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STOMACH
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127
gastrectomy and length of the efferent or absorptive limb. Bougie size
has decreased down to a size of 40 French by many surgeons, and
the absorptive channel has increased from 200 to 300 cm to decrease
protein and vitamin deficiencies while maintaining excellent weight
loss. Diarrhea can be troublesome after DS-BPD and SADI-S, but by
increasing the length of the absorptive channel, this may become less
of a problem for most patients.
The sleeve gastrectomy is performed as previously described. The
dissection is then continued a few centimeters past the pylorus where
the duodenum is divided with the endoscopic linear stapler. The
omentum is then divided with the energy device at a point where the
path of the small bowel is unobstructed as it travels to be anastomosed to the first part of the duodenum.
The surgeon then measures the absorptive limb by starting at the
ileocecal valve and walking back the bowel 300 cm. This point on the
bowel is then carefully brought up to the duodenum and stay sutures
are then placed while making sure there is no twisting nor tension
present before creating the anastomosis.
The anastomosis may be formed using a stapler technique, in
which an endoscopic stapler is used to join the small bowel to the
duodenum and then the common enterotomy opening is closed with
either a suture or another stapler firing, taking care not to make the
open channel too tight. The anastomosis can also be formed by using
handsewn two-layer suturing technique.
It is recommended to place a stitch from the afferent limb, just
before the anastomosis, to the gastric antrum to prevent an obstruction from the limb rotating. The mesenteric defect between the small
bowel mesentery and transverse colon mesentery can be sutured
closed to prevent possible internal herniation, but in the SADI-S
operation this is still controversial when it is discussed, with many
surgeons finding that it is unnecessary. Hopefully, future analysis
of long-term outcomes data will help resolve the need for this step.
Intragastric Balloon
IGBs are gas- or fluid-filled devices that are deployed in the stomach
for a period of 6 to 12 months. As a result of being a temporary
implant, they require two endoscopic procedures (one for insertion
and another for removal of the IGB). Though initially appealing to
patients, IGBs have been plagued by poor tolerability and concerns
regarding safety. Furthermore, as a result of the device needing to
be removed, weight regain is somewhat expected. The mechanism
of action is unclear with theories ranging from that of effective
volume reduction due to space occupation to alterations in gastric
emptying; some believe there are even neurohormonal benefits.
Notably, regardless of the IGB type, weight loss seems to taper at
3 months, and this appears to be the result of an accommodation
phenomenon. Therefore, newer space-occupying devices attempt to
circumnavigate this by being adjustable. There is even a capsule that
is taken twice a day before meals that dissolves, releasing hundreds of
hydrogel beads that result in temporary space occupation.
Endoscopic Sleeve Gastroplasty
ESG was first reported in 2013 and, since then, has disseminated
globally, being performed by gastroenterologists and surgeons alike.
It attempts to recapitulate laparoscopic greater curvature plication
through an over-the-scope attachment of the OverStitch (Apollo
Endosurgery, Austin, TX) and 2-0 nonabsorbable monofilament
sutures. A running suture pattern is performed using a tissue helix
such that plications are made to the distal gastric fundus (a small
residual fundal pouch is inevitable). The procedure is performed
on an outpatient basis with 5 to 9 running full-thickness sutures
being placed with a total procedure duration of 1 hour. The current
technique results in a stomach with decreased gastric volume and
reduced compliance. Published data demonstrate outcomes that it
is more effective than even high intensity diet and lifestyle program,
but it is less effective than laparoscopic sleeve gastrectomy. ESG has
been used not only as a primary weight loss therapy but in patients
who have had weight regain and dilation of the stomach after surgical
sleeve gastrectomy.
ENHANCED RECOVERY AFTER SURGERY
We implemented an Enhanced Recovery After Surgery (ERAS)
program for bariatric surgery at our center in 2017 and published a
decrease in length of stay from 2.77 days to 1.77 days (P <0.001) with
a reduced 30-day readmission rate from 7.94% to 2.86% (P
On the day of surgery, patients have a scopolamine patch placed if
there is no contraindication. During the operation, opioids are minimized, acetaminophen 1000 mg IV is given, no Foley is placed, and
no drains are used for routine bariatric surgery operations. Dexamethasone 4 to 8 mg IV is given after induction, and postoperatively,
we give our sleeve gastrectomy patients a second dose of dexamethasone IV 8 hours after leaving the operating room. Ondansetron is
used intraoperatively and postoperatively to prevent nausea as well as
treat it. Metoclopramide is used if ondansetron is not enough to treat
a patient’s postoperative nausea complaints. Patients are instructed
to walk soon after surgery. Clear liquids are started that evening and
increased the following morning, with discharge on postoperative
day number one. Oral acetaminophen is used for pain control as
well as oral narcotics for breakthrough pain, but it is stressed to the
patient to try and avoid narcotics if possible. IV narcotics are discouraged and avoided if possible. The patient is discharged once they
are drinking enough to maintain hydration at home.
= 0.011).
OUTCOMES AND COMPLICATIONS
After any of the bariatric procedures, patients are seen in follow-up at
2 weeks to ensure that they are well-hydrated, tolerating oral intake,
and without wound complications. They are then seen at 3, 6, 12, 18,
and 24 months and then annually thereafter to follow weight loss
and nutritional issues. For patients who undergo flexible endoscopic
techniques, more rigorous surveillance in the first 24 months is necessary as there is a greater propensity for weight regain. Regardless
of the procedural technique, patients are encouraged to meet with
dieticians and remain with their support groups indefinitely.
For 1 month after surgery, patients are all maintained on a
high-protein puree consistency diet; after that they gradually are
advanced to solid food. They also receive multivitamins, calcium,
and vitamin B
patients with gastric bypass and DS-BPD who are at higher risk for
malabsorption and possible malnutrition. Supplemental iron should
be considered for menstruating women.
Weight loss after gastric bypass and DS-BPD occurs primarily in
the first 12 to 18 months after surgery and averages approximately
70% and 80% excess weight loss (EWL), respectively. Sleeve gastrectomy patients typically have less EWL, on average 50% to 60% over
a 2-year period.
One of the most important outcome measures after bariatric surgery is remission of obesity-related metabolic diseases, such as type 2
diabetes. More than 70% to 80% of patients with diabetes experience
complete remission after undergoing gastric bypass or DS-BPD. The
restrictive operations have a 50% remission rate of diabetes. Hypertension, sleep apnea, hyperlipidemia, and fatty liver disease have
similar remission rates after surgery. Flexible endoscopic approaches
confer less weight loss than their surgical counterparts and do not
appear to induce the weight-independent metabolic benefits seen
with bariatric surgery.
