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Small bowel obstruction secondary to transport aircraft: Coincidence or reality?
+Model CLINRE-449; No. of Pages 3
ARTICLE IN PRESS
Clinics and Research in Hepatology and Gastroenterology (2013) xxx, xxx—xxx
Available online at
www.sciencedirect.com
CLINICAL CHALLENGE
Small bowel obstruction secondary to transport aircraft: Coincidence or reality? D. Massalou a,b,∗, M. Fournier a, B. Salucki a, P. Baqué a a b
Acute care surgery unit, St Roch Hospital, University Hospital of Nice, University of Nice Sophia-Antipolis, Nice, France Biomechanical Applied Laboratory, UMRT24, IFSTTAR, Aix-Marseille University, Marseille, France
Summary Small bowel obstructions (SBO) are a leading cause of admission to general surgery, posing the problem of the aetiology and treatment based on the diagnosis. More than 300 patients were admitted for SBO in 2011 in our institution. In our clinical practice, we have had to care for patients with SBO immediately after air travel, all of whom had an antecedent of abdominal surgery by laparotomy. The finding of episodes of acute SBO immediately following a commercial flight has never been reported in the literature. We report the cases of four patients for whom we offer several pathophysiological hypotheses, and we publish the first dietary rules for people with a history of intraperitoneal surgery to adopt during a flight. © 2013 Elsevier Masson SAS. All rights reserved.
Introduction Small bowel obstructions account for 20% of hospitalizations in the surgical ward. Sixty to 80% of all bowel obstructions are of the small bowel [1]. The main aetiology of mechanical SBO is the existence of postoperative adhesions (49% of cases) [2]; after an assault, these adhesions occur in 95% of patients who had a peritoneal opening for any kind of abdominal surgery [3]. The mortality of acute SBO was estimated at 5.5% [4]. Transport aircraft has been recognized as a factor favouring the occurrence of diseases [5,6] such as deep vein thrombosis of the lower limbs [7] or spontaneous pneumothorax [8].
∗ Corresponding author. UCSU chirurgie, hôpital Saint-Roch, 15, rue Pierre-Devoluy, 06006 Nice cedex 1, France. E-mail address: [email protected] (D. Massalou).
During the year 2011, we treated four patients in our university hospital for mechanical SBO immediately following a flight. The finding of episodes of SBO immediately after a commercial flight has never been reported in the literature. We shall present each of these patients admitted in 2011 in our institution. There were three men and one woman with a mean age of 61 years (45—75).
Clinical records Patient 1 A 63-year-old man who had been vomiting for 24 hours was sent for emergency abdominal pain. His unique antecedent was left colectomy for a former complicated sigmoid diverticulitis. He had made a two-hour flight 24 hours ago and had started vomiting at the end of the flight. A clinical examination, blood tests and abdominal CT revealed a proximal SBO without peritoneal irritation. Given the patient’s
2210-7401/$ – see front matter © 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.clinre.2013.05.007
Please cite this article in press as: Massalou D, et al. Small bowel obstruction secondary to transport aircraft: Coincidence or reality? Clin Res Hepatol Gastroenterol (2013), http://dx.doi.org/10.1016/j.clinre.2013.05.007
+Model CLINRE-449; No. of Pages 3
ARTICLE IN PRESS
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D. Massalou et al. Table 1 The volume of the gas is inversely proportional to the pressure at constant temperature. Expansion of gaz’ volume Altitude (feet)
Altitude (meters)
Gaz’ volume
0 5000 10 000 15 000 18 000 20 000
0 1500 3000 4500 5400 6000
1.0 1.2 1.5 1.9 2.0 2.4
favourable clinical response and the absence of signs of CT scan severity, medical treatment was undertaken. Resumption of transit was observed after 24 hours of hospitalization; the patient left our department three days later.
Patient 2 A 75-year-old woman with a history of cholecystectomy treated by a midline laparotomy, was presented to the emergency department with a SBO complicated by abdominal rigidity and ileum pain. She had made a 4-hour flight and the SBO had started during the flight. Midline incision skirting around the umbilicus eliminated the adhesion responsible for SBO. Resumption of transit was observed on the second postoperative day and she was allowed to leave the hospital three days later.
