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61 Case on Short Bowel Syndrome
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325
by solely hyperphagia and combined with several vitamin and mineral (in particular Mg) supplements.
This patient is an excellent example of the relatively few medical options we have
to treat Crohn’s disease postoperatively, thereby preventing new surgical procedures. On top of that, an abdominal operation for alleviating Crohn’s itself carries
risks for complications requiring additional surgical interventions. Surely, this may
lead to intestinal failure and to short bowel syndrome [ 1 – 3 ]. The latter condition is
generally considered to be directly related to the length of the remaining intestine.
Interestingly, patients with Crohn’s disease appear to start with a shorter total small
bowel length even before any surgery has been performed [ 1 , 3 ]. Total length of the
intestines, it must be noted, is one of the characteristics of successful digestion.
Once the ileum has been removed, its function cannot be restored, whereas the
ileum can adapt to jejunal functions if the latter has been resected. Furthermore, the
presence or absence of the valve of Bahuin is pivotal for increasing the capacity of
the small intestines to digest. Also, the length and function of the colon contribute
primarily via the absorption of bacteria-generated and short-chain fatty acids to the
nutritional balance of energy (and water and salts).
When short bowel syndrome develops following surgical resections, the therapeutic and clinical approach comprises three phases, specifi ed below (Tables 61.1
and 61.2 ).
Intestinal parts remaining Characteristic risks regarding nutrition
Duodenum, >2 m jejunum, and colon Oral intake will suffi ce
Duodenum, jejunum, ileum, of which
60–100 cm resected
Duodenum, jejunum, ileum > 1 m resected Decreased bile salt pool, thus fat maldigestion
<1 m jejunum Excessive fl uids and mineral losses, oral intake
>1.5 m small bowel + ileostomy or 60–90 cm
small bowel + most of colon
<60 cm small bowel + intact colon Probably ongoing dependence on TPN
<100–140 cm small bowel, no colon Probably ongoing dependence on TPN
<115 cm small bowel + jejunostomy Probably ongoing dependence on TPN
<60 cm + jejunocolonic or ileocolonic
anastomosis
<35 cm small bowel + duodenostomy or
jejunostomy
Malabsorption vitamin B12, bile salts pool
intact by increased production in liver
and decrease in fat-soluble vitamins
will be lost concomitantly
Initial TPN dependent, but high probability of
(partial) weaning into enteral nutrition
Probably ongoing dependence on TPN
Probably ongoing dependence on TPN
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Parenteral Enteral Complications
Phase 1 (acute) TPN, preferably following
indirect calorimetry
Fluids and minerals
to compensate for
excessive loss
Phase 2
(adaptation)
Phase 3
(maintenance)
TPN initially to cover all
nutritional needs, up till
assessment of intestinal
absorption capacity
Calculated decrease in TPN
may follow
Follow-up by regular
anthropometric
measurements (fat-free
mass, muscle strength,
indirect calorimetry)
Ideally, total weaning
of TPN
If not, balanced TPN
and enteral feeding
scheme
If possible, oral scheme
with nutritional
supplements
No enteral challenges
as long as fl uid
homoeostasis is
compromised
Commonly introduc-
tion small amount
of complex food
(fat) at day 4–5
postoperatively
Increase of enteral
feeding, as
clinically accepted
Proton pump
inhibition
High-dose vitamin D
and calcium
Social reintegration
Personalized dietary
advices regarding
enteral feeding
needs and
supplemental oral
feedings
Follow-up by
long-term
nutritional
assessments,
usually at yearly
basis
Social reintegration
A.A. van Bodegraven
Hemodynamic
instability
Mineral disturbances
Malnutrition
Vitamin defi ciencies
Osteoporosis
Calcium oxalate
kidney stones
Bacterial overgrowth
TPN complications
Malnutrition
Osteoporosis
Vitamin defi ciencies,
usually fat soluble
Zinc and magnesium
defi ciency
1. Acute phase
• This is the period directly following surgery and it is characterized by an
imbalanced water and mineral homeostasis
• In this phase of an approximate duration of 1 month, the total parenteral nutrition and supplementation of excessive losses of water and minerals are
warranted to stabilize the patient
2. Adaptation phase
• A phase to stimulate intestinal adaptation by a gradual increase of intestinal
nutrient exposure, preferably of complex foods (fat)
• This phase may take at least 1 year, but probably up to as much as 2–3 years
for gaining a maximal result in terms of digestive capacity
61 Case on Short Bowel Syndrome
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327
• Predicting the necessity of either parenteral or enteral supplemental feeding is
diffi cult and the outcome depends, among other matters, on quality and anatomy of the remaining intestine
3. Maintenance phase
• This phase gradually comes about in the wake of the adaptation phase
• It concerns the permanent dietetic treatment done on an individual basis and
comprises all macronutrients and micronutrients
• The careful monitoring of postsurgical intestinal functions as carried out by a
dedicated (nutritional) team is warranted [ 4 , 5 ]
1. Keller J, Panter H, Layer P. Management of the short bowel syndrome after extensive small
bowel resection. Best Pract Res Clin Gastroenterol. 2004;18:977–92.