Overall complication rates after bariatric surgery are less than
15% in most reports. Like most surgeries, there are early and late
complications for bariatric surgery. Early or perioperative complications include bleeding, anastomotic leakage, and deep venous thrombosis. The mortality rate is less than 0.5% and is usually attributable
to a pulmonary embolus or sepsis from anastomotic leak. Persistent
supplements. This is especially important for
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unexplained tachycardia higher than 120 beats/min may be an early
sign of sepsis, and an appropriate workup should be considered.
Vitamin B
, calcium, iron, vitamin D, and protein deficiencies
12
are long-term complications that can occur within the first year after
surgery. Rigorous monitoring of nutrition status is necessary. Vitamin B
deficiency also can occur in patients with protracted vomiting
1
after surgery, and they may experience extremity paresthesias, confusion, and nystagmus. Lower extremity weakness and paresthesias
also can be seen with vitamin B
deficiency. Anastomotic stenosis
12
and obstruction at the gastrojejunostomy in the first few months
after surgery occur in less than 5% of patients after gastric bypass and
usually can be managed with endoscopic dilation.
Internal hernias are also a possible complication and can occur at
any time after surgery. The symptoms of internal hernia can be similar to an acute bowel obstruction or become chronic and described
as postprandial periumbilical cramping pain. If internal hernia is
suspected, operative intervention may be required to avoid possible
bowel ischemia.
In general, the results of weight loss surgery are excellent, with
most patients losing more than 50% of their excess weight with
dramatic improvement or remission of metabolic disease. Approximately 10% to 15% of patients either do not achieve significant
weight loss or partially regain their weight after 2 to 3 years. Ideally,
these patients respond to dietary counseling, although some may
need operative revision or conversion to a more malabsorptive procedure, such as the DS-BPD.
Unfortunately, no perfect method exists for choosing the best
operation for each individual patient. Certainly, a multidisciplinary
team approach is helpful in providing patient support throughout the
preoperative and postoperative course. Reducing obesity-related diseases should be the major goal, not merely cosmetic improvement.
Patients must understand that bariatric procedures are a tool to assist
with weight loss, and it must be combined with lifelong changes in
dietary, exercise, and lifestyle habits.
S u g g e S t e d R e a d i n g S
Adams TD, Gress RE, Smith S, etal. Long-term mortality after gastric bypass
surgery. N Engl J Me. 2007;357:753.
ASMBS. Estimate of Bariatric Surgery Numbers, 2011–2019. https://asmbs.
org/resources/estimate-of-bariatric-surgery-numbers. Retrieved March
2021.
Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systemic
review and meta-analysis. J Am Med Assoc. 2004;292:1724.
CDC. Adult Obesity Facts. https://www.cdc.gov/obesity/data/adult.html.
Retrieved June 2021.
Fayad L, Adam A, Schweitzer M, et al. Endoscopic sleeve gastroplasty ver-
sus laparoscopic sleeve gastrectomy: a case-matched study. Gastrointest
Endosc. 2019;89(4):782–788.
Kumbhari V, Hill C, Sullivan S, Kumbhari V, etal. Bariatric endoscopy: state-
of-the-art. Curr Opin Gastroenterol. 2017;33(5):358–365.
Taylor J, Canner J, Cronauer C, etal. Implementation of an enhanced recovery
program for bariatric surgery. Surg Endosc. 2020;34:2675–2681.
S B
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Management of Small
Bowel Obstruction
Charudutt Paranjape, MD, and George Velmahos, MD
INTRODUCTION
Small bowel obstruction (SBO) accounts for 2% to 4% of emergency
department (ED) visits for abdominal pain and accounts for as many
as 16% of surgical admissions and more than 300,000 operations
annually in the United States. The associated cost is over $2 billion
in inpatient costs annually. Although some obstructions occur in
the large intestine, close to 80% of bowel obstructions occur in
the small intestine. Unfortunately, patients may experience a high
complication rate including strangulation. The overall mortality rate
associated with SBO is less than 3%, but the rates escalate to 7% to
14% in the elderly.
CAUSES
Postoperative adhesions account for 75% to 80% of all cases of SBO.
Adhesive small bowel obstruction (ASBO) represents a common
entity among emergency surgical diseases, accounting for 4.6% for all
types of operations. Among patients operated on for prior ASBO, the
incidence of operative intervention increases to 15.6%. Other causes
of SBO include congenital anatomic abnormalities (e.g., midgut volvulus, ileal atresia, de novo adhesions), disorders of the bowel wall
(e.g., intussusception, stricture, tumor), extrinsic compression (e.g.,
compression from mass), intraluminal disorders (e.g., meconium
ileus, gallstones, foreign body, bezoar), strangulated hernias (most
common cause of SBO in undeveloped countries), foreign bodies
(e.g., bezoars, swallowed objects, gallstones), radiation, endometriosis, and infection (a common cause in undeveloped countries, such
as tuberculosis). In the absence of previous intraabdominal surgery,
abdominal wall hernia with small bowel incarceration is the most
common cause of bowel obstruction. Older patients with suspected
SBO but no prior abdominal surgery and the absence of a hernia on
examination should be evaluated for malignancy.
CLINICAL PRESENTATION
The diagnosis of SBO is not always straightforward, as many patients
have variable symptoms at onset, and some cases may initially be
misdiagnosed. Patients may describe nausea and vomiting, intermittent abdominal pain, abdominal distension, hyperactive bowel
sounds, and inability to keep food and fluids down. Symptoms may
then progress to continuous pain, hypoactive bowel sounds, and
worsening vomiting. However, these signs and symptoms are not
specific for diagnosis, and patients with SBO may continue to pass
stool and flatus. Specific historical elements that should be discerned
include previous bowel obstructions and their management, abdominal operations, radiation, and other abdominal disorders (e.g.,
inflammatory bowel disease [IBD], neoplasm).
The physical examination should begin with evaluating for systemic toxicity necessitating resuscitation, followed by abdominal
examination and evaluation for the presence of any hernia causing
the obstruction. Peritonitis, localized tenderness, hypotension, or
tachycardia suggest strangulation and bowel ischemia. Fever, leukocytosis, decreased urine output, altered mental status, and metabolic acidosis are also concerning for systemic toxicity and bowel
ischemia. Persistent pain that continues to worsen or pain out of
proportion to examination is suggestive of ischemia or closed-loop
obstruction and should be evaluated without delay. Palpation of the
abdomen of patients with SBO is critical and a learned art. Significant pain to light percussion, focal tap tenderness, and guarding are
potential signs of peritonitis and merit close attention and possible
surgical exploration. Rectal examination is mandatory because it can
identify fecal impaction, rectal masses, blood, or the rare obturator
hernia, all of which would critically alter management.
