Surgery For Small Bowel Obstruction Research Articles

Small bowel obstruction in patients previously operated on for colorectal cancer.

To find out the incidence, aetiology, and outcome of patients operated on for small bowel obstruction after previous operation for colorectal cancer. Retrospective cohort study. District hospital serving a defined population, Norway. 472 consecutive patients operated on for colorectal cancer, followed up for a median of 5.5 years (range 2.0-16.8) or until death; 351 had had a resection with curative intent, and 121 a palliative operation. Incidence and aetiology of small bowel obstruction, postoperative mortality, and long term survival. Small bowel obstruction necessitated operation in 36/351 (10%) after resection with curative intent, and in 5/121 (4%) after a palliative operation. The causes of obstruction were benign adhesions (n=21), local recurrence (n=17) and peritoneal carcinomatosis (n=3). One patient died of a myocardial infarction and six of cancer within 30 days of the operation for small bowel obstruction. The estimated median survival after the operation for small bowel benign obstruction was 1.9 years (SE=0.6) compared with 0.36 years (SE=0.04) for malignant obstruction (p=0.0007, logrank test). Late small bowel obstruction by adhesions was associated with higher blood loss during the primary operation (p=0.02). None of the 62 patients who took thiazide diuretics at the time of the primary operation later developed obstructive adhesions. 41/472 patients (9%) developed small bowel obstruction after the primary operation for colorectal cancer. The aetiology was benign in 21 and malignant in 20 patients. Survival after operation for the obstruction was far better with benign than with malignant obstruction.

Delay in operative treatment among patients with small bowel obstruction.

Delay in operative treatment for small bowel obstruction (SBO) has been shown to affect outcome adversely. The objective of this study was to detect time trends in treatment delay for patients with SBO during the study period 1961 to 1995 and to investigate factors influencing and factors affected by delay. The records of 815 patients with 921 operations for SBO from 1961-1995 were studied. Patients with large bowel obstruction, paralytic ileus and SBO caused by abdominal cancer or intussusception were excluded. Data were analysed with descriptive statistics and multiple linear regression analyses. Old age and female sex were associated with increased treatment delay. Delay in hospital increased from 5 hours (median) in the 1960'ies to 16 hours (median) in the 1990'ies. Treatment delay correlated significantly with postoperative morbidity and hospital stay. Mortality increased after prolonged treatment delay in SBO caused by hernias whereas no significant increase in mortality was observed among adhesive obstructions. Hospital delay increased throughout the study period. Old patients and women had a longer median treatment delay than did young ones and men. Treatment delay led to an increase in postoperative morbidity and hospital stay after surgery for SBO.

Laparoscopic extraperitoneal inguinal hernia repair versus open mesh repair: A prospective randomized controlled trial

Background. This study was designed to compare an open tension-free technique (Lichtenstein repair) with a laparoscopic totally extraperitoneal hernia repair (TEP). Methods. One hundred sixty-eight men aged 30 to 65 years with primary or recurrent inguinal hernia were randomized to TEP or open mesh technique in the manner of Lichtenstein. Follow-up was after 1 and 6 weeks, and 1 year. Results. Eighty-one patients were randomized to TEP, and 87 to open repair. For 1 patient in each group, the operation was converted to a different type of repair. No difference was seen in overall complications between the 2 groups. However, 1 patient in the TEP group underwent operation for small bowel obstruction after surgery. A higher frequency of postoperative hematomas was seen in the open group (P <.05). Patients in the TEP group consumed less analgesic after surgery (P <.001), returned to work earlier (P <.01), and had a shorter time to full recovery (P <.01). Two recurrences occurred in the TEP group 1 year after surgery. Conclusion. The TEP technique was associated with less postoperative pain, a shorter time to full recovery, and an earlier return to work compared with the open tension-free repair. No difference was seen in overall complications. However, 2 recurrences did occur after 1 year in the TEP group. (Surgery 2003;133:464-72.)

Occlusion de l'intestin grêle sur bride congénitale chez 16 adultes

During embryogenesis, abnormal adhesion of the peritoneal folds induces a congenital band which can cause small bowel obstruction. Patients and methods. – From 1987 to 2001, 16 adult patients underwent surgery for small bowel obstruction due to a congenital band. There were 8 men and 8 women with a mean age of 59 years (range 23–90). None presented previous abdominal surgery. Results. – Six patients presented acute abdominal pain the month before hospitalization. Among the 16 patients, 9 were operated at admission, and 7 after initial surveillance. Suspected diagnosis before operation was small bowel obstruction in 8 cases (with a diagnosis of congenital band in 3); perforated duodenal ulcer ( n = 2); appendicitis ( n = 2); mesenteric infarction ( n = 1); diverticultis ( n = 1); cholecystitis ( n = 1); and strangulated hernia ( n = 1). During operation performed through laparotomy or laparoscopy, a congenital band was noted in 100% of the cases, associated with intestinal necrosis in 5. One patient died postoperatively. Conclusion. – Because small bowel obstruction by congenital band is a rare condition, it represents a frequent problem of diagnosis. In this situation, the possibility of intestinal necrosis expose the patient to a possible fatal outcome.

Risk of small bowel obstruction after the ileal pouch-anal anastomosis.