Patient 3 A 61-year-old man with a history of left colectomy and hepatectomy had a SBO after a long flight lasting more than 24 hours. A careful interview revealed that the occlusive symptoms had begun shortly after takeoff and diminished after leaving the plane. Progressive feeding under hospital surveillance for 24 hours was introduced.
Patient 4 A 45 year-old-man with a history of lower midline laparotomy 20 years ago for peritonitis presented an acute mechanical obstruction of the small bowel after a flight of 3 hours, with symptoms that began after an hour of air travel. Medical treatment in our institution allowed him to leave after three days of hospitalization.
Discussion Based on the experience of these four patients, we suspect a link between air travel and the occurrence of mechanical SBO in patients with a history of abdominal surgery. At high altitudes, barometric pressure decreases and gases expand in keeping with Boyle-Mariotte’s law: Pressure × Volume = Constant. Accordingly, the volume of all hollow organs increases, posing a problem of distension of the intestinal wall and colon (Table 1). This distension may
be problematic in patients during repatriation in the immediate postoperative period [9]. This phenomenon has also been studied for underwater activities, where the pressure increases during descent and decreases during ascent to the surface. These changes are a crucial barometer for divers because pulmonary barotrauma can occur if the ascent is too quick or the diver does not exhale completely. Similarly, intestinal distension may occur, mainly producing painful manifestations called ‘‘divers colic’’ which is relieved by the removal of excess gas. Civil and military aviation authorities have implemented cabin pressurization so as to assure the viability of air transport. Pressure in a commercial aircraft cruising at an altitude of 8,000 to 10,000 m is equivalent to the atmospheric pressure at a maximum altitude of nearly 2,500 m [10]. The ascent to the aircraft’s cruising altitude is responsible for a 30% increase in the volume of gas [10], and may decompensate chronic respiratory disease such as COPD [10] or create a pneumothorax if there is a pre-existing pulmonary bleb [8]. The pathophysiological mechanism responsible for these syndromes seems to be the occlusive pressure difference in air travel, resulting in the clinical expression of flanges or intraperitoneal obstacles that were previously asymptomatic. Health recommendations and temporary or permanent bans have been issued by various air passenger safety groups for crew and patients undergoing repatriation (below is a non-exhaustive list): • to avoid thrombosis: avoid sitting for long periods, wear anti-thrombosis stockings, thrombosis prophylaxis: oral hydration, no alcohol and coffee during long-haul flights [10]; • to avoid embolism: cons-indication of taking the plane a minimum of 12 to 24 hours after scuba diving [11]; • pneumothorax: cons-indication up to six weeks after thoracic drainage or major thoracic surgery [10]; • general surgery: cons-indication within five days after laparoscopy or within 10 to 14 days of any other type of surgery [6]. In the absence of sufficient scientific methodology, a causal link between aviation and travel SBO cannot be stated. However, because of the large number of air travellers, the secondary obstruction may require a real public health measure consisting of explanations to passengers and aircrew with a history of abdominal surgery: light meals should be offered to those passengers with a history of laparotomy if it is impossible for them not to eat while in flight (particularly for the pilots). Prospective studies or cohorts, however, are necessary to examine the impact of this phenomenon and experimental studies on animals are needed to verify the pathophysiology.
Conclusion During flight, differences in cabin pressure appear to be responsible for the following pathological phenomena of the digestive tract: intestinal dilatation and mechanical small
Please cite this article in press as: Massalou D, et al. Small bowel obstruction secondary to transport aircraft: Coincidence or reality? Clin Res Hepatol Gastroenterol (2013), http://dx.doi.org/10.1016/j.clinre.2013.05.007
+Model CLINRE-449; No. of Pages 3
ARTICLE IN PRESS
Small bowel obstruction secondary to transport aircraft bowel obstruction. So we recommend that travellers and aircrew with a history of abdominal surgery avoid eating or eat only a light meal prior to and during their flight.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Maglinte DD, Kelvin FM, Rowe MG, Bender GN, Rouch DM. Smallbowel obstruction: optimizing radiologic investigation and nonsurgical management. Radiology 2001;218(1):39—46. [2] Mucha Jr P. Small intestinal obstruction. Surg Clin North Am 1987;67(3):597—620. [3] Menzies D, Ellis H. Intestinal obstruction from adhesions — how big is the problem? Ann R Coll Surg Engl 1990;72(1):60—3. [4] Otamiri T, Sjödahl R, Ihse I. Intestinal obstruction with strangulation of the small bowel. Acta Chir Scand 1987;153(4):307—10.
