Partial Small Bowel Obstruction Research Articles

Intraoperative enteroscopy in the diagnosis of partial intestinal obstruction in infancy

We present the case of a 4-month-old infant with a prolonged illness due to an occult intestinal stricture. Diagnosis of the lesion escaped conventional radiologic and surgical methods and required intraoperative enteroscopy. Resection of the stricture lead to prompt clinical improvement. Our patient illustrates a primary diagnostic use of intraoperative enteroscopy in the detection of a partial intraluminal small bowel obstruction. As further experience accumulates with small bowel endoscopy, roles for therapeutic enteroscopy (such as polypectomy, photocoagulation, and perhaps balloon dilatation) will certainly arise. Such endeavors will depend on the continued productive collaboration between members of the surgical and gastroenterological teams.

A prospective, randomized trial of short versus long tubes in adhesive small-bowel obstruction

Background: Many cases of acute adhesive small-bowel obstruction (SBO) can be successfully treated with intestinal tube decompression. There is considerable controversy, however, regarding whether a short nasogastric tube (NGT) or a long nasointestinal tube (LT) is the best method of intestinal tube decompression. Patients and methods: A prospective, randomized trial was conducted to compare NGT and LT decompression with respect to the success of nonoperative treatment and morbidity of surgical intervention in 55 patients with acute adhesive SBO. Results: Twenty-eight patients were managed with NGT and 27 with LT. There were 44 cases of partial SBO (23 NGT, 21 LT) and 11 cases of complete SBO (5 NGT, 6 LT). Twenty-one patients ultimately required operation, including 13 managed with NGT (46%) and 8 with LT (30%) ( P = 0.16). The mean period between admission and operation was 60 hours in the NGT group versus 65 hours in the LT group. At operation, 3 patients in the NGT group had ischemic bowel that required resection. Postoperative complications occurred in 23% of patients treated with NGT versus 38% of patients treated with LT ( P = 0.89). Postoperative ileus averaged 6.1 days for NGT patients versus 4.6 days for LT patients ( P = 0.44). There were no deaths. Conclusions: Patients with adhesive SBO can safely be given a trial of tube decompression upon hospital admission. There was no advantage of one type of tube over the other in patients with adhesive SBO.

Staging Laparotomy for Endometrial Carcinoma: Assessment of Peritoneal Spread

To evaluate surgical staging procedures in women with endometrial carcinoma, we examined the techniques used to assess the peritoneal cavity in 295 clinical stage I patients treated between 1985 and 1993. These patients were felt to be at increased risk for extrauterine disease because of significant myometrial invasion, high-grade (2 or 3), or variant histology (papillary serous, clear cell, or mixed). Patients had a mean of two intraperitoneal samples taken: 224 patients (76%) had at least an omental biopsy and peritoneal cytology. Additional peritoneal biopsy sites included pericolic gutters (50), pelvic peritoneum (45), bowel serosa/mesentery (24), diaphragm (22), appendix (11), and adhesions (7). At the time of staging laparotomy, 22 patients (7.5%) had gross evidence of peritoneal spread, which was readily confirmed by directed biopsy. In the 273 women without gross peritoneal disease, 3 (1%) had occult metastases detected by routine biopsy, 3 (1%) had microscopic metastases in palpably abnormal biopsies, and 22 bad positive cytology as the only evidence of peritoneal disease. Only three operative complications were potentially attributable to peritoneal assessment: cystotomy (1), partial small bowel obstruction (1), and ileus (1). Peritoneal failures have been noted in 12 patients over a mean follow-up interval of 39 months. Seven of these patients had obvious peritoneal disease at laparotomy. Two of the remaining 5 had optimal peritoneal sampling and represent false-negative cases. A staging laparotomy that included total abdominal hysterectomy with adnexal resection, cytology, omental biopsy, and biopsy of grossly abnormal sites would have potentially identified all patients with known peritoneal disease. Routine biopsy of other grossly normal peritoneal sites is associated with extremely low yield and is not recommended.

