Management of Intestinal Obstruction-Yonas.pptx

Describes pathophysiology investigation and management of intestinal obstraction

1. Management of I ntestinal O bstruction Yonas Ademe , MD September 25, 2019 Moderator: Dr. Hailu , Consultant General Surgeon 1

2. Outline Proper diagnosis of intestinal obstruction General management of a patient with bowel obstruction Management of common etiologies of bowel obstruction Presentation objectives 2

3. Outline Part I: Basics of bowel obstruction Introduction History Epidemiology Pathophysiology diagnosis Part II: General management of bowel obstruction Operative Non-operative Part III: Management of specific etiologies of bowel obstruction Small bowel Large bowel Summary References Presentation outline 3

4. Part I: Basics 4

5. Introduction I ntestinal obstruction , is a complete or partial mechanical or functional obstruction of the intestines which prevents the normal movement of the products of digestion The small bowel, large bowel or both may be affected Independent of the underlying etiology, bowel obstruction remains a major cause of morbidity and mortality 5

6. History Bowel obstruction has been documented throughout history, with cases detailed in the Ebers Papyrus of 1550 BC and by Hippocrates Praxagoras appears to have performed the earliest recorded operation for bowel obstruction around 350 BC when he relieved the obstruction of a bowel segment by creating a decompressive , diverting enterocutaneous fistula 6

7. Epidemiology Intestinal obstruction account for 1.2% of all surgical diseases and 5% of emergency surgical admissions Both sexes are equally affected and the condition can occur at any age In rural Africa, acute intestinal obstruction accounts for a great proportion of morbidity and mortality, and Ethiopia is one of the countries where intestinal obstruction constitutes a major cause of morbidity and mortality 7

8. Epidemiology The etiologies and thereby the prevalence of bowel obstruction vary widely throughout the world depending on: Ethnicity T he age group considered D ietary habits G eographic location T ime of the year 8

9. Etiology: Mechanical Intraluminal Intramural Extramural Foreign body Gall stone Worm ball Neoplasms Strictures Hernias Volvulus Intussusception Adhesions Compression 9

10. Etiology: Functional Abdominal surgery Intra-abdominal collection Electrolyte disturbance Medications Retroperitoneal hemorrhage Smooth-muscle disorders Neurologic disorders Endocrine disorders Paralytic ileus Pseudo-obstruction 10

11. Etiology: Developed countries Bowel obstruction: 20% of acute abdomen Small bowel: 80 % Large bowel: 20% Etiology Small bowel Adhesions: 60% Neoplasms: 20% Obstructed hernia: 10% Crohn disease: 5% Miscellaneous: 5% Large bowel Malignancies: 60% Diverticualar disease: 20% Colonic volvulus: 1-5% Miscellaneous: 15 -20% 11

12. Etiology: Ethiopia Bowel obstruction: 26% of acute abdomen Small bowel: 52.3% Large bowel: 46.7% Etiology Small bowel Adhesions (51%) Small bowel volvulus (23%) Obstructed hernia Miscellaneous Large bowel Colonic volvulus (58.5%) Malignancies (15%) Intussusception Miscellaneous Pattern of Acute Abdomen in Adult Patients in Tikur Anbessa Teaching Hospital B. Kotiso et al., 2007 12 Surgically Treated Acute Abdomen at Gondar University Hospital, Ethiopia. S. Tsegaye et al., 2007 Pattern of Non-traumatic Acute Abdomen in Patients from Ayder Comprehensive Specialized Hospital Girmay Hagos Araaya et al., 2019 Small bowel Small bowel volvulus Larger bowel Sigmoid volvulus

13. Classification Duration Acute Vs. C hronic Site Small bowel Vs. Large bowel Pathophysiology Mechanical Vs. Functional Extent Complete Vs. Partial T ype of obstruction Simple Vs. Complicated (Closed loop and Strangulated) 13

14. Pathophysiology Sequestration of fluid and gas inside intestinal lumen Distention of intestine + increase in intraluminal and intramural pressure Impairment of microvascular perfusion Bacterial overgrowth Intestinal perforation Bacterial translocation Sepsis Peritonitis Dysmotility Decreased absorption I ntraluminal hypersecretion Hypovolemia Shock 14

