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412
Fig. 29.1 Small bowel
obstruction from adhesions
G. Perrone et al.
multifactorial nature of adhesion pathogenesis. Extensive literature on the subject
demonstrates both the complexity of the issue and the myriad resources allocated to
this condition, yet few interdisciplinary studies have been conducted involving
experts from different elds. Currently the medical community only recognizes the
“tip of the iceberg” and will continue treating the condition inadequately until it is
more comprehensively explored [4]. In the case of suspected strangulation or after
failed conservative management, open surgery is the preferred method for the surgical treatment of adhesive SBO, but laparoscopy (Fig.29.2) is gaining widespread
acceptance especially in a selected group of patients. “Good” surgical technique and
anti-adhesive barriers are the main current concepts of adhesion prevention. The
World Society of Emergency Surgery 2013 guidelines stated that in the absence of
signs of strangulation or peritonitis, NOM can be prolonged up to 72h. After 72h of
NOM without resolution, surgery is recommended. The risk of adhesions is greater
in patients of less than 40years of age undergoing abdominal surgery. The increase
in life expectancy has resulted in an increase of the “old youngs who underwent
multiple surgeries” that in life have had several occlusive episodes. A Van Goor’s
study underlines that patient age and three or more previous laparotomies appeared
to be independent parameters predicting inadvertent enterotomy. Patients with inadvertent enterotomy had signicantly more postoperative complications and urgent
re-laparotomies, a higher rate of admission to the intensive care unit and parenteral
nutrition usage, and a longer postoperative hospital stay [5].
In an unselected patient series of intestinal obstruction, a history of previous
gynecologic pathology is a signicant factor contributing to the total number of
instances of intestinal obstruction in females. Surgical peritoneal closure may also
result in an increase in the incidence of intestinal obstruction [6].
There are no guidelines for surgical management of malignant BO caused by
peritoneal carcinomatosis, mainly when it involves the elderly; so, its treatment is
still debated. In outlining indications and benets of palliative surgery for
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Fig. 29.2 Laparoscopic lysis
of small bowel adhesions
413
obstructive carcinomatosis and in determining what prognostic factors, including
age, have independent and signicant association with outcome, surgical palliation
can provide relief of obstructive symptoms as well as improved survival in wellselected patients, even if elderly.
Despite advances in diagnostic modalities, small bowel tumors are notoriously
difcult to diagnose and are often advanced at the time of denitive treatment.
Small intestinal neoplasms are uncommon cancers. They may occur sporadically, in
association with genetic diseases (e.g., familial adenomatous polyposis coli or
Peutz-Jeghers syndrome) or in association with chronic intestinal inammatory disorders (e.g., Crohn’s disease or celiac sprue). Benign small intestinal tumors (e.g.,
leiomyoma, lipoma, hamartoma, or desmoid tumor) usually are asymptomatic but
may present with complications. Primary malignancies of the small intestine,
including adenocarcinoma, leiomyosarcoma, carcinoid, and lymphoma, are often
symptomatic and may present with intestinal obstruction [7].
Since the small intestine is relatively inaccessible to routine endoscopy, diagnosis of small intestinal neoplasms is often delayed for months after the onset of
symptoms. Recently the increase of small bowel endoscopy and other diagnostic
tools allows earlier nonoperative diagnosis. Even though radical resection of small
bowel cancer plays an important role, 5-year overall survival remains low [
8].
SBO in an oncology patient is a common and serious medical problem which is
associated with diagnostic as well as therapeutic dilemmas. While the condition is
most commonly caused by postoperative adhesions and peritoneal carcinomatosis,
other causes have been reported—linitis plastica caused by metastatic lobular carcinoma of the breast, patterns of malignant melanoma’s metastasis to the small bowel,
intussusception in a patient treated for osteosarcoma with history of multiple metastases, a case of jejunal intussusception with gastrointestinal bleeding caused by
metastatic testicular germ cell cancer.