Presentation and management of laparoscopic incisional hernias

The incidence of incisional hernias at 12 mm trocar sites after laparoscopy has been reported as approximately 3%. We report on three cases involving this post-operative complication. The patients underwent a laparoscopically-assisted hysterectomy (LAVH) with fascial closure of 12 mm ports. Each patient presented on postoperative day number two with crampy abdominal pain, nausea and vomiting. Abdominal x-ray findings were consistent with a partial small bowel obstruction. Two patients were re-explored laparoscopically shortly after presentation. One was found to have omental herniation into the pre-peritoneal space which was easily reduced endoscopically with blunt traction. The second patient had a loop of ileum herniating through a small fascial defect. The hernia was repaired by expanding the fascial defect and then digitally replacing the ileum intraperitoneally. The third patient was managed conservatively with nasogastric tube decompression. When symptoms did not resolve completely, the patient was re-explored laparoscopically on postoperative day 21. An adherent loop of small bowel was found in the pre-peritoneal space. Due to trauma in reducing the hernia, a segmental resection of bowel was performed extracorporeally by pulling the damaged bowel through the trocar incision. No patient had complications from the repaired hernias. To avoid this postoperative complication, we now use the Grice suture needle to close both the peritoneum and fascia of all 12-mm trocar incisions. In managing trocar incisional hernias we found that early laparoscopic evaluation allowed both diagnosis and expedient treatment of the patient. Conservative management resulted in a more adherent herniation which was less amenable to easy repair

Prevention of radiation enteritis in children, using a pelvic mesh sling

Between 1986 and 1991, the authors used polyglycolic acid mesh slings (placed at or above the sacral promontoryl) in eight children with pelvic malignancies to exclude all small bowel from the pelvis during pelvic radiation therapy. The only complications of this treatment were prolonged postoperative ileus (one patient) and temporary, partial small bowel obstruction (one patient). The average amount of radiation administered to the pelvis postoperatively was 5,349 ± 556 cGy. In one of the eight patients, gastrointestinal symptoms (diarrhea for 24 hours) developed during radiation therapy. Early radiological evaluation confirmed that the small bowel was out of the pelvis in all five of the patients studied. Mesh disruption occurred between 2 and 5 months postoperatively (mean, 3.4 ± 1.5 months) and was often identified symptom-atically by the patient. Seven of the eight survived, with disease remission in six. Pelvic disease was absent at the time of death in the one patient who did not survive. Throughout the follow-up period (mean, 20 months) no survivor has had delayed symptoms of radiation enteritis. In children with pelvic malignancies in whom aggressive application of pelvic irradiation is required, the use of an absorbable pelvic mesh sling appears efficacious in preventing radiation-associated enteritis.

Obturator hernia presenting as small bowel obstruction

Obturator hernia is a rare but important cause of small bowel obstruction that is associated with difficult diagnosis and high mortality. In the past 7 years, 16 patients with small bowel obstruction due to obturator hernia diagnosed at operation were seen at the Department of Surgery, the University of Hong Kong, Queen Mary Hospital. They represented 1% (16 of 1,554) of all hernia repair performed and 1.6% (16 of 1,000) of mechanical intestinal obstruction encountered during the same period. Elderly emaciated women with chronic disease were commonly affected. All patients presented with partial or complete mechanical small bowel obstruction. Right-sided obturator hernia outnumbered left-sided hernia, and bilateral hernia was found in only one patient. The majority of patients required resection of their strangulated small bowel. Most of the hernial orifices were closed with interrupted nonabsorbable sutures. Morbidity and mortality rates were significantly high for this group of debilitated patients with chronic disease who underwent late operation for this elusive diagnosis.

Loop ileostomy is a safe option for fecal diversion.

