Journal of Indian Association of Pediatric Surgeons
Journal of Indian Association of Pediatric Surgeons
                                                   Official journal of the Indian Association of Pediatric Surgeons                           
Year : 2012  |  Volume : 17  |  Issue : 1  |  Page : 20--22

Postoperative adhesive intestinal obstruction: The role of intestinal stenting


Ravikumar Ramanathan Valkodai, Rajamani Gurusami, Vijayagiri Duraisami 
 Department of Paediatric Surgery, G. Kuppusami Naidu Memorial Hospital, Coimbatore, Tamil Nadu, India

Correspondence Address:
Ravikumar Ramanathan Valkodai
Department of Paediatric Surgery, G. Kuppusami Naidu Memorial Hospital, Coimbatore - 641 037, Tamil Nadu
India

Abstract

Aim: Six children with adhesive obstruction in the postoperative period were treated with stenting the small bowel with long intestinal tube. Materials and Methods : In two children the stenting was done through jejunostomy, and in the other four through the base of appendix. Results: During a follow-up period of 2-14 years, there had been no recurrence. Conclusions: Use of an intraluminal tube stent in preventing recurrent small bowel obstruction due to adhesions is safe and effective when used on appropriately selected patients.



How to cite this article:
Valkodai RR, Gurusami R, Duraisami V. Postoperative adhesive intestinal obstruction: The role of intestinal stenting.J Indian Assoc Pediatr Surg 2012;17:20-22


How to cite this URL:
Valkodai RR, Gurusami R, Duraisami V. Postoperative adhesive intestinal obstruction: The role of intestinal stenting. J Indian Assoc Pediatr Surg [serial online] 2012 [cited 2019 Dec 12 ];17:20-22
Available from: http://www.jiaps.com/text.asp?2012/17/1/20/91081


Full Text

 Introduction



When peritoneal cavity is opened, in whatever type of surgery, bowel obstruction may develop due to bands or adhesions. Minimal adhesions resolve with conservative management. Laparoscopy may help if the obstruction is due to localized adhesions or bands. However, gross distension with dense adhesions will need laparotomy for correction. The release of such adhesions results in serosal injury to the bowel and is a potential threat for re-adhesion and obstruction. Use of intraluminal tube stenting of the bowel after release of adhesions precludes recurrent small bowel obstructions. We have used the above procedure in six children, with satisfactory outcome.

 Materials and Methods



Over a period of 14 years, six children needed intraluminal stenting of the bowel to prevent recurrent obstruction. Four of these children needed two surgeries in the immediate postoperative period. In two other children who developed adhesive obstruction in the postoperative period, release of dense adhesions resulted in raw areas in peritoneum and the bowel, and stenting of the bowel was done to prevent re-adhesion. Of the six children, three were following surgery for Hirschsprung's disease, while the other three were due to intestinal duplication, Meckel's diverticulum and meconium ileus.

In the absence of the availability of pediatric size Baker's [1] type of tube which has a bulb distally for easy passage across the bowel, we used two 10F Ryle's tubes of 100 cm each, stitched together and guided through a jejunostomy in two children. The tubes were stitched with 2/0 silk twice and tested to see that it does not break before passing across the bowel. There had been no breakage in the series. In four other children, the tubes were guided upward through the base of the appendix after appendicectomy to the jejunum. In children with gross distension of bowel, a 10F Ryle's tube with side holes was inserted through a purse string in upper jejunum and the bowel was decompressed by suction, and then the second tube was stitched to the first and guided toward the cecum. Similar procedure was done when the tubes were guided from the base of the appendix after appendicectomy. The stenting through the base of the appendix after appendicectomy and subsequent fixation of the tube through right iliac fossa results in natural lie of the bowel. The spillage of the small bowel contents from the dilated gut is prevented. The four children in whom the above method was done went home without any problem.

