 |
|
PRACTICE MANAGEMENT GUIDELINES
FOR SMALL BOWEL OBSTRUCTION
EAST Practice Parameter Workgroup for Management of Small Bowel Obstruction
Jose J. Diaz, Jr. MD; Co-Chair
Vanderbilt University Medical Center
Nashville, TN
E-mail: jose.diaz@vanderbilt.edu
Faran Bokhari, MD; Vice-Chair
Stroger Hospital of Cook County
Chicago, IL
fbokhari2000@yahoo.com
Nathan T. Mowery, MD
Vanderbilt University Medical Center
Nashville, TN
nate.mowery@vanderbilt.edu
Jose A. Acosta, MD
San Diego, CA
macosta@centennialpr.net
Ernest F.J, Block, MD
Orlando Regional Healthcare System
Orlando, FL
eblock@orhs.org
William J. Bromberg, MD
Memorial Health University Medical Center
Savannah, GA
brombwi1@memorialhealth.com
Bryan R. Collier, DO
Vanderbilt University Medical Center
Nashville, TN
Bryan.collier@vanderbilt.edu
Daniel C. Cullinane, MD
Mayo Clinic
Rochester, MN
cullinane.daniel@mayo.edu
Kevin M. Dwyer, MD
Inova Fairfax Hospital
Falls Church, VA
kevin.dwyer@inova.com
Margaret M. Griffen, MD
SHANDS – Jacksonville
Jacksonville, FL
maggie.griffen@jax.ufl.com
John C. Mayberry, MD
Oregon Health & Science University
Portland, OR
mayberrj@ohsu.edu
Rebecca Jerome
Vanderbilt University Medical Center
Nashville, TN
rebecca.jerome@vanderbilt.edu
Practice Management Guidelines for Small Bowel Obstruction
I. Statement of the Problem
The description of patients presenting with small bowel obstruction dates
back to the third or fourth century, when early surgeons created
enterocutaneous fistulas to relieve a bowel obstruction. Despite this
success with operative therapy, the nonoperative management of these
patients with attempted reduction of hernias, laxatives, ingestion of heavy
metals (e.g., lead or mercury), and leeches to remove toxic agents from the
blood was the rule until the late 1800s, when antisepsis and aseptic
surgical techniques made operative intervention safer and more acceptable. A
better understanding of the pathophysiology of bowel obstruction and the use
of isotonic fluid resuscitation, intestinal tube decompression, and
antibiotics have greatly reduced the mortality rate for patients with
mechanical bowel obstruction.1, 2 However, the means for determining when a
period of observation is warranted versus early surgical intervention
continues to be an area of debate. With the advances in imaging techniques
additional information can be supplied to the clinical information obtained
from the history and physical. The question of whether these technological
advancements have allowed a more sophisticated evaluation of these patients
is yet to be determined. In addition which tests supply the most information
has yet to be clearly described.
Additionally the optimal length of observation continues to be debated. In
the era of a push toward shorter hospital stays correctly identifying
patients who are to fail observation is even more important. It is important
to determine if clinical or radiographic clues can increase our sensitivity
in determining such patients.
Finally, as minimally invasive surgery grows and finds new applications are
there reproducible benefits to the patients in pursuing these intervention
as both a diagnostic and therapeutic intervention.
II. Process
A computerized search of the National Library of Medicine MEDLINE database
was undertaken using the PubMed Entrez interface. English language citations
during the period of 1991 through 2006 using the primary search strategy:
intestinal obstruction[mh] AND intestine, small[mh] AND humans[mh] NOT (case
reports[pt] OR letter[pt] OR comment[pt] OR news[pt])
Review articles were also excluded. The PubMed Related Articles algorithm
was also employed to identify additional articles similar to the items
retrieved by the primary strategy. Of approximately 550 articles identified
by these two techniques, those dealing with either prospective or
retrospective studies examining small bowel obstruction were selected,
comprising 131 institutional studies evaluating diagnosis and management of
adult patients with suspected or proven small bowel obstruction. The
articles were reviewed by a group of eleven trauma / critical care surgeons
who collaborated to produce this practice management guideline. (Table 1)
The correlation between the evidence and the level of recommendations is as
follows:
Level 1: This recommendation is convincingly justifiable based on the
available scientific information alone. It is usually based on Class I data,
however, strong Class II evidence may form the basis for a level 1
recommendation, especially if the issue does not lend itself to testing in a
randomized format. Conversely, weak or contradictory Class I data may not be
able to support a level 1 recommendation.
Level 2: This recommendation is reasonably justifiable by available
scientific evidence and strongly supported by expert critical care opinion.
It is usually supported by Class II data or a preponderance of Class III
evidence.
Level 3: This recommendation is supported by available data but adequate
scientific evidence is lacking. It is generally supported by Class III data.
This type of recommendation is useful for educational purposes and in
guiding future studies.3
III. Recommendations (Figure 1 – Flow diagram)
Diagnosis:
1. All patients being evaluated for small bowel obstruction should have
plain films due to the fact that plain films are as sensitive as CT to
differentiate obstruction vs. non-obstruction. LEVEL III
2. All patients with inconclusive plain films for complete or high grade SBO
should have a CT as CT scan gives incremental information over plain films
in regard to differentiating grade of obstruction and etiology of small
bowel obstruction leading to changes in planned management. LEVEL I
3. Multiple signs on CT suggesting strangulation should suggest a low
threshold for operative intervention (Table 2). LEVEL II
4. MRI and ultrasound are an alternative to CT with similar sensitivity and
identification of etiology, but have several logistical limitations. LEVEL
III
5. There is a variety of literature that contrast studies should be
considered in patients who fail to improve after 48 hours of conservative
management as a normal contrast study can rule out operative small bowel
obstruction. LEVEL II
6. Nonionic low osmolar weight contrast is an alternative to barium for
contrast studies to evaluate for SBO for diagnostic purposes. LEVEL I
Management:
1. Patients with plain film finding of small bowel obstruction and Clinical
markers (fever, leukocytosis, tachycardia, metabolic acidosis and continuous
pain) or peritonitis on physical exam warrant exploration. LEVEL I
2. Patients without the above mentioned clinical picture, and a partial SBO
or a complete SBO can undergo non-operative management safely; although,
complete obstruction has a higher level of failure. LEVEL I
3. Patients without resolution of the there SBO by day 3-5 of non-operative
management should undergo water soluble study or surgery. LEVEL III
4. There is no significant difference with regard to the decompression
achieved, the success of nonoperative treatment, or the morbidity rate after
surgical intervention comparing long tube decompression with the use of
nasogastric tubes. LEVEL I
5. Water soluble contrast (Gastrograffin) given in the setting of partial
SBO can improve bowel function (time to BM), decrease length of stay, and is
both therapeutic and diagnostic. LEVEL II
6. In a highly selected group of patients the laparoscopic treatment of
small bowel obstruction should be considered and leads to a shorter hospital
length of stay. LEVEL II
Scientific Foundation
A. Historical Background
Mechanical small-bowel obstruction is the most frequently encountered
surgical disorder of the small intestine. Although a wide range of
etiologies for this condition exist, intra-abdominal adhesions related to
prior abdominal surgery is the etiologic factor in up to 75% of cases of
small-bowel obstruction. More than 300,000 patients are estimated to undergo
surgery to treat adhesion-induced small-bowel obstruction in the United
States annually.4
B. Diagnostic Evaluation of Small Bowel Obstruction
The diagnostic evaluation should focus on the following goals:
distinguishing mechanical obstruction from ileus; determining the etiology
of the obstruction; discriminating partial (low grade) from complete (high
grade) obstruction; and discriminating simple from strangulating
obstruction.
Important elements to obtain on history include prior abdominal operations
(suggesting the presence of adhesions) and the presence of abdominal
disorders (e.g., intra-abdominal cancer or inflammatory bowel disease) that
may provide insights into the etiology of obstruction. Upon examination, a
meticulous search for hernias (particularly in the inguinal and femoral
regions) should be conducted. The stool should be checked for gross or
occult blood, the presence of which is suggestive of intestinal
strangulation.
Plain Films
The diagnosis of small-bowel obstruction is usually confirmed with
radiographic examination. The abdominal series consists of a radiograph of
the abdomen with the patient in a supine position, a radiograph of the
abdomen with the patient in an upright position, and a radiograph of the
chest with the patient in an upright position. There is class III evidence
to suggest that plain films are as sensitive as CT for the detection of a
high grade bowel obstruction (86% vs. 82%).5 Data also suggests that plain
films are less sensitive in the setting of low grade or partial bowel
obstruction. The sensitivity of abdominal radiographs in the detection of
small-bowel obstruction ranges from 70 to 86%.6, 7 Despite these
limitations, abdominal radiographs remain an important study in patients
with suspected small-bowel obstruction because of their widespread
availability and low cost.
Computed tomographic (CT)
There is numerous Class II data to suggest that CT provides incremental
information over other imaging forms to the level, etiology and accuracy at
differentiating low grade from high grade bowel obstruction leading to
changes in planned management.8-10 Computed tomographic (CT) scanning is 80
to 90% sensitive and 70 to 90% specific in the detection of small-bowel
obstruction.11 The findings of small-bowel obstruction include a discrete
transition zone with dilation of bowel proximally, decompression of bowel
distally, intraluminal contrast that does not pass beyond the transition
zone, and a colon containing little gas or fluid.
There is class II data to suggest that CT is 85 -100% sensitive for ischemia
and strangulation later confirmed by surgery.12-15 Ischemia was suggested on
CT with: serrated beak, unusual course of mesenteric vasculature, mesenteric
haziness, reduced wall enhancement, wall thickening, mesenteric fluid,
mesenteric venous congestion, and ascites.16-18 CT scanning also offers a
global evaluation of the abdomen and may therefore reveal the etiology of
obstruction.19-21 The global picture afforded is especially relevant when
evaluating the acute abdomen when multiple etiologies are on the
differential diagnosis.
