Abdominal shake for early postoperative adhesive obstruction

Abstract

Adhesive obstruction in the early postlaparotomy period is not an uncommon problem; it usually manifests by clinical signs of colic, vomiting, abdominal distention, and reduced stool output as well as passage of flatus [ [1] Akgur F.M. Tanyel F.C. Buyukpamukcu N. Hicsonmez A. Adhesive small bowel obstruction in children: the place and predictors of success for conservative treatment. J Pediatr Surg. 1991; 26: 37-41 Abstract Full Text PDF PubMed Scopus (40) Google Scholar . Local signs may include some tenderness without peritonism and obstructive bowel sounds. Radiologic confirmation of obstruction with dilated loops of bowel, often fluid filled, and fluid levels is apparent to a varying degree. Ultrasound scans may confirm dilated loops of bowel with active peristalsis and exclude postoperative small bowel intussusception as a cause. Approximately half of all patients will respond to conservative measures alone. If symptoms and signs do not settle with conventional management of nasogastric tube drainage and intravenous fluid support, laparotomy or laparoscopy is indicated [ 2 Vijay K. Anindya C. Bhanu P. Mohan M. Rao P.L. et al. Adhesive small bowel obstruction (ASBO) in children—role of conservative management. Med J Malaysia. 2005; 60: 81-84 PubMed Google Scholar , 3 van der Zee D.C. Bax N.M. Management of adhesive bowel obstruction in children is changed by laparoscopy. Surg Endosc. 1999; 13: 925-927 Crossref PubMed Scopus (27) Google Scholar ]. Frequently, all that is found on exploration as the cause of the obstruction is an area of flimsy adhesion of a loop of bowel to another or to the parietal peritoneum, the omentum, or other solid organs, which is easily released with a sweep of the exploring hand. After 2 such explorations more than a decade ago, I started the practice of performing an abdominal shake as part of the therapeutic package. Depending on the size of the child and with due warning to the child and the caregivers, the patient, lying supine in bed, was gently but firmly shaken from side to side for a few seconds, holding the child at the hips or lower chest on each side. Occasionally, there was evidence of some discomfort, but usually there was none. In a surprising number of cases, the symptoms and signs of obstruction quickly resolved. Those patients who did not respond to the shake and conservative measures went for laparotomy and adhesiolysis. This became a fairly established practice at the Red Cross Children's Hospital in Cape Town, where I was working then; I believe that it has been used subsequently by several of the pediatric surgical trainees who passed through our service. I have recently had cause to do the same technique in the liver and intestinal transplant unit of the Birmingham Children's Hospital on 3 patients who developed intestinal obstruction within the first 10 days after their transplant, with remarkable resolution of symptoms and signs. Two patients had undergone liver transplantation, and the third had received a second isolated bowel transplant.