Abstract
Background
Postoperative inflammatory ileus (PII) is characterised by long-term re-obstruction, following temporary defecation. An intestinal fistula excision (IFE) with severe abdominal adhesions could increase the risk of PII in patients with sarcopenia. On the other hand, the postoperative outcomes are negatively impacted owing to chronic preoperative inflammation, as measured by the visceral fat area (VFA) and the total abdominal muscle area index (TAMAI) ratio. This study aims to evaluate the predictability of VFA/TAMAI for postoperative PII after IFE.
Methods
Four tertiary centres participated in this retrospective cohort study. Patients with sarcopenia who underwent IFE between January 2018 and October 2022 were enrolled. VFA/TAMAI was evaluated as a risk factor for PII.
Results
We included 177 eligible patients (102 [57.6%] males) with a median age of 51 years (interquartile range [IQR]: 38–61 years) in this study. PII occurred in 16.9% of patients (n = 30), with an interval of four days (IQR: 3–5 days) between IFE and temporary defecation. The duration of the re-obstruction after temporary defecation was 23 days (IQR: 21–30 days), following temporary defecation that lasted for one days (IQR: 1–2 days). The adjusted logistic regression revealed that VFA/TAMAI was associated with PII (odds ratio = 1.51, 95% confidence interval: 1.02–2.19; p = 0.03).
Conclusion
VFA/TAMAI was associated with inflammatory ileus after IFE with severe abdominal adhesions in patients with sarcopenia.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12893-025-03196-x.
Keywords: Body composition, Surgery, Outcomes, Ileus, Gastroenterology, Postoperative
Fan Yang, MD1; Shikun Luo, MD2, 3;Zhiwu Hong, MD1;Weiliang Tian, MD1; Guoping Zhao MD2; Xinying Wang MD 1Risheng Zhao MD2; Weiwei Shang, MD2; Yunzhao Zhao; MD2; Xin Xu, RN2; Zheng Yao, MD2; Qian Huang, MD1.
1Department of general surgery, Jinling Hospital, Nanjing, Jiangsu, China.
2Department of general surgery, Jiangning Hospital, Nanjing, Jiangsu, China.
3Jiangning Clinical Medical College, Kangda College, Nanjing Medical University, Jiangning Hospital, Nanjing, Jiangsu, China.
Address for correspondence:
Xinying Wang. Department of general surgery, Jinling Hospital, Zhongshan Road NO.305, Nanjing, Jiangsu, China. wangxynj@163.com.
Risheng Zhao. Department of general surgery, Jiangning Hospital, Hushan Road NO.169, Nanjing, Jiangsu, China. dr_zhaorisheng@163.com.
Yunzhao Zhao. Department of general surgery, Jiangning Hospital, Hushan Road NO.169, Nanjing, Jiangsu, dr_zhaoyunzhao@163.com.
Xin Xu. Department of general surgery, Jiangning Hospital, Hushan Road NO.169, Nanjing, Jiangsu, China. Rn_xuxin@163.com.
Zheng Yao. Department of general surgery, Jiangning Hospital, Hushan Road NO.169, Nanjing, Jiangsu, China. Dr_yaozheng@163.com.
Qian Huang. Department of general surgery, Jinling Hospital, Zhongshan Road NO.305, Nanjing, Jiangsu, China. Dr_dochqnj@163.com.
Introduction
Chronic preoperative abdominal inflammation is observed in patients with severe abdominal adhesions following an abdominal infection [1, 2], and can be assessed using the body composition (ratio of the visceral fat area [VFA] to the total abdominal muscle area index [TAMAI], VFA/TAMAI) in patients with sarcopenia [3, 4]. It weakens the immune system, delays wound healing [4], prolongs acute inflammation and magnifies postoperative inflammation [4], and negatively impacts postoperative outcomes of major abdominal surgery.
