Post on 22-Jun-2018
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Management of recurrent small bowel obstruction
Aliu Sanni MD
Kings County Hospital Center
21st June, 2012.
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Case presentation
• 35yr old male presents with abdominal pain, nausea and vomiting.
• s/p Exploratory laparotomy, extensive lysis of adhesions and small bowel resection for recurrent small bowel obstruction POD#7
• PSH: GSW abdomen (2004), s/p exploratory laparotomy, multiple SBR with six SB anastomosis at initial surgery
• Recurrent admissions for SBO necessitating Ex-lap, LOA and SBR twice in the past
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Case presentation
• On arrival T=98.2, BP 128/76 PR=117
• General- in moderate distress
• Abdomen- distended, tender with peritonitis
• Chest- CTA bilat
• CVS-S1S2, no murmur
• WBC- 15000
• BMP, Coags- WNL
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Imaging
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Case presentation
• Resuscitation
• Operative intervention
• Exploratory laparotomy- frozen abdomen, no frank perforation.
• Abdominal washout
• Generous use of fibrin glue
• Drainage with large Jackson Pratt tubes
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Case presentation
Hospital course
• POD#1- TPN
• POD#3- Discontinue JP drains
• POD#8- Regular diet
• POD#11- Discharged home
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Management of Recurrent Small Bowel Obstruction
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Pathophysiology
• Occurs when the normal propulsion and passage of intestinal contents does not occur.
• Gas and fluid accumulates in the lumen proximal to obstruction
• Leads to translocation of bacteria • Build up in intraluminal pressure and
impairment of intestinal microvascular perfusion
• Ultimate intestinal ischemia and gangrene
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Mechanical bowel obstruction
• Physical blockage of intestinal lumen
• Intrinsic or extrinsic to intestinal wall
• Partial obstruction-transit of some intestinal content
• Complete obstruction- possible strangulation, ischemia
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Functional obstruction
• AKA Pseudo-obstruction
• Secondary to factors that cause intestinal paralysis
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Clinical presentation
• Abdominal pain, nausea, vomiting and obstipation
• Laboratory findings reflect fluid depletion
• Mild leukocytosis
• Strangulated obstruction- pain out of proportion to examination, tachycardia, marked leukocytosis and peritoneal signs.
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Diagnosis
• History of previous abdominal surgery
• Meticulous physical examination to search for hernias
• AXR- flat and upright films
• CT Scan Abdomen- transition point. Other anatomical abnormalities.
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Management
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Recurrent small bowel obstruction
• Incidence of up to 34% in all patients regardless of the management modality.
• More common in patients with multiple adhesions, matted adhesions, previous admission for SBO, previous pelvic and colorectal surgery
• Numerous attempts have been made to control formation of adhesions
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Plication
• Suturing of adjacent loops of small bowel into an orderly pattern to prevent mechanical obstruction e.g. Noble plication, Childs-Phillips transmesenteric plication.
• Complications- High rates of enterocutaneous fistula, abdominal abscess and wound infection
• Rate of recurrent obstruction up to 19%.
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Intraluminal Stenting
• Splinting the bowel with long intestinal tubes
• Baker’s Tube- tube jejunostomy with passage of long tube through small intestine to colon
• Lennard tube- rigid tube passed naso-intestinally.
• Complications- Intra-abdominal leak, persistent enterocutaneous fistula, obstruction at jejunostomy site.
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Summary
• Recurrent small bowel obstruction is a very common surgical dilemma.
• Plication and intraluminal stenting are historical procedures with significant morbidity.
• Watchful waiting in patients with recurrent small bowel obstruction
• Meticulous surgical technique to prevent enterotomies.
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