While adhesions are the most common cause of SBO, hernias remain the most
frequent cause of strangulation in patients presenting with this condition [9]. In the
physical examination of an elderly patient with SBO, care should be taken to
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G. Perrone et al.
examine the hernial sites; an irreducible mass or tenderness calls for immediate
operation. Obstruction by widespread intraperitoneal malignancy is the result of
xation and puckering of the bowel, often in several places. After the bowel has
been decompressed, there is usually no call for any surgical procedure other than
lateral anastomosis to relieve the obstruction. Abdominal hernias may be classied
as groin hernias (femoral and inguinal) and ventral hernias (umbilical, epigastric,
spigelian, and incisional). Strangulated hernias remain a signicant challenge, as
they are sometimes difcult to diagnose purely by physical examination yet require
urgent surgical intervention. Early surgical intervention of a strangulated hernia
with obstruction is crucial as delayed diagnosis can lead to bowel resection with
longer recovery and its attendant complications. Strangulated hernias can have serious deleterious effects such as bowel obstruction, bacterial translocation, and intestinal wall necrosis (potentially resulting in bowel perforation). It poses a signicant
risk to emergency hernia repair, as there is an increased incidence of surgical eld
contamination, leading to high rates of postoperative infection and probably recurrence. Patients should undergo emergency hernia repair immediately when intestinal strangulation is suspected (grade 1C recommendation). Unfortunately, morbidity
and mortality rates remain high for patients who undergo emergency repair of
abdominal hernias. Early diagnosis of strangulated obstruction maybe difcult, and
delayed diagnosis can lead to septic complications. However, in the case of suspected bowel strangulation, the benets outweigh the risks of surgery, and patients
should undergo immediate surgical intervention [10].
Lumbar hernias are rare conditions, and about 300 cases have been reported since
the rst description by Barbette in 1672. Therefore, strangulation or incarceration is
also exceptionally encountered. Lumbar hernia is seen mostly in association with
other abdominal wall hernias in elderly patients. They can also be bilateral as seen in
this case. It was reported that the coexistence of lumbar hernia and other abdominal
wall hernia is observed in 13% of patients. These reports suggest that a patient presenting with a lumbar hernia should be explored for the presence of a coexisting
hernia, such as inguinal, femoral, or obturator hernia. In our case, except for the
contralateral lumbar hernia, no other type of abdominal wall hernia was seen [11].
Obturator hernia was rst described by Ronsil in 1724 [12]. The incidence is
nearly 1% of all hernias [13]. With the nickname “little old lady’s hernia,” it usually
occurs in multiparous and elderly emaciated women due to a wider pelvis and
enlarged obturator canal. The other risk factors include chronic obstructive pulmonary disease, chronic constipation, and ascites. The cardinal clinical symptom is
acute intestinal obstruction. The patient can have a positive Howship-Romberg sign,
which is caused by the intermittent irritation of the obturator nerve. It was reported
that 15–50% patients of obturator hernia may have positive Howship-Romberg. To
examine the thigh, adductor reex might be valuable for differentiating osteoarthritis from obturator hernia. The loss of the adductor reex, named as the HanningtonKiff sign, sometimes is observed on the affected side, while the patellar tendon
reex was intact on the same side [14].
Paraduodenal hernia is an unusual form of internal hernia that results from a congenital midgut malrotation. It is classied as either right or left, depending on
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415
anatomic features and embryologic origin. Left hernias are three times more common
than right. Clinical symptoms may be intermittent and nonspecic, such as nausea,
distention and abdominal pain, or sometimes acute SBO or ischemia. The average age
at diagnosis is usually 38years. The paraduodenal hernia is an uncommon disorder
characterized by extremely variable clinical manifestations, from absolute asymptomatic to occlusion with ischemia or intestinal infarction. The importance of putting in
the differential diagnosis of this disease in the case of occlusive pictures without an
obvious cause is not to be underestimated. The instrumental images, and in particular
the TACs, show quite a characteristic picture and are difcult to interpret by the radiologist or the experienced surgeon when not aware of this pathological condition. In a
review of the literature, we found the disease in only six elderly patients (73–95years),
most of them carrying a left paraduodenal hernia. This is indicative of the rarity of the
disease and thus the likelihood of a correct diagnosis [15].
Nutritional status is very important, especially in older adults because of its
effects on quality of life. Phytobezoar, for instance, that can lead to SBO has risk
factors such as excessive consumption of foods with high-ber content and inadequate chewing. These factors are related to dietary habits. Furthermore, the aging
process and some related physiologic changes can predispose older adults to phytobezoar formation [16].
