Management of recurrent small bowel obstruction Aliu Sanni MD Kings County Hospital Center
Management of recurrent small
bowel obstruction
Aliu Sanni MD
Kings County Hospital Center
21st June, 2012.
Case presentation
• 35yr old male presents with abdominal pain,
nausea and vomiting.
• s/p Exploratory laparotomy, extensive lysis of
adhesions and small bowel resection for
recurrent small bowel obstruction POD#7
• PSH: GSW abdomen (2004), s/p exploratory
laparotomy, multiple SBR with six SB
anastomosis at initial surgery
• Recurrent admissions for SBO necessitating Exlap, LOA and SBR twice in the past
Case presentation
On arrival T=98.2, BP 128/76 PR=117
General- in moderate distress
Abdomen- distended, tender with peritonitis
Chest- CTA bilat
CVS-S1S2, no murmur
WBC- 15000
BMP, Coags- WNL
Case presentation
• Resuscitation
• Operative intervention
• Exploratory laparotomy- frozen abdomen, no
frank perforation.
• Abdominal washout
• Generous use of fibrin glue
• Drainage with large Jackson Pratt tubes
Case presentation
Hospital course
• POD#1- TPN
• POD#3- Discontinue JP drains
• POD#8- Regular diet
• POD#11- Discharged home
Management of Recurrent Small
Bowel Obstruction
• Occurs when the normal propulsion and
passage of intestinal contents does not occur.
• Gas and fluid accumulates in the lumen
proximal to obstruction
• Leads to translocation of bacteria
• Build up in intraluminal pressure and
impairment of intestinal microvascular
• Ultimate intestinal ischemia and gangrene
Mechanical bowel obstruction
• Physical blockage of intestinal lumen
• Intrinsic or extrinsic to intestinal wall
• Partial obstruction-transit of some intestinal
• Complete obstruction- possible strangulation,
Functional obstruction
• AKA Pseudo-obstruction
• Secondary to factors that cause intestinal
Clinical presentation
• Abdominal pain, nausea, vomiting and
• Laboratory findings reflect fluid depletion
• Mild leukocytosis
• Strangulated obstruction- pain out of
proportion to examination, tachycardia,
marked leukocytosis and peritoneal signs.
• History of previous abdominal surgery
• Meticulous physical examination to search for
• AXR- flat and upright films
• CT Scan Abdomen- transition point. Other
anatomical abnormalities.
Recurrent small bowel obstruction
• Incidence of up to 34% in all patients
regardless of the management modality.
• More common in patients with multiple
adhesions, matted adhesions, previous
admission for SBO, previous pelvic and
colorectal surgery
• Numerous attempts have been made to
control formation of adhesions
• Suturing of adjacent loops of small bowel into
an orderly pattern to prevent mechanical
obstruction e.g. Noble plication, Childs-Phillips
transmesenteric plication.
• Complications- High rates of enterocutaneous
fistula, abdominal abscess and wound
• Rate of recurrent obstruction up to 19%.
Intraluminal Stenting
• Splinting the bowel with long intestinal tubes
• Baker’s Tube- tube jejunostomy with passage
of long tube through small intestine to colon
• Lennard tube- rigid tube passed nasointestinally.
• Complications- Intra-abdominal leak,
persistent enterocutaneous fistula,
obstruction at jejunostomy site.
• Recurrent small bowel obstruction is a very
common surgical dilemma.
• Plication and intraluminal stenting are
historical procedures with significant
• Watchful waiting in patients with recurrent
small bowel obstruction
• Meticulous surgical technique to prevent