This study was undertaken to prospectively assess all morbidity and mortality associated with temporary loop ileostomy. Eighty-three consecutive patients of a median age of 45 years required temporary fecal diversion after either ileoanal or low colorectal anastomosis (n = 72), for perianal Crohn's disease (n = 5), or for other reasons (n = 6). All loop ileostomies were supported with a rod, and fecal diversion was maintained for a mean of 10 weeks. To date, 67 patients have had re-establishment of intestinal continuity. Stoma closure was affected through a parastomal incision in 64 patients; in three, a laparotomy was required. The closure was stapled side to side in 49 patients, while a hand-sewn anastomosis was done in the other 18 patients; all skin wounds were left open. The mean length of surgery for ileostomy closure was 56 minutes, and the mean hospital stay was five days. Nine patients (10.8 percent) developed 10 complications, nine of which required hospitalization. Specifically, four patients developed dehydration and electrolyte abnormalities secondary to high stoma output, and two had anastomotic leaks that spontaneously healed following conservative management. One patient developed a superficial wound infection that spontaneously drained itself. One patient developed a partial small bowel obstruction that resolved without surgery after a four-day hospitalization. One stoma retracted after supporting rod removal and prompted premature closure. There was no stomal ischemia, hemorrhage, prolapse, or mortality in this series. Thus, loop ileostomy is a safe way to achieve fecal diversion.

Perioperative Use of Octreotide in Gastrointestinal Surgery

The evolution of gastrointestinal endocrinology has led to the design and application of analogs of gut peptides to treat disease. Octreotide, a long-acting analog of the inhibitory peptide somatostatin, has proven useful in the management of disorders such as carcinoid syndrome and secretory diarrhea due to VIPoma. More recent experience suggests a role for this peptide in the management of certain complications of gastrointestinal surgery. Prophylactic use of octreotide appears warranted in the prevention of carcinoid crisis in selected patients with carcinoid syndrome undergoing invasive procedures, and in the prevention of complications in selected patients undergoing pancreatic surgery. Evidence from placebo-controlled trials supports a role for octreotide in the management of dumping symptoms in severely affected patients, at least in the short term. Octreotide appears to serve a useful adjunctive role in controlling output from postoperative gastrointestinal fistulae and may hasten closure, particularly in pancreatic fistulae. Selected patients with ileostomy diarrhea and short bowel syndrome benefit from octreotide treatment, but the long-term value of the peptide in controlling stool output is less clear. Rare patients with other forms of postoperative secretory diarrhea have been successfully treated with octreotide. Finally, animal and early human experience suggests that octreotide may have a role as an adjunctive treatment of partial small bowel obstruction. In most of these conditions, the available data is sparse and further controlled trials are warranted.

Radiological appearances of small intestinal leiomyomas

During a 5 year period we have identified leiomyomas of the small intestine in six patients using enteroclysis. Gastrointestinal bleeding were the presenting symptoms in five and partial small bowel obstruction in one. The time interval between the onset of symptoms and radiological diagnosis ranged between 3 months and 5 years. All patients had previously been investigated by a number of endoscopic and barium radiology examinations and one had undergone a nondiagnostic laparotomy. The jejunum was the site of involvement in one patient and the ileum in five. The growth was intraluminal in two cases, extraluminal in three and bidirectional (dumb-bell) in one. Radiological appearances included round or broad-based semilunar intraluminal filling defects with encroachment of the lumen, or intussusception, displacement and/or indentation of the intestinal wall with effacement of the overlying mucosa or an ulcer crater, tenting deformity and mass effect on neighbouring loops. All six patients came to operation. Pre-operative radiological diagnosis was correct in five and suggestive in one. There was excellent correlation between the radiological appearances and morphology of the pathology specimens.

Intestinal stricture due to lap-belt injury.

In motor vehicle accidents, the lap-type seat belt can result in blunt trauma to the abdomen. The prevalence of intestinal injury has increased with the use of lap-belt restraints, and these injuries are usually apparent immediately. We describe a child with a lap-belt injury that resulted in intestinal stricture, which was manifested in a delayed fashion as partial smallbowel obstruction. This complication should be considered whenever a child who is restrained by a lap belt during a motor vehicle accident is injured.

Laparoscopic Adhesiolysis for Small Bowel Obstruction

The relatively new field of endoscopic surgery shows much promise and allows alternative treatment options. With increasing numbers of surgeons gaining experience with this technique, new approaches to old conditions are being reported. We present the case of a young female with partial small bowel obstruction secondary to an adhesive band; the condition was readily diagnosed using the laparoscope and treated. We show that in appropriate patient selection, this method is a viable and easily performed alternative to formal laparotomy.

