ACUTE CARE SURGERY QUESTION

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Early post-op SBO is a different animal than standard adhesive
obstruction in my experience. Two weeks is an awful time to re-explore
(as you note). 

The evidence in routine adhesive SBO is that waiting is safe unless
there is point tenderness, elevated WBC or etc. and the likelihood of
spontaneous resolution goes down markedly after 5 days so that's my rule
in this scenario.

Early post op SBO is another kettle of fish and I'll try to either pull
the trigger early (<7 days) or wait 6 weeks. It's not easy though and
the patients are miserable — but not as miserable as they'd be with
multiple fistulae.

If anyone's interested I've attached the EAST SBO guidelines that were
recently published in JT (J Trauma. 64(6):1651-1664, June 2008 ) — but
they SPECIFICALLY do not address early post-op SBO.

Regards,
Bill

William J. Bromberg, MD, FACS
Savannah Surgical Group
912 350-7412

>>> <moore677 at aol.com> 1/25/2009 12:52 PM >>>

 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 
> --?

> trauma-list : TRAUMA.ORG?

> To change your settings or unsubscribe visit:?

> http://www.trauma.org/index.php?/community/? 

>?

>   
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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