Postoperative small bowel obstruction in infants and children: a problem following Nissen fundoplication

A serious consequence of antireflux surgery is postoperative small bowel obstruction in an infant who cannot speak and has been rendered unable to vomit. We reviewed the operative rate for small bowel obstruction following all antireflux operations (210 Nissen fundoplications, 16 Hill fundoplications, 12 modified Thal fundoplications, and 3 Boerema anterior gastropexies) performed on children at our institution between January 1977 and July 1984. Eighteen patients (17 Nissen fundoplications, one Hill fundoplication) were operated upon for small bowel obstruction within two years after the primary operation. The most consistent clinical findings in these children were abdominal distention and a decreased frequency of bowel movements. For operations performed between January 1982 and July 1984, reoperation for small bowel obstruction was needed in 6.1% (6/99) of children following Nissen fundoplication as compared to 0.9% (6/649), P less than 0.001) of children following other major laparotomies. A combination of our experience with that reported by others suggests an estimated incidence of postoperative adhesive small bowel obstruction of 5.5% (24/436) for Nissen fundoplication, 0.9% (3/347) for modified Thal fundoplication, and 0.8% (1/126) for Boerema anterior gastropexy. The performance of a Nissen fundoplication has led to a significant rate of reoperation for small bowel obstruction compared with other major laparotomies and antireflux operations performed in children.     

Posttraumatic small bowel obstruction in children

Background

The diagnosis of intestinal injuries in children after blunt abdominal trauma can be difficult and delayed. Most children who suffer blunt abdominal trauma are managed nonoperatively, making the diagnosis of intestinal injuries more difficult. We sought to gain information about children who develop intestinal obstruction after blunt abdominal trauma by reviewing our experience.

Methods

Review of records from a pediatric tertiary care center over an 11.5-year period revealed 5 patients who developed small bowel obstruction after blunt trauma to the abdomen. The details of these patients were studied.

Results

All patients were previously managed nonoperatively for blunt abdominal trauma. Intestinal obstruction developed 2 weeks to 1 year (median, 21 days) after the trauma. Abdominal x-ray, computerized tomography scan, or barium meal studies were used to establish the diagnosis. The pathology was either a stricture, an old perforation, or adhesions causing the intestinal obstruction. Laparotomy with resection and anastomosis was curative.

Conclusions

Posttraumatic small bowel obstruction is a clinical entity that needs to be watched for in all patients managed nonoperatively for blunt abdominal trauma.     

Early postoperative small bowel obstruction.

The hospital records of 41 patients with a diagnosis of early postoperative small bowel obstruction were reviewed in an attempt to identify criteria which could be used to separate those patients who would require an operation to resolve their obstruction, from those who would resolve with nonoperative therapy. The usual symptoms, signs and roentgenologic changes seen with mechanical bowel obstruction were not useful discriminants in making such a determination. All patients were initially treated nonoperatively with intestinal intubation, antibiotics and parenteral fluids. Thirty patients resolved without an operation and 11 required an operation. There was one death in the latter group, an overall mortality of 2.4%. Initial nonoperative therapy is warranted in such patients.     

Cholelithic small bowel obstruction

Results of treatment of 18 patients with cholelithic small bowel obstruction are analyzed. All of them were female aged 62 to 84 years with severe concomitant diseases. Different variants of clinical manifestation of small bowel obstruction, significance of diagnostic methods, the causes of delayed hospitalization and operation are analyzed in details. Fourteen patients have been operated with diagnosis of intestinal obstruction but only at 3 of them the true cause of disease has been assumed before surgery. Enterolithotomy was performed at 15 patients, resection of small intestine together with gallstone - at 3 patients. Recurrence of cholelithic obstruction was seen at one patient on 8th day after surgery. Postoperative lethality was 27.7%, but only at one case the purulent complications and multiple organ failure was the cause of lethality. Recommendations for improvement of treatment results and prophylaxis of cholelithic small bowel obstruction are given.     

Postlaparoscopic small bowel obstruction

Background: Patients with early postoperative small bowel obstruction (SBO) are usually managed nonoperatively with nasogastric suction, intravenous fluids, and observation. The majority of early postoperative SBO resolve without an operation. Methods: We performed a retrospective review of patients who had been diagnosed with postlaparoscopic SBO at three Chicago area teaching hospitals. Results: The patients were initially managed nonoperatively for up to 7 days. However, all of them subsequently required an operation. In every case, the postlaparoscopic SBO was caused by the small bowel being incarcerated in a peritoneal defect created either by trocar placement or peritoneal incision for herniorrhaphy. Conclusion: In contradistinction to the approach used for early SBO after laparotomy, prompt operative intervention for postlaparoscopic SBO is recommended.     

