Intestinal obstruction

Intestinal obstruction in a tertiary care centre in India: Are the differences with the western experience becoming less?

Background

Patients with intestinal obstruction consist of a major proportion of emergency room visits and the complication is associated with a significant morbidity and mortality. It has a diverse aetiology which varies from country to country. In developed countries it is mainly due to adhesions and in developing countries due to obstructed hernias. Although there are numerous studies from the western world on this subject there have been few recent publications from the developing world.

Patients and methods

We retrospectively analyzed all the patients admitted with intestinal obstruction to our department from January 1996 to December 2019. Their demographic data, duration of symptoms before presenting to the hospital and interval between admission and surgery were noted along with the cause and level of obstruction. The type of procedure, post-operative complications, mortality or whether re-exploration was done were also noted. Post-operative complications were graded according to the Clavien Dindo classification.

Results

A total of 986 patients presented with intestinal obstruction during this period out of which 743 patients underwent surgery. The commonest cause of obstruction was adhesions in 273 (36.7%) – the proportion increased significantly from 23% in 1996–2004 to 51.6% in 2013–2019. This was followed by carcinoma [130(17.5%)], tuberculosis [111(14.9%)], strictures [94(12.7%)] and hernia (5.4%). Colorectal surgery was the most common previous procedure in the adhesions group [85(31.1%)].The overall operative mortality was 41 (5.5%).

Conclusion

The aetiology of intestinal obstruction in our hospital is now mainly due to adhesions and is thus shifting towards the western pattern. But tuberculosis and obstructed inguinal hernias still constitute of a sizable proportion of our patients.

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Post-operative adhesions have now become a common cause of intestinal obstruction our tertiary care centre situated in a developing country.

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These were most commonly preceded by operations on the colon and rectum.

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Our overall mortality rate was comparable with those reported from the west. Old age, malignancy and strangulation were associated with a higher risk of mortality as has been the experience from other centres.

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Compared to Western reports our patient population was younger, males predominated.

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Although the proportion of patients with adhesions is rising tuberculosis continues to be an important cause for intestinal obstruction.

Case Report: 7-Year-Old Boy with Incarcerated Internal Hernia Leading to Extensive Intestinal Necrosis Due to a Large Congenital Mesenteric Defect

We present a case of a 7-year-old boy with acute abdominal symptoms initially misdiagnosed as constipation. Delayed imaging diagnostics revealed an ileus with contorted small intestine, so laparotomy was indicated. An acute bowel obstruction was found based on an incarcerated internal hernia. Small and large bowel segments were incarcerated into a large mesenteric defect leading to extended intestinal necrosis. About 30 cm of necrotic small bowel and 15 cm of large intestine were resected, two primary anastomoses were performed. The mesenteric defect was closed with two running sutures. The boy's clinical outcome was very good. Two aspects are discussed: the initial clinical misdiagnosis of acute bowel obstruction in a child leading to a delay of diagnostics and therapy on the one hand and the origin of mesenteric defects on the other. In children with abdominal pain, ultrasound must be performed as soon as possible and pediatric surgeons have to be involved early. There should be an awareness of the fact, that mesenteric defects and other congenital malformations can occur more often than we suspect it. In the case of an internal hernia, a misjudgement of the clinical condition may be very harmful for the patient and can lead to a short bowel syndrome or even death.

Small bowel knots

INTRODUCTION

Intertwining of bowel loops to form a knot is very rare cause of intestinal obstruction. Among intestinal knots, ileoileal knotting is the most rare, with only a handful of cases reported in literature. We present a rare case of ileoileal knotting and review of small bowel knots. The aim of this review was to summarise the existing evidence on small bowel knots and to postulate the possible mechanisms for knotting.

METHODS

A systematic search was conducted for literature published up to December 2019 using MEDLINE, PubMed and Google Scholar databases, together with the references of the full-text articles retrieved. Papers with case reports of small bowel knots were considered to be eligible for inclusion in the review.