DIAGNOSIS
Although the history and physical examination can guide the clinician toward a diagnosis of SBO, they are not sufficiently sensitive
or specific for the diagnosis of SBO and its potential complications;
thus, imaging has become essential for a diagnosis.
Laboratory Testing
There are no laboratory tests that are sensitive or specific for the
diagnosis of SBO or that can reliably predict ischemic bowel. Recommended tests in patients with abdominal pain, nausea, and vomiting
include a basic metabolic panel with magnesium and phosphate,
a complete blood count with differential, and if bowel ischemia is
suspected, a lactic acid level. A basic metabolic panel can identify
electrolyte imbalances and renal dysfunction caused by hypovolemia.
Patients with SBO may have hypokalemia, contraction alkalosis, or
metabolic acidosis. A CBC (with differential) can assess leukocytosis.
Leukocytosis with a left shift is a nonspecific indicator of inflammation and/or infection; it does not correlate with disease severity.
An elevated lactic acid level can be seen with bowel ischemia, but
notably, a normal lactate level does not rule it out. An elevated lactic
acid level can also be a nonspecific indicator of inadequate perfusion
of any number of organs.
Imaging
Plain Radiography
Plain radiographs may have a role in the initial diagnostic evaluation
because of their widespread availability, low cost, and ability to follow
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disease progression serially; however, the sensitivity of plain films
is 66% to 85%. In addition, over 20% of abdominal radiographs in
patients with SBO are nonspecific or normal. The typical gas pattern for SBO on plain film demonstrates dilated gas- or fluid-filled
loops of small bowel in the setting of a gasless or nondistended
colon (Fig. 1). However, a patient with SBO may demonstrate more
subtle findings on x-ray study, and a plain film can simply show airfluid levels with a normal or slightly distended colon. Small bowel
perforation may be diagnosed with upright radiography, although
not with an optimal level of accuracy. The severity of SBO can be
underestimated on abdominal radiography if the dilated bowel loops
are predominantly fluid-filled. If a strong suspicion for SBO is present, other testing is recommended as a negative radiograph cannot
exclude the diagnosis.
Computed Tomography
CT is the imaging modality of choice and currently considered the
standard of care for imaging SBO in most cases. Per the Eastern
Association for the Surgery of Trauma (EAST) guidelines, level 1 evidence recommends the use of CT for diagnosing SBO. Intravenous
contrast is desirable in the absence of contraindications. Although
oral contrast may not be used in the initial CT scan as it causes
delays and possible aspiration, Gastrografin may be given in partial
adhesive SBO at a later point to expedite resolution of the obstruction. CT identifies the site of obstruction (transition point between
distended and collapsed bowel) with a 93% sensitivity and 67%
specificity and can detect bowel ischemia or closed-loop obstruction.
Findings concerning for bowel wall compromise include bowel wall
edema or hemorrhage, altered bowel wall enhancement, interloop
ascites, mesenteric edema/fat stranding, vascular engorgement, and/
or vessel occlusion. As in abdominal radiographs, pneumatosis of the
bowel wall, mesenteric and/or portal venous gas, and extraluminal
free air are late signs of bowel wall compromise and indicate bowel
wall necrosis in the setting of SBO. Despite the sensitivity of CT in
detecting direct and indirect signs of bowel compromise, it cannot
be used alone for the decision to operate. Such a decision is always
based on a combination of clinical, laboratory, and imaging findings.
Magnetic Resonance Imaging
Advantages of MRI over CT include lack of ionizing radiation,
improved soft tissue contrast, the ability to provide dynamic information regarding bowel distention and motility, and relatively safe
intravenous contrast agents. MRI possesses high sensitivity and
specificity for diagnosis. MRI possesses limitations, including limited
availability, long scan times, high cost, variability in examination
quality, and lower spatial and temporal resolution compared with
CT. At this time, except for pregnant women and children, CT is
preferred over MRI.
CLASSIFICATION
The aforementioned diagnostic process will allow the patient to be
categorized into one of three groups (Fig. 2).
Partial Small Bowel Obstruction
Patients with partial small bowel obstruction (pSBO) have incomplete obstruction with luminal narrowing, but some contents continue to pass through the intestine. Clinically, this is recognized
when patients exhibit the signs, symptoms, and radiographic findings consistent with SBO, but exhibit a benign abdominal examination and continue to pass bowel movements and flatus.
Complete Small Bowel Obstruction
These patients have obstruction with no passage of luminal contents
beyond the point of obstruction. Clinically, this is recognized when
patients exhibit the signs, symptoms, and radiographic findings
consistent with SBO and are not passing bowel movements or flatus.
Complete Small Bowel Obstruction with Bowel
Compromise
The bowel is considered compromised when there is ischemia or
injury that has led or may lead to necrosis and/or perforation of the
bowel wall. There is a high risk of morbidity and mortality if compromised bowel is not treated in an expedient manner. Signs, symptoms,
and imaging findings of bowel compromise are shown in Table 1.
FIG. 1 Plain x-ray of the abdomen showing many distended small bowel
loops caused by a distal obstruction.
MANAGEMENT
The initial goal of evaluating a patient with SBO is to immediately
identify hemodynamic instability, the presence of strangulation or
bowel ischemia, and the need for urgent operative intervention.
These decisions should be made concurrently with resuscitation.
Patients with SBO should be provided intravenous fluid resuscitation
and electrolyte replacement, symptomatic control with antiemetics
and analgesics, and bowel rest by nil per os. Decompression via
nasogastric tube (NGT) is necessary in most but not all cases. Early
evaluation by a surgical service is desirable.
Nonoperative Management
Expectant therapy and symptomatic management are typically recommended for patients without peritonitis or hemodynamic instability, with high success rates.
The use of NGT decompression is based on old and often debated
evidence. Supposedly, proximal decompression facilitates relief of the
obstruction, but the pain and discomfort to the patient is not negligible. The exact population that can be managed safely without it has
not been accurately determined, although it exists.
