INTESTINAL OBSTRUCTION REPAIR
Category: General Surgery
Abstract : Intestinal obstruction repair Definition An intestinal obstruction is a
partial or complete blockage of the small or large intestine. Surgery is
sometimes necessary to relieve the obstruction. Purpose The small
intestine is composed of three major sections: the duodenum just below the
stomach; the jejunum, or middle portion; and the ileum, which empties into the
large
Intestinal obstruction repair
Definition
An intestinal obstruction is a
partial or complete blockage of the small or large intestine. Surgery is
sometimes necessary to relieve the obstruction.
Purpose
The small
intestine is composed of three major sections: the duodenum just below the
stomach; the jejunum, or middle portion; and the ileum, which empties into the
large intestine.
The large intestine is composed of the colon, where stool is
formed; and the rectum, which empties to the outside of the body through the
anal canal. A blockage that occurs in the small intestine is called a small
bowel obstruction, and one that occurs in the colon is a colonic obstruction.
There are numerous conditions that may lead to an intestinal
obstruction. The three most common causes of small bowel obstruction are
adhesions, which are bands of scar tissue that form in the abdomen following
injury or surgery; hernias, which develop when a portion of the intestine
protrudes through a weak spot in the abdominal wall; and cancerous tumors.
Adhesions account for approximately 50% of all small bowel obstructions, hernias
for 15%, and tumors for 15%.
Other causes include volvulus, or formation
of kinks or knots in the bowel; the presence of foreign bodies in the digestive
tract; intussusception, which occurs when a portion of the intestine telescopes
or pulls over another portion; infection; and congenital defects. While most
small bowel blockages can be treated with the administration of intravenous (IV)
fluids and decompression of the bowel by the insertion of a nasogastric (NG)
tube, surgical intervention is necessary in approximately 25% of patients with a
partial obstruction, and 50% - 65% of patients with a complete obstruction.
An obstruction of the large intestine is less common than blockages of
the small intestine. Blockages of the large bowel are usually caused by colon
cancer; volvulus; diverticulitis (inflammation of sac-like structures called
diverticula that form in the intestines); ischemic colitis (inflammation of the
colon resulting from insufficient blood flow); Crohn’s disease (a disease that
causes chronic inflammation of the intestines); inflammation due to radiation
therapy; and the presence of foreign bodies. As in the case of small bowel
obstruction, most patients with a blockage of the large intestine can be treated
with IV fluids and bowel decompression.
Demographics
Approximately
300,000 intestinal obstruction repairs are performed in the United States each
year. Among patients who are admitted to the hospital for severe abdominal pain,
20% have an intestinal obstruction. While bowel obstruction can affect
individuals of any age, different conditions occur at higher rates in certain
age groups. Children under the age of two, for example, are more likely to
present with intussusceptions or congenital defects. Elderly patients, on the
other hand, have a higher rate of colon cancer.
Description
After
the patient has been prepared for surgery and given general anesthesia, the
surgeon usually enters the abdominal cavity by way of a laparotomy, which is a
large incision made through the patient’s abdominal wall. This type of surgery
is sometimes referred to as open surgery. An alternative to laparotomy is
laparoscopy, a surgical procedure in which a laparoscope (a thin tube with a
built-in light source) and other instruments are inserted into the abdomen
through small incisions.
The internal operating field is then visualized
on a video monitor that is connected to the scope. In some patients, the
technique may be used for abdominal exploration in place of a laparotomy.
Laparoscopy is associated with faster recovery times, shorter hospital stays,
and smaller surgical scars, but requires advanced training on the part of the
surgeon as well as costly equipment. Moreover, it offers a more limited view of
the operating field.
Treating an intestinal obstruction depends on the
condition causing the blockage. Some of the more common surgical procedures used
to treat bowel obstructions include:
• Lysis of adhesions. The process of
removing these bands of scar tissue is called lysis. After the abdominal cavity
has been opened, the surgeon locates the obstructed area and delicately dissects
the adhesions from the intestine using surgical scissors and forceps.
•
Hernia repair. This procedure involves an incision placed near the location of
the hernia through which the hernia sac is opened. The herniated intestine is
placed back in the abdominal cavity and the muscle wall is repaired.
•
Resection with end-to-end anastomosis. Resection means to remove part or all of
a tissue or structure. Resection of the small or large intestine, therefore,
involves the removal of the obstructed or diseased section. Anastomosis is the
connection of two cut ends of a tubular structure to form a continuous channel;
the anastomosis of the intestine is most often accomplished with sutures or
surgical staples.
• Resection with ileostomy or colostomy. In some
patients, an anastomosis is not possible because of the extent of the diseased
tissue. After the obstruction and diseased tissue is removed, an ileostomy or
colostomy is created. Ileostomy is a surgical procedure in which the small
intestine is attached to the abdominal wall; waste then exits the body through
an artificial opening called a stoma and collects in a bag attached to the skin
with adhesive. Colostomy is a similar procedure with the exception that the
colon is the part of the digestive tract that is attached to the abdominal wall.
Diagnosis / Preparation
To diagnose an intestinal obstruction, the
physician first gives a physical examination to determine the severity of the
patient’s condition. The abdomen is examined for evidence of scars, hernias,
distension, or pain. The patient’s medical history is also taken, as certain
factors increase a person’s risk of developing a bowel obstruction (including
previous surgery, older age, and a history of constipation). A series of x rays
may be taken of the abdomen, as a definitive diagnosis of obstruction can be
made by x ray in 50–60% of patients.
Computed tomography (CT; an imaging
technique that uses x rays to produce two-dimensional cross-sections on a
viewing screen) or ultrasonography (an imaging technique that uses
high-frequency sounds waves to visualize structures inside the body) may also be
used to diagnosis intestinal obstruction.
Unless a patient presents with
symptoms that indicate immediate surgery may be necessary (high fever, severe
pain, a rapid heart beat, etc.), a course of IV fluids, NG decompression, and
antibiotic therapy is usually prescribed in an effort to avoid surgery.
Aftercare
After surgery, the patient’s NG tube remains until bowel
function returns. The patient is closely monitored for signs of infection,
leakage from an anastomosis, or other complications.
Risks
Complications associated with intestinal obstruction repair include
excessive bleeding; infection; formation of abscesses (pockets of pus); leakage
of stool from an anastomosis; adhesion formation; paralytic ileus (temporary
paralysis of the intestines); and reoccurrence of the obstruction.
Normal results
Most patients who undergo surgical repair of an
intestinal obstruction have an uneventful recovery and do not experience a
recurrence of the obstruction.
Morbidity and mortality rates
The
mortality rate of small bowel obstruction ranges from 2% for a simple
obstruction to 25% for a strangulation obstruction that compromises the blood
supply and is treated after a lapse of 36 hours. Large bowel obstruction carries
a mortality rate of 2% for volvulus to 40% if part of the bowel is gangrenous.
Alternatives
Such nonsurgical techniques as the administration of IV
fluids and bowel decompression with a NG tube are often successful in relieving
an intestinal obstruction. Patients who present with more severe symptoms that
are indicative of a bowel perforation or strangulation, however, require
immediate surgery.
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