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.     

Complications of negative laparotomy for trauma

Controversy continues about how often a negative laparotomy should be accepted in the management of patients with blunt and penetrating trauma. A key issue is the complications, especially small bowel obstruction. To define these complications, the charts of 248 patients who underwent negative laparotomy for trauma were examined. There were 185 patients with penetrating injuries and 63 with blunt injuries. Associated injuries were present in 119 patients. Acute perioperative morbidity occurred in 53 percent of the patients with associated injuries and 22 percent of patients with no associated injuries. On long-term follow-up, five patients developed small bowel obstructions. The incidence of small bowel obstruction was related to operative exposure. We have concluded that early morbidity after a negative laparotomy is more common when associated injuries are present. The risk of postoperative small bowel obstruction is small, especially when extensive operative dissection is not necessary. Abdominal exploration should not be discarded as a viable diagnostic and therapeutic procedure in patients with equivocal findings.     

术后早期炎性肠梗阻12例诊断与治疗

目的研究术后早期炎性肠梗阻的诊断以及治疗措施。方法回顾性分析12例术后早期炎性肠梗阻患者的病例资料。结果 11例患者经保守治疗治愈,平均治愈时间14 d。1例中转手术治疗后治愈。结论术后早期炎性肠梗阻应仍以保守治疗为主。小剂量低分子肝素、胃肠外营养及生长抑素的联合应用具有较佳的疗效。     

术后早期炎性肠梗阻42例诊治观察

目的探讨术后早期炎性肠梗阻的发病机制、临床特点、诊治方法及预防措施。方法对2008年10月至2012年7月山西省定襄县中医院收治的42例腹部手术后早期炎性肠梗阻患者的临床资料进行回顾分析,42例患者均表现为排气后肠蠕动一度恢复、进食后又出现以腹胀为主的肠梗阻症状,经查体和X线腹部平片确诊。结果 40例经保守治疗后治愈,于5～21d（中位时间9d）肠蠕动重新恢复,效果良好。2例保守治疗2周不见缓解,1例由于黏连导致血运障碍而行部分小肠切除术,另1例腹腔肠管广泛黏连、扩张,行黏连松解术并肠排列术,中位治愈时间为15d。结论术后早期炎性肠梗阻,多发于腹部手术后2周以内,治疗取决于引起梗阻的原因及临床病情进展情况,首选保守治疗。     

腹部手术后早期小肠内疝的诊治

目的 研究术后早期小肠内疝的临床特点. 方法回顾性研究1994-2006年38例腹部手术后早期小肠梗阻(early postoperative small bowel obstruction,EPSBO)患者的临床资料.结果 手术治疗术后早期小肠梗阻(发生于术后30 d内)的38例中各种原因所致小肠内疝占9例(23.7%).男6例,女3例,平均年龄53.6岁(32～72岁).术后出现症状的平均时间为7.8 d(2～17 d),平均行保守治疗时间为3.4 d(1～8 d).术后早期内疝的主要临床表现为:完全性机械性梗阻表现,症状重,进展快,可早期出现肠绞窄.影像学检查可能发现特征性内疝表现,以增强CT检查最佳.本组术中见6例患者已发生肠绞窄,其中4例患者发生肠坏死.本组共行肠切除术5例.术后平均住院时间为15.8 d(8～42 d).1例患者术后发生切口感染,无围术期死亡患者.结论 小肠内疝可发生于术后早期,易于发生绞窄坏死,应积极外科手术治疗,可获得理想的效果.     

腹部手术后早期炎性肠梗阻的处理

目的腹部手术后早期发生的肠梗阻原因较复杂,处理亦较困难,尤其是炎性肠梗阻,既有麻痹性因素,亦有机械性因素,使外科医师的医疗决策难以取舍,如是否需要手术、手术的时机、以及手术可能造成的并发症等均值得探讨。我科自1987年至1996年12月共收治了重型术后炎性肠梗阻48例,40例(83.3%)经非手术治疗痊愈;7例(14.6%)于症状消退后择期手术治疗并存症后治愈,1例2.1%死亡,临床非手术治疗时间为9～58天,平均27.6±10天,取得较满意的结果,为这种类型的肠梗阻治疗提供了一些经验。     

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目的 探讨术后早期炎性肠梗阻的临床特点及处理方法。方法 分析８１例术后早期炎性肠梗阻的临床特点及治疗结果。结果 ８１例均经胃肠减压,应用生长抑素,肠外营养等支持疗法,平均治愈时间为１４．５ｄ,无一例再手术。结论 术后早期炎性肠梗阻多发生在术生５￣７ｄ,可表现为典型的肠梗阻体征,多由小肠无菌性炎症致广泛肠粘连引起,多数病例采用保守疗法可治愈。     

