laparoscopic treatment of small bowel obstruction (SBO)

pi
a
ST dig
AM ita
l
e
PA d
i
VI so
ET la
AT let
t
A u
Gian Luca Baiocchi*, Nereo Vettoretto**, Mauro Zago***,
Luca Ansaloni°, Federico Gheza*, Ferdinando Agresta°°
Ann. Ital. Chir.
Published online (EP) 7 April 2014
pii: S2239253X14021525
www.annitalchir.com
ra
A common case with common problems:
laparoscopic treatment
of small bowel obstruction (SBO)
*Department of Medical and Surgical Sciences, Surgical Clinic, University of Brescia, Brescia, Italy
**Laparoscopic Surgery Unit, Azienda Ospedaliera M. Mellini, Chiari (BS), Italy
***Department General and Emergency Surgery, Istituto Clinico Città Studi, Milano, Italy
°Department General Surgery, Ospedali Riuniti, Bergamo (BG), Italy
°°Department General Surgery, Presidio Ospedaliero, Adria (RO), Italy
A common case with common problems. Laparoscopic treatment of small bowel obstruction (SBO)
BACKGROUND: Laparoscopic approach to patients with suspected small bowel obstruction (SBO) is not yet widely accepted nor clearly standardized; due to the absence of randomized trials, many questions still remain matter of debate.
METHODS: By describing a single typical case of acute intestinal occlusive syndrome in a 82 years old woman, in which
a SBO was suspected on the basis of previous surgical history and CT scan imaging, every single step of therapy is discussed, including the decision to perform explorative laparoscopy, the first trocar placement, the decision to continue by
laparoscopy or to convert in laparotomy, and finally the small bowel resection and re-anastomosis.
RESULTS: The decision to approach a suspected SBO by laparoscopy should be taken on the basis of a number of features which would predict the success rate, such as mild abdominal distention, proximal obstruction, partial obstruction,
small bowel diameter less than 4 cm, previous appendenctomy, anticipated single band adhesion. In these cases laparoscopic approach may improve post-operative outcomes in terms of reduced postoperative ileus, hospitalization and wound
infection rate.
CONCLUSIONS: In selected, not unusual cases of SBO, a laparoscopic approach is feasible and effective. A growing
Literature, mainly based upon retrospective series, is available.
WORDS:
Conversion, Laparoscopy, Mortality, Small bowel obstruction, Surgery
co
KEY
Introduction
Adhesions are the leading cause of SBO, accounting for
about 75% of all SBO, and represent a very common
clinical picture the surgeon must face to in the daily
Pervenuto in Redazione Marzo 2013. Accettato per la pubblicazione
Luglio 2013
Correspondence to: Dr. Gian Luca Baiocchi, III Chirurgia, Spedali Civili
di Brescia, P.le Spedali Civili 1, 25123 Brescia, Italy (e-mail: [email protected]; [email protected])
practice 1; from a population-based study investigating
more than 32000 SBO cases in California in 2007, 1
out of 4 patients needed urgent surgery, 1-year mortality was surprisingly high at 23% and 5-years recurrence
rate was also significant (19%) 2. Immediate intervention is mandatory in case of suspected strangulation,
small bowel torsion, ischemic or necrotic bowel; in these
cases, time is crucial, as risk of bowel resection significantly increases after 24 hours. In the remaining cases,
conservative therapy should be chosen, eventually along
with gastrografin administration after 48 hours have
elapsed without clinical improvement 3.
Laparoscopic treatment of SBO may have more than one
rationale reasons, such as the infrequent need for bowPublished online (EP) 7 April 2014 - Ann. Ital. Chir
1
G.L. Baiocchi, et al.
ra
peritoneal effusion, and empty colon (Fig. 1). A likely
diagnosis of small bowel obstruction from adherences was
done, and, considering the general conditions, severe
abdominal pain, leukocytosis and peritoneal effusion,
immediate intervention was decided.