2. Wierdsma NJ, van Bodegraven AA. Energetische verliezen uit een korte darm; meer dan alleen
vet (Short bowel energy-loss-more than just fats). Ned Tijdschr Geneeskd. 2005;19:149–54.
3. Borowiec AM, Fedorak RN. Predicting, treating and preventing postoperative recurrence of
Crohn’s disease: The state of the fi eld. Can J Gastroenterol. 2011;25:140–6.
4. Estívariz CF, Luo M, Umeakunne K, et al. Nutrient intake from habitual oral diet in patients
with severe short bowel syndrome living in the south-eastern United States. Nutrition. 2008;24:
330–9.
5. Elriz K, Palascak-Juif V, Joly F, et al. Crohn’s disease patients with chronic intestinal failure
receiving long-term parenteral nutrition: a cross-national adult study. Aliment Pharmacol Ther.
2011;34:931–40.
Chapter 62
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Case on Recurrence of Intestinal
Obstruction Because of Adhesions
Miguel A. Cuesta and Rebecca P.M. Brosens
Keywords Sigmoid resection • Diverticulitis • Intestinal obstruction • Recurrence
obstruction
First Patient
Diagnosis and Indication for Surgery
A 70-year-old man was readmitted, now for the third time to hospital. Two years
before he had undergone without problems a sigmoid resection due to recurrent
diverticulitis with stenosis. But 6 months after that, he underwent a relaparotomy
because of small bowel intestinal obstruction caused by adhesions. One year later,
again he was admitted to hospital because of intestinal obstruction (Fig. 62.1 ). He
was treated conservatively for 4 days without success, and because of increasing
abdominal pain, he was again operated.
Operation
During the relaparotomy, an important multiadherential process was found without
a real intestinal caliber difference. Extensive adhesiolysis was performed with some
perforation of small bowel loops, all being closed.
M. A. Cuesta , M.D. () • R. P.M. Brosens
Department of Surgery , VU University Medical Center ,
Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_62,
© Springer International Publishing Switzerland 2014
329
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Fig. 62.1 AP view of
intestinal obstruction on the
plain X-ray of abdomen
Postoperative Course
M.A. Cuesta and R.P.M. Brosens
Patient had a diffi cult postoperative recovery, involving use of a nasogastric tube for
1 week and total parenteral nutrition (TPN). Two months later, he was admitted
again with small bowel intestinal obstruction and then it was decided to await
recovery of the transit. Conservative treatment consisted of applying a nasogastric
tube for emptying the upper gastrointestinal tract, TPN, and enemas. Patient was
mobilized in order to stimulate the peristalsis that seemed to be absent. Problem was
that he had progressive pain, the nasogastric tube was not productive, and patient
did not pass any gas or stools.
A plain abdomen X-ray and a new CT scan showed important distension of the
small bowel with some degree of intestinal pneumatosis (Fig. 62.2a, b ). This sign,
together with rising leukocytes, prompted us to explore the abdomen again by laparotomy in order to exclude any ischemia of the intestines. During this relaparotomy,
the bowels seemed a block, showing adhesion between loops. A long procedure was
engaged to inspect the entire bowel. Several perforations and serosa lesions were
closed. No ischemia was found, even though an important distension. Bowels were
decompressed and a conservative treatment was started. Patient experienced diffi cult periods, having ups and downs with much pain, but fi nally after a period of 2
weeks, he could start with oral feeding and go home.
