Introductory Chapter: Nuances of Surgical Technique for the Treatment of Adhesive Small Bowel Obstruction

*Dmitry Garbuzenko*

#### **1. Introduction**

Adhesive small bowel obstruction is one of the most formidable urgent surgical diseases of the abdominal organs [1]. Surgeons that encounter this disease are well aware of how insidious it is and how difficult it is to treat this pathology. Adhesive small bowel obstruction may often be successfully resolved conservatively. However, if conservative treatment is not effective within 72 h, and if there are signs of peritonitis, strangulation, or bowel ischemia, surgery is necessary [2]. Very often, a surgeon on call decides on the necessity of surgery. This surgeon might not have a lot of experience, but has to deal with the disease face-to-face. However, even experienced specialists may run into significant difficulties during such surgical interventions [3]. The only way to disengage from such a situation with honor is to strictly follow tactics and techniques developed by doctors involved in emergency abdominal surgery. In this chapter, I would like to share the nuances of performing surgery in patients with acute adhesive small bowel obstruction, based on more than 35-year experience of night shifts in an urgent surgical clinic.

#### **2. Surgical access**

Despite the achievements of laparoscopic surgery, in most cases of adhesive small bowel obstruction, surgery is performed via a wide incision of the anterior abdominal wall. The optimal surgical approach is midline laparotomy, which, if necessary, is extended up to the umbilicus or down to the pubic symphysis. If the patient has previously undergone midline laparotomy, it is expedient to start surgery with an incision upper or lower the scar. In any case, the scar, encapsulated non-absorbable sutures, and granulation tissue are excised, and the incision is treated with an antiseptic solution.

The parietal peritoneum in the area of the postoperative scar of the anterior abdominal wall always has gross adhesions with aponeurosis forming the *linea alba*. Moreover, as a rule, internal organs are fixed to the *linea alba* by adhesions. Therefore, the peritoneum should be lifted with tweezers and opened very carefully, since the dilated bowel loops may be easily damaged. It is better to keep the surgical site dry for a better view but achieve it without electrocauterization. When a small penetration into the abdominal cavity is achieved, the available area of the peritoneal cavity is carefully examined with a finger. Next, the abdominal wall is lifted with

a Farabeuf retractor or Maikulicz clamp applied to the aponeurosis edge, and the adhered organs are bluntly and sharply dissected; so, the aponeurosis and parietal peritoneum are prepared for the subsequent extension of the incision. When the abdominal cavity is opened, the dilated loops of the small bowel tend to slip out and should be kept with gauze pads moistened in an antiseptic solution. The gauze pads should be fixed, so as not to accidentally leave them in the peritoneal cavity.

#### **3. Examination of the abdominal cavity**

Sometimes the cause of intestinal obstruction is detected immediately, but more often an examination of the abdominal cavity is required. First of all, palpation should be performed. If it yields no result, the intestine should be moved to the left to try to isolate and examine the cecum. Obviously, the cecum is constricted in small bowel obstruction and dilated in large bowel obstruction. When the level of intestinal obstruction is determined, the next step is to search for an obstacle. To identify adhesions that obstructed the small bowel, it is necessary to examine it in the oral direction, starting from the cecum. The site of obstruction is where the constricted small bowel becomes dilated.

Such manipulations are possible only if the bowel is moderately dilated and adhesions are mild. Otherwise, a surgeon has to sort through the intestinal loops sequentially, which is difficult to do without preliminary nasointestinal intubation.

#### **4. Technique of adhesiolysis**

Adhesiolysis is started when the site of obstruction is found. The dissection of "loose" adhesions, which are more common in early adhesive bowel obstruction, is not technically difficult. Such adhesions can be destroyed with a finger, but undue force should not be exerted as it may lead to damage to the serous layer of the intestine. Otherwise, adhesions may be cut with scissors. In the latter case, scissors are used in a reverse manner. The tips of closed scissors are inserted between the adhered organs and then opened to separate them. This helps to find the "layer" between the bowel loops fixed to each other.

The greatest technical difficulties arise when the long portions of bowel loops are intimately fixed to each other and/or to the parietal peritoneum. The resulting single conglomerate is sometimes so dense that it is almost impossible to identify the borderline between the organs. In such cases, the safest way to separate the intestine is to excise it with the adjacent peritoneum.

To eliminate dense planar intestinal adhesions, space is created in the place of their least severity in the direction of the posterior abdominal wall. The index finger of the right hand is introduced into this space and the adhesions are separated along the posterior surface of the intestinal conglomerate by pendulum-like movements and without excessive force. As a rule, their density in this area is not so pronounced, so there is a chance to partially release the intestinal loops located there. After reaching some mobility, the bowel loops are rotated anteriorly, and the dissection of adhesions is completed. If it is not possible to separate the obstructioncausing conglomerate of the bowel loops, then, in the absence of signs of their non-viability, an intestinal anastomosis is performed. Otherwise, a pathologically altered portion of the small bowel is resected.

During adhesiolysis, a surgeon may inadvertently damage the wall of the intestine, especially the dilated proximal portion. In this case, superficial slit-like defects of the serous layer should not be sutured, since after emptying the intestines

**3**

*Introductory Chapter: Nuances of Surgical Technique for the Treatment of Adhesive Small Bowel…*

their edges, as a rule, are converged by themselves. If not only the serous but also the muscle layer is damaged, seromuscular sutures should be applied with absorbable suture material on an atraumatic needle 4/0 or 5/0. If the intestinal lumen is accidentally opened, the perforated area is immediately plugged to prevent the release of contents. Strict adherence to the rules of aseptic technique is extremely important since the microflora located in the proximal dilated loop is always highly virulent. Therefore, in the case of abdominal contamination, there is a high risk of infectious postoperative complications. Before suturing, the damaged portion of the bowel should be separated from the surrounding adhesions and isolated from the abdominal cavity with gauze pads. Then, intestinal clamps are applied above and below the wound and the gauze pads are removed, the remnants of the intestinal contents are aspirated, and the site of perforation and adjacent tissues are treated with an antiseptic solution. The wound is sutured in the transverse direction with a double-row interrupted suture by using an absorbable suture material on an

After eliminating the obstruction, it is necessary to assess the viability of the portion of the small bowel involved in the pathological process. Absolute signs of its necrosis are a change in color to dark purple or black, absence of tone, peristalsis, pulsation of the mesenteric vessels and arteries of the intestinal wall, and specific

In doubtful cases, the altered bowel loop is immersed in the abdominal cavity and after 15–20 min its viability is checked. During this time, a surgeon may perform hemostasis, nasointestinal intubation, and aspirate intestinal contents. A more aggressive way is to warm a doubtful area with gauze pads moistened with hot saline. If these measures are not effective, the bowel is recognized as non-viable, which

Resection of the necrotic small intestine should be performed within healthy tissues to be sure that circulatory disturbances at the point of a cut are minimal. Considering more pronounced microcirculatory changes in the proximal loop, the cut should be 30–40 cm above and 15–20 cm below the site of visible necrosis. From a practical point of view, it should be noted that, due to the significant extensibility of the small bowel, it is impossible to determine the indicated length. Therefore, it is necessary to visually assess the condition of the mucous layer of the remaining bowel loops (color, bleeding, etc.). After resection, a side to side bowel anastomosis is the most appropriate. A two-row interrupted suture is applied with absorbable

The main indications for nasointestinal intubation in acute adhesive bowel obstruction are the dilation of the small bowel lumen for more than 5 cm and the need for its resection. An anesthetist in the operating room usually helps in installing the nasointestinal tube through the nose into the stomach. After this, the surgeon fixes the pylorus with the left hand and moves the tube tip through the stomach into the duodenal bulb with the right hand. Next, the tube is advanced through the duodenum by pushing its portion in the stomach. If the anatomy of the duodenum is normal, this maneuver may be done quite simply and quickly. However, if the duodenum is significantly deformed, the tube tip is slowly moved

*DOI: http://dx.doi.org/10.5772/intechopen.93216*

atraumatic needle 4/0–5/0.

serves as an indication for its resection.

**5. Resection of the gangrenous small bowel**

suture material on an atraumatic needle 4/0 or 5/0.

**6. Nasointestinal intubation**

putrefactive odor.

#### *Introductory Chapter: Nuances of Surgical Technique for the Treatment of Adhesive Small Bowel… DOI: http://dx.doi.org/10.5772/intechopen.93216*

their edges, as a rule, are converged by themselves. If not only the serous but also the muscle layer is damaged, seromuscular sutures should be applied with absorbable suture material on an atraumatic needle 4/0 or 5/0. If the intestinal lumen is accidentally opened, the perforated area is immediately plugged to prevent the release of contents. Strict adherence to the rules of aseptic technique is extremely important since the microflora located in the proximal dilated loop is always highly virulent. Therefore, in the case of abdominal contamination, there is a high risk of infectious postoperative complications. Before suturing, the damaged portion of the bowel should be separated from the surrounding adhesions and isolated from the abdominal cavity with gauze pads. Then, intestinal clamps are applied above and below the wound and the gauze pads are removed, the remnants of the intestinal contents are aspirated, and the site of perforation and adjacent tissues are treated with an antiseptic solution. The wound is sutured in the transverse direction with a double-row interrupted suture by using an absorbable suture material on an atraumatic needle 4/0–5/0.

After eliminating the obstruction, it is necessary to assess the viability of the portion of the small bowel involved in the pathological process. Absolute signs of its necrosis are a change in color to dark purple or black, absence of tone, peristalsis, pulsation of the mesenteric vessels and arteries of the intestinal wall, and specific putrefactive odor.

In doubtful cases, the altered bowel loop is immersed in the abdominal cavity and after 15–20 min its viability is checked. During this time, a surgeon may perform hemostasis, nasointestinal intubation, and aspirate intestinal contents. A more aggressive way is to warm a doubtful area with gauze pads moistened with hot saline. If these measures are not effective, the bowel is recognized as non-viable, which serves as an indication for its resection.

#### **5. Resection of the gangrenous small bowel**

Resection of the necrotic small intestine should be performed within healthy tissues to be sure that circulatory disturbances at the point of a cut are minimal. Considering more pronounced microcirculatory changes in the proximal loop, the cut should be 30–40 cm above and 15–20 cm below the site of visible necrosis. From a practical point of view, it should be noted that, due to the significant extensibility of the small bowel, it is impossible to determine the indicated length. Therefore, it is necessary to visually assess the condition of the mucous layer of the remaining bowel loops (color, bleeding, etc.). After resection, a side to side bowel anastomosis is the most appropriate. A two-row interrupted suture is applied with absorbable suture material on an atraumatic needle 4/0 or 5/0.

#### **6. Nasointestinal intubation**

The main indications for nasointestinal intubation in acute adhesive bowel obstruction are the dilation of the small bowel lumen for more than 5 cm and the need for its resection. An anesthetist in the operating room usually helps in installing the nasointestinal tube through the nose into the stomach. After this, the surgeon fixes the pylorus with the left hand and moves the tube tip through the stomach into the duodenal bulb with the right hand. Next, the tube is advanced through the duodenum by pushing its portion in the stomach. If the anatomy of the duodenum is normal, this maneuver may be done quite simply and quickly. However, if the duodenum is significantly deformed, the tube tip is slowly moved

*Intestinal Obstructions*

a Farabeuf retractor or Maikulicz clamp applied to the aponeurosis edge, and the adhered organs are bluntly and sharply dissected; so, the aponeurosis and parietal peritoneum are prepared for the subsequent extension of the incision. When the abdominal cavity is opened, the dilated loops of the small bowel tend to slip out and should be kept with gauze pads moistened in an antiseptic solution. The gauze pads

Sometimes the cause of intestinal obstruction is detected immediately, but more

often an examination of the abdominal cavity is required. First of all, palpation should be performed. If it yields no result, the intestine should be moved to the left to try to isolate and examine the cecum. Obviously, the cecum is constricted in small bowel obstruction and dilated in large bowel obstruction. When the level of intestinal obstruction is determined, the next step is to search for an obstacle. To identify adhesions that obstructed the small bowel, it is necessary to examine it in the oral direction, starting from the cecum. The site of obstruction is where the

Such manipulations are possible only if the bowel is moderately dilated and adhesions are mild. Otherwise, a surgeon has to sort through the intestinal loops sequentially, which is difficult to do without preliminary nasointestinal intubation.

Adhesiolysis is started when the site of obstruction is found. The dissection of "loose" adhesions, which are more common in early adhesive bowel obstruction, is not technically difficult. Such adhesions can be destroyed with a finger, but undue force should not be exerted as it may lead to damage to the serous layer of the intestine. Otherwise, adhesions may be cut with scissors. In the latter case, scissors are used in a reverse manner. The tips of closed scissors are inserted between the adhered organs and then opened to separate them. This helps to find the "layer"

The greatest technical difficulties arise when the long portions of bowel loops are intimately fixed to each other and/or to the parietal peritoneum. The resulting single conglomerate is sometimes so dense that it is almost impossible to identify the borderline between the organs. In such cases, the safest way to separate the intestine

To eliminate dense planar intestinal adhesions, space is created in the place of their least severity in the direction of the posterior abdominal wall. The index finger of the right hand is introduced into this space and the adhesions are separated along the posterior surface of the intestinal conglomerate by pendulum-like movements and without excessive force. As a rule, their density in this area is not so pronounced, so there is a chance to partially release the intestinal loops located there. After reaching some mobility, the bowel loops are rotated anteriorly, and the dissection of adhesions is completed. If it is not possible to separate the obstructioncausing conglomerate of the bowel loops, then, in the absence of signs of their non-viability, an intestinal anastomosis is performed. Otherwise, a pathologically

During adhesiolysis, a surgeon may inadvertently damage the wall of the intestine, especially the dilated proximal portion. In this case, superficial slit-like defects of the serous layer should not be sutured, since after emptying the intestines

should be fixed, so as not to accidentally leave them in the peritoneal cavity.

**3. Examination of the abdominal cavity**

constricted small bowel becomes dilated.

between the bowel loops fixed to each other.

is to excise it with the adjacent peritoneum.

altered portion of the small bowel is resected.

**4. Technique of adhesiolysis**

**2**

from the bulb into the vertical part of the duodenum. Then, the tube is advanced to the lower horizontal part of the duodenum with the right hand placed under the mesentery of the transverse colon. As a rule, from there the tube is easily moved beyond the Treitz ligament into the jejunum. This may not work out due to the deformation of the duodenojejunal transition, which should be eliminated. Forced tube advancement is unacceptable due to the danger of intestinal wall perforation.

When the nasointestinal tube tip passed the Treitz ligament, the tube is advanced through the small intestine, which is the easiest step of intubation. The operating surgeon moves the tube through the proximal part of the bowel, while the assistant straightens the bowel loops and directs the tube tip towards the ileocecal transition. At this step, it is necessary to avoid the formation of excessive tube loops in the stomach, which occur in the absence of synchronous actions of the surgeon and the anesthetist advancing the tube into the stomach. The tube tip should not be inserted into the cecum. The destruction of the ileocecal flap may cause colonic contents reflux and colonization of the small intestine by fecal microflora.

If the small intestine was resected, the tube tip is installed 30–50 cm distal to the intestinal anastomosis.

Intestinal aspiration is performed after intubation is completed. Next, it is necessary to verify the correct location of the nasointestinal tube, since the presence of loops, flexures, and deformations makes decompression ineffective. It is very important to determine the location of the last lateral perforation of the tube, which should be in the middle part of the stomach. Its displacement into the esophagus is strictly unacceptable, because it may lead to aspiration of the gastric contents into the respiratory tract in the postoperative period. A less dangerous mistake is to leave the last lateral perforation in the duodenum. In this case, patients may experience vomiting, as the cavity of the stomach is undrained. The tube may be marked with a narrow strip of adhesive tape near the last lateral perforation to facilitate its search.

At the end of the surgery, a surgeon should check hemostasis and remove the fluid from the abdominal cavity. The drainage tube is installed through a contraperture and placed in the pelvic cavity. The anterior abdominal wall layers are sutured with absorbable suture material.