Intervention started by open laparoscopy by umbilical
first access. While entering the peritoneum was not difficult, large adhesions between omentum and the previous laparotomy hampered a full vision of the abdominal cavity. Two operating trocars were inserted under
visual control in right iliac area, and the bowel was cautiously explored up to the right hypocondrium, where a
small bowel loop was incarcerated over the liver, as suspected. A heavy band was sectioned by scissors and the
bowel was reduced behind. The reduced small bowel was
ischemic, thus a small midline laparotomy was performed
and small bowel resection and side-to-side anastomosis
pi
a
ST dig
AM ita
l
e
PA d
i
VI so
ET la
AT let
t
A u
el resection and the hypothesis that late recurrence is
facilitated by peritoneal scar tissue from laparotomy and
small bowel manipulation. On the other side, limited
working space and difficult access may explain the bad
results reported by an audit from the French Association
for Surgical Research in 2001: 308 cases were retrieved
from 35 centers in the period 1988-1996. No more than
54.6% of the operations were concluded by laparoscopy,
and while common advantages of laparoscopic approach
such as reduced postoperative ileus, hospitalization and
wound infection were reported, about 1 out of 20
patients underwent early re-operation for incomplete
removal of the SBO cause. This prompted the Authors
to conclude that “the risk of immediate conversion and
complications indicate that laparoscopic surgery for SBO
should be entertained with caution” 4. However, about
10 years later, 2 reviews of more than 1000 cases 5,6,
and the guidelines of the World Society of Emergency
Surgery 7 stated that conversion rate is about 33% (mostly due to dense adhesions, need for bowel resection,
unidentified etiology and iatrogenic injury), missed perforations about 1%, visceral lesions 6.5%, overall morbidity 15.5%, mortality 1.5% and early recurrence rate
2.1%; these figures compare favorably with those reported for open treatment.
In all the reported retrospective studies, predictors of
laparoscopic treatment success were mild abdominal distention, proximal obstruction, partial obstruction, singleband obstruction and previous appendectomy, while predictors of failure were complete or distal obstruction,
small bowel loop diameter larger than 4 cm, more than
2 previous abdominal operations and a delay of more
than 24 hours after diagnosis 8.
Patient and Methods
co
An 82 years old lady, affected by a recent traumatic
femur rupture, was carried to the Emergency Department
complaining of epigastric bloating lasting 24 hours, with
no gas passage, and sudden severe right upper quadrant
pain, with nausea and vomiting of undigested food. Her
medical history included a previous cholecistectomy of
about 20 years earlier by right paramedian laparotomy,
chronic hypertension and a previous acute myocardial
infarction. On physical examination, the patient was
quite shocked, having a pulse rate of 105 bpm and blood
pressure 98/64 mmHg. The abdomen was distended and
tympanic, with increased bowel sounds and there were
no stools in the rectum. Routine laboratory study showed
17.000 WBC, Hgb at 10.3 gr/dl and creatinine at 1.8
mg/dl. Nasogastric suction tube was inserted, with abundant output of feculent fluid; 3 gr iv piperacilline and
100 mg tramadol were administered. CT scan was
promptly performed, showing diffusely dilated and fluid-filled loops of small bowel, the presence of small bowel under the right diaphragm and over the liver, huge
2
Ann. Ital. Chir - Published online (EP) 7 April 2014
Fig. 1: CT scan showed diffusely dilated and fluid-filled loops of small
bowel, the presence of small bowel under the right diaphragm and over
the liver, huge peritoneal effusion, and empty colon.
A common case with common problems: laparoscopic treatment of small bowel obstruction (SBO)
was performed. The post-operative course was uneventful and the patient was discharged to rehabilitation in
5th post-operative day.
4. Levard H, Boudet MJ, Msika S, Molkhou JM, Hay JM,
Laborde Y, Gillet M, Fingerhut A; French Association for Surgical
Research: Laparoscopic treatment of acute small bowel obstruction: A
multicentre retrospective study. ANZ J Surg, 2001:71:641-46.
