Ileus tube placement combined with laparoscopy in the treatment of refractory small bowel obstruction: Case series and literature review
Wei-Hai Shi, Hao-Qiang Chao, Nian-Yuan Ye
Abstract
Post-surgery small bowel obstruction (SBO) has substantial morbidity and mortality. Even with refinement of surgical technique, SBO still remains challenging with the most common causes of acute hospital admission. Most SBOs can be managed with conservative treatment. However, the palliative methods may fail to relieve the symptoms in some clinical settings. Currently, laparotomy is the standard of care for difficult SBO. And laparoscopy offers an alternative approach for operative intervention in SBO and was first described by Bastug et al in 1991. Emerging literature demonstrated that laparoscopic surgery for SBO is less invasive, resulting in a shorter hospital stay than open surgery. And most recurrent adhesive SBO can be managed with ileus tube placement. This case series is to evaluate the efficacy of transnasal ileus tube placement combined with laparoscopic surgery in the treatment of consecutive 5 cases of refractory SBO post oncologic gastrointestinal surgery.
Introduction
There is a high incidence (12%–18%) of adhesive small bowel obstruction (SBO) post operation.1–3 And SBO is the most common causes of acute hospital admission.4 Furthermore, admission for adhesion-related SBO is associated with a mortality rate as high as 10%.5 Most SBOs (67.2%) can be managed with conservative treatment.6 However, the palliative methods may fail to relieve the symptoms at some clinical settings. Currently, the laparotomy is the standard care for difficult adhesive SBO.
Laparoscopy offers an alternative approach for operative intervention in adhesional SBO and was first described by Bastug et al7 in 1991. Despite multiple studies, laparoscopy is not yet fully accepted as treatment of choice for SBO.8 A retrospective study found that laparoscopic surgery for SBO is less invasive than open surgery and equally feasible in selected patients.9 And most recurrent adhesive SBO can be managed with ileus tube placement.10
The authors reported our experience of management refractory SBO post operation for gastrointestinal tract malignancies using transnasal ileus tube catheterization combined with laparoscopy adhesiolysis in this case series.
Case Report
Case 1
A patient with SBO refused any further operative therapy after 4 days conservative therapy, so only ileus tube intubation was used to relief his symptoms. The patient was discharged without bowel obstruction 20 days after admission. He died of brain metastasis 11 months later.
Case 2
Laparoscopic lysis of adhesions was performed to manage SBO post 3 days conservative therapy, but obstruction symptoms were not relieved 3 days post-procedure, necessitating placement of the ileus tube. He was able to restart his normal diet 8 days later.
Case 3
An intestinal volvulus was diagnosed with mesenteric vessel rotation sign by enhanced
abdominal computed tomography imaging at admission. Decision was made by surgeon to
place the ileus tube first for failed 3 days conservative management. Laparoscopic
surgery was then performed to lyse the adhesive band after the ileus tube deployment
for a week. The patient recovered fully and was discharged another 7 days later (Fig. 1
Case 4
The process was very similar to Case 1, SBO was developed on the 9th day post laparoscopic rectal cancer resection, while he was at hospital. While failing conservative treatment for 1 week, his intestinal function returned to normal 14 days later post ileus tube placement.
Case 5
Therapy process was identical as Case 3, except no evidence of volvulus. First line therapy was ileus tube placement 1 week for failed 3 days conservative treatment, followed by laparoscopy ahesiolysis.
No conversion to laparotomy was need in this series.
Mean follow-up was 11.6 ± 4.5 months (range, 2–18 months). All patients survived except Case 1. No recurrence SBO was recorded during the follow-up.
Discussion
Combining with ileus tube placement, laparoscopic surgery as an initial management of SBO post previous oncologic surgery is effective as well as safe, and may avoid conversion to more aggressive laparotomy. No serious complications occurred in this series, such as iatrogenic small bowel perforation, massive bleeding or surgical cite serious infection. No recurrence SBO was reported during mean 11.6 months follow-up interval.
Adhesive post-surgical SBO has a high rate of morbidity and mortality, with an even poorer prognosis from previous oncologic operations. There is a surgery teaching dogma says that “to never let sun rise and set on a episode of small bowel obstruction”. In the past decade, two thirds SBOs were managed with conservative treatment, one third need aggressive operative treatment.6 Laparotomy is the standard care for SBO even though this approach tends to generate new adhesions and predisposes the patient to more recurrence of SBO due to the operative abdominal wall trauma, peritoneal cavity bleeding and surgical site infection. Compared with laparoscopy, open surgery seems increase the risk of SBO by a factor of four.3 Laparoscopy has been shown to be superior to open surgery in the management of adhesive SBO with less pain, faster recovery, less invasive, fewer complications and shorter hospital stays.12–14 With the combination of sharp dissection with use of electrocautery or the ultrasonic scalpel for lysis of adhesions and attention to active electrode of the instrument while gently grasping the opposite small bowel, the risk of inadvertent iatrogenic perforation may be significantly reduced.11 With the refinement of laparoscopic technique, less than 25% of cases of SBO were need conversion to laparotomy.15
Non-surgical, internal intestinal splinting using a nasointestinal ileus tube under fluoroscopy is simple, safe and effective treatment of recurrent adhesive SBO, even in some inoperable patients and showed promising outcomes. Long tube placement during operative SBO was more popular utilization in Japan than Western countries.16 The ileus tube has advantages over nasogatric tube in initial or palliative treatment of SBO.10,17 Transnasal ileus tube intubation can provide early intestinal decompression, sufficient working space and accurate diagnostic information to indicate the obstruction site and transition zone for laparoscopic resection of SBO.