Patients with partial adhesive SBO without strangulation are good
candidates for water-soluble contrast medium such as Gastrografin
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FIG. 2 Diagram of the three CT patterns of closed-loop small bowel obstruction, which is defined as obstruction of the bowel lumen at two sites located
next to each other, creating a closed loop. (A) In typical closed-loop obstruction, the afferent loop (asterisk) and closed loop (arrowheads) are dilated and
the efferent loop (arrow) is collapsed. (B) In collapsed closed-loop obstruction, the closed loop (arrowheads) is collapsed, the afferent loop (asterisk) is dilated, and the efferent loop (arrow) is collapsed. (C) In flat-belly closed-loop obstruction, the closed loop is dilated (arrowheads) and the afferent (asterisk) and
efferent (arrow) loops are collapsed. (From Rondenet C, Millet I, Corno, L.,etal.CT diagnosis of closed loop bowel obstruction mechanism is not sufficient to indicate
emergent surgery.Eur Radiol. 2020;30:1105–1112.)
TABLE 1 Findings Consistent with Small Bowel Compromise
Clinical Presentation of SBO Concerning Radiographic Signs
• Severeabdominalpain
• Fever
• Hypotension
• Tachypnea
• Tachycardia
• Mentalstatuschanges
• Peritonealsigns(guardingonexamination,reboundtenderness)
• Nonreducibleherniawithseverepainandoverlyingskinchanges
(erythema and/or dark discoloration)
• Decreasedurineoutput
• Leukocytosis
• Elevatedlactate
SBO, Small bowel obstruction.
for both diagnostic and therapeutic purposes. Gastrografin is administered orally or most commonly by NG tube in doses of 100 mL in
50 mL of water, either immediately at admission, or if conservative
therapy with decompression fails, after 48 hours. After administration, Gastrografin appearing in the colon within 24 hours on x-ray
study predicts resolution without surgical intervention. The radiograph can be repeated every 8 to 12 hours as long as the patient’s
examination, symptoms, laboratory tests, and vital signs improve
or remain stable. Literature suggests that this intervention is safe
and can reduce the need for surgery, SBO time to resolution, and
hospital stay. Nonoperative techniques can be utilized for 2 to 3
days, but if the patient demonstrates no improvement or no passage
of Gastrografin into the colon, operative therapy should be strongly
considered.
Abdominal x-ray or CT abdomen/pelvis:
• Pneumatosis,mesentericand/orportalvenousgas,andextralu-
minal free intraperitoneal air are late signs and indicate bowel
necrosis in the setting of SBO.
Other signs:
• Bowelwalledemaorhemorrhage
• Alteredbowelwallenhancement(decreased,absent,ordelayed
hyperenhancement)
• Interloopascites
• Mesentericedema/fatstranding,ascites,vascularengorgementor
occlusion
• Multipletransitionzones:Closed-loopobstructiondemonstrates
radial small bowel arrangement with a U- or C-shaped configuration, converging at the site of obstruction.
• Swirlingofmesentericvessels(alsoknownastheswirl sign or
whirl sign) may indicate volvulus and/or closed-loop obstruction.
Operative Management
Patients with signs of strangulation or generalized peritonitis, evidence of clinical deterioration (continuous or worsening pain, fever,
hypotension, tachycardia, metabolic acidosis), or concern for bowel
compromise based on imaging should undergo surgical exploration
(level 1 recommendation per EAST guidelines). Nearly all other
patients can be offered a trial of nonoperative management. Close
monitoring during nonoperative management allows identification
of patients with worsening symptoms who should be explored. A
greater point of debate presents the time of surgery for those who
have a benign abdominal examination but remain with a persistent
obstruction. From the old dictum of “never let the sun rise or set on a
small bowel obstruction,” we now accept that nonoperative treatment
can continue for days. The likelihood for spontaneous resolution
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TABLE 2 Eastern Association for the Surgery
of Trauma Practice Management Guideline for
Managing SBO
Recommendation
Management
Patients with generalized peritonitis
or other evidence of clinical deterioration (fever, leukocytosis, tachycardia, acidosis, continuous pain)
should undergo timely surgical
exploration.
Patients with no evidence of clinical
deterioration can safely undergo
nonoperative management initially.
CT findings consistent with bowel
ischemia require a low threshold for
operative intervention.
Laparoscopic treatment of SBO is a
viable option compared with laparotomy in selected cases.
Water-soluble contrast should be con-
sidered for patients with partial SBO
that has not resolved in 48 hours.
SBO, Small bowel obstruction.
Level
1
1
2
2
2
FIG. 3 Closed loop small bowel obstruction.
required to be performed by a member of a surgical team. If ischemic bowel is suspected (severe pain, tense hernia, overlying skin
changes), urgent surgical exploration should be performed. The surgical team admitting the patient may decide to reduce the bowel and
monitor post–hernia reduction (typically at least 24 hours) if there
are no concerns for bowel compromise.
decreases after the third day, and a number of studies suggest that
the likelihood of complications increases. However, the evidence is
poor and controversial. The EAST guidelines for general operative
management are shown in Table 2.
Laparoscopic Management
Historically, abdominal exploration through laparotomy was the
standard treatment for SBO, but laparoscopy has been used with
a higher frequency over recent years. In a systematic review and
meta-analysis of 14 nonrandomized studies, laparoscopic adhesiolysis reduced the risk of morbidity, in-hospital mortality, and surgical
infections. Predictors for successful laparoscopic treatment of SBO
are the following: a history of ≤2 laparotomies, appendectomy as the
sole previous operation and cause of the obstruction, no previous
median laparotomy incision, and a single adhesive band.
SBO WITH CONFOUNDING
CONDITIONS
Closed-Loop SBO
Patients with closed-loop SBO are at increased risk for both strangulation and failure of nonoperative treatment (Fig. 3). The threshold
for surgical exploration lowers significantly, and vigilance increases.
However, it must be emphasized that not all closed-loop obstructions
automatically need an operation. As stated earlier, the decision to
operate is a combination of various factors, including clinical presentation and imaging findings, and not just a picture on CT.
SBO with a Transition Point at the Site of a Hernia
Patients presenting with a transition zone at the site of an abdominal
wall hernia require special attention. These obstructions should only
be reduced by the surgical team. Assessment for ischemic bowel is
Geriatric Patients
Because of medical comorbidities, especially in the emergency setting, patients older than 60 years and 80 years have twice and thrice
the risk of adverse outcomes after surgery, respectively, relative to
younger adults. Preoperative cardiac risk stratification and physiologic optimization is desirable when not leading to undue delays.
Overall, the decision to operate in geriatric patients should balance
the desire to intervene early and before fragile physiologic reserves
are exhausted, while not liberalizing major abdominal surgery on
frail individuals. Goals of care, code status, and discharge disposition
should ideally be discussed at the time of admission.
