Sticky Situations
What can serve as both a diagnostic and therapeutic tool for SBO?
Gastrograffin challenge
3 common causes of acute SBO
Adhesions
Hernia
Malignancy
65F underwent small bowel resection with primary anastomosis 6 days ago. She presents with increased pain, fever, and tachycardia. What should you be worried about?
anastomotic leak
What is it called when an end ileostomy is everted with seromuscular sutures?
Brooked
Are parastomal hernias more common with ileostomies or colostomies?
colostomies
What are 3 problems caused by adhesions?
SBO
Chronic pain
Female infertility
What electrolyte abnormality is associated with SBO?
hypokalemic, hypochloremic metabolic alkalosis
This malignant small bowel tumor requires segmental resection but generally does NOT require significant lymphadenectomy
GIST
Depending on the course of the first operation, stoma closure should not be undertaken for at least ___ weeks.
When an end ileostomy is created in the setting of a perforated viscus, significant contamination, or significant adhesions, timing to reversal can be extended to at least ___ months
6 weeks
4-6 months
What protein forms a sticky layer that can cause surfaces to stick together and form scar tissue?
Fibrin
You are operating on your patient with an adhesive SBO when you notice you made an inadvertent enterotomy. What is the management if it is full-thickness involving <50% of the bowel circumference?
What if it is >50%?
Formal resection & re-anastomosis
Plain film findings suspicious for gallstone ileus
calcified gallstone outside the biliary tree
findings suggestive of SBO
pneumobilia (gas in biliary tree)
During laparoscopic exploration for SBO, you encounter diffusely dilated small bowel.
Where should you begin tracing the bowel to identify the obstruction?
A. Start at the ligament of Treitz and follow distally
B. Start at the cecum and follow proximally
C. Identify decompressed bowel and follow it proximally
D. Identify the most dilated loop and follow it distally
E. Begin by examining the transverse colon
C. Identify decompressed bowel and follow it proximally
Considerations for stoma site
mark in lying, sitting, standing positions
patient should be able to see stoma
flat surface
avoid creases/belt line
According to Fiser, what is the most common organism responsible for peristomal skin infection
candida
Your patient has an adhesive SBO with bowel compromise and ischemia, but their labs appear completely normal - why can this happen?
Compromised venous outflow
Management of small bowel intussusception in pediatric patients versus adult patients
Peds → air enema reduction attempts x 2 before operative reduction
Adults → surgery (resect intussuscepted bowel and lead point)
A patient undergoes surgery for strangulated SBO. After adhesiolysis and resolution of the obstruction, there is a segment of bowel with questionable viability. The patient is hemodynamically stable. What can you do?
Place the bowel in warm, saline-moistened sponge for 15-20 minutes and re-assess
What is normal ileostomy output and what is the classic acid-base disturbance associated with high ileostomy output?
800-1200 ml/day
hyperchloremic metabolic acidosis
According to Fiser, what is the most common cause of a fistula near stoma site?
Crohns
What did the LASSO randomized clinical trial find regarding laparoscopic vs open adhesiolysis for SBO?
Laparoscopy provides short-term benefits (shorter LOS, faster recovery) without increasing complications, but does not have superior long-term outcomes
Steps of laparotomy for gallstone ileus
- Run the bowel to look for stones
- Milk the stone away from IC valve
- Enterotomy to remove stone
- Close enterotomy transversely
- Usually no cholecystectomy
During an open small bowel resection, you completed a stapled side-to-side anastomosis. What should be done before completing the operation?
A. Ligate the mesenteric vessels of the remaining bowel
B. Close the mesenteric defect
C. Oversew the entire staple line
D. Divide the remaining mesentery
E. Place a drain through the mesenteric defect
B. Close the mesenteric defect
You are following up in clinic with your patient who has an end ileostomy and notice the ileal mucosa is pulled away from the edge of the skin, what is the appropriate management?
2 months later he returns and there is stoma necrosis, how can you evaluate the extent of the necrosis and what is the appropriate management if it is below the level of the fascia?
Mucocutaneous separation → topical wound care
Anoscopy, test tube trick
Necrosis below fascia → emergent reintervention
Name and components of the gallstone ileus classic triad on imaging
Rigler triad: small bowel obstruction, pneumobilia, ectopic gallstone