Laparoscopy and ileus tube may be a good marriage in the treatment of intractable SBO. Ileus tube intubation either pre or post laparoscopic adhesiolysis may increase the success rate of SBO therapy. Optional use these two minimally invasive techniques would decrease the conversion rate to laparotomy, especially in some oncologic patients with advanced disease.18,19
The limitation of the case series is its small sample size and a single institutional retrospective experience. Further large scale randomized controlled trials are warranted to demonstrate the benefit of this mini-invasive strategy in the treatment of refractory SBO.
Conflicts of Interest
No potential conflict of interest relevant to this article was reported.
Acknowledgments
This project was supported by Changzhou High-Level Medical Talent Training Project (2016CZBJ059).
Article information
Articles from International Journal of Gastrointestinal Intervention are provided here courtesy of International Journal of Gastrointestinal Intervention
References
- Dindo D, Schafer M, Muller MK, Clavien PA, Hahnloser D. Laparoscopy for small bowel
obstruction: the reason for conversion matters. Surg Endosc. 2010;24:792-7.
- Duron JJ, du Montcel ST, Berger A, Muscari F, Hennet H, Veyrieres M. Prevalence and
risk factors of mortality and morbidity after operation for adhesive postoperative
small bowel obstruction. Am J Surg. 2008;195:726-34.
- Angenete E, Jacobsson A, Gellerstedt M, Haglind E. Effect of laparoscopy on the risk
of small-bowel obstruction: a population-based register study. Arch Surg. 2012;147:359-65.
- Suh SW, Choi YS. Laparoscopy for small bowel obstruction caused by single adhesive
band. JSLS. 2016;20.
- Menzies D, Parker M, Hoare R, Knight A. Small bowel obstruction due to postoperative
adhesions: treatment patterns and associated costs in 110 hospital admissions. Ann R Coll Surg Engl. 2001;83:40-6.
- Jafari MD, Jafari F, Foe-Paker JE, Phelan MJ, Carmichael JC, Pigazzi A. Adhesive small
bowel obstruction in the United States: has laparoscopy made an impact?. Am Surg. 2015;81:1028-33.
- Bastug DF, Trammell SW, Boland JP, Mantz EP, Tiley EH. Laparoscopic adhesiolysis for
small bowel obstruction. Surg Laparosc Endosc. 1991;1:259-62.
- Wiggins T, Markar SR, Harris A. Laparoscopic adhesiolysis for acute small bowel obstruction:
systemic review and pooled analysis. Surg Endosc. 2015;29:3432-42.
- Otani K, Ishihara S, Nozawa H, Kawai K, Hata K, Kiyomatsu T. A retrospective study
of laparoscopic surgery for small bowel obstruction. Ann Med Surg (Lond). 2017;16:34-9.
- Chen XL, Ji F, Lin Q, Chen YP, Lin JJ, Ye F. A prospective randomized trial of transnasal
ileus tube vs nasogastric tube for adhesive small bowel obstruction. World J Gastroenterol. 2012;18:1968-74.
- Tierris I, Mavrantonis C, Stratoulias C, Panousis G, Mpetsou A, Kalochristianakis
N. Laparoscopy for acute small bowel obstruction: indication or contraindication?.
Surg Endosc. 2011;25:531-5.
- Zimmermann M, Hoffmann M, Laubert T, Bruch HP, Keck T, Benecke C. Laparoscopy for
bowel obstruction--a contradiction? Results of a multi-institutional survey in Germany.
Int J Colorectal Dis. 2016;31:1011-9.
- Oyasiji T, Helton SW. Survey of opinions on operative management of adhesive small
bowel obstruction: laparoscopy versus laparotomy in the state of Connecticut. Surg Endosc. 2011;25:2516-21.
- Simmons JD, Rogers EA, Porter JM, Ahmed N. The role of laparoscopy in small bowel
obstruction after previous laparotomy for trauma: an initial report. Am Surg. 2011;77:185-7.
- Sajid MS, Khawaja AH, Sains P, Singh KK, Baig MK. A systematic review comparing laparoscopic
vs open adhesiolysis in patients with adhesional small bowel obstruction. Am J Surg. 2016;212:138-50.
- Shibuya N, Ishizuka M, Iwasaki Y, Takagi K, Nagata H, Aoki T. Usefulness of a laparoscopic
approach for treatment of small-bowel obstruction due to intersigmoid hernia: a case
report. Surg Case Rep. 2017;3:22.
- Cui H, Jiang X, Li H. Adhesive small-bowel obstruction treatment using internal intestinal
splinting with a nasointestinal ileus tube. Minerva Chir. 2015;70:327-30.
- Ohtsuka T, Nagai E, Toma H, Ohuchida K, Takanami H, Odate S. Single-incision laparoscopy-assisted
surgery for bowel obstruction: report of three cases. Surg Today. 2011;41:1519-23.
- Nordin A, Freedman J. Laparoscopic versus open surgical management of small bowel
obstruction: an analysis of clinical outcomes. Surg Endosc. 2016;30:4454-63.
