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A staged surgical approach to save ischemic bowel
A Staged Surgical
Approach
to Save Ischemic
Bowel
By Tina Palmieri, Ken Kimura, Robert T. Soper, and Frank A. Mitros Iowa City, Iowa 0 A 15~year-old girl developed bowel strangulation of 80% of her small intestine by an omental sling. At exploration, only 100 cm of proximal jejunum remained clearly viable and the remaining small bowel looked necrotic. The transitional bowel between normal and ischemic segments was exteriorized to form a double-barreled jejunostomy. Twelve hours later a “second look” operation was performed. The bowel distal to the exteriorization appeared still seminecrotic but blood flow recovery was demonstrated along the mesenteric border by Doppler oxymeter. No bowel resection was performed. Two months later the jejunostomy was converted to a Bishop-Koop type side-to-end jejunostomy. In the ensuing 2 months, the patient passed both gas and stool per rectum, and oral feedings were gradually increased, retaining the jejunal stoma as a “safety valve.” Later, the stoma was taken down, stenotic bowel segments were resected, and the bowel was finally reconstructed by an end-to-end anastomosis, preserving approximately 80% of the small intestine. This management strategy provides an alternative approach to the conventional practice of simple resection of severely ischemic bowel, allowing maximal salvage of bowel with reversible high-grade ischemic change in selected patients. Copyright 81 1993 by W.B. Saunders Company INDEX WORDS: Bowel strangulation; omental sling; jejunal diverticulum; ischemic bowel; staged salvaging procedure.
T
HE TRADITIONAL procedure of choice for treating bowel with questionable ischemic necrosis has been resection of the involved bowel segment. However, when extensive segments of bowel are involved, this therapy often leads to the short-bowel syndrome with the patient permanently dependent on parenteral nutrition. We describe an alternative staged approach that we used successfully to salvage 80% of near-strangulated bowel in a young girl. CASE REPORT A IS-year-old girl was referred with a 24-hour history of intermittent sharp epigastric pain accompanied by emesis of clear fluid. During the subsequent 6 hours. she developed abdominal distension and hypovolemic shock requiring large volumes of intravenous fluid administration. Abdominal computed tomography demonstrated multiple dilated fluid-filled small bowel loops. At exploratory laparotomy an extensive portion of the small bowel appeared strangulated by entrapment by an omental sling extending between transverse colon and a diverticulum in the proximal jejunum (Fig IA). After division of the omental sling, only 100 cm of proximal jejunum remained clearly viable. The bowel at the transition between normal and ischemic jejunum was simply exteriorized in the left upper quadrant (Fig IB). Twelve hours later. the abdomen was reentered to find the involved bowel still seminecrotic in appearance. However. blood flow recovery was determined by Doppler oxymeter along the mesenteric border. The exteriorized bowel was converted to a double-barreled jetunostomy (Fig 1C). The patient was managed by total parenteral nutrition for
Journal ofPediatric Surgery, Vol28, No 6 (June), 1993: pp 861.862
_
Fig 1. (A) All but 100 cm of proximal jejunum was strangulated by a constricting omantal sling adherent to a proximal jejunal diverticulum. (B) The jejune1 diverticulum was exteriorized and the involved segment released. (C) The jejunal diverticulum was resected and the exteriorized bowel was converted to a double-barreled jejunostomy. (0) The jejunostomy was converted to a side-to-end anestomosis.