Pregnancy
SBO in pregnancy is rare; it is estimated that a practicing surgeon
may manage 1 to 2 cases in a career. One-half of reported SBO cases
during pregnancy are caused by adhesions. Fetal mortality averages
21% and is more likely with surgery in the first trimester. An urgent
MRI is advised absent immediate indications for surgery. Pregnancy
is not an absolute contraindication to ionizing radiation from radiographs or CT scans; however, the risks and benefits of fetal exposure
to radiation must be carefully weighed. Overall, the same rules of
operative versus nonoperative management that are used in the general population apply also to pregnancy.
Obstruction Due to Inflammatory Bowel Disease
Although most IBD patients are admitted to a medical service, early
surgical consultation is recommended in the presence of an acute
SBO. Evidence of intestinal obstruction represents one of the defining characteristics for severe/fulminant IBD. Although there is no
strong evidence in support of specific treatment algorithms on the
acute management of intestinal obstruction associated with IBD, a
number of evidence-based recommendations have been made. It has
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been recommended that the treatment plan be based on factors such
as the location and length of the stricture, degree of concomitant
inflammation, degree of upstream bowel dilation, and other accompanying features, such as abscess or phlegmon. Early cross-sectional
imaging with a CT enterography (CTE) protocol is essential as is the
early involvement of both gastroenterology and colorectal surgery in
the treatment team. The team should determine early surgery versus
neoadjuvant antiinflammatory therapy and the need for antibiotics
and/or abscess drainage.
Malignancy
Unlike nonmalignant etiologies, these patients tend to have a subacute clinical picture with a slow insidious onset that is typical of
partial SBO. For patients who present with SBO caused by a nonmetastatic or locally advanced primary small bowel tumor, an operative
intervention with curative intent remains the principal tenet of management. The differential for these tumors typically includes small
bowel neuroendocrine tumors, adenocarcinomas, lymphomas, and
gastrointestinal stromal tumors. For such patients, oncologic principles should include a resection of the involved segment of bowel
along with a 5- to 10-cm margin proximally and distally as well as
removal of all associated mesentery. Small bowel resection is a preferable approach when the site of obstruction is isolated, the tumor
causing the obstruction is intrinsic to bowel, negative margins are a
possibility, and the postoperative outcome is potentially curative. A
small bowel bypass is preferable if the tumor causing the obstruction
cannot be completely resected and multiple sites of bowel obstruction exist. The goal with bypass is palliation. For patients who present with obstruction from incurable advanced disease, the factors
affecting the final treatment plan include established goals of care set
forth by the patient with the guidance of the surgeon and the medical
oncologist. It is beneficial to involve a palliative care specialist at this
juncture as well.
Virgin Abdomen
Based on findings in recent reviews, SBO in virgin abdomen (VA)
has a mostly benign cause; this is in contrast with older literature
and surgical textbooks that suggest malignancy as the main cause
of obstruction in VA patients. Etiology and treatment results for
patients with SBO in VA are largely comparable to the results in
patients with SBO after previous abdominal surgery. CT has a pivotal role in the assessment of SBO in VA to assess the etiology and
to evaluate if the bowel is compromised, demanding early surgery.
Moreover, modern high-resolution CT is also useful in minimizing
the risk of failure to detect a malignant cause. As with ASBO in
general, the majority of cases with SBO in VA can be treated by nonoperative trial initially. Nevertheless, a laparotomy remains indicated
in case of a nonresolving obstruction. The need to perform surgical
exploration in every patient with SBO in VA can be waived. Noninvasive diagnostics with high accuracy for detection of malignancy and
a close follow-up are mandatory.
Bariatric Surgery
Bariatric patients can present with obstruction from the same causes
as all other patients, but also carry a greater risk of internal hernia,
intussusception, and closed-loop obstructions resulting from surgical creation of mesenteric defects. CT results for patients with a
history of laparoscopic Roux-en-Y gastric bypass may be subtle. A
significantly dilated small bowel with a transition point is often a late
finding. Elevated amylase and/or lipase may be a significant finding
in this patient population, especially with acute obstruction of the
biliopancreatic limb. Reviewing the CT scan with the radiologist to
discuss any subtle findings and having a lower threshold to proceed
to the operating room for any suspicious findings is recommended.
Early intervention is necessary to prevent the loss of significant
portions of bowel to ischemia with resulting increased morbidity and
mortality. Laparoscopic enterolysis is feasible and safe. Careful bowel
handling and clearly identifying all three limbs is essential because
mesenteric or internal hernia can occur at multiple sites.
Early Postoperative Small Bowel Obstruction
Pivotal problems in the management of obstruction in the early postoperative period (3–4 weeks after surgery) are differentiation of ileus
from mechanical obstruction and distinction between simple and
strangulating obstruction if mechanical obstruction is present. Early
postoperative small bowel obstruction (ESBO) poses an interesting
dilemma for the surgeon. Although some ESBOs will resolve with
nonoperative/conservative treatment, waiting beyond the 2-week
period after the index surgery can result in forcing the surgeon to
operate in a “hostile abdomen” because of significant inflammatory/
postoperative adhesions. The decision to reoperate should account
for clinical and radiographic signs suggesting impending strangulation or closed-loop obstruction, elapsed length of time of nonoperative management, and the nature of the index operation. Early
reoperation should be considered after certain laparoscopic procedures. Surgeons managing SBO can benefit from understanding the
unique features of ESBO after Roux-en-Y gastric bypass.
CONCLUSION
Small bowel obstructions remain an exceedingly common reason for
emergency/unplanned admissions. SBO is a significant burden to
the healthcare system, accounting for over 300,000 admissions per
year and $1.3 billion per year in US healthcare costs. They present
a management dilemma for clinicians and, most importantly, are a
significant burden to patients because of the use of nasogastric tubes,
need for operative intervention, and the often recurrent nature of the
disease process. Unique variations of SBO pose challenging clinical
decision dilemmas. The management of SBO is based on clinical
evaluation, biological tests, and CT imaging. The goal of the initial
assessment of a patient with SBO is to quickly identify signs of bowel
ischemia that would necessitate urgent surgical intervention with
concurrent resuscitation. The challenge for the emergency general
surgeon is identifying as quickly as possible the minority of patients
presenting with SBO who will not resolve without surgery. In the
absence of any “alarming” signs, the patient can be managed with a
trial of nonoperative management. Incorporation of a water-soluble
contrast agent challenge early in the treatment algorithm can efficiently predict the success of nonoperative management and potentially hasten the return of bowel function, reducing hospital length
of stay. Absence of passage of contrast into the cecum or interval
deterioration of clinical examination suggests the need for operative
intervention. Adhesive SBO can lead to small bowel strangulation,
which is considered a major cause of morbidity and mortality.