腹部手术后早期炎性肠梗阻的治疗

目的 探讨术后早期炎性肠梗阻的特点及治疗原则。方法 回顾性分析近期经治的术后早期炎性肠梗阻 9例。结果 1例患者经手术治疗,分离粘连时引起多发性肠破裂、肠瘘,后经保守治疗治愈; 8例患者均经胃肠减压、抗炎、应用生长抑素等保守治疗治愈,平均治愈时间为 21. 5 d,无 1例肠坏死。结论 术后早期炎性肠梗阻的特点： (1)发生于腹部手术后早期,虽有机械性因素,但大多都是腹腔内炎症所致广泛粘连引起; (2)症状以腹胀为主,腹痛相对轻,部分患者有少量肛门排气排便,体征虽典型,但较少发生绞窄; (3)保守治疗大都有效,治疗上最好先予以生长抑素为主的保守治疗,应严密观察,如出现肠坏死、腹膜炎征象时则再及时中转手术。     

术后早期炎性肠梗阻综合治疗疗效分析

目的探讨综合治疗在术后早期炎性肠梗阻疗效。方法回顾分析43例术后早期炎性肠梗阻患者的临床资料。结果 39例早期炎性肠梗阻经胃肠减压、生长抑素、糖皮质激素和肠外营养等综合措施治愈,平均治愈时间12.1±8.4d;4例经手术治疗治愈。结论非手术综合治疗是术后早期炎性肠梗阻的有效治疗方法。     

术后早期炎性肠梗阻诊治体会（附17例报告）

目的　探讨术后早期炎性肠梗阻的临床特点及处理方法。方法　回顾性分析 1 7例术后早期炎性肠梗阻的临床特点及治疗结果。结果　保守治疗 1 4例 ,平均治愈时间 1 0d ;再次手术 3例。结论　术后早期炎性肠梗阻有其临床表现特点 ,多数病例采用保守疗法可治愈。     

Preoperative recognition of intestinal strangulation obstruction. Prospective evaluation of diagnostic capability

Early recognition of intestinal strangulation in patients with small bowel obstruction is essential to allow safe nonoperative management of selected patients. We prospectively evaluated preoperative diagnostic parameters as well as the preoperative judgement of the senior attending surgeon for the determination of the presence or absence of intestinal strangulation in 51 consecutive patients who were about to undergo laparotomy for complete mechanical small bowel obstruction. Strangulation was present in 21 (42 percent) of the 51 patients. No preoperative clinical parameter, including the presence of continuous abdominal pain, fever, peritoneal signs, leukocytosis, or acidosis, or a combination thereof proved to be sensitive, specific, and predictive for strangulation. Moreover, the senior surgeon's experienced clinical judgement detected strangulation in only 10 of 21 patients with strangulation preoperatively (sensitivity, 48 percent). Indeed, only 1 of these 10 patients had an early, reversible lesion, whereas 9 had advanced, irreversible infarction. Only 25 of 36 preoperative assessments of simple obstruction proved correct (predictive value of an assessment of no strangulation, 69 percent). Overall, the preoperative assessment was correct in only 35 of the 51 patients (efficiency, 70 percent). These data show that in patients with complete mechanical small bowel obstruction, the preoperative diagnosis of strangulation cannot be made or excluded reliably by any known clinical parameter, combination of parameters, or by experienced clinical judgement. Nonoperative management of complete intestinal obstruction is therefore undertaken at a calculated risk (31 +/- 51 percent in the present series) of delaying definitive treatment of intestinal ischemia.     

Laparoscopic port site Richter's hernia - An important lesson learnt

Introduction

We report a case of small bowel obstruction with strangulation caused by a port site hernia following a laparoscopic appendicectomy and the successful management of the problem by employing a laparoscopy assisted technique. The aim of this report is to emphasize the importance of fascial closures of trocar sites in order to significantly decrease postoperative morbidity.