Enteroclysis
A limitation of CT scanning is its low sensitivity (<50%) in the detection
of low-grade or partial small-bowel obstruction. A subtle transition zone or
unsuspected closed loop obstruction may be difficult to identify in the
axial images obtained during CT scanning. In such cases, contrast
examinations of the small bowel, either small-bowel series (small-bowel
follow-through) or enteroclysis, can be helpful.22 Nonionic low osmolar
weight contrast is an alternative to barium for contrast studies to evaluate
for SBO.23 These examinations are more labor intensive and less-rapidly
performed than CT scanning, but may offer greater sensitivity in the
detection of luminal and mural etiologies of obstruction, such as primary
intestinal tumors, with sensitivity and specificity approaching 100% when
coupled with CT.24 Enteroclysis is rarely performed in the acute setting,
but offers greater sensitivity than small-bowel series in the detection of
lesions that may be causing partial small-bowel obstruction.25
Ultrasound
Class II data suggests ultrasound is comparable to plain film for the
diagnosis, etiology and strangulation in small bowel obstruction and can
better identify free fluid which may signal the need for operative
intervention.26-30
MRI
Class II data reports the accuracy MRI at least approaches that of CT with
both differentiating obstruction vs no obstruction at an almost 100%
sensativity.31 MRI has also been shown to be effective in defining location
and etiology of obstruction with at least equivalent accuracy of CT.32-34
Limitations of MRI include: lack of availability after hours, poor
definition of mass lesions, and poor visualization of colonic obstructions
did not show inflammation as well as CT, and does not show viability.35, 36
C. Evaluation of the Evidence Supporting Early Operative Management
The standard therapy for small-bowel obstruction is expeditious surgery. The
rationale for this approach is to minimize the risk for bowel strangulation,
which is associated with an increased risk for morbidity and mortality. The
literature would suggest that clinical signs supported by simple imaging
studies can identify the vast majority of patients presenting with surgical
small bowel obstruction.37, 38 Early operative intervention in patients with
fever, leukocytosis, peritonitis, tachycardia, metabolic acidosis, and
continuous pain will identify strangulation 45% of the time39-41 Complete
SBO should be operated on early as the primary mode of therapy. Studies
would suggest that 31-43% of patients with complete SBO or peritonitis will
resolve without requiring some form of bowel resection. 42, 43
Other reported benefits of the operative management of SBO is the
description by class II data that reports lower reoccurrence rate and longer
disease free intervals with operative intervention when compared to
conservative management. 44-47
D. Evaluation of the Evidence Supporting Conservative Management
Exceptions to the recommendation for expeditious surgery for intestinal
obstruction include partial small-bowel obstruction, obstruction occurring
in the early postoperative period, intestinal obstruction as a consequence
of Crohn's disease, and carcinomatosis.
Progression to strangulation (3-6% with conservative management) is unlikely
to occur with partial small-bowel obstruction, and an attempt at
nonoperative resolution is warranted.48 Level II data suggests that
nonoperative management has been documented to be successful in 65 to 81% of
patients with partial small-bowel obstruction or in patients without
peritonitis. Of those successfully treated non-operatively, only 5 to 15%
have been reported to have symptoms that were not substantially improved
within 48 hours after initiation of therapy.49-52 Therefore, most patients
with partial small obstruction whose symptoms do not improve within 48 hours
after initiation of nonoperative therapy should undergo surgery. There has
been some level III data to suggest that this time period can be safely
lengthened to 5 days without increase the likelihood of strangulation
necessitating bowel resection although definite data to support these claims
is not available. Patients undergoing non-operative therapy should be
followed with serial abdominal exams for signs of peritonitis which would
necessitate immediate operative intervention.
Adjuncts to Conservative Management
Hypertonic contrast in PSBO
The administration of hypertonic water-soluble contrast agents, such as
Gastrografin used in upper GI and small-bowel follow-through examinations,
causes a shift of fluid into the intestinal lumen, thereby increasing the
pressure gradient across the site of obstruction. Level II data suggests
that this effect may speed the return of bowel function (time to bowel
movement) and decrease the length of stay of patients undergoing
non-operative management of partial small bowel obstruction.53-58
E. Operative Approach
Successful laparoscopic surgery for bowel obstruction is being reported with
greater frequency. Reported data suggest that up to 60% of small-bowel
obstruction cases caused by adhesions may be amenable to laparoscopic
therapy.59 The reported conversion rate is 20-51.9%60-67 and the
complication rate (bowel injury) is 6.5-18.0%.60, 68 Conversion to open
procedure have been reported secondary to density of adhesions, inability to
fix the obstruction, cause of obstruction not amenable to laparoscopic
therapy, intestinal necrosis, and intestinal perforation. Factors that favor
laparoscopic success are SBO post appendectomy, with bands as cause, with
less then two previous surgeries, and shorter time of symptoms.69 It has
been reported that conversion rate can be decreased to as low as 6.9% when
the surgery is guided by preoperative enteroclysis.70 The laparoscopic
treatment of small bowel obstruction appears to be effective and leads to a
shorter hospital stay in a highly selected group of patients.71, 72 There
has also been literature to support that patients treated with laparoscopic
intervention have lower hernia rate and SBO but require the same amount of
operative intervention.73 Patients fitting the criteria for consideration of
laparoscopic management include those with (1) mild abdominal distention
allowing adequate visualization, (2) a proximal obstruction, (3) a partial
obstruction, and (4) an anticipated single-band obstruction. Currently,
patients who have advanced, complete, or distal small bowel obstructions are
not candidates for laparoscopic treatment. Unfortunately, the majority of
patients with obstruction are in this group. Similarly, patients with matted
adhesions or those who remain distended after nasogastric intubation should
be managed with conventional laparotomy. Therefore, the future role of
laparoscopic procedures in the treatment of these patients remains to be
defined.
F. Adjuncts to Surgery
Antibiotics
Broad-spectrum antibiotics are commonly administered because of concerns
that bacterial translocation may occur in the setting of small-bowel
obstruction; however, there are no controlled data to support or refute this
approach.74
Long Tube
Prospective randomized trials demonstrated no significant differences with
regard to the decompression achieved, the success of nonoperative treatment,
or the morbidity rate after surgical intervention compared with the use of
nasogastric tubes. Furthermore, the use of these long tubes has been
associated with a significantly longer hospital stay, duration of
postoperative ileus, and postoperative complications in some series.
Therefore, it appears that long intestinal tubes offer no benefit in the
preoperative setting over nasogastric tubes.75, 76
Hyaluronic acid-carboxycellulose membrane (Seprafilm)
The overall rate of post-operative SBO showed no difference with or without
Seprafilm. However, Seprafilm did have lower (1.8 vs 3.4%) of SBO requiring
reoperation.77-80
V. Summary
To summarize, plain abdominal radiographs are usually diagnostic of bowel
obstruction in more than 60% of the cases, but further evaluation (possibly
by CT or barium radiography) may be necessary in 20% to 30% of cases. CT
examination is particularly useful in patients with a history of abdominal
malignancy, in postsurgical patients, and in patients who have no history of
abdominal surgery and present with symptoms of bowel obstruction. Barium
studies are recommended in patients with a history of recurring obstruction
or low-grade mechanical obstruction to precisely define the obstructed
segment and degree of obstruction.
VI. Future Investigations
Future studies should be conducted in a prospective, randomized fashion
concentrating on the timing of operative intervention for small bowel
obstruction.
REFERENCES
1. Hartwell JA and Hoguet JP. Experimental intestinal obstruction in dogs
with special reference to the cause of death and the treatment by large
amounts of normal saline solution. JAMA 59, 82-87. 1912.
Ref Type: Abstract
2. Wangensteen OH. Historical aspects of the management of acute intestinal
obstruction. Surgery. 1969;65:363-383.
3. PRACTICE MANAGEMENT GUIDELINES FOR TRAUMA EAST AD HOC COMMITTEE ON
GUIDELINE DEVELOPMENT. 1-23-0098.
Ref Type: Conference Proceeding
4. Ray NF, Denton WG, Thamer M, Henderson SC, Perry S. Abdominal
adhesiolysis: inpatient care and expenditures in the United States in 1994.
J Am Coll Surg. 1998;186:1-9.
5. Maglinte DD, Reyes BL, Harmon BH et al. Reliability and role of plain
film radiography and CT in the diagnosis of small-bowel obstruction. AJR Am
J Roentgenol %1996 Dec ;167 (6 ):1451 -5.
6. Maglinte DD, Heitkamp DE, Howard TJ, Kelvin FM, Lappas JC. Current
concepts in imaging of small bowel obstruction. Radiol Clin North Am.
2003;41:263-83, vi.
7. Suri S, Gupta S, Sudhakar PJ, Venkataramu NK, Sood B, Wig JD. Comparative
evaluation of plain films, ultrasound and CT in the diagnosis of intestinal
obstruction. Acta Radiol %1999 Jul ;40 (4):422 -8.
8. Daneshmand S, Hedley CG, Stain SC. The utility and reliability of
computed tomography scan in the diagnosis of small bowel obstruction. Am
Surg %1999 Oct ;65 (10):922 -6.
9. Suri S, Gupta S, Sudhakar PJ, Venkataramu NK, Sood B, Wig JD. Comparative
evaluation of plain films, ultrasound and CT in the diagnosis of intestinal
obstruction. Acta Radiol %1999 Jul ;40 (4):422 -8.
10. Taourel PG, Fabre JM, Pradel JA, Seneterre EJ, Megibow AJ, Bruel JM.
Value of CT in the diagnosis and management of patients with suspected acute
small-bowel obstruction. AJR Am J Roentgenol %1995 Nov ;165 (5):1187 -92.
11. Maglinte DD, Heitkamp DE, Howard TJ, Kelvin FM, Lappas JC. Current
concepts in imaging of small bowel obstruction. Radiol Clin North Am.
2003;41:263-83, vi.
12. Daneshmand S, Hedley CG, Stain SC. The utility and reliability of
computed tomography scan in the diagnosis of small bowel obstruction. Am
Surg %1999 Oct ;65 (10):922 -6.
13. Makita O, Ikushima I, Matsumoto N, Arikawa K, Yamashita Y, Takahashi M.
CT differentiation between necrotic and nonnecrotic small bowel in closed
loop and strangulating obstruction. Abdom Imaging %1999 Mar -Apr;24 (2):120
-4.
14. Obuz F, Terzi C, Sokmen S, Yilmaz E, Yildiz D, Fuzun M. The efficacy of
helical CT in the diagnosis of small bowel obstruction. Eur J Radiol %2003
Dec ;48 (3):299 -304.
