DOI: 10.1097/TA.0b013e318198d6a2

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PMID: 19359950

Issn Print: 0022-5282

Publication Date: 2009/04/01


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Letters to the Editor

Salih Pekmezci; Kaya Saribeyoglu; Ugur Korman

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Excerpt

We read with great interest the article entitled “Guidelines for Management of Small Bowel Obstruction” by Diaz et al.1 It was based on a detailed review of the literature and discussed critical steps of the management of small bowel obstruction (SBO). The authors have also proposed an algorithm concerning this issue. However, we noticed that there were some critical points that had to be discussed and corrected in this review.
The authors have cited our study on selective laparoscopic adhesiolysis, which was performed according to preoperative enteroclysis findings, in patients with recurrent SBO.2 Nevertheless, the results of our study, which were presented in the appendix of this review, did not match with those of our article. The correct results should be “N = 15; enteroclysis-guided laparoscopy conversion rate of 6.7%,” which were mentioned in another line of the list.
Furthermore, there was a controversial proposal, presented in the algorithm. The authors suggested to perform enteroclysis if nasogastric decompression and gastrointestinal rest have failed. Enteroclysis is being performed through a catheter, which is placed distal to the ligament of Treitz, and a balloon at the tip of the catheter is inflated to prevent contrast agent reflux to duodenum.3 Barium and 0.5% methylcellulose solution in water are then infused with a pump at a rate of 200 to 250 mL/min. Therefore, it is a dynamic study that has the advantage of simulating the transit of the foods in small bowel. It is very useful in chronic recurrent SBO because it shows the location, degree, and nature of the obstruction. Moreover, some other diagnoses, such as Crohn’s disease, tumors, radiation enteritis, etc. can be excluded. The enteroclysis process is based on pumping the contrast agent into the small bowel by blocking the back flow; thus, the procedure has bowel perforation risks in complete SBO. Therefore, enteroclysis is contraindicated in patients who do not tolerate semi-solid diet. The risks that the procedure bears in nonresolved SBO are much higher than the expected benefits. In our experience, we first perform abdominal computerized tomography in all patients to rule out a malignancy; then the bowel decompression is performed. Enteroclysis is performed in patients who can tolerate semi-solid diet for at least 24 to 48 hours before the investigation and a selective laparoscopic adhesiolysis is performed according to the radiologic findings.4 If the conservative management fails, patients will undergo laparoscopic adhesiolysis without any further investigation.
We do think that the algorithm suggested by Diaz et al. must be revised, especially in failed attempts of small bowel decompression.
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