Postoperative Adhesive Intestinal Obstructions

Adhesive intestinal obstructions are a common pathological condition after surgery. Unlike strangulation bowel obstruction accompanying circulatory disturbance, adhesive intestinal obstructions often improve with conservative treatment such as fasting and fluid therapy. However, it recurs in many patients, and thus saline cathartics and Chinese herbal medicines are given prophylactically. In patients with recurrent adhesive intestinal obstructions, identifying the adhesions and dividing them with minimally invasive laparoscopic surgery may be useful for improving the quality of life.

A 78-year-old man was admitted to our hospital for a thorough examination. At the age of 50 years, he had undergone emergency surgery for a rupture of the intestine and pelvic fracture due to an accident. The intestine was completely ruptured 150 cm from the terminal ileum, and end-to-end anastomosis was performed. Thereafter, a few to 10 episodes of bowel obstruction recurred each year, requiring hospitalization once or twice a year. To prevent bowel obstruction, he ate foods that had been processed with a blender.

Double-balloon endoscopy through the anus showed stenosis of the lower jejunum (Fig. 10.5.2a). A contrast-enhanced study with meglumine sodium amidotrizoate and the endoscope showed a filling defect around the endoscope tip (Fig. 10.5.2b), and a tattoo was placed near the stenotic site. Later, double-balloon endoscopy through the mouth revealed a tight bend of the lower jejunum, and the endoscope reached the tattoo placed caudal to the bend. The site was located in the center of the abdomen with no mobility and consistent

Fig. 10.5.2. Postoperative adhesive intestinal obstruction a Stenosis by extrinsic compression revealed by double-balloon endoscopy through the anus b No flow of contrast medium to the rostral side of the stenosis on a selective, contrast-enhanced radiograph (through the anus)

Fig. 10.5.2. Postoperative adhesive intestinal obstruction a Stenosis by extrinsic compression revealed by double-balloon endoscopy through the anus b No flow of contrast medium to the rostral side of the stenosis on a selective, contrast-enhanced radiograph (through the anus)

with the surgical scar, leading to the conclusion that the site had resulted from adhesion to the abdominal wall (Fig. 10.5.2c). Computed tomography of the abdomen filled with gas revealed one adhesion to the abdominal wall in the subumbilical region (Fig. 10.5.2d), and laparoscopic division of adhesion was performed. As expected preoperatively, the adhesion was found rostral to the tattoo, which was divided (Fig. 10.5.2e). The tattoo was found near

Balloon Abdomen Xray

c Selective, contrast-enhanced radiograph (through the mouth), with the round mark indicating the umbilicus d Computed tomography of the abdomen filled with gas revealed adhesion to the abdominal wall e Adhesion found by laparoscopy f Laparoscopic view after division of the adhesion. The arrow indicates the tatoo

c Selective, contrast-enhanced radiograph (through the mouth), with the round mark indicating the umbilicus d Computed tomography of the abdomen filled with gas revealed adhesion to the abdominal wall e Adhesion found by laparoscopy f Laparoscopic view after division of the adhesion. The arrow indicates the tatoo the divided site (Fig. 10.5.2f). He had a normal diet after division of the adhesion without recurrence of bowel obstruction symptoms.

Adhesive intestinal obstructions may be treated by laparotomy or laparoscopic surgery. Chopra et al. reported that laparoscopic surgery was useful and associated with less frequent complications, shorter operating time, and shorter length of hospital stay compared with laparotomy [2]. It is, however, difficult to locate precisely adhesions preoperatively. In some cases, laparoscopic surgery fails to identify the adhesion and stenosis and therefore has to be converted to laparotomy. As in this case, a tattoo placed at the stenotic site during double-balloon endoscopy serves as a useful mark for laparoscopic surgery. Preoperative double-balloon endoscopy is a therapeutic option in some patients undergoing elective division of adhesions.

■ References

1. Asakura H (1994) Blind loop syndrome. In: Domain specific syndrome series — gastrointestinal tract syndromes. Nippon Rinsho, Tokyo, pp 667-670

2. Chopra R, McVay C, Phillips E, et al (2003) Laparoscopic lysis of adhesions. Am Surg 69:966-968

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