the following 2 months. Radiographic contrast studies and endoscopy serially showed recovery of viability and motility of the involved bowel. Later, the jejunostomy was converted to a BishopKoop type side-to-end jejunostomy (Fig lD).’ The patient passed both gas and stools per rectum, and oral feedings were gradually increased. retaining the jejunal stoma as a “safely valve.” Two
From the Departments of Surgeryund Patholoc. The Unir,er,$v Iowa College of Medicine, Iowa City, IA. Presented at the 25th Annual Meeting of the Pacific Association Pediattic SuTeoeons. Albuquerque, New Mexico, Ma)* 17.21, 1992. Address reprint requests to Ken Kimuru, MD. Department Surgm: The Umrzer.si& of Iowa Hospitals und Clirucs. Iowu City, 52242. Copvright ‘il 1993 by W. B. Saunders Company 0022.34681931280600-77$03.00~0
of of’ of IA
861
862
PALMIERI ET AL
months later, the stoma was taken down and 25 cm of strictured bowel was resected. The bowel was reconstructed by an end-to-end anastomosis. The postoperative course was complicated by severe abdominal pain and emesis. A contrast study showed a remaining stenotic bowel segment, which was resected 2 months later. The patient finally recovered normal intestinal function, with reestablishment of satisfactory oral intake. The remaining bowel constitutes approximately 80% of the original, allowing her to be free of parenteral nutrition. DISCUSSION
Extensive small bowel ischemia presents a clinical quandry for the surgeon, who must determine the need for and extent of resection necessary at the time of initial laparotomy. Multiple methods have been proposed to determine bowel viability at the time of surgery, including fluoroscein and Doppler studies, but none permits ongoing evaluation of the remaining bowel segment after surgery.2-4 The three-staged method that we describe permits serial endoscopic and radiologic evaluation of the marginally viable segment. Nonfunctional or strictured segments can be resected, if necessary, thus maximizing bowel
preservation. Not all patients with ischemic bowel, however, are candidates for this procedure. Bowel with clearly irreversible full thickness injury or gangrene at initial operation, or without evidence of peristalsis or blood flow at “second look” operations needs to be resected. Patients with continued or sudden deterioration caused by persistent ischemia or perforation of involved bowel may require further resection in the early postoperative period. Also, the patient and family must be prepared to tolerate the multiple operations needed to restore intestinal continuity when this scheme is used. The judgment and experience of the surgeon thus play a vital role in determining who is an appropriate candidate for this procedure. The three-staged management strategy for ischemit bowel caused by extrinsic strangulation provides an alternative approach to the traditional practice of extensive resection of severely ischemic bowel. It permits serial evaluation of marginally viable bowel, thus providing maximal salvage of bowel with reversible high-grade ischemic changes in selected patients.
REFERENCES 1. Bishop HC, Koop CE: Management of meconium ileus: Resection, Roux-en-Y anastomosis and ileostomy irrigation with pancreatic enzymes. Ann Surg 145:410-414,1957 2. Bulkley GB, Zuidema GD, Hamilton SR, et al: Intraoperative determination of small intestinal viability following ischemic injury. Ann Surg 193:628-237. 1981
3. Sheridan WG, Lowndes tissue oximetty in the human 159:314-319, 1990 4. Carter MS, Fantini GA, and quantitative fluorescence Am J Surg 147:117-123, 1984
RH, Young HL: Intraoperative gastrointestinal tract. Am J Surg Sammartano RJ. et al: Qualitative in determining intestinal viability.
Approach
to Save Ischemic
Bowel
By Tina Palmieri, Ken Kimura, Robert T. Soper, and Frank A. Mitros Iowa City, Iowa 0 A 15~year-old girl developed bowel strangulation of 80% of her small intestine by an omental sling. At exploration, only 100 cm of proximal jejunum remained clearly viable and the remaining small bowel looked necrotic. The transitional bowel between normal and ischemic segments was exteriorized to form a double-barreled jejunostomy. Twelve hours later a “second look” operation was performed. The bowel distal to the exteriorization appeared still seminecrotic but blood flow recovery was demonstrated along the mesenteric border by Doppler oxymeter. No bowel resection was performed. Two months later the jejunostomy was converted to a Bishop-Koop type side-to-end jejunostomy. In the ensuing 2 months, the patient passed both gas and stool per rectum, and oral feedings were gradually increased, retaining the jejunal stoma as a “safety valve.” Later, the stoma was taken down, stenotic bowel segments were resected, and the bowel was finally reconstructed by an end-to-end anastomosis, preserving approximately 80% of the small intestine. This management strategy provides an alternative approach to the conventional practice of simple resection of severely ischemic bowel, allowing maximal salvage of bowel with reversible high-grade ischemic change in selected patients. Copyright 81 1993 by W.B. Saunders Company INDEX WORDS: Bowel strangulation; omental sling; jejunal diverticulum; ischemic bowel; staged salvaging procedure.