I do not doubt that each experienced surgeon may offer personal original techniques that he or she uses during surgery for acute adhesive small bowel obstruction. Nevertheless, I would like to hope that the small nuances of the surgical technique described in this modest essay may help to avoid big problems during such surgical interventions.

#### **Author details**

#### Dmitry Garbuzenko

Department of Faculty Surgery, South Ural State Medical University, Chelyabinsk, Russia

\*Address all correspondence to: garb@inbox.ru

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**5**

*Introductory Chapter: Nuances of Surgical Technique for the Treatment of Adhesive Small Bowel…*

*DOI: http://dx.doi.org/10.5772/intechopen.93216*

[1] Garbuzenko DV. Selected Lectures in Emergency Abdominal Surgery. Saarbrücken, Germany: LAP LAMBERT Academic Publishing GmbH & Co.;

[2] Ten Broek RPG, Krielen P, Di Saverio S, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World Journal of Emergency Surgery.

[3] Stich R, Makkas M. Fehler und Gefahren bei Chirurgischen

Deutsch: Verlag: G. Fischer; 1923

Operationen. Mit 146 zum Teil Farbigen Abbildungen im Text und 2 Tafeln. Jena,

**References**

2012

2018;**13**:24

*Introductory Chapter: Nuances of Surgical Technique for the Treatment of Adhesive Small Bowel… DOI: http://dx.doi.org/10.5772/intechopen.93216*

#### **References**

*Intestinal Obstructions*

intestinal anastomosis.

**4**

**Author details**

interventions.

Russia

Dmitry Garbuzenko

with absorbable suture material.

\*Address all correspondence to: garb@inbox.ru

provided the original work is properly cited.

Department of Faculty Surgery, South Ural State Medical University, Chelyabinsk,

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

I do not doubt that each experienced surgeon may offer personal original techniques that he or she uses during surgery for acute adhesive small bowel obstruction. Nevertheless, I would like to hope that the small nuances of the surgical technique described in this modest essay may help to avoid big problems during such surgical

from the bulb into the vertical part of the duodenum. Then, the tube is advanced to the lower horizontal part of the duodenum with the right hand placed under the mesentery of the transverse colon. As a rule, from there the tube is easily moved beyond the Treitz ligament into the jejunum. This may not work out due to the deformation of the duodenojejunal transition, which should be eliminated. Forced tube advancement is unacceptable due to the danger of intestinal wall perforation. When the nasointestinal tube tip passed the Treitz ligament, the tube is advanced through the small intestine, which is the easiest step of intubation. The operating surgeon moves the tube through the proximal part of the bowel, while the assistant straightens the bowel loops and directs the tube tip towards the ileocecal transition. At this step, it is necessary to avoid the formation of excessive tube loops in the stomach, which occur in the absence of synchronous actions of the surgeon and the anesthetist advancing the tube into the stomach. The tube tip should not be inserted into the cecum. The destruction of the ileocecal flap may cause colonic

contents reflux and colonization of the small intestine by fecal microflora.

If the small intestine was resected, the tube tip is installed 30–50 cm distal to the

Intestinal aspiration is performed after intubation is completed. Next, it is necessary to verify the correct location of the nasointestinal tube, since the presence of loops, flexures, and deformations makes decompression ineffective. It is very important to determine the location of the last lateral perforation of the tube, which should be in the middle part of the stomach. Its displacement into the esophagus is strictly unacceptable, because it may lead to aspiration of the gastric contents into the respiratory tract in the postoperative period. A less dangerous mistake is to leave the last lateral perforation in the duodenum. In this case, patients may experience vomiting, as the cavity of the stomach is undrained. The tube may be marked with a narrow strip of adhesive tape near the last lateral perforation to facilitate its search. At the end of the surgery, a surgeon should check hemostasis and remove the fluid from the abdominal cavity. The drainage tube is installed through a contraperture and placed in the pelvic cavity. The anterior abdominal wall layers are sutured

[1] Garbuzenko DV. Selected Lectures in Emergency Abdominal Surgery. Saarbrücken, Germany: LAP LAMBERT Academic Publishing GmbH & Co.; 2012

[2] Ten Broek RPG, Krielen P, Di Saverio S, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World Journal of Emergency Surgery. 2018;**13**:24

[3] Stich R, Makkas M. Fehler und Gefahren bei Chirurgischen Operationen. Mit 146 zum Teil Farbigen Abbildungen im Text und 2 Tafeln. Jena, Deutsch: Verlag: G. Fischer; 1923

**7**

**Chapter 2**

**Abstract**

minimally invasive era.

**1. Introduction**

Index (PAI) (**Figure 1**) [4, 5].

Adhesive Small Bowel Obstruction

Roughly 60% of all cases of small bowel obstruction are caused by adhesions. Adhesions are a form of internal scar tissue, which develop in over 45–93% of patients who undergo abdominal surgery. With this relatively high incidence, the population at risk for adhesive small bowel obstruction (ASBO) is enormous. Minimally invasive surgery reduces surgical wound surface and thus holds promise to reduce adhesion formation. The use of minimally invasive techniques results in a 50% reduction of adhesion formation as compared to open surgery. However, since ASBO can be caused by just a single adhesive band, it is uncertain whether a reduction in adhesion formation will also lead to a proportional decrease in the incidence of ASBO. Minimally invasive surgery might also improve operative treatment of ASBO, accelerating gastro-intestinal recovery time and lowering the risk of recurrent ASBO associated with adhesion reformation. We will discuss recent evidence on the impact of minimally invasive surgery on the incidence of ASBO and the role of minimally invasive surgery to resolve ASBO. Finally, we will debate additional measures, such as the use of adhesion barriers, to prevent adhesion formation and adhesion-related morbidity in the

**Keywords:** adhesions, adhesive small bowel obstruction, minimally invasive surgery,

As many as 60% of all episodes of small bowel obstruction (SBO) are caused by adhesions [1]. Adhesions are attachments of abdominal structures by internal scar tissue that are the result of healing of the peritoneum after it has been damaged, in most cases by surgery [2]. Adhesions can be filmy or dense and be present as an isolated band or as a 'curtain' or tangle with difficulty recognizing visceral structures. The degree of density and vascularization is traditionally classified using the Zühlke classification (**Table 1**) [3]. A more comprehensive and clinically relevant classification including projected locations of adhesions is the Peritoneal Adhesion

Adhesions develop in 89–93% of patients undergoing open abdominal or pelvic surgery [6, 7]. Incidence rates of adhesion formation are lower after minimally invasive surgery, 45–62% [7, 8]. Adhesions can also develop after other causes of peritoneal trauma, such as inflammatory conditions or radiotherapy [2].

laparoscopy, adhesion barrier, adhesion reduction strategies

in the Minimally Invasive Era

*Pepijn Krielen, Martijn W. J. Stommel,* 

*Richard P. G. ten Broek and Harry van Goor*

#### **Chapter 2**

## Adhesive Small Bowel Obstruction in the Minimally Invasive Era

*Pepijn Krielen, Martijn W. J. Stommel, Richard P. G. ten Broek and Harry van Goor*

#### **Abstract**

Roughly 60% of all cases of small bowel obstruction are caused by adhesions. Adhesions are a form of internal scar tissue, which develop in over 45–93% of patients who undergo abdominal surgery. With this relatively high incidence, the population at risk for adhesive small bowel obstruction (ASBO) is enormous. Minimally invasive surgery reduces surgical wound surface and thus holds promise to reduce adhesion formation. The use of minimally invasive techniques results in a 50% reduction of adhesion formation as compared to open surgery. However, since ASBO can be caused by just a single adhesive band, it is uncertain whether a reduction in adhesion formation will also lead to a proportional decrease in the incidence of ASBO. Minimally invasive surgery might also improve operative treatment of ASBO, accelerating gastro-intestinal recovery time and lowering the risk of recurrent ASBO associated with adhesion reformation. We will discuss recent evidence on the impact of minimally invasive surgery on the incidence of ASBO and the role of minimally invasive surgery to resolve ASBO. Finally, we will debate additional measures, such as the use of adhesion barriers, to prevent adhesion formation and adhesion-related morbidity in the minimally invasive era.

**Keywords:** adhesions, adhesive small bowel obstruction, minimally invasive surgery, laparoscopy, adhesion barrier, adhesion reduction strategies

#### **1. Introduction**

As many as 60% of all episodes of small bowel obstruction (SBO) are caused by adhesions [1]. Adhesions are attachments of abdominal structures by internal scar tissue that are the result of healing of the peritoneum after it has been damaged, in most cases by surgery [2]. Adhesions can be filmy or dense and be present as an isolated band or as a 'curtain' or tangle with difficulty recognizing visceral structures. The degree of density and vascularization is traditionally classified using the Zühlke classification (**Table 1**) [3]. A more comprehensive and clinically relevant classification including projected locations of adhesions is the Peritoneal Adhesion Index (PAI) (**Figure 1**) [4, 5].

Adhesions develop in 89–93% of patients undergoing open abdominal or pelvic surgery [6, 7]. Incidence rates of adhesion formation are lower after minimally invasive surgery, 45–62% [7, 8]. Adhesions can also develop after other causes of peritoneal trauma, such as inflammatory conditions or radiotherapy [2].


**Table 1.** *Zühlke classification.*



**9**

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era*

The occurrence of adhesions does not only cause a lifelong risk of adhesive small bowel obstruction (ASBO). Other clinical consequences of adhesions are difficulties during reoperation, female infertility, and chronic visceral pain; making it the most common cause of long-term complications in peritoneal surgery [1]. The incidence of ASBO is 2–3% in the first years after surgery in all patients who undergo abdominal or pelvic surgery [1]. The risk of ASBO depends on the anatomical location of surgery and the extent of surgery and peritoneal injury [1–10]. ASBO risk varies from 0.5% in abdominal wall surgery, 1.2% after upper gastrointestinal tract surgery to 3.2% in lower gastro-intestinal tract surgery and

Given the high incidence of adhesions and adhesion-related complications, one would assume that every surgeon is aware of the risks of adhesions. However, awareness on the full size of the problem only arose in response to the publication of the Surgical and Clinical Adhesion Research (SCAR) study two decades ago. The SCAR large population based study demonstrated that one of three patients undergoing abdominal surgery is readmitted for a cause possibly related to adhesions [11]. Subsequently adhesion-related complications gained increasing awareness of clinicians, hospitals and vendors, and adhesion reduction strategies were introduced. Laparoscopic surgeons hypothesized that minimally invasive surgical techniques would reduce peritoneal injury and thereby could solve the problem of adhesion formation. Other strategies to reduce adhesion formation were the development of adhesion barriers, the banishment of powdered gloves, and the introduction of new

Over the past decades, minimally invasive surgery has become the standard approach in many surgical disciplines. The rapid introduction of minimally invasive surgery was largely fueled by short-term benefits such as quicker recovery, reduced pain, and better cosmetic outcome [13]. Furthermore, surgeons strongly believed in the effectiveness of minimally invasive surgical techniques to reduce adhesion formation and subsequent morbidity [14]. For this reasons adhesion barriers are only seldomly used in minimally invasive surgery [15], and are believed to be needed only in open surgery. Despite good evidence of effective reduction of adhesion formation and subsequent adhesion-related morbidity, the use of adhesion barriers in open surgery is also limited [16]. Reasons for not using adhesion barriers are the lack of trust in adhesion reduction, the expected limited impact on adhesion-related complications, and the costs of the barriers [15]. The limited use of adhesion barriers has slowed down the research and development of adhesion-prevention strate-

Studies on adhesion formation in minimally invasive surgery report a reduction

of approximately 50% in the extent of postoperative adhesions compared with open surgery [7]. Unfortunately, trials comparing open and minimally invasive surgery have not been designed and powered to compare long-term adhesionrelated outcomes [17]. Therefore, the effect of the broad implementation of minimally invasive surgery on clinically relevant outcome parameters such as ASBO and readmissions is unknown [17]. A reduction in adhesion formation, does not necessarily correlate with a proportionate reduction in the risk of ASBO; a single adhesive band may cause a life-threatening bowel obstruction, whereas extensive dense abdominal adhesions may be asymptomatic [18]. Nevertheless, potential benefits of minimally invasive surgery in preventing adhesion-related morbidity

Minimally invasive surgery may also play a role in the treatment of ASBO. Approximately 25% of patients with ASBO require surgery to resolve the bowel obstruction [1], and recurrence rates are high [19]. The minimally invasive

*DOI: http://dx.doi.org/10.5772/intechopen.91896*

4.2% in pediatric surgery [1].

sealing devices [12].

gies in the past decade.

seem compelling.

**Figure 1.** *Peritoneal adhesion index.*

*Adapted from Ref. [3].*

*Zühlke classification.*

**Table 1.**

**Grade Description**

0 No adhesions or insignificant adhesions

dissection is necessary

I Adhesions that are filmy and easy to separate by blunt dissection

II Adhesions with beginning vascularization that can be dissected blunt but some sharp

III Adhesions with clear vascularization that can only be dissected using sharp dissection IV Adhesions which strongly attached organs, dissection is only possible by sharp dissection, damage of organs is hardly preventable

**8**

**Figure 1.**

*Peritoneal adhesion index.*

The occurrence of adhesions does not only cause a lifelong risk of adhesive small bowel obstruction (ASBO). Other clinical consequences of adhesions are difficulties during reoperation, female infertility, and chronic visceral pain; making it the most common cause of long-term complications in peritoneal surgery [1]. The incidence of ASBO is 2–3% in the first years after surgery in all patients who undergo abdominal or pelvic surgery [1]. The risk of ASBO depends on the anatomical location of surgery and the extent of surgery and peritoneal injury [1–10]. ASBO risk varies from 0.5% in abdominal wall surgery, 1.2% after upper gastrointestinal tract surgery to 3.2% in lower gastro-intestinal tract surgery and 4.2% in pediatric surgery [1].

Given the high incidence of adhesions and adhesion-related complications, one would assume that every surgeon is aware of the risks of adhesions. However, awareness on the full size of the problem only arose in response to the publication of the Surgical and Clinical Adhesion Research (SCAR) study two decades ago. The SCAR large population based study demonstrated that one of three patients undergoing abdominal surgery is readmitted for a cause possibly related to adhesions [11]. Subsequently adhesion-related complications gained increasing awareness of clinicians, hospitals and vendors, and adhesion reduction strategies were introduced. Laparoscopic surgeons hypothesized that minimally invasive surgical techniques would reduce peritoneal injury and thereby could solve the problem of adhesion formation. Other strategies to reduce adhesion formation were the development of adhesion barriers, the banishment of powdered gloves, and the introduction of new sealing devices [12].

Over the past decades, minimally invasive surgery has become the standard approach in many surgical disciplines. The rapid introduction of minimally invasive surgery was largely fueled by short-term benefits such as quicker recovery, reduced pain, and better cosmetic outcome [13]. Furthermore, surgeons strongly believed in the effectiveness of minimally invasive surgical techniques to reduce adhesion formation and subsequent morbidity [14]. For this reasons adhesion barriers are only seldomly used in minimally invasive surgery [15], and are believed to be needed only in open surgery. Despite good evidence of effective reduction of adhesion formation and subsequent adhesion-related morbidity, the use of adhesion barriers in open surgery is also limited [16]. Reasons for not using adhesion barriers are the lack of trust in adhesion reduction, the expected limited impact on adhesion-related complications, and the costs of the barriers [15]. The limited use of adhesion barriers has slowed down the research and development of adhesion-prevention strategies in the past decade.

Studies on adhesion formation in minimally invasive surgery report a reduction of approximately 50% in the extent of postoperative adhesions compared with open surgery [7]. Unfortunately, trials comparing open and minimally invasive surgery have not been designed and powered to compare long-term adhesionrelated outcomes [17]. Therefore, the effect of the broad implementation of minimally invasive surgery on clinically relevant outcome parameters such as ASBO and readmissions is unknown [17]. A reduction in adhesion formation, does not necessarily correlate with a proportionate reduction in the risk of ASBO; a single adhesive band may cause a life-threatening bowel obstruction, whereas extensive dense abdominal adhesions may be asymptomatic [18]. Nevertheless, potential benefits of minimally invasive surgery in preventing adhesion-related morbidity seem compelling.