15. Pathophysiology Speed of progression Small bowel Vs. Large bowel Simple Vs. Closed loop Partial Vs. Complete 15

16. C linical features - Symptoms I ntermittent crampy abdominal pain Abdominal distention Nausea and vomiting Acute obstipation Acute Vs. Chronic Proximal Vs. Distal Partial Vs. Complete Mechanical Vs. Ileus Simple Vs. Strangulated 16

17. Clinical features – Physical findings GA V/S HEENT Abdominal findings Visible bowel loops Abdominal distention Hyper/hypo-active bowel sounds T enderness (localized or diffuse) DRE findings Diagnosis Etiology Patient status Mechanical Vs. Ileus Simple Vs. Strangulated 17

18. Laboratories CBC Hemoconcentration Reflecting intravascular volume depletion Mild leukocytosis OFT Electrolytes Arterial blood pH and serum lactate concentrations 18

19. Imaging – X-ray Often confirmatory Sensitivity of 70 to 80 % but low specificity The abdominal series consists of: A radiograph of the abdomen with the patient in a supine position A radiograph of the abdomen with the patient in an upright position A radiograph of the chest with the patient in an upright position 19

20. Imaging – X-ray Small bowel Vs. Large bowel Proximal Small bowel Vs. Distal Small bowel Mechanical Vs. Ileus Complications Etiology (foreign body) 20

21. Imaging – X-ray Limitations Closed loop obstruction B ecause the involved bowel with a proximal and distal occlusion may be fluid filled and lack any gas Strangulation P ortal venous gas I ntestinal pneumatosis Etiology 21

22. Imaging – CT scan Becoming increasingly the imaging test of choice Diagnostic accuracy of >90% in intestinal obstruction 80 to 90% sensitive and 70 to 90% specific Ideally done with oral contrast 22

23. Imaging – CT scan Findings suggesting IO A discrete transition zone with dilation of bowel proximally Decompression of bowel distally Intraluminal contrast that does not pass beyond the transition zone Description of etiology 23

24. Imaging – CT scan Closed-loop obstruction U-shaped or C-shaped dilated bowel loop associated with a radial distribution of mesenteric vessels converging toward a torsion point 24

25. Imaging – CT scan Strangulation Pneumatosis intestinalis Portal venous gas Poor uptake of IV contrast into the wall of the affected bowel Thickening of the bowel wall Mesenteric haziness Mallo et al. Sensitivity: 83% Specificity: 92% P ositive predictive value: 79% N egative predictive value: 93 % Sheedy et al. Sensitivity: 15% Specificity: 94 % 25

26. Imaging – Contrast studies Hyperosmotic water soluble contrast ( gastrograffin ) Advantages Diagnostic Therapeutic Limitation B ecomes diluted rapidly with an established SBO Dilute b arium contrast Advantage Better details in distal obstructions Limitations Barium peritonitis I nspissation in the obstructed LBO 26

27. Imaging – Ultrasound R eported specificity is 82%, sensitivity is 95%, and overall accuracy is 81% Advantages Available, cheap and non-invasive Etiology Limitations H ighly operator-dependent Bowel gas artifact D ifficult to perform in obese patients 27

28. Imaging – MRI D iagnostic accuracy exceeding 90 % is achievable Advantage D istinguishing benign from malignant bowel strictures in patients with suspected malignant bowel obstruction Limitations Time consuming and requires substantial expertise D oes not have a greater diagnostic accuracy than CT 28

29. Imaging – Video capsule endoscopy (VCE) A valuable diagnostic tool in patients with subacute or chronic intestinal obstruction P articularly helpful in patients with obstruction related to a stricture caused by inflammation or malignancy Overall, VCE may provide a diagnosis in nearly 40% of previously undiagnosed patients 29

30. Detection of ischemia 30

31. Part II: General Management 31

32. General management Hemodynamic and metabolic support Isotonic fluid should be given intravenously Crystalloids Vs. Colloids Correction of metabolic and/or electrolyte imbalances Monitoring Stable patients with normal renal function Indwelling bladder catheter Unstable patients or those with impaired cardiac, pulmonary or renal function C entral venous or pulmonary arterial pressure 32

33. General management NG tube decompression Decreases distention Decreases nausea and vomiting Decreases risk of aspiration Improves ventilation in patients with respiratory compromise Nasogastric Vs. Nasointestinal tube A prospective, randomized trial of short versus long tubes in adhesive small-bowel obstruction Phillip R.Fleshner et al. 33

34. General management Broad spectrum antibiotics Indications B owel ischemia Peritonitis Surgery is planned They are given by some because of concerns that bacterial translocation may occur in the setting of SBO 34

