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Tue Jan 27 05:14:54 GMT 2009

My apologies for the tardiness of this reply.  This question comes up about once a month at my institution.  

My personal feeling is that if they NEVER open up as a primary event after their first surgery (never pass gas, never stool, never tolerate clears) and remain with obstructive symptoms (bloating, high nasogastric outputs, oral contrast CT revealing obstructive pattern with definable transition point) then relaparotomy is indicated ideally within the first ten days.  My rationale for right or wrong is that it is more likely to be an event related to the first operation which led to the obstruction such as a technical problem caused by surgeon (mesenteric defect with internal hernia, incomplete stapled anastamosis, bowel caught in the abdominal closure) that won't get better unless you go back in and fix what you broke.  

BUT...if they show signs of opening up after their first operation (pass gass, stool, tolerate a diet) THEN obstruct within the first two weeks of surgery my approach is to ride out the storm as long as it takes, a month or longer if necessary with TPN and good nasogastric decompression.  There is a good body of data that supports this approach and that most cases will eventually go on to open up on their own.  My observations have supported this bias.

A relaparotomy within the first month is an absolute nightmare and almost always ends like you've described below.  Exceptions to this rule are the development of any three of the following:  Worsening abdominal pain, fever without cause, leukocytosis without cause, rising lactate without cause, aspiration, worrisome radiographic findings (small bowel fecalization, pneumatosis, everyone knows them).   

My opinion.

Ben Reynolds, PA-C
Pittsbugh, PA

________________________________
From: "moore677 at aol.com" <moore677 at aol.com>
To: trauma-list at trauma.org
Sent: Sunday, January 25, 2009 12:52:44 PM
Subject: Re: ACUTE CARE SURGERY QUESTION

Patient had no evidence of complete SBO, either clinically or radiographically (gastrograffin with UGI/SBFT).? She had a completely benign abdomen with no fever or elevated WBC.? She swears she was passing some flatus, but no BM.? After two enterotomies and multiple serosal tears later in an extremely hostile abdomen, I just wonder if this patient should've been given some more time.

Dell.................

-----Original Message-----
From: Massimo Chiarugi <m.chiarugi at dc.med.unipi.it>
To: Trauma &amp; Critical Care mailing list <trauma-list at trauma.org>
Sent: Sun, 25 Jan 2009 2:48 am
Subject: Re: ACUTE CARE SURGERY QUESTION

moore677 at aol.com ha scritto:?

> Not trauma, but is acute care-related question.? How many of you would operate on postoperative partial small bowel obstruction which persists 2 weeks after failed conservative management, including TPN?? Which of you would go longer than 2 weeks, and if so, how long would you wait if the patient did not have a fever or elevated WBC and a benign abdomen?? 
>?

> I did a RHC on a patient with a cecal volvulus who was 1 week s/p lap Nissen.? She developed signs of pSBO 1 week after hemicolectomy and was managed for 17 days with no improvement.? Traditional teaching has been to wait at least 2 weeks then operate.? Preop imaging included a CT scan and an UGI/SBFT.? UGI/SBFT had no contrast to anastomosis at 8 hours and ?extra-luminal contrast in RUQ (where anastomosis was).?

>?

> After being in that belly, I think I should've waited as long as possible, and maybe longer than that.? She had horrible adhesions.? Anastomosis was fine and no internal hernia.?

>?

> Dell.............?

>?

>?

> Forrest "Dell" Moore, MD, FACS?

> Trauma Critical Care Surgery?

> Co-director Trauma & Surgical ICU?

> St. Joseph's Hospital and Medical Center?

> Phoenix, AZ?

> Cell 480 284 1703 
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>  
Dear Forrest,?
?

I believe that decision to cut should not be related to the length of 
the postop SBO but  to changes in the clinical scenario (physical exam, 
fever, WBC and others). After  a few days of watching I would suggest to 
give the patient gastrografin (not barium) orally or by NG route. If SBO 
will not resolve after gastrogafin administration, need to surgery is 
likely (complete SBO ). Conversely, patients in which gastrografin 
promotes evacuation (even if minimal)  have a very low chance to be 
operated and conservative management may be safety prolonged. It is not 
necessary to have abdominal serial x-ray films after contrast ingestion: 
the decison is simply made on a clinical event.?
?

Massimo Chiarugi?
?

Massimo Chiarugi, MD, FACS?

Department of Surgery, University of Pisa?

Santa Chiara Hospital?

55 Via Roma?

56100 PISA Italy?
?

m.chiarugi at dc.med.unipi.it?

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