Case report

A 31 years old female presented with a classic clinical picture of acute appendicitis. She underwent an uneventful laparoscopic appendicectomy. A 12 mm trocar was used at the umbilical port. On Postoperative day three, the patient developed abdominal distension, crampy abdominal pain, nausea and bilious vomiting. Her white cell count increased to 16,500/mm³, and CRP was 145. X-ray abdomen showed dilated small bowel with multiple air fluid levels. CT scan showed a herniated loop of small bowel into the trocar site with small bowel obstruction. Laparoscopy was done to confirm the Richter''s hernia into trocar site with small bowel obstruction. The bowel loop could not be reduced laparoscopically. Limited exploration of the trocar site confirmed findings with necrosis of the antimesenteric portion of the small bowel. A limited bowel resection and anastomosis was performed. The patient had an uneventful recovery.

Conclusion

Most port site hernias present within 10 days of the primary procedures, delayed hernias have been reported. CT scan is a helpful adjunct to differentiate port site hematoma from incarcerated small bowel. The knowledge of such a complication and its early diagnosis are important to avoid complications.     

Laparoscopic diagnosis and treatment of small bowel obstruction caused by postoperative intussusception

Small bowel obstruction is a common problem, especially for patients who have had previous abdominal surgery possibly complicated by postoperative adhesions. In contrast to adhesions, postoperative intussusception is an unusual cause of small bowel obstruction. We report a case of small bowel obstruction that occurred one month after antrectomy for duodenal ulcer with massive bleeding. Laparoscopic surgery was attempted after conservative treatment failed. A segment of jejunojejunal intussusception about 50 cm below the ligament of Treitz was identified and laparoscopic reduction of the intussusception was performed. The patient had an uneventful postoperative course and remained asymptomatic at 10-month follow-up. Although not frequently encountered, postoperative intussusception should be considered a possible etiology in patients with postoperative small bowel obstruction. In experienced hands, the laparoscopic approach offers a feasible option for correct diagnosis and appropriate treatment in this situation.     

小肠减压管联合泛影葡胺在术后早期炎性肠梗阻治疗中的作用

目的评价经鼻置入小肠减压管行小肠减压、并注入泛影葡胺行小肠造影在术后早期炎性肠梗阻治疗中的作用。方法首都医科大学附属北京同仁医院普通外科于2011年4月至2012年7月间有12例腹部手术患者术后早期出现炎性肠梗阻,经鼻胃管减压等常规保守治疗2周后,肠梗阻症状改善不明显,遂经鼻置人小肠减压管行小肠减压,同时经减压管注入泛影葡胺行小肠造影,了解小肠蠕动情况及肠道梗阻情况,并利用泛影葡胺促进肠蠕动的治疗作用,观察其治疗效果。结果在置入小肠减压管后,12例患者腹胀症状均有所缓解,其中11例在置入小肠减压管后3周内腹部坚韧感消失,恢复正常排气并逐渐开始经口进食;1例患者在50d后仍未排气,再次行手术治疗,术后3d患者恢复自主排气。随访6个月,全组患者无一例复发肠梗阻。结论对于症状较重、病程较长并经常规处理无效的术后早期炎性肠梗阻患者,应用小肠减压管行小肠减压并注入泛影葡胺行小肠造影的方法安全有效,能够避免二次手术。     

对大肠癌术后早期炎性肠梗阻诊治的探讨

目的：探讨大肠癌术后早期炎性肠梗阻的特点及治疗方法；方法：分析10例大肠癌术后出现早期炎性肠梗阻的临床表现并进行综合保守治疗；结果：10例患者保守治疗全部成功；结论：术后早期炎性肠梗阻是一种非细菌性炎性肠梗阻，以发生在术后早期，腹胀、呕吐明显，腹痛轻或无为主要临床特点，治疗应采用保守治疗。     

小肠梗阻术后感染性并发症危险因素分析

目的 讨论小肠梗阻术后感染性并发症的危险因素,以减少术后感染.方法 回顾分析2006年1月-2012年12月于首都医科大学宣武医院接受手术治疗的154例小肠梗阻患者的临床资料.Logistic回归分析术后感染性并发症的独立危险因素.结果 154例小肠梗阻患者接受手术治疗,术后感染率27.9％.回归分析发现,患者年龄（≥65岁）（OR 6.71,95％ CI3.15 ～ 16.33）、术中肠管破裂（OR2.71,95％CI1.19～7.25）、延迟（≥72 h）手术（OR 11.33,95％ CI 4.62 ～ 20.20）及手术时间（≥180 min）（OR 2.90,95％CI 1.26 ～9.83）是影响感染性并发症发生的危险因素.结论 术后感染是小肠梗阻术后的常见并发症.早期手术、术中轻柔操作防止肠管破裂可能是减少术后感染的有效措施.     

