www.downstatesurgery.org 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 Exlap, LOA and SBR twice in the past www.downstatesurgery.org 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 www.downstatesurgery.org Imaging www.downstatesurgery.org 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 www.downstatesurgery.org Case presentation Hospital course • POD#1- TPN • POD#3- Discontinue JP drains • POD#8- Regular diet • POD#11- Discharged home www.downstatesurgery.org Management of Recurrent Small Bowel Obstruction www.downstatesurgery.org 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 www.downstatesurgery.org 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 www.downstatesurgery.org www.downstatesurgery.org Functional obstruction • AKA Pseudo-obstruction • Secondary to factors that cause intestinal paralysis www.downstatesurgery.org www.downstatesurgery.org 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. www.downstatesurgery.org 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. www.downstatesurgery.org www.downstatesurgery.org www.downstatesurgery.org www.downstatesurgery.org Management www.downstatesurgery.org 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 www.downstatesurgery.org 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%. www.downstatesurgery.org 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 nasointestinally. • Complications- Intra-abdominal leak, persistent enterocutaneous fistula, obstruction at jejunostomy site. www.downstatesurgery.org www.downstatesurgery.org 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. www.downstatesurgery.org