Enteroclysis-guided laparoscopic adhesiolysis in recurrent adhesive small bowel obstructions

Diagnosis and Treatment of Small Bowel Strangulation Due To Congenital Band: Three Cases of Congenital Band in Adults Lacking a History of Trauma or Surgery

BACKGROUND Among the causes of constipation are bands and adhesions that lead to obstructions at different points in the intestinal tract. These can occur as a consequence of healing following surgery or trauma. However, an entity known as congenital band exists where a band is present from birth. Here we report three such cases of adults with symptoms of intestinal obstruction, in whom a congenital band was discovered through exploratory laparoscopy. CASE REPORT All three of these patients presented lacking a history of any abdominal trauma or previous abdominal surgeries, a fact that is often used to exclude an adhesion as a differential. All three recovered quickly and had relief of their symptoms following surgical intervention. CONCLUSIONS Bands and adhesions are common surgical causes of small bowel obstruction, leading to symptoms such as nausea, vomiting, constipation, and obstipation. These bands almost always result from a prior abdominal surgery or from a recent abdominal trauma. The three cases presented here show a far more unusual picture of a band, one that is congenitally present, as there was an absence of such a history. This is significant because clinical suspicion of a band is often very low due to a lack of distinguishing clinical and diagnostic features, and when the past history is negative.

Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group

Background

In 2013 Guidelines on diagnosis and management of ASBO have been revised and updated by the WSES Working Group on ASBO to develop current evidence-based algorithms and focus indications and safety of conservative treatment, timing of surgery and indications for laparoscopy.

Recommendations

In absence of signs of strangulation and history of persistent vomiting or combined CT-scan signs (free fluid, mesenteric edema, small-bowel feces sign, devascularization) patients with partial ASBO can be managed safely with NOM and tube decompression should be attempted. These patients are good candidates for Water-Soluble-Contrast-Medium (WSCM) with both diagnostic and therapeutic purposes. The radiologic appearance of WSCM in the colon within 24 hours from administration predicts resolution. WSCM maybe administered either orally or via NGT both immediately at admission or after failed conservative treatment for 48 hours. The use of WSCM is safe and reduces need for surgery, time to resolution and hospital stay.

NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution, surgery is recommended.

Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age <40 years and matted adhesions. WSCM does not decrease recurrence rates or recurrences needing surgery.

Open surgery is often used for strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach is advisable using open access technique. Access in left upper quadrant or left flank is the safest and only completely obstructing adhesions should be identified and lysed with cold scissors. Laparoscopic adhesiolysis should be attempted preferably if first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained.

Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin decrease incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery.

Adhesions quantification and scoring maybe useful for achieving standardized assessment of adhesions severity and for further research in diagnosis and treatment of ASBO.

Evaluation and management of small-bowel obstruction: an Eastern Association for the Surgery of Trauma practice management guideline

BACKGROUND

Small-bowel obstruction (SBO) represents as many as 16% of surgical admissions and more than 300,000 operations annually in the United States. The optimal strategies for the diagnosis and management of SBO continue to evolve secondary to advances in imaging techniques, critical care, and surgical techniques. This updated systematic literature review was developed by the Eastern Association for the Surgery of Trauma to provide up-to-date evidence-based recommendations for SBO.

METHODS

A search of the National Library of Medicine MEDLINE database was performed using PubMed interface for articles published from 2007 to 2011.

RESULTS

The search identified 53 new articles that were then combined with the 131 studies previously reviewed by the 2007 guidelines. The updated guidelines were then presented at the 2012 annual EAST meeting.

CONCLUSION

Level I evidence now exists to recommend the use of computed tomographic scan, especially multidetector computed tomography with multiplanar reconstructions, in the evaluation of patients with SBO because it can provide incremental clinically relevant information over plains films that may lead to changes in management. Patients with evidence of generalized peritonitis, other evidence of clinical deterioration, such as fever, leukocytosis, tachycardia, metabolic acidosis, and continuous pain, or patients with evidence of ischemia on imaging should undergo timely exploration. The remainder of patients can safely undergo initial nonoperative management for both partial and complete SBO. Water-soluble contrast studies should be considered in patients who do not clinically resolve after 48 to 72 hours for both diagnostic and potential therapeutic purposes. Laparoscopic treatment of SBO has been demonstrated to be a viable alternative to laparotomy in selected cases.

