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First week postoperative intestinal obstruction in children

Bilal Mirza, Afzal Sheikh

Department of Pediatric Surgery The Children’s Hospital and The Institute of Child Health, Lahore, Pakistan

 

Correspondence

Dr Bilal Mirza

Department of Pediatric Surgery, The Children’s Hospital and The Institute of Child Health
H/No. 428 Nishter Block Allama Iqbal Town, Lahore, Pakistan
Mobile: 923454772583
Email : This email address is being protected from spambots. You need JavaScript enabled to view it.


Abstract

Aim: This study was conducted to determine the etiology, management, and outcome of the patients that developed intestinal obstruction within 7 days of the abdominal surgery.

Material and method: Retrospectively, there were a total of 11 patients that developed early postoperative intestinal obstruction (PIO) during February 2009- Jun 2011.

Results: The mean postoperative day at which signs of intestinal obstruction developed was 3.4 day. The mean postoperative day of re-operation was 4.1 day. An increase in bilious aspirate or bilious vomiting (11 patients), abdominal distension (9 patients), constipation (8 patients), mucous or empty rectum on digital rectal examination (6 patients), and a palpable mass of intussusception (1 patient) were the clinical features of PIO. The etiology of PIO was intussusception in 4, soft adhesions in 4, internal herniation in 1, missed type IV congenital pouch colon (CPC) with colostomy twist in 1 patient, and gossypiboma in 1 patient. One patient remained critical postoperatively and expired. Intussusception and adhesions are the main causes of early PIO. Early identification and prompt management is advocated as intestinal gangrene may be followed in the early PIO.

Keywords: postoperative intestinal obstruction, intussusception, adhesions, etiology

 

Introduction

Postoperative intestinal obstruction (PIO) is infrequently observed phenomenon with an incidence of 0.1-3%. Adhesions are reported as frequent causes of PIO, however, they are considered to play a role after two weeks of the operation. The other causes that may develop PIO within first two weeks of the operation are intussusception, internal herniation, volvulus, abscess, and so on [1-4].

Early PIO is referred to intestinal obstruction occurring between 2 weeks to 6 weeks of the operation. The clinical data is scanty with reference to PIO within first week of the operation. Similarly, adhesions are not considered in the etiology of PIO occurring before two weeks of the operation [2-6]. In our observation adhesions may also cause intestinal obstruction within first week of the operation. Therefore this retrospective study was conducted to identify etiology and management of the patients who developed PIO within a week of operation.

Materials and Methods

Medical record of all the patients, who developed postoperative intestinal obstruction within a week of initial operation, including demographic information, history, clinical examination, investigations performed, operative notes and outcome, was reviewed retrospectively. There have been about 2870 laparotomies in the study tenure. The patients who developed PIO after first week, or managed conservatively were excluded.

Results

There were a total of 11 patients that developed mechanical intestinal obstruction in the early postoperative course (7days). Nine were males and 2 females. The age of presentation was ranged between 2 days and 6 years (Mean= 1.77 yrs SD± 1.87).

With reference to first operation, nine patients were operated in our hospital whereas in two patients the first operation was performed in some other setup and referred to our hospital after development of PIO (1 with anorectal malformation and 1 with typhoid perforation of ileum). Table 1 describes the operative diagnosis during first surgery. The mean postoperative day at which intestinal obstruction developed was 3.4 (SD±0.7).

The clinical features evident of postoperative intestinal obstruction were increase in bilious aspirate through nasogastric tube or bilious vomiting in 11 patients, abdominal distension in 9 patients, constipation in 8 patients, mucous or empty rectum on digital rectal examination in 6 patients and a palpable mass of intussusception in 1 patient.

Abdominal radiograph was suggestive of air fluid levels in all patients (fig. 1). Ultrasound of abdomen gave intussusception in 2 patients and gaseous distension of adynamic bowel loops in others. Serum electrolytes were normal except in one patient of retroperitoneal grade 2 immature teratoma where serum calcium was low 7.5 mg/dl (normal range 8.4-10.2 mg/dl).

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Figure 1: Abdominal radiograph of the patient in whom CDH was repaired that then developed intestinal obstruction.

The second operation was performed on average 4.1 (SD ±1) postoperative day. The etiology of mechanical intestinal obstruction was postoperative intussusception in 4 patients (fig. 2), small bowel adherent to the site of appendectomy in 2 patients, adhesions causing kink of small bowel distal to the anastomosis for Meckel’s diverticulum in 2 patients, internal herniation through the mesenteric defect in one patient, missed type IV congenital pouch colon (CPC) and 180˚ stoma twist in 1 patient, and gossypiboma in 1 patient (fig. 3, 4).

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Figure 2: Postoperative intussusception in the patient of eventration of diaphragm.

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Figure 3, 4: Gossypiboma

Postoperative intussusception was ileo-ileal in all patients that were manually reduced. In 4 other patients with adhesions adhesionolysis was performed. In case of internal herniation through the mesenteric defect, about 10 cm of small bowel was gangrenous, therefore sacrificed and ileo-ileal end-to-end anastomosis was performed. In case of missed CPC and stoma twist the pouch colon was excised with revised end colostomy done. In case of gossypiboma, the operative findings were pus in the peritoneal cavity and a mopping sponge was present in the abdomen, around which small bowel was adherent, thus resulting in small bowel obstruction. Ten patients showed uneventful recovery while one patient with retroperitoneal immature teratoma had stormy postoperative course and expired on 15th postoperative day due to multiorgan failure. The summary of all the patients and events is given in table 1.

