Adhesive small bowel adhesions

obstruction: Evolutions in
diagnosis, management and
prevention
Fausto Catena, Salomone Di Saverio, Federico
Coccolini, Luca Ansaloni, Belinda De Simone, Massimo
Sartelli, Harry Van Goor

World J Gastrointest Surg 2016 March 27; 8(3): 222-

231
 Abstract
• Intra-abdominal adhesions following abdominal
surgery  major unsolved problem
• Adhesion is 1st cause of small bowel obstruction.
• Diagnosis is based on clinical evaluation, water-
soluble contrast follow- through and CT scan
• no signs of strangulation, peritonitis or severe
intestinal impairment  non-operative
management
• suspected strangulation or after failed
conservative management open surgery
 Introduction
• Adhesive disease = most frequently encountered
disorder of the small intestine
• the incidence of adhesive small bowel obstruction
(ASBO) following all types of abdominal operations was
2.4%
• There is a diagnostic dilemma on how to distinguish
between adhesive SBO and other causes, and how to
distinguish between ASBO that needs emergency
surgery OR conservatively.
• Regarding surgical treatment laparoscopy has gained
popularity but also is associated with increased risk of
iatrogenic complications.
 Epidemiology
• ASBO is a common cause that accounts for 4%
of all emergency department admissions and
20% of emergency surgical procedures
• These fibrous bands are thought to occur in
up to 93% of patients undergoing abdominal
surgery
 Diagnosis
Preliminary assessment
Detailed anamnesis & PE :
Discontinuous abdominal pain, nausea, vomiting, history of previous
abdominal surgery
Laboratory:
WBC, electrolytes, BUN, CR, C-RP, serum lactate, LDH, Creatine kinase.
In patients present with systemic signs (fever, tachycardia, hypotension,
altered mental status)  + ABG

• Typical inflammatory markers (WBC & CRP) cannot discriminate between the
inflammation due to ASBO or that caused by other inflammatory conditions.

• LDH, CK, Serum lactate  may increase due to bowel hypoperfusion.

Rises only at a stage when widespread

Rises in any ischemic bowel infarction is already well established
rate (unspecific) (highly sensitive)
 Diagnosis
Preliminary assessment
Suspicions of ASBO

Supine & erect abdominal x-ray Abdominal ultrasound (limited

w/ eventual administration of value)
WSCM (Water soluble contrast
medium)
 Distension/peristaltis
 Multiple air fluid levels  Differences in mucosal folds
 Distensions of small bowel loops around transition point
 Absence of gas in the colon

* The reason or site of obstruction is not usually clear • Sensitivity : 79-83%

on plain radiography since a specific site between the • Specificity : 67-83%
enlarged proximal and undilated distal bowel frequently • Accuracy : 64-82%
cannotbe recognized with certainty.
 Diagnosis
Preliminary assessment
• Recent reports: Intestinal fatty acid binding protein (which is
released by necrotic enterocytes) may become a useful
marker for the detection of bowel ischemia.

• In conclusion, laboratory tests can simply indicate general

disease severity & to support or rule out an emergency
surgical choice only in the context of agreement of a number
of other clinical findings.

• Moreover, serum tests may indicate needed adjustment of

electrolyte abnormalities and fluid resuscitation.
 Diagnosis
Secondary evaluation
ASBO diagnosis : Secondary evaluation

Abdominal CT with IV Contrast Abdominal MRI (limited value)

Medium
Restricted to those patients
 Evaluate the severity of the having CT or iodine contrast
obstruction contraindications
 Identifying the cause of obstruction
 Recognizing complication Water-soluble contrast follow-through
(ischemia, necrosis, perforation)
Patient initially treated with NOM in
• Sensitivity : 90-94% order to rule out complete ASBO and
• Specificity : 96% predict the need for surgery
• Accuracy : 95%
CT has been demonstrated to be highly
diagnostic in ASBO, especially in all patients with
inconclusive plain X-ray
 Non-operative Management
Treatment of ASBO

 No signs of : strangulation, peritonitis or  Signs of : strangulation & peritonitis

severe intestinal impairment  Carcinomatosis or irreducible hernia
 Partial ASBO  No signs of resolution (with NOM)
 Signs of resolution on admission within 72 hours

Non operative management Operative management

 NGT or LT decompression  Laparoscopic exploration
 Intravenous fluid administration  Open approach
 Clinical observation

Water soluble contrast medium

No contrast in colon within 24-36h
administration

Appearance of contrast in colon within 4-24h

 predict resolution of ASBO
 Non-operative Management
• Oral Th/ with Magnesium oxide & L. acidophilus &
Simethicone may be considered to help the
resolution of NOM in partial ASBO w/ positive results
in shortening the hospital stay.