The peritoneum might be repeatedly damaged due to improper drainage in early stage, ultimately leading to severe adhesion with residual chronic inflammation in patients with intestinal fistula. It is logical to deduce that, due to the preoperative exaggerated chronic inflammation, postoperative intestinal dysfunction could be observed after an intestinal fistula excision (IFE) with severe abdominal adhesion. Postoperative inflammatory ileus (PII) as a type of postoperative intestinal dysfunction, proposed by Jieshou Li, academician of the Chinese Academy of Sciences, is a compound gastrointestinal obstruction (mechanical and dynamic may coexist) that develops shortly after peritoneal surgery due to bowel and/or mesenteric oedema and exudation [5–7]. Intestinal mechanical factors and motility disorder without concurrent strangulation could be involved in PII [7, 8]. PII diagnosis is summarised as follows [5–7]: (1) defecation is temporarily resumed, followed by recurrent bowel obstruction with nausea, omitting, no flatus and defecation, and no prominent abdominal pain; hard abdomen on physical examination with normal or weakened bowel sounds (symptoms occurred within two weeks after IFE); (2) mesenteric and/or bowel oedema are identified after symptom onset, and mesenteric vascular disease is ruled out using enhanced CT; (3) gastroenterography reveals significantly decreased intestinal peristalsis. Conservative management is the main treatment for PII, but the symptoms are often serious and the treatment cycle is long [5–8]. In summary, sarcopenic patients with severe abdominal adhesion following intestinal fistula are likely to exhibit an unbalanced VFA/TAMAI due to persistent chronic inflammation. In such cases, patients with chronic inflammation are at increased risk of heightened intra-abdominal inflammation following surgical trauma [9], which can lead to edema and impaired blood supply [8], subsequently raising the risk of postoperative PII. The objective of the present study was to evaluate the predictive value of VFA/TAMAI for PII following IFE in patients with sarcopenia and severe abdominal adhesions.
Materials and methods
This retrospective cohort study adhered to the ethical standards outlined in the Declaration of Helsinki and approved by the institutional review board. This study was approved by the ethics committee of Jiangning Hospital, 2024-03-046-K01.
Patients
We evaluated sarcopenic patients who underwent IFE with severe abdominal adhesions at four tertiary centres between January 2018 and October 2022, retrospectively. Patients less than18 years, with postoperative abdominal infection, or without complete records were excluded. Discharge was the follow-up end-point. The postoperative inflammatory index VFA/TAMAI was evaluated as a risk factor for PII.
Preoperative management
Intestinal fistula were managed followed the SOWATS treatment guideline, which consisted of six dimensions: sepsis, optimization of nutritional state, wound care, anatomy (of the fistula), timing of definitive surgery, and surgical strategy [10]. The definitive surgery would not be considered until the following conclusive criteria could be met: BMI ≥ 18.0 kg/m2 with normal physical strength, haemoglobin ≥ 100 g/L, and albumin (Alb) ≥ 30 g/L. Lastly, the interval should have exceeded at least 3 months after the fistula occurrence. All patients were given enteral nutrition (EN) in the preoperative management (parenteral nutrition[PN] was used in some cases if necessary). A gastric tube was placed in the morning of the surgery day for the postoperative gastrointestinal decompression.
Surgical strategy
IFE was performed by the chief surgeon at each of the four centres. The digestive tract was gradually dissociated during surgery. A latero-lateral end anastomosis was performed using a linear stapler for each intestinal fistula. Hernia repair was performed during IFE in patients with an enteroatmospheric fistula. Onlay mesh repair was combined with component separation technology. A biological patch was used during the procedure. A negative pressure drainage system was placed under all incisions before surgery completion.
Postoperative management
Haemoglobin and Alb were maintained at > 100 g/L and > 30 g/L, respectively, by infusing red blood cells and human serum Alb. EN was implemented after defecation. The rate of EN administration increased from 20 mL/h to 70 mL/h, with an increase of 10 mL/h per day. PN was administered from postoperative day 1 and was halved when EN was administered at 50 mL/h. PN administration was terminated once total EN was administered. Herein, patients with severe aseptic inflammation and PII might have had a fever and increased leukocytes and C-reactive protein (CRP). As a result, imaging, microbial diagnosis, and procalcitonin levels were used for comprehensively assessing postoperative abdominal infection. CT was performed on the seventh day after IFE, and the obvious ascites were punctured, drained, and cultured. Patients without ascites (or culture-negative ascites) and continuous normal procalcitonin were considered free from an abdominal infection.
