Intestinal Obstruction Following Operation for Inflammatory Disease of the Bowel*
E. S. R. HUGHES, M.D., F. T. MCDERMOTT, M.D.,
PATIENTS UNDERGOING operation for inflammatory disease o f the bowel seem p r o n e to acute smallintestinal obstruction. A n u m b e r need laparotomy to relieve the obstruction.. In this communication, details o f a series o f patients r e q u i r i n g l a p a r o t o m y are reviewed. T h e r e are 1,612 patients with inflammatory disease o f the bowel in the Monash University D e p a r t m e n t o f Surgery series (ESRH, 1950-1978) and, of these, 463 patients have had excisional surgery. A m o n g the latter group, 42 patients (9.1 per cent) have r e q u i r e d s u b s e q u e n t l a p a r o t o m y f o r acute small-intestinal obstruction. In two o f these details are incomplete and have been omitted f r o m f u r t h e r analysis. Patients with Acute Intestinal Obstruction Age and Sex: T h e r e were 21 female and 19 male patients. In this series the youngest patient u n d e r g o ing operation for colitis was 15 years, the oldest 56 years. T h e highest incidence o f initial operation was in the third decade, with 34 o f 40 operations perf o r m e d in the first f o u r decades. lnitial operative procedure: No single operative procedure appeared especially culpable except Aylett's operation in which a total colectomy is perf o r m e d and an ileorectal anastomosis is protected by a loop ileostomy. Interval between initial operation and laparotomy f o r acute intestinal obstruction: Obstruction requir-
j.
P. MASTERTON,M.D.
From the Department of Surge~, Mor~ash University Alfred Hospital, Prahran, Victoria, Australia
ing operation was most c o m m o n in the first two years (28 cases) and especially in the first postoperative m o n t h (nine cases). In only two patients did obstruction occur for the first time after 10 years (at 15 and 17 years, respectively). Causes of obstruction: In 26 instances the acute obstruction was caused by adhesions. T h e r e was no special pattern followed by the adhesions which were either single or multiple. In three of the 26 patients, the adhesions were caused by a small chronic abscess. In 13, the obstruction was related to the stoma: a twisted loop stoma (3), torsion o f a loop o f bowel in relation to the stoma (3), chronic p e r f o r a t i o n with secondary stenosis (2), para-stomal hernia (1), defect in stomal m e s e n t e r y (1), stomal stenosis (2), and probable stomal stenosis (1). In one case Crohn's disease o f the small bowel was responsible for intestinal obstruction requiring operation. Procedure adopted at laparotomy: In 35 o f the 40 cases adhesions were divided. O n e patient n e e d e d resection of a segment o f intestine because o f Crohn's disease. In two cases, an end ileostomy was established, and in the r e m a i n i n g two, a loop ileostomy in continuity.
Results of Intervention * Received for publication April 12, 19791 Address for reprint requests to Professor Sir Edward Hughes: Department of Surgery, Monash University, Alfred Hospital, Prahran 3181, Victoria, Australia.
In the series of 40 patients u n d e r g o i n g l a p a r o t o m y for acute intestinal obstruction there were t h r e e postoperative deaths. T h e first patient never r e c o v e r e d
0012-3706/79/1000/0469/$00.65 9 American Society of Colon and Rectal Surgeons 469
470
Dis. Col. & Rect.
H U G H E S E T AL.
TABLr 1.
Octobe~ 1979
Laparotomyfor Small Intestinal Obstruction FollowingResection of the Bowel Obstructions Number of Patients
Resection for colonic a n d rectal t u m o r Resection for i n f l a m m a t o r y disease o f the bowel
Reoperation Within O n e blonth of Primary Resection
Total Number
Per Cent o f Total Patients
2,474
l1
58
2.3
463
9
42
9.1
any form of fluid or electrolyte stability and died on the fourth postoperative day. In the second case operation was apparently successful but two weeks later, the patient developed further obstructive symptoms which were treated conservatively; he died two weeks after the operation for obstruction. The third patient lost large, uncontrollable quantities of fluid from the ileostomy following relief of the obstruction and succumbed to renal failure. T h e r e were five remote deaths. One followed ileorectal anastomosis 10 months after relief of obstruction. The second followed reconstruction of an ileostomy 19 years after the obstructive episode. The third, a 16-year-old boy, died suddenly five months after operation; and the fourth, a 17-year-old boy, died four months after the obstruction and the day after closure of theloop Aylett ileostomy. Autopsies failed to establish the cause of death in these two young men. A fifth death was caused by Crohn's disease of the remaining small bowel nine years after relieving an intestinal obstruction. Three patients have required further laparotomy to relieve r e c u r r e n t acute bowel obstruction one month, 12 years and 16 years later, respectively. Two of the three have required additional intervention. Long-term results: In 20 patients in this series intervention for the acute intestinal obstruction occurred 10 years or more ago. In 13 cases adhesions were responsible; of the 10 long-term survivors, two required f u r t h e r laparotomy for acute adhesion obstruction. In three patients a twisted loop ileostomy was the cause and the sole survivor had subsequent intestinal problems. In three cases torsion of the gut in the region of the ileostomy was followed by further operation for adhesion obstruction in one of the two survivors. One further patient with a probable stomal obstruction died. Of the original 20 patients there were 15 survivors and three have required operative re-intervention for further bowel obstruction.