Minimally invasive surgery may also play a role in the treatment of ASBO. Approximately 25% of patients with ASBO require surgery to resolve the bowel obstruction [1], and recurrence rates are high [19]. The minimally invasive

approach is hypothesized to accelerate recovery, and might also reduce risk of regrowth of adhesions and subsequent recurrence of ASBO. A caveat is the small working space and vulnerability of the bowel caused by the distention of the obstructed bowel that could result in iatrogenic injuries. In this chapter, we discuss recent evidence on the effects of the introduction of minimally invasive surgery on the burden of adhesions and ASBO. We further discuss the role of minimally invasive surgery in the treatment of patients with ASBO. We end with a contemplation on the awareness of adhesion-related complications and the value of adhesion barriers in minimally invasive surgery.

#### **2. The problem of adhesive small bowel obstruction**

The vast majority of adhesions develop after abdominal or pelvic surgery, although adhesions can also form after abdominal and pelvic radiation and peritoneal inflammation [2]. Adhesions are associated with a lifelong risk of ASBO. Incidence and morbidity of ASBO might be somewhat difficult to estimate and compare between studies based on different definitions for ASBO. Most accepted definition of ASBO is an episode of SBO with the presence of adhesions confirmed during reoperation. However, operative confirmation of adhesions is often not possible because many ASBO episodes are managed non-operatively. Therefore a second definition of ASBO is commonly applied: an episode of SBO interpreted as matching ASBO on radiological imaging after excluding other potential causes of bowel obstruction e.g. hernia, tumor, bezoar.

In a systematic review, the incidence of SBO by any cause after surgery is estimated 9% [1]. In 42 etiological studies on SBO, adhesions accounted for 56% of all SBO episodes, either by operative confirmation or by excluding all other potential causes of SBO [1]. The incidence of postoperative ASBO confirmed by surgery is estimated at 2.4%. Depending on the type of initial surgical procedure, the incidence varied between 0.5 and 4.2% [1]. As mentioned, this estimate is conservative because most episodes of ASBO are managed non-operative.

Another way to estimate the burden of ASBO is based on population studies. In the SCAR study more than one in three patients were readmitted for a cause possibly related to adhesions, and more than 1 in 20 patients (6%) who underwent open abdominal or pelvic surgery were readmitted for a directly adhesion-related cause [11]. The most common diagnosis for a directly adhesionrelated readmission was ASBO [11]. More recent population studies in the UK and USA show that ASBO remains a major contributor to the morbidity, mortality and costs related to emergency abdominal surgery. In the UK in 2016, 51% of all emergency laparotomies were for ASBO [20]. Similar results were found in the USA between 2008 and 2011, where SBO needing adhesiolysis belonged to the top 5 of emergency surgical procedures [21]. Given these numbers and the number of patients undergoing abdominal or pelvic surgery, the impact of ASBO on a population level is high.

ASBO causes significant morbidity and a hospital admission for SBO is associated with 2.5% mortality [1]. Initial non-operative management of ASBO includes gastric decompression, fluid resuscitation and nil per os, which is successful in 70–90% [1–23]. In a sizable number of cases ASBO will result in emergency or delayed, after failed initial conservative management, abdominal surgery. Open or minimally invasive adhesiolysis to resolve the obstruction is associated with a incidence of 6–20% enterotomies [24, 25]. In general, complex adhesiolysis is associated with bleeding, sepsis, wound infections and increased mortality,

**11**

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era*

of complications associated with surgical intervention [28].

term clinical efficacy e.g. ASBO could benefit from using CLAS.

The economic burden of ASBO is high. Operative management is the single most important determinant of costs. However, based on fewer recurrences of ASBO after surgical treatment, surgery may save costs at the long term [34]. Several studies have been reported regarding the treatment costs of

ASBO. Most have important limitations reporting part of the costs or costs based on reimbursement prices rather than true healthcare costs [35–37]. We modeled in a recent study, costs for ASBO in the Netherlands using a micro-costing method including costs of length of stay, ICU days, operative time, medication, parenteral feeding, imaging studies and laboratory studies [38]. This modeling revealed total healthcare costs of patients operated for ASBO of €16305 (SD €2513) with a mean hospital stay of 16.0 ± 11 days. For non-operatively treated patients costs would be €2277 (SD €265) with a mean hospital stay of 4.0 ± 2.0 days. The majority of the costs were due to ward stay, operative time, ICU stay and (parental) feeding. All surgical procedures for ASBO in this study consisted of open adhesiolysis. Costs estimated in this study were higher compared to previous estimates of treatment costs for ASBO with comparable lengths of stay and, as a result of its design better reflecting reality [35–37]. In the study we adhered to international guidelines for the diagnosis and treatment of ASBO increasing generalizability of outcomes for developed countries.

even in the absence of bowel injury [26]. Mean length of hospital stay for ASBO ranges from 4 to 13 days and generally depends the type of treatment and the

Effort is made to predict the severity of ASBO using peri-operative scores

[29, 30]. However, the scores are not widely adopted for clinical use. The American Association for the Surgery of Trauma (AAST) developed a score based on clinical, imaging, operative and pathologic criteria to grade disease severity of ASBO [31, 32]. The AAST grade uses clinical criteria (flatus, bowel sounds abdominal distention), pathologic criteria (bowel perforation), imaging criteria on CT (intestinal distention, transition point, contrast flow) and operative criteria (intestinal distention, impeding bowel compromise, peritonitis) to define the grade of ASBO on a scale from 1 to 4. A higher AAST score for emergency ASBO is associated with an increase in length of hospital stay, pneumonia, and more severe complications [33]. Recently the Clinical Adhesion Score (CLAS) was developed, measuring the full spectrum of the long-term burden of adhesion formation in post-operative patients. CLAS calculates the overall morbidity based on four domains: ASBO, difficulties during reoperation, female infertility or subfertility, and chronic abdominal pain (data not yet published). Evaluation of current and new adhesion prevention strategies regarding long-

Both operative and conservative management of ASBO are associated with a risk of recurrent ASBO. Operative management includes repeated peritoneal injury with risk of adhesion reformation and re-ASBO. Non-operative management of ASBO does not dissolve abdominal adhesions and harbors the risk of a new episode of ASBO. In a recent study of patients presenting with a first episode of ASBO, operative management was associated with a lower risk of recurrence compared with non-operative management (13% vs. 21%) after a median follow-up of 3.6 years [19]. The study also showed an increased risk of ASBO with every previous episode of ASBO in accordance to findings done 25 years ago [27]. Also the time between episodes of ASBO decreases with an increase in number of episodes [19]. Despite the higher recurrence rate after conservative treatment, current guidelines still recommend a trial of non-operative management of ASBO in order to avoid the risk

*DOI: http://dx.doi.org/10.5772/intechopen.91896*

treatment complications [1].

barriers in minimally invasive surgery.

**2. The problem of adhesive small bowel obstruction**

tial causes of bowel obstruction e.g. hernia, tumor, bezoar.

because most episodes of ASBO are managed non-operative.

approach is hypothesized to accelerate recovery, and might also reduce risk of regrowth of adhesions and subsequent recurrence of ASBO. A caveat is the small working space and vulnerability of the bowel caused by the distention of the obstructed bowel that could result in iatrogenic injuries. In this chapter, we discuss recent evidence on the effects of the introduction of minimally invasive surgery on the burden of adhesions and ASBO. We further discuss the role of minimally invasive surgery in the treatment of patients with ASBO. We end with a contemplation on the awareness of adhesion-related complications and the value of adhesion

The vast majority of adhesions develop after abdominal or pelvic surgery, although adhesions can also form after abdominal and pelvic radiation and peritoneal inflammation [2]. Adhesions are associated with a lifelong risk of ASBO. Incidence and morbidity of ASBO might be somewhat difficult to estimate and compare between studies based on different definitions for ASBO. Most accepted definition of ASBO is an episode of SBO with the presence of adhesions confirmed during reoperation. However, operative confirmation of adhesions is often not possible because many ASBO episodes are managed non-operatively. Therefore a second definition of ASBO is commonly applied: an episode of SBO interpreted as matching ASBO on radiological imaging after excluding other poten-

In a systematic review, the incidence of SBO by any cause after surgery is estimated 9% [1]. In 42 etiological studies on SBO, adhesions accounted for 56% of all SBO episodes, either by operative confirmation or by excluding all other potential causes of SBO [1]. The incidence of postoperative ASBO confirmed by surgery is estimated at 2.4%. Depending on the type of initial surgical procedure, the incidence varied between 0.5 and 4.2% [1]. As mentioned, this estimate is conservative

Another way to estimate the burden of ASBO is based on population studies. In the SCAR study more than one in three patients were readmitted for a cause possibly related to adhesions, and more than 1 in 20 patients (6%) who underwent open abdominal or pelvic surgery were readmitted for a directly adhesion-related cause [11]. The most common diagnosis for a directly adhesionrelated readmission was ASBO [11]. More recent population studies in the UK and USA show that ASBO remains a major contributor to the morbidity, mortality and costs related to emergency abdominal surgery. In the UK in 2016, 51% of all emergency laparotomies were for ASBO [20]. Similar results were found in the USA between 2008 and 2011, where SBO needing adhesiolysis belonged to the top 5 of emergency surgical procedures [21]. Given these numbers and the number of patients undergoing abdominal or pelvic surgery, the impact of ASBO

ASBO causes significant morbidity and a hospital admission for SBO is associated with 2.5% mortality [1]. Initial non-operative management of ASBO includes gastric decompression, fluid resuscitation and nil per os, which is successful in 70–90% [1–23]. In a sizable number of cases ASBO will result in emergency or delayed, after failed initial conservative management, abdominal surgery. Open or minimally invasive adhesiolysis to resolve the obstruction is associated with a incidence of 6–20% enterotomies [24, 25]. In general, complex adhesiolysis is associated with bleeding, sepsis, wound infections and increased mortality,

**10**

on a population level is high.

even in the absence of bowel injury [26]. Mean length of hospital stay for ASBO ranges from 4 to 13 days and generally depends the type of treatment and the treatment complications [1].

Both operative and conservative management of ASBO are associated with a risk of recurrent ASBO. Operative management includes repeated peritoneal injury with risk of adhesion reformation and re-ASBO. Non-operative management of ASBO does not dissolve abdominal adhesions and harbors the risk of a new episode of ASBO. In a recent study of patients presenting with a first episode of ASBO, operative management was associated with a lower risk of recurrence compared with non-operative management (13% vs. 21%) after a median follow-up of 3.6 years [19]. The study also showed an increased risk of ASBO with every previous episode of ASBO in accordance to findings done 25 years ago [27]. Also the time between episodes of ASBO decreases with an increase in number of episodes [19]. Despite the higher recurrence rate after conservative treatment, current guidelines still recommend a trial of non-operative management of ASBO in order to avoid the risk of complications associated with surgical intervention [28].

Effort is made to predict the severity of ASBO using peri-operative scores [29, 30]. However, the scores are not widely adopted for clinical use. The American Association for the Surgery of Trauma (AAST) developed a score based on clinical, imaging, operative and pathologic criteria to grade disease severity of ASBO [31, 32]. The AAST grade uses clinical criteria (flatus, bowel sounds abdominal distention), pathologic criteria (bowel perforation), imaging criteria on CT (intestinal distention, transition point, contrast flow) and operative criteria (intestinal distention, impeding bowel compromise, peritonitis) to define the grade of ASBO on a scale from 1 to 4. A higher AAST score for emergency ASBO is associated with an increase in length of hospital stay, pneumonia, and more severe complications [33]. Recently the Clinical Adhesion Score (CLAS) was developed, measuring the full spectrum of the long-term burden of adhesion formation in post-operative patients. CLAS calculates the overall morbidity based on four domains: ASBO, difficulties during reoperation, female infertility or subfertility, and chronic abdominal pain (data not yet published). Evaluation of current and new adhesion prevention strategies regarding longterm clinical efficacy e.g. ASBO could benefit from using CLAS.

The economic burden of ASBO is high. Operative management is the single most important determinant of costs. However, based on fewer recurrences of ASBO after surgical treatment, surgery may save costs at the long term [34]. Several studies have been reported regarding the treatment costs of ASBO. Most have important limitations reporting part of the costs or costs based on reimbursement prices rather than true healthcare costs [35–37]. We modeled in a recent study, costs for ASBO in the Netherlands using a micro-costing method including costs of length of stay, ICU days, operative time, medication, parenteral feeding, imaging studies and laboratory studies [38]. This modeling revealed total healthcare costs of patients operated for ASBO of €16305 (SD €2513) with a mean hospital stay of 16.0 ± 11 days. For non-operatively treated patients costs would be €2277 (SD €265) with a mean hospital stay of 4.0 ± 2.0 days. The majority of the costs were due to ward stay, operative time, ICU stay and (parental) feeding. All surgical procedures for ASBO in this study consisted of open adhesiolysis. Costs estimated in this study were higher compared to previous estimates of treatment costs for ASBO with comparable lengths of stay and, as a result of its design better reflecting reality [35–37]. In the study we adhered to international guidelines for the diagnosis and treatment of ASBO increasing generalizability of outcomes for developed countries.

Nevertheless costs may vary among countries due to differences in admission and discharge policies, and prices of diagnostics, materials, medication and feeding.

#### **3. Impact of minimally invasive surgery on morbidity of ASBO**

It has been suggested from a few studies that the decreased adhesion formation after minimally invasive surgery associates with a lower incidence of ASBO. This decrease seems limited compared to open surgery as concluded from one systematic review and one trial reported by our group [1–17]. Differences in definitions of ASBO used, types of procedures, outcome parameters and length of follow-up in the studies, preclude a firm conclusion on the beneficial effect of minimally invasive surgery on development of ASBO.

To estimate the impact of minimally invasive surgery at a population level on adhesion-related complications, ASBO in particular, our group recently reported the results of the SCAR update study [39]. Over 72,000 patients, who were operated between June 2009 and June 2011, were followed for a minimum of 5 years. Readmissions were classified, according to the initial SCAR study (1999), as directly-related to adhesions e.g. adhesive small bowel obstruction, possibly related to adhesions, e.g. any small bowel obstruction and reoperations potentially complicated by adhesions e.g. right hemicolectomy years after an appendectomy. Approximately 30% of all index procedures were minimally invasive. Patients who underwent minimally invasive surgery were readmitted less frequently for directly related causes compared with patients after open surgery (1.7% vs. 4.3%). Possibly related readmissions and reoperations potentially complicated by adhesions were also less frequent (16.0% vs. 18.2% and 8.6% vs. 15.0%). Multivariate analysis revealed a 32% reduction in directly adhesion-related readmissions associated with minimally invasive surgery. Readmission rates were similar when comparing patients with open surgery in the SCAR and those in the SCAR update study. The overall small differences found in readmission rates could be explained by the difference in follow-up, 10 years in the SCAR study and 5 years in the SCAR update study. Despite the finding of a small reduction in readmission rates after initial minimally invasive surgery, the overall burden of adhesion-related readmissions on a population level remains high.

To further elaborate differences in adhesion-related readmissions between minimally invasive and open surgery, we analyzed patients with colorectal procedures (data not yet published). This type of surgery is known for its adhesion formation propensity and associated morbidity. Over 15,000 patients underwent colorectal surgery of whom almost one-third with a minimally invasive approach. For open colorectal surgery readmission rates were comparable between the SCAR study and the SCAR update study. Minimally invasive colonic and/or rectal surgery reduced the total number of directly adhesion-related readmissions. However in patients who underwent a (sub)total colectomy readmission rates were over 15% irrespective of an open or minimally invasive approach. Minimally invasive surgery did not reduce adhesion-related complications in rectal procedures. We concluded that an extended colectomy and rectal resection do not benefit from minimally invasive surgery regarding adhesion-related complications. We hypothesized that the large extent of the dissection and injury to the visceral and lateral parietal peritoneum needed in both surgical techniques abolishes the preventive effect of the minimally invasive technique on adhesion formation to the ventral peritoneum, where the injury is relatively limited for both approaches.

