Small Bowel Obstruction. Isidro Martínez Casas, MD FACS Servicio de Cirugía General Hospital de Torrevieja - PDF

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Small Bowel Obstruction Isidro Martínez Casas, MD FACS Servicio de Cirugía General Hospital de Torrevieja Aims Scale the problem Etiology Key decisions Initial management Diagnosis Definitive treatment

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Small Bowel Obstruction Isidro Martínez Casas, MD FACS Servicio de Cirugía General Hospital de Torrevieja Aims Scale the problem Etiology Key decisions Initial management Diagnosis Definitive treatment Pitfalls Scale of the problem 16% of surgical admissions 300,000 operations per year in U.S. Recurrence 8.7 to 53% Mortality 3-7%, 15% if strangulation Etiology True obstruction Adhesions (80%) Non- adhesive Cancer Hernia (2 nd ) Gallstone ileus Volvulus Chron... Functional Ileus Post-op sepsis Pseudo-obstruction Morphine Diabetes Constipation Intraluminal obstruction Intramural obstruction Extrinsic obstruction Constipation Motility disorders peristaltic activity Colic pain Distention Secretion Pharmacology Luminal air & fluid Release of mediators (Pg, VIP) Nausea & vomiting Epithelial damage Hyperemia, edema Hypovolemia Shock, MOF Consider Etiology: adhesional vs. non-adhesional Completeness: partial vs. complete Obstruction: single vs. closed loop Timing: early vs. late ( 30 POD) Patophysiology of adhesions Inhibition of fibrinolytic and extracellular matrix degradation system Induction of inflammatory response (cytokynes and TGF-β1) Induction of tissue hypoxia (VEGF) Key decisions Strangulation/ischaemia Cause Grade If adhesions: How long do I treat conservative Ischemia signs SIRS: Fever, tachycardia, leucocitosis, tachypnea Continous pain...peritonitis Metabolic acidosis: lactate 50% CT signs Reduced bowel wall enhancement Wall thickening 2mm Mesenteric venous congestion Mesenteric fluid Pneumatosis Portal gas 2 = 96% Pain 4 days Guarding CRP 75 mg/l 4 = 100% WBC count 10x10 9 /l Free fluid on CT 500ml Reduced bowel wall enhancement Initial management Nasogastric tube Fluidotherapy Antibiotics? X Ray...CT!!...Water soluble contrast medium Risk factors for adhesions Age 60 yo Peritonitis Emergency surgery Omental resection Previous laparotomy 5 years Type of surgery: extent of peritoneal damage Colorectal or gynecologic surgery Radiographic workup Plain X ray Small bowel contrast studies Ultrasound CT MRI Sens 75% 98% 84% 93% 95%... not yet defined X ray Do not differentiate strangulation vs. simple obstruction No information regarding cause CT SBO signs Radial distribution of mesenteric vessels CT SBO signs Radial distribution of mesenteric vessels Transition zone (distal decompressed bowel) Triangular convergent bowel CT SBO signs Radial distribution of mesenteric vessels Transition zone Triangular convergent bowel Small bowel feces sign Closed loop (C shape) CT SBO signs Radial distribution of mesenteric vessels Transition zone Triangular convergent bowel Small bowel feces sign Closed loop Whirl sign Key decisions Previous abdominal surgery? No Surgery Yes Adhesions? Yes Conservative management Limit 48-72h Treatment Most ASBO patients resolve within 5 days! Indications for delayed surgery: Evolving peritoneal signs Persistent ileus or NGT 500cc on day 3 Pain lasting 4 days Persistent laboratory or CT signs Surgery within 6 weeks of SBO?? Water-soluble contrast Sodium + meglumine ditriazoates 1,900 mosm/l 100 ml by NGT 3 hours occlusion No clear timing for X ray Contraindications! Alternatives... Branco BC, Barmparas G, Schnüriger B, Inaba K, Chan LS, Demetriades D. Systematic review and meta-analysis of the diagnostic and therapeutic role of water-soluble contrast agent in adhesive small bowel obstruction. Br J Surg 2010; 97(4): Predicts resolution in 24 hours Reduces need for surgery Reduces time to surgery Reduces hospital stay No increase of morbidity-mortality rates Let s be conservative! 2002; 195(1): Partial SBO Early postoperative? Chron s disease Carcinomatosis 2013; 216: of 242 patients PCT 0.57 ng/ml Sens 83% ischemia 0.17 ± 0.32 ng/ml 0.53 ± 0.73 ng/ml p ± 0.32 ng/ml 1.16 ± 0.87 ng/mlp 0.001 Laparoscopy Less postoperative pain Quicker return of intestinal function Shorter hospital stay Reduced full recovery time Fewer wound complications Nagle A, Ukiji M, Denham W, Murayama K 2004; 187(4): Decreased adhesion formation Laparoscopy Select patients Mild abdominal distention Proximal/partial obstruction Postappendectomy Band presumed Shorter time of symptoms 2 previous surgeries Contraindications Massive abdominal distention Peritonitis Hemodinamic instability Severe comorbidity Surgeon confort level Low threshold for conversion Registry Pitfalls Use contrast medium always with NGT Adhesions in handover: If ileus persist or NGT 500cc on day 3 go for surgery If early postoperative (4-6weeks), be conservative unless laparoscopy In patients with malignancy, investigate the cause Recurrence risk factors Age 40 yo Matted adhesions Postoperative surgical complications Take home Ischemia? No Yes Lx Previous abdominal surgery? No Surgery Yes TC Adhesions? Yes Gastrografin Conservative management Limit 48-72h Recomended readings J Trauma 2012; 73(5): S362-S369 J Trauma 2013; 74(1): Recomended readings Obrigado Assemble the team Bring the book Consider your protection
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