NONOPERATIVE TREATMENT

With improved surgical and anesthetic management, mortality from small-bowel

obstruction has decreased during the past 50 to 60 years from approximately 25%
to 5% 51 Initial therapy is directed at correction of intravascular fluid and
electrolyte abnormalities. The patient should be given nothing by mouth.
Nasogastric tube suction can provide symptomatic improvement for patients with
emesis. Resolution of the obstiuction may occur after adequate hydration and
decompression via a nasogastric tube, avoiding the need for surgical intervention.
This nonoperative approach is often successful in those patients with either partial
obstruction from adhesions or obstructions related to impaction of food particles at
the sites of luminal narrowing, such as a Crohn's stricture. In addition to standard
nasogastric tubes, a variety of long intestinal tubes have been used in an attempt at
optimizing luminal decompression. The tubes are generally weighted with a
mercury-filled balloon and passed into the stornach, ancl the patient is placed in the
right låteral decubitus position in the hope that peristalsis will carry the tube beyond
the pylorus and into the more distal intestine. Fleshner et al. conducted a
prospective, randomized trial in 55 patients with acute adhesive small-bowel
obstruction and found no advantage of one tube type over the other.57 This
prospective study confirmed previous retrospective studies in the lit- 58'59 that have
shown no advantage of long intestinal erature tubes (Table 31.3). Obstruction
caused by incarcerated hernia can sometimes be relieved by reduction of the hernia,
a procedure that should be performed cautiously and only by experienced clinicians.
Excessive external pressure will lead to significant patient discomfort and, in rare
circumstances, an inadvertent reduction "en masse" may occur, resulting in
disappearance of the hernia bulge but with persistent bowel obstruction and possible
strangulation within the constricting peritoneal sac
OPERATIVE TFEATMENT
Surgical intervention is indicated for those patients with complete small-bowel
obstruction who have any signs or symptoms indicative of strangulation or for those
patients with silnple obstruction that has not resolved within a sonable period of
nonoperative therapy, generally 24 to 48 h Most clinicians would agree that
constant or severe pain, especially associated with fever or signs of peritoneal
irritationare indications for urgent laparotomy.

The surgical approach to most patients with small-bowel obstruction is

straightforward and includes laparotomy with adhesiolysis and resection of
nonviable intestine. The determination of when and how much intestine to remove
is usually simple and is based upon the purple or black discoloration that occurs in
severely ischemic or necrotic intestine. In addition to the normal pink coloration,
viable intestine has mesenteric arterial pulsations and normal motility. In some
cases of more limited ischemic damage, adhesiolysis should be followed by a IO-
to 15-min period of ebservation to allow for possible improvement in the gross
appearance of the in volved segment. Laser Doppler flowmetry has been advocated
as an intraoperative method to assess bowel viability.60 Bulk. studied 71 ischemic
bowel segments and found ley et al 61 fluorescein ultraviolet fluorescence to be
more accurate in determining bowel viability than either standard clinical judgment
or Doppler blood flow measurements. In making the, judgment as to the extent of
resection, it should be kept in mind that a given marginally viable segment of
intestine may survive in the short term, only to be followed weeks or months later
by stricture formation that requires resection. As such, it is probably best to remove
any segment that is not clearly viable by gross examination at the time, of
adhesiolysis. In most cases, all the adhesions should be lysed to ensure that the
obstruction is relieved and perhaps to prevent future recurrences. When an
obstructing lesion is identified, resection with primary anastomosis is performed.
Since the advent of minimally invasive surgical techniques in the 1980s,
some surgeons have employed a laparoscopic approach to patients with small-
bowel obstruction, A single adhesive band may be lysed laparoscopically or a small
laparotomy performed overlying the area of obstruction, thereby avoiding a long
incision in the abdominal wall. Laparoscopy in the setting of a bowel obstruction
can be performed safely, but the open technique is preferred to avoid the blind
insertion of needles or trochars. into the peritoneal cavity when distended loops of
bowel are present.
Obstruction of the intestine occurs when there is impairment in the normal
flow of luminal contents caused by an extrinsic or intrinsic encroachment on the
lumen. Intestinal pseudoobstruction, or adynamic ileus, can mimic mechanical
obstruction, but differs in that the underlying problem is due to disordered motility.
The key to management of small intestinal obstruction is early diagnosis.
Identification of those patients with strangulation is of critical importance because
prompt surgical correction is needed to minimize morbidity and mortality.
Numerous clinical and radiologic criteria can be helpful in distinguishing simple
from strangulating obstruction, although this differentiation remains a challenge to
even the most experienced clinicians.