Therefore, surgery is indicated in patients with clinical deterioration or with radiologic evidence of strangulation and/or persistent
obstruction. Laparoscopic surgery is becoming more common in the
management of SBO and has distinct advantages in selected patients.
S u g g e S t e d R e a d i n g S
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bowel obstruction in virgin abdomen: a WSES position paper. World J
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Small bowel obstruction. Surg Clin North Am. 2018;98(5):945–971.
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Am J Surg. 2020;219(3):535–539.
Ten Broek RPG, Krielen P, Di Saverio S, etal. Bologna guidelines for diag-
nosis and management of adhesive small bowel obstruction (ASBO):
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2017 update of the evidence-based guidelines from the world society of
emergency surgery ASBO working group. World J Emerg Surg. 2018;13:24.
Vercruysse G, Busch R, Dimcheff D, et al. Evaluation and Management of
Mechanical Small Bowel Obstruction in Adults: Ann Arbor (MI): Michigan
Medicine University of Michigan; April 2021.
Management of Crohn’s
Disease of the Small
Bowel
John Peter Ricci, MD, and Mark A. Talamini, MD
rohn’s disease is a chronic inflammatory transmural disease that
can affect the entire gastrointestinal (GI) tract. As often is stated
C
in medical school lectures, it can present anywhere from “the mouth
to the anus.” Most commonly, it occurs in the small intestine with
the terminal ileum being the most common location. Its incidence
is increasing worldwide and now is noted to be present in 201 of
100,000 adults in the United States. Its exact cause is unclear and
continues to be an enigma despite intense investigation. A complex
interaction of genetics, environment, and the microbiome with the
host’s immune system appears central in understanding the origin of
Crohn’s disease. Clinically, it tends to be a cyclical disease in symptoms and pathophysiology. There are episodes of alternating active
inflammation and relative dormancy that contribute to the overall
difficulty in management. There is a large spectrum of severity in
presentation ranging from mild inflammation to significant complications including strictures, perforations, hemorrhage, abscess
formation, and malignant degeneration.
The clinical hallmark of Crohn’s disease is abdominal pain and
diarrhea. The broader spectrum of associated symptoms may include
hematochezia, fever, anorexia, weight loss, fatigue, nausea, emesis,
malnutrition, vitamin deficiency, and stunted growth in younger
patients. Most patients are diagnosed between 15 and 30 years of
age, but a second spike in diagnosis has been noted in the sixth
decade of life, largely in females. In its early presentation, Crohn’s
disease must be differentiated clinically from acute GI conditions
such as appendicitis and bowel obstruction. Definitive diagnosis is
not always easily obtained and depends on a detailed family history,
environmental history, and physical examination. CT enterography
and MRI enterography have become essential in the initial evaluation
of these patients as have blood tests to monitor and follow inflammatory markers. Endoscopy and colonoscopy are performed for
direct visualization of bowel mucosa and to obtain tissue diagnosis.
Capsule endoscopy can be employed for further direct evaluation of
the small bowel mucosa. At initial presentation, 40% of patients will
have terminal ileal disease, 20% colonic disease, 10% proximal small
bowel disease, 10% perianal disease, and 20% will have involvement
of more than one anatomic location.
Over the past 20 years, medical management of inflammatory
bowel disease has improved significantly with the development of
tumor necrosis factor (TNF) inhibitors and other biologic therapies.
Despite this fact, surgery remains a significant treatment option in
the management of a large cohort of patients, and approximately
one-half of Crohn’s patients will require some surgical intervention
within 10 years of diagnosis. Surgery for Crohn’s disease is not curative; therefore its application in patient management can be challenging. Overall, the goals of surgical treatment are alleviating symptoms,
Zamary K, Spain DA. Small bowel obstruction: the sun also rises?. J
Gastrointest Surg. 2020;24(8):1922–1928.
Zins M, Millet I, Taourel P. Adhesive small bowel obstruction: predictive
radiology to improve patient management. Radiology. 2020;296(3):480–
492.
improving quality of life, and preserving bowel length. Surgery can
provide remission of active inflammation that cannot be obtained
with medical therapy alone. It can also be used to treat strictures,
abscesses, and fistulas that also will not respond to medicine.
MULTIDISCIPLINARY MANAGEMENT
The optimal management of the Crohn’s disease patient requires a
team approach. This team is anchored by the surgeon and gastroenterologist. A multidisciplinary group will also require input from
radiology, pathology, social work, nutrition, enterostomal therapy,
and associated specialties. Complex cases often are reviewed in a
formal organized setting in which a member from each specialty is
represented so the best treatment plan can be formulated.
MEDICAL TREATMENT
Mild to moderate disease is noted in the majority of patients at initial presentation. Standard initial management, in these cases, will
usually include 5-aminocalycylates or budesonide depending on the
location of disease. Acute flares can be treated with short courses of
corticosteroids with transition to maintenance therapy once an adequate remission has been achieved. TNF inhibitors have drastically
changed the approach to patients with moderate to severe disease.
Studies have shown fistula resolution and combination therapy with
methotrexate has demonstrated high mucosal healing rates. Newer
biologic agents including anti-interleukin12/23 antibody (ustekinumab), anti–alpha-4 beta-7 integrin antibody (vedolizumab), and
JAKs-based therapies (tofacitinib) continue to be developed with
new molecular targets to decrease inflammation.
These new medications have been shown to decrease the need
for surgical intervention in milder forms of the disease. They also
provide the gastroenterologist a means of delaying surgery for prolonged periods. However, surgery remains an important treatment
option for severe disease and disease that is otherwise refractory to
medical management.
INDICATIONS FOR SURGERY
The main indications for surgery in Crohn’s disease are obstruction,
perforation, and failure of medical management. Emergency surgery
is infrequently required as free perforation and massive bleeding
are rare and obstruction is usually gradual in presentation. Acute
appendicitis can occur, but this often is treated with antibiotics as
associated small bowel and colonic inflammation are usually noted
before intervention on CT imaging. Patients with long-standing
Crohn’s disease are at increased risk of developing adenocarcinoma.
Principles of surgical management would be the same as a patient
with de novo adenocarcinoma of the small bowel. However, diagnosis is commonly an incidental finding after standard Crohn’s disease
surgery.