35. Operative Management Indications Closed loop obstruction Suspected ischemia Perforation Large bowel obstruction 35

36. Operative Management Incision First surgery Incision providing adequate exposure Previous surgery Early post-operative obstruction Previous incision Vs. Virgin incision Late post-operative obstruction Previous incision Vs. Virgin incision 36

37. Operative Management Exploration I dentify the site and cause of obstruction If the point of obstruction is not obvious, decompressed bowel distal to the obstruction can be identified and followed proximally to the point of obstruction Care should be taken when handling the obstructed bowel at or near the point of obstruction when acutely obstructed 37

38. Operative Management Operative procedure Address the etiology Address the bowel Viable End of exploration Short lengths of ischemic bowel Resection and primary anastomosis 38

39. Operative Management Operative procedure Long segment of ischemic bowel B owel of uncertain viability should be left intact and the patient re-explored in 24 to 48 hours in a " second-look " operation Ischemia close to ileocecal valve Ileoileostomy in the region adjacent to the ileocecal valve is safe and results in fewer complications than ileotransverse anastomosis 39

40. Operative Management Criteria suggesting viability Usually visual inspection alone is adequate Normal color Peristalsis Marginal arterial pulsations Snipping a small piece of the mesenteric fat and checking for bleeding In borderline cases Doppler probe IV fluorescein 40

41. Operative Management Intraoperative intestinal decompression Manual retrograde decompression into the stomach I ntraoperative passage of a long nasointestinal tube P erformance of a controlled enterotomy Post-operative advantage or disadvantage? Effect of manual bowel decompression (milking) in the obstructed small bowel Törer N et al., 2008 Although it reduces muscle contractility, a milking procedure in an intestinal obstruction model does not cause peristaltic deterioration, histopathologic or inflammatory changes, or alterations in the degree of bacterial translocation Clinical outcomes of manual bowel decompression (milking) in the mechanical small bowel obstruction: a prospective randomized clinical trial Ezer A. et al., 2012 The resumption of a regular diet and postoperative hospital stay (P = .68) were not significantly different in the milking and control group. Similarly, there were no differences between the 2 groups regarding respiratory complications (P = .34), bacterial translocation (P = 1), or wound infection (P = 1 ) 41

42. Operative Management Post-op complications General complications Paralytic ileus Resection associated Anastomotic leak Internal hernias Short bowel syndrome Recurrent obstruction 42

43. Non-operative management When indicated, this approach is reported to be successful in 62–85% of patients Only 5 to 15% have been reported to have symptoms that were not substantially improved within 48 hours after initiation of therapy R ate of success is influenced likely by: Type of bowel obstruction (Complete Vs. Partial) The surgeon’s threshold for conversion to operative management 43

44. Non-operative management Indications No closed loop obstruction No evidence of bowel ischemia No sign of peritonitis Contraindications Absolute Closed loop obstruction Evidence of bowel ischemia Sign of peritonitis Relative LBO Complete obstruction 44

45. Non-operative management A study of 145 patients with CT-diagnosed HGSBO 46 % of the overall cohort were managed non-operatively Length of stay and complications were significantly increased in the operative group Non-operative management was associated with a higher recurrence rate and shorter time to recurrence 45

46. Non-operative management 55 patients with SBO were studied 45 % of patients with a complete obstruction successfully managed non-operatively 66 % of patients with a partial obstruction were successfully managed non-operatively No mortality I ncidence of intestinal ischemia at operation based on the presence or absence of complete versus partial obstruction was not described There was no advantage of one type of tube over the other in patients with adhesive SBO 46

47. Non-operative management 166 patients with SBO were studied 42% of patients with complete obstruction were successfully managed non-operatively 79% of patients with partial obstruction were successfully managed non-operatively T here was a greater rate of bowel strangulation ( 10% vs 4%) and need for resection ( 14% vs 8%) in the group with complete obstruction at the time of operation for treatment failure 6 % mortality in patients with a complete obstruction initially managed non-operatively versus 0% mortality for patients with a partial obstruction initially managed non-operatively 47

48. Non-operative management The studies and the unreliability of clinical acumen to recognize strangulation obstruction accurately have led many surgeons to favor early operation for all patients with a complete small bowel obstruction! “The sun should never rise or set on a (complete ) small bowel obstruction” 48