Bologna Guidelines for Diagnosis and Management of Adhesive Small Bowel Obstruction (ASBO): 2010 Evidence-Based Guidelines of the World Society of Emergency Surgery

Background

There is no consensus on diagnosis and management of ASBO. Initial conservative management is usually safe, however proper timing for discontinuing non operative treatment is still controversial. Open surgery or laparoscopy are used without standardized indications.

Methods

A panel of 13 international experts with interest and background in ASBO and peritoneal diseases, participated in a consensus conference during the 1^st International Congress of the World Society of Emergency Surgery and 9^th Peritoneum and Surgery Society meeting, in Bologna, July 1-3, 2010, for developing evidence-based recommendations for diagnosis and management of ASBO. Whenever was a lack of high-level evidence, the working group formulated guidelines by obtaining consensus.

Recommendations

In absence of signs of strangulation and history of persistent vomiting or combined CT scan signs (free fluid, mesenteric oedema, small bowel faeces sign, devascularized bowel) patients with partial ASBO can be managed safely with NOM and tube decompression (either with long or NG) should be attempted. These patients are good candidates for Water Soluble Contrast Medium (WSCM) with both diagnostic and therapeutic purposes. The appearance of water-soluble contrast in the colon on X-ray within 24 hours from administration predicts resolution. WSCM may be administered either orally or via NGT (50-150 ml) both immediately at admission or after an initial attempt of conservative treatment of 48 hours. The use of WSCM for ASBO is safe and reduces need for surgery, time to resolution and hospital stay.

NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution surgery is recommended.

Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age <40 years and matted adhesions. WSCM does not affect recurrence rates or recurrences needing surgery when compared to traditional conservative treatment.

Open surgery is the preferred method for surgical treatment of strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach can be attempted using open access technique. Access in the left upper quadrant should be safe. Laparoscopic adhesiolysis should be attempted preferably in case of first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained.

Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin can reduce incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery.

Management of acute small bowel obstruction from intestinal adhesions: indications for laparoscopic surgery in a community teaching hospital

PURPOSE

The aim of this study is to compare the results of laparoscopic management of acute small bowel obstruction (SBO) from abdominal adhesions to both exploratory laparotomy and secondary conversion to open surgery.

MATERIALS AND METHODS

Ninety-three patients (mean age 61 years) with adhesion-induced SBO were divided into successful laparoscopy (66 patients [71%]), secondary conversion (24 [26%]), and primary laparotomy (three patients).

RESULTS

Patients with successful laparoscopy had more simple adhesions (57%), fewer prior operations, and lower American Society of Anesthesiologists (ASA) class. Operative time was shortest in the laparoscopy group (74.3 +/- 4.4 min), as was the duration of both intensive care unit and hospital stay. Mortality was 6%, regardless of operative technique.

CONCLUSIONS

A trial of laparoscopic adhesiolysis by a surgeon with advanced laparoscopic skills seems advisable in the majority of patients with acute adhesive SBO, whereas patients with more extensive adhesions, higher ASA class, and more than two prior abdominal operations often require laparotomy to achieve equally satisfactory outcome.

Laparoscopic lysis of adhesions

BACKGROUND

Intra-abdominal adhesions constitute between 49% and 74% of the causes of small bowel obstruction. Traditionally, laparotomy and open adhesiolysis have been the treatment for patients who have failed conservative measures or when clinical and physiologic derangements suggest toxemia and/or ischemia. With the increased popularity of laparoscopy, recent promising reports indicate the feasibility and potential superiority of the minimally invasive approach to the adhesion-encased abdomen.

METHODS

The purpose of this study was to assess the outcome of laparoscopic adhesiolysis and to provide technical tips that help in the success of this technique.

RESULTS

The most important predictive factor of adhesion formation is a history of previous abdominal surgery ranging from 67%-93% in the literature. Conversely, 31% of scars from previous surgery have been free of adhesions, whereas up to 10% of patients without any prior surgical scars will have spontaneous adhesions of the bowel or omentum. Most intestinal obstructions follow open lower abdominopelvic surgeries such as colectomy, appendectomy, and hysterectomy. The most common complications associated with adhesions are small bowel obstruction (SBO) and chronic pain syndrome. The treatment of uncomplicated SBO is generally conservative, especially with incomplete obstruction and the absence of systemic toxemia, ischemia, or strangulation. When conservative treatment fails, surgical options include conventional open or minimally invasive approaches; the latter have become increasing more popular for lysis of adhesions and the treatment of SBO. Generally, 63% of the length of a laparotomy incision is involved in adhesion formation to the abdominal wall. Furthermore, the incidence of ventral hernia after a laparotomy ranges between 11% and 20% versus the 0.02%-2.4% incidence of port site herniation. Additional benefits of the minimally invasive approaches include a decreased incidence of wound infection and postoperative pneumonia and a more rapid return of bowel function resulting in a shorter hospital stay. In long-term follow up, the success rate of laparoscopic lysis of adhesions remains between 46% and 87%. Operative times for laparoscopy range from 58 to 108 minutes; conversion rates range from 6.7% to 43%; and the incidence of intraoperative enterotomy ranges from 3% to 17.6%. The length of hospitalization is 4-6 days in most series.