Discussion
5. Ghosheh B, Salameh JR: Laparoscopic approach to acute small
bowel obstruction: review of 1061 cases. Surg Endosc, 2007; 21:1945949.
ra
6. Catena F, Di Saverio S, Kelly MD, Biffl WL, Ansaloni L,
Mandalà V, Velmahos GC, Sartelli M, Tugnoli G, Lupo M,
Mandalà S, Pinna AD, Sugarbaker PH, Van Goor H, Moore EE,
Jeekel J: Bologna Guidelines for Diagnosis and Management of
Adhesive Small Bowel Obstruction (ASBO): 2010 Evidence-Based
Guidelines of the World Society of Emergency Surgery. World J Emerg
Surg, 2011; 6:5-19.
pi
a
ST dig
AM ita
l
e
PA d
i
VI so
ET la
AT let
t
A u
The present case shows that laparoscopy is no longer
only a diagnostic tool in SBO; in selected cases (anticipated single band adhesion, bowel loop no larger than
4 cm, etc) laparoscopic approach may be attempted, with
demonstrated post-operative benefit; open laparoscopy is
suggested, and tailored mini-laparotomy may represent a
useful solution for vitality assessment and bowel resection-anastomosis.
Acknowledgments
The Authors would like to thank Professor Abe Fingerhut
and Professor Selman Uranues for reviewing the case presentation at the 12th European Congress of Trauma and
Emergency Surgery (Milan, Italy, 27-30 April 2011), and
for animating the Session “Laparoscopy in Emergency
Surgery: common practices vs old and new guidelines”.
References
1. Benfatto G, Tenaglia L, Catania G, Benfatto S, Catalano F,
Biondi A, Giovinetto R, Giovinetto A: Predictive factors and treatment of small bowel adhesive obstruction. Ann Ital Chir, 2003;
74(6):687-92; discussion 692-93.
2. Foster NM, McGory ML, Zingmond DS, Ko CY: Small bowel obstruction: A population-based appraisal. J Am Coll Surg, 2006;
203:170-76.
7. Agresta F, Ansaloni L, Baiocchi GL, Bergamini C, Campanile
FC, Carlucci M, Cocorullo G, Corradi A, Franzato B, Lupo M,
Mandalà V, Mirabella A, Pernazza G, Piccoli M, Staudacher C,
Vettoretto N, Zago M, Lettieri E, Levati A, Pietrini D, Scaglione
M, De Masi S, De Placido G, Francucci M, Rasi M, Fingerhut
A, Uranüs S, Garattini S: Surg Endosc, 2012; 26(8) Laparoscopic
approach to acute abdomen from the Consensus Development Conference
of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie
(SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società
Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d’Urgenza
e del Trauma (SICUT), Società Italiana di Chirurgia nell’Ospedalità
Privata (SICOP), and the European Association for Endoscopic Surgery
(EAES).:2134-64. doi: 10.1007/s00464-012-2331-3. Epub 2012 Jun
27.
8. Sauerland S, Agresta F, Bergamaschi R, Borzellino G, Budzynski
A, Champault G, Fingerhut A, Isla A, Johansson M, Lundorff P,
Navez B, Saad S, Neugebauer EAM: Laparoscopy for abdominal emergencies. Evidence-based guidelines of the European Association for
Endoscopic Surgery. Surg Endosc, 2006; 20:14-29.
9. Bergamini C, Borrelli A, Lucchese M, Manca G, Presenti L,
Reddavide S, Tonelli P, Valeri A: Laparoscopic approach to the “acute”
and “chronic” bowel obstruction. Ann Ital Chir, 2002; 73(6):579-85;
discussion 585-86.
co
3. Basile M, Galica V: Radiopaque markers equal Gastrografin in
the study of small bowel obstructions (SBO) A preliminary study. 2013;
84(1):55-59.
Published online (EP) 7 April 2014 - Ann. Ital. Chir
3
pi
a
ST dig
AM ita
l
e
PA d
i
VI so
ET la
AT let
t
A u
co
ra

Download Report