Variability in the management of adhesive small bowel obstruction in children

BackgroundThis study assessed inter-hospital variability in operative-vs-nonoperative management of pediatric adhesive small bowel obstruction (ASBO).MethodsA multi-institutional retrospective study was performed examining patients 1–21 years-of-age presenting with ASBO from 2010 to 2019 utilizing the Pediatric Health Information System. Multivariable mixed-effects logistic regression was performed assessing inter-hospital variability in operative-vs-nonoperative management of ASBO.ResultsAmong 6410 pediatric ASBO admissions identified at 46 hospitals, 3,239 (50.5%) underwent surgery during that admission. The hospital-specific rate of surgery ranged from 35.3% (95%CI: 28.5–42.6%) to 74.7% (66.3–81.6%) in the unadjusted model (p < 0.001), and from 35.1% (26.3–45.1%) to 73.9% (66.7–79.9%) in the adjusted model (p < 0.001). Factors associated with operative management for ASBO included admission to a surgical service (OR 2.8 [95%CI: 2.4–3.2], p < 0.001), congenital intestinal and/or rotational anomaly (OR 2.5 [2.1–3.1], p < 0.001), diagnostic workup including advanced abdominal imaging (OR 1.7 [1.5–1.9], p < 0.001), non-emergent admission status (OR 1.5 [1.3–1.8], p < 0.001), and increasing number of complex chronic comorbidities (OR 1.3 [1.2–1.4], p < 0.001). Factors associated with nonoperative management for ASBO included increased hospital-specific annual ASBO volume (OR 0.98 [95%CI: 0.97–0.99], p = 0.002), older age (OR 0.97 [0.96–0.98], p < 0.001), public insurance (OR 0.87 [0.78–0.96], p = 0.008), and presence of coinciding non-intestinal congenital anomalies, neurologic/neuromuscular disease, and/or medical technology dependence (OR 0.57 [95%CI: 0.47–0.68], p < 0.001).ConclusionsRates of surgical intervention for ASBO vary significantly across tertiary children's hospitals in the United States. The variability was independent of patient and hospital characteristics and is likely due to practice variation.Level of evidenceIII     

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.     

Early postoperative small bowel obstruction

BACKGROUND: Early postoperative small bowel obstruction (EPSBO) is a distinct clinical entity that is often difficult to differentiate from postoperative ileus. METHODS: A literature search was performed for articles dealing with early postoperative small bowel obstruction using Medline and Google. RESULTS AND CONCLUSION: When bowel function does not return within 5 days after surgery, causes of persistent ileus should be excluded and treated. Most instances of mechanical EPSBO can be treated expectantly for at least 10-14 days with almost no risk of bowel strangulation. Some causes of obstruction (for example herniation at a laparoscopic trocar site) require early reintervention, whereas in other cases (such as radiation enteritis, carcinomatosis) reintervention may be deferred indefinitely. Many episodes of EPSBO resolve without the cause being elucidated.     

Etiology of small bowel obstruction

BACKGROUND: Small bowel obstruction (SBO) is a major cause of morbidity and financial expenditure in hospitals around the world. The leading cause of SBO in the western world has become adhesions. The goal of this study was to determine the causes of SBO. METHODS: The medical records of all patients admitted to one hospital between 1986 and 1996 with the diagnosis of SBO were reviewed retrospectively. This included 552 patients accounting for 1,001 admissions. RESULTS: The etiology of SBO was adhesions (74%), Crohn's disease (7%), neoplasia (5%), hernia (2%), radiation (1%), and miscellaneous (11%). Patients with Crohn's disease were younger than patients with other etiologies. Surprisingly, recurrence rates were similar for patients treated operatively as for those treated nonoperatively with the exception in the hernia group where higher recurrence rates were noted for patients initially treated in a nonoperative manner. CONCLUSION: The most common cause of SBO is adhesions followed by Crohn's disease and neoplasia.     