Discussion
The high incidence of acute intestinal obstruction following operation for inflammatory disease of the bowel has been highlighted in several recent publications. In contrast, obstruction following resection for cancer of the large bowel is relatively uncommon (Table 1). Ritchie t reviewed a 15-year experience of inflammatory disease of the bowel at St. Mark's Hospital a n d r e p o r t e d t h a t 32 patients r e q u i r e d laparotomy for acute obstruction, to give an incidence of 13 per cent. Jones et al. 2 recorded a 20 per cent incidence in the 86 patients in their series subjected to ileorectal anastomosis. Prophylaxis is difficult to practice because of the haphazard distribution of the adhesions. However, special care should be exercised in the construction of the ileostomy. Loop ileostomies seem best reserved for the occasional case only. The infrequency with which Crohn's disease recurred in the small bowel following excision of the colon in this series is in keeping with the Boston experience? The special tendency for this complication to occur in the early postoperative period in this series is also noted by Ritchie 1 in her review of the St. Mark's patients but was not apparent in the Leeds cases, s The relative infrequency of late obstruction is notable in all three series. In the Monash series it was not necessary to resect any bowel on account of strangulation. Mostly the operative procedure consisted of simple division of adhesions. Occasionally a proximal ileostomy was constructed to protect a difficult dissection. The obstruction proved fatal in three cases in this series. This emphasizes the need to adopt an active approach. If the acute obstructive episode does not settle down promptly, a laparotomy should be performed. The decision is difficult because acute intestinal obstructions tend to resolve without surgical intervention.
Volume 22
Number 7
OBSTRUCTION AFTER INFLAMMATION OPERATION
Summary
471
References
A c u t e s m a l l - i n t e s t i n a l o b s t r u c t i o n is n o t a n u n common complication following excisional operation for inflammatory disease of the bowel. In the Monash s e r i e s t h e m o s t c o m m o n c a u s e was a d h e s i o n f o r m a tion. Stoma problems accounted for a small number. T h e r e was a s p e c i a l t e n d e n c y f o r t h e c o m p l i c a t i o n to appear soon after the excisional surgery. A significant mortality rate accompanied obstructive complication a n d , o v e r t h e l o n g t e r m , o n e in f i v e p a t i e n t s n e e d e d further surgery for a recurrence.
1. Ritchie JK: Ulcerative colitis treated by ileostomy and excisional surgery: Fifteen years' experience at St. Mark's Hospital. B r J Surg 59: 345, 1972. 2. Jones PF, Munro A, Ewen SW: Colectomy and ileorectal anastomosis for colitis: Report on a personal series, with a critical review. B r J Surg 64: 615, 1977 3. Hughes ES: Surgery in ulcerative colitis. Med J Aust i: 743, 1964 4. Nugent FW, Veidenheimer MC, Meissner WA, et al: Prognosis after colonic resection for Crohn's disease of the colon. Gastroenterology 65: 398, 1973 5. WattsJM, de Dombal FT, Goligher JC: Early results of surgery for ulcerative colitis. Br J Surg 53: 1005, 1966
Announcement The American Society for Gastrointestinal Endoscopy Postgraduate Course. "Endoscopy Update--1980," will be held on Thursday and Friday, May 22 and May 23, 1980 in Salt Lake City, Utah. The one and one-half day course will emphasize newer concepts and advances in gastrointestinal bleeding, ERCP, papillotomy and colonoscopy. Formal presentations and panel discussions will take place in the mornings. The afternoon session will be divided into video-tape sessions of colonoscopy, colonoscopic polypectomy, ERCP, and papillotomy. In depth commentary will be provided in dealing with each endoscopic technique. The other half of the afternoon session will be composed of small group seminars. A distinguished faculty has been assembled to present the course. The Course Director is Francis J. Tedesco, M.D. and Assistant Course Director is Joseph W. Griffin, Jr., M.D. For further information, contact the A/S/G/E Postgraduate registration supervisor, Charles B. Slack, Inc., 6900 Grove Road, Thorofare, New Jersey 08086, 609-848-1000.