15. Zalcman M, Sy M, Donckier V, Closset J, Gansbeke DV. Helical CT signs in
the diagnosis of intestinal ischemia in small-bowel obstruction. AJR Am J
Roentgenol %2000 Dec ;175 (6 ):1601 -7.
16. Obuz F, Terzi C, Sokmen S, Yilmaz E, Yildiz D, Fuzun M. The efficacy of
helical CT in the diagnosis of small bowel obstruction. Eur J Radiol %2003
Dec ;48 (3):299 -304.
17. Zalcman M, Sy M, Donckier V, Closset J, Gansbeke DV. Helical CT signs in
the diagnosis of intestinal ischemia in small-bowel obstruction. AJR Am J
Roentgenol %2000 Dec ;175 (6 ):1601 -7.
18. Ha HK, Kim JS, Lee MS et al. Differentiation of simple and strangulated
small-bowel obstructions: usefulness of known CT criteria. Radiology %1997
Aug ;204 (2):507 -12.
19. Lappas JC, Reyes BL, Maglinte DD. Abdominal radiography findings in
small-bowel obstruction: relevance to triage for additional diagnostic
imaging. AJR Am J Roentgenol %2001 Jan ;176 (1):167 -74.
20. Maglinte DD, Heitkamp DE, Howard TJ, Kelvin FM, Lappas JC. Current
concepts in imaging of small bowel obstruction. Radiol Clin North Am.
2003;41:263-83, vi.
21. Suri S, Gupta S, Sudhakar PJ, Venkataramu NK, Sood B, Wig JD.
Comparative evaluation of plain films, ultrasound and CT in the diagnosis of
intestinal obstruction. Acta Radiol %1999 Jul ;40 (4):422 -8.
22. Maglinte DD, Nolan DJ, Herlinger H. Preoperative diagnosis by
enteroclysis of unsuspected closed loop obstruction in medically managed
patients. J Clin Gastroenterol %1991 Jun ;13(3):308 -12.
23. Sandikcioglu TG, Torp-Madsen S, Pedersen IK, Raaschou K, Mygind T,
Thomsen HS. Contrast radiography in small bowel obstruction. A randomized
trial of barium sulfate and a nonionic low-osmolar contrast medium. Acta
Radiol %1994 Jan ;35 (1):62 -4.
24. Boudiaf M, Jaff A, Soyer P, Bouhnik Y, Hamzi L, Rymer R. Small-bowel
diseases: prospective evaluation of multi-detector row helical CT
enteroclysis in 107 consecutive patients. Radiology %2004 Nov ;233 (2):338
-44 Epub 2004 Sep 30.Epub.
25. Boudiaf M, Jaff A, Soyer P, Bouhnik Y, Hamzi L, Rymer R. Small-bowel
diseases: prospective evaluation of multi-detector row helical CT
enteroclysis in 107 consecutive patients. Radiology %2004 Nov ;233 (2):338
-44 Epub 2004 Sep 30.Epub.
26. Czechowski J. Conventional radiography and ultrasonography in the
diagnosis of small bowel obstruction and strangulation. Acta Radiol %1996
Mar ;37 (2):186 -9.
27. Grassi R, Romano S, D'Amario F et al. The relevance of free fluid
between intestinal loops detected by sonography in the clinical assessment
of small bowel obstruction in adults. Eur J Radiol %2004 Apr;50 (1):5-14.
28. Ko YT, Lim JH, Lee DH, Lee HW, Lim JW. Small bowel obstruction:
sonographic evaluation. Radiology %1993 Sep ;188 (3):649 -53.
29. Schmutz GR, Benko A, Fournier L, Peron JM, Morel E, Chiche L. Small
bowel obstruction: role and contribution of sonography. Eur Radiol %1997 ;7
(7 ):1054 -8.
30. Suri S, Gupta S, Sudhakar PJ, Venkataramu NK, Sood B, Wig JD.
Comparative evaluation of plain films, ultrasound and CT in the diagnosis of
intestinal obstruction. Acta Radiol %1999 Jul ;40 (4):422 -8.
31. Kim JH, Ha HK, Sohn MJ et al. Usefulness of MR imaging for diseases of
the small intestine: comparison with CT. Korean J Radiol %2000 Jan -Mar
;1(1):43 -50.
32. Beall DP, Fortman BJ, Lawler BC, Regan F. Imaging bowel obstruction: a
comparison between fast magnetic resonance imaging and helical computed
tomography. Clin Radiol %2002 Aug ;57 (8 ):719 -24.
33. Kim JH, Ha HK, Sohn MJ et al. Usefulness of MR imaging for diseases of
the small intestine: comparison with CT. Korean J Radiol %2000 Jan -Mar
;1(1):43 -50.
34. Regan F, Beall DP, Bohlman ME, Khazan R, Sufi A, Schaefer DC. Fast MR
imaging and the detection of small-bowel obstruction. AJR Am J Roentgenol
%1998 Jun ;170 (6 ):1465 -9.
35. Regan F, Beall DP, Bohlman ME, Khazan R, Sufi A, Schaefer DC. Fast MR
imaging and the detection of small-bowel obstruction. AJR Am J Roentgenol
%1998 Jun ;170 (6 ):1465 -9.
36. Beall DP, Fortman BJ, Lawler BC, Regan F. Imaging bowel obstruction: a
comparison between fast magnetic resonance imaging and helical computed
tomography. Clin Radiol %2002 Aug ;57 (8 ):719 -24.
37. Bogusevicius A, Maleckas A, Pundzius J, Skaudickas D. Prospective
randomised trial of computer-aided diagnosis and contrast radiography in
acute small bowel obstruction. Eur J Surg %2002 ;168 (2):78 -83.
38. Kim JH, Ha HK, Kim JK et al. Usefulness of known computed tomography and
clinical criteria for diagnosing strangulation in small-bowel obstruction:
analysis of true and false interpretation groups in computed tomography.
World J Surg %2004 Jan ;28 (1):63 -8 Epub 2003 Dec 4.Epub.
39. Fevang BT, Jensen D, Svanes K, Viste A. Early operation or conservative
management of patients with small bowel obstruction? Eur J Surg %2002 ;168
(8 -9 ):475 -81.
40. Takeuchi K, Tsuzuki Y, Ando T et al. Clinical studies of strangulating
small bowel obstruction. Am Surg %2004 Jan ;70 (1):40 -4.
41. Tsumura H, Ichikawa T, Hiyama E, Murakami Y, Sueda T. Systemic
inflammatory response syndrome (SIRS) as a predictor of strangulated small
bowel obstruction. Hepatogastroenterology %2004 Sep -Oct ;51 (59 ):1393 -6.
42. Fevang BT, Jensen D, Svanes K, Viste A. Early operation or conservative
management of patients with small bowel obstruction? Eur J Surg %2002 ;168
(8 -9 ):475 -81.
43. Nauta RJ. Advanced abdominal imaging is not required to exclude
strangulation if complete small bowel obstructions undergo prompt
laparotomy. J Am Coll Surg %2005 Jun ;200 (6 ):904 -11.
44. Fevang BT, Fevang J, Lie SA, Soreide O, Svanes K, Viste A. Long-term
prognosis after operation for adhesive small bowel obstruction. Ann Surg
%2004 Aug ;240 (2):193 -201.
45. Landercasper J, Cogbill TH, Merry WH, Stolee RT, Strutt PJ. Long-term
outcome after hospitalization for small-bowel obstruction. Arch Surg %1993
Jul ;128 (7 ):765 -70.discussion.
46. Miller G, Boman J, Shrier I, Gordon PH. Natural history of patients with
adhesive small bowel obstruction. Br J Surg %2000 Sep ;87 (9 ):1240 -7.
47. Williams SB, Greenspon J, Young HA, Orkin BA. Small bowel obstruction:
conservative vs. surgical management. Dis Colon Rectum %2005 Jun ;48 (6
):1140 -6.
48. Fevang BT, Jensen D, Svanes K, Viste A. Early operation or conservative
management of patients with small bowel obstruction? Eur J Surg %2002 ;168
(8 -9 ):475 -81.
49. Brolin RE, Krasna MJ, Mast BA. Use of tubes and radiographs in the
management of small bowel obstruction. Ann Surg. 1987;206:126-133.
50. Peetz DJ, Jr., Gamelli RL, Pilcher DB. Intestinal intubation in acute,
mechanical small-bowel obstruction. Arch Surg. 1982;117:334-336.
51. Cox MR, Gunn IF, Eastman MC, Hunt RF, Heinz AW. The safety and duration
of non-operative treatment for adhesive small bowel obstruction. Aust N Z J
Surg %1993 May ;63 (5):367 -71.
52. Fevang BT, Jensen D, Svanes K, Viste A. Early operation or conservative
management of patients with small bowel obstruction? Eur J Surg %2002 ;168
(8 -9 ):475 -81.
53. Assalia A, Schein M, Kopelman D, Hirshberg A, Hashmonai M. Therapeutic
effect of oral Gastrografin in adhesive, partial small-bowel obstruction: a
prospective randomized trial. Surgery %1994 Apr;115 (4):433 -7.
54. Burge J, Abbas SM, Roadley G et al. Randomized controlled trial of
Gastrografin in adhesive small bowel obstruction. Anz J Surg %2005 Aug ;75
(8 ):672 -4.
55. Choi HK, Chu KW, Law WL. Therapeutic value of gastrografin in adhesive
small bowel obstruction after unsuccessful conservative treatment: a
prospective randomized trial. Ann Surg %2002 Jul ;236 (1):1-6.
56. Choi HK, Law WL, Ho JW, Chu KW. Value of gastrografin in adhesive small
bowel obstruction after unsuccessful conservative treatment: a prospective
evaluation. World J Gastroenterol %2005 Jun 28 ;11(24 ):3742 -5.
57. Fevang BT, Jensen D, Fevang J et al. Upper gastrointestinal contrast
study in the management of small bowel obstruction--a prospective randomised
study. Eur J Surg %2000 Jan ;166 (1):39 -43.
58. Yagci G, Kaymakcioglu N, Can MF, Peker Y, Cetiner S, Tufan T. Comparison
of Urografin versus standard therapy in postoperative small bowel
obstruction. J Invest Surg %2005 Nov -Dec ;18 (6 ):315 -20.
