Adhesive Small Bowel Obstruction in Children: The Place and Predictors of Success for Conservative Treatment By Feza M. Akgtir, F. Cahit Tanyei, Nebil Btiyiikpamuky,
and Akgiin Hi@nmez
Ankara, Turkey @The records of 230 adhesive small bowel obstruction (ASBO) episodes in 181 patients have been reviewed to observe the place of conservative treatment and to establish criteria to predict the success of conservative trial. Immediate operation has been reserved for 81 episodes that have presented with fever and leucocytosis and/or localized abdominal tenderness, or complete obstruction. The remaining 149 episodes have initially undergone conservative trial. Although 110 episodes (73.8%) have been cured with conservative trial, 39 (26.2%) subsequently necessitated surgical intervention. No adverse occurrences have been observed during or after delayed operations. There was no strangulated bowel nor mortality both in delayed operation and conservatively treated groups. Recurrence has occurred with rates of 18.75% and 36.47% after surgery and conservative treatment, respectively, being significantly different (P < .Ol), but the treatment method of the previous episode has been without influence on the method used in the recurrent obstruction (P > .05). Among the assumed predictive criteria, age at recent laparotomy (P < .02), time elapsed between recent laparotomy and obstructive episode (P < .02), the primary condition necessitating laparotomy (P < .Ol), the incision of previous laparotomy (P < .05), and duration of conservative trial (P < .Ol) correlated significantly with the success of conservative trial. The number of previous laparotomies and obstructive episodes (P > .05) have not showed correlation. By the conservative approach used in selected patients with ASBO, 40% overall have been spared operation, without any adverse occurrences. Using the proposed criteria, the success rate of conservative treatment can be predicted. Copyright o 1991 by W.B. Saunders Company INDEX WORDS: Adhesive small bowel obstruction.
T
HE DIAGNOSIS of adhesive small bowel obstruction (ASBO) is easily made but treatment is somewhat controversial. It has been stated that there is no place for conservative treatment in infancy and childhood.‘-’ However, in adults, conservative treatment consisting of nasogastric or nasointestinal decompression and parenteral fluids has been advocated in selected patients.8-‘4 At this institution, it is believed that conservative modalities should also take place in the treatment of ASBO encountered in children. Therefore, a retrospective clinical study has been performed to observe the place of conservative treatment and to determine if there were criteria to predict the success of conservative trial in children. MATERIALS AND METHODS The records of 181 patients (60 girls, 121 boys) aged 1 month to 16 years, treated for ASBO between January 1976 and January JournalofPediatric Surgery, Vol26, No 1 (January), 1991:
pp 37-41
1989 at Hacettepe University Children’s Hospital, Department of Pediatric Surgery, were evaluated retrospectively. Each episode has been evaluated separately in the 181 patients who had 230 episodes of ASBO. The diagnosis of ASBO was established in patients who were admitted with abdominal pain, nausea, vomiting, failure to pass flatus and stool, and who showed air-fluid levels on plain erect abdominal radiographs. At admission fever (axillary temperature > 37S”C), localized abdominal tenderness, leucocytosis (white blood cell (WBC) count > 10,000 cells per mm’), evidence of complete obstruction (history of fecaloid vomiting and/or wide based air-fluid levels without gas in the colon above peritoneal reflection on plain erect abdominal radiographs) have been recorded. In the presence of fever and leucocytosis and/or localized abdominal tenderness and/or evidence of complete obstruction or free peritoneal air, surgical treatment has been applied; the rest of the patients have undergone conservative trial without taking into account any other criteria (Fig 1). Conservative trial has consisted of nasogastric decompression, parenteral fluid, electrolyte resuscitation and maintenance, and restriction of analgesics and antibiotics. Hourly fever determinations, observation for passage of fatus and feces, physical examination for localized abdominal tenderness every 4 hours, records of the amount and quality of nasogastric drainage material every 8 hours, daily WBC count, and plain erect abdominal radiographs were evaluated. and evaluation has been repeated more frequently in the presence of any doubt during conservative trial. Elevation of temperature and increase in WBC count without any other cause and/or appearance of localized abdominal tenderness on physical examination, persistence of the same patterns of air-fluid levels for 24 hours or even getting wider based on plain erect abdominal radiographs, and worsening in the amount and quality of the nasogastric drainage material have all been accepted as indications for operation in patients under conservative trial. Conservative treatment has been continued without any time limitations for those patients who have been without fever and leucocytosis and/or localized abdominal tenderness, with air-fluids levels becoming narrower based, or passage of gas to the colon above the peritoneal reflexion on plain erect abdominal radiographs, with improvement of nasogastric drainage material in amount and quality and/or starting passage of flatus and feces. Operative findings, procedures, and complications of patients who have undergone surgery as initial treatment or after unsuccessful conservative treatment were compared to evaluate the risk of conservative treatment,