Strong predictors of NOM failure:

• The presence of ascites, complete ASBO (no evidence
of air within the large bowel)
• increased serum creatine phosphokinase
• and ≥ 500 ml from nasogastric tube on the third
NOM day
 Non-operative Management

• Free intraperitoneal fluid, mesenteric edema, lack of the

“small bowel feces sign” at CT-scan, history of vomiting,
severe abdominal pain (VAS > 4), abdominal guarding, raised
white cell count and devascularized bowel at CT-scan 
predict the need for emergency laparotomy

• In fact, the use of surgery to solve ASBO is controversial, as

surgery induces the formation of new adhesions. As a
counterpart, a delay in operation for ASBO places patients at
higher risk for bowel resection.
 Non-operative Management

• Retrospective analysis showed that in patients with a ≤ 24 h

wait time until surgery, only 12% experienced bowel resection
and in patients with a ≥ 24 h wait time until surgery, 29%
required bowel resection.

• Schraufnagel et al: rates of complications, resection,

prolonged length of stay and death were higher in patients
admitted for ASBO and operated on after a time period of ≥
4d.
 Non-operative Management
Diagnostic – therapeutical role of WSCA
(Water Soluble Contrast Agent)
• The most commonly utilised contrast medium  Gastrografin
• It is a mixture of sodium diatrizoate and megluminediatrizoate
• Osmolarity : 2150 mOsm/L
• Gastrografin also decreases oedema of the small bowel wall and
it may also enhance smooth muscle contractile activity that can
generate effective peristalsis and overcome the obstruction
 SURGERY
1. Open Surgery (in case suspected
strangulation or after failed conservative
management)
2. Laparoscopy (first episode of ASBO/
anticipated single band adhesion)
 Open Surgery
• A metaanalysis by Li et al found that there was no
statistically significant difference between open
vs laparoscopic adhesiolysis in the number of
intraoperative bowel injuries, wound infections,
or overall mortality.
• Conversely there was a statistically significant
difference in the incidence of overall and
pulmonary complications and a considerable
reduction of prolonged ileus in the laparoscopic
group compared with the open group.
 Laparoscopy
Potential advantages:
• Less postoperative pain
• Faster return of intestinal function
• Shorter hospital stay
• Reduced recovery time
• Allowing an earlier return to full activity
• Fewer wound complication
• Decreased post operative adhesion formation
• A panel of experts recommended that the
only absolute exclusion criteria for
laparoscopic adhesiolysis in SBO are those
related to pneumoperitoneum (e.g.,
hemodynamic instability or cardiopulmonary
impairment)
• Laparoscopic adhesiolysis is technically challenging, given
the bowel distension and the risk of iatrogenic injuries if
the small bowel is not appropriately handled.
• Key technical steps are to avoid grasping the distended
loops and handling only the mesentery or the distal
collapsed bowel.
• It is also mandatory to fully explore the small bowel
starting from the cecum and running the small bowel distal
to proximal until the transition point is found and the
band/transition point identified.
• After release of the band, the passage into distal bowel is
restored and the strangulation mark on the bowel wall is
visible and should be carefully inspected.
• Because of the consistent risks of inadvertent
enterotomies and the subsequent significant
morbidity, particularly in elderly patients and
those with multiple (three or more) previous
laparotomies, the lysis should be limited to
the adhesions causing the mechanical
obstruction or strangulation or those located
at the transition point area
• Predictors of Bowel injury
– the number of previous laparotomies
– anatomical site of the operation,
– presence of bowel fistula and laparotomy via a
preexisting median scar
 Prevention
• Surgical Technique
 Increasing the number of patients without any
peritoneal adhesion should be the general aim of
adhesion prevention.
 “Good” surgical technique and anti-adhesive
barriers are the main current concepts of adhesion
prevention.
 laparoscopy and not closing the peritoneum lower
the incidence of adhesions
 However, the burden of adhesions in laparoscopy is
still significant most likely due to the necessity to
make specimen extraction incisions in addition to
trocar incisions and the unavoidable peritoneal
trauma by surgical dissection and the use of CO2
pneumoperitoneum (intraperitoneal pressure and
• Anti-adhesive barriers
 For one type of barrier
(Hyaluronatecarboxymethylcellulose, HA-CMC,
Seprafilm, Sanofi, Paris, France) the reduction of
incidence of adhesive small bowel obstruction after
colorectal surgery has also been established without
patient harm
 Oxidized regenerated cellulose (Interceed, Ethicon,
West Somerville, NJ, United States) reduces the
incidence of adhesion formation following fertility
surgery but the impact on small bowel obstruction
after gynecological surgery has not been studied
 Drawback of both products is the difficulty to use in
 Conclusion
• there are not yet devices able to totally
prevent the intraperitoneal adhesion
formation after abdominal surgery
• only the use of correct surgical technique and
the avoidance of traumatic intraperitoneal
organ maneuvers may help to reduce
postoperative adhesion incidence.