Laparoscopic adhesiolysis in acute small bowel obstruction

At the beginning of the laparoscopic surgery, intestinal obstruction was considered an absolute contraindication for this approach, because of the high risk of injuring the bowel. Today laparoscopic surgery for small bowel obstruction is still under evaluation. Adhesions are the most common cause of obstruction; although an important proportion of these patients can be nonoperatively treated, some of these require immediate operation. The aim of this review was to evaluate the reliability and immediate results of laparoscopic management of small bowel obstruction by postoperative adhesions. Laparoscopic management of acute small bowel obstruction is feasible, but it is often difficult and may be hazardous. The patients with acute obstruction may be undergo laparoscopy after a careful selection. Morbidity is low if the operation is performed by skilled. The immediate benefit is rapid intestinal motility and shorter hospital stay. The long-term effect is the prevention of small bowel obstruction recurrences by new postoperative adhesions.     

The ileoanal reservoir

One hundred nine men and 71 women with a mean age of 31 years had construction of 164 S, 2 J, and 14 other ileoanal reservoirs. Postoperative gastrointestinal complications included small bowel obstruction in 11 percent and ileus, hemorrhage, and sepsis in 6 percent, 5 percent, and 11 percent, respectively. There was a 13 percent incidence of miscellaneous postoperative complications. Pouch perianal fistulas developed in 5 percent of patients, and pouch vaginal and other pouch fistulas developed in an additional 4 percent. During long-term follow-up, small bowel obstruction developed in 27 percent of patients, and enterolysis or enterectomy was required in 15 percent of patients. One hundred fourteen patients who were followed for a mean length of 5 years after ileostomy closure (range 16 to 88 months) were evaluated for functional outcome. Function improved with time in 63 percent of patients and remained stable in another 33 percent; only 4 percent had long-term deterioration. Ninety-five percent of patients would again choose an ileoanal reservoir over a permanent ileostomy. This long-term assessment shows that although the ileoanal reservoir is a viable option in the management of mucosal ulcerative colitis, it should not be recommended to every patient.     

Surgical aspects of gastrointestinal persimmon phytobezoar treatment

One hundred thirteen patients presented with gastrointestinal complications due to persimmon phytobezoars during a 3 year period. One hundred three patients had a history of persimmon ingestion. One hundred five patients had undergone previous gastric operation for duodenal ulcer, one patient underwent highly selective vagotomy, and seven patients had not undergone previous operation. An elevated temperature, leukocytosis, and decreased bowel sounds were typical early clinical manifestations of small bowel obstruction by persimmon phytobezoars. In 13 patients, gastric bezoars were found, in 20 patients, gastric and intestinal bezoars, and in 80 patients, intestinal bezoars. One hundred patients were treated surgically. In 14 of the 20 patients with concomitant gastric and intestinal phytobezoars, extraction of the bezoars was achieved by gastrotomy. Of the remaining six patients, it was achieved by intraoperative milking of the gastric bezoar into the small bowel in two patients and by conservative treatment in four patients. Of the 100 patients who presented with small bowel obstruction, 60 were treated by milking of the bezoar into the large bowel, 34 by enterotomy, and 6 by conservative therapy with intravenous fluids, gastric suction, and a water-soluble contrast meal. Small bowel resection of a gangrenous segment was necessary in two patients. Two patients died after operation because of sepsis and respiratory complications. Eleven of the 13 patients in whom postoperative wound infection developed underwent gastrotomy or enterotomy. We conclude that the treatment of choice of intestinal obstruction due to persimmon phytobezoars is milking of the bezoar into the large bowel without enterotomy. Preoperative or operative endoscopy should be performed in patients presenting with complications of gastrointestinal phytobezoars. Patients who have undergone gastric operation should be warned against the risk of persimmon ingestion.     

Elective laparoscopy for small bowel obstruction

We performed elective laparoscopic adhesiolysis in 21 patients with small bowel obstruction. The procedure was completely laparoscopic or laparoscopy assisted in 17 patients, but 4 patients required full laparotomy due to internal hernia in 2, perforation of the small bowel associated with dense adhesions in 1, and carcinoma of the cecum in 1. In patients with a laparoscopic or laparoscopy-assisted procedure, the mean operating time, mean time until the return of bowel function, and mean postoperative stay were 94 minutes, 3.3 days, and 9.9 days, respectively. During follow-up for 14 to 44 months, 3 patients developed recurrent obstruction, 1 patient suffered from catheter-induced thrombosis, and 1 patient died from lung cancer. Elective laparoscopy can be performed safely and effectively in selected patients with intermittent small bowel obstruction.