After resuming total EN, the patients were instructed to follow a liquid diet, following which they were discharged after confirming the absence of obstruction and a recurrent fistula using gastrointestinal radiography.
Recovery of digestive function in PII
Herein, the recovery of digestive function was confirmed if EN could be gradually resumed after defecation and there were no intestinal obstruction-related complaints, such as abdominal distension, vomiting, etc. The treatment of PII included gastrointestinal decompression via nasogastric and nasoenteric routes. Low dose somatostatin was used to alleviate symptoms (3 mg/day).
In patients with PII, temporarily resumed defecation was not considered digestive recovery. Only if the EN could be gradually resumed after re-defecation the recovery of digestive function was confirmed.
Data collection and statistical analysis
Demographic data (sex, age, and BMI), preoperative laboratory examination results, and fistula characteristics were recorded within one week before surgery. TAMAI, VFA, and subcutaneous fat area (SFA) were evaluated using enhanced CT within one week before IFE. Relevant data during and after IFE, postoperative imaging, microbiological, and laboratory results were investigated based on the medical records. The abdominal adhesion status was evaluated according to Hobson et al.’s study [11]. Abdominal adhesions were classified as follows: Grade I = no adhesions; Grade II = minimal adhesions localised to one or two areas; Grade III = diffuse but not extensive adhesions; Grade IV = diffuse extensive adhesions that are easily lysed; Grade V = diffuse extensive, dense adhesions that are challenging to lyse [8]. Patients with grade IV or V adhesions were diagnosed with severe adhesions. Image J (NIH, Bethesda, MD, USA) was used to evaluate body composition on CT. Two consecutive axial CT images at the level of the L3’s inferior endplate were processed and then averaged for each patient. All CT scans were conducted using the same scanner model and a standardized scanning protocol. The scanning parameters were as follows: tube voltage of 120 kV, automatic tube current modulation (range: 100–400 mA), slice thickness of 5 mm, and slice interval of 5 mm. All measurements were independently performed by two trained radiologists, each of whom performed measurements twice for each patient, with a minimum one-week interval, to assess intra-observer consistency. Sarcopenia was defined as a TAMAI of < 43 cm2/m2 in males with a body mass index (BMI) of < 25 kg/m2, < 53 cm2/m2 in males with a BMI of ≥ 25 kg/m2, and < 41 cm2/m2 in females [12].
Statistical analyses were performed using the Statistical Package for the Social Sciences version 26.0 for Windows (IBM, Analytics, Armonk, NY). Continuous variables were evaluated using the Mann–Whitney U and Kruskal–Wallis tests, and Fisher’s exact test was used for categorical variables. Logistic regression and Cox regression were used to assess the correlations with other clinical indices after adjustment for potential confounders. Statistical significance was set at p < 0.05.
Results
Clinical characteristics of the enrolled patients
We initially selected 193 patients with sarcopenia who underwent IFE with severe abdominal adhesions, of which 16 patients were excluded from the study (two younger than 18 year old, eight without complete data, and six with postoperative abdominal infections). Finally, we included 177 eligible patients (102 [57.6%] males) with a median age of 51 years (interquartile range [IQR]: 38–61 years) and a median BMI of 19.6 kg/m2 (IQR: 18.9–21.0 kg/m2). An interval of 4 months was observed from fistula occurrence to IFE (IQR: 3.0–5.0) months. Trauma (n = 106), obstruction due to previous abdominal surgery (n = 59), mesenteric thrombosis (n = 9), and unclear perforation (n = 3) were the aetiological factors involved. Twenty-three (13.0%) patients received extra PN (Table 1).
Table 1.