Internal abdominal hernias present an infrequent surgical diagnosis and are usually encountered accidentally during surgery. They are generally considered as an
extremely rare cause of ileus.
The incidence of the diverticulum of the SB varies from 0.2 to 1.3% in autopsy
studies to 2.3% when assessed on enteroclysis. It occurs mostly in patients in the
sixth decade of their life. Of all small bowel diverticula, jejunal diverticulum is the
most common type. This rare entity is usually asymptomatic. However, they may
cause chronic nonspecic symptoms for a long period of time like dyspepsia,
chronic postprandial pain, nausea, vomiting, borborygmi, alternating diarrhea and
constipation, weight loss, anemia, and steatorrhea or rarely lead to complications
like hemorrhage, obstruction, and perforation. Obstruction can be due to enterolith,
adhesions, intussusception, and volvulus. The condition is difcult to diagnose
because patients generally present with symptoms that mimic other diseases. Only
27 cases of SBO by enterolith expelled from small bowel diverticula have been
reported in the literature. Jejunal diverticular disease should be considered in the
differential diagnosis of mechanical small bowel obstruction without an obvious
cause, especially in the elderly population.
The prevalence of inammatory bowel disease (IBD) increases in the elderly
population. There is no increased risk for developing intestinal cancer among
patients with elderly onset IBD in this population-based cohort. There are increased
risks of developing lymphoproliferative and myeloproliferative disorders in all
IBD.Thiopurine exposure was not found as associated with an increased risk to
lymphoproliferative disorders. These data reinforce the difference between elderly
onset IBD as compared with patients with a younger age at IBD onset [
17].
Among elderly patients, the incidence of ulcerative colitis (UC) is higher than
that of Crohn’s disease (CD). Elderly patients with a new diagnosis of UC are more
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G. Perrone et al.
likely to be male and have left-sided colitis. Elderly patients with a new diagnosis
of CD are more likely to be female and have colonic disease. Conversely, increasing
age at diagnosis has been associated with a lower likelihood of having any family
history of IBD, perianal disease in CD, and extraintestinal manifestations. This
increase in inammatory diseases in the elderly has meant that it is increasingly
common to nd older people with bowel obstruction from Crohn’s disease [18].
The large bowel obstructions (LBO) are caused by carcinomas of the colon
which slowly progress to give complete obstruction, inammatory disease, fecal
impaction, sigmoid volvulus, and cecal volvulus. Malignancy accounts for 80% of
LBO. Acute obstruction of the colon rectum is a more serious emergency than
occlusion of SBO because of the risk of cecal distention, necrosis, and perforation.
The onset of peritonitis due to cecal perforation in the elderly patient is insidious,
and the seriousness of the situation may not be apparent until the patient goes into
shock. Among patients with malignant large bowel tumors, obstruction in the left
colon is more common than in the right colon.
Colorectal cancer (CRC) is a major source of morbidity and mortality in the
elderly population, and surgery is often the only denitive management option.
Emergency surgery for acute colonic obstruction is associated with a signicant risk
of mortality and morbidity and with a high percentage of stoma creation (either
temporary or permanent). Right-sided colonic obstructions are usually treated by
one-stage resection with primary anastomosis for all but the frailest patients,
whereas controversy continues to revolve around emergency management of
obstructed left colon cancer (OLCC). The WSES’s consensus conference of 2010
aimed to analyze the available scientic evidence on treatment modalities for OLCC
and how this is implemented in clinical practice. The goal of the authors was to offer
practical and scientically supported suggestions to manage OLCC.The committee
made every effort to collect and classify the best available scientic evidence on
treatment of OLCC [19].
Age itself is not a risk factor for the development of complications in patients
undergoing surgery for colorectal cancer. Age alone should not be a reason to avoid
therapeutic or palliative surgery in these patients; instead patient selection should
focus on clinical condition and ASA levels.
One-stage surgery appears to be superior to two- or three-stage procedures.
Stenting is a promising option, allowing the resection to be carried out in an elective
setting. Stenting appears to be a safe and effective addition to the armamentarium of
treatment options for colorectal obstructions [20].