E. S. R. HUGHES, M.D., F. T. MCDERMOTT, M.D.,
PATIENTS UNDERGOING operation for inflammatory disease o f the bowel seem p r o n e to acute smallintestinal obstruction. A n u m b e r need laparotomy to relieve the obstruction.. In this communication, details o f a series o f patients r e q u i r i n g l a p a r o t o m y are reviewed. T h e r e are 1,612 patients with inflammatory disease o f the bowel in the Monash University D e p a r t m e n t o f Surgery series (ESRH, 1950-1978) and, of these, 463 patients have had excisional surgery. A m o n g the latter group, 42 patients (9.1 per cent) have r e q u i r e d s u b s e q u e n t l a p a r o t o m y f o r acute small-intestinal obstruction. In two o f these details are incomplete and have been omitted f r o m f u r t h e r analysis. Patients with Acute Intestinal Obstruction Age and Sex: T h e r e were 21 female and 19 male patients. In this series the youngest patient u n d e r g o ing operation for colitis was 15 years, the oldest 56 years. T h e highest incidence o f initial operation was in the third decade, with 34 o f 40 operations perf o r m e d in the first f o u r decades. lnitial operative procedure: No single operative procedure appeared especially culpable except Aylett's operation in which a total colectomy is perf o r m e d and an ileorectal anastomosis is protected by a loop ileostomy. Interval between initial operation and laparotomy f o r acute intestinal obstruction: Obstruction requir-
j.
P. MASTERTON,M.D.
From the Department of Surge~, Mor~ash University Alfred Hospital, Prahran, Victoria, Australia
ing operation was most c o m m o n in the first two years (28 cases) and especially in the first postoperative m o n t h (nine cases). In only two patients did obstruction occur for the first time after 10 years (at 15 and 17 years, respectively). Causes of obstruction: In 26 instances the acute obstruction was caused by adhesions. T h e r e was no special pattern followed by the adhesions which were either single or multiple. In three of the 26 patients, the adhesions were caused by a small chronic abscess. In 13, the obstruction was related to the stoma: a twisted loop stoma (3), torsion o f a loop o f bowel in relation to the stoma (3), chronic p e r f o r a t i o n with secondary stenosis (2), para-stomal hernia (1), defect in stomal m e s e n t e r y (1), stomal stenosis (2), and probable stomal stenosis (1). In one case Crohn's disease o f the small bowel was responsible for intestinal obstruction requiring operation. Procedure adopted at laparotomy: In 35 o f the 40 cases adhesions were divided. O n e patient n e e d e d resection of a segment o f intestine because o f Crohn's disease. In two cases, an end ileostomy was established, and in the r e m a i n i n g two, a loop ileostomy in continuity.
Results of Intervention * Received for publication April 12, 19791 Address for reprint requests to Professor Sir Edward Hughes: Department of Surgery, Monash University, Alfred Hospital, Prahran 3181, Victoria, Australia.
In the series of 40 patients u n d e r g o i n g l a p a r o t o m y for acute intestinal obstruction there were t h r e e postoperative deaths. T h e first patient never r e c o v e r e d
0012-3706/79/1000/0469/$00.65 9 American Society of Colon and Rectal Surgeons 469
470
Dis. Col. & Rect.
H U G H E S E T AL.
TABLr 1.
Octobe~ 1979
Laparotomyfor Small Intestinal Obstruction FollowingResection of the Bowel Obstructions Number of Patients
Resection for colonic a n d rectal t u m o r Resection for i n f l a m m a t o r y disease o f the bowel
Reoperation Within O n e blonth of Primary Resection
Total Number
Per Cent o f Total Patients
2,474
l1
58
2.3
463
9
42
9.1
any form of fluid or electrolyte stability and died on the fourth postoperative day. In the second case operation was apparently successful but two weeks later, the patient developed further obstructive symptoms which were treated conservatively; he died two weeks after the operation for obstruction. The third patient lost large, uncontrollable quantities of fluid from the ileostomy following relief of the obstruction and succumbed to renal failure. T h e r e were five remote deaths. One followed ileorectal anastomosis 10 months after relief of obstruction. The second followed reconstruction of an ileostomy 19 years after the obstructive episode. The third, a 16-year-old boy, died suddenly five months after operation; and the fourth, a 17-year-old boy, died four months after the obstruction and the day after closure of theloop Aylett ileostomy. Autopsies failed to establish the cause of death in these two young men. A fifth death was caused by Crohn's disease of the remaining small bowel nine years after relieving an intestinal obstruction. Three patients have required further laparotomy to relieve r e c u r r e n t acute bowel obstruction one month, 12 years and 16 years later, respectively. Two of the three have required additional intervention. Long-term results: In 20 patients in this series intervention for the acute intestinal obstruction occurred 10 years or more ago. In 13 cases adhesions were responsible; of the 10 long-term survivors, two required f u r t h e r laparotomy for acute adhesion obstruction. In three patients a twisted loop ileostomy was the cause and the sole survivor had subsequent intestinal problems. In three cases torsion of the gut in the region of the ileostomy was followed by further operation for adhesion obstruction in one of the two survivors. One further patient with a probable stomal obstruction died. Of the original 20 patients there were 15 survivors and three have required operative re-intervention for further bowel obstruction.