Characteristics of the patients
| Characteristics | Total |
|---|---|
| Demographic data | |
| Male, No. (%) | 103 (58.2) |
| Age, years; (median, IQR) | 51.0 (38.0–61.0) |
| BMI, kg/m2,(median, IQR) | 19.6 (18.9–21.0) |
| Fistula characteristics | |
| Interval from fistula occurred to SIFE, months, (median, IQR) | 4.0 (3.0–5.0) |
| Distance from Treitz to the fistula, No. (%) | |
| < 100 cm | 20 (11.3) |
| ≥ 100 cm | 157 (88.7) |
| Length of small intestine, No. (%) | |
| < 300 cm | 29 (16.4) |
| ≥ 300 cm | 148 (83.6) |
| PN required, No. (%) | 23 (13.0) |
| Complicated with ventral hernia, No. (%) | 127 (71.8) |
| Etiology, No. (%) | |
| Trauma | 106 (59.9) |
| Obstruction | 59 (33.3) |
| Others | 12 (6.8) |
| Laboratory test results | |
| Hemoglobin before SIFE, g/L; (median, IQR) | 126.0 (117.0–132.0) |
| Albumin before SIFE, g/L; (median, IQR) | 36.2 (34.1–38.3) |
| CRP before SIFE, mg/L; (median, IQR) | 7.2 (6.1–14.8) |
| WBC before SIFE, 109/L; (median, IQR) | 6.7 (6.1–7.9) |
| Intraoperative condition and postoperative care | |
| Abdominal adhesion grade V | 75 (42.4) |
| Duration of SIFE, hours; (median, IQR) | 4.75 (3.5–6.0) |
| Deciliter of bleeding loss during SIFE, dL; (median, IQR) | 11.0 (9.0–17.0) |
| The amount of red blood cell suspension input during SIFE and 48 h after SIFE#, No. (%) | |
| <10U | 101 (57.1) |
| ≥10U | 76 (42.9) |
| The amount of albumin input during SIFE and 48 h after SIFE##, No. (%) | |
| <100 g | 95 (53.7) |
| ≥100 g | 82 (46.3) |
| Comorbidity, No. (%) | |
| Hypertensio | 12 (6.8) |
| Elevated fasting blood glucose | 21 (11.9) |
# In order to maintain the Hemoglobin > 100 g/L within 48 h after SIFE
## In order to maintain the Albumin > 30 g/L within 48 h after SIFE
The body composition characteristics are presented in Table 2. The median VFA/TAMAI of the 177 patients was 2.4 cm2/m2 (IQR: 1.8–3.1)cm2/m2, with 59, 65, and 53 patients having a VFA/TAMAI of < 2, ≥2 and < 3, and ≥ 3, respectively. Patients with a VFA/TAMAI of ≥ 3 had higher preoperative inflammatory indices, including Alb, CRP, and white blood cells (WBCs) (Supplementary Table 1).
Table 2.
Characteristics about sarcopenia
| Characteristics | |
|---|---|
| NO. (%) | 177 (100) |
| TAMAI, cm2/m2(median,IQR ) | 31.5 (26.4 - 35.9) |
| VFA, cm2(median,IQR ) | 78.0 (56.7 - 93.5) |
| VFA/TAMAI (median,IQR ) | 2.4 (1.8 - 3.1) |
| VFA/TAMAI, NO. (%) | |
| < 2 | 59 (33.3) |
| ≥2 and < 3 | 65 (36.7) |
| ≥ 3 | 53 (29.9) |
| SFA,cm2/ m2(median,IQR ) | 80.0 (59.0 - 110.0) |
| VFA/ SFA | 0.93 (0.65 - 1.28) |
| VFA/ SFA, NO. (%) | |
| < 1 | 95 (53.7) |
| ≥ 1 | 82 (46.3) |
Recovery of digestive function
The time for recovery of digestive function was 10 days (IQR: 8–15 days) in all participants (10 days [IQR: 8–12] days in the non-PII patients and 26 days [IQR: 23–32 days] in the PII patients). The recovery time was 9 days (IQR: 6–12) days, 10 days (IQR: 9–14) days, and 16 days (IQR: 9–23) days in patients with a VFA/TAMAI of < 2, ≥2 and < 3, and ≥ 3, respectively (p < 0.001, Fig. 1).