49. Non-operative management Indications No closed loop obstruction No evidence of bowel ischemia No sign of peritonitis No complete obstruction Contraindications Absolute Closed loop obstruction Evidence of bowel ischemia Sign of peritonitis Relative LBO Complete obstruction 49

50. Non-operative management Measures NPO (For complete obstruction) Fluid and electrolyte replacement NG tube decompression Connected to sump suction Close monitoring History, P/E, Investigations ? Antibiotics ?Analgesics Contrast agents 50

51. Non-operative management Administration of water-soluble oral contrast has not only diagnostic but also therapeutic and prognostic value Diagnostic : Partial Vs. Complete Predicts likelihood of success of non-operative management R educes the need for surgery Reduces length of stay by about 2 days Reduces time to resolution by about 28 hours Therapeutic The hypertonic water-soluble contrast agent causes a shift of fluid into the intestinal lumen, thereby increasing the pressure gradient across the site of obstruction accelerating resolution of partial SBO 51

52. Non-operative management Oral Urografin in Postoperative Small Bowel Obstruction Shyr-Chyr   Chen, 1999 A study of 116 patients with SBO In 63.8% of the patients the contrast medium reached the colon within the first 8 hours In 36.2 % of the patients the contrast medium failed to reach the colon within the first 8 hours The presence of Urografin in the colon within 8 hours of ingestion as an indicator for non-operative treatment had a sensitivity of 90.2%, a specificity of 100%, and an accuracy of 93.1% Therapeutic Value of Gastrografin in Adhesive Small Bowel Obstruction After Unsuccessful Conservative Treatment: A Prospective Randomized Trial Hok -Kwok Choi et al., 2002 Patients in whom contrast failed to reach the large bowel within 24 hours were considered to have complete obstruction, and laparotomy was performed Water-soluble contrast agent in adhesive small bowel obstruction: a systematic review and meta-analysis of diagnostic and therapeutic value Marco Ceresoli et al. 2016 WSCA had a sensitivity of 92% and a specificity of 93% in predicting resolution of obstruction without surgery D iagnostic accuracy increased significantly if abdominal X-rays were taken after 8  hours 52

53. Non-operative management When to convert to operative management? Worsening of clinical condition Complete obstruction Signs of bowel ischemia Signs of peritonitis Imaging (X-ray/CT scan) Signs of complete obstruction Signs of ischemia Signs of perforation No improvement in symptoms Continuous abdominal pain Fever Tachycardia Localized/diffuse tenderness Leukocytosis 3 signs: 82 % predictive value for strangulation 4 signs: 100% predictive value for strangulation Preoperative recognition of intestinal strangulated obstruction Sarr MG et al. 53

54. Non-operative management Most patients with partial SBO whose symptoms do not improve within 48 hours after initiation of non-operative therapy should undergo surgery The authors concluded that a 2-day limit of watchful waiting before surgery is not associated with an increase in mortality or postoperative morbidity, although inpatient costs were higher 54

55. Non-operative management An algorithm to a non-operative management of SBO 55

56. O utcome of management 56

57. Part III: Management of Specific E tiologies 57

58. Adhesive bowel obstruction 58

59. I ntroduction Adhesions may be defined as abnormal, inflammatory attachments of connective tissue between tissue surfaces They can be congenital or acquired (Post-inflammatory or post-op) L eading cause of SBO in Western societies 59

60. I ntroduction Following laparotomy, there is >5% lifetime incidence of SBO caused by adhesions Following surgery for SBO caused by adhesions, the probability of recurrent obstruction ranges from 20 to 30% 60

61. Pathophysiology Adhesion formation to some degree is nearly universal after laparatomy and starts as early as the first postoperative hours A dhesion formation is a surface event associated with some form of peritoneal injury The inciting trauma triggers a local fibrinous inflammatory response T he full establishment of this response is present 5-7 days post-op 61

62. P athophysiology The operations associated most frequently with adhesive bowel obstruction are those involving the structures in the infra- mesocolic compartment and especially in the pelvic region C olonic , rectal, and gynecologic procedures 62

63. Timing of obstruction Adhesive bowel obstruction may occur at any time postoperatively after a laparatomy A s early as within the first postoperative months to more than 8 decades after the index operation 20% occur within 30 days 20 occur between 1 and 12 months 20 % occur between 1 and 5 years 40% occur after 5 years 63