59. Fischer CP, Doherty D. Laparoscopic approach to small bowel obstruction.
Semin Laparosc Surg. 2002;9:40-45.
60. Borzellino G, Tasselli S, Zerman G, Pedrazzani C, Manzoni G.
Laparoscopic approach to postoperative adhesive obstruction. Surg Endosc
%2004 Apr;18 (4):686 -90 Epub 2004 Mar %19. 1919.
61. Chopra R, Mcvay C, Phillips E, Khalili TM. Laparoscopic lysis of
adhesions. Am Surg %2003 Nov ;69 (11):966 -8.
62. Leon EL, Metzger A, Tsiotos GG, Schlinkert RT, Sarr MG. Laparoscopic
management of small bowel obstruction: indications and outcome. J
Gastrointest Surg %1998 Mar -Apr;2(2):132 -40.
63. Levard H, Boudet MJ, Msika S et al. Laparoscopic treatment of acute
small bowel obstruction: a multicentre retrospective study. Anz J Surg %2001
Nov ;71 (11):641 -6.
64. Wullstein C, Gross E. Laparoscopic compared with conventional treatment
of acute adhesive small bowel obstruction. Br J Surg %2003 Sep ;90 (9 ):1147
-51.
65. Liauw JJ, Cheah WK. Laparoscopic management of acute small bowel
obstruction. Asian J Surg %2005 Jul ;28 (3):185 -8.
66. Suzuki K, Umehara Y, Kimura T. Elective laparoscopy for small bowel
obstruction. Surg Laparosc Endosc Percutan Tech %2003 Aug ;13(4):254 -6.
67. Tsumura H, Ichikawa T, Murakami Y, Sueda T. Laparoscopic adhesiolysis
for recurrent postoperative small bowel obstruction. Hepatogastroenterology
%2004 Jul -Aug ;51 (58 ):1058 -61.
68. Chopra R, Mcvay C, Phillips E, Khalili TM. Laparoscopic lysis of
adhesions. Am Surg %2003 Nov ;69 (11):966 -8.
69. Levard H, Boudet MJ, Msika S et al. Laparoscopic treatment of acute
small bowel obstruction: a multicentre retrospective study. Anz J Surg %2001
Nov ;71 (11):641 -6.
70. Suter M, Zermatten P, Halkic N, Martinet O, Bettschart V. Laparoscopic
management of mechanical small bowel obstruction: are there predictors of
success or failure? Surg Endosc %2000 May ;14(5):478 -83.
71. Leon EL, Metzger A, Tsiotos GG, Schlinkert RT, Sarr MG. Laparoscopic
management of small bowel obstruction: indications and outcome. J
Gastrointest Surg %1998 Mar -Apr;2(2):132 -40.
72. Strickland P, Lourie DJ, Suddleson EA, Blitz JB, Stain SC. Is
laparoscopy safe and effective for treatment of acute small-bowel
obstruction? Surg Endosc %1999 Jul ;13(7 ):695 -8.
73. Duepree HJ, Senagore AJ, Delaney CP, Fazio VW. Does means of access
affect the incidence of small bowel obstruction and ventral hernia after
bowel resection? Laparoscopy versus laparotomy. J Am Coll Surg %2003 Aug
;197 (2):177 -81.
74. Sagar PM, MacFie J, Sedman P, May J, Mancey-Jones B, Johnstone D.
Intestinal obstruction promotes gut translocation of bacteria. Dis Colon
Rectum %1995 Jun ;38 (6 ):640 -4.
75. Meissner K. Effectiveness of intestinal tube splinting: a prospective
observational study. Dig Surg %2000 ;17(1):49 -56.
76. Meissner K. Small bowel obstruction following extended right
hemicolectomy and subtotal colectomy: assessing the benefit of prophylactic
tube splinting. Dig Surg %2001 ;18 (5):388 -92.
77. Fazio VW, Cohen Z, Fleshman JW et al. Reduction in adhesive small-bowel
obstruction by Seprafilm adhesion barrier after intestinal resection. Dis
Colon Rectum %2006 Jan ;49 (1):1-11.
78. Kudo FA, Nishibe T, Miyazaki K, Murashita T, Nishibe M, Yasuda K. Use of
bioresorbable membrane to prevent postoperative small bowel obstruction in
transabdominal aortic aneurysm surgery. Surg Today %2004;34 (8 ):648 -51.
79. Kudo FA, Nishibe T, Miyazaki K, Murashita T, Nishibe M, Yasuda K. Use of
bioresorbable membrane to prevent postoperative small bowel obstruction in
transabdominal aortic aneurysm surgery. Surg Today %2004;34 (8 ):648 -51.
80. Mohri Y, Uchida K, Araki T et al. Hyaluronic acid-carboxycellulose
membrane (Seprafilm) reduces early postoperative small bowel obstruction in
gastrointestinal surgery. Am Surg %2005 Oct ;71 (10):861 -3.
Evidentiary Tables
Practice Management Guidelines
for Management of Small Bowel Obstruction in the Setting of Previous
Abdominal Surgery
1991 – Present
|
First Author |
Year |
Reference
Title |
Class |
Conclusions |
|
Diagnosis – Plain Film/KUB |
|
Lappas JC |
2001 |
Abdominal
radiography findings in small-bowel obstruction: relevance to triage
for additional diagnostic imaging. AJR Am J Roentgenol. 2001
Jan;176(1):167-74. |
III |
(N=81;
retrospective) Plain films help differentiate low grade from high
grade but CT gives incremental and needed if plain film was
inconclusive |
|
Maglinte DD |
1997 |
Reliability and
role of plain film radiography and CT in the diagnosis of
small-bowel obstruction. AJR Am J Roentgenol. 1996
Dec;167(6):1451-5. |
III |
Plain films and
CT have equal sensitivity for grade of obstruction. They recommend
plain films initially on all suspected SBO with CT as a follow-up if
needed for clinical purposes. |
|
Diagnosis -CT |
|
Bogusevicius A |
2002 |
Prospective
randomised trial of computer-aided diagnosis and contrast
radiography in acute small bowel obstruction. Eur J Surg.
2002;168(2):78-83. |
I |
Computer program
that differentiates between complete and partial SBO when 36
clinical variables, including the plain radiographic findings, are
entered, but the time to diagnosis was only 1 hour with the computer
program and 16 hours with contrast radiography. |
|
Zalcman M |
2000 |
Helical CT signs
in the diagnosis of intestinal ischemia in small-bowel obstruction.
AJR Am J Roentgenol. 2000 Dec;175(6):1601-7. |
II |
(N=144:
retrospective) They specifically looked for reduced wall
enhancement, wall thickening, mesenteric fluid mesenteric venous
congestion, and ascites in order to determine presence of ischemia.
Strangulation was prospectively diagnosed if reduced wall
enhancement or 2 of the other 4 signs were present. |
|
Lazarus DE |
2004 |
Frequency and
relevance of the "small-bowel feces" sign on CT in patients with
small-bowel obstruction.
AJR Am J
Roentgenol. 2004 Nov;183(5):1361-6. |
II |
(N=34:
retrospective) The feces sign helped identify the point of
obstruction and was more likely in higher degrees of obstruction.
|
|
Obuz F |
2003 |
The efficacy of
helical CT in the diagnosis of small bowel obstruction.
Eur J Radiol.
2003 Dec;48(3):299-304. |
II |
(N=41;
Prospective) Helical CT (1998-2001) CT was 83% accurate in
differentiating obstruction vs non-obstruction, 85% accurate in
determining cause, and 100% accurate in determining
strangulation/ischemia. |
|
Suri S |
1999 |
Comparative
evaluation of plain films, ultrasound and CT in the diagnosis of
intestinal obstruction.
Acta Radiol.
1999 Jul;40(4):422-8. |
II |
(N=32;
Prospective) Suspected SBO who had plain radiographs, US and CT scan
(1990-93). Plain radiography was 75% accurate, US was 84% accurate,
and CT was 94% accurate at determining obstruction vs no
obstruction. Level of obstruction 60%, 70%, and 93%. Cause of
obstruction 7%, 23%, and 87%. |
|
Taourel PG |
1995 |
Value of CT in
the diagnosis and management of patients with suspected acute
small-bowel obstruction. AJR Am J Roentgenol. 1995
Nov;165(5):1187-92. |
II |
(N=57;
Prospective) Patients with suspicion of SBO (1991 - 1994). The
surgeon was interviewed prior to the CT scan. In 33 pts the
clinician wanted to differentiate between SBO or ileus and in 24 pts
the clinician wanted to know the cause of SBO. CT correctly changed
the differentiation between SBO & ileus in 21% of cases. CT changed
the diagnosis (cause) of SBO in 43% and correctly changed presence
or absence of strangulation in 23. |
|
Catalano O |
1997 |
The faeces sign.
A CT finding in small-bowel obstruction.
Radiologe.
1997 May;37(5):417-9. |
III |
(N=94;
Retrospective) Feces sign was only present in 7% of cases, only 1 of
which had strangulation. |
|
Chou CK |
2000 |
Differentiation
of obstructive from non-obstructive small bowel dilatation on CT.
Eur J Radiol.
2000 Sep;35(3):213-20. |
III |
(N=146;
Retrospective) Evaluated 4 criteria: continuity of proximal SB,
transition zone, intraluminal fluid, & colonic contents. The
probability of true obstruction was calculated for each sign.
Continuity 69%, Transition zone abrupt 80%, high amount of SB fluid
79%, minimal colonic contents 90%. |
|
Daneshmand S |
1999 |
The utility and
reliability of computed tomography scan in the diagnosis of small
bowel obstruction.
Am Surg. 1999
Oct;65(10):922-6. |
III |
Retrospective
study of 103 pts (1997-8) with suspected SBO. Comparison of plain
radiographs with CT in determining partial vs complete SBO and in
determining cause. Plain films were 75% sensitive and 53% specific
for partial vs complete. CT was 92% sensitive and 71% specific.
Cause was correctly determined or inferred to be adhesions by CT in
91% of cases. |
|
Gollub MJ |
2006 |
Does the CT
whirl sign really predict small bowel volvulus?: Experience in an
oncologic population.
