, the pneumoperitoneum was reestablished, and two atraumatic clamps were used to retrograde explore the entire bowel from the cecum. For the open surgery group, an upper abdominal exploratory incision was made, the abdomen was entered layer by layer, and the small intestine was gently exteriorized. The stenosis-dilation junction was located, and the obstruction was relieved. If bowel necrosis was found, resection and anastomosis or enterostomy was performed, followed by layered closure of the abdomen. (Fig. 1–2)

Statistical Indicators

General patient data, operation time (from skin incision to completion of closure), postoperative recovery time to normal diet, postoperative hospital stay (discharge criteria: 1 day after normal diet resumption, no discomfort, normal eating and bowel movements, no wound abnormalities), incidence of complications, and medical costs were collected.

Statistical Methods

SPSS 17.0 statistical software was used for data analysis. The χ2 test was used for the comparison of count data. Normally distributed measurement data were expressed as mean ± standard deviation and analyzed using the independent sample t-test; non-normally distributed data were expressed as M(P25, P75) and analyzed using the nonparametric Mann-Whitney U test. A P-value < 0.05 was considered statistically significant.

All surgeries were successfully completed, with no intraoperative bowel necrosis observed. There were no conversions to open surgery in the laparoscopic group, and no postoperative complications such as incisional hernia, wound infection, or pneumonia occurred. No adhesive bowel obstructions were reported during follow-up. (Table 1)

Table 1

Comparison of General Data between Laparoscopy Group and Laparotomy Group
Group	Number	Gender	Weight [kg, M(P25, P75)]	Age (Months, Mean ± SD)	Foreign Body Type	Operation Time [min, M(P25, P75)]	Surgical Method	Conversion to Open Surgery	Postoperative Fasting Time (days, Mean ± SD)	Hospitalization Time (days, Mean ± SD)	Hospital Costs (Yuan)
Laparoscopic Group	6	Male/Female 2/4	18.3 (14.5, 21.7)	64.59 ± 36.47	SpongeBob 2; Hairball 2; Tannic Stool 2	100 ± 65	Laparoscopic removal of foreign body via umbilical incision	None	4 (5 ± 3.65)	5.5 (5 ± 7.5)	20,098.5 (18,995, 25,890
Open Surgery Group	4	Male/Female 2/2	15.5 (14.2, 19.7)	55.31 ± 35.72	SpongeBob 1; Hairball 1; Date Pit Foreign Body 2	125 ± 140	Open exploration + bowel incision for foreign body removal	Yes	5 (4.25 ± 6)	6 (5 ± 8.6)	26,333.5 (17,243, 35,569)
Statistical Value	-			1.167		0.875			0.986	-1.782	-1.751
P Value	-	0.243		0.268		0.342			< 0.001	0.041	0.098

1. Comparison of General Data between the Two Groups

Six children underwent laparoscopic surgery (laparoscopic group), and six underwent traditional open surgery (open group). There were no statistically significant differences in gender, age, or weight between the two groups (P > 0.05). The laparoscopic group had shorter operation times, postoperative fasting times, and hospital stays compared to the open group. However, the difference in operation times between the two groups was not statistically significant (P > 0.05); the differences in postoperative fasting times and hospital stays were statistically significant (both P < 0.05). There was no statistically significant difference in hospital costs between the laparoscopic and open groups (P > 0.05).

Summarizing and analyzing these cases indicate that laparoscopy has the advantages of minimal trauma and rapid postoperative recovery in treating pediatric intestinal obstructions caused by gastrointestinal foreign bodies, making it worth promoting in clinical practice.

Acute small bowel obstruction is a common acute abdominal condition in pediatric surgery. If conservative treatment is ineffective or there is suspicion of bowel strangulation, emergency surgery is required [6]. Traditional surgical methods involve open surgery, which is characterized by significant trauma, slow postoperative recovery, severe pain, and a risk of recurrent adhesive bowel obstruction. Furthermore, pediatric cases of acute and chronic bowel obstruction caused by gastrointestinal foreign bodies are not uncommon, and many of these children require emergency surgery. Previous literature reports primarily focus on open surgery, with fewer reports on laparoscopic minimally invasive surgery [7, 8]. However, in large pediatric medical centers, laparoscopic treatment of bowel obstruction caused by gastrointestinal foreign bodies is becoming mainstream. We reviewed recent surgical trends to determine the most appropriate treatment for this type of bowel obstruction.

In the management of acute bowel obstruction in children, conservative treatment typically lasts for 12–48 hours. During this period, there is a cessation of gas and stool passage, and the child’s abdominal pain and distension do not improve or even worsen. As conservative treatment continues, the gastrointestinal decompression increasingly yields more contents, which may change from clear to bile-like or even fecal-like. If abdominal X-rays or enhanced abdominal CT scans show no significant improvement, active exploration is necessary. Regarding the choice of surgical method, there are fewer reports of laparoscopic treatment for acute bowel obstruction caused by gastrointestinal foreign bodies in children. According to Farinella et al [9]., laparoscopic adhesiolysis can be performed in children with fewer than two previous surgeries, postoperative adhesive obstruction after appendectomy, preoperative diagnosis of adhesive bowel obstruction, and surgery performed within 24 hours of symptom onset. O’Connor et al [10]. also suggest that extensive dense adhesions, bowel resection, or iatrogenic bowel injury require timely conversion to open surgery. Suter et al [11]. believe that bowel obstruction with bowel dilatation exceeding 4 cm often necessitates conversion to open surgery.