Discussion
The high incidence of acute intestinal obstruction following operation for inflammatory disease of the bowel has been highlighted in several recent publications. In contrast, obstruction following resection for cancer of the large bowel is relatively uncommon (Table 1). Ritchie t reviewed a 15-year experience of inflammatory disease of the bowel at St. Mark's Hospital a n d r e p o r t e d t h a t 32 patients r e q u i r e d laparotomy for acute obstruction, to give an incidence of 13 per cent. Jones et al. 2 recorded a 20 per cent incidence in the 86 patients in their series subjected to ileorectal anastomosis. Prophylaxis is difficult to practice because of the haphazard distribution of the adhesions. However, special care should be exercised in the construction of the ileostomy. Loop ileostomies seem best reserved for the occasional case only. The infrequency with which Crohn's disease recurred in the small bowel following excision of the colon in this series is in keeping with the Boston experience? The special tendency for this complication to occur in the early postoperative period in this series is also noted by Ritchie 1 in her review of the St. Mark's patients but was not apparent in the Leeds cases, s The relative infrequency of late obstruction is notable in all three series. In the Monash series it was not necessary to resect any bowel on account of strangulation. Mostly the operative procedure consisted of simple division of adhesions. Occasionally a proximal ileostomy was constructed to protect a difficult dissection. The obstruction proved fatal in three cases in this series. This emphasizes the need to adopt an active approach. If the acute obstructive episode does not settle down promptly, a laparotomy should be performed. The decision is difficult because acute intestinal obstructions tend to resolve without surgical intervention.
Volume 22
Number 7
OBSTRUCTION AFTER INFLAMMATION OPERATION
Summary
471
References
A c u t e s m a l l - i n t e s t i n a l o b s t r u c t i o n is n o t a n u n common complication following excisional operation for inflammatory disease of the bowel. In the Monash s e r i e s t h e m o s t c o m m o n c a u s e was a d h e s i o n f o r m a tion. Stoma problems accounted for a small number. T h e r e was a s p e c i a l t e n d e n c y f o r t h e c o m p l i c a t i o n to appear soon after the excisional surgery. A significant mortality rate accompanied obstructive complication a n d , o v e r t h e l o n g t e r m , o n e in f i v e p a t i e n t s n e e d e d further surgery for a recurrence.
1. Ritchie JK: Ulcerative colitis treated by ileostomy and excisional surgery: Fifteen years' experience at St. Mark's Hospital. B r J Surg 59: 345, 1972. 2. Jones PF, Munro A, Ewen SW: Colectomy and ileorectal anastomosis for colitis: Report on a personal series, with a critical review. B r J Surg 64: 615, 1977 3. Hughes ES: Surgery in ulcerative colitis. Med J Aust i: 743, 1964 4. Nugent FW, Veidenheimer MC, Meissner WA, et al: Prognosis after colonic resection for Crohn's disease of the colon. Gastroenterology 65: 398, 1973 5. WattsJM, de Dombal FT, Goligher JC: Early results of surgery for ulcerative colitis. Br J Surg 53: 1005, 1966
Announcement The American Society for Gastrointestinal Endoscopy Postgraduate Course. "Endoscopy Update--1980," will be held on Thursday and Friday, May 22 and May 23, 1980 in Salt Lake City, Utah. The one and one-half day course will emphasize newer concepts and advances in gastrointestinal bleeding, ERCP, papillotomy and colonoscopy. Formal presentations and panel discussions will take place in the mornings. The afternoon session will be divided into video-tape sessions of colonoscopy, colonoscopic polypectomy, ERCP, and papillotomy. In depth commentary will be provided in dealing with each endoscopic technique. The other half of the afternoon session will be composed of small group seminars. A distinguished faculty has been assembled to present the course. The Course Director is Francis J. Tedesco, M.D. and Assistant Course Director is Joseph W. Griffin, Jr., M.D. For further information, contact the A/S/G/E Postgraduate registration supervisor, Charles B. Slack, Inc., 6900 Grove Road, Thorofare, New Jersey 08086, 609-848-1000.