From the Department of Pediatric Surgety Hacettepe University Children’s Hospital, Ankara, Turkey. Date accepted: November 20, 1989. Address reprint requests to F. C. Tanyel> Department of Pediattic Surgery, Hacettepe University Children’s Hospital. Sihhiye-Ankara, Turkey 06100. Copyright o 1991 by W.B. Saunders Companv 0022-3468/9I12601-0009$03.00~0 37
38
AKGUR ET AL
Fever and leucocytosis abdominal tenderness and/or evidence of complete obstruction, which are: -fecaloid vomiting or nasogastric drainage -and/or wide based air fluid levels without gas in the colon above peritoneal reflection (ves) _ operate
Table 2. Initial Method of Treatment
I
* and/orlocalized
Evidence of partial obstruction, which are: -non fecaloid vomiting or nasogastric drainage -and/or smaller based air fluid levels
I
(Yes)
Conservative trial -observe for passage of flatus and feces -do physical examination for localized abdominal tenderness -determine fever and WBC count -record amount and quality of nasogastric drainage material -obtain erect plain abdominal radiographs Fig 1.
Decision-making
in ASBO.
The patients initially being treated conservatively have been evaluated to determine criteria for predicting a successful outcome according to the final resuk, which is success or necessitating surgical treatment. These criteria have been (1) age at recent laparotomy; (2) time elapsed between recent laparotomy and obstructive episode; (3) the primary condition necessitating laparotomy; (4) the incision of previous laparotomy; (5) duration of conservative trial; (6) number of previous laparotomies; and (7) number of obstructive episodes. x2 And t tests were used for statistical analysis. P values less than 0.05 were accepted as statistically significant. RESULTS
Two hundred thirty episodes of ASBO in 181 patients have been treated. One hundred forty-four patients had one, 27 had two, eight had three, and the remaining two patients had four episodes of ASBO. Table 1. Primary Condition in Patients With ASS0
Condition
NO.
Appendicitis w/w0 perforation
52
28.73
Blunt abdominal trauma
26
14.36
lntussusception
21
11.60
15
8.29
12
6.63
Intraperitoneal/retroperitoneaI malignancy Conditions requiring colonic pull-through operations* Neonatal laparotomiest Penetrating abdominal trauma Miscellaneous Total
10
5.52
9
4.97
36
19.89
181
100.00
“Hirschsprung’s disease, anorectal malformation, polyposis coli. tOmphalocele,
malrotation, jejunoileal atresia.
Method
in ASS0
No. of Episodes
Immediate operation
Frequency WI
81
44.7
Conservative trial
149
55.3
Total
230
100.00
The most frequent cause of ASBO has been appendicitis with or without drainage. Other causes, in decreasing order, have been blunt abdominal trauma, intussusception, and intraperitoneal-retroperitoneal malignancy (Table 1). Eighty-one instances were considered to need immediate operation and were operated on after resuscitation. One hundred forty-nine initially had conservative trial (Table 2). Although 39 of the patients initially selected for conservative trial have needed operation, 110 patients have been successfully treated with the method (Table 3). The mean duration of conservative treatment was 3.0 + 1.22 days. A total of 120 patients (81 initially and 39 after conservative trial) had surgical intervention for ASBO. No strangulated bowel has been encountered after delayed operations. Incidental injury to bowel have been the same in both groups (P > .05) (Table 4). Operative procedures performed for immediate and delayed operations have been different, necessitating more aggressive surgery for the immediate group (P < .OS) (Table 5). Postoperative infection rates have shown no difference (P > .05) and no mortality has been encountered in the delayed operation group (Table 6). Two deaths were encountered in this series. One occurred after preoperative perforation with advanced peritonitis treated by enterostomy; the other after sepsis caused by peritonitis resulting from anastomotic leakage not responding to surgical and medical modalities. Eighteen recurrent ASBO have occurred following 96 surgically treated first episodes (18.75%). Recurrence rate after conservative treatment is 36.47%; that is, 31 recurrences of 85 episodes initially treated conservatively. The difference is statistically significant (P < .Ol) (Table 7). Six recurrent episodes after previous surgical treatment have been treated surgically (33.33%) and 12 conservatively (66.66%). On Table 3. Results of Conservative Trials No. of Episodes Unsuccessful
Frequency (W
39
26.2
Successful
110
73.8
Total
149
100.00
ADHESIVE SMALL BOWEL OBSTRUCTION
IN CHILDREN
Table 4. Time of Operation Versus Preoperative
Table 10. Time Elapsed Between Recent Laparotomy and
and
Obstructive Episode Versus Success of Conservative Trial
Peroperative Complications Delayed Operation (n = 39)
Immediate Operation tn = 81)
Strangulation
Total (n = 120)
NO.