To determine the incidence of small bowel obstruction (SBO), to identify risk factors for its development, and to determine the most common sites of adhesions causing SBO in patients undergoing ileal pouch-anal anastomosis (IPAA). All patients undergoing IPAA at Mount Sinai Hospital were included. Data were obtained from the institution's database, patient charts, and a mailed questionnaire. SBO was based on clinical, radiologic, and surgical findings. Early SBO was defined as a hospital stay greater than 10 or 14 days because of delayed bowel function, or need for reoperation or readmission for SBO within 30 days. All patients readmitted after 30 days with a discharge diagnosis of SBO were considered to have late SBO. Between 1981 and 1999, 1,178 patients underwent IPAA (664 men, 514 women; mean age 40.7 years). A total of 351 episodes of SBO were documented in 272 (23%) patients during a mean follow-up of 8.7 years (mean 1.29 episodes/patient). Fifty-four patients had more than one SBO. One hundred fifty-four (44%) of the SBOs occurred in the first 30 days; 197 (56%) were late SBOs. The cumulative risk of SBO was 8.7% at 30 days, 18.1% at 1 year, 26.7% at 5 years, and 31.4% at 10 years. The need for surgery for SBO was 0.8% at 30 days, 2.7% at 1 year, 6.7% at 5 years, and 7.5% at 10 years. In patients requiring laparotomy, the obstruction was most commonly due to pelvic adhesions (32%), followed by adhesions at the ileostomy closure site (21%). A multivariate analysis showed that when only late SBOs were considered, performance of a diverting ileostomy and pouch reconstruction both led to a significantly higher risk of SBO. The risk of SBO after IPAA is high, although most do not require surgical intervention. Thus, strategies that reduce the risk of adhesions are warranted in this group of patients to improve patient outcome and decrease healthcare costs.

Complications and death after surgical treatment of small bowel obstruction: A 35-year institutional experience.

To study factors influencing complications and death after operations for small bowel obstruction (SBO) using multifactorial statistical methods. Death after surgery for SBO is believed to be influenced by factors such as old age, comorbidities, bowel gangrene, and delay in treatment. No studies have been reported in which adverse factors related to death and complications have been systematically investigated with modern statistical methods. The authors studied retrospectively 877 patients who underwent 1,007 operations for SBO from 1961 to 1995. Patients with paralytic ileus, intussusception, and abdominal cancer were excluded. Odds ratios for death, complications, postoperative hospital stay, and strangulation were calculated by means of logistic regression analyses. Death and complication rates decreased during the study period. Old age, comorbidity, nonviable strangulation, and a treatment delay of more than 24 hours were significantly associated with an increased death rate. The rate of nonviable strangulation increased markedly with patient age. Major factors increasing the complication rate were old age, comorbidity, a treatment delay of more than 24 hours, and the need for repeat surgery. Death and complication rates after SBO decreased from 1961 to 1995. Major factors influencing the rates were age, comorbidity, nonviable strangulation, and treatment delay. Nonviable strangulation was more common in old patients.

Traitement cœlioscopique des occlusions du grêle

Laparoscopic surgery for small bowel obstruction is still under evaluation. A review of the literature retrieved over 200 published cases. Technically, the open laparoscopy procedure seems mandatory to avoid bowel injuries. Grasping the enlarged bowel and using monopolar cautery should be avoided. The surgeon should also be sure that at the end of the procedure adhesiolysis was correct. Evaluation of the results must also take into account that most studies were retrospective and included few patients. The cumulative effectiveness rate of laparoscopy was 60%. Failures were mainly due to multiple adhesions, iatrogenic perforations to the intestine, and colonic cancers not recognized before the procedure. There was no prospective study comparing laparoscopy with laparotomy. Finally, it is not proved at present that laparoscopy prevents the recurrence of adhesions after digestive surgery. Owing to the results of the literature, laparoscopic surgery for acute small bowel obstruction does not appear as based on fact.

A CASE OF HEMORRHAGIC MULTIPLE INTESTINAL ULCER IN THE BLIND LOOP

This paper describes a case of blind loop syndrome with repeated anal bleeding caused by multiple ulcer at the blind loop which was formed after a side to side anastomosis of the ileum was performed for intestinal obstruction 30 years before. A 62-year-old female who had undergone a bypass surgery for small bowel obstruction at the age of 30 was admitted to the hospital because of melana and lower abdominal pain. Small intestinal studies with barium, RI and angiography suggested bleeding from the ileum. Then the blind portion was resected and an end to end anastomesis was performed. The surgical specimen showed side to side anastomosis about 55cm from the terminal ileum, and a dilated blind loop. Multiple intestinal ulcers were seen in the blind loop which were histologically diagnosed as nonspecific ulcers. We have to entertain a possibility of bleeding from the blind loop, when the bleeding case of unknown origin following an intestinal surgery is encountered.

CLOSTRIDIAL WOUND INFECTION: A HAZARD OF SMALL-BOWEL DECOMPRESSION

Two cases of clostridial wound infection which followed operation for small-bowel obstruction are presented. The diagnosis and treatment of the condition are discussed, and methods of reducing the risk are suggested.

Frequency of wound complications after surgery for small bowel obstruction

1. 1. Surgery for small bowel obstruction is followed by a high incidence of wound complications. At Cleveland Metropolitan General Hospital the incidence has been 20 per cent. There were twenty-four suppurative wound infections, three wound dehiscences, and one case of cellulitis in 143 consecutive cases between 1959 and 1969. None of the complications was fatal. 2. 2. The rate of wound complications was sharply increased in those patients in whom the small bowel was opened. The intestine was entered in 39 per cent of the patients, resulting in 76 per cent of the wound problems. 3. 3. Antibiotics appear to offer no protection against wound complications. Fifty-six per cent of the patients receiving such therapy had 79 per cent of the wound problems. 4. 4. Delay is associated with a higher incidence of wound infection. The seventy-nine patients whose symptoms were present longer than forty-eight hours accounted for 19 (68 per cent) of all wound problems. 5. 5. There was no relationship in this series between wound complications and location of the obstruction, sex, or age.