Obstruction
Obstruction is the most common indication for surgery in Crohn’s
disease. The natural history is that of gradual onset in the setting of
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chronic relapsing disease. The cycling of inflammation and repair
over time in an affected segment eventually converts soft pliable
bowel into a constricted “stovepipe.” Clinically as this process
progresses, the symptomatology evolves from intermittent partial
obstruction experienced during episodes of transmural inflammation to chronic partial obstruction that exists between episodes of
acute inflammation. The latter situation is commonly referred to
as a fibrostenotic stricture. Once this stricture has developed, minimal acute inflammation can lead to obstructive symptoms and an
acute flare. On imaging, proximal bowel to the stricture is noted
to be dilated, prompting treatment frequently with corticosteroids
and antibiotics. All strictures have some component of chronic
scarring, and it can be difficult to differentiate a stricture that is
largely inflammatory versus one that is largely fibrostenotic. Both
MRI and CT enterography have improved significantly over the
past decade, making this differentiation somewhat clearer. In the
authors’ practice, once the patient is treated acutely with anti-inflammatory medication and is noted to be asymptomatic, imaging
is repeated. If persistent dilation of the bowel proximal to the stricture is appreciated, predominant fibrostenotic disease is assumed
to be present. This is a clear indication for surgical intervention
as medication will not be effective in the treatment of chronic scar
tissue. If the bowel is noted to be decompressed, medical therapy
should be optimized.
Perforation
Perforation is the next most common indication for surgery. As a
transmural inflammatory process, Crohn’s disease can cause localized perforation with abscess formation leading to fistulization. The
pathophysiology is that of the inflammatory process in the affected
bowel perforated into the peritoneal cavity, usually forming a walled
off abscess. This abscess can become chronic requiring long-term
antibiotics or percutaneous drainage. If an abscess persists, it
ultimately will require surgical intervention. If the abscess can be
treated nonoperatively, a multidisciplinary approach should be used
to determine ongoing treatment on an individual basis. A small
resolved abscess on a patient on minimal medical therapy would
likely benefit from medical escalation and optimization, whereas a
resolved abscess in a patient who has failed three biological medications would likely be offered surgery.
Frequently, these abscesses can “burrow” to adjacent “innocent”
structures, creating a fistula. The structures most commonly involved
are pieces of bowel (enteroenteric/enterocolonic fistula), the bladder
(enterovesical fistula), or the skin (enterocutaneous fistula). When
the process creates a clean fistula into another portion of the GI
tract without an associated abscess, the decision regarding surgery
depends on the impact of this connection. Thus, enteroenteric or
enterocolonic fistula are not in themselves a definite indication for
surgery. Only when the fistula causes worsening clinical symptoms
or nutritional deficiencies should surgery be performed. In addition,
studies have shown that TNF inhibitors have some effect in treating
GI tract fistula. Enterovesical fistulas are usually not life-threatening,
but they lead to recurrent urinary tract infections, pyelonephritis,
and, in rare cases, urosepsis. In addition, the symptoms of pneumaturia and fecaluria are generally intolerable to most patients. Surgical
repair should be pursued in this situation. Similarly, enterocutaneous
fistulas require surgical intervention because of chronic drainage
from the abdominal wall, chronic abdominal wall wounds, dehydration, and frequent nutritional deficiencies.
Failure of Medical Management
Failure of medical management is probably the most difficult indication to determine as it is largely patient dependent. The surgeon, gastroenterologist, and patient must work closely together to determine
when during the treatment process surgical intervention is most
have advanced, new treatments continually become available that
have allowed some patients to avoid surgery while only delaying it for
others. Clearly, given their long-term consequences, inability to wean
steroids after an acute flare and transition to maintenance therapy
is an absolute indication for surgery. It is less clear how to proceed
when a patient remains symptomatic and has tried multiple medications, but additional options exist. In these instances, attempting
additional second- and third-line therapies can take several months
to determine success and possibly delay the inevitable need for surgery. It should also be noted that eliminating the burden of active
disease and inducing remission surgically can provide patients with
a “fresh start” off all agents and allows previously failed medications
to be reattempted.
PREOPERATIVE CONSIDERATIONS
Timing
The timing of surgery is important in maximizing the clinical
outcome. The patient’s willingness or resistance to surgery affects
decision making. The input of the surgeon and gastroenterologist
regarding recommendations is imperative. Operating too soon when
the bowel is intensely inflamed is technically challenging and puts
non-diseased bowel at risk. Allowing an acute flare time to resolve,
at least partially, can greatly affect outcome. Every effort should be
made to convert more emergent situations to urgent and elective
scenarios. Active abscesses should be drained percutaneously. Conversely, these patients frequently have some aspect of malnutrition,
and waiting too long for intervention can worsen this situation. In
rare instances when a significant length of bowel is at risk, bowel rest
and total parenteral nutrition may be required.
Once a decision regarding elective surgery has been made, the
patient’s current disease state must be assessed to inform preoperative planning. The patient’s general medical condition must be
assessed and optimized. If nutritional deficits exist and time allows,
nutritional improvement should be pursued. The authors follow a
strict enhanced recovery protocol and surgical site infection bundle.
A standard mechanical bowel preparation with oral antibiotics is
given unless a prolonged high-grade bowel obstruction is present. In
this case, an extended period of clear liquid diet is employed. Patients
are maintained on a clear liquid diet until 2 hours before surgery
and are given a carbohydrate-rich beverage preoperatively. If bowel
diversion is anticipated, the patient is evaluated by an enterostomal
therapist for preoperative stoma siting.
Medications
Prolonged and chronic use of corticosteroids has clearly been shown
to adversely affect wound healing and to increase the risk of surgical
site infection. This is especially an issue as dosages increase from
lower to higher daily prednisone equivalents. All efforts should be
made to wean or discontinue steroids before surgery, but this is
frequently not an option in the actively inflamed patient. In addition, patients may require perioperative steroid supplementation
depending on duration of use and dosage to prevent acute adrenal
insufficiency. More recently, the question of TNF inhibitor impact
on wound healing has come into question. Unfortunately, the literature provides no definitive guidance on this matter. Some studies
have shown no effect, with others showing a significantly increased
incidence of infectious complications when patients have taken the
medications within 6 to 8 weeks before surgery.
Consideration of bowel diversion with stoma creation must
be entertained when patients are on long-term steroid treatment.
This is likely true to a lesser extent when a patient has taken a TNF
inhibitor in the perioperative period. Malnutrition and bowel quality
also must be taken into account when considering stoma creation.
This ideally will be discussed with the patient preoperatively and the
patient will be referred to enterostomal therapy for evaluation.