J Comput
Assist Tomogr. 2006 Jan-Feb;30(1):25-32. |
III |
Retrospective
analysis of 1200+ CT scans of pts with suspected SBO at a cancer
center. Whirl sign was found in 33 pts by a senior radiologist and
14 pts by a senior radiology resident. The whirl sign had a
sensitivity of 64% for volvulus by the senior radiologist and much
less by the resident. They concluded that the whirl sign is a
relatively poor predictor of volvulus in this population |
|
Ha HK |
1997 |
Differentiation
of simple and strangulated small-bowel obstructions: usefulness of
known CT criteria.
Radiology.
1997 Aug;204(2):507-12. |
III |
(N=84;
Retrospective) Patients with known outcomes, simple vs strangulated
SBO (1991-1996). They identified 6 CT findings as best at
determining strangulation: reduced wall enhancement, serrated beak,
ascites, and unusual course of mesenteric vasculature, mesenteric
haziness, and mesenteric venous engorgement. Using these signs they
were able to find 85% of strangulations |
|
Jaffe TA |
2006 |
Small-bowel
obstruction: coronal reformations from isotropic voxels at
16-section multi-detector row CT.
Radiology.
2006 Jan;238(1):135-42. Epub 2005 Nov 17. |
III |
Retrospective
analysis of added value of coronal reformations (2003-4) in 100 pts
with suspected SBO. Coronal images added confidence to the three
reader’s diagnostic accuracy of obstruction vs no obstruction. |
|
Kim JH |
2004 |
Usefulness of
known computed tomography and clinical criteria for diagnosing
strangulation in small-bowel obstruction: analysis of true and false
interpretation groups in computed tomography.
World J Surg.
2004 Jan;28(1):63-8. |
III |
Retrospective
study of 146 CTs looking for strangulation vs no strangulation
(1992-98). Three radiologists were 72% - 82% accurate in
determining strangulation. The four clinical criteria, fever,
tenderness, tachycardia, leukocytosis, without CT findings were
equally accurate, however! |
|
Makita O |
1999 |
CT
differentiation between necrotic and nonnecrotic small bowel in
closed loop and strangulating obstruction.
Abdom
Imaging. 1999 Mar-Apr;24(2):120-4. |
III |
Retrospective
analysis of CT findings differentiating necrosis from non-necrosis
in 25 pts with proven strangulation. Findings predictive of
necrosis were: ascites, vascular dilatation, mesenteric
attenuation, and radial distribution, but mesenteric attenuation was
most predictive. |
|
Diagnosis –MRI |
|
Beall DP |
2002 |
Imaging bowel
obstruction: a comparison between fast magnetic resonance imaging
and helical computed tomography.
Clin Radiol.
2002 Aug;57(8):719-24. |
II |
Prospective
comparison of helical CT (oral/IV contrast) with ultrafast HASTE MRI
in 44 pts with suspected SBO (1997 -1998). Findings: CT (71%,
Sensitivity; 71% Specificity) MR (95% sensitivity; 100%
Specificity). in differentiating obstruction vs no obstruction. No
mention of differentiating high-grade vs low grade obstruction.
Limitations of MRI include lack of availability after hours, poor
definition of cause of obstruction, and poor visualization of
colonic obstructions. |
|
Kim JH |
2000 |
Usefulness of MR
imaging for diseases of the small intestine: comparison with CT.
Korean J
Radiol. 2000 Jan-Mar;1(1):43-50. |
III |
Prospective
comparison of helical CT (oral/IV contrast) with HASTE MRI in 34 pts
with a variety of SB diseases (1996 - 1999). 15 pts had suspected
SBO. MRI and CT were both 100% accurate in diagnosing or excluding
SBO. MRI was better at determining the precise cause of obstruction
(73% v 60%). MRI poor at looking at omentum. |
|
Lee JK |
1998 |
MR imaging of
the small bowel using the HASTE sequence.
AJR Am J
Roentgenol. 1998 Jun;170(6):1457-63. |
III |
MR with HASTE
sequence can distinguish between normal small bowel and abnormal
small bowel. Motion did not affect these studies |
|
Regan F |
1998 |
Fast MR imaging
and the detection of small-bowel obstruction.
AJR Am J
Roentgenol. 1998 Jun;170(6):1465-9. |
III |
HASTE MR can be
highly accurate in diagnosing SBO and identifying the level of
obstruction 26/29 patients with SBO were said to have been correctly
identified by HASTE MR (sensitivity 90%, specificity 86%) and 73%
had the correct level of obstruction identified. Limitations
identified include: absence of dilation in situations where
prolonged NG suction has been employed, MRI is not good at
identifying masses including malignancies, did not show inflammation
as good as CT, and does not show viability.
|
|
Diagnosis –Ultrasound |
|
Schmutz GR |
1997 |
Small bowel
obstruction: role and contribution of sonography.
Eur Radiol.
1997;7(7):1054-8. |
II |
Ultrasound was
performed on 123 patients who were evaluated for small bowel
obstruction. Of these patients14 had too much gas on initial
evaluation and the study was not concluded. Overall accuracy was
81%. Determination of location of obstruction was 80% accurate in
the true positives. Determination of cause of obstruction was 63%
accurate in the true positives. The studies were performed by an
experienced radiologist. Ultrasound was better in identifying the
cause of obstruction than plain films. |
|
Czechowski J
|
1996 |
Conventional
radiography and ultrasonography in the diagnosis of small bowel
obstruction and strangulation. Acta Radiol. 1996 Mar;37(2):186-9. |
III |
Retrospective
review of 96 pts (1992-1993) who had acute abdomen and conventional
radiography was not diagnostic. The study compares plain
radiography versus ultrasound in patients with suspected small bowel
obstruction. The authors claim that US added information such as
the location of the obstruction and whether strangulation was
present (absence of peristalsis, extraluminal fluid). |
|
Grassi R |
2004 |
The relevance of
free fluid between intestinal loops detected by sonography in the
clinical assessment of small bowel obstruction in adults. Eur J
Radiol. 2004 Apr;50(1):5-14. |
III |
Retrospective
review of 184 patients (2002) in whom SBO was eventually confirmed.
These pts all had both plain films and US. Purpose of the study was
to determine if intraperitoneal fluid was helpful in differentiating
high-grade vs low-grade obstruction. The authors report that US was
100% accurate in finding free fluid but in 34 pts (20%), the free
fluid was explained by medical causes. When these pts were excluded
from analysis, surgery confirmed free fluid and either thin walled
small bowel or impending necrosis in all pts. |
|
Ko YT |
1993 |
Small bowel
obstruction: sonographic evaluation. Radiology. 1993
Sep;188(3):649-53. |
III |
Retrospective
review of 54 pts with known or suspected BO (1987 – 1992). Pts had
already had plain films except for 2 pregnant pts. SBO was
correctly diagnosed in 89%. Level of obstruction was correctly
predicted in 76%. Cause of obstruction 20%. Ultrasound is better
than plain film but does not show strangulation well. |
|
Diagnosis –Enteroclysis |
|
Boudiaf M |
2004 |
Small-bowel
diseases: prospective evaluation of multi-detector row helical CT
enteroclysis in 107 consecutive patients.
Radiology.
2004 Nov;233(2):338-44. |
II |
CT enteroclysis
is well tolerated reliable imaging allows detection of extraluminal
disease. Should be routine for patients with low grade obstruction
in a non-acute setting. |
|
Umschaden HW |
2000 |
Small-bowel
disease: comparison of MR enteroclysis images with conventional
enteroclysis and surgical findings.
Radiology.
2000 Jun;215(3):717-25. |
II |
MR enteroclysis
was performed on 18 patients with inflammatory disease and 12
patients with small bowel obstruction. Findings between
conventional and MR enteroclysis had a high concordance rate.
|
|
Barloon TJ
|
1994 |
Does a normal
small-bowel enteroclysis exclude small-bowel disease? A long-term
follow-up of consecutive normal studies.
Abdom
Imaging. 1994 Mar-Apr;19(2):113-5. |
III |
Enterocolysis
accurately shows closed loop obstruction in 25/27 patients.
|
|
Maglinte DD
|
1991 |
Preoperative
diagnosis by enteroclysis of unsuspected closed loop obstruction in
medically managed patients.
J Clin
Gastroenterol. 1991 Jun;13(3):308-12. |
III |
Retrospective
study of 27 patients who were found to have closed loop obstruction
on conventional enteroclysis performed 2-8 after admission for small
bowel obstruction. Of these patients, 25 were taken to the
operating room and found the have a non-strangulated closed loop
obstruction. |
|
Diagnosis – Contrast Studies |
|
Anderson CA |
1997 |
Contrast
radiography in small bowel obstruction: a prospective, randomized
trial.
Mil Med. 1997
Nov;162(11):749-52. |
I |
Prospective
randomized study comparing early barium UGI versus plain radiography
in patients admitted for small bowel obstruction. The results did
not show any difference in time to surgery, complications or length
of stay between groups. But, barium study correctly differentiated
between operative and non-operative SBO. |
|
Blackmon S |
2000 |
The
use of water-soluble contrast in evaluating clinically equivocal
small bowel obstruction.
Am Surg. 2000 Mar;66(3):238-42; discussion 242-4. |
III |
(418
patients: retrospective)The study looks at the use of gastograffin
transit time to help in the diagnosis of patients admitted for with
a diagnosis of small bowel obstruction. Patients are given
gastrograffin and undergo serial abdominal films. If the contrast
does not reach the colon in 6 hours the study is said to be
positive. One of the problems with this study is that close to 50%
(65) of patients with a positive study did not require surgery. 2
deaths from gastrografin aspiration. |
|
Brochwicz-Lewinski MJ |
2003 |
Small bowel obstruction--the water-soluble follow-through revisited.
Clin Radiol. 2003 May;58(5):393-7. |
I |
Prospective randomized
study of patients with suspected small bowel obstruction who were
divided in two groups based on if they had an upper gi with small
bowel follow through(SBFT) or not. The group with the SBFT had a
lower incidence of operation but this difference did not achieve
statistical difference. The length of stay was not affected by the
SBFT. The patients were randomized and the surgeons changed their
clinical management plan based on the results.
|
|
Makanjuola D. |
1998 |
Computed tomography compared with small bowel enema in clinically
equivocal intestinal obstruction.