3 [5] Muhm JM, Rock PB, McMullin DL, Jones SP, Lu IL, Eilers KD, et al. Effect of aircraft-cabin altitude on passenger discomfort. N Engl J Med 2007;357(1):18—27. [6] Silverman D, Gendreau M. Medical issues associated with commercial flights. Lancet 2009;373(9680):2067—77. [7] Hughes RJ, Hopkins RJ, Hill S, Weatherall M, Van de Water N, Nowitz M, et al. Frequency of venous thromboembolism in low to moderate risk long distance air travellers: the New Zealand Air Traveller’s Thrombosis (NZATT) study. Lancet 2003;362(9401):2039—44. [8] Baumann MH. Pneumothorax and air travel: lessons learned from a bag of chips. Chest 2009;136(3):655—6. [9] Beninati W, Meyer MT, Carter TE. The critical care air transport program. Crit Care Med 2008;36(7 Suppl):S370—6. [10] Coker RK, Boldy D, Buchdhal R, Cramer D, Denison D, Gradwell D. Managing passengers with respiratory disease planning air travel: British Thoracic Society recommendations. Thorax 2002;57(4):289—304. [11] Freiberger JJ, Denoble PJ, Pieper CF, Uguccioni DM, Pollock NW, Vann RD. The relative risk of decompression sickness during and after air travel following diving. Aviat Space Environ Med 2002;73(10):980—4.
Please cite this article in press as: Massalou D, et al. Small bowel obstruction secondary to transport aircraft: Coincidence or reality? Clin Res Hepatol Gastroenterol (2013), http://dx.doi.org/10.1016/j.clinre.2013.05.007
ARTICLE IN PRESS
Clinics and Research in Hepatology and Gastroenterology (2013) xxx, xxx—xxx
Available online at
www.sciencedirect.com
CLINICAL CHALLENGE
Small bowel obstruction secondary to transport aircraft: Coincidence or reality? D. Massalou a,b,∗, M. Fournier a, B. Salucki a, P. Baqué a a b
Acute care surgery unit, St Roch Hospital, University Hospital of Nice, University of Nice Sophia-Antipolis, Nice, France Biomechanical Applied Laboratory, UMRT24, IFSTTAR, Aix-Marseille University, Marseille, France
Summary Small bowel obstructions (SBO) are a leading cause of admission to general surgery, posing the problem of the aetiology and treatment based on the diagnosis. More than 300 patients were admitted for SBO in 2011 in our institution. In our clinical practice, we have had to care for patients with SBO immediately after air travel, all of whom had an antecedent of abdominal surgery by laparotomy. The finding of episodes of acute SBO immediately following a commercial flight has never been reported in the literature. We report the cases of four patients for whom we offer several pathophysiological hypotheses, and we publish the first dietary rules for people with a history of intraperitoneal surgery to adopt during a flight. © 2013 Elsevier Masson SAS. All rights reserved.
Introduction Small bowel obstructions account for 20% of hospitalizations in the surgical ward. Sixty to 80% of all bowel obstructions are of the small bowel [1]. The main aetiology of mechanical SBO is the existence of postoperative adhesions (49% of cases) [2]; after an assault, these adhesions occur in 95% of patients who had a peritoneal opening for any kind of abdominal surgery [3]. The mortality of acute SBO was estimated at 5.5% [4]. Transport aircraft has been recognized as a factor favouring the occurrence of diseases [5,6] such as deep vein thrombosis of the lower limbs [7] or spontaneous pneumothorax [8].
∗ Corresponding author. UCSU chirurgie, hôpital Saint-Roch, 15, rue Pierre-Devoluy, 06006 Nice cedex 1, France. E-mail address: [email protected] (D. Massalou).
