Closed Loop Small Bowel Obstruction Research Articles

Rare Cause of Intestinal Obstruction After Laparoscopic Radical Nephrectomy: Internal Herniation via a Mesenteric Defect

A 43-year-old man had painless macroscopic hematuria and was diagnosed with a 9-cm renal carcinoma in the lower pole of the left kidney. He underwent laparoscopic transperitoneal left radical nephrectomy (LRN) with an uneventful recovery. Eleven days later, he developed intestinal obstruction (IO). Abdominal computed tomography scan showed dilated small bowels occupying the left renal fossa. Laparotomy revealed closed-loop small bowel obstruction resulting from internal intestinal herniation via a 5-cm mesenteric defect. It was repaired after the herniated bowels were reduced. This case illustrates a rare cause of IO after LRN, in which mesenteric defect is necessary.

Closed-Loop Small-Bowel Obstruction

Multidetector computed tomography is a highly accurate method in evaluating high-grade intestinal obstruction. Closed-loop obstruction is a relatively uncommon subcategory of small-bowel obstruction; however, it is associated with a high risk of vascular impairment and is, therefore, important to diagnose accurately. Closed-loop obstruction is often caused by conditions such as internal hernias, congenital bands, postoperative adhesions, and malrotation. The purpose of this article is to review the imaging features of closed-loop bowel obstruction and various underlying conditions. Special emphasis will be placed on the technique of multidetector computed tomography and its role in diagnosing this entity.

Does Serum Hexosaminidase Activity Play a Role in the Diagnosis of Strangulated Bowel Obstruction? An Experimental Study

Strangulation is associated with an increased risk of mortality and morbidity in patients with mechanical bowel obstruction. The accurate and early recognition of the presence of strangulation is important to allow safe nonoperative treatment. A number of studies have shown that there was no single and reliable test to detect or exclude the presence of strangulation. The aim of this study was to evaluate the role of serum hexosaminidase (Hex) levels in recognition of strangulation in an experimental model of closed loop small bowel obstruction. Forty-two Wistar albino rats were divided into four groups: I, control (n = 5); II, sham laparotomy (n = 5); III, simple obstruction (n = 16); and IV, strangulation groups (n = 16). Activity levels of total Hex and its fractions (Hex A and B) were assayed in serum samples obtained from rats after 3 and 8 hr. Samples of small bowel were also evaluated histologically. Histological evaluation of bowel sections obtained from the strangulation group after 8 hr, revealed transmural hemorrhagic infarction in all animals with a mean +/- SD total Hex activity of 978.25 +/- 150 nmol/hr/ml, which was significantly higher than that in the other groups (P < 0.001). Although sections of bowel from the strangulation group after 3 hr showed severe ischemic injury, the activities of total Hex, Hex A, and Hex B were not different from those of the control, sham, and simple obstruction groups. Histological examination of these groups did not show any sign of ischemia. Total Hex, Hex A, and Hex B activities in the strangulation group were all significantly greater than the activities seen in the simple obstruction group (P < 0.001, for all). In conclusion, increased serum hex levels indicate irreversible transmural infarction only in the late period of strangulation in the closed loop small bowel obstruction model. It seems unuseful for detecting reversible and/or irreversible ischemia in the early period of strangulation.

Serum cytosolic β-glucosidase elevation and early ischemic injury to guinea pig small intestine

Background: The lack of an early, sensitive marker for intestinal ischemia has led to delay in diagnosis and worsened outcome for patients with acute onset of this condition. Our preliminary studies revealed that guinea pig cytosolic β-glucosidase (CBG) is expressed predominantly in the small intestine, with lower levels in the liver and pancreas and undetectable levels in other organs. Cytosolic β-glucosidase was investigated as a serum marker of small intestinal ischemia in a guinea pig model. Methods: Guinea pigs underwent anesthesia, sham laparotomy, 30 minutes of mesenteric ischemia followed by 6 hours of reperfusion, 6 hours of sustained mesenteric ischemia, or closed-loop small bowel obstruction. Serum samples were assayed for CBG activity. At the conclusion of the ischemia/reperfusion experiments, small bowel samples were assayed for residual enzyme activity, and paraffin sections were graded for the severity of histologic injury. Results: Serum CBG activity rose rapidly after intestinal ischemia with and without reperfusion. Peak enzyme activities were elevated 23-fold for reperfused animals ( P < .001) by 4 hours. For nonreperfused animals, peak serum CBG activities reached 29-fold above baseline and were significantly higher than the CBG activities of reperfused animals at 4 hours ( P < .01) and at 6 hours ( P < .05). Mucosal injury ranged from undetectable to moderate and corresponded in severity with both peak serum enzyme activity and decreased residual activity in the small bowel. In animals subjected to closed-loop obstruction, there was a mean increase of serum CBG of 9.2-fold from 4 to 6 hours after establishment of obstruction ( P < .05). Conclusions: In the guinea pig model, CBG is a sensitive marker of ischemic injury caused by arterial occlusion or closed-loop obstruction of the small bowel. (Surgery 1999;125:202-10.)