64. Diagnosis Clinical features Partial Vs. Complete Simple Vs. Complicated History of previous abdominal operation Imaging X-ray CT-scan 64

65. T reatment General management Applicable Operative Vs. Non-operative management Many patients who are treated conservatively for adhesive SBO do not require future readmissions Less than 20% of such patients will have a readmission over the subsequent 5 years with another episode of bowel obstruction 65

66. Treatment SBO within 6 weeks of a prior laparotomy Conservative management preferred Surgery if there are signs of complete obstruction , bowel ischemia , or peritonitis SBO after 6 weeks of a prior laparotomy Initial conservative treatment Operative treatment 66

67. Treatment Operative intervention Access Open Vs. L aparascopic Position Supine Vs. Modified lithotomy Incision Early post-operative obstruction P revious incision Vs. Virgin incision Late post-operative obstruction Previous incision (enter above or below the prior incision) V irgin incision (e.g. paramedian incision) Early versus late adhesiolysis for adhesive-related intestinal Obstruction Chu DI , 2013 Laparoscopic approach associated with significantly lower rates of overall complications and a shorter length of hospital stay (4 V s . 10 days) 67

68. T reatment Lysis of adhesions Skin: Knife S ubcutaneous tissue: electrocautery Fascia: Mayo scissors Take down adhesions from the anterior abdominal wall Separate the central abdominal contents from each other Close s ero-myotomies using interrupted sutures ?Put adhesion barrier over the bowel 68

69. C omplications of surgery Entero -cutaneous fistula Gentle adhesion release Prolonged paralytic ileus Intra-op Post-op Recurrent obstruction ? Adhesion barriers 69

70. P revention Laparoscopy Swedish National Inpatient Register Laparascopy has 4 fold less risk of adhesion compared to open surgery Cornerstones of adhesion prevention during open surgery Good surgical technique Careful handling of tissue Minimal use and exposure of peritoneum to foreign bodies Use of Hyaluronan based agents 70

71. Primary small B owel Volvulus 71

72. I ntroduction S mall bowel volvulus is twisting of the small intestine about its mesentery Primary Vs. Secondary It results in obstruction and hampered venous return followed by ischemia ultimately causing gangrene 72

73. E pidemiology Incidence Western world: 1.5 to 5.7 per 100,000 Africa and Asia: 24 to 60 per 100,000 More commonly seen in people who eat large meals infrequently Young males, from rural areas, with bulky fiber rich diet Tense and muscular abdominal wall Erect posture during and/or after eating Muslims during the month of Ramadan Parasitism Higher incidence seen in regions with endemic parasitism 235 patients with acute IO SIV: 98 (41.7 %) Mean age: 34 years Male to female ratio: 8.8:l Y oung adults most of whom were farmers M ortality rate was 13.3% Trend of small intestinal volvulus in north western Ethiopia Ghebrat K., 1998 Small intestinal volvulus in southern Ethiopia M.Demissie , 2001 SIV is commonest cause of SBO SIV is second most common cause of IO Primary more common than secondary Typical patient: young adult, male, muscular, farmer, from a rural area whose diet is bulky and mainly made of cereals Seasonal variation of primary small intestinal volvulus in North Western Ethiopia Ghebrat K., 2001 Prevalence was significantly higher during the months of June through October than during the months of November to May 73

74. P athophysiology Rapid filling of the proximal intestines with high bulky chyme Proximal bowel loops pulled down to the pelvis and distal bowel loops pushed up 74

75. D iagnosis Clinical features Features of SBO Imaging X-ray CT-scan C-shaped loop “Whirl’ sign 75

76. T reatment SBV without ischemia Simple detorsion (recommendation) The risk of recurrence is not well established but generally rare Post-laparotomy intra-peritoneal adhesions are thought to be the factor to prevent recurrence Gangrenous SBV Resection and anastomosis 76

77. O utcome P rognosis depends on: Age D uration of symptoms L ength of small intestine involved The mortality reported from different places varies from 9% to 32.1% 77

78. Sigmoid Volvulus 78

79. I ntroduction Torsion of the sigmoid colon along its own mesentery Torsion of 180 degrees results in clinical obstruction , and further torsion to 360 degrees causes strangulation Perforation occurs in areas of necrosis at the point of torsion, within the closed loop , or in the proximal thin-walled cecum 79

80. E pidemiology 1.9 % of cases of large bowel obstruction in the United States and up to 10% to 50% of cases in Africa, the Middle East, and South America Old age M>F 80