The Crypto Post-Op Pizza

To the Editor. —My patient is a 14-year-old boy who had an appendectomy and was discharged from the hospital on the second day after his operation. On the morning of his fourth postoperative day, I received a call from the patient's mother, who claimed that her son was very sick. On readmission to the hospital, I found him in distress with signs and symptoms of partial small-bowel obstruction, which was confirmed by roentgenogram. Intravenous fluids were started, but just prior to insertion of a nasogastric tube, I was called away. On my return, 20 minutes later, I was surprised to see that the patient's condition had improved markedly, which he attributed to the recent passage of a large amount of feces and flatus. A nasogastric tube was not inserted, and, by the following day, the patient was asymptomatic and was discharged from the hospital. I heard nothing further from him

Colectomy for constipation

The results of total abdominal colectomy (TAC) with ileorectal anastomosis as a treatment for colonic inertia (CI) were prospectively assessed. One hundred sixty-three patients were evaluated for chronic constipation between July 1988 and November 1990. Patients underwent pancolonic transit times, anorectal manometry, cinedefecography (CD), and electromyography (EMG). CI was defined as diffuse marker delay on transit study without evidence of puborectalis contraction on CD or EMG. Sixteen patients (10 percent; 15 females and 1 male) with a mean age of 45 years (range, 24-75 years) with CI underwent TAC. Preoperative bowel frequency ranged from three per week to one per month; all 16 patients evacuated only with high doses of laxatives, enemas, or both. TAC was performed with no postoperative mortality or major morbidity; three patients were readmitted four times for successful conservative treatment of partial small bowel obstruction. At a mean follow-up of 15 months (range, 2-35 months), these 16 patients reported a mean frequency of spontaneous bowel evacuations of 3.5 per day (range, one to six per day). Patient satisfaction with the operation was "excellent" or "good" in 15 cases (94 percent). Thorough preoperative physiologic evaluation permits the selection of a small group of patients with CI who may benefit tremendously from TAC.

Foreign Body in the Gastrointestinal Tract

We have reported a case of complete transluminal migration of a retained laparotomy sponge that caused repeated partial small bowel obstruction. Diagnosis was made when roentgenograms showed multiple positions of the laparotomy marker. The sponge was surgically removed. This is the 69th reported case of complete transluminal migration and distal movement of a laparotomy sponge.

Let sleeping dogs lie

A surgical aphorism has long held that the omentum is the "watchdog of the abdomen." However, detractors believe that leaving the omentum behind after colectomy precipitates later small bowel obstruction. A retrospective comparison was made between a group of 406 patients (Group I) having omentectomy with proctocolectomy and ileoanal anastomosis and a group of 239 patients (Group II) having a similar procedure without omentectomy. Follow-up in this series of 645 patients was 4.3 +/- 2.1 years (mean +/- SEM). No difference was present in the rate of partial small bowel obstruction or complete small bowel obstruction between Group I patients (32 percent partial, 12 percent complete) and Group II patients (29 percent partial, 12 percent complete; P greater than 0.1). However, a better outcome with regard to postoperative sepsis and sepsis requiring operation was apparent in Group II patients retaining the omentum (4 percent and 3 percent, respectively) than in Group I patients (10 percent and 8 percent, respectively), in whom the omentum was removed (P less than 0.01). As this experience would support, we urge surgeons to "let sleeping dogs lie" and, when possible, retain the omentum when performing colectomy or proctocolectomy.

Plasma electrolyte status following enteroclysis in patients with partial small-bowel obstruction.

BARLOON, THOMAS J. MD; YANG, C J CALVIN MD; BERBAUM, KEVIN S. PhD; LU, CHARLES C. MD; HONDA, HIROSHI MD Author Information

Small bowel enteroclysis survey.

A survey questionnaire was sent to 125 radiology programs to determine the frequency and indications for the use of small bowel enteroclysis. Sixty-seven of the 84 respondents perform small bowel enteroclysis while 17 do not. The 3 most common indications for enteroclysis are detection of unexplained gastrointestinal bleeding, partial small bowel obstruction, and Crohn's disease. We conclude that although small bowel enteroclysis is a well-established examination, there are wide differences in the frequency with which it is performed, the techniques of examination, and indications for its use.