%
NO.
%
17.28
-
-
14
11.66
2
2.46
-
-
2
1.66
3
3.70
5
4.16
No.
%
14
Preoperative perforation Incidental perforation
2
5.12
Table 5. Time of Operation Versus Operative Procedure Performed Immediate Operatron tn = 811
Lysis of adhesions
NO.
%
62
76.54
16
19.75
3
3.70
Delayed Operation (n = 39) NO. 37
Total (n = 120)
%
NO.
%
94.87
99
82.50
2.56
Lysis + resection of bowel Lysis + enterestomy
1” -
17
14.16
-
3
2.50
2.56
1
0.83
Lysis + perforation repair
1*
“Result of incidental bowel perforation.
Table 6. Time of Operation Versus Postoperative
NO.
Complications
Delayed Operation (n = 39)
Immediate Operation In = 81) %
Total (n = 120)
NO.
%
NO.
1
2.56
%
Wound infection
4
4.93
5
4.16
Anastomotic leakage
2
11.76*
-
-
2
11.76*
Mortality
2
2.46
-
-
2
1.66
*Among 17 episodes of resection and anastomosis.
Table 7. Treatment
of Previous Episode Versus Incidence of Recurrence
Treatment Previous
of
Recurrence
Previous Episode
Episode
NO.
(No.)
%
Surgical
96
18
18.75
Conservative
85
31
36.47
Table 8. Treatment
Time (mo)
No. of Conservative Trials
%
.OS) (Table 8). In regard to the predictive criteria in determining the success of conservative trial, if the recent laparotomy causing ASBO has been performed during infancy, success of conservative trial is 60.72%, but increases to 82.70% if performed after 8 years of age; the difference is significant (P < .02) (Table 9). Success rate is 81.49% if the time elapsed between last laparotomy and obstructive episode is under 3 months, but decreases to 59.26% if the time elapsed is more than 18 months; the difference is significant (P < .02) (Table 10). The primary condition necessitating laparotomy has also influenced success; that is, if the primary condition is appendicitis the success rate is 91.91%, but it is 50% if the condition requires colonic pull-through (P < .Ol) (Table 11). If the incision of previous laparotomy is gridiron, success rate is 88.47%, but 60% if there are two incisions; the difference is significant (P < .05) (Table 12). If more than 48 hours have passed under conservative trial, the success rate is 82.32% versus 62.32% for less than 48 hours; the difference is significant (P < .Ol) (Table 13). Number of previous laparotomies and number of previous ASBO episodes has no influence on the success rate of conservative trial; differences are not significant (P > .05) (Tables 14 and 15). Table 11. Primary Condition Versus Success of Conservative Trial No. of
Treatmentof Recurrence of
Previous Episode
NO.
%
of Previous Episode Versus Treatment of Recurrence
Treatment
Unsuccessful
Successful NO.
Surgical
Recurrence (No.)
NO.
%
Conservative NO.
%
Surgical
18
6
33.33
12
66.66
Conservative
31
18
58.08
13
41.92
Condition
Successful Conservative Trials NO. %
Unsuccessful NO.
%
Appendicitis w/w0 perfora33
30
91.91
3
9.09
Blunt abdominal trauma
tion
21
16
76.20
5
23.80
Miscellaneous
39
28
71.79
11
28.21
IntraperitoneaVretroperiTable 9. Age During Recent Operation Versus Success of Conservative Trial No. of
Successful
toneal malignancy lntussusception
Unsuccessful
NO.
