Adhesions continue to be a common consequence of abdominal surgery with serious morbidity and occasional cause of death as well as an economic burden [1
]. The etiology of adhesion formation remains incompletely understood, and, in spite of advances in surgical techniques, there is little change in the epidemiology of adhesions. This is even so in the era of laparoscopic surgery. Adhesions continue to be mysterious not only in terms of their occurrence but also because of their complications which can occur as early as few days after surgery or remain dormant for several years after the initial procedure. This was the case in our series where we saw adhesive intestinal obstruction as early as 1 week following, surgery and as late as 12 years following the initial operation but, in 66% of our patients, adhesive intestinal obstruction occurred within 1 year from the initial operation. In Janik et al. series, adhesive intestinal obstruction developed within 2 years in 80% of their patients, and in another series adhesive intestinal obstruction developed within 3 months from the initial operation [3
]. The reason for this variation is not known. The causes predisposing to adhesive intestinal obstruction are also variable, but appendectomy continues to be the commonest cause. In a series of 871 children who had appendectomy, 1.3% of them developed adhesive intestinal obstruction, and this was the highest (3.4%) in those who had perforated appendicitis [7
]. This was also the case in our series. The reason for this is not exactly known, but infection is considered one of the common triggers for adhesion formation. Another contributing factor for adhesion formation is multiple operations as in patients with Hirschsprung's disease who are usually subjected to several operations. This is not related to the original operation but rather to the fact that there was more than one operation. This is specially so if there was infection or contamination. Multiple operations are known to be associated with increased deposition of fibrin which tends to form bridges between adjacent tissues leading to adhesions which can be degraded by the normal fibrinolytic factors. This, however, is not the case always, and surgery, infection, and hypoxia are known to diminish the fibrinolytic activity. The rapid wound healing in children may be the reason for the low incidence of adhesions in children when compared to adults. The exact incidence of adhesive intestinal obstruction in children is not known but has been reported to vary from 2.2% to 8.3% [2
]. This is in contrast to adults, where in many counties adhesive intestinal obstruction is considered the second commonest cause of intestinal obstruction after obstructed abdominal wall hernias.
The treatment of adhesive intestinal obstruction is still controversial. Conservative treatment forms the basis for the management of adhesive intestinal obstruction both in children and adults. In the pediatric age group, the response to this is, however, variable. Akgur et al. reported a 40% overall success rate with conservative treatment in a series of 230 episodes of adhesive intestinal obstruction in 181 children [6
]. Vijay et al. reported a 48.6% response to conservative treatment in a series of 74 episodes of adhesive intestinal obstruction, and, in their series, children below 1 year of age responded poorly to conservative management [5
]. This, however, was associated with an overall resection rate of 16% and a resection rate of 33% in those who underwent operative adhesiolysis. Festen and Janik et al., on the other hand, reported a low success rate with conservative management of adhesive intestinal obstruction in infants and children [3
]. This was the case in our series where only 9% responded to conservative treatment. In our series, there was also a 25% resection rate. It is, however, difficult to say for sure that this resection rate could have been reduced by adapting an early surgical intervention. Considering the low success rate with conservative treatment and the fact that delay in operative treatment is also known to affect the outcome adversely by increasing the morbidity, intestinal resections, hospital stay, and cost, we like others advocate early surgical intervention in infants and children with adhesive intestinal obstruction [2
]. Early surgical intervention saves the child a great deal of pain and discomfort and allows a quick recovery with early discharge from the hospital. Operative adhesiolysis is, however, known to be associated with a high rate of adhesion reformation as well as the risk of inadvertent enterotomy. We encountered two recurrences only in our series. This, however, does not reflect the actual recurrence as it is difficult to say for sure that there were no other recurrences taking in consideration that adhesions may be treated by specialists other than the initial surgeon. The recent advances in minimal invasive surgery with miniaturization of instruments have made it possible for many of the operative procedures to be carried out laparoscopically both in infants and children. This is including laparoscopic adhesiolysis which was shown to be feasible and safe in experienced hands [8
]. Not only this but laparoscopy being less invasive and with its widespread use, it is expected to decrease the incidence of adhesive intestinal obstruction. This, however, needs to be substantiated by future studies.