The bowel is returned in anatomical way; the adhesions which are certain to recur are thereby fixed with the bowel in a non-obstructing position. The child can be fed orally after 3-4 days when the bowel function returns to normal. The tubes were kept for 10 days and then removed. Stenting through jejunostomy was preferred when there was gross distension of proximal bowel for easy decompression and the base of the appendix in the rest [Figure 1].{Figure 1}

 Results



[Table 1] summarizes the case histories and outcome.{Table 1}

 Discussion



Postoperative intraperitoneal adhesions, or bands, resulting from any type of abdominal surgery are the main cause of adhesive postoperative small bowel obstructions, which represent a lifelong issue. After successful relief of obstruction in dense and extensive adhesions, there is no proven method to prevent formation of further adhesions postoperatively, and a small number of patients are plagued by recurrent obstruction. The need for repeated laparotomy in such patients can pose great technical difficulties for the surgeon.

Various methods of prevention of recurrence of adhesive obstructions were tried in adult patients earlier. Plication of the small intestine is often performed in situations suggesting an increased risk of subsequent adhesive obstruction. This can be accomplished by the external suture methods of Noble [2] and modified technique of transmesenteric plication described by Childs and Phillips. [3] The major objections to Noble's plication are the duration of the operation and the incidence of postoperative complications. Hyaluronate carboxymethylcellulose preparations have been shown to reduce the extent of adhesions in pediatric patients. [4] However, in adult patients, several other studies have shown that the use of hyaluronate carboxymethylcellulose agents is associated with a significantly higher incidence of intra-abdominal abscesses and anastomotic leaks. [5]

A variant of the plication method involves intraluminal intestinal intubation. Again, accepting that adhesions will form, intestinal intubation relies on the intrinsic stiffness of the intraluminal tube to permit adhesion formation in a favorable position and to avoid kinking of the bowel whilst adhesions form. The tube is later removed. [6]

Intraluminal stenting of the small bowel after adhesiolysis was originally described by White in 1956 [7] as a possible way to maintain small bowel patency while fresh adhesions form, thereby reducing the risk of subsequent adhesional obstruction. It was popularized by Baker who introduced a long intestinal tube with a Foley's type of bulb distally to facilitate smooth introduction of the tube through jejunostomy. He emphasised on the need to decompress the distended bowel thoroughly at the time of surgical release of the obstructing adhesion. [1]

Complications associated with the jejunal route of stent insertion are infection or prolonged drainage from the jejunostomy site following tube removal, or obstruction at the jejunostomy site and intussusception. [8],[9],[10]

Of the six cases who had intestinal tubing, four children had recurrent adhesive obstruction in the immediate postoperative period. In two children, the adhesions were so dense in the first instance and the intestinal stenting was done to prevent further small bowel obstruction. Technically it would be easy to pass the tube across the bowel if there is a Foley type of bulb in the tube, and in its absence, Ryle's tube was used in our cases. In the above series, there had been no complication at the tube site or in its removal though there is a report that the tube got kinked and there was difficulty in its extraction. [8]

The spillover of the intestinal contents, with its attendant complication of intra-abdominal abscess or wound infection in grossly distended bowel is prevented during jejunostomy or the retrograde passage of tube by passing initially a 10F Ryle's tube with multiple holes and the bowel is decompressed by suction and the second tube attached to it later. Baker [1] returned the bowel with the tube in situ in an orderly manner simulating a plication and wrote that he has only incomplete evidence in some cases that the orderly intestinal pattern is permanently maintained. We returned the bowel into abdomen in the anatomical way as the return of bowel in the plicated manner in small children was technically difficult. However, in the follow-up, there had been no recurrence.

 Conclusions



Intestinal intubation in the treatment of patients with recurrent adhesive small bowel obstruction has been documented in adult patients. But there are very few reports of its use in children. The present study, though with a small number of patients, shows its utility in preventing recurrent small bowel obstruction where initial surgery has produced adhesive obstruction. It is unlikely to be of use in the treatment of localized adhesions or situations where formation of generalized adhesions is uncommon.

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