Fig. 1.
Percentage of patients with recovery of digestive function; VFA/TAMAI <2 vs 2≤VFA/TAMAI < 3, Log- rank p = 0.005, VFA/TAMAI≥3 vs 2≤VFA/TAMAI < 3, Log- rank p = 0.01, VFA/TAMAI <2 vs VFA/TAMAI≥3, Log- rank p = 0.003
Cox regression revealed that VFA/TAMAI negatively impacted the recovery of digestive function (adjusted hazard [HR] = 0.83, 95% confidence interval [CI]: 0.71–0.96; p = 0.01, Fig. 2A).
Fig. 2.
A Risk factors associated with recovery of digestive function. B. Risk factors associated with PII
PII
PII occurred in 16.9% of the 177 patients (n = 30). The interval from IFE to temporary defecation was four days in 30 patients (IQR: 3–5) days. The temporary defecation lasted for 1 day (IQR: 1–2) days. The re-obstruction after temporary defecation lasted for 23 days (IQR: 21–30) days (Supplementary Table 2). Extra abdominal surgery for PII was not performed in any of the cases. EN was administered after digestive function recovery following the re-obstruction.
The association between VFA/TAMAI and PII
The incidence of PII in patients with a VFA/TAMAI < 2, ≥2 and < 3, and ≥ 3 was 11.9% (n = 6), 12.3% (n = 9), and 28.3% (n = 15) (p = 0.03), respectively. Patients with a VFA/TAMAI ≥ 3 were more likely to develop PII compared to patients with a VFA/TAMAI < 2 (p = 0.03) and a VFA/TAMAI of ≥ 2 and < 3 (p = 0.03), while patients with a VFA/TAMAI < 2 and a VFA/TAMAI of ≥ 2 and < 3 had a probability of p = 0.94 to develop PII.
Table 3 presents the unadjusted logistic regression for PII. Patients with PII had higher abdominal adhesion levels, a greater VFA/TAMAI, and more Alb usage during IFE and 48 h after IFE. The adjusted logistic regression revealed an association between VFA/TAMAI and PII (odds ratio [OR] = 1.51, 95% CI: 1.02–2.19; p = 0.03, Fig. 2B).
Table 3.
Unadjusted logistic regression for PII
| Characteristics | PII group (n = 30) | Non PII group (n = 147) | p |
|---|---|---|---|
| Demographic data | |||
| Male, No. (%) | 21 (70) | 82 (55.8) | 0.14 |
| Age, years; (median, IQR) | 51.0 (36.0–62.0) | 51.0 (38.0–58.0) | 0.39 |
| BMI, kg/m2,(median, IQR) | 19.9 (19.0–21.3) | 19.6 (18.8–21.0) | 0.58 |
| Fistula characteristics | |||
| Interval from fistula occurred to SIFE, months, (median, IQR) | 4.0 (3.8–5.0) | 4.0 (3.0–5.0) | 0.68 |
| Distance from Treitz to the fistula, No. (%) | 0.38 | ||
| < 100 cm | 2 (6.7) | 18 (12.2) | |
| ≥ 100 cm | 28 (93.3) | 129 (87.8) | |
| Length of small intestine, No. (%) | 0.12 | ||
| < 300 cm | 2 (6.7) | 27 (18.4) | |
| ≥ 300 cm | 28 (93.3) | 120 (81.6) | |
| PN required, No. (%) | 3 (10) | 20 (13.6) | 0.59 |
| Complicated with ventral hernia, No. (%) | 24 (80) | 103 (70.1) | 0.27 |
| Etiology, No. (%) | 0.44 | ||
| Trauma | 15 (50) | 91 (61.9) | |
| Obstruction | 12 (40) | 47 (31.9) | |
| Others | 3 (10) | 9 (6.1) | |
| Laboratory test results | |||