**13**

formation.

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era*

**4. Management of adhesive small bowel obstruction**

need to be involved in practice guidelines and protocols.

Adequate management of ASBO depends on an initially correct diagnosis. Although ASBO is a common diagnosis with clear signs and symptoms, misdiagnosis and delayed diagnosis are a substantial clinical problem. Up to 50% of older patients are initially not adequately diagnosed [42]. Failure to diagnose represents 70% of malpractice claims in ASBO [43, 44]. In this regard it is important to note that patients with ASBO can initially present themselves to a variety of physicians, including general practitioners, surgeons, internal medicine physicians, geriatricians and gastroenterologists. To improve diagnosis of ASBO, multiple specialists

Based on expert opinion the diagnosing of ASBO includes a medical history with an assessment of potential causes of SBO, e.g. previous abdominal surgery, inflammatory bowel disease, important symptoms such as vomiting, absence of stools or flatus, intermittent colicky abdominal pain and abdominal distention. Common pitfalls in diagnosing ASBO are the less prominent pain present in the elderly [42], reporting of watery diarrhea by patients with an incomplete obstruction and normal stool passage in the first days after onset due to stool still present in the colon. The recent update of the international guidelines for diagnosis and management of ASBO gives the current best available evidence for management of ASBO once the diagnosis of bowel obstruction has been established [28]. The first priority in management is to establish the cause of obstruction and to determine if urgent surgical treatment is required. ASBO is the single most common cause for SBO, the differential diagnosis includes strangulated abdominal wall or groin hernia, tumor, paralysis, constipation or bezoars. Laboratory tests should include blood count, CRP, electrolytes, creatinine and lactate. Imaging studies can include water-soluble contrast studies or computer tomography (CT) scans. CT scan is the preferred imaging technique for the diagnosis of ASBO, it can accurately rule out other causes of obstruction and identify patients who might require emergency surgery [28]. Water-soluble contrast enhances the diagnostic accuracy of CT scans. Signs that might suspect ASBO on imaging studies are an abrupt change in bowel diameter and the exclusion of other causes of SBO. The value of plain X-rays is limited [28].

The SCAR update study has demonstrated that minimally invasive surgery is associated with less adhesion-related readmissions. Hence, the overall burden of adhesion-related readmissions on a population level remains high. Adhesion formation therefore continues to be a challenge in abdominal surgery, also in the minimally invasive era. Minimally invasive procedures were only performed in approximately one-third of procedures in 2009–2011, whereas currently in the Netherlands about 75% of colonic resections are performed minimally invasive (by laparoscopy or robot) [40]. On a population base a further decline in adhesionrelated complications can be expected with an increase of minimally invasive abdominal operations. However, we like to warn against unbridled optimism regarding the overall impact of minimally invasive surgery on the burden of adhesions because open surgery is still being preferred when a complicated condition is expected in the abdominal cavity e.g. after multiple previous procedures, with large inflammatory mass or locally advanced cancer [41]. Many of these conditions are complex specifically due to presence of adhesions at baseline surgery and the need to perform adhesiolysis before entering the operative area. It is known that the propensity to reform adhesions after adhesiolysis is higher than de novo adhesion

*DOI: http://dx.doi.org/10.5772/intechopen.91896*

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era DOI: http://dx.doi.org/10.5772/intechopen.91896*

*Intestinal Obstructions*

sive surgery on development of ASBO.

a population level remains high.

injury is relatively limited for both approaches.

feeding.

Nevertheless costs may vary among countries due to differences in admission and discharge policies, and prices of diagnostics, materials, medication and

It has been suggested from a few studies that the decreased adhesion formation after minimally invasive surgery associates with a lower incidence of ASBO. This decrease seems limited compared to open surgery as concluded from one systematic review and one trial reported by our group [1–17]. Differences in definitions of ASBO used, types of procedures, outcome parameters and length of follow-up in the studies, preclude a firm conclusion on the beneficial effect of minimally inva-

To estimate the impact of minimally invasive surgery at a population level on adhesion-related complications, ASBO in particular, our group recently reported the results of the SCAR update study [39]. Over 72,000 patients, who were operated between June 2009 and June 2011, were followed for a minimum of 5 years. Readmissions were classified, according to the initial SCAR study (1999), as directly-related to adhesions e.g. adhesive small bowel obstruction, possibly related to adhesions, e.g. any small bowel obstruction and reoperations potentially complicated by adhesions e.g. right hemicolectomy years after an appendectomy. Approximately 30% of all index procedures were minimally invasive. Patients who underwent minimally invasive surgery were readmitted less frequently for directly related causes compared with patients after open surgery (1.7% vs. 4.3%). Possibly related readmissions and reoperations potentially complicated by adhesions were also less frequent (16.0% vs. 18.2% and 8.6% vs. 15.0%). Multivariate analysis revealed a 32% reduction in directly adhesion-related readmissions associated with minimally invasive surgery. Readmission rates were similar when comparing patients with open surgery in the SCAR and those in the SCAR update study. The overall small differences found in readmission rates could be explained by the difference in follow-up, 10 years in the SCAR study and 5 years in the SCAR update study. Despite the finding of a small reduction in readmission rates after initial minimally invasive surgery, the overall burden of adhesion-related readmissions on

To further elaborate differences in adhesion-related readmissions between minimally invasive and open surgery, we analyzed patients with colorectal procedures (data not yet published). This type of surgery is known for its adhesion formation propensity and associated morbidity. Over 15,000 patients underwent colorectal surgery of whom almost one-third with a minimally invasive approach. For open colorectal surgery readmission rates were comparable between the SCAR study and the SCAR update study. Minimally invasive colonic and/or rectal surgery reduced the total number of directly adhesion-related readmissions. However in patients who underwent a (sub)total colectomy readmission rates were over 15% irrespective of an open or minimally invasive approach. Minimally invasive surgery did not reduce adhesion-related complications in rectal procedures. We concluded that an extended colectomy and rectal resection do not benefit from minimally invasive surgery regarding adhesion-related complications. We hypothesized that the large extent of the dissection and injury to the visceral and lateral parietal peritoneum needed in both surgical techniques abolishes the preventive effect of the minimally invasive technique on adhesion formation to the ventral peritoneum, where the

**3. Impact of minimally invasive surgery on morbidity of ASBO**

**12**

The SCAR update study has demonstrated that minimally invasive surgery is associated with less adhesion-related readmissions. Hence, the overall burden of adhesion-related readmissions on a population level remains high. Adhesion formation therefore continues to be a challenge in abdominal surgery, also in the minimally invasive era. Minimally invasive procedures were only performed in approximately one-third of procedures in 2009–2011, whereas currently in the Netherlands about 75% of colonic resections are performed minimally invasive (by laparoscopy or robot) [40]. On a population base a further decline in adhesionrelated complications can be expected with an increase of minimally invasive abdominal operations. However, we like to warn against unbridled optimism regarding the overall impact of minimally invasive surgery on the burden of adhesions because open surgery is still being preferred when a complicated condition is expected in the abdominal cavity e.g. after multiple previous procedures, with large inflammatory mass or locally advanced cancer [41]. Many of these conditions are complex specifically due to presence of adhesions at baseline surgery and the need to perform adhesiolysis before entering the operative area. It is known that the propensity to reform adhesions after adhesiolysis is higher than de novo adhesion formation.

#### **4. Management of adhesive small bowel obstruction**

Adequate management of ASBO depends on an initially correct diagnosis. Although ASBO is a common diagnosis with clear signs and symptoms, misdiagnosis and delayed diagnosis are a substantial clinical problem. Up to 50% of older patients are initially not adequately diagnosed [42]. Failure to diagnose represents 70% of malpractice claims in ASBO [43, 44]. In this regard it is important to note that patients with ASBO can initially present themselves to a variety of physicians, including general practitioners, surgeons, internal medicine physicians, geriatricians and gastroenterologists. To improve diagnosis of ASBO, multiple specialists need to be involved in practice guidelines and protocols.

Based on expert opinion the diagnosing of ASBO includes a medical history with an assessment of potential causes of SBO, e.g. previous abdominal surgery, inflammatory bowel disease, important symptoms such as vomiting, absence of stools or flatus, intermittent colicky abdominal pain and abdominal distention. Common pitfalls in diagnosing ASBO are the less prominent pain present in the elderly [42], reporting of watery diarrhea by patients with an incomplete obstruction and normal stool passage in the first days after onset due to stool still present in the colon.

The recent update of the international guidelines for diagnosis and management of ASBO gives the current best available evidence for management of ASBO once the diagnosis of bowel obstruction has been established [28]. The first priority in management is to establish the cause of obstruction and to determine if urgent surgical treatment is required. ASBO is the single most common cause for SBO, the differential diagnosis includes strangulated abdominal wall or groin hernia, tumor, paralysis, constipation or bezoars. Laboratory tests should include blood count, CRP, electrolytes, creatinine and lactate. Imaging studies can include water-soluble contrast studies or computer tomography (CT) scans. CT scan is the preferred imaging technique for the diagnosis of ASBO, it can accurately rule out other causes of obstruction and identify patients who might require emergency surgery [28]. Water-soluble contrast enhances the diagnostic accuracy of CT scans. Signs that might suspect ASBO on imaging studies are an abrupt change in bowel diameter and the exclusion of other causes of SBO. The value of plain X-rays is limited [28].

Urgent surgery is required in case of signs of ischemia, perforation or strangulation of the bowel, generalized peritonitis and/or hemodynamic instability. No single test is highly sensitive for ischemia and strangulation. Sensitivity of physical examination for the detection of strangulation is only 48% in experienced hands [45]. Laboratory tests indicating peritonitis or ischemia are a CRP above 75 and a white blood cell count above 10.000/mm3 [45–47]. Again, a CT scan is most accurate in assessing strangulation and perforation and the need for emergency surgery [28]. CT abnormalities indicating strangulation or perforation are free intraperitoneal air or fluid, closed loop obstruction, mesenteric edema or engorgement, mesenteric swirling, pneumatosis intestinalis, decreased or lack of bowel enhancement or thickened bowel wall [48–50].

If bowel obstruction is caused by adhesions, and signs of peritonitis, ischemia, and strangulation are absent, initial conservative treatment is reportedly safe. Conservative treatment is successful in 70–90% of all episodes of ASBO [1–23]. Conservative treatment of ASBO consists of nil per os and decompression of the gastro-intestinal tract using a naso-gastric tube. Further management includes fluid resuscitation, correction of electrolyte disturbances, nutritional support and prevention of aspiration. Optimal duration of a conservative trial is debated; prolonged management for more than 72 h has been associated with adverse outcomes and increased mortality [20, 51–54]. Water-soluble contrast studies seem useful in the follow-up of conservative management of ASBO. If contrast has not reached to colon 24–48 h following administration, continuation of conservative management is likely to fail and surgical management should be considered [28].

An algorithm for the diagnosis and treatment of ASBO is presented in **Figure 2** [28].

#### **4.1 Role of minimally invasive surgery in the management of ASBO**

Operative treatment of ASBO historically comprises an explorative laparotomy with adhesiolysis. The increased use of minimally invasive surgery has raised the question whether minimally invasive surgery is feasible and effective for the treatment of ASBO. Benefits of minimally invasive adhesiolysis are reduction of peritoneal injury possibly resulting in less adhesion reformation, a quick recovery and minimal post-operative pain. Twenty-five years ago the first cases of minimally invasive surgery for treatment of ASBO have been described [55]. Thereafter a few series were reported but adequate comparative trials are scarce [56–60]. Minimally invasive surgery for ASBO is challenging because there is little laparoscopic working space due to the distended bowel. Also visibility can be hampered by multiple adhesions. There are concerns that minimally invasive surgery increases the risk of iatrogenic bowel perforations [57]. Suitability of minimally invasive surgery for ASBO further depends on patient characteristics. In case of hemodynamic instability open surgery is required because patients cannot tolerate the pneumoperitoneum.

One randomized trial comparing minimally invasive and open surgery for ASBO has been performed [56]. Only patients with a high suspicion of a single adhesive band causing the obstruction were included. Patients with confirmed or suspected peritoneal carcinosis, known multiple adhesions, previous open surgery for endometriosis, aorta, iliac vessels or Crohn's disease, previous generalized peritonitis, abdominal malignancy, previous abdominal radiotherapy or recent operations within 30 days were all excluded. Patients started with conservative management of ASBO. If the obstruction did not resolve patients were randomized between open and laparoscopic adhesiolysis. The trial was open label, therefore patients and care providers were not blinded. During 5 years 566 patients were included in the study, 104 patients underwent surgery, 51 were randomly assigned to the open surgery

**15**

**Figure 2.**

*Algorithm for the diagnosis and treatment of ASBO.*

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era*

group, and 53 to the laparoscopic surgery group. Patients in the laparoscopic group had a shorter length of stay (4.2 days) compared with the open group (5.5 days). Mortality and postoperative complications did not differ between the groups. The few matched cohort studies comparing minimally invasive and open surgery for ASBO reported comparable results to those of the trial mentioned above

*DOI: http://dx.doi.org/10.5772/intechopen.91896*

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era DOI: http://dx.doi.org/10.5772/intechopen.91896*

*Intestinal Obstructions*

blood cell count above 10.000/mm3

thickened bowel wall [48–50].

**Figure 2** [28].

Urgent surgery is required in case of signs of ischemia, perforation or strangulation of the bowel, generalized peritonitis and/or hemodynamic instability. No single test is highly sensitive for ischemia and strangulation. Sensitivity of physical examination for the detection of strangulation is only 48% in experienced hands [45]. Laboratory tests indicating peritonitis or ischemia are a CRP above 75 and a white

assessing strangulation and perforation and the need for emergency surgery [28]. CT abnormalities indicating strangulation or perforation are free intraperitoneal air or fluid, closed loop obstruction, mesenteric edema or engorgement, mesenteric swirling, pneumatosis intestinalis, decreased or lack of bowel enhancement or

If bowel obstruction is caused by adhesions, and signs of peritonitis, ischemia, and strangulation are absent, initial conservative treatment is reportedly safe. Conservative treatment is successful in 70–90% of all episodes of ASBO [1–23]. Conservative treatment of ASBO consists of nil per os and decompression of the gastro-intestinal tract using a naso-gastric tube. Further management includes fluid resuscitation, correction of electrolyte disturbances, nutritional support and prevention of aspiration. Optimal duration of a conservative trial is debated; prolonged management for more than 72 h has been associated with adverse outcomes and increased mortality [20, 51–54]. Water-soluble contrast studies seem useful in the follow-up of conservative management of ASBO. If contrast has not reached to colon 24–48 h following administration, continuation of conservative management

is likely to fail and surgical management should be considered [28].

**4.1 Role of minimally invasive surgery in the management of ASBO**

An algorithm for the diagnosis and treatment of ASBO is presented in

with adhesiolysis. The increased use of minimally invasive surgery has raised the question whether minimally invasive surgery is feasible and effective for the treatment of ASBO. Benefits of minimally invasive adhesiolysis are reduction of peritoneal injury possibly resulting in less adhesion reformation, a quick recovery and minimal post-operative pain. Twenty-five years ago the first cases of minimally invasive surgery for treatment of ASBO have been described [55]. Thereafter a few series were reported but adequate comparative trials are scarce [56–60]. Minimally invasive surgery for ASBO is challenging because there is little laparoscopic working space due to the distended bowel. Also visibility can be hampered by multiple adhesions. There are concerns that minimally invasive surgery increases the risk of iatrogenic bowel perforations [57]. Suitability of minimally invasive surgery for ASBO further depends on patient characteristics. In case of hemodynamic instability open

surgery is required because patients cannot tolerate the pneumoperitoneum.