%
NO.
%
and Akgiin Hi@nmez
Ankara, Turkey @The records of 230 adhesive small bowel obstruction (ASBO) episodes in 181 patients have been reviewed to observe the place of conservative treatment and to establish criteria to predict the success of conservative trial. Immediate operation has been reserved for 81 episodes that have presented with fever and leucocytosis and/or localized abdominal tenderness, or complete obstruction. The remaining 149 episodes have initially undergone conservative trial. Although 110 episodes (73.8%) have been cured with conservative trial, 39 (26.2%) subsequently necessitated surgical intervention. No adverse occurrences have been observed during or after delayed operations. There was no strangulated bowel nor mortality both in delayed operation and conservatively treated groups. Recurrence has occurred with rates of 18.75% and 36.47% after surgery and conservative treatment, respectively, being significantly different (P < .Ol), but the treatment method of the previous episode has been without influence on the method used in the recurrent obstruction (P > .05). Among the assumed predictive criteria, age at recent laparotomy (P < .02), time elapsed between recent laparotomy and obstructive episode (P < .02), the primary condition necessitating laparotomy (P < .Ol), the incision of previous laparotomy (P < .05), and duration of conservative trial (P < .Ol) correlated significantly with the success of conservative trial. The number of previous laparotomies and obstructive episodes (P > .05) have not showed correlation. By the conservative approach used in selected patients with ASBO, 40% overall have been spared operation, without any adverse occurrences. Using the proposed criteria, the success rate of conservative treatment can be predicted. Copyright o 1991 by W.B. Saunders Company INDEX WORDS: Adhesive small bowel obstruction.
T
HE DIAGNOSIS of adhesive small bowel obstruction (ASBO) is easily made but treatment is somewhat controversial. It has been stated that there is no place for conservative treatment in infancy and childhood.‘-’ However, in adults, conservative treatment consisting of nasogastric or nasointestinal decompression and parenteral fluids has been advocated in selected patients.8-‘4 At this institution, it is believed that conservative modalities should also take place in the treatment of ASBO encountered in children. Therefore, a retrospective clinical study has been performed to observe the place of conservative treatment and to determine if there were criteria to predict the success of conservative trial in children. MATERIALS AND METHODS The records of 181 patients (60 girls, 121 boys) aged 1 month to 16 years, treated for ASBO between January 1976 and January JournalofPediatric Surgery, Vol26, No 1 (January), 1991:
pp 37-41
1989 at Hacettepe University Children’s Hospital, Department of Pediatric Surgery, were evaluated retrospectively. Each episode has been evaluated separately in the 181 patients who had 230 episodes of ASBO. The diagnosis of ASBO was established in patients who were admitted with abdominal pain, nausea, vomiting, failure to pass flatus and stool, and who showed air-fluid levels on plain erect abdominal radiographs. At admission fever (axillary temperature > 37S”C), localized abdominal tenderness, leucocytosis (white blood cell (WBC) count > 10,000 cells per mm’), evidence of complete obstruction (history of fecaloid vomiting and/or wide based air-fluid levels without gas in the colon above peritoneal reflection on plain erect abdominal radiographs) have been recorded. In the presence of fever and leucocytosis and/or localized abdominal tenderness and/or evidence of complete obstruction or free peritoneal air, surgical treatment has been applied; the rest of the patients have undergone conservative trial without taking into account any other criteria (Fig 1). Conservative trial has consisted of nasogastric decompression, parenteral fluid, electrolyte resuscitation and maintenance, and restriction of analgesics and antibiotics. Hourly fever determinations, observation for passage of fatus and feces, physical examination for localized abdominal tenderness every 4 hours, records of the amount and quality of nasogastric drainage material every 8 hours, daily WBC count, and plain erect abdominal radiographs were evaluated. and evaluation has been repeated more frequently in the presence of any doubt during conservative trial. Elevation of temperature and increase in WBC count without any other cause and/or appearance of localized abdominal tenderness on physical examination, persistence of the same patterns of air-fluid levels for 24 hours or even getting wider based on plain erect abdominal radiographs, and worsening in the amount and quality of the nasogastric drainage material have all been accepted as indications for operation in patients under conservative trial. Conservative treatment has been continued without any time limitations for those patients who have been without fever and leucocytosis and/or localized abdominal tenderness, with air-fluids levels becoming narrower based, or passage of gas to the colon above the peritoneal reflexion on plain erect abdominal radiographs, with improvement of nasogastric drainage material in amount and quality and/or starting passage of flatus and feces. Operative findings, procedures, and complications of patients who have undergone surgery as initial treatment or after unsuccessful conservative treatment were compared to evaluate the risk of conservative treatment,