Clin Radiol. 1998 Mar;53(3):203-8. |
III |
49
pts had both CT and ‘small bowel enema’. 43/49 pts had definite
intestinal obstruction (42 per surgery). SBE was more sensitive in
detecting Bowel obstruction than CT (100% vs 83%). The 7 missed by
CT had short segment stenosis.
Conclusion: In clinically suspicious cases of obstruction where CT
is neg, use SBE |
|
Sandikcioglu TG |
1994 |
Contrast radiography in small bowel obstruction. A randomized trial
of barium sulfate and a nonionic low-osmolar contrast medium.
Acta Radiol. 1994 Jan;35(1):62-4. |
I |
Nonionic low osmolar weight contrast is an alternative to barium for
contrast studies to evaluate for SBO.
|
|
Chung CC |
1996 |
A prospective
study on the use of water-soluble contrast follow-through radiology
in the management of small bowel obstruction.
Aust N Z J Surg. 1996
Sep;66(9):598-601. |
II |
Safe
procedure, early surgery should occur if patients have “significant
obstruction” (contrast doesn’t reach cecum in 4 hours) and a 4 hour
cutoff for contrast reaching the cecum in predictive of outcome for
SBO in those with history of surgery. |
|
Joyce WP
|
1992 |
The value of
water-soluble contrast radiology in the management of acute small
bowel obstruction.
Ann R Coll
Surg Engl. 1992 Nov;74(6):422-5. |
II |
Water-soluble contrast study is safe and easy to use and diagnostic
study of choice for suspected SBO. Normal contrast study can rule
out operative SBO. |
|
Peck JJ |
1999 |
The role of
computed tomography with contrast and small bowel follow-through in
management of small bowel obstruction.
Am J Surg.
1999 May;177(5):375-8.
|
III |
With
equivocal findings of SBO first CT and then SBFT should be used. The
combined sensitivity and specificity are 95% and 86% respectively,
higher than those of each alone.
|
|
Enochsson L |
2001 |
Contrast
radiography in small intestinal obstruction, a valuable diagnostic
tool?
Eur J Surg.
2001 Feb;167(2):120-4. |
III |
The
outcome of oral contrast studies can be predicted by plain
radiographs. Contrast studies are safe and may be therapeutic.
|
|
Dixon PM
|
1993 |
The small bowel
enema: a ten year review.
Clin Radiol.
1993 Jan;47(1):46-8. |
III |
Routine use of small bowel enema in evaluation of patients with
suspected small bowel pathology demonstrates a very high sensitivity
(93.1%) and specificity (96.9%) and obstruction had a sensitivity of
98%. |
|
Conservative Management – General Considerations |
|
Conservative Management – Clinical Indicators/Time Period |
|
Miller G |
2000 |
Natural history
of patients with adhesive small bowel obstruction.
Br J Surg.
2000 Sep;87(9):1240-7. |
III |
Patients are never free of risk for post-op obs 2nd to
adhesions (14% present >20 yrs post-op). Rate of recurrence was 33%
overall (32% for operation, 34% (NS) for cons. Mgmt), each
recurrence raised risk of future recurrence. Colorectal procedures
were more likely to result in matted adhesions v. single bands and
result in more readmits. Recurrence rates b/w op and non-op were
similar. |
|
Nauta RJ |
2005 |
Advanced
abdominal imaging is not required to exclude strangulation if
complete small bowel obstructions undergo prompt laparotomy.
J Am Coll
Surg. 2005 Jun;200(6):904-11. |
III |
Paper validates that complete SBO warrants no additional imaging
other than plain films. 71% of PSBO by plain film without
peritonitis resolved with conservative management. In patients with
complete SBO, there was a very high rate of bowel resection (31%).
This suggests that a complete SBO is a surgical disease.
|
|
Seror D
|
1993 |
How
conservatively can postoperative small bowel obstruction be treated?
Am J Surg.
1993 Jan;165(1):121-5; discussion 125-6. |
III |
73%
response to conservative tx in all SBO (Complete and Partial). No
difference in WBC, fever, pulse in those who required surgery. No
worse outcome in those watched over 5 days BUT no one that hadn’t
gotten better by 5 days got better w/o surgery. Weak support of
conclusions.
|
|
Williams SB |
2005 |
Small bowel
obstruction: conservative vs. surgical management.
Dis Colon
Rectum. 2005 Jun;48(6):1140-6. |
III |
Incidence of recurrent SBO is higher in conservatively managed pts
than in operatively managed pts (40.5% v. 26.8%). Time to
recurrence in conservative managed patients was shorter (153 v. 411
days)
|
|
Miller G |
2002 |
Readmission for
small-bowel obstruction in the early postoperative period: etiology
and outcome.
Can J Surg.
2002 Aug;45(4):255-8. |
III |
Defined early post-op bowel obstruction as within 50 days because
had big group who presented b/w 35-50 days. Most frequent procedure
was a small bowel operation for SBO. 23% required operation. 3.3%
strangulation. Suggests non-operative management of post-op
obstruction. |
|
Shih SC |
2003 |
Adhesive small
bowel obstruction: how long can patients tolerate conservative
treatment?
World J
Gastroenterol. 2003 Mar;9(3):603-5. |
III |
Paper really suggests if you wait too long, you will have
complications. |
|
Fevang BT |
2002 |
Early operation
or conservative management of patients with small bowel obstruction?
Eur J Surg.
2002;168(8-9):475-81. |
II |
Significant difference in strangulation between early and late
operation; suggests surgeons can choose which patients need
immediate surgery based on clinical evaluation. Operate for
continuous pain, fever, tachycardia, peritonitis, leukocytosis, met
acidosis
|
|
Ryan MD |
2004 |
Adhesional small
bowel obstruction after colorectal surgery.
ANZ J Surg.
2004 Nov;74(11):1010-2. |
III |
The
3 year rate for SBO following a colorectal procedure is 3.6%. 48%
required OR on first admission for SBO, only 1 for strangulation.
|
|
Conservative Management – Adjuncts |
|
Assalia A
|
1994 |
Therapeutic
effect of oral Gastrografin in adhesive, partial small-bowel
obstruction: a
prospective randomized trial.
Surgery. 1994
Apr;115(4):433-7. |
I |
100
cc of GG sped return of bowel function (time to first stool) from
23.4h to 6.2 hrs. GG decreased LOS from 4.4d to 2.2d. Trend to
improvement in conservative mgmt but not stat sig (21% control v.
10% GG P=0.52). No GG complications
|
|
Biondo S |
2003 |
Randomized
clinical study of Gastrografin administration in patients with
adhesive small bowel obstruction.
Br J Surg.
2003 May;90(5):542-6. |
I |
All
patients who passed Gastrografin to the colon w/in 24 hours
tolerated early feeding and did not require operation. They operated
on every patient who did not pass GG to the colon in 24 hrs with no
further trial of rx – CANNOT say that failure to pas GG predicts
non-op failure (they didn’t try) but they claim that every patient
who failed had a closed loop at surgery (not strangulation). |
|
Burge J |
2005 |
Randomized
controlled trial of Gastrografin in adhesive small bowel
obstruction.
ANZ J Surg.
2005 Aug;75(8):672-4. |
I |
100
cc of GG reduced time to resolution of sbo from 21 to 12 hrs. LOS
decreased by 1 day.GG did not change the number of people who failed
non-op mgmt
|
|
Chen SC |
2006 |
Specific oral
medications decrease the need for surgery in adhesive partial
small-bowel obstruction.
Surgery. 2006
Mar;139(3):312-6. |
I |
Patients treated with MgOxide, Lactobacillus, and Simethicone for
PSBO (by GG study) had a higher incidence of non-op mgmt (77 V 90%
p<0.01). This combination of meds may reduce need for operation in
PSBO
|
|
Choi HK |
2002 |
Therapeutic
value of gastrografin in adhesive small bowel obstruction after
unsuccessful conservative treatment: a prospective randomized trial.
Ann Surg.
2002 Jul;236(1):1-6. |
I |
They
randomized GG v. surgery after 48hrs of cons mgmt and showed that
most of the GG patients did not require surgery. |
|
Fevang BT |
2000 |
Upper
gastrointestinal contrast study in the management of small bowel
obstruction--a prospective randomised study.
Eur J Surg.
2000 Jan;166(1):39-43. |
I |
In
this non-blinded study GG mixed with barium had no effect on
resolution of SBO, need for operation, rate of strangulation.
Resolution was not different from the literature (PSBO 76%; Complete
41%).
|
|
Yagci G |
2005 |
Comparison of
Urografin versus standard therapy in postoperative small bowel
obstruction.
J Invest
Surg. 2005 Nov-Dec;18(6):315-20. |
II |
Time
to first stool shorter in Urografin group. UG group had better
non-op mgmt rate (89.4 to 75.4% p<0.05). UG group had shorter LOS
(2.73d v. 6.1d). |
|
Gowen GF |
2003 |
Long tube
decompression is successful in 90% of patients with adhesive small
bowel obstruction.
Am J Surg.
2003 Jun;185(6):512-5. |
III |
In
patients w/o signs of strangulation a nasally placed long tube
(using endoscopy to pass into the jejunum) had a 90% resolution
rate for SBO |
|
Roadley G |
2004 |
Role of
Gastrografin in assigning patients to a non-operative course in
adhesive small bowel obstruction.
ANZ J Surg.
2004 Oct;74(10):830-2. |
III |
Finding GG in the colon 4h post administration reliably predicts
successful non-op mgmt.
|
|
Conservative Management – Antibiotics |
|
Sagar PM
|
1995 |
Intestinal
obstruction promotes gut translocation of bacteria.
Dis Colon
Rectum. 1995 Jun;38(6):640-4. |
II |
Bacteria were found in mesenteric lymph nodes at a much greater
frequency in obstructed v. non-obs patients (39.9% v. 7.3% p,
0.001). Post-op septic complications were more likely in pts that
had + mes. Lymph nodes (36.1 v. 11.1% P<0.05)
|
|
Conservative Management – Nutrition |
|
Operative Intervention – General Considerations |
|
Fevang BT |
2004 |
Long-term
prognosis after operation for adhesive small bowel obstruction.
Ann Surg.
2004 Aug;240(2):193-201. |
III |
Study suggesting lower risk of recurrence if treated surgically.
However risk of needing surgery if future episode is the same. The
highest risk is after 5 years, but can occur even decades later.