One randomized trial comparing minimally invasive and open surgery for ASBO has been performed [56]. Only patients with a high suspicion of a single adhesive band causing the obstruction were included. Patients with confirmed or suspected peritoneal carcinosis, known multiple adhesions, previous open surgery for endometriosis, aorta, iliac vessels or Crohn's disease, previous generalized peritonitis, abdominal malignancy, previous abdominal radiotherapy or recent operations within 30 days were all excluded. Patients started with conservative management of ASBO. If the obstruction did not resolve patients were randomized between open and laparoscopic adhesiolysis. The trial was open label, therefore patients and care providers were not blinded. During 5 years 566 patients were included in the study, 104 patients underwent surgery, 51 were randomly assigned to the open surgery

Operative treatment of ASBO historically comprises an explorative laparotomy

[45–47]. Again, a CT scan is most accurate in

**14**

#### **Figure 2.**

*Algorithm for the diagnosis and treatment of ASBO.*

group, and 53 to the laparoscopic surgery group. Patients in the laparoscopic group had a shorter length of stay (4.2 days) compared with the open group (5.5 days). Mortality and postoperative complications did not differ between the groups.

The few matched cohort studies comparing minimally invasive and open surgery for ASBO reported comparable results to those of the trial mentioned above [59, 60]. There seems a trend towards a faster recovery in selected patients. Studies showed no major differences in complications or mortality. A few studies specifically addressed the potential drawbacks of the minimally invasive approach and suggested an increased risk of bowel injury [59]. Notably, the non-matched cohorts frequently claim large beneficial effects of the laparoscopic approach [40–58]. However, these studies have a high risk of various types of selection bias, mainly excluding patients who are more sick or are suspected of multiple adhesions.

It seems that minimally invasive adhesiolysis holds promise for patients with signs of a single adhesive band and an uncomplicated disease course. Further studies are needed to identify patients who can benefit from minimally invasive adhesiolysis and patients who can be harmed by minimally invasive treatment for ASBO.

#### **5. Future perspectives**

#### **5.1 Awareness of adhesions formation by minimally invasive surgery**

Morbidity of adhesion formation in minimally invasive surgery is often underestimated. Less than 25% of surgeons and 5–83% of gynecologists routinely inform their patients about adhesions and the life term risk of adhesion-related complications [14–62]. However, recent evidence shows that adhesion-related morbidity remains high in the minimally invasive era [39]. Not informing patients about the risk of adhesions might therefore be considered negligent. Increased awareness of adhesions might create an urge for the development and refinement of adhesion prevention strategies.

Awareness of adhesions may improve by growing awareness for intra-operative complications in general. Impact of adhesions on the operative course of reoperations for ASBO or other indications is often underreported. In a prospective comparison of operative notes and observation by an independent researcher, one in seven iatrogenic bowel injuries was not reported in operative notes, and almost one in three minor injuries [63]. In recent years, there is increasing scientific interest in the consequences of intra-operative events. IAEs are associated with 40% more hospital admissions, a twofold higher readmission rate, and with worse post-operative outcome [64–70]. Recently the Classification of Intraoperative Complications (CLASSIC) has been developed as a new tool for systematic classification for intra-operative complications (iAEs) [71]. CLASSIC defines iAEs as any deviation from the ideal intraoperative course, including technical failures, surgical and anesthesiological difficulties. The score has been update to five grades of severity (https://clinicaltrials.gov/ct2/show/NCT03009929). Lysis of adhesions at reoperations is associated with post-operative increase of sepsis, intra-abdominal complications, wound infections, longer hospital stay, and higher hospital costs [26–72]. As such, adhesiolysis qualifies as an iAE if adhesiolysis is not the intended surgical procedure. We currently investigate the contribution of adhesiolysis and associated intra-operative complications e.g. bleeding, inadvertent enterotomy to the CLASSIC.

Recent published guidelines may also increase awareness of adhesions and treatment of ASBO [28]. An old saying on ASBO is 'you must not let the sun rise on ASBO', all patients presenting with ASBO were operated if conservative management failed to resolve the bowel obstruction within 24 h. Recent insights report that a conservative trial can safely be prolonged to 72 h [51, 52]. The current guideline states that conservative treatment should be instigated in all patients without signs of ischemia, perforation or strangulation of the bowel, generalized peritonitis and/or hemodynamic instability [28]. Contradictory, some studies report lower

**17**

minimally invasive surgery.

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era*

recurrence rates of ASBO after surgical management of ASBO [19–27]. A further disadvantage of prolonged conservative management is the further clinical deterioration of highly comorbid patients who receive starvation treatment for a few days [73]. Minimally invasive surgery could change the paradigm again towards earlier surgical intervention because of faster recovery, reduced length of hospital stay and

Considering the high impact of adhesion-related complications on a population level that is not substantially decreased by minimally invasive surgery, there is a

Until now the most promising approach for reduction of adhesion formation is routinely applying an adhesion barrier. Adhesion barriers are bioresorbable liquids, gels or films that keep injured peritoneal wound surfaces separated. During separation the peritoneal wound can heal with restoration of peritoneal tissue morphology and function without 'scarring' (adhesions). A large systematic review and meta-analysis in 2014 of 28 trials (n = 5191) showed benefits of several adhesion barriers in predominantly open abdominal surgery [16]. However, adhesion barriers are seldomly applied in abdominal or pelvic surgery [14]. Only 1 in 7 surgeons ever uses adhesion barriers [14]. Reluctance of surgeons to use adhesions barriers seems caused by doubts about cost-effectiveness and the need and possibility of adhesion

Cost-effectiveness of adhesion prevention in minimally invasive surgery is an important perquisite for implementation in every day practice. We performed a modeling study on cost-effectiveness of adhesion barriers in minimally invasive procedures with a high risk of adhesion formation [74]. Two strategies were compared: current clinical practice (colorectal surgery without the use of an adhesion barrier) and colorectal surgery with the use of an adhesion barrier (hyaluronate carboxymethylcellulose). Whilst hyaluronate carboxymethylcellulose as such is not applicable in minimally invasive surgery and a gel form has not properly been studied in minimally invasive surgery, probabilities were extrapolated from data of open colorectal surgery. Probability estimates were derived from literature. Costs of treatment of ASBO were derived from our previous report [38]. Cost of hyaluronate carboxymethylcellulose was estimated on \$630, based on the mean number of films used in studies on hyaluronate carboxymethylcellulose [12–75]. We concluded that using an adhesion barrier was more effective than not using a barrier in minimally invasive surgery, but it was more expensive. However, mean expected direct

healthcare costs in the 4 years following index surgery increased with only \$163 per patient. Cost estimates in this modeling study only included direct health care costs. Societal costs (e.g. absence from work) were not modeled in this study. Therefore an increase of \$163 in direct health care may be neglectable considering potential gain in societal costs. Further research is needed on long term savings regarding socioeconomic costs with adhesion barriers also including the new SCAR update data of

An important limitation of most barriers is the inability to properly use these in minimally invasive surgery. Most barriers were developed more than two to three decades ago and were films intended for use in open surgery. This limitation and the disregard needing barriers in minimally invasive surgery have impeded implementation and continued research and development of barriers suitable for minimally invasive surgery (and open surgery). Recently some new barriers have been developed suitable for minimally invasive surgery. Studies on these new barriers are performed mostly in gynecologic populations, and show effectiveness

*DOI: http://dx.doi.org/10.5772/intechopen.91896*

the mentioned lower recurrence rates of ASBO.

pressing need to develop new adhesion reduction strategies.

**5.2 Adhesion reduction strategies**

prevention in minimally invasive surgery.

recurrence rates of ASBO after surgical management of ASBO [19–27]. A further disadvantage of prolonged conservative management is the further clinical deterioration of highly comorbid patients who receive starvation treatment for a few days [73]. Minimally invasive surgery could change the paradigm again towards earlier surgical intervention because of faster recovery, reduced length of hospital stay and the mentioned lower recurrence rates of ASBO.

#### **5.2 Adhesion reduction strategies**

*Intestinal Obstructions*

**5. Future perspectives**

prevention strategies.

[59, 60]. There seems a trend towards a faster recovery in selected patients. Studies showed no major differences in complications or mortality. A few studies specifically addressed the potential drawbacks of the minimally invasive approach and suggested an increased risk of bowel injury [59]. Notably, the non-matched cohorts frequently claim large beneficial effects of the laparoscopic approach [40–58]. However, these studies have a high risk of various types of selection bias, mainly excluding patients who are more sick or are suspected of multiple adhesions. It seems that minimally invasive adhesiolysis holds promise for patients with signs of a single adhesive band and an uncomplicated disease course. Further studies are needed to identify patients who can benefit from minimally invasive adhesiolysis

and patients who can be harmed by minimally invasive treatment for ASBO.

**5.1 Awareness of adhesions formation by minimally invasive surgery**

Morbidity of adhesion formation in minimally invasive surgery is often underestimated. Less than 25% of surgeons and 5–83% of gynecologists routinely inform their patients about adhesions and the life term risk of adhesion-related complications [14–62]. However, recent evidence shows that adhesion-related morbidity remains high in the minimally invasive era [39]. Not informing patients about the risk of adhesions might therefore be considered negligent. Increased awareness of adhesions might create an urge for the development and refinement of adhesion

Awareness of adhesions may improve by growing awareness for intra-operative

complications in general. Impact of adhesions on the operative course of reoperations for ASBO or other indications is often underreported. In a prospective comparison of operative notes and observation by an independent researcher, one in seven iatrogenic bowel injuries was not reported in operative notes, and almost one in three minor injuries [63]. In recent years, there is increasing scientific interest in the consequences of intra-operative events. IAEs are associated with 40% more hospital admissions, a twofold higher readmission rate, and with worse post-operative outcome [64–70]. Recently the Classification of Intraoperative Complications (CLASSIC) has been developed as a new tool for systematic classification for intra-operative complications (iAEs) [71]. CLASSIC defines iAEs as any deviation from the ideal intraoperative course, including technical failures, surgical and anesthesiological difficulties. The score has been update to five grades of severity (https://clinicaltrials.gov/ct2/show/NCT03009929). Lysis of adhesions at reoperations is associated with post-operative increase of sepsis, intra-abdominal complications, wound infections, longer hospital stay, and higher hospital costs [26–72]. As such, adhesiolysis qualifies as an iAE if adhesiolysis is not the intended surgical procedure. We currently investigate the contribution of adhesiolysis and associated intra-operative complications e.g. bleeding, inadvertent enterotomy to

Recent published guidelines may also increase awareness of adhesions and treatment of ASBO [28]. An old saying on ASBO is 'you must not let the sun rise on ASBO', all patients presenting with ASBO were operated if conservative management failed to resolve the bowel obstruction within 24 h. Recent insights report that a conservative trial can safely be prolonged to 72 h [51, 52]. The current guideline states that conservative treatment should be instigated in all patients without signs of ischemia, perforation or strangulation of the bowel, generalized peritonitis and/or hemodynamic instability [28]. Contradictory, some studies report lower

**16**

the CLASSIC.

Considering the high impact of adhesion-related complications on a population level that is not substantially decreased by minimally invasive surgery, there is a pressing need to develop new adhesion reduction strategies.

Until now the most promising approach for reduction of adhesion formation is routinely applying an adhesion barrier. Adhesion barriers are bioresorbable liquids, gels or films that keep injured peritoneal wound surfaces separated. During separation the peritoneal wound can heal with restoration of peritoneal tissue morphology and function without 'scarring' (adhesions). A large systematic review and meta-analysis in 2014 of 28 trials (n = 5191) showed benefits of several adhesion barriers in predominantly open abdominal surgery [16]. However, adhesion barriers are seldomly applied in abdominal or pelvic surgery [14]. Only 1 in 7 surgeons ever uses adhesion barriers [14]. Reluctance of surgeons to use adhesions barriers seems caused by doubts about cost-effectiveness and the need and possibility of adhesion prevention in minimally invasive surgery.

Cost-effectiveness of adhesion prevention in minimally invasive surgery is an important perquisite for implementation in every day practice. We performed a modeling study on cost-effectiveness of adhesion barriers in minimally invasive procedures with a high risk of adhesion formation [74]. Two strategies were compared: current clinical practice (colorectal surgery without the use of an adhesion barrier) and colorectal surgery with the use of an adhesion barrier (hyaluronate carboxymethylcellulose). Whilst hyaluronate carboxymethylcellulose as such is not applicable in minimally invasive surgery and a gel form has not properly been studied in minimally invasive surgery, probabilities were extrapolated from data of open colorectal surgery. Probability estimates were derived from literature. Costs of treatment of ASBO were derived from our previous report [38]. Cost of hyaluronate carboxymethylcellulose was estimated on \$630, based on the mean number of films used in studies on hyaluronate carboxymethylcellulose [12–75]. We concluded that using an adhesion barrier was more effective than not using a barrier in minimally invasive surgery, but it was more expensive. However, mean expected direct healthcare costs in the 4 years following index surgery increased with only \$163 per patient. Cost estimates in this modeling study only included direct health care costs. Societal costs (e.g. absence from work) were not modeled in this study. Therefore an increase of \$163 in direct health care may be neglectable considering potential gain in societal costs. Further research is needed on long term savings regarding socioeconomic costs with adhesion barriers also including the new SCAR update data of minimally invasive surgery.

An important limitation of most barriers is the inability to properly use these in minimally invasive surgery. Most barriers were developed more than two to three decades ago and were films intended for use in open surgery. This limitation and the disregard needing barriers in minimally invasive surgery have impeded implementation and continued research and development of barriers suitable for minimally invasive surgery (and open surgery). Recently some new barriers have been developed suitable for minimally invasive surgery. Studies on these new barriers are performed mostly in gynecologic populations, and show effectiveness reducing adhesions [76, 77]. The important next step in adhesion prevention is the development of a new generation of barriers suitable for minimally invasive use in general surgery [78, 79]. Using increased knowledge of the pathophysiology of adhesions, new barriers consist of bioactive and targeted technology e.g. modulation of inflammation [2]. Pilpel and colleagues developed a liquid solution modulating the fibrin matrix which is generated by the hemostatic system after peritoneal injury [80]. This novel therapy is currently tested in animal models. Roberston and colleagues are testing a drug (L-Alanyl-L-Glutamine) to regulate the formation of adhesions due to hypoxia and oxidative stress caused by surgical injury of the vascular supply to the tissue caused by surgical intervention [81]. The first results of this drug in a double-blinded placebo controlled study show that L-Alanyl-L-Glutamine is safe to use and is effective at reducing adhesion formation after laparoscopic myomectomies [82]. Definitive results from this study are expected in due time. When proven safe, effective and affordable in patients, these new bioactive and targeted technology agents should be administered during index minimally invasive surgery to break the sequence of intra- and postoperative adhesion-(re) formation related complications.

#### **6. Conclusions**

Adhesion-related morbidity remains a clinically relevant problem in the minimally invasive era. Minimally invasive surgery is associated with only a modest reduction in adhesion-related readmissions and incidence of ASBO. The growing body of scientific evidence provides the clinician with a firm guideline for the diagnosis and treatment of ASBO. Minimally invasive surgery in the management of ASBO appears to be safe and effective alternative to open adhesiolysis, however in a very selected patient group. To allow as many patients as possible to benefit from a minimally invasive approach future research should focus on the selection criteria for minimally invasive surgery in ASBO. Adhesion-related morbidity is often underestimated and complications of adhesiolysis underreported. Raising awareness of adhesions therefore remains important. Using newly proposed scores for intraoperative complications, may increase awareness for the intra-operative events caused by adhesions. Adhesion barriers can safely reduce adhesion formation, are cost-effective in open colorectal surgery and effective with slightly higher costs in minimally invasive surgery. Future research should focus on new bioactive barriers that are easily applicable in minimally invasive abdominal surgery and safe to use. Preventing adhesions during first minimally invasive surgery is key to break the sequence of intra- and postoperative adhesion (re)formation related complications.