CONCLUSIONS

Laparoscopic lysis of adhesions seems to be safe in the hands of well-trained laparoscopic surgeons. This technique should be mastered by the advanced laparoscopic surgeon not only for its usefulness in the pathologies discussed here but also for adhesions commonly encountered during other laparoscopic procedures.

Laparoscopic Diagnosis and Treatment of Acute Small Bowel Obstruction Resulting From a Congenital Band

Acute small bowel obstruction is a common problem, especially for those patients with previous abdominal surgery that can cause postoperative adhesions. Acute, non-postoperative small bowel obstruction is less common and has various etiologies. We report a case of acute small bowel obstruction without previous abdominal surgery. The patient underwent laparoscopic exploration, and a congenital band was found to cause direct compression of the ileum and entrapment of a segment of bowel loop. There was evidence of bowel strangulation. The color and peristalsis of the entrapped bowel loop recovered gradually after division of the band, and segmental bowel resection was avoided. He has remained asymptomatic since the procedure. We suggest early and aggressive surgical intervention for patients with acute, non-postoperative small bowel obstruction to avoid possible complications of bowel strangulation and gangrene. A laparoscopic approach may be a safe, feasible, and favorable option for correct diagnosis and appropriate treatment in this situation.

Advanced abdominal imaging is not required to exclude strangulation if complete small bowel obstructions undergo prompt laparotomy

BACKGROUND

When small bowel obstruction is demonstrated clinically or radiographically to be complete, operation is advocated because of the demonstrated association of strangulation obstruction with complete obstruction and the difficulty of diagnosing strangulation obstruction. Short observation periods, fluoroscopic procedures, and cross-sectional imaging are used in treatment of partial obstruction by those who believe that observation is futile or dangerous. This approach holds that few patients resolve after a day or two of observation; if this premise were true, protracted observation should see few patients resolve and some require resection for necrotic bowel after failed observation. Observer bias and the spectrum of nonnecrotic ischemia makes end-point analysis after laparotomy difficult to interpret; few criteria or incentives exist for a surgeon to speculate that a patient brought to surgery might have recovered without it.

STUDY DESIGN

I reviewed the clinical courses of 413 obstructed patients seen over 13 years.

RESULTS

Seventy-two patients underwent immediate treatment for complete obstruction, 294 resolved without operation, and 47 patients required operation after a period of observation ranging from 3 to 15 days. All observed patients were followed using clinical examination, leukocyte count, and plain film radiography only. No bowel resections were required in patients who were observed.

CONCLUSIONS

Research opportunities exist for use of alternatives to plain film imaging in treatment of partial small bowel obstruction, but this series does not support the premise that there is a risk for bowel ischemia or bowel resection by observing patients with partial small bowel obstruction or by following them with plain films alone. Indeed, such a strategy resulted in resolution in 294 of 341 patients so treated, with readmission and reoperation rates comparable with those reported in series in which earlier operation was undertaken.

Laparoscopic adhesiolysis for small bowel obstruction

BACKGROUND

Historically, laparotomy and open adhesiolysis have been the treatment for patients requiring surgery for small bowel obstruction. Laparoscopic adhesiolysis has not gained wide acceptance. The indications and outcomes of laparoscopic adhesiolysis for small bowel obstruction are not well established. The purpose of this paper is to review the literature on laparoscopic adhesiolysis for small bowel obstruction and to discuss patient selection, surgical technique, and outcomes.

DATA SOURCES

Medline search from 1980 to 2002.

CONCLUSIONS

Laparoscopic adhesiolysis has been shown to be safe and feasible in experienced hands. For selected patients, laparoscopic adhesiolysis offers the advantages of decreased length of stay, faster return to full activity, and decreased morbidity. Patient selection and surgical judgment appear to be the most important factors for a successful outcome.