T
HE TRADITIONAL procedure of choice for treating bowel with questionable ischemic necrosis has been resection of the involved bowel segment. However, when extensive segments of bowel are involved, this therapy often leads to the short-bowel syndrome with the patient permanently dependent on parenteral nutrition. We describe an alternative staged approach that we used successfully to salvage 80% of near-strangulated bowel in a young girl. CASE REPORT A IS-year-old girl was referred with a 24-hour history of intermittent sharp epigastric pain accompanied by emesis of clear fluid. During the subsequent 6 hours. she developed abdominal distension and hypovolemic shock requiring large volumes of intravenous fluid administration. Abdominal computed tomography demonstrated multiple dilated fluid-filled small bowel loops. At exploratory laparotomy an extensive portion of the small bowel appeared strangulated by entrapment by an omental sling extending between transverse colon and a diverticulum in the proximal jejunum (Fig IA). After division of the omental sling, only 100 cm of proximal jejunum remained clearly viable. The bowel at the transition between normal and ischemic jejunum was simply exteriorized in the left upper quadrant (Fig IB). Twelve hours later. the abdomen was reentered to find the involved bowel still seminecrotic in appearance. However. blood flow recovery was determined by Doppler oxymeter along the mesenteric border. The exteriorized bowel was converted to a double-barreled jetunostomy (Fig 1C). The patient was managed by total parenteral nutrition for
Journal ofPediatric Surgery, Vol28, No 6 (June), 1993: pp 861.862
_
Fig 1. (A) All but 100 cm of proximal jejunum was strangulated by a constricting omantal sling adherent to a proximal jejunal diverticulum. (B) The jejune1 diverticulum was exteriorized and the involved segment released. (C) The jejunal diverticulum was resected and the exteriorized bowel was converted to a double-barreled jejunostomy. (0) The jejunostomy was converted to a side-to-end anestomosis.
the following 2 months. Radiographic contrast studies and endoscopy serially showed recovery of viability and motility of the involved bowel. Later, the jejunostomy was converted to a BishopKoop type side-to-end jejunostomy (Fig lD).’ The patient passed both gas and stools per rectum, and oral feedings were gradually increased. retaining the jejunal stoma as a “safely valve.” Two
From the Departments of Surgeryund Patholoc. The Unir,er,$v Iowa College of Medicine, Iowa City, IA. Presented at the 25th Annual Meeting of the Pacific Association Pediattic SuTeoeons. Albuquerque, New Mexico, Ma)* 17.21, 1992. Address reprint requests to Ken Kimuru, MD. Department Surgm: The Umrzer.si& of Iowa Hospitals und Clirucs. Iowu City, 52242. Copvright ‘il 1993 by W. B. Saunders Company 0022.34681931280600-77$03.00~0
of of’ of IA
861
862
PALMIERI ET AL
months later, the stoma was taken down and 25 cm of strictured bowel was resected. The bowel was reconstructed by an end-to-end anastomosis. The postoperative course was complicated by severe abdominal pain and emesis. A contrast study showed a remaining stenotic bowel segment, which was resected 2 months later. The patient finally recovered normal intestinal function, with reestablishment of satisfactory oral intake. The remaining bowel constitutes approximately 80% of the original, allowing her to be free of parenteral nutrition. DISCUSSION
Extensive small bowel ischemia presents a clinical quandry for the surgeon, who must determine the need for and extent of resection necessary at the time of initial laparotomy. Multiple methods have been proposed to determine bowel viability at the time of surgery, including fluoroscein and Doppler studies, but none permits ongoing evaluation of the remaining bowel segment after surgery.2-4 The three-staged method that we describe permits serial endoscopic and radiologic evaluation of the marginally viable segment. Nonfunctional or strictured segments can be resected, if necessary, thus maximizing bowel
preservation. Not all patients with ischemic bowel, however, are candidates for this procedure. Bowel with clearly irreversible full thickness injury or gangrene at initial operation, or without evidence of peristalsis or blood flow at “second look” operations needs to be resected. Patients with continued or sudden deterioration caused by persistent ischemia or perforation of involved bowel may require further resection in the early postoperative period. Also, the patient and family must be prepared to tolerate the multiple operations needed to restore intestinal continuity when this scheme is used. The judgment and experience of the surgeon thus play a vital role in determining who is an appropriate candidate for this procedure. The three-staged management strategy for ischemit bowel caused by extrinsic strangulation provides an alternative approach to the traditional practice of extensive resection of severely ischemic bowel. It permits serial evaluation of marginally viable bowel, thus providing maximal salvage of bowel with reversible high-grade ischemic changes in selected patients.
REFERENCES 1. Bishop HC, Koop CE: Management of meconium ileus: Resection, Roux-en-Y anastomosis and ileostomy irrigation with pancreatic enzymes. Ann Surg 145:410-414,1957 2. Bulkley GB, Zuidema GD, Hamilton SR, et al: Intraoperative determination of small intestinal viability following ischemic injury. Ann Surg 193:628-237. 1981
3. Sheridan WG, Lowndes tissue oximetty in the human 159:314-319, 1990 4. Carter MS, Fantini GA, and quantitative fluorescence Am J Surg 147:117-123, 1984
RH, Young HL: Intraoperative gastrointestinal tract. Am J Surg Sammartano RJ. et al: Qualitative in determining intestinal viability.