Table 1: Summary of all the patient and events

 

Patient

 

Age/sex

 

Initial surgery diagnosis

 

2nd  surgery diagnosis

Management performed

 

1

 

2d

Imperforate anus- colostomy done

Type IV CPC and  180˚ twist of stoma

CPC excised  with end colostomy

2

15d

Left CDH—repaired

Intussusception

Manual reduction

 

3

 

2m

Left sided eventration of diaph—plicated

 

do

 

do

 

 

4

 

 

3m

Retroperitoneal grade 2 immature teratoma—excised in toto

 

 

do

 

 

do

 

5

 

4m

 

RVF—sigmoid loop colostomy  done

 

do

 

do

 

 

6

 

 

2y

 

Intussusception—resection and ileocolic anastomosis done

 

Internal herniation through unhealed mesen- teric defect

 

Resection

of gangrenous ileum and anastomosis

 

 

7

 

 

3y

 

Meckels diverticulum- diverticulectomy

 

Soft adhesions causing kink distal to anastomosis

 

 

Adhesionolysis

 

8

 

3y

 

do

 

do

 

do

 

 

9

 

 

4y

 

 

Acute appendicitis- appendectomy

 

Small bowel adherent to site

of appendectomy and grater omentum

 

 

do

 

10

 

5y

 

do

 

do

 

do

 

 

11

 

 

5.5y

 

Typhoid perforation of distal ileum

 

Gossypiboma

(mopping sponge)

 

 

Gossypiboma Removal

CDH= congenital diaphragmatic hernia, RVF= rectovestibular fistula, diaph= diaphragm


Discussion

Early PIO is less frequent complication of abdominal surgery that requires reoperation. Many studies depicted 10 cases of early PIO each year with an incidence of 0.1% to 3%. The total incidence of PIO would be higher if all the cases of early as well as late PIO are considered. The term early PIO is variable with regard to the duration. Some authors consider it within first 30 days of operation, whereas, other consider it between two to six weeks [1,2, 5-8]. We selected initial seven days to further pinpoint the spectrum of etiology of PIO; in fact >60% cases of PIO develop within first week of the operation.

There is diversity of opinions among surgeons as to the diagnosis of early PIO. The postoperative ileus, incision pain, electrolyte imbalance and administration of narcotic analgesics for pain relief are considered the factors that may simulate early PIO and contrarily they may masquerade true cases of early PIO [1, 5, 9-13]. In our series the diagnosis of early PIO was made clinically and supported by abdominal radiograph and ultrasonography. With better learning curve it is not always as difficult to diagnose early PIO as reported in other studies. The cases of RVF (rectovestibular fistula) and Imperforate anus were straight forward as colostomy did not work after 48 hours of operation.

Two cases of acute appendicitis did not improve postoperatively rather they developed abdominal distension, pain, and bilious vomiting indicating intestinal obstruction. Similarly in other cases, non resolution of the ileus, gradual increase in the nasogastric bile, abdominal distension and constipation, palpable mass of intussusception in one case, empty rectum or mucous in it are important features that helped us in the diagnosis of early PIO. Ultrasonography, abdominal radiograph, contrast bowel studies, CT scan etc. are important diagnostic tools. The role of contrast studies and CT scan etc. is not defined yet in case of first week PIO. We diagnosed cases without using costly investigations; abdominal radiograph and ultrasound proved sufficient to aid the clinical suspicion of early PIO; nevertheless, these investigations were not of much help in exactly identifying the cause of early PIO.

The most common cause of PIO is interloop adhesions, however their presence as an etiology is considered after 2 weeks of the operation. The other reported causes of PIO are intussusception, internal herniation, cecal volvulus, intra-abdominal abscess, gossypiboma, and phlegmon. Postoperative intussusception is reported to cause PIO in 10% of the cases. Its proportion increases when cases occurring within first 2 weeks of operation are taken into the account [2-6]. In our study, the etiology of PIO within first week of operation was intussusception, adhesions, internal herniation, missed type IV CPC with colostomy twist, and gossypiboma. The incidence of postoperative intussusception is 0.01% to 0.25% which is negligible. Various tertiary care centers, throughout the world, have reported only few cases occurring over tenure of decades. We are seeing, on average, 2 patients of postoperative intussusception each year. The data from other centres of the region as to postoperative intussusception is very scanty therefore a true incidence of postoperative intussusception, in our population, cannot be commented upon rightly.

The management of early PIO is considered as tricky as its diagnosis. It’s a fact that even in cases of true early PIO the treatment is delayed or remained conservative in order to rule out postoperative ileus. But the other major concern is intestinal ischemia and gangrene that may follow in case of delayed identification and intervention. Some studies depicted no intestinal gangrene in treatment as well as conservative group; however, the mortality was proportionately more in the conservative group. Nevertheless, few case reports have depicted volvulus and ischemia of gut in the early postoperative period [2-4, 11-13]. In our study one patient with internal herniation developed intestinal gangrene that required intestinal resection.

In conclusion, not only intussusception but adhesions too are main causes of early postoperative intestinal obstruction. Moreover, intestinal ischemia and gangrene may also manifest in the first week of operation; therefore, early identification and prompt management is advocated to avoid these perils in the treatment course.

 

 

 

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