**19**

**Author details**

The Netherlands

Pepijn Krielen\*, Martijn W. J. Stommel, Richard P. G. ten Broek and Harry van Goor

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Department of Surgery, Radboud University Medical Center, Nijmegen,

\*Address all correspondence to: pepijn.krielen@radboudumc.nl

provided the original work is properly cited.

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era*

*DOI: http://dx.doi.org/10.5772/intechopen.91896*

#### **Conflict of interest**

The authors declare no conflict of interest.

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era DOI: http://dx.doi.org/10.5772/intechopen.91896*

*Intestinal Obstructions*

formation related complications.

**6. Conclusions**

**Conflict of interest**

The authors declare no conflict of interest.

reducing adhesions [76, 77]. The important next step in adhesion prevention is the development of a new generation of barriers suitable for minimally invasive use in general surgery [78, 79]. Using increased knowledge of the pathophysiology of adhesions, new barriers consist of bioactive and targeted technology e.g. modulation of inflammation [2]. Pilpel and colleagues developed a liquid solution modulating the fibrin matrix which is generated by the hemostatic system after peritoneal injury [80]. This novel therapy is currently tested in animal models. Roberston and colleagues are testing a drug (L-Alanyl-L-Glutamine) to regulate the formation of adhesions due to hypoxia and oxidative stress caused by surgical injury of the vascular supply to the tissue caused by surgical intervention [81]. The first results of this drug in a double-blinded placebo controlled study show that L-Alanyl-L-Glutamine is safe to use and is effective at reducing adhesion formation after laparoscopic myomectomies [82]. Definitive results from this study are expected in due time. When proven safe, effective and affordable in patients, these new bioactive and targeted technology agents should be administered during index minimally invasive surgery to break the sequence of intra- and postoperative adhesion-(re)

Adhesion-related morbidity remains a clinically relevant problem in the minimally invasive era. Minimally invasive surgery is associated with only a modest reduction in adhesion-related readmissions and incidence of ASBO. The growing body of scientific evidence provides the clinician with a firm guideline for the diagnosis and treatment of ASBO. Minimally invasive surgery in the management of ASBO appears to be safe and effective alternative to open adhesiolysis, however in a very selected patient group. To allow as many patients as possible to benefit from a minimally invasive approach future research should focus on the selection criteria for minimally invasive surgery in ASBO. Adhesion-related morbidity is often underestimated and complications of adhesiolysis underreported. Raising awareness of adhesions therefore remains important. Using newly proposed scores for intraoperative complications, may increase awareness for the intra-operative events caused by adhesions. Adhesion barriers can safely reduce adhesion formation, are cost-effective in open colorectal surgery and effective with slightly higher costs in minimally invasive surgery. Future research should focus on new bioactive barriers that are easily applicable in minimally invasive abdominal surgery and safe to use. Preventing adhesions during first minimally invasive surgery is key to break the sequence of intra- and postoperative adhesion (re)formation related complications.

**18**

#### **Author details**

Pepijn Krielen\*, Martijn W. J. Stommel, Richard P. G. ten Broek and Harry van Goor Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands

\*Address all correspondence to: pepijn.krielen@radboudumc.nl

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

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[2] Stommel MW, Strik C, van Goor H. Response to pathological processes in the peritoneal cavity—Sepsis, tumours, adhesions, and ascites. Seminars in Pediatric Surgery. 2014;**23**(6):331-335

[3] Zuhlke HV et al. Pathophysiology and classification of adhesions. Langenbecks Archiv für Chirurgie. Supplement II, Verhandlungen der Deutschen Gesellschaft für Chirurgie. Deutsche Gesellschaft für Chirurgie. 1990:1009-1016. Available from: https://www.ncbi.nlm.nih.gov/ pubmed/?term=1983476

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[10] Barmparas G et al. The incidence and risk factors of post-laparotomy adhesive small bowel obstruction. Journal of Gastrointestinal Surgery. 2010;**14**(10):1619-1628

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[16] Ten Broek RPG et al. Benefits and harms of adhesion barriers for abdominal surgery: A systematic review and meta-analysis. Lancet. 2014;**383**(9911):48-59

[17] Yamada T et al. Meta-analysis of the risk of small bowel obstruction following open or laparoscopic colorectal surgery. The British Journal of Surgery. 2016;**103**(5):493-503

**21**

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era*

[27] Barkan H, Webster S, Ozeran S. Factors predicting the recurrence of adhesive small-bowel obstruction. American Journal of Surgery.

[28] Ten Broek RPG et al. Bologna guidelines for diagnosis and

Emergency Surgery. 2018;**13**:24

[29] Zielinski MD et al. Small bowel obstruction—Who needs an operation? A multivariate prediction model. World Journal of Surgery.

[30] Jancelewicz T et al. Predicting strangulated small bowel obstruction: An old problem revisited. Journal of Gastrointestinal Surgery.

[31] Shafi S et al. Measuring anatomic severity of disease in emergency general surgery. Journal of Trauma and Acute Care Surgery. 2014;**76**(3):884-887

[33] Hernandez MC et al. Application of the AAST EGS grade for adhesive small bowel obstruction to a multi-national patient population. World Journal of Surgery. 2018;**42**(11):3581-3588

[34] Colonna AL et al. Nonoperative management of adhesive small bowel obstruction: What is the break point? American Journal of Surgery.

[32] Utter GH et al. ICD-9-CM and ICD-10-CM mapping of the AAST emergency general surgery disease severity grading systems: Conceptual approach, limitations, and recommendations for the future. Journal of Trauma and Acute Care Surgery.

2015;**78**(5):1059-1065

2016;**212**(6):1214-1221

2010;**34**(5):910-919

2009;**13**(1):93-99

management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World Journal of

1995;**170**(4):361-365

*DOI: http://dx.doi.org/10.5772/intechopen.91896*

[18] Diamond MP et al. Adhesion prevention and reduction: Current status and future recommendations of a multinational interdisciplinary consensus conference. Surgical Innovation. 2010;**17**(3):183-188

[19] Behman R et al. Association of surgical intervention for adhesive small-bowel obstruction with the risk of recurrence. JAMA Surgery.

[20] NELA Project Team. The Third Patient Report of the National Emergency Laparotomy Audit

[21] Scott JW et al. Use of national burden to define operative emergency general surgery. JAMA Surgery.

(NELA). London: The Royal College of

[22] Fazel MZ, Jamieson RW, Watson CJ. Long-term follow-up of the use of the Jones' intestinal tube in adhesive small bowel obstruction. Annals of the Royal College of Surgeons of England.

[24] Wullstein C, Gross E. Laparoscopic compared with conventional treatment

2019;**154**(5):413-420

Anaesthetists; 2017

2016;**151**(6):e160480

2009;**91**(1):50-54

[23] Schraufnagel D, Rajaee S, Millham FH. How many sunsets? Timing of surgery in adhesive small bowel obstruction: A study of the nationwide inpatient sample. Journal of Trauma and Acute Care Surgery. 2013;**74**(1):181-187. discussion 187-9

of acute adhesive small bowel obstruction. The British Journal of Surgery. 2003;**90**(9):1147-1151

[25] Fevang BT et al. Long-term prognosis after operation for adhesive small bowel obstruction. Annals of Surgery. 2004;**240**(2):193-201

[26] ten Broek RP et al. Adhesiolysisrelated morbidity in abdominal surgery. Annals of Surgery. 2013;**258**(1):98-106

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era DOI: http://dx.doi.org/10.5772/intechopen.91896*

[18] Diamond MP et al. Adhesion prevention and reduction: Current status and future recommendations of a multinational interdisciplinary consensus conference. Surgical Innovation. 2010;**17**(3):183-188

[19] Behman R et al. Association of surgical intervention for adhesive small-bowel obstruction with the risk of recurrence. JAMA Surgery. 2019;**154**(5):413-420

[20] NELA Project Team. The Third Patient Report of the National Emergency Laparotomy Audit (NELA). London: The Royal College of Anaesthetists; 2017

[21] Scott JW et al. Use of national burden to define operative emergency general surgery. JAMA Surgery. 2016;**151**(6):e160480

[22] Fazel MZ, Jamieson RW, Watson CJ. Long-term follow-up of the use of the Jones' intestinal tube in adhesive small bowel obstruction. Annals of the Royal College of Surgeons of England. 2009;**91**(1):50-54

[23] Schraufnagel D, Rajaee S, Millham FH. How many sunsets? Timing of surgery in adhesive small bowel obstruction: A study of the nationwide inpatient sample. Journal of Trauma and Acute Care Surgery. 2013;**74**(1):181-187. discussion 187-9

[24] Wullstein C, Gross E. Laparoscopic compared with conventional treatment of acute adhesive small bowel obstruction. The British Journal of Surgery. 2003;**90**(9):1147-1151

[25] Fevang BT et al. Long-term prognosis after operation for adhesive small bowel obstruction. Annals of Surgery. 2004;**240**(2):193-201

[26] ten Broek RP et al. Adhesiolysisrelated morbidity in abdominal surgery. Annals of Surgery. 2013;**258**(1):98-106

[27] Barkan H, Webster S, Ozeran S. Factors predicting the recurrence of adhesive small-bowel obstruction. American Journal of Surgery. 1995;**170**(4):361-365

[28] Ten Broek RPG et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World Journal of Emergency Surgery. 2018;**13**:24

[29] Zielinski MD et al. Small bowel obstruction—Who needs an operation? A multivariate prediction model. World Journal of Surgery. 2010;**34**(5):910-919

[30] Jancelewicz T et al. Predicting strangulated small bowel obstruction: An old problem revisited. Journal of Gastrointestinal Surgery. 2009;**13**(1):93-99

[31] Shafi S et al. Measuring anatomic severity of disease in emergency general surgery. Journal of Trauma and Acute Care Surgery. 2014;**76**(3):884-887

[32] Utter GH et al. ICD-9-CM and ICD-10-CM mapping of the AAST emergency general surgery disease severity grading systems: Conceptual approach, limitations, and recommendations for the future. Journal of Trauma and Acute Care Surgery. 2015;**78**(5):1059-1065

[33] Hernandez MC et al. Application of the AAST EGS grade for adhesive small bowel obstruction to a multi-national patient population. World Journal of Surgery. 2018;**42**(11):3581-3588

[34] Colonna AL et al. Nonoperative management of adhesive small bowel obstruction: What is the break point? American Journal of Surgery. 2016;**212**(6):1214-1221

**20**

*Intestinal Obstructions*

**References**

[1] ten Broek RP et al. Burden of adhesions in abdominal and pelvic surgery: Systematic review and metanalysis. BMJ. 2013;**347**:f5588

[2] Stommel MW, Strik C, van Goor H. Response to pathological processes in the peritoneal cavity—Sepsis, tumours, adhesions, and ascites. Seminars in Pediatric Surgery. 2014;**23**(6):331-335

[9] Parker MC et al. Colorectal surgery: The risk and burden of adhesion-related complications. Colorectal Disease.

[10] Barmparas G et al. The incidence and risk factors of post-laparotomy adhesive small bowel obstruction. Journal of Gastrointestinal Surgery.

[11] Ellis H et al. Adhesion-related hospital readmissions after abdominal and pelvic surgery: A retrospective cohort study. Lancet.

[12] Ten Broek RP et al. Different surgical techniques to reduce postoperative adhesion formation: A systematic review and meta-analysis. Human Reproduction Update.

[13] Kuhry E et al. Long-term results of laparoscopic colorectal cancer resection. Cochrane Database of Systematic Reviews. 2008;**2**:CD003432

[14] van Steensel S et al. Adhesion awareness in 2016: An update of the national survey of surgeons. PLoS One.

awareness: A national survey of surgeons. World Journal of Surgery.

[16] Ten Broek RPG et al. Benefits and harms of adhesion barriers for abdominal surgery: A systematic review and meta-analysis. Lancet.

[17] Yamada T et al. Meta-analysis of the risk of small bowel obstruction following open or laparoscopic

Surgery. 2016;**103**(5):493-503

colorectal surgery. The British Journal of

[15] Schreinemacher MH et al. Adhesion

2004;**6**(6):506-511

2010;**14**(10):1619-1628

1999;**353**(9163):1476-1480

2013;**19**(1):12-25

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2010;**34**(12):2805-2812

2014;**383**(9911):48-59

[3] Zuhlke HV et al. Pathophysiology and classification of adhesions. Langenbecks Archiv für Chirurgie. Supplement II, Verhandlungen der Deutschen Gesellschaft für Chirurgie. Deutsche Gesellschaft für Chirurgie. 1990:1009-1016. Available from: https://www.ncbi.nlm.nih.gov/ pubmed/?term=1983476

[4] Coccolini F et al. Peritoneal adhesion index (PAI): Proposal of a score for the "ignored iceberg" of medicine and surgery. World Journal of Emergency

Surgery. 2013;**8**(1):6

1990;**72**(1):60-63

2001;**15**(1):41-43

[5] Fugazzola P et al. Validation of peritoneal adhesion index as a standardized classification to universalize peritoneal adhesions definition. Journal of Peritoneum (and Other Serosal Surfaces). 2017;**2**:61-69

[6] Menzies D, Ellis H. Intestinal obstruction from adhesions—How big is the problem? Annals of the Royal College of Surgeons of England.

[7] Stommel MWJ et al. Multicenter observational study of adhesion formation after open- and laparoscopic surgery for colorectal cancer. Annals of

[8] Polymeneas G et al. A comparative study of postoperative adhesion formation after laparoscopic vs open cholecystectomy. Surgical Endoscopy.

Surgery. 2018;**267**(4):743-748

[35] Shapter SL, Paul MJ, White SM. Incidence and estimated annual cost of emergency laparotomy in England: Is there a major funding shortfall? Anaesthesia. 2012;**67**(5):474-478

[36] ten Broek RP et al. Epidemiology and prevention of postsurgical adhesions revisited. Annals of Surgery. 2016;**263**(1):12-19

[37] Wilson MS. Practicalities and costs of adhesions. Colorectal Disease. 2007;**9**(Suppl 2):60-65

[38] Krielen P et al. In-hospital costs of an admission for adhesive small bowel obstruction. World Journal of Emergency Surgery. 2016;**11**:49

[39] Krielen P et al. Adhesionrelated readmissions after open and laparoscopic surgery: A retrospective cohort study (SCAR update). Lancet. 2020;**395**(10217):33-41

[40] Behman R et al. Laparoscopic surgery for adhesive small bowel obstruction is associated with a higher risk of bowel injury: A population-based analysis of 8584 patients. Annals of Surgery. 2017;**266**(3):489-498

[41] Licciardello A et al. Preoperative risk factors for conversion from laparoscopic to open cholecystectomy. European Review for Medical and Pharmacological Sciences. 2014;**18** (2 Suppl):60-68

[42] Ozturk E et al. Small bowel obstruction in the elderly: A plea for comprehensive acute geriatric care. World Journal of Emergency Surgery. 2018;**13**:48

[43] Ellis H, Crowe A. Medico-legal consequences of post-operative intraabdominal adhesions. International Journal of Surgery. 2009;**7**(3):187-191

[44] Choudhry AJ et al. Medical malpractice in the management of small bowel obstruction: A 33-year review of case law. Surgery. 2016;**160**(4):1017-1027

[45] Sarr MG, Bulkley GB, Zuidema GD. Preoperative recognition of intestinal strangulation obstruction. Prospective evaluation of diagnostic capability. American Journal of Surgery. 1983;**145**(1):176-182

[46] Krause WR, Webb TP. Geriatric small bowel obstruction: An analysis of treatment and outcomes compared with a younger cohort. American Journal of Surgery. 2015;**209**(2):347-351

[47] Shih SC et al. Adhesive small bowel obstruction: How long can patients tolerate conservative treatment? World Journal of Gastroenterology. 2003;**9**(3):603-605

[48] Zielinski MD et al. Prospective, observational validation of a multivariate small-bowel obstruction model to predict the need for operative intervention. Journal of the American College of Surgeons. 2011;**212**(6):1068-1076

[49] Millet I et al. Assessment of strangulation in adhesive small bowel obstruction on the basis of combined CT findings: Implications for clinical care. Radiology. 2017;**285**(3):798-808

[50] Millet I et al. Value of CT findings to predict surgical ischemia in small bowel obstruction: A systematic review and meta-analysis. European Radiology. 2015;**25**(6):1823-1835

[51] Sakakibara T et al. The indicator for surgery in adhesive small bowel obstruction patient managed with long tube. Hepato-Gastroenterology. 2007;**54**(75):787-790

[52] Keenan JE et al. Trials of nonoperative management exceeding 3 days are associated with increased morbidity in patients undergoing surgery for uncomplicated adhesive

**23**

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era*

score-matched analysis. Surgical Endoscopy. 2017;**31**(12):5348-5355

[61] Meuleman T et al. Adhesion awareness: A nationwide survey of gynaecologists. European Journal of Obstetrics, Gynecology,

[62] Hackethal A et al. Awareness and perception of intra-abdominal adhesions and related consequences:

and Reproductive Biology. 2013;**169**(2):353-359

Survey of gynaecologists in German hospitals. European Journal of Obstetrics, Gynecology,

and Reproductive Biology. 2010;**150**(2):180-189

Surgery. 2013;**100**(3):426-432

[64] Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System.

pubmed/25077248

2011;**254**(6):907-913

2015;**158**(5):1382-1388

[63] ten Broek RP, van den Beukel BA, van Goor H. Comparison of operative notes with real-time observation of adhesiolysis-related complications during surgery. The British Journal of

Washington, DC: Institute of Medicine (US) Committee on Quality of Health Care in America; 2000. Available from: https://www.ncbi.nlm.nih.gov/

[65] Vonlanthen R et al. The impact of complications on costs of major surgical procedures: A cost analysis of 1200 patients. Annals of Surgery.