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TECHNICAL CONSIDERATIONS FOR
SURGICAL INTERVENTION
Once it has been determined that surgery is the next step in treatment for a patient, meticulous preparation is required. This is
necessary to plan the possible extent of resection and identify all
areas of active disease. The entire small bowel should be evaluated,
and the exact state of the disease should be elucidated. Usually this
involves a current axial imaging study (CT or MRI enterography).
If questions remain regarding the small bowel anatomy or disease
state, capsule endoscopy or small bowel push enteroscopy can be
pursued. The colon should be evaluated via colonoscopy. The cecum
and the terminal ileum in particular merit examination because the
state of colonic disease can be more difficult to evaluate intraoperatively than small bowel disease. Endoscopy should be performed for
disease in the duodenum and proximal jejunum. Despite extensive
workup, intraoperative assessment can sometimes alter the surgical
plan.
Preoperatively, findings of the workup and contingencies must be
reviewed with the patient. The possible nutritional effects of surgery
and the possible role of a stoma should be discussed, as previously
noted. The more information the patient and family understand
regarding the plan, the better.
Resection
The mainstay of surgical therapy for Crohn’s disease of the small
intestine is resection. The most commonly faced initial operative
scenario is a tight, but reasonably short segment of chronically
obstructed and scarred terminal ileum. The most common operation, therefore, is an ileocecectomy. This accounts for approximately
half of the surgery for Crohn’s disease on the small intestine. Additional ascending colon may need to be included with the resection
specimen depending on the disease activity noted on colonoscopy.
Consideration of isolated terminal ileal resection should be considered only if 15 centimeters or more of normal small intestine
is present just proximal to the ileocecal valve. A short, isolated
segment of terminal ileum is extremely susceptible to recurrent
inflammation.
In virtually all cases, the authors attempt laparoscopic access, dissection, and mobilization of the targeted diseased tissue. The laparoscope is placed in a periumbilical or umbilical position with a Hassan
port via a direct cut-down technique. A 10-mm 30-degree scope is
used to maximize visualization from a variety of angles. Generally,
three 5-mm ports are employed on the left side of the abdomen as
working ports. Upon entrance into the abdomen, full evaluation of
the GI tract should be performed. This should be correlated with the
visual information from the preoperative evaluation. If isolated mid
small bowel disease is noted, this can be identified and easily externalized through extension of the umbilical port for resection and
re-anastomosis. If a fistula exists, it must be identified. Enteroenteric
fistula of the terminal ileum to itself can usually be preserved as
the entire segment of bowel usually requires en bloc resection as an
inflammatory mass. If the terminal ileum is fistulizing to otherwise
“innocent” portions of the GI tract, the fistula must be transected
and the healthy bowel must be assessed. This situation typically
occurs with a small bowel to sigmoid colon fistula. In this scenario,
the fistula opening in the sigmoid colon must be debrided to healthy
tissue and can be closed primarily. The author prefers a handsewn
two-layer approach in this situation, but a stapled repair can also
be performed. In some instances, colonic resection will be required
given associated inflammation in the area. A similar approach to
fistulas must be employed for “innocent” small bowel involvement. A
fistula to the bladder is usually taken down with primary repair of the
bladder if a definite opening is noted, and prolonged Foley catheter
drainage is performed. The catheter is removed after CT cystogram
confirms healing of the bladder.
Sufficient mobilization of tissue for resection must be performed.
This almost always involves some mobilization of the cecum, right
colon, and terminal ileal mesentery from the retroperitoneum.
This can be performed in a lateral-to-medial or medial-to-lateral
approach. However, the medial-to-lateral technique cannot always
be performed because of significantly thickened mesentery. Care
must be taken in this dissection to ensure that the proper plane is
identified and retroperitoneal tissue is preserved. The ureter should
be identified clearly. In rare cases of extreme inflammation, this is
not possible. In this situation, dissection of the ureter should be performed in the pelvis to better evaluate its course. In addition, if this
inflammation is noted and expected, preoperative ureteral catheter
placement should be performed.
As stated earlier, the specimen is generally extracted through
an extended umbilical incision. If extensive pelvic inflammation
is noted, the incision may need to be extended inferiorly. Vascular
transection can be performed intracorporeally, however frequently
the bowel mesentery is significantly foreshortened and thickened
from chronic inflammation. Transecting this mesentery can be tortuous and may require proximal vascular control to prevent extensive
blood loss. Attempt at laparoscopic transection should be considered
carefully.
The basic principle of small bowel resection for Crohn’s disease
is to remove all of the grossly involved disease while preserving as
much bowel length as possible. The authors attempt to measure
pre-resection and post-resection bowel length so it will be notated if
additional surgery is performed in the future. Grossly involved bowel
is best determined by visual and tactile evaluation. Fat creeping
should not be present, and the mesenteric margin should be palpable in unaffected intestine. Division of the mesentery, as previously
noted, can be difficult. The authors generally use a combination of
approaches including a vessel-sealing energy device, vascular staplers, and sutures to control bleeding from exceptionally thickened
mesentery. When at all possible, transection of mesentery distally
should be attempted so as not to compromise the vascular supply of
otherwise healthy bowel.
The worst complication in any bowel surgery is anastomotic
dehiscence, and this is no different for the Crohn’s disease patient.
Anastomotic techniques have been studied at length with no
definitive determination on the superiority of stapled or handsewn
anastomosis. It is the authors’ opinion, however, that the technique
employed should be that which is most comfortable for the primary surgeon. This should hopefully maximize reproducibility and
quality. The mesenteric defect is closed, when possible, to prevent
internal herniation but is left fully open for large defects that cannot
be reapproximated.
Ileostomy
As previously noted, sometimes patients will require temporary
bowel diversion after surgery for Crohn’s disease of the small intestine. This usually is required when the bowel or the patient is not
healthy enough to undergo primary anastomosis. This can occur
with extensive contamination from a drained abscess or if the bowel
is noted to be significantly dilated precluding healthy anastomosis.
High-dose steroid use and severe malnutrition can also create such
an environment. Rarely, a proximal diversion is required when significant inflammation of long segments of small intestine are noted.
In this situation, too much bowel is involved to resect, and proximal
diversion is performed as a last-ditch effort to induce remission.
Unfortunately, this diversion will undoubtedly be accompanied by a
high-output stoma requiring parenteral nutrition.
Disease of the Duodenum
Crohn’s disease of the duodenum frequently presents with nausea,
epigastric fullness, and emesis. It is easily diagnosed with imaging
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