FINDINGS

A total of 14 case reports were evaluated. There was no clear predilection for age or sex. Mostly cases were from Asia and Africa with no cases from the West. The presenting complaints were abdominal pain (93%), vomiting (64%), abdominal distention (57 %) and obstipation (43%). The bowel was gangrenous in 78% of cases. All underwent exploration, with the majority requiring resection and anastomosis of the involved segment.

CONCLUSION

Ileoileal knotting is a very rare cause of intestinal obstruction. Possible mechanisms include loaded bowel with longer mesentery, vigorous peristalsis, single bulky meal, pregnancy and intussusception. The condition is extremely difficult to diagnose preoperatively and it is usually diagnosed intraoperatively. The standard of treatment is resection of gangrenous part and anastomosis.

Herniation of the broad ligament… And the other side?

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Internal hernia is a classical cause of small bowel obstruction but remains rare.

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Discuss the appropriate management of internal hernia.

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Broad ligament hernias account for less than 5% of internal hernia.

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When performing surgery for broad ligament hernia, consider looking for contralateral hernia.

Introduction

Broad ligament herniation is a very uncommon cause of small bowel obstruction. Surgery permits reduction of the hernia and closure of the defect to prevent recurrence.

Presentation of case

We report a rare case of a 35 year old woman admitted in our hospital for recurrence of a small-bowel obstruction, secondary to internal hernia. The patient underwent intestinal resection in 2018 for herniated left broad ligament of the uterus strangulated.

This time, the computed tomography revealed a double junctional syndrome with ileal dilation localized in right side of uterus. Emergency surgery confirmed internal hernia with passage of ileal loops through the right broad ligament. After reduction of the hernia, closure of the defect was performed to prevent recurrence. For the first time, a check of other classic abdominal hernias was carried out.

Discussion

Internal hernias are responsible for less than 5% of mechanical bowel obstruction. Broad ligament hernias represent only 4–7% of these hernias.

The diagnosis is often delayed, because of its rarity and lack of surgical history. Surgery confirms the diagnosis, treats the occlusion and prevents recurrence.

The presence of several internal hernias has never been studied and no recommendation has been made on this topic.

Conclusion

This case demonstrate the importance of a systematic exploration of other internal abdominal hernias during the surgery, especially a contralateral broad ligament hernia.

2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation

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Obstruction and perforation due to colorectal cancer represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic challenge. The aims of the current paper are to update the previous WSES guidelines for the management of large bowel perforation and obstructive left colon carcinoma (OLCC) and to develop new guidelines on obstructive right colon carcinoma (ORCC).

Methods

The literature was extensively queried for focused publication until December 2017. Precise analysis and grading of the literature has been performed by a working group formed by a pool of experts: the statements and literature review were presented, discussed and voted at the Consensus Conference of the 4th Congress of the World Society of Emergency Surgery (WSES) held in Campinas in May 2017.

Results

CT scan is the best imaging technique to evaluate large bowel obstruction and perforation. For OLCC, self-expandable metallic stent (SEMS), when available, offers interesting advantages as compared to emergency surgery; however, the positioning of SEMS for surgically treatable causes carries some long-term oncologic disadvantages, which are still under analysis. In the context of emergency surgery, resection and primary anastomosis (RPA) is preferable to Hartmann’s procedure, whenever the characteristics of the patient and the surgeon are permissive. Right-sided loop colostomy is preferable in rectal cancer, when preoperative therapies are predicted.

With regards to the treatment of ORCC, right colectomy represents the procedure of choice; alternatives, such as internal bypass and loop ileostomy, are of limited value.

Clinical scenarios in the case of perforation might be dramatic, especially in case of free faecal peritonitis. The importance of an appropriate balance between life-saving surgical procedures and respect of oncologic caveats must be stressed. In selected cases, a damage control approach may be required.

Medical treatments including appropriate fluid resuscitation, early antibiotic treatment and management of co-existing medical conditions according to international guidelines must be delivered to all patients at presentation.

Conclusions

The current guidelines offer an extensive overview of available evidence and a qualitative consensus regarding management of large bowel obstruction and perforation due to colorectal cancer.