62 Case on Recurrence of Intestinal Obstruction Because of Adhesions
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Fig. 62.2 ( a , b ) CT scan
showing intestinal
obstruction with pneumatosis
a
b
331
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M.A. Cuesta and R.P.M. Brosens
Second Patient
Diagnosis and Indication for Surgery
A 70-year-old man was referred to us after different abdominal operations because
of recurrent intestinal obstruction. He was known with chronic ischemia in the
lower extremities taking as medication Ascal ® . Using plain abdomen X-ray and CT
scan, a small bowel intestinal obstruction was diagnosed. He had been operated on
6 months before because of cecal cancer by means of right hemicolectomy. Because
of leakage he underwent a relaparotomy involving dismantling of the anastomosis
and ileostomy. Reversal of the stomas led to a torsion of the anastomosis with intestinal obstruction and a new reoperation. Three months later—because of intestinal
obstruction and lack of improvement after 2 days of conservative treatment—the
surgeon decided to operate him again. Through a median laparotomy, multiple
adhesions were taken down, but a clear obstruction was not observed. Quality of the
bowels was considered normal, but multiple serosa defects were repaired.
Postoperative Course: Identifi cation and Treatment
of Complication
During the postoperative period, the abdomen remained distended for a period of 2
weeks without any activity or peristalsis. Patient was treated by nasogastric tube
and total parenteral nutrition. He had abdominal pain, and since the operation he
had been receiving opiates. Suspicion about mesenteric ischemia led to performing
a CT angiography that revealed an important stenosis of the celiac trunk and the
superior mesenteric artery (SMA) (Fig. 62.3a, b ).
Under a diagnosis of chronic mesenteric ischemia, the patient was referred to us.
We decided to perform an angiography and to stent the stenosis in order to increase
the arterial fl ow in an attempt to normalize the intestinal peristalsis (Fig. 62.4a, b ).
Conservative treatment was continued, all opiates were stopped, and fi nally after a
period of 2 weeks, passage recovered. Following treatment by coumarin as anticoagulant, the patient could be discharged.
Discussion
Lessons of these cases are twofold. Many centers hold as principle to operate a small
bowel obstruction after applying 24 h of conservative treatment. Immediate operation holds only for those patients having strangulation complaints at admission,
62 Case on Recurrence of Intestinal Obstruction Because of Adhesions
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Fig. 62.3 ( a , b ) CT
angiography showing
stenosis of the superior
mesenteric artery (SMA)
a
b
333
pain, unrest, leukocytosis, and eventually high lactate levels; such patients should be
operated on immediately because of the danger for ischemia of bowels included in
adhesions, internal hernia, or volvulated loops. Other patients with quiet abdomen
can be treated conservatively.
The pertaining question now is: How many days involved doing such? My rule
will be that if there is a progression to normality, less distension, and less production
by the nasogastric tube, I would prefer to continue with conservative therapy. In the
case of no changes, diagnosis should be done. However, the “24-h rule” no longer
holds. In the case of a recurrent operation because of already known adhesions, we
prefer to wait longer, using conservative treatment with nasogastric tube and TPN.
Too easily decided-on reoperations will harm the patient, establish more adhesions,
and generate diffi cult operations in the future. Before considering a reoperation,
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ab
M.A. Cuesta and R.P.M. Brosens
Fig. 62.4 ( a , b ) Celiac trunk and SMA have been stented
a CT scan should be done to look for complications of the last operations or a cause
for the ileus (as portrayed in the second patient with mesenteric ischemia).
Importantly, administering all the opiate medications should be stopped.
Chapter 63
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Case on Inadvertent Small Bowel Lesion
During Laparoscopic Operation
Laura Gonzalez Sanchez
Keywords Laparoscopic hysterectomy • Uterus fi broid • Intestinal lesion •
Laparoscopy
Diagnosis and Indication for Surgery
A 44-year-old homemaker with a history of four prior deliveries was operated by
the gynecologist using laparoscopic hysterectomy to alleviate recurrent bleeding
produced by a uterus fi broid of 12 cm in length. The operation was successful and
blood loss amounted to 200 cc.
Postoperative Course: Identifi cation and Treatment
of Complication
A drain was left in Douglas cavity and on the fi rst postoperative day it produced a
suspicious fl uid. It was not typical of small bowel contents and its analysis revealed
19,800 mg/dl amylase! Gynecologist and internist considered a pancreatic fi stula,
probably constituting an operation trauma to the pancreas, so she was initially
treated with conservative management. The next day, the patient was presented to
the surgeon on duty because of progressive abdominal pain, high fever, and leukocytosis of 23,000 cell/fi eld. Under suspicion of high small bowel perforation, the
surgeon decided to perform a CT scan (Figs.
L. Gonzalez Sanchez , M.D.
Department of Surgery , Hospital J. Negrin , Tenerife , Spain
e-mail: lgsanchez08@gmail.com
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_63,
© Springer International Publishing Switzerland 2014
63.1 and 63.2 ). On the CT scan an
335
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