Volvulus of the intestine is a surgical emergency. Volvulus of the small bowel is
more common in children and is most often secondary to malrotation. Colonic volvulus is a rare cause of large bowel obstruction but more common than small bowel
volvulus in the elderly. Cecal volvulus (Fig.29.3) is most commonly due to lack of
xation. Colonic volvulus has a specic radiographic appearance; however, small
bowel volvulus is difcult to distinguish from other causes of small bowel obstruction by radiographic means. New surgical techniques with minimally invasive surgery are increasingly being applied to this old problem with good results in selected
cases. The incidence of small bowel volvulus in adults varies widely with
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Fig. 29.3 Cecum volvulus
417
geographic location. In the Western world, it is rare and accounts for 1.7–6.2% of
all SBO.Obstructions can be viewed as either primary (in a normal abdominal cavity) or, more commonly, secondary (due to anatomic malformations, malrotation,
adhesions, tumors, or diverticula). Presentation is that of an acute small bowel
obstruction, with abdominal pain, nausea, and vomiting. Peritoneal signs, palpable
mass, fever, and leukocytosis are indicators of gangrenous bowel. Plain abdominal
radiographs usually show a nonspecic pattern of SBO.Treatment is laparotomy
with either detorsion or resection if the bowel involved is compromised, with correction of the underlying cause as appropriate. Volvulus of the colon accounts for
10–13% of all large bowel obstruction in the United States. It can involve any segment but most frequently occurs in the sigmoid or cecum. Volvulus of the sigmoid
colon is the most common large bowel volvulus; it occurs in 70–80% of cases. It is
usually secondary to a redundant colon, which may be associated with several illnesses. It is more common in the elderly, institutionalized patient. Typical radiographic ndings are the “bent inner tube” with the point usually directed to the right
upper quadrant. The preferred approach in the stable patient who can undergo a
bowel preparation would be elective sigmoid resection. Other options range from
cecostomy, transverse colostomy, sigmoid colostomy, operative detorsion, and
emergent resection [Hartmann procedure, obstructive resection (Paul-Mikulicz),
primary anastomosis] to elective resection with primary anastomosis. Other less
frequently used options would include tube sigmoidostomy, mesocoloplasty, sigmoidopexy to the transverse colon, sigmoidopexy to the parietes, and xations of
the sigmoid mesentery. In patients with peritoneal signs where compromised bowel
is suspected, denitive treatment with laparotomy and bowel resection is indicated.
Ten to twenty percent of colonic volvulus is cecal volvulus. It is associated with lack
of xation of the right colon to the peritoneum and is more prevalent in a younger
patient population. It manifests in two main forms: axial rotation of the cecum and
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G. Perrone et al.
the ileum around the mesentery (true volvulus) and the less common cecal bascule,
where the bowel folds up on itself. Radiographic ndings are those of large bowel
obstruction with a “coffee bean” deformity directed toward the left upper quadrant.
Patients with cecal volvulus are more likely to need initial surgical treatment, with
cecopexy, cecostomy, or resection. Detorsion alone is not recommended due to the
high recurrence rate. Volvulus of the transverse colon is rare (2–4%), and splenic
exure volvulus is the least common site. Diagnosis is usually intraoperative, and
resection is the preferred treatment. A minimally invasive approach is feasible both
in the acute and especially the elective settings but depends on the surgeon’s experience [21].
The incidence of diverticulitis increases with age. Although left-sided colonic
diverticulosis is more common among elderly patients, the most common acute
mode of presentation is intestinal obstruction due to an exacerbation of the peridiverticular inammation or to the adhesion of a loop of small bowel to the inamed
colon. The obstruction may be complete and require a defunctioning proximal
colostomy for its relief. The decision regarding surgical treatment must be based on
the severity of the underling diverticulitis, the degree of intestinal obstruction, and
also the claried presence of malignant colorectal disease [22].
The fecal impactions (“fecaloma”) are dehydrated fecal masses that form in the
bulb rectal, especially in bedridden elderly patients, who, sometimes, for reasons of
central vascular disease and/or dementia, have no cognizance of reection of defecation. So, the incomplete evacuation of stool may lead to the formation of a large
mass of hard and unmovable stool in the rectum, in fact, “fecal impaction.” The
rectosigma becomes distended, and the hard irregular mass (stercoroma) is not sufciently plastic to be expelled through the disproportionately small anal canal by
the patient, who tries a generally weak defecation. The RX direct abdomen is an
examination which is usually performed to assess whether there are “air-uid levels” or worse “free air in the abdomen,” radiological signs of acute surgical abdomen, or more simply “signs of fecal impaction,” e.g., U-bends, vision of feces in the
rectal ampoule, etc., or even bowel obstruction.