During the year 2011, we treated four patients in our university hospital for mechanical SBO immediately following a flight. The finding of episodes of SBO immediately after a commercial flight has never been reported in the literature. We shall present each of these patients admitted in 2011 in our institution. There were three men and one woman with a mean age of 61 years (45—75).
Clinical records Patient 1 A 63-year-old man who had been vomiting for 24 hours was sent for emergency abdominal pain. His unique antecedent was left colectomy for a former complicated sigmoid diverticulitis. He had made a two-hour flight 24 hours ago and had started vomiting at the end of the flight. A clinical examination, blood tests and abdominal CT revealed a proximal SBO without peritoneal irritation. Given the patient’s
2210-7401/$ – see front matter © 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.clinre.2013.05.007
Please cite this article in press as: Massalou D, et al. Small bowel obstruction secondary to transport aircraft: Coincidence or reality? Clin Res Hepatol Gastroenterol (2013), http://dx.doi.org/10.1016/j.clinre.2013.05.007
+Model CLINRE-449; No. of Pages 3
ARTICLE IN PRESS
2
D. Massalou et al. Table 1 The volume of the gas is inversely proportional to the pressure at constant temperature. Expansion of gaz’ volume Altitude (feet)
Altitude (meters)
Gaz’ volume
0 5000 10 000 15 000 18 000 20 000
0 1500 3000 4500 5400 6000
1.0 1.2 1.5 1.9 2.0 2.4
favourable clinical response and the absence of signs of CT scan severity, medical treatment was undertaken. Resumption of transit was observed after 24 hours of hospitalization; the patient left our department three days later.
Patient 2 A 75-year-old woman with a history of cholecystectomy treated by a midline laparotomy, was presented to the emergency department with a SBO complicated by abdominal rigidity and ileum pain. She had made a 4-hour flight and the SBO had started during the flight. Midline incision skirting around the umbilicus eliminated the adhesion responsible for SBO. Resumption of transit was observed on the second postoperative day and she was allowed to leave the hospital three days later.
Patient 3 A 61-year-old man with a history of left colectomy and hepatectomy had a SBO after a long flight lasting more than 24 hours. A careful interview revealed that the occlusive symptoms had begun shortly after takeoff and diminished after leaving the plane. Progressive feeding under hospital surveillance for 24 hours was introduced.
Patient 4 A 45 year-old-man with a history of lower midline laparotomy 20 years ago for peritonitis presented an acute mechanical obstruction of the small bowel after a flight of 3 hours, with symptoms that began after an hour of air travel. Medical treatment in our institution allowed him to leave after three days of hospitalization.
Discussion Based on the experience of these four patients, we suspect a link between air travel and the occurrence of mechanical SBO in patients with a history of abdominal surgery. At high altitudes, barometric pressure decreases and gases expand in keeping with Boyle-Mariotte’s law: Pressure × Volume = Constant. Accordingly, the volume of all hollow organs increases, posing a problem of distension of the intestinal wall and colon (Table 1). This distension may
be problematic in patients during repatriation in the immediate postoperative period [9]. This phenomenon has also been studied for underwater activities, where the pressure increases during descent and decreases during ascent to the surface. These changes are a crucial barometer for divers because pulmonary barotrauma can occur if the ascent is too quick or the diver does not exhale completely. Similarly, intestinal distension may occur, mainly producing painful manifestations called ‘‘divers colic’’ which is relieved by the removal of excess gas. Civil and military aviation authorities have implemented cabin pressurization so as to assure the viability of air transport. Pressure in a commercial aircraft cruising at an altitude of 8,000 to 10,000 m is equivalent to the atmospheric pressure at a maximum altitude of nearly 2,500 m [10]. The ascent to the aircraft’s cruising altitude is responsible for a 30% increase in the volume of gas [10], and may decompensate chronic respiratory disease such as COPD [10] or create a pneumothorax if there is a pre-existing pulmonary bleb [8]. The pathophysiological mechanism responsible for these syndromes seems to be the occlusive pressure difference in air travel, resulting in the clinical expression of flanges or intraperitoneal obstacles that were previously asymptomatic. Health recommendations and temporary or permanent bans have been issued by various air passenger safety groups for crew and patients undergoing repatriation (below is a non-exhaustive list): • to avoid thrombosis: avoid sitting for long periods, wear anti-thrombosis stockings, thrombosis prophylaxis: oral hydration, no alcohol and coffee during long-haul flights [10]; • to avoid embolism: cons-indication of taking the plane a minimum of 12 to 24 hours after scuba diving [11]; • pneumothorax: cons-indication up to six weeks after thoracic drainage or major thoracic surgery [10]; • general surgery: cons-indication within five days after laparoscopy or within 10 to 14 days of any other type of surgery [6]. In the absence of sufficient scientific methodology, a causal link between aviation and travel SBO cannot be stated. However, because of the large number of air travellers, the secondary obstruction may require a real public health measure consisting of explanations to passengers and aircrew with a history of abdominal surgery: light meals should be offered to those passengers with a history of laparotomy if it is impossible for them not to eat while in flight (particularly for the pilots). Prospective studies or cohorts, however, are necessary to examine the impact of this phenomenon and experimental studies on animals are needed to verify the pathophysiology.