81. P athophysiology Anatomic features Large and redundant colon Long mesentery with n arrow base Predisposing conditions Chronic fecal loading High fiber diet Constipation Pregnancy HSD “ D olichomesocolic colon” C ommonly found in male subjects and people over the age of 30 Bhatnagar et al ., 2004 Acquired Vs. Congenital 81

82. P athophysiology Pattern of gangrene ( Bhatnagar et al., 2004) G angrene confined to sigmoid colon (74%) Gangrene extending beyond the confines of the area under constriction on one or both sides (26 %) In 15% of the cases, the gangrenous sigmoid may be involved in knotting with ileum 82

83. D iagnosis Clinical features Features of LBO Simple Vs. Gangrenous Imaging X-ray “Coffee bean” or “omega loop” sign (60%) Barium enema “Bird’s beak” sign (≈100%) CT-scan W hirl sign (≈100%) Girmay et al., 2019 Simple (60%) Vs. Gangrenous (40%) 83

84. T reatment No signs of gangrene or peritonitis Initially : resuscitation followed by endoscopic detorsion R igid proctoscope Vs. Flexible sigmoidoscope or colonoscope Goals R elieve obstruction due to volvulus P revent re- volvulization A llow time for bowel preparation prior to surgery Success rate: 60% to 90% Recurrence rate: 70% Mortality rate after recurrent sigmoid volvulus: 36 % Screening colonscopy After some time : bowel preparation and colectomy 84

85. Treatment Obvious signs of gangrene or peritonitis (clinical or endoscopic signs) 1 stage: R-E-E-A 2 stage: Hartman’s procedure Overall patient condition Status of the bowel Intra-abdominal condition An algorithm for the management of sigmoid colon volvulus and the safety of primary resection: experience with 827 cases Oren D, Atamanalp SS, Aydinli B, et al ., 2007 Resection and primary anastomosis is the first choice, and it can be performed with acceptable mortality and morbidity rates if the patient is stable and a tension-free anastomosis is possible Clamping before detorsion ? Decompression before resection? Ballantyne GH et al., 1982 Pahlman et al., 1989 Kuzu MA et al., 2002 Bhatnagar et al., 2004 Oren et al., 2007 Primary resection and anastomosis Reported mortality rate of 16 to 33 % 85

86. Treatment Intra-op finding of a viable sigmoid Non-respective methods (recurrence rate of 9% to 44%) Simple detorsion Sigmoidopexy Meso-sigmoidoplasty Extraperitonealization Resective methods Primary R-E-E-A Hartmann’s procedure 86

87. Recurrence Recurrence rate: 40%, 60%, 80% The interval of time between recurrent episodes ranges from 2 to 35 months 87

88. Recurrence The presence or absence of a previous attack makes a significant difference in the occurrence of gangrenous bowel Recurrence after sigmoid colectomy Treatment of sigmoid volvulus: experience in Gondar, north-west Ethiopia Mohammed K. et al ., 1998 24% of patients with no previous attack had gangrenous bowel compared with 4% after recurrence Minimizing recurrence after sigmoid volvulus Chung et al. 6/27 (22%) patients developed recurrent volvulus 88

89. Outcome - Mortality Overall mortality ( Bhatnagar 2004, Asbun 1992, Bagarani 1993, Oren 2007, Pahlman 1989, Kuzu MA 2002) Non-gangrenous SV: 6 to 24% G angrenous SV: 11 to 80 % Factors that influence the adverse outcome Advanced age Associated comorbidities Delay in presentation or diagnosis F ecal peritonitis P revious episodes of volvulus Septic shock 89

90. O utcome M orbidity rate is approximately 6 to 26% ( Bhatnagar 2004, Asbun 1992, Bagarani 1993, Oren 2007, Pahlman 1989 ) Causes of morbidity Wound infection I ntra-abdominal abscess Evisceration A nastomotic leakage Stomal complications R espiratory complications DVT 90

91. Colonic tumor obstruction 91

92. I ntroduction 16% patients ( 7% to 30 % ) with colon cancer present with acute bowel obstruction M ajority of the obstructions occur at the rectosigmoid junction Followed by the sigmoid colon Synchronous lesions, in the setting of an obstructing lesion, may occur in up to 15% 92

93. D iagnosis Clinical features Suggestive of malignancy Imaging studies (abdominal x-ray or CT scan) F eatures of a large or small bowel obstruction Diameter of the cecum Urgent intervention required if diameter is ≥12 cm 93