The frequency of fecal impaction is higher in geriatric patients admitted and
treated in psychiatric hospitals. Patients who are immobilized for a long period
(e.g., those with myocardial infarction or orthopedic problems) tend to develop a
fecal impaction if not administered with mild laxatives for constipation. A careful
rectal examination is not harmful in these patients and should be done routinely for
early detection of impaction or occult intestinal bleeding.
Interesting complications but with rare conditions that accompany fecal packing
are hernia, volvulus applicant megacolon, ileus, adynamic and leveling with gaseous
distention, rectal prolapse, dystocia, and intestinal obstruction [23]. A fecaloma in the
small intestine is extremely rare. However, this should be considered in differential
diagnosis when symptoms of acute mechanical SBO develop in a child with constipation. Diagnosis is usually made from radiographic ndings of a mobile intraluminal
mass with a smooth outline and no mucosal attachment. Most fecalomas are successfully treated by conservative methods such as laxatives, enemas, and rectal evacuation. When conservative treatments have failed, a surgical intervention may be needed.
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Laparoscopic techniques are gradually replacing many common surgical procedures that are performed in an increasingly aging population. Laparoscopy places
different physiologic demands on the body to open surgery. PubMed was searched
for evidence related to the use of laparoscopy in the elderly population to treat common surgical pathologies. Randomized trials, systematic reviews, and meta- analyses
were preferred. Currently, over 40% of all surgeries performed in the United States
are on patients older than 65years. By the end of the twenty-rst century, Americans
are expected to live 20years longer than the current average. However, elderly
patients clearly show higher rates of surgical morbidity and mortality overall.
Laparoscopic techniques show decreased wound complications, postoperative
ileum, intraoperative blood loss, and reduced need for postoperative rehabilitation.
In conclusion, laparoscopic surgery is safe in the elderly population and affords
multiple advantages including decreased pain and convalescence. However, the
physiology of laparoscopy places demands on elderly patients that typically present
with more medical comorbidities. Elderly patients represent a large cohort of surgical patients and are therefore profoundly affected by this shift in care. Where feasible, laparoscopic surgery is becoming the gold standard in the treatment of many
common pathologies that disproportionately affect elderly patients. The benets of
laparoscopy have been well documented, including decreased postoperative pain,
decreased length of hospital stay, improved cosmesis, and a quicker return to normal activity. On the contrary, laparoscopy may be more technically challenging,
owing to a signicant learning curve among surgeons, and carries with it a distinct
milieu of physiologic demands on the elderly patient. The surgical requirements for
laparoscopic surgery place unique physiological demands on the patient and present
a distinct challenge in the elderly patient. The insufation of carbon dioxide gas can
create acid-base disturbances, changes in blood gas balance, and alterations of cardiovascular and pulmonary physiology. While most of these changes do not result
in clinical signicance, they can become more of a factor in patients with comorbidity conditions, especially those that result in decreased cardiopulmonary reserve, as
is common in elderly patients [
24].
Utilization of abdominopelvic computed tomography (CT) in geriatric patients presenting to the emergency department (ED) with acute abdominal symptoms strongly
inuences clinical management and signicantly affects disposition. As the US population ages, the clinical impact of emergent CT in the elderly will intensify [25].
Intussusception is dened as a segment of the gastrointestinal tract and mesentery within the lumen of an adjacent segment. It is a rare condition that in adults can
occur anywhere in the gastrointestinal tract from the stomach to the rectum. Only
5% of all intussusceptions are presented in adults and in 1–5% of all cases of intestinal obstruction.
Conclusions
Most operations on elderly subjects are performed to correct or avert serious
lesions. Once a decision is made that surgical treatment is indicated, the advanced
age of the patient is a good reason for operating without delay. The improved
outlook in recent years can be attributed to a more hopeful attitude on the part of
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the surgeon, better anesthesia, and an increase in our knowledge. It is in the care
of the sick, elderly, surgical patient that the value of a medical team drawn from
several specialties is most evident.
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