© Springer International Publishing Switzerland 2016
Abe Fingerhut, Ari Leppäniemi, Raul Coimbra, Andrew B. Peitzman, Thomas M. Scalea and Eric J. Voiglio (eds.)Emergency Surgery Course (ESC®) Manual10.1007/978-3-319-21338-5_1616. Small Bowel Emergency Surgery
Fausto Catena1 , Carlo Vallicelli1 , Federico Coccolini2 , Salomone Di Saverio3 and Antonio D. Pinna1
(1)
General, Emergency and Transplant Surgery Department, St Orsola-Malpighi University Hospital, Bologna, Italy
(2)
General and Emergency Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
(3)
Emergency and Trauma Surgery Unit, Maggiore Hospital Regional Trauma Center, Bologna, Italy
16.2 Crohn’s Disease
16.4.1 Meckel’s Diverticulum
16.6.1 Gallstone Ileus
16.6.2 Pneumatosis Intestinalis
16.6.3 Small Bowel Ulceration
Objectives
To identify those patients with bowel obstruction who require an urgent operation because of bowel strangulation
To recognize on a CT a mechanical small bowel obstruction and the location of obstruction and small bowel feces sign
The small bowel measures 6–7 m in length from pylorus to ileocecal valve. The jejunum begins at the ligament of Treitz. Jejunum and ileum are suspended by a mobile mesentery covered by a visceral peritoneal lining that extends onto the external surface of the bowel to form the serosa. Adhesions may limit the mobility of loops and lead to obstruction or internal hernia. Jejunum and ileum receive their blood from the superior mesenteric artery (SMA). Although mesenteric arcades form a rich collateral network, occlusion of a major branch of the SMA may result in segmental intestinal infarction. Venous drain is via the superior mesenteric vein, which then joins the splenic vein behind the neck of the pancreas to form the portal vein. Peyer’s patches are lymphoid aggregates present on the antimesenteric border of distal ileum. Smaller follicles are present through all small bowel. Lymphatic drainage of intestine is abundant. Regional lymph nodes follow the vascular arcades and then drain toward the cisterna chyli. Jejunal and ileal walls consist of serosa, muscularis, submucosa, and mucosa.
16.1 Acute Band or Adhesive Small Bowel Obstruction
Common surgical emergency and major cause of admission to emergency surgery departments
Early diagnosis is essential to management
Principle symptoms are abdominal pain, absence of flatus or stool, nausea or vomiting, dehydration, and abdominal distension if the obstruction is not in proximal jejunum.
Proximal obstruction tends to present with more frequent cramps, whereas distal obstructions cause less severe cramps with longer duration between episodes.
Laboratory tests:
Elevated hematocrit because of intravascular volume loss.
Significant leukocytosis is suggestive of strangulation.
Plain X-rays of the abdomen (not used in most places) reveals dilatation of the small bowel and air-fluid levels.
CT scan, with IV contrast, shows the dilatation of proximal bowel and the collapse of distal bowel.
Bowel wall thickening, mesenteric edema, asymmetrical enhancement with contrast, pneumatosis, and portal venous gas are suggestive of strangulation.
The zone between the presence and absence of small bowel feces may also help identify the site of obstruction.
Ultrasound may also be useful.
The key to management of small bowel obstruction is early identification of intestinal strangulation, because mortality increases from two- to tenfold in such cases
Therapy
Preoperatively
Correction of depletion of intravascular fluids and electrolyte abnormalities.
Nothing by mouth.
Insert nasogastric tube in patients with emesis.
In patients with adhesive small intestine obstruction, water-soluble contrast medium (Gastrografin) with a follow-through study is not only a diagnostic tool but can also be therapeutic
Surgical intervention is mandatory for patients with complete small bowel obstruction with signs or symptoms indicative of strangulation or those patients with obstruction that has not resolved within 24–48 h of nonoperative treatment
Laparotomy or laparoscopy can be used
Laparoscopy is best adapted to small bowel obstruction by bands, post appendectomy.
The open technique for first trocar insertion is mandatory.
Exposure may be difficult in case of massive bowel dilatation, multiple band adhesions, and sometimes posterior band adhesions, more difficult to treat laparoscopically.
Ischemia and/or necrotic bowel may require conversion.
Predictive factors for successful laparoscopic adhesiolysis include:
Less than three previous laparotomies
A non-median previous laparotomy (e.g., McBurney)
Unique band adhesion
Early laparoscopic management (possibly within 24 h)
No signs of peritonitis
Surgeon experience
Relative contraindication:
Three or more previous laparotomies
Multiple adherences
Absolute contraindications
Massive dilatation (more than 4 cm)
Signs of peritonitis
Severe cardiovascular or respiratory comorbidities
Hemostatic disorders
Hemodynamic instability
Goals of surgery
Adhesiolysis
Determination of bowel viability: two alternatives
Resection of non-viable intestine
Extension of intestinal resection depends on demarcation between purple or black discoloration of ischemic or necrotic bowel from viable intestine, recognized also by mesenteric arterial pulsations and normal motility
Observation of limited ischemia after adhesiolysis for 10–15 min, applying warm saline, looking for possible improvement in the gross appearance of the involved segment
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