Use of tubes and radiographs in the management of small bowel obstruction.

During the past 10 years 311 consecutive patients were admitted with 342 episodes of small bowel obstruction (SBO). There were 193 cases of partial small bowel obstruction (PSBO) and 149 cases of complete small bowel obstruction (CSBO) as determined by interpretation of the abdominal radiographs done on admission. The purpose of this review was to determine the reliability of the admission plain abdominal radiographs and subsequent upper gastrointestinal (UGI) contrast studies in predicting the need for operative intervention. The use of nasogastric tubes (NGT) versus nasointestinal (long) tubes (NIT) was correlated with the following outcome variables; length of hospital stay (LOS), timing of operative intervention, incidence of postoperative complications, and duration of postoperative ileus. Long tubes (NIT) were used in 64 episodes of PSBO and 81 episodes of CSBO, whereas nasogastric tubes (NGT) were used in 116 cases of PSBO and 68 cases of CSBO. Thirty-eight of 193 (19%) patients with PSBO required operation (20 of 116 with NGT and 18 of 64 with NIT), whereas 125 of 149 (84%) patients with CSBO required operation (60 of 68 with NGT and 65 of 81 with NIT). Need for operation was not correlated with whether or not long tubes passed beyond the pylorus; 50 passed versus 33 not passed in operative groups (p = 0.15). Twelve of 83 patients with NIT had operation within 24 hours versus 52 of 80 patients with NGT (p less than 0.001). In six of 64 patients who had surgery within 24 hours, complications developed versus in 39 of 99 patients operated on more than 24 hours after admission (p less than or equal to 0.001). In 29 of 83 patients treated with NIT, postoperative complications developed versus in 16 of 80 patients with NGT (p less than or equal to 0.04). The mean duration of postoperative ileus in patients with NIT was 7 days versus 4.1 days for NGT patients (p less than 0.001). The mean LOS was 12.2 days for NGT patients versus 21 days for patients with NIT (p less than 0.001). Barium UGI contrast studies were performed in 57 patients to establish the presence of obstruction. In 34 of 57 patients the UGI disclosed mechanical obstruction that required operative intervention. In the remaining 23 patients no obstruction was demonstrated, and all 23 patients recovered without operation. In conclusion, there is no inherent superiority of NIT versus NGT in the treatment of SBO.(ABSTRACT TRUNCATED AT 400 WORDS)

The Cholescintigraphic Pattern of Small Bowel Obstruction

An elderly patient presenting with acute abdominal pain, nausea, and vomiting underwent a hepatobiliary scan. This demonstrated normal filling of the gallbladder but dilatation of the small bowel, which was found to correspond radiographically to partial small bowel obstruction.

Gastrointestinal motility following small bowel obstruction in the opossum

The motility of the gastrointestinal tract of six opossums with total and four with partial small bowel obstruction was evaluated. Following the establishment of small bowel obstruction, the migrating myoelectric complex was substituted by a new pattern which was characterized by periods of intense spike activity interspersed with quiescent periods. In the experiments with total intestinal obstruction, the frequency and duration of the periods of intense spike activity were related to the recording site and the time after establishment of intestinal obstruction. The frequency of spike bursts in the ileum proximal and distal to the obstruction was the greatest in the first 2 days after the establishment of the obstruction, while in the antrum and proximal small bowel, the frequency of bursts of spike potentials increased gradually from the first to the fourth postobstruction day ( P < 0.01). However, there was no change in the frequency, duration, and localization of periods of intense spike activity during the 5 days following the establishment of partial intestinal obstruction. We concluded that following intestinal obstruction, the migrating myoelectric complex is substituted by a myoelectric pattern that is characterized by periods of intense spike activity interspersed with quiescent periods. In the animals with total intestinal obstruction, the periods of increased motility are initially more frequent in the bowel proximal and distal to the obstruction and afterwards in the stomach and upper small bowel.