Based on our treatment experience, six children underwent laparoscopic surgery with an extended umbilical incision, successfully extracting the bowel and removing the foreign body without needing conversion to open surgery. Compared with six children who underwent traditional open surgery during the same period, the laparoscopic group had statistically significant differences in postoperative fasting time and hospitalization duration (4 (5 ± 3.65) days and 5.5 (5 ± 7.5) days, respectively, compared to 5 (4.25 ± 6) days and 6 (5 ± 8.6) days in the open surgery group, with P < 0.05 for both). The laparoscopic group had significantly shorter operation times and faster postoperative recovery. Families showed a higher acceptance of laparoscopic treatment compared to open surgery. Therefore, based on relevant literature and our own experience [12], we believe that for acute bowel obstruction caused by gastrointestinal foreign bodies, minimally invasive surgery is indicated in the following situations:

No history of previous abdominal surgery.

Abdominal enhanced CT or ultrasound suggests the possibility of gastrointestinal foreign bodies, or families can clearly indicate a history of foreign body ingestion.

Mild abdominal distension, with X-rays indicating high or proximal jejunal obstruction, and no signs of pneumoperitoneum.

No significant improvement in symptoms and signs after 12–48 hours of active non-surgical treatment, necessitating surgical intervention.

Contraindications for minimally invasive surgery in such cases include:

Multiple previous abdominal surgeries with severe bowel adhesions.

Significant abdominal distension and abnormal bowel dilatation, indicating limited laparoscopic operative space.

Presence of peritoneal irritation signs, suspected gastrointestinal perforation, or potential bowel resection.

Hemodynamic instability or poor general condition.

Foreign bodies such as multiple magnets that could cause multiple secondary gastrointestinal perforations.

Contraindications to laparoscopic pneumoperitoneum.

In conclusion, compared to traditional open surgery, laparoscopic treatment for bowel obstruction caused by gastrointestinal foreign bodies is safe, has fewer complications, and is effective, with a reduced incidence of postoperative bowel adhesions. By carefully considering the patient’s medical history, clinical presentation, and preoperative examinations, and strictly adhering to surgical indications, minimally invasive surgery can achieve satisfactory outcomes. However, this study is a single-center retrospective study, not a randomized controlled trial, and there may be biases in patient and surgical plan selection. We believe that with advancements in laparoscopic technology and improvements in equipment, its application in pediatric small bowel obstruction will become increasingly widespread.

Ethics approval and consent to participate

All therapeutic methods were carried out in accordance with relevant guidelines and regulations. This study was approved by Ethical Committee of Shanghai Children’s Hospital and the study methodology conformed to Helsinki Declaration standards as revised in 2000. The Ethical Committee of Shanghai Children’s Hospital granted permission to access and use the medical records of participants of the study. All data remained confidential, and the legal guardians of all participants signed the informed contents. Appropriate measures were applied to ensure the confidentiality of the data.

Consent for publication

Written parental consents for the publication have been obtained.

Competing interests

The authors have no financial and non-financial conflicts of interest.

Availability of data and material

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This work was supported by Shanghai Health Planning Commission Grant (20214Y04976).

Authors' contributions

All authors have worked on the manuscript. Wei Wu, Min Dong wrote the manuscript under the supervision of ZhiBao Lv. Wanli Zhang, Lulu Zheng and Jun Sun performed surgery procedure, treated and followed up the patient.

Acknowledgements

We should thank Department of General Surgery, Shanghai Children’s Hospital, School of medicine, Shanghai Jiao Tong University and Huzhou Maternity & Child Health Care Hospital for their support.

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Sara A, Lucille, et al. Utilization of single-incision laparoscopy in the management of ingested magnets. J Laparoendosc Adv Surg Tech A. 2023;34(6). 10.1089/lap.2023.0394.
Quitadamo P, Anselmi F, Caldore M, et al. Foreign body ingestion in children: beware of disk batteries and multiple magnets. Acta Paediatr. 2021;110(10):2862–4. 10.1111/apa.15957.
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Nordin A, Freedman J, et al. Laparoscopic versus open surgical management of small bowel obstruction: an analysis of clinical outcomes. Surg Endosc. 2016;30(10):4454–63. 10.1007/s00464-016-4776-2.
Di Saverio S, Birindelli A, Broek RT, et al. Laparoscopic adhesiolysis: not for all patients, not for all surgeons, not in all centres. Updates Surg. 2018;70(4):557–61. 10.1007/s13304-018-0534-4.
Jin Y, Gao Z, Zhang Y, et al. Management of multiple magnetic foreign body ingestion in pediatric patients. BMC Pediatr. 2022;22(1):448. 10.1186/s12887-022-03501-0.
Farinella E, Cirocchi R, La Mura F, et al. Feasibility of laparoscopy for small bowel obstruction. World J Emerg Surg. 2009;4:3. 10.1186/1749-7922-4-3.
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No competing interests reported.

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You are reading this latest preprint version

Acute Intestinal Obstruction Caused by Gastrointestinal Foreign Bodies in Children: A Comparison of Laparoscopic Treatment and Open Surgery

Status:

Version 1

Abstract

Objective

Methods

Results

Conclusion

Figures

Introduction

Methods

Population

Inclusion criteria

Clinical Manifestations

Surgical Methods

Statistical Indicators

Statistical Methods

Results

1. Comparison of General Data between the Two Groups

Discussion

Declarations

References

Additional Declarations

Status:

Version 1