Multiple matted adhesions have more recurrence than single bands (at
least those rx’d surgically) |
|
Landercasper J
|
1993 |
Long-term
outcome after hospitalization for small-bowel obstruction.
Arch Surg.
1993 Jul;128(7):765-70; discussion 770-1. |
III |
Rate
of recurrence is higher with non-op mgmt (38% v. 21% p<0.001).
Complete SBO v. Partial – no difference in recurrence either op or
non-op. Op v. non-op no diff in mortality
|
|
Early
Operative – Clinical Indications/Subgroups |
|
Tortella BJ
|
1995 |
Incidence and
risk factors for early small bowel obstruction after celiotomy for
penetrating abdominal trauma.
Am Surg. 1995
Nov;61(11):956-8. |
II |
(N=341; Prospective) Patients who had a laparotomy for penetrating
trauma. The hypothesis is that they would have a higher incidence of
post-operative SBO, defined as SBO in 6 months post-exploration. The
incidence was higher, 7.4% as compared to a reported 0.69% for
post-operative SBO |
|
Meagher AP
|
1993 |
Non-operative
treatment of small bowel obstruction following appendicectomy or
operation on the ovary or tube.
Br J Surg.
1993 Oct;80(10):1310-1. |
III |
(N=330; Retrospective) Patients with Appendectomy/tubo-ovarian
procedures are more likely to require operative intervention (95%
vs. 53 |
|
Potts FE 4th |
1999 |
Utility of fever
and leukocytosis in acute surgical abdomens in octogenarians and
beyond.
J Gerontol A
Biol Sci Med Sci. 1999 Feb;54(2):M55-8. |
III |
(N=117) Patients with fever and leukocytosis that are in their 80’s
most likely have Acute cholecystitis and viscous perforation. |
|
Velasco JM |
1998 |
Postlaparoscopic
small bowel obstruction. Rethinking its management.
Surg Endosc.
1998 Aug;12(8):1043-5. |
III |
(N=5) Post laparoscopic SBOs will need surgical resolution and will
not resolve spontaneously as up to73% will do after laparotomy |
|
Huang JC |
2005 |
Small bowel
volvulus among adults.
J
Gastroenterol Hepatol. 2005 Dec;20(12):1906-12. |
III |
(N=19) Volvulus although rare in adults can occur, and will always
need surgical therapy. |
|
Takeuchi K |
2004 |
Clinical studies
of strangulating small bowel obstruction.
Am Surg. 2004
Jan;70(1):40-4. |
III |
(N=280; retrospective) Purpose was to identify aspects of clinical
or laboratory exam that would identify patients with gangrenous
bowel. Only 92 (24%) of the 280 patients required surgery and 37 of
these had strangulation or intestinal gangrene (13) with small bowel
resection. Only factors that were significant for gangrenous small
bowel were SIRS (12/13) versus (1/24), elevated or low WBC, and base
deficit or acidosis. |
|
Tsumura H |
2004 |
Systemic
inflammatory response syndrome (SIRS) as a predictor of strangulated
small bowel obstruction.
Hepatogastroenterology. 2004 Sep-Oct;51(59):1393-6. |
III |
(N=95) SIRS and abdominal guarding are predictive of strangulation
in SBO. |
|
Ellis CN
|
1991 |
Small bowel
obstruction after colon resection for benign and malignant diseases.
Dis Colon
Rectum. 1991 May;34(5):367-71. |
III |
(N=118) Patients with surgical correction of SBO after history of
colon surgery. Patients often get SBO from reoccurrence and it
carries higher morbidity and mortality |
|
Matter I |
1997 |
Does the index
operation influence the course and outcome of adhesive intestinal
obstruction?
Eur J Surg.
1997 Oct;163(10):767-72. |
III |
(N=248) Purpose to look for what types of operations would lead to
future SBO. . The previous surgeries were divided into 4 groups:
Upper abdominal, small bowel resection, appendectomy /gynecology,
and colon resection. The procedure that led to most SBO/yr was
appendectomy - 3.1. SBO occurred earliest after resection of small
bowel and then colon, with in the first year. Complete obstruction
was highest after small bowel resection, 20/26, though only 3
required surgery. |
|
Montz FJ |
1994 |
Small bowel
obstruction following radical hysterectomy: risk factors, incidence,
and operative findings.
Gynecol
Oncol. 1994 Apr;53(1):114-20. |
III |
(N=98) Retrospective review patients who had radical hysterectomy
for non-adnexal gynecologic cancer. Radiation greatly increases
incidence of SBO. |
|
Early
Operative – Radiographic Indications |
|
Chen SC |
2005 |
Progressive
increase of bowel wall thickness is a reliable indicator for surgery
in patients with adhesive small bowel obstruction.
Dis Colon
Rectum. 2005 Sep;48(9):1764-71. |
II |
(N=121) US demonstrating increase in bowel wall thickness > 3mm are
indicator for surgery. Divided into 2 groups: Group 1 – initial SB
wall thickness > 3mm, group 2 – SB wall < 3mm. 9(18.4%) of group 1
patients needed surgery and only 4 (5.6%) of group 2. |
|
Chen SC |
1999 |
Oral urografin
in postoperative small bowel obstruction. World J Surg. 1999
Oct;23(10):1051-4. |
II |
Urografin in the colon at 8 hours predicts successful non-operative
treatment. Oral gastrographin is a good diagnostic tool for
prediction of the success of non-operative management of SBO
|
|
Perea Garcia J |
2004 |
Adhesive small
bowel obstruction: predictive value of oral contrast administration
on the need for surgery.
Rev Esp Enferm Dig.
2004 Mar;96(3):191-200. |
II |
Conclusion is that earlier use of contrast can lead to earlier
decision as to need of surgery or progression of non-operative
management of SBO. . |
|
Early
Operative – Time Period |
|
Sosa J
|
1993 |
Management of
patients diagnosed as acute intestinal obstruction secondary to
adhesions.
Am Surg. 1993
Feb;59(2):125-8. |
III |
(N=97) Retrospective analysis of 115 admissions for 97 patients with
SBO. 3 groups: early operation (< 24 hours) n = 21, non-operative
management group B1 failed, n = 33, and successful, n = 62. Primary
reason for early operation was tenderness or surgeon’s choice. 4
bowel resections 2ndary to strangulation in this group. The group
with the only 2 deaths, highest complication rate 36%, and highest
strangulation rate was group B1. |
|
Late
Operative – Clinical Indications/Subgroups |
|
Ellozy SH |
2002 |
Early
postoperative small-bowel obstruction: a prospective evaluation in
242 consecutive abdominal operations.
Dis Colon
Rectum. 2002 Sep;45(9):1214-7. |
II |
(N=95) Prospective surveillance of 242 operations performed of 225
patients and monitoring for early post-operative SBO (EPSBO). The
majority of the procedure involved the colon, and 45 patients had
previous SBO. There were 23 incidents of EPSBO. 20 resolved by day 6
with just NG suction. The other 3 had surgery on day 2, day 16 and
day 29 with the latter with SB necrosis and resection. There were no
factors identified with this small group of patients predictive of
EPSBO |
|
Andersson RE |
2001 |
Small bowel
obstruction after appendicectomy.
Br J Surg.
2001 Oct;88(10):1387-91. |
III |
Interesting study looking at the national registry of all Swedish
hospitals and the appendectomies done over the past 30+ years.
245400 patients underwent appendectomy over that time period and
there were 2659 SBO operations since on the patients. There were
245400 matched controls with 245 operations for SBO. Cumulated risk
of surgery for SBO after appendectomy after 4 weeks is 0.41, at 1
year, 0.63, at 10 years 0.97, and at 30 years 1.30. This is lower
then previously though. The cumulative risk increases with the
operative diagnosis with mesenteric adenitis at 1.42 at 30 years,
perforated appendicitis at 2.76, and other at 3.24. Acute
appendicitis carries the lowest risk of appendicitis at 0.75 |
|
Edna TH |
1998 |
Small bowel
obstruction in patients previously operated on for colorectal
cancer.
Eur J Surg.
1998 Aug;164(8):587-92. |
III |
(N=472) Study of 472 patients with operation for colorectal CA
followed for 5.5 years to establish the incidence of SBO. 351 had a
curative procedure, the other 121 palliative. 36/351 of the curative
developed an SBO that needed surgery, while 5/121 of the palliative
procedures developed SBO post operation. Etiology of SBO cancer in
half and these patients' post-op mortality was much higher. > 1000
cc blood loss at initial surgery leads to a higher rate of SBO, as
does the greater dissection of a curative procedure |
|
Fraser SA |
2002 |
Immediate
postlaparotomy small bowel obstruction: a 16-year retrospective
analysis.
Am Surg. 2002
Sep;68(9):780-2. |
III |
(N=52) Retrospective review of 15 years of experience to find 52
patients with immediate post-operative SBO. 22 of these patients
needed surgical correction. Timing of SBO was about 8 days post-op.
timing to beginning of symptoms to surgery was 5 days. Rate of
non-operative treatment was 60%, and these patients had less
complications and less LOS |
|
Siporin K
|
1993 |
Small bowel
obstruction after abdominal aortic surgery.
Am Surg. 1993
Dec;59(12):846-9. |
III |
(N=44) Retrospective review of 1475 patients with either AAA repair
or Graft replacement of the Aorta for occlusive disease to identify
the incidence of SBO in this population. 44 patients with SBO in the
immediate post-operative period (to 30 days) found. 18 required
operation, lysis of adhesions and 2 resections. |
|
Butler JA
|
1991 |
Small bowel
obstruction in patients with a prior history of cancer.
Am J Surg.
1991 Dec;162(6):624-8. |
III |
(N=54; Retrospective) Patients with complete or partial SBO after
surgery at some time for cancer. 37 (69%) of these patients had
operative therapy. 67% of the group had chemo/radiation therapy. 50%
had known recurrence. 25/37 with surgery had recurrent cancer as the
cause of the CA. Only 11 patients cleared non-operatively. 49% of
the operative patients had major complications, and the operative
mortality was 16%, in hospital mortality of 22%. |
|
Late
Operative – Radiographic Indications |
|
Choi HK |
2005 |
Value of
gastrografin in adhesive small bowel obstruction after unsuccessful
conservative treatment: a prospective evaluation.