Post-operative bowel obstruction. Part 2: Mechanical post-operative small bowel obstruction by bands and adhesions

Small Bowel obstruction due to post-operative adhesions is a common problem in a general surgical practice. Any laparotomy initiates the lifelong risk of this complication. Mortality rates have improved dramatically in the last three decades. The basic evaluation and treatment of small bowel obstruction is well defined but many individual strategies may result from the variety of clinical presentations and from techniques and equipment available to a local surgical practice. Recent advances in surgical techniques and preventive strategies may improve overall results. Results will remain linked to the continuous aging of the populations of Western countries.     

Recurrent adhesive small bowel obstruction

Adhesive obstruction of the small bowel complicates about 5% of laparotomies; of these, 5–10% have recurrent attacks. The etiology of adhesions is incompletely understood and attempts to prevent their formation are of unproven value. Patients with recurrent acute obstruction that threatens strangulation, or that fails to subside, require laparotomy. If numerous adhesions have to be divided, it is worth considering a procedure to encourage fresh adhesions to form in a favorable pattern. Suture plication of the bowel by Noble's technique has a high incidence of complications and recurrent obstruction, and transmesenteric plication cannot be used in the presence of sepsis. Splinting of the entire small bowel by intraoperative passage of a long tube, which is left indwelling for 2–3 weeks, appears to be effective and safe. We have used this method in 140 patients without associated complications; of these, 17 had recurrent intestinal obstruction after 1–5 previous laparotomies for adhesions. A meticulous adhesiolysis followed by transluminal splinting through a jejunostomy has been followed by freedom from recurrence during 103 patient-years of follow-up.

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Resumen La obstrucción por adherencias es una complicación que ocurre en alrededor del 5% de las laparotomías, y de los pacientes que la desarrollan 5–10% sufren episodios recurrentes. La etiología de las adherencia no es totalmente conocida, y los intentos orientados a prevenir su formación han probado ser de utilidad no comprobada. Los pacientes con obstrucción aguda que presagia estrangulación o que no cede con un manejo de unos días de reposo intestinal y líquidos parenterales, requieren laparotomía. Cuando es necesario dividir numerosas adherencias, es Útil considerar la realización de un procedimiento que promueva la formación de adherencias frescas en un patrón ordenado y favorable. La plicación mediante suturas segÚn la técnica de Noble se acompaña de una elevada tasa de complicaciones y de obstrucción recurrente, y la plicación transmesentérica está contraindicada en presencia de sepsis. La fijación de la totalidad del intestino delgado mediante la colocación intraoperatoria de un tubo intestinal largo, el cual es dejado por 2–3 semanas, parece ser un método efectivo y seguro. Hemos utilizado tal método en 140 pacientes sin complicaciones; de éstos, 17 presentaban obstrucción recurrente después de 1–5 laparotomías previas por adherencias. La meticulosa lisis de las adherencias seguida de la fijación transluminal mediante tubo colocado a través de una yeyunostomía a 10–15 cm del ángulo duodenoyeyunal ha resultado en ausencia de recurrencia en 103 pacientes-año de seguimiento.

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Résumé L'occlusion de l'intestin grÊle secondaire à des adhérences complique environ 5% des laparotomies et récidive dans 5–10% des cas. L'étiologie précise des adhérences n'est pas parfaitement connue et toutes les méthodes de prévention qui ont été tentées n'ont pas fait leur preuve. Tous les malades qui présentent des attaques répétées et des menaces d'étranglement intestinal doivent Être opérés. Si les adhérences à lever sont très nombreuses il est nécessaire d'avoir recours à une méthode thérapeutique qui favorise la reconstitution en bon ordre de nouvelles adhérences. La plicature ordonnée des anses intestinales selon la technique de Noble est suivie de nombreuses complications et de récidive, la plicature transmésentérique selon la technique de Child ne peut Être employée en cas d'infection. C'est la raison pour laquelle il convient de substituer à ces modes de plicature, celle qui fait appel à un long tube intradigestif qui est laissé en place 2–3 semaines. La méthode est dénuée de danger et efficace. Elle a été employée chez 140 malades sans aucune complication alors mÊme que 17 d'entre eux présentaient des occlusions à répétition, et avaient subi de l à 5 laparotomies. Cette technique de libération des adhérences suivie de la plicature ordonnée des anses intestinales sur un tube introduit dans le grÊle par la voie d'une petite jéjunostomie a permis d'enregistrer l'absence de récidives de l'occlusion chez 103 malades qui ont été attentivement suivis.