Conclusion During flight, differences in cabin pressure appear to be responsible for the following pathological phenomena of the digestive tract: intestinal dilatation and mechanical small
Please cite this article in press as: Massalou D, et al. Small bowel obstruction secondary to transport aircraft: Coincidence or reality? Clin Res Hepatol Gastroenterol (2013), http://dx.doi.org/10.1016/j.clinre.2013.05.007
+Model CLINRE-449; No. of Pages 3
ARTICLE IN PRESS
Small bowel obstruction secondary to transport aircraft bowel obstruction. So we recommend that travellers and aircrew with a history of abdominal surgery avoid eating or eat only a light meal prior to and during their flight.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Maglinte DD, Kelvin FM, Rowe MG, Bender GN, Rouch DM. Smallbowel obstruction: optimizing radiologic investigation and nonsurgical management. Radiology 2001;218(1):39—46. [2] Mucha Jr P. Small intestinal obstruction. Surg Clin North Am 1987;67(3):597—620. [3] Menzies D, Ellis H. Intestinal obstruction from adhesions — how big is the problem? Ann R Coll Surg Engl 1990;72(1):60—3. [4] Otamiri T, Sjödahl R, Ihse I. Intestinal obstruction with strangulation of the small bowel. Acta Chir Scand 1987;153(4):307—10.
3 [5] Muhm JM, Rock PB, McMullin DL, Jones SP, Lu IL, Eilers KD, et al. Effect of aircraft-cabin altitude on passenger discomfort. N Engl J Med 2007;357(1):18—27. [6] Silverman D, Gendreau M. Medical issues associated with commercial flights. Lancet 2009;373(9680):2067—77. [7] Hughes RJ, Hopkins RJ, Hill S, Weatherall M, Van de Water N, Nowitz M, et al. Frequency of venous thromboembolism in low to moderate risk long distance air travellers: the New Zealand Air Traveller’s Thrombosis (NZATT) study. Lancet 2003;362(9401):2039—44. [8] Baumann MH. Pneumothorax and air travel: lessons learned from a bag of chips. Chest 2009;136(3):655—6. [9] Beninati W, Meyer MT, Carter TE. The critical care air transport program. Crit Care Med 2008;36(7 Suppl):S370—6. [10] Coker RK, Boldy D, Buchdhal R, Cramer D, Denison D, Gradwell D. Managing passengers with respiratory disease planning air travel: British Thoracic Society recommendations. Thorax 2002;57(4):289—304. [11] Freiberger JJ, Denoble PJ, Pieper CF, Uguccioni DM, Pollock NW, Vann RD. The relative risk of decompression sickness during and after air travel following diving. Aviat Space Environ Med 2002;73(10):980—4.
Please cite this article in press as: Massalou D, et al. Small bowel obstruction secondary to transport aircraft: Coincidence or reality? Clin Res Hepatol Gastroenterol (2013), http://dx.doi.org/10.1016/j.clinre.2013.05.007