Management of recurrent small bowel obstruction of recurrent small bowel obstruction ... • POD#11-...

Management of recurrent small bowel obstruction

Aliu Sanni MD

Kings County Hospital Center

21st June, 2012.

www.downstatesurgery.org

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


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


Imaging


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


Case presentation

Hospital course

• POD#1- TPN

• POD#3- Discontinue JP drains

• POD#8- Regular diet

• POD#11- Discharged home


Management of Recurrent Small Bowel Obstruction


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


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



Functional obstruction

• AKA Pseudo-obstruction

• Secondary to factors that cause intestinal paralysis



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.


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.





Management


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


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%.


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.



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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