From the Department of Pediatric Surgety Hacettepe University Children’s Hospital, Ankara, Turkey. Date accepted: November 20, 1989. Address reprint requests to F. C. Tanyel> Department of Pediattic Surgery, Hacettepe University Children’s Hospital. Sihhiye-Ankara, Turkey 06100. Copyright o 1991 by W.B. Saunders Companv 0022-3468/9I12601-0009$03.00~0 37
38
AKGUR ET AL
Fever and leucocytosis abdominal tenderness and/or evidence of complete obstruction, which are: -fecaloid vomiting or nasogastric drainage -and/or wide based air fluid levels without gas in the colon above peritoneal reflection (ves) _ operate
Table 2. Initial Method of Treatment
I
* and/orlocalized
Evidence of partial obstruction, which are: -non fecaloid vomiting or nasogastric drainage -and/or smaller based air fluid levels
I
(Yes)
Conservative trial -observe for passage of flatus and feces -do physical examination for localized abdominal tenderness -determine fever and WBC count -record amount and quality of nasogastric drainage material -obtain erect plain abdominal radiographs Fig 1.
Decision-making
in ASBO.
The patients initially being treated conservatively have been evaluated to determine criteria for predicting a successful outcome according to the final resuk, which is success or necessitating surgical treatment. These criteria have been (1) age at recent laparotomy; (2) time elapsed between recent laparotomy and obstructive episode; (3) the primary condition necessitating laparotomy; (4) the incision of previous laparotomy; (5) duration of conservative trial; (6) number of previous laparotomies; and (7) number of obstructive episodes. x2 And t tests were used for statistical analysis. P values less than 0.05 were accepted as statistically significant. RESULTS
Two hundred thirty episodes of ASBO in 181 patients have been treated. One hundred forty-four patients had one, 27 had two, eight had three, and the remaining two patients had four episodes of ASBO. Table 1. Primary Condition in Patients With ASS0
Condition
NO.
Appendicitis w/w0 perforation
52
28.73
Blunt abdominal trauma
26
14.36
lntussusception
21
11.60
15
8.29
12
6.63
Intraperitoneal/retroperitoneaI malignancy Conditions requiring colonic pull-through operations* Neonatal laparotomiest Penetrating abdominal trauma Miscellaneous Total
10
5.52
9
4.97
36
19.89
181
100.00
“Hirschsprung’s disease, anorectal malformation, polyposis coli. tOmphalocele,
malrotation, jejunoileal atresia.
Method
in ASS0
No. of Episodes
Immediate operation
Frequency WI
81
44.7
Conservative trial
149
55.3
Total
230
100.00
The most frequent cause of ASBO has been appendicitis with or without drainage. Other causes, in decreasing order, have been blunt abdominal trauma, intussusception, and intraperitoneal-retroperitoneal malignancy (Table 1). Eighty-one instances were considered to need immediate operation and were operated on after resuscitation. One hundred forty-nine initially had conservative trial (Table 2). Although 39 of the patients initially selected for conservative trial have needed operation, 110 patients have been successfully treated with the method (Table 3). The mean duration of conservative treatment was 3.0 + 1.22 days. A total of 120 patients (81 initially and 39 after conservative trial) had surgical intervention for ASBO. No strangulated bowel has been encountered after delayed operations. Incidental injury to bowel have been the same in both groups (P > .05) (Table 4). Operative procedures performed for immediate and delayed operations have been different, necessitating more aggressive surgery for the immediate group (P < .OS) (Table 5). Postoperative infection rates have shown no difference (P > .05) and no mortality has been encountered in the delayed operation group (Table 6). Two deaths were encountered in this series. One occurred after preoperative perforation with advanced peritonitis treated by enterostomy; the other after sepsis caused by peritonitis resulting from anastomotic leakage not responding to surgical and medical modalities. Eighteen recurrent ASBO have occurred following 96 surgically treated first episodes (18.75%). Recurrence rate after conservative treatment is 36.47%; that is, 31 recurrences of 85 episodes initially treated conservatively. The difference is statistically significant (P < .Ol) (Table 7). Six recurrent episodes after previous surgical treatment have been treated surgically (33.33%) and 12 conservatively (66.66%). On Table 3. Results of Conservative Trials No. of Episodes Unsuccessful
Frequency (W
39
26.2
Successful
110
73.8
Total
149
100.00
ADHESIVE SMALL BOWEL OBSTRUCTION
IN CHILDREN
Table 4. Time of Operation Versus Preoperative
Table 10. Time Elapsed Between Recent Laparotomy and
and
Obstructive Episode Versus Success of Conservative Trial
Peroperative Complications Delayed Operation (n = 39)
Immediate Operation tn = 81)
Strangulation
Total (n = 120)
NO.