94. T reatment Resectability of the tumor S ite of the tumor Presence of synchronous tumors S tatus of bowel I ntra-abdominal condition P atient status E xpected patient survival 94

95. T reatment Resectable tumor Right side Resection and anastomosis Left side 1 stage On-table lavage with segmental colon resection, intraoperative colonoscopy, and primary anastomosis 2 stage Hartmann’s procedure 3 stage Defunctioning loop colostomy, followed by resection and anastomosis and last by closure of the defunctioning stoma Unresectable tumor Right side Ileocolic bypass Diversion ileostomy Left side Diversion colostomy Colonoscopic self-expanding metallic stent Safe and highly successful (>90%) 95

96. T reatment LBO secondary to a resectable tumor with liver metastases? 96

97. Outcomes Success in relieving colonic obstruction Emergency surgery: 99 % Stenting: >90% Overall complication rate Emergency surgery: 51% Stenting: 48.5% Cirocchi et al. 97

98. Post-op Ileus 98

99. Introduction Following most abdominal operations or injuries, the motility of the GIT is transiently impaired Surgical stress-induced sympathetic reflexes Inflammatory response-mediator release Anesthetic/analgesic effects 99

100. Introduction The return of normal motility generally follows a characteristic temporal sequence Small-intestinal motility: within first 24 hours Gastric motility: 48 hours Colonic motility: 3 to 5 days Routine postoperative ileus should be expected and requires no diagnostic evaluation 100

101. Definition A recent global survey synthesized the results of available data Postoperative ileus Interval from surgery until passage of flatus/stool AND tolerance of an oral diet Prolonged postoperative ileus ≥ 2 of the following occurring on or after day 4 post-op without prior resolution of post-op ileus Inability to tolerate oral diet Nausea/vomiting Distension Absence of flatus Radiologic confirmation 101

102. Implications Prolonged ileus R eported to occur in 10% to 15% of patients undergoing intestinal surgery M ajor cause of morbidity in hospitalized patients T he most frequently implicated cause of delayed discharge following abdominal operations 102

103. Etiology Intra-abdominal collection Pus Blood Bile GI content Electrolyte disturbances Medications Retroperitoneal hemorrhage 103

104. Diagnosis Clinical features Similar features as mechanical obstruction Abdominal pain B owel sound Imaging Plain abdominal x-ray Distinction between ileus and mechanical obstruction may be difficult Etiology CT-scan Preferable 104

105. Treatment Limit oral intake TPN may be required IV Fluids and electrolytes NG tube If vomiting or abdominal distention are prominent Correct the underlying inciting factor ? Prokinetic agents 105

106. Prevention Intraoperative measures Laparoscopic approach, if possible Minimalize handling of the bowel Restricted intra-op fluid administration Postoperative measures Avoid nasogastric tubes Early enteral feeding Restricted IV fluid administration Correct electrolyte abnormalities Epidural anesthesia, if indicated Consider mu- opiod antagonists 106

107. Early postoperative bowel obstruction 107

108. I ntroduction It is a relatively uncommon problem but remains a very real dilemma encountered in every practice Reported to occur in 0.7% to 9% of patients, with a higher rate in patients undergoing pelvic surgery, especially colorectal procedures Definition S urgery literature defines early obstruction from 30 days to 6 weeks after the original operation Schwartz’s: 30 days Maingot’s : 6 weeks 108

109. E tiology Mechanical Early post-op adhesions (90%) A nastomotic edema/stenosis Hernias Internal herniation Fascial herniation Intususception Intramural intestinal hematoma Functional Anastomotic leak I ntra-abdominal abscess H ematoma Bile 109

110. D iagnosis It is often difficult, if not impossible, to distinguish early obstruction from postoperative ileus Vague symptoms Unreliable physical findings Similar imaging findings CT scanning or small bowel series often required To look for etiology Poor at differentiating ileus versus partial mechanical obstruction 110

111. T reatment Conservative management No compelling indications Complete obstruction, strangulation, and/or peritonitis No other remediable causes Collections Hernias No response Wait 111

112. Intestinal obstruction is a common surgical emergency Imaging has a key role in diagnosis Pre-operative stabilization of the patient is of paramount importance for good surgical outcome Management decisions should be individualized Summary 112

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117. References Text books 117

118. Thank You! 118