| Hemoglobin before SIFE, g/L; (median, IQR) | 125.5 (119.5–132.3) | 126.0 (116.0–132.0) | 0.73 |
| Albumin before SIFE, g/L; (median, IQR) | 36.5 (35.2–37.8) | 36.2 (34.4–38.3) | 0.51 |
| CRP before SIFE, mg/L; (median, IQR) | 7.9 (6.9–22.0) | 7.6 (6.5–14.2) | 0.10 |
| WBC before SIFE, 109/L; (median, IQR) | 6.9 (6.0–7.9) | 6.4 (5.8–7.6) | 0.61 |
| Intraoperative condition and postoperative care | |||
| Abdominal adhesion grade V | 18 (60) | 57 (38.8) | 0.03 |
| Duration of SIFE, hours; (median, IQR) | 5.2 (3.9–6.0) | 4.8 (3.5–5.8) | 0.13 |
| Deciliter of bleeding loss during SIFE, dL; (median, IQR) | 10.2 (9.0–17.3) | 11.0 (9.0–17.0) | 0.73 |
| The amount of red blood cell suspension input during SIFE and 48 h after SIFE#, No. (%) | 0.72 | ||
| <10U | 18 (60) | 83 (56.5) | |
| ≥10U | 12 (40) | 64 (43.5) | |
| The amount of albumin input during SIFE and 48 h after SIFE##, No. (%) | 0.01 | ||
| <100 g | 10 (33.3) | 85 (57.8) | |
| ≥100 g | 20 (66.7) | 62 (42.2) | |
| Comorbidity, No. (%) | |||
| Hypertensio | 4 (13.3) | 8 (5.4) | 0.12 |
| Elevated fasting blood glucose | 5 (16.7) | 16 (10.9) | 0.28 |
| Characteristics about sarcopenia | |||
| TAMAI, cm2/m2 (median, IQR) | 30.6 (26.2–33.7) | 31.3 (26.6–36.2) | 0.34 |
| VFA, cm2(median, IQR) | 79.5 (64.3–100.3) | 78.6 (56.0–91.0) | 0.25 |
| VFA/TAMAI (median, IQR) | 2.7 (1.8–3.6) | 2.4 (1.8–3.1) | 0.03 |
| SFA, cm2/m2 (median, IQR) | 82.0 (58.5–113.8) | 80.5 (59.0–110.0) | 0.35 |
| VFA/SFA | 0.9 (0.6–1.4) | 0.9 (0.7–1.3) | 0.71 |
# In order to maintain the Hemoglobin > 100 g/L within 48 h after SIFE
## In order to maintain the Albumin > 30 g/L within 48 h after SIFE
Subgroup analysis
VFA/TAMAI was the only factor associated with PII in males (adjusted OR = 1.59, 95% CI: 1.03–2.48; p = 0.03). In females, the unadjusted regression analysis identified VFA/TAMAI as the only potential factor (OR = 1.79, 95% CI: 1.14–2.82; p = 0.01). When patients were subgrouped based on bleeding volume, no statistically significant predictors of PII were found in patients with bleeding less than 1000 mL (n = 58) in the unadjusted regression (OR for VFA/TAMAI = 0.16, 95% CI: 0.84–3.14; p = 0.15). However, an association between VFA/TAMAI and PII was observed in patients with bleeding ≥ 1000 mL (adjusted OR = 1.52, 95% CI: 1.03–2.18; p = 0.03).
The postoperative inflammatory index
The postoperative inflammatory index comprised the postoperative CRP and WBC levels. The CRP on day 1 after IFE was 117 mg/dL (IQR: 101–130 mg/dL), 130 mg/dL (IQR: 118–142 mg/dL), and 157 mg/dL (IQR: 129–171 mg/dL, p < 0.001) and the WBC count on day 1 after IFE was 13 × 109/L (IQR: 12 × 109/L-15 × 109/L), 15 × 109/L (IQR: 14 × 109/L-18 × 109/L), and 19 × 109/L (IQR: 16 × 109/L-22 × 109/L, p < 0.001) in patients with a VFA/TAMAI of < 2, ≥2 and < 3, and ≥ 3, respectively.
