Surgery of the small bowel is a mainstay of practice for the general and acute care surgeon. Any abdominal operation must take into consideration the small bowel, both as a potential site of pathology or iatrogenic injury during the operation itself, and postoperatively, when ileus or adhesive small bowel obstruction may extend hospital length of stay. Despite the widespread importance of small bowel pathology to surgeons, the care of these patients relies on traditional surgical teaching. Evidence-based management in this area remains nascent, with few randomized controlled trials providing data to either support or refute dogma. Surgeons’ reluctance to undertake a study that appears to deviate from standard care may contribute, in part, to the paucity of high-quality data.
Of the extant studies in the area, many focus on streamlining care for patients with postoperative ileus or adhesive small bowel obstruction. Nonpharmocologic methods such as gum chewing,1 as well as newer pharmaceuticals such as Alvimopan,2 have been studied in an attempt to reduce the incidence of postoperative ileus, and Gastrografin has been suggested to facilitate resolution of partial small bowel obstruction.3 Surgical technique has also evolved over the years, with the development of new energy devices for mesenteric ligation and the linear cutting stapler for bowel anastomoses. It has now become common practice to use a variety of staplers for intestinal anastomoses, but controversy remains regarding the equivalency of hand-sewn and stapled anastomoses.
The topics presented in this review highlight recent developments and recommendations regarding the management of surgical issues of the small bowel. This discussion represents a sampling of the few high-quality studies in the area, and demonstrates the need for rigorous clinical trials to further inform surgical practice. Hopefully, further randomized controlled trials will clarify factors to improve outcomes in patients with small bowel disease, and ultimately guide standardization of care.
a. Gastrografin for Adhesive Small Bowel Obstruction
Randomized clinical study of Gastrografin administration in patients with adhesive small bowel obstruction.
Biondo S, Parés D, Mora L, Martı Ragué J, Kreisler E, Jaurrieta E Br J Surg. 2003;90(5):542–546.
Takeaway Point: The use of oral Gastrografin can help diagnose a complete small bowel obstruction, and hasten resolution of a partial small bowel obstruction.
Commentary: The authors present a randomized study of orally administered Gastrografin to identify patients who will need an operation for a small bowel obstruction, and to speed recovery of bowel function in patients with partial obstructions. They demonstrate an overall shorter hospital stay in patients receiving Gastrografin studies, both those requiring surgery, and those managed nonoperatively. Gastrografin has the potential to expedite identification of patients with complete small bowel obstruction who will require operation, and to hasten the resolution of partial obstructions that can be safely managed conservatively.