Management of recurrent small bowel obstruction. Aliu Sanni MD Kings County Hospital Center 21 st June, 2012.

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1 Management of recurrent small bowel obstruction Aliu Sanni MD Kings County Hospital Center 21 st June, 2012.

2 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

3 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 BMP, Coags- WNL

4 Imaging

5 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

6 Case presentation Hospital course POD#1- TPN POD#3- Discontinue JP drains POD#8- Regular diet POD#11- Discharged home

7 Management of Recurrent Small Bowel Obstruction

8 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

9 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

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11 Functional obstruction AKA Pseudo-obstruction Secondary to factors that cause intestinal paralysis

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13 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.

14 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.

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18 Management

19 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

20 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%.

21 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.

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23 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.

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