Serum cytosolic [beta ]-glucosidase elevation and early ischemic injury to guinea pig small intestine

<h2>Abstract</h2> <b>Background:</b> The lack of an early, sensitive marker for intestinal ischemia has led to delay in diagnosis and worsened outcome for patients with acute onset of this condition. Our preliminary studies revealed that guinea pig cytosolic β-glucosidase (CBG) is expressed predominantly in the small intestine, with lower levels in the liver and pancreas and undetectable levels in other organs. Cytosolic β-glucosidase was investigated as a serum marker of small intestinal ischemia in a guinea pig model. <b>Methods:</b> Guinea pigs underwent anesthesia, sham laparotomy, 30 minutes of mesenteric ischemia followed by 6 hours of reperfusion, 6 hours of sustained mesenteric ischemia, or closed-loop small bowel obstruction. Serum samples were assayed for CBG activity. At the conclusion of the ischemia/reperfusion experiments, small bowel samples were assayed for residual enzyme activity, and paraffin sections were graded for the severity of histologic injury. <b>Results:</b> Serum CBG activity rose rapidly after intestinal ischemia with and without reperfusion. Peak enzyme activities were elevated 23-fold for reperfused animals (<i>P</i> < .001) by 4 hours. For nonreperfused animals, peak serum CBG activities reached 29-fold above baseline and were significantly higher than the CBG activities of reperfused animals at 4 hours (<i>P</i> < .01) and at 6 hours (<i>P</i> < .05). Mucosal injury ranged from undetectable to moderate and corresponded in severity with both peak serum enzyme activity and decreased residual activity in the small bowel. In animals subjected to closed-loop obstruction, there was a mean increase of serum CBG of 9.2-fold from 4 to 6 hours after establishment of obstruction (<i>P</i> < .05). <b>Conclusions:</b> In the guinea pig model, CBG is a sensitive marker of ischemic injury caused by arterial occlusion or closed-loop obstruction of the small bowel. (Surgery 1999;125:202-10.)

Use of laparoscopy in the diagnosis and treatment of patients with surgical abdominal sepsis.

Patients often present to the surgeon with abdominal pain, tenderness, and fever. Many exhibit progressive sepsis due to abdominal pathology. Delay in diagnosis and treatment often occurs due to the use of multiple, time-consuming, expensive diagnostic studies. We delineate the use of diagnostic laparoscopy in subsets of patients in whom confusion exists as to the cause of abdominal sepsis--i.e., females in child-bearing years, elderly patients, obese patients, immunosuppressed patients, and patients with suppression of physical findings. The methodical assessment of the entire abdominal cavity is performed utilizing manipulation of the patient's position (Trendelenburg, supine, reverse Trendelenburg, left side up, right side up) and meticulous inspection of the entire small bowel. Diagnoses included acute appendicitis, gangrenous appendicitis, perforated appendicitis with peritonitis or abscess, gangrenous cholecystitis, ischemic bowel disease, perforating carcinoma of the colon, perforating diverticulitis with abscess or peritonitis, tubo-ovarian abscess, closed-loop small-bowel obstruction, megacolon, and perforation of the colon. Laparoscopic treatment of 96% of the patients was performed successfully and a laparoscopic-assisted approach was used in the remainder. There was one mortality (cardiac) and no major morbidity. The development of a Formal Diagnostic Exploratory Laparoscopic (FDEL) approach has aided in the assessment of each of the diagnoses of sepsis in the abdominal cavity. The diagnostic and therapeutic approach laparoscopically avoids extensive preoperative studies, avoids delay in operative intervention, and appears to minimize morbidity and shorten the postoperative recovery interval.

Cecal volvulus

A review of 561 cases of cecal volvulus that were published between 1959 and 1989 along with 7 new cases, was performed to characterize the clinical and laboratory profile and to evaluate the various surgical options in treating this life-threatening condition. The age and sex distribution of these patients have changed over the years and shifted toward older patients (mean, 53 years) and female predominance (female:male ratio, 1.4:1). The clinical presentation was usually of distal closed-loop small bowel obstruction. Forty-six percent of the plain abdominal radiographs were suspected for cecal volvulus, but only 17 percent were diagnostic. Barium enema had a high rate of accuracy (88 percent) and was associated with minimal complications. True volvulus was 6 times more common than bascule, and gangrenous cecum was found in 20 percent of cases. Detorsion alone and cecopexy had almost similar complications, mortality, and recurrence rates (15, 10, and 13 percent, respectively), whereas, resection, which was performed primarily for gangrenous cecum, had higher rates. However, the highest rates of complications (52 percent), mortality (22 percent), and recurrence (14 percent) were noticed after cecostomy. These data suggest that resection should be reserved for patients with necrotic cecum and that detorsion is sufficient for patients with viable cecum. Cecostomy should be abandoned.