[66] Ramly EP et al. The financial impact of intraoperative adverse events in abdominal surgery. Surgery.

[67] Nandan AR et al. The impact of major intraoperative adverse events on hospital readmissions. American Journal

of Surgery. 2017;**213**(1):10-17

[68] Vibert E et al. Arterial lactate concentration at the end of an elective hepatectomy is an early predictor of the

*DOI: http://dx.doi.org/10.5772/intechopen.91896*

small bowel obstruction. Journal of Trauma and Acute Care Surgery.

[53] Fevang BT et al. Early operation or conservative management of patients with small bowel obstruction? The European Journal of Surgery.

[54] Foster NM et al. Small bowel obstruction: A populationbased appraisal. Journal of the American College of Surgeons.

[55] Mouret P. L'adesiolisi coelioscopia. In: Testas P, Delaitre B, editors. Chirurgia digestiva per via

coelioscopica. Edizioni Vigot, Friburgo;

[56] Sallinen V et al. Laparoscopic versus open adhesiolysis for adhesive small bowel obstruction (LASSO): An international, multicentre, randomised, open-label trial. The Lancet Gastroenterology & Hepatology.

[57] Di Saverio S et al. Laparoscopic adhesiolysis: Not for all patients, not for all surgeons, not in all centres. Updates

in Surgery. 2018;**70**(4):557-561

[58] Kelly KN et al. Laparotomy for small-bowel obstruction: First choice or last resort for adhesiolysis? A laparoscopic approach for smallbowel obstruction reduces 30-day complications. Surgical Endoscopy.

[59] Hackenberg T et al. Laparoscopic versus open surgery for acute adhesive small-bowel obstruction: A propensity score-matched analysis. Scandinavian Journal of Surgery. 2017;**106**(1):28-33

[60] Yao S et al. Does laparoscopic adhesiolysis decrease the risk of recurrent symptoms in small bowel obstruction? A propensity

2014;**76**(6):1367-1372

2002;**168**(8-9):475-481

2006;**203**(2):170-176

1994. pp. 53-69

2019;**4**(4):278-286

2014;**28**(1):65-73

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era DOI: http://dx.doi.org/10.5772/intechopen.91896*

small bowel obstruction. Journal of Trauma and Acute Care Surgery. 2014;**76**(6):1367-1372

*Intestinal Obstructions*

2016;**263**(1):12-19

2007;**9**(Suppl 2):60-65

[35] Shapter SL, Paul MJ, White SM. Incidence and estimated annual cost of emergency laparotomy in England: Is there a major funding shortfall? Anaesthesia. 2012;**67**(5):474-478

bowel obstruction: A 33-year review of case law. Surgery. 2016;**160**(4):1017-1027

[45] Sarr MG, Bulkley GB, Zuidema GD. Preoperative recognition of intestinal strangulation obstruction. Prospective evaluation of diagnostic capability. American Journal of Surgery.

[46] Krause WR, Webb TP. Geriatric small bowel obstruction: An analysis of treatment and outcomes compared with a younger cohort. American Journal of

[47] Shih SC et al. Adhesive small bowel obstruction: How long can patients tolerate conservative treatment? World Journal of Gastroenterology.

[48] Zielinski MD et al. Prospective, observational validation of a

multivariate small-bowel obstruction

model to predict the need for operative intervention. Journal of the American College of Surgeons.

[49] Millet I et al. Assessment of strangulation in adhesive small bowel obstruction on the basis of combined CT findings: Implications for clinical care. Radiology. 2017;**285**(3):798-808

[50] Millet I et al. Value of CT findings to predict surgical ischemia in small bowel obstruction: A systematic review and meta-analysis. European Radiology.

[51] Sakakibara T et al. The indicator for surgery in adhesive small bowel obstruction patient managed with long tube. Hepato-Gastroenterology.

nonoperative management exceeding 3 days are associated with increased morbidity in patients undergoing surgery for uncomplicated adhesive

2011;**212**(6):1068-1076

2015;**25**(6):1823-1835

2007;**54**(75):787-790

[52] Keenan JE et al. Trials of

Surgery. 2015;**209**(2):347-351

1983;**145**(1):176-182

2003;**9**(3):603-605

[36] ten Broek RP et al. Epidemiology and prevention of postsurgical

adhesions revisited. Annals of Surgery.

[37] Wilson MS. Practicalities and costs of adhesions. Colorectal Disease.

[38] Krielen P et al. In-hospital costs of an admission for adhesive small bowel obstruction. World Journal of Emergency Surgery. 2016;**11**:49

[39] Krielen P et al. Adhesionrelated readmissions after open and laparoscopic surgery: A retrospective cohort study (SCAR update). Lancet.

[40] Behman R et al. Laparoscopic surgery for adhesive small bowel obstruction is associated with a higher risk of bowel injury: A population-based analysis of 8584 patients. Annals of Surgery. 2017;**266**(3):489-498

[41] Licciardello A et al. Preoperative risk factors for conversion from laparoscopic to open cholecystectomy. European Review for Medical and Pharmacological Sciences. 2014;**18**

[42] Ozturk E et al. Small bowel obstruction in the elderly: A plea for comprehensive acute geriatric care. World Journal of Emergency Surgery.

[43] Ellis H, Crowe A. Medico-legal consequences of post-operative intraabdominal adhesions. International Journal of Surgery. 2009;**7**(3):187-191

[44] Choudhry AJ et al. Medical

malpractice in the management of small

2020;**395**(10217):33-41

(2 Suppl):60-68

2018;**13**:48

**22**

[53] Fevang BT et al. Early operation or conservative management of patients with small bowel obstruction? The European Journal of Surgery. 2002;**168**(8-9):475-481

[54] Foster NM et al. Small bowel obstruction: A populationbased appraisal. Journal of the American College of Surgeons. 2006;**203**(2):170-176

[55] Mouret P. L'adesiolisi coelioscopia. In: Testas P, Delaitre B, editors. Chirurgia digestiva per via coelioscopica. Edizioni Vigot, Friburgo; 1994. pp. 53-69

[56] Sallinen V et al. Laparoscopic versus open adhesiolysis for adhesive small bowel obstruction (LASSO): An international, multicentre, randomised, open-label trial. The Lancet Gastroenterology & Hepatology. 2019;**4**(4):278-286

[57] Di Saverio S et al. Laparoscopic adhesiolysis: Not for all patients, not for all surgeons, not in all centres. Updates in Surgery. 2018;**70**(4):557-561

[58] Kelly KN et al. Laparotomy for small-bowel obstruction: First choice or last resort for adhesiolysis? A laparoscopic approach for smallbowel obstruction reduces 30-day complications. Surgical Endoscopy. 2014;**28**(1):65-73

[59] Hackenberg T et al. Laparoscopic versus open surgery for acute adhesive small-bowel obstruction: A propensity score-matched analysis. Scandinavian Journal of Surgery. 2017;**106**(1):28-33

[60] Yao S et al. Does laparoscopic adhesiolysis decrease the risk of recurrent symptoms in small bowel obstruction? A propensity

score-matched analysis. Surgical Endoscopy. 2017;**31**(12):5348-5355

[61] Meuleman T et al. Adhesion awareness: A nationwide survey of gynaecologists. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2013;**169**(2):353-359

[62] Hackethal A et al. Awareness and perception of intra-abdominal adhesions and related consequences: Survey of gynaecologists in German hospitals. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2010;**150**(2):180-189

[63] ten Broek RP, van den Beukel BA, van Goor H. Comparison of operative notes with real-time observation of adhesiolysis-related complications during surgery. The British Journal of Surgery. 2013;**100**(3):426-432

[64] Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine (US) Committee on Quality of Health Care in America; 2000. Available from: https://www.ncbi.nlm.nih.gov/ pubmed/25077248

[65] Vonlanthen R et al. The impact of complications on costs of major surgical procedures: A cost analysis of 1200 patients. Annals of Surgery. 2011;**254**(6):907-913

[66] Ramly EP et al. The financial impact of intraoperative adverse events in abdominal surgery. Surgery. 2015;**158**(5):1382-1388

[67] Nandan AR et al. The impact of major intraoperative adverse events on hospital readmissions. American Journal of Surgery. 2017;**213**(1):10-17

[68] Vibert E et al. Arterial lactate concentration at the end of an elective hepatectomy is an early predictor of the postoperative course and a potential surrogate of intraoperative events. Annals of Surgery. 2015;**262**(5):787-792. discussion 792-3

[69] Kinaci E et al. Intraoperative acidosis is a new predictor for postoperative pancreatic fistula after pancreaticoduodenectomy. Hepatobiliary & Pancreatic Diseases International. 2016;**15**(3):302-309

[70] Parker MC et al. Postoperative adhesions: Ten-year follow-up of 12,584 patients undergoing lower abdominal surgery. Diseases of the Colon and Rectum. 2001;**44**(6):822-829. discussion 829-30

[71] Rosenthal R et al. Definition and classification of intraoperative complications (CLASSIC): Delphi study and pilot evaluation. World Journal of Surgery. 2015;**39**(7):1663-1671

[72] Mavros MN et al. Intraoperative adverse events: Risk adjustment for procedure complexity and presence of adhesions is crucial. Journal of the American College of Surgeons. 2015;**221**(2):345-353

[73] Karamanos E et al. Diabetes mellitus in patients presenting with adhesive small bowel obstruction: Delaying surgical intervention results in worse outcomes. World Journal of Surgery. 2016;**40**(4):863-869

[74] Krielen P et al. Cost-effectiveness of the prevention of adhesions and adhesive small bowel obstruction after colorectal surgery with adhesion barriers: A modelling study. World Journal of Emergency Surgery. 2019;**14**:41

[75] Strik C et al. Risk factors for future repeat abdominal surgery. Langenbeck's Archives of Surgery. 2016;**401**(6):829-837

[76] Weng CH et al. A simple technique for placement of Seprafilm(R)-a sodium hyaluronate/carboxymethylcellulose absorbable barrier-during laparoscopic myomectomy. Journal of Minimally Invasive Gynecology. 2019. Available from: https://pubmed.ncbi.nlm.nih. gov/31877383/

[77] Raimondo D et al. Cellulose absorbable barrier for prevention of de-novo adhesion formation at the time of laparoscopic myomectomy: A systematic review and meta-analysis of randomized controlled trials. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2019;**245**:107-113

[78] Chaturvedi AA et al. Prevention of postsurgical adhesions using an ultrapure alginate-based gel. The British Journal of Surgery. 2013;**100**(7):904-910

[79] Chaturvedi AA et al. Ultrapure alginate gel reduces adhesion reformation after adhesiolysis. International Journal of Colorectal Disease. 2014;**29**(11):1411-1416

[80] Pilpel Y et al. Metabolic syndrome is a risk factor for post-operative adhesions: Need for novel treatment strategies. Hormone and Metabolic Research. 2019;**51**(1):35-41

[81] Robertson LM et al. Evitar (l-Alanyl-l-glutamine) regulates key signaling molecules in the pathogenesis of postoperative tissue fibrosis. Reproductive Sciences. 2019;**26**(6):724-733

[82] Robertson LM, Rislund DC, Lim HJ, Pierson RA, Tulandi T, Gargiolo AR, et al. A novel therapeutic approach to prevent adhesion: A double blind randomized study (DBRCT) of intraperitoneal L-Alanyl-L-Glutamine (A-G or EvitarTM) for the prevention of adhesion in laparoscopic myomectomies. In: Abstract Presentation at 47th Global Congress of Minimally Invasive Gynecology; Las Vegas, Nevada. 2018

**25**

**Chapter 3**

**Abstract**

**1. Introduction**

**1.1 Epidemiology**

**1.2 Pathophysiology**

Gallstones Ileus

diagnostic test of choice is an abdominal CT scan.

diagnosis and treatment can be problematic.

**Keywords:** gallstone ileus, cholecystoenteric fistula, cholecystitis

*Giovanni Petracca, Francesco Zappia and Fabrizio Silvaggio*

The ileus of gallstones is a rare complication of cholelithiasis which occurs in less than 1% of patients and is the cause of 1–4% of cases of obstruction of the small intestine. The pathogenesis involves the formation of a bilioenteric fistula. Abdominal computed tomography (CT) shows pneumobilia, dilated loops of small intestine, and ectopic gallstones that obstruct the intestinal lumen. In literature, enterolithotomy is the most frequently used procedure for the ileum of gallstones. Enterolithotomy plus cholecystectomy and/or fistulectomy are indicated only in selected patients. The clinical signs and symptoms depend on the site of the obstruction and usually include abdominal pain, nausea, and vomiting. The

The biliary ileum is defined as a mechanical intestinal obstruction due to the impact of one or more gallstones in the gastrointestinal tract and is a rare complication of cholelithiasis. The term "ileum" is an improper term, since obstruction is a true mechanical phenomenon [1, 2], while gastrointestinal obstruction from gallstones would be an appropriate term. Biliary ileum is not very common and

Biliary ileus causes 1–4% of all cases of obstruction of the small intestine. This is 25% in patients over 65 years of age and is responsible for about three of the 10 million admissions to hospital and 15 for about 1 million surgical procedures (0.0015%).

The biliary ileum is often preceded by an initial episode of acute cholecystitis. Inflammation in the gallbladder and surrounding structures leads to the formation of adhesion. Inflammation and the pressure effect of gallstones causes erosion through the gallbladder wall, leading to the formation of fistulas between the gallbladder and the adiacent portion of the gastrointestinal tract, with further passage of gallstones [3, 4]. Less commonly, a gallstone can enter the duodenum through the common bile duct and through a dilated papilla of Vater [5]. The most frequent fistula occurs between the gallbladder and the duodenum due to their proximity [6–9]. The stomach, small intestine, and transverse portion of the colon may also be involved (**Table 1**) [1–4, 10, 11].

It is more common in women than in men with a 5:1 female-to-male ratio.

## **Chapter 3** Gallstones Ileus

*Giovanni Petracca, Francesco Zappia and Fabrizio Silvaggio*

## **Abstract**

*Intestinal Obstructions*

discussion 792-3

829-30

postoperative course and a potential surrogate of intraoperative events. Annals of Surgery. 2015;**262**(5):787-792. hyaluronate/carboxymethylcellulose absorbable barrier-during laparoscopic myomectomy. Journal of Minimally Invasive Gynecology. 2019. Available from: https://pubmed.ncbi.nlm.nih.