Other complications and length of stay in hospital
The complications, including incision infection, anastomotic leakage, and gastrointestinal bleeding, are presented in Supplementary Table 3. The adjusted logistic regression analysis revealed that VFA/TAMAI (OR = 1.78, 95% CI: 1.21–2.62, p = 0.04) and intraoperative bleeding (OR = 1.12, 95% CI: 1.04–1.21, p = 0.04) were associated with leakage, while VFA/TAMAI was not associated with incision infection or gastrointestinal bleeding. The postoperative length of stay was 13 days (IQR: 10–18 days) in patients without PII, compared to 32 days (IQR: 28–45 days) in patients with PII.
Discussion
Herein, we reported the association between VFA/TAMAI and PII after IFE with severe abdominal adhesions in patients with sarcopenia.
IFE with severe abdominal adhesions seems to be a surgical nightmare. The anatomy is elusive, and the procedure is arduous, with massive trauma and bleeding [8]. An exaggerated postoperative inflammatory reaction seems inevitable in this case. According to Boelens et al. [13] and Tian et al. [14, 15], a high postoperative inflammatory response significantly increased the risk for postoperative complications and a prolonged hospital length of stay following major abdominal surgery. A possible theory for the pathogenesis of PII, a rare complication, is that the surgical trauma is responsible for the severe postoperative inflammation, resulting in persistent mesangial and intestinal oedema, thereby hindering digestive function recovery. In the present study, we utilized adhesion scores based on the system developed by Hobson et al. [11]. Other scoring systems, such as those by Zühlke et al. [16], the American Fertility Society (AFS) adhesion scoring system [17], and more comprehensive adhesion scoring systems [18], were also considered. However, the primary cause of adhesions in patients with intestinal fistulas is often inadequate drainage, which can lead to adhesions extending beyond the area surrounding the fistula. The extent of these adhesions requires careful evaluation, and their severity may vary due to repeated peritoneal irritation from persistent infection. This variability highlights the need to assess both the firmness and extent of the adhesions. Existing scoring systems often overemphasize either the firmness [17] or the extent of adhesions [16], which may be more relevant to specific diseases for which the scoring systems were designed. The scoring system employed in this study incorporates both the firmness and extent of adhesion. However, it should be noted that other scoring systems also account for both factors, but they tend to be overly complex (with scores ranging from 1 to 12 points), making intraoperative assessment particularly challenging.
Although many surgeons are aware of the postoperative inflammatory reaction’s potential impact on outcomes following abdominal surgery, the focus has recently turned to preoperative chronic inflammation’s potential impact. Chronic inflammation promotes myoblast-to-adipocyte transition, and myoblasts exhibit (pre)adipocyte-like characteristics. Several studies have indicated that body composition imbalance in sarcopenia is a better clinical indicator of chronic inflammation [19–22]. Clinically, VFA/TAMAI is a relatively simple method to evaluate body composition. Reportedly, it is associated with postoperative morbidity and mortality after abdominal or pelvic surgery [23]. An association between VFA/TAMAI and a postoperative pancreatic fistula after pancreaticoduodenectomy was reported by Jang et al. [24]. Ha et al. [25] reported an association between VFA/TAMAI and increased post-liver transplant mortality. Chathura et al. [26] reported that VFA/TAMAI could serve as a significant independent predictor of postoperative morbidity after pancreatic resection. An association between VFA/TAMAI and severe postoperative complications after gastrectomy was reported by Zhang et al. [26]. One possible explanation for these phenomena is that patients with pathological VFA hyperplasia may have more fragile tissue in the surgical field, which could increase exudation and exacerbate the postoperative inflammatory response, leading to poor postoperative outcomes. Alternatively, another hypothesis suggests that preoperative chronic inflammation, which affects VFA/TAMAI, may be linked to impaired immune function [4], thereby amplifying postoperative inflammation [4]. The subgroup analysis also yielded similar results, even in patients with intraoperative bleeding of less than 1000 mL. However, only 58 patients with bleeding of less than 1000 mL were included in the analysis, indicating a small sample size. Based on the results presented in our study, where the p-value reached 0.15, it can be inferred that the significance might become apparent with an expanded sample size. In this study, patients with a higher VFA/TAMAI had a higher postoperative inflammatory index, despite an insignificant influence on the characteristics of the surgical progress. The increased chronic inflammation indicated by a higher VFA/TAMAI was therefore assumed to be the catalyst for an exacerbated postoperative inflammatory response despite having little effect on surgical trauma. We believe that patients with the risk factors mentioned in the study, particularly those with high VFA/TAMAI ratios, should be closely monitored for postoperative ileus (PII). It is important to emphasize that, unlike mechanical intestinal obstruction, PII can often be effectively managed with appropriate nursing care, medical interventions, and patience. Even in cases where patients experience prolonged postoperative ileus (typically lasting 20–30 days), the ultimate outcome is frequently favorable. This underscores the importance of proper management and patience in dealing with PII, as opposed to more invasive interventions that might be necessary for mechanical obstructions.