%
NO.
%
17.28
-
-
14
11.66
2
2.46
-
-
2
1.66
3
3.70
5
4.16
No.
%
14
Preoperative perforation Incidental perforation
2
5.12
Table 5. Time of Operation Versus Operative Procedure Performed Immediate Operatron tn = 811
Lysis of adhesions
NO.
%
62
76.54
16
19.75
3
3.70
Delayed Operation (n = 39) NO. 37
Total (n = 120)
%
NO.
%
94.87
99
82.50
2.56
Lysis + resection of bowel Lysis + enterestomy
1” -
17
14.16
-
3
2.50
2.56
1
0.83
Lysis + perforation repair
1*
“Result of incidental bowel perforation.
Table 6. Time of Operation Versus Postoperative
NO.
Complications
Delayed Operation (n = 39)
Immediate Operation In = 81) %
Total (n = 120)
NO.
%
NO.
1
2.56
%
Wound infection
4
4.93
5
4.16
Anastomotic leakage
2
11.76*
-
-
2
11.76*
Mortality
2
2.46
-
-
2
1.66
*Among 17 episodes of resection and anastomosis.
Table 7. Treatment
of Previous Episode Versus Incidence of Recurrence
Treatment Previous
of
Recurrence
Previous Episode
Episode
NO.
(No.)
%
Surgical
96
18
18.75
Conservative
85
31
36.47
Table 8. Treatment
Time (mo)
No. of Conservative Trials
%
.OS) (Table 8). In regard to the predictive criteria in determining the success of conservative trial, if the recent laparotomy causing ASBO has been performed during infancy, success of conservative trial is 60.72%, but increases to 82.70% if performed after 8 years of age; the difference is significant (P < .02) (Table 9). Success rate is 81.49% if the time elapsed between last laparotomy and obstructive episode is under 3 months, but decreases to 59.26% if the time elapsed is more than 18 months; the difference is significant (P < .02) (Table 10). The primary condition necessitating laparotomy has also influenced success; that is, if the primary condition is appendicitis the success rate is 91.91%, but it is 50% if the condition requires colonic pull-through (P < .Ol) (Table 11). If the incision of previous laparotomy is gridiron, success rate is 88.47%, but 60% if there are two incisions; the difference is significant (P < .05) (Table 12). If more than 48 hours have passed under conservative trial, the success rate is 82.32% versus 62.32% for less than 48 hours; the difference is significant (P < .Ol) (Table 13). Number of previous laparotomies and number of previous ASBO episodes has no influence on the success rate of conservative trial; differences are not significant (P > .05) (Tables 14 and 15). Table 11. Primary Condition Versus Success of Conservative Trial No. of
Treatmentof Recurrence of
Previous Episode
NO.
%
of Previous Episode Versus Treatment of Recurrence
Treatment
Unsuccessful
Successful NO.
Surgical
Recurrence (No.)
NO.
%
Conservative NO.
%
Surgical
18
6
33.33
12
66.66
Conservative
31
18
58.08
13
41.92
Condition
Successful Conservative Trials NO. %
Unsuccessful NO.
%
Appendicitis w/w0 perfora33
30
91.91
3
9.09
Blunt abdominal trauma
tion
21
16
76.20
5
23.80
Miscellaneous
39
28
71.79
11
28.21
IntraperitoneaVretroperiTable 9. Age During Recent Operation Versus Success of Conservative Trial No. of
Successful
toneal malignancy lntussusception
Unsuccessful
NO.
%
NO.
%