World J
Gastroenterol. 2005 Jun 28;11(24):3742-5. |
II |
(N=212) 100cc of Gastrografin used 48h post SBO without improvement
delineated those who needed surgery (contrast not in colon at 24h)
and those who did not (contrast in colon at 24h). The need for OR
reduced by 74% with a strangulation rate of 0.8%. |
|
Onoue S |
2002 |
The value of
contrast radiology for postoperative adhesive small bowel
obstruction.
Hepatogastroenterology. 2002 Nov-Dec;49(48):1576-8. Related
Articles, Links
|
II |
(N=107) 40 cc Gastrografin + 40cc water provided within 24h of SBO
admission after NGT decompression and IVF. Gastrograffin is useful
in identifying and treating SBO non-operatively, though the
incidence of strangulation is not affected. |
|
Late
Operative – Time Period |
|
Cox MR
|
1993 |
The safety and
duration of non-operative treatment for adhesive small bowel
obstruction.
Aust N Z J
Surg. 1993 May;63(5):367-71. |
III |
(N=123) 2 or more indicators (fever, tachycardia, constant pain,
WBC>16) of SB strangulation on admission demonstrates by OR 76%
non-viable SB. Without indicators, 69% managed non-op with
resolution of SB. Evidence does not support author’s statement to
abandon non-op at 48h. |
|
Operative Approach – Laproscopic vs. Open |
|
Borzellino G |
2004 |
Laparoscopic
approach to postoperative adhesive obstruction.
Surg Endosc.
2004 Apr;18(4):686-90. |
III |
(N=65) Using laparoscopy, 6.5% intraop complication, 20% conversion
rate and 15.4% recurrence. US guide to enter abdomen without any
injury on entrance. Relative contraindications such as massive
distention, no free quadrant, and suspected strangulation discussed.
Author emphasizes success with numbers above. |
|
Chopra R |
2003 |
Laparoscopic
lysis of adhesions.
Am Surg. 2003
Nov;69(11):966-8. |
III |
(N=75) Using laparoscopy, 4.3% SB resection, 32% conversion rate,
and overall lower OR time, infectious complications, post-op ileus,
and LOS. Author states “viable option.” |
|
Duepree HJ |
2003 |
Does means of
access affect the incidence of small bowel obstruction and ventral
hernia after bowel resection? Laparoscopy versus laparotomy.
J Am Coll
Surg. 2003 Aug;197(2):177-81. |
III |
(N=716) Use of laparoscopy for bowel resection decreases ventral
hernia and SBO requiring hospital readmission. SB requiring
operative intervention was similar between laparoscopy and open.
|
|
Wullstein C |
2003 |
Laparoscopic
compared with conventional treatment of acute adhesive small bowel
obstruction.
Br J Surg.
2003 Sep;90(9):1147-51. |
III |
(N=104) Using laparoscopy, 17.3% perforation, 51.9% conversion, and
longer operative times. Post-operative complications, return of
bowel function, and LOS less for laparoscopy. |
|
Leon EL |
1999 |
Laparoscopic
management of small bowel obstruction: indications and outcome.
J Gastrointest Surg.
1998 Mar-Apr;2(2):132-40. |
III |
(N=40) Laparoscopy successful 35% assisted 30%, and 35% conversion.
. Reasons for conversion included dense adhesions, need for bowel
resection, Crohns, 2 cancers and large lymph nodes. Those converted
longer LOS. |
|
Levard H |
2001 |
Laparoscopic
treatment of acute small bowel obstruction: a multicentre
retrospective study.
ANZ J Surg.
2001 Nov;71(11):641-6. |
III |
(N=308) Laparoscopy conversion rate 45.4%. Factors that favor
laparoscopic success are SBO post appendectomy, with bands as cause,
with less then 2 previous surgeries, and shorter time of symptoms.
Those not converted had shorter LOS, fewer complications, and
earlier bowel function. |
|
Liauw JJ |
2005 |
Laparoscopic
management of acute small bowel obstruction.
Asian J Surg.
2005 Jul;28(3):185-8. |
III |
(N=9) Conversion rate of 22%. |
|
Suter M |
2000 |
Laparoscopic
management of mechanical small bowel obstruction: are there
predictors of success or failure?
Surg Endosc.
2000 May;14(5):478-83. |
III |
(N=15) Enteroclysis guided laparoscopy conversion rate of 6.7%. |
|
Suzuki K |
2003 |
Elective
laparoscopy for small bowel obstruction.
Surg Laparosc
Endosc Percutan Tech. 2003 Aug;13(4):254-6. |
III |
(N=40) Laparoscopy conversion rate of 40%. Intraop enterotomies 10%.
Late recurrence 2.5% |
|
Tsumura H |
2004 |
Laparoscopic
adhesiolysis for recurrent postoperative small bowel obstruction.
Hepatogastroenterology. 2004 Jul-Aug;51(58):1058-61.
|
III |
(N=83) 57% initial success rate with duration of surgery (>120min)
and bowel diameter (>4cm) predictive of conversion. Reoperation rate
of 9%. Bowel perforation and need for conversion increased post-op
complications. |
|
Pekmezci S |
2002 |
Enteroclysis-guided laparoscopic adhesiolysis in recurrent adhesive
small bowel obstructions.
Surg Laparosc
Endosc Percutan Tech. 2002 Jun;12(3):165-70. |
III |
(N=21) 57% laparoscopy only, 24% assisted, 19% conversion rate.
Utilizing laparoscopy (+/- assisted) diminished time for bowel
function and LOS. |
|
Strickland P |
1999 |
Is laparoscopy
safe and effective for treatment of acute small-bowel obstruction?
Surg Endosc.
1999 Jul;13(7):695-8. |
III |
(N=25) Complete adhesiolysis 72%. Lap assisted 24%. Open 4%.
Utilizing laparoscopy (+/- assisted) diminished time for bowel
function and LOS. |
|
Operative Approach – Adjuncts |
|
Fazio VW |
2006 |
Reduction in
adhesive small-bowel obstruction by Seprafilm adhesion barrier after
intestinal resection.
Dis Colon
Rectum. 2006 Jan;49(1):1-11. |
I |
(N=1791) Pt blinded randomized multicenter trial to eval Seprafilm.
The overall rate of post-operative SBO showed no difference with or
without Seprafilm. However, Seprafilm did have lower (1.8 vs 3.4%)
of SBO requiring reoperation (N=90). |
|
Kieffer RW
|
1993 |
Indications for
internal stenting in intestinal obstruction.
Mil Med. 1993
Jul;158(7):478-9. |
III |
(N=16) Using internal stenting with Baker jejunal tube, recurrent
rate of obstruction was 25%. Non-obstructive intra-abdominal
complication rate 18.7%. |
|
Meissner K |
2000 |
Effectiveness of
intestinal tube splinting: a prospective observational study.
Dig Surg.
2000;17(1):49-56. |
II |
(N=186) With internal splinting, 9% complications, 2% procedural
complications, 3% reoperation. No early SBO. Lower late SBO compared
to historical outcome data. |
|
Kudo FA |
2004 |
Use of
bioresorbable membrane to prevent postoperative small bowel
obstruction in transabdominal aortic aneurysm surgery.
Surg Today.
2004;34(8):648-51. |
III |
(N=51) Early SBO was lower with Seprafilm evident by earlier diet
intake and less abdominal complaints. No reoperations were required
in either group. |
|
Meissner K |
2001 |
Small bowel
obstruction following extended right hemicolectomy and subtotal
colectomy: assessing the benefit of prophylactic tube splinting.
Dig Surg.
2001;18(5):388-92. |
III |
(N=34) Intestinal tube splinting showed non-statistical fewer early
and late SBO |
|
Mohri Y |
2005 |
Hyaluronic acid-carboxycellulose
membrane (Seprafilm) reduces early postoperative small bowel
obstruction in gastrointestinal surgery.
Am Surg. 2005
Oct;71(10):861-3. |
III |
(N=184) Incidence of early SBO lower with Seprfilm. No difference in
surgical site infection. |
|
Sprouse LR 2nd |
2001 |
Twelve-year
experience with the Thow long intestinal tube: a means of preventing
postoperative bowel obstruction.
Am Surg. 2001
Apr;67(4):357-60. |
III |
(N=34) Transgastric Thow tube had no long term (>4y) with pts who
had operative intervention for adhesion SBO. Follow-up recorded via
phone calls to patients (25 of 34). Complications all related to
gastrostomy (25%) |
|
Rodriguez-Ruesga
R |
1995 |
Twelve-year
experience with the long intestinal tube.
World J Surg.
1995 Jul-Aug;19(4):627-30; discussion 630-1. |
III |
(N=47) Complex surgical patient with median 4 previous laparotomies.
23.4% recurrent SBO, only 2 required reoperation. |
|
Korenaga D |
2001 |
Factors
influencing the development of small intestinal obstruction
following total gastrectomy for gastric cancer: the impact of
reconstructive route in the Roux-en-Y procedure.
Hepatogastroenterology. 2001 Sep-Oct;48(41):1389-92. |
III |
(N=48) 22.9% presented with mechanical obstruction and
antecolic anastomosis found to be predictive factor. 45% required
reoperation. |
|
Poon JT |
2004 |
Small bowel
obstruction following low anterior resection: the impact of
diversion ileostomy.
Langenbecks
Arch Surg. 2004 Aug;389(4):250-5. |
II |
(N=214) SBO following LAR is 10.3%, the majority benign and not
malignant recurrence. Diverting ileostomy increases incidence of
early SBO. |
|
Holmdahl L |
1997 |
Adhesions:
prevention and complications in general surgery.
Eur J Surg.
1997 Mar;163(3):169-74. |
III |
Survey sent out to surgical department heads in Sweden. 84%
(87units) response rate. >4700 admissions for adhesion SBO, 47%
operative rate. Over 1500 operations/y complicated by previously
formed adhesions. Author suggests washing gloves and suturing
peritoneum could help but no evidence provided. |
|
SBO in
Pregnancy |
|
Meyerson S
|
1995 |
Small bowel
obstruction in pregnancy.
Am J
Gastroenterol. 1995 Feb;90(2):299-302. |
III |
9
cases over 15 years and 150,386 deliveries. Previous surgery 8 of 9
cases. Operation required in 8 of 9 patients. No maternal deaths. 3
of 9 fetal deaths (22-30 wks) |
|