First limitation was that the retrospective nature and limited sample size of this study might explain the deviation. However, the number of patients enrolled in our study might be sufficient because the number of cases of intestinal fistula with severe abdominal adhesions is scarce. Second, as a very rare complication after abdominal surgery, research on PII is lacking, resulting in a limited understanding of its pathogenesis. In our research, it seemed to be exceedingly challenging to explain the occurrence of re-obstruction following temporary defecation after abdominal surgery. Laboratory research is necessary to address this concern. Third, somatostatin was used in PII patients, thus the recovery of gastrointestinal function might be affected. However, the dosage of somatostatin was limited. In addition, the main outcome of this study was not be influenced. Another limitation is that the patients were followed-up until discharged. Thus, we could not evaluate whether patients belonging to the non-PII patients developed a re-obstruction after discharge. Possibly there were patients with PII who were misdiagnosed as having a recovered intestinal function and discharged from the hospital in the case of temporary defecation. In other words, PII occurring in some patients might not have been recorded, resulting in a bias. However, following our strategy of resuming total EN, the time interval from administering the initial EN to discharge was at least 5 days, which was significantly longer than the temporary defecation in the PII patients. It is reasonable to assume that the likelihood of a missed diagnosis of PII was low.
Conclusion
VFA/TAMAI was associated with PII after IFE with severe abdominal adhesions in patients with sarcopenia.
Supplementary Information
Acknowledgements
None.
Authors’ contributions
Data curation, Weiliang Tian; Formal analysis, Weiwei Shang and Zheng Yao; Investigation, Weiliang Tian, Xin Xu, Qian Huang, and Zheng Yao; Methodology, Weiwei Shang, Yunzhao Zhao, Risheng Zhao, Xin Xu, and Zheng Yao; Project administration, Zheng Yao; Resources, Risheng Zhao, Weiliang Tian and Fan Yang; Software, Weiwei Shang, Yunzhao Zhao, Xin Xu and Zheng Yao; Supervision, Qian Huang, Risheng Zhao and Zheng Yao; Visualization, Guoping Zhao; Writing – original draft, Fan Yang, Zhiwu Hong, and Weiliang Tian. Shikun Luo, Xinying Wang and Fan Yang revised the manuscript. Funding-Shikun Luo；Fan Yang, Zhiwu Hong, and Shikun Luo were the first authors. Xinying Wang, Risheng Zhao, Yunzhao Zhao, Zheng Yao, Xin Xu, and Qian Huang were the corresponding authors.
Funding
Support: Research and Development Fund Project of Kangda College,
Nanjing Medical University (KD2023KYJJ227).
Data availability
The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was approved by the ethics committee of Jiangning Hospital, 2024-03-046-K01. Informed consent was obtained by all individuals participating in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Xinying Wang, Email: wangxynj@163.com.
Risheng Zhao, Email: dr_zhaorisheng@163.com.
Xin Xu, Email: Rn_xuxin@163.com.
Qian Huang, Email: Dr_dochqnj@163.com.
Zheng Yao, Email: Dr_yaozheng@163.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.