[77] Raimondo D et al. Cellulose absorbable barrier for prevention of de-novo adhesion formation at the time of laparoscopic myomectomy: A systematic review and meta-analysis of randomized controlled trials. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2019;**245**:107-113

[78] Chaturvedi AA et al. Prevention of postsurgical adhesions using an ultrapure alginate-based gel. The British Journal of Surgery. 2013;**100**(7):904-910

[79] Chaturvedi AA et al. Ultrapure alginate gel reduces adhesion reformation after adhesiolysis. International Journal of Colorectal Disease. 2014;**29**(11):1411-1416

[80] Pilpel Y et al. Metabolic syndrome is a risk factor for post-operative adhesions: Need for novel treatment strategies. Hormone and Metabolic

[82] Robertson LM, Rislund DC, Lim HJ, Pierson RA, Tulandi T, Gargiolo AR, et al. A novel therapeutic approach to prevent adhesion: A double blind randomized study (DBRCT) of intraperitoneal L-Alanyl-L-Glutamine (A-G or EvitarTM) for the prevention of adhesion in laparoscopic

Research. 2019;**51**(1):35-41

2019;**26**(6):724-733

[81] Robertson LM et al. Evitar (l-Alanyl-l-glutamine) regulates key signaling molecules in the pathogenesis of postoperative tissue fibrosis. Reproductive Sciences.

myomectomies. In: Abstract

Las Vegas, Nevada. 2018

Presentation at 47th Global Congress of Minimally Invasive Gynecology;

gov/31877383/

[69] Kinaci E et al. Intraoperative acidosis is a new predictor for postoperative pancreatic fistula after pancreaticoduodenectomy. Hepatobiliary & Pancreatic Diseases International. 2016;**15**(3):302-309

[70] Parker MC et al. Postoperative adhesions: Ten-year follow-up of 12,584 patients undergoing lower abdominal surgery. Diseases of the Colon and Rectum. 2001;**44**(6):822-829. discussion

[71] Rosenthal R et al. Definition and classification of intraoperative complications (CLASSIC): Delphi study and pilot evaluation. World Journal of

Surgery. 2015;**39**(7):1663-1671

2015;**221**(2):345-353

2016;**40**(4):863-869

2019;**14**:41

[72] Mavros MN et al. Intraoperative adverse events: Risk adjustment for procedure complexity and presence of adhesions is crucial. Journal of the American College of Surgeons.

[73] Karamanos E et al. Diabetes mellitus in patients presenting with adhesive small bowel obstruction: Delaying surgical intervention results in worse outcomes. World Journal of Surgery.

[74] Krielen P et al. Cost-effectiveness of the prevention of adhesions and adhesive small bowel obstruction after colorectal surgery with adhesion barriers: A modelling study. World Journal of Emergency Surgery.

[75] Strik C et al. Risk factors for future repeat abdominal surgery. Langenbeck's Archives of Surgery.

[76] Weng CH et al. A simple technique for placement of Seprafilm(R)-a sodium

2016;**401**(6):829-837

**24**

The ileus of gallstones is a rare complication of cholelithiasis which occurs in less than 1% of patients and is the cause of 1–4% of cases of obstruction of the small intestine. The pathogenesis involves the formation of a bilioenteric fistula. Abdominal computed tomography (CT) shows pneumobilia, dilated loops of small intestine, and ectopic gallstones that obstruct the intestinal lumen. In literature, enterolithotomy is the most frequently used procedure for the ileum of gallstones. Enterolithotomy plus cholecystectomy and/or fistulectomy are indicated only in selected patients. The clinical signs and symptoms depend on the site of the obstruction and usually include abdominal pain, nausea, and vomiting. The diagnostic test of choice is an abdominal CT scan.

**Keywords:** gallstone ileus, cholecystoenteric fistula, cholecystitis

### **1. Introduction**

The biliary ileum is defined as a mechanical intestinal obstruction due to the impact of one or more gallstones in the gastrointestinal tract and is a rare complication of cholelithiasis. The term "ileum" is an improper term, since obstruction is a true mechanical phenomenon [1, 2], while gastrointestinal obstruction from gallstones would be an appropriate term. Biliary ileum is not very common and diagnosis and treatment can be problematic.

#### **1.1 Epidemiology**

Biliary ileus causes 1–4% of all cases of obstruction of the small intestine. This is 25% in patients over 65 years of age and is responsible for about three of the 10 million admissions to hospital and 15 for about 1 million surgical procedures (0.0015%). It is more common in women than in men with a 5:1 female-to-male ratio.

#### **1.2 Pathophysiology**

The biliary ileum is often preceded by an initial episode of acute cholecystitis. Inflammation in the gallbladder and surrounding structures leads to the formation of adhesion. Inflammation and the pressure effect of gallstones causes erosion through the gallbladder wall, leading to the formation of fistulas between the gallbladder and the adiacent portion of the gastrointestinal tract, with further passage of gallstones [3, 4]. Less commonly, a gallstone can enter the duodenum through the common bile duct and through a dilated papilla of Vater [5]. The most frequent fistula occurs between the gallbladder and the duodenum due to their proximity [6–9]. The stomach, small intestine, and transverse portion of the colon may also be involved (**Table 1**) [1–4, 10, 11].

Once inside the duodenal, intestinal, or gastric lumen, gallstones usually proceed distally and can pass spontaneously through the rectum, or they can cause obstruction. Less commonly if the bile stone is in the stomach, proximal migration can occur and the bile stone can be vomited [4]. The size of the gallstones, the site of fistula formation, and the intestinal lumen will determine whether or not intestinal obstruction will occur. Most gallstones less than 2–2.5 cm can pass spontaneously through a normal gastrointestinal tract and will be excreted in the stool without problems [1–4]. Clavien et al. [12] reported that an obstructive gallstone size ranges from 2 to 5 cm. Nakao et al. [6] found that gallstones had sizes ranging from 2 to 10 cm, with an average of 4.3 cm. The obstruction site can be found in any portion of the gastrointestinal tract. If gallstones enter the duodenum, the most common intestinal obstruction will be the terminal ileum and ileocecal valve due to their relatively narrow lumen and potentially less active peristalsis. Less frequently, gallstones obstruct the proximal ileum or jejunum, especially if the gallstones are large enough. Less common positions include the stomach and duodenum (Bouveret syndrome) and colon (**Table 2**) [1, 3, 4, 8, 9, 13].

The presence of diverticula, neoplasms, or intestinal stenoses secondary to Crohn's disease, reduce the size of the lumen and can cause an occlusion of gallstones on the narrowing site [1–3, 14]. Biliary ileum has been reported at anastomosis sites after partial gastrectomy and Billroth II reconstruction and after biliointestinal bypass in two cases [15, 16]. Ischemia can develop at the occlusion site of gallstones due to the pressure generated against the intestinal wall and proximal distension. Necrosis and perforation may occur followed by peritonitis [3]. The presentation of the biliary ileum may be preceded by a history of previous biliary symptoms, with rates ranging between 27 and 80% of patients [7, 12, 13, 17–19]. Acute cholecystitis can be present in 10–30% of patients at the time of intestinal obstruction. Jaundice was found in only 15% of patients or less. Bile symptoms can be absent in up to a third of cases [1–3, 8, 9, 12, 20, 21].


**Table 1.**

*Frequency of bilio-enteric fistulas in patients with ileus from gallstones.*


**27**

*Gallstones Ileus*

present [1–4, 30].

**2. Diagnosis**

*DOI: http://dx.doi.org/10.5772/intechopen.93576*

The biliary ileum can manifest itself as an acute, intermittent, or chronic episode of gastrointestinal obstruction. Nausea, vomiting, cramping abdominal pain, and variable distension are commonly present [1, 3, 8, 12, 13, 20, 22–29]. The intermittent nature of pain and vomiting of the proximal gastrointestinal material, which later becomes dark and fecaloid, is due to partial or total occlusion of gallstones [5, 18]. The character of vomiting depends on the location of the obstruction. When gallstones are in the stomach or upper small intestine, vomiting is mainly gastric in content (becoming fecaloid when the ileum is obstructed). In particular, Bouveret's syndrome presents signs and symptoms of gastric outlet obstruction. Nausea and vomiting were reported in 86% of cases, while abdominal pain or discomfort was reported in 71%. If the bile stone does not completely obstruct the lumen, the presentation will be partially obstructed. Recent weight loss, anorexia, early satiety, and constipation can be reported by the patient. Bouveret syndrome has also been reported to be preceded by bleeding of the upper gastrointestinal tract secondary to duodenal erosion caused by gallstones, with hematemesis and melena, respectively, in 15 and 7% [8, 9, 30, 31]. The physical examination can be nonspecific. Patients are often seriously ill, with signs of dehydration, abdominal distension, and decrease in intestinal peristalsis and obstructive jaundice. Fever, toxicity, and physical signs of peritonitis can be noted if perforation of the intestinal wall occurs. The examination can be completely normal if no obstacles are currently

The symptoms and signs of the biliary ileum are mostly nonspecific [7, 26, 29]. The intermittence of symptoms could also interfere with a correct diagnosis, if the clinical manifestations at the moment correspond to a partial obstruction or a distal migration of the gallstones. Patients usually present 4–8 days after the onset of symptoms, and diagnosis is usually made 3–8 days after the onset of symptoms [1, 2, 29, 32–38]. A high index of suspicion will be useful, particularly in an elderly patient with intestinal obstruction and previous gallstone disease; Bouveret syndrome

Simple abdominal radiographs are of fundamental importance for establishing the diagnosis. In 1941, Rigler et al. [39] described four radiographic signs in the biliary ileum: (1) partial or complete intestinal obstruction; (2) pneumobilia or contrast material in the biliary tree; (3) an aberrant limestone; and (4) changing the position of such gallstones on serial film. The presence of two of the first three signs was considered pathognomonic and was found in 20–50% of

cases [1, 2, 20, 37, 38, 40–44]. Although pathognomonic, Rigler's triad ratios range from 0 to 87% [19]. Careful inspection for pneumobilia should be performed, as it is present in most patients with biliary ileus but is sometimes identified only in retrospective observation [20, 37, 38, 41–43]. Pneumobilia can occur following previous biliary surgery or endoscopic interventions. Therefore, clinical evaluation must be taken into account when evaluating this radiological sign [1, 2, 37, 38, 40–44]. In 1978, Balthazar et al. [45] described a fifth sign, which consists of two hydro-plane levels in the upper right quadrant of the abdominal radiography. The medial air fluid level corresponds to the duodenum and the lateral level to the gallbladder. These authors found that this sign was present in 24% of patients at the time of hospitalization. In Bouveret's syndrome, a dilated stomach is expected to be seen on a

can be suspected in a patient with gastric outlet obstruction.

**2.1 Normal abdominal radiography**

**Table 2.** *Place range (%).*

#### *Gallstones Ileus DOI: http://dx.doi.org/10.5772/intechopen.93576*

*Intestinal Obstructions*

Once inside the duodenal, intestinal, or gastric lumen, gallstones usually proceed distally and can pass spontaneously through the rectum, or they can cause obstruction. Less commonly if the bile stone is in the stomach, proximal migration can occur and the bile stone can be vomited [4]. The size of the gallstones, the site of fistula formation, and the intestinal lumen will determine whether or not intestinal obstruction will occur. Most gallstones less than 2–2.5 cm can pass spontaneously through a normal gastrointestinal tract and will be excreted in the stool without problems [1–4]. Clavien et al. [12] reported that an obstructive gallstone size ranges from 2 to 5 cm. Nakao et al. [6] found that gallstones had sizes ranging from 2 to 10 cm, with an average of 4.3 cm. The obstruction site can be found in any portion of the gastrointestinal tract. If gallstones enter the duodenum, the most common intestinal obstruction will be the terminal ileum and ileocecal valve due to their relatively narrow lumen and potentially less active peristalsis. Less frequently, gallstones obstruct the proximal ileum or jejunum, especially if the gallstones are large enough. Less common positions include the stomach and duodenum

The presence of diverticula, neoplasms, or intestinal stenoses secondary to Crohn's disease, reduce the size of the lumen and can cause an occlusion of gallstones on the narrowing site [1–3, 14]. Biliary ileum has been reported at anastomosis sites after partial gastrectomy and Billroth II reconstruction and after biliointestinal bypass in two cases [15, 16]. Ischemia can develop at the occlusion site of gallstones due to the pressure generated against the intestinal wall and proximal distension. Necrosis and perforation may occur followed by peritonitis [3]. The presentation of the biliary ileum may be preceded by a history of previous biliary symptoms, with rates ranging between 27 and 80% of patients [7, 12, 13, 17–19]. Acute cholecystitis can be present in 10–30% of patients at the time of intestinal obstruction. Jaundice was found in only 15% of patients or less. Bile symptoms can

(Bouveret syndrome) and colon (**Table 2**) [1, 3, 4, 8, 9, 13].

be absent in up to a third of cases [1–3, 8, 9, 12, 20, 21].

*Frequency of bilio-enteric fistulas in patients with ileus from gallstones.*

**Type of fistula (%)** Colecystoduodenal 32.5 to 96.5 Colecystogastric 0 to 13.3 Colecystoduodenal 0 to 2,5 Colecystoileal 0 to 2,5 Colecystocolic 0 to 10.9

**Place %** Duodenum 0-10.5 Stomach 0-20 Proximal ileus 0-50 Distal ileus 0-89.5 Colon 0-8.1 Undetermined 0-25

**26**

**Table 2.** *Place range (%).*

**Table 1.**

The biliary ileum can manifest itself as an acute, intermittent, or chronic episode of gastrointestinal obstruction. Nausea, vomiting, cramping abdominal pain, and variable distension are commonly present [1, 3, 8, 12, 13, 20, 22–29]. The intermittent nature of pain and vomiting of the proximal gastrointestinal material, which later becomes dark and fecaloid, is due to partial or total occlusion of gallstones [5, 18]. The character of vomiting depends on the location of the obstruction. When gallstones are in the stomach or upper small intestine, vomiting is mainly gastric in content (becoming fecaloid when the ileum is obstructed). In particular, Bouveret's syndrome presents signs and symptoms of gastric outlet obstruction. Nausea and vomiting were reported in 86% of cases, while abdominal pain or discomfort was reported in 71%. If the bile stone does not completely obstruct the lumen, the presentation will be partially obstructed. Recent weight loss, anorexia, early satiety, and constipation can be reported by the patient. Bouveret syndrome has also been reported to be preceded by bleeding of the upper gastrointestinal tract secondary to duodenal erosion caused by gallstones, with hematemesis and melena, respectively, in 15 and 7% [8, 9, 30, 31]. The physical examination can be nonspecific. Patients are often seriously ill, with signs of dehydration, abdominal distension, and decrease in intestinal peristalsis and obstructive jaundice. Fever, toxicity, and physical signs of peritonitis can be noted if perforation of the intestinal wall occurs. The examination can be completely normal if no obstacles are currently present [1–4, 30].

#### **2. Diagnosis**

The symptoms and signs of the biliary ileum are mostly nonspecific [7, 26, 29]. The intermittence of symptoms could also interfere with a correct diagnosis, if the clinical manifestations at the moment correspond to a partial obstruction or a distal migration of the gallstones. Patients usually present 4–8 days after the onset of symptoms, and diagnosis is usually made 3–8 days after the onset of symptoms [1, 2, 29, 32–38]. A high index of suspicion will be useful, particularly in an elderly patient with intestinal obstruction and previous gallstone disease; Bouveret syndrome can be suspected in a patient with gastric outlet obstruction.

#### **2.1 Normal abdominal radiography**

Simple abdominal radiographs are of fundamental importance for establishing the diagnosis. In 1941, Rigler et al. [39] described four radiographic signs in the biliary ileum: (1) partial or complete intestinal obstruction; (2) pneumobilia or contrast material in the biliary tree; (3) an aberrant limestone; and (4) changing the position of such gallstones on serial film. The presence of two of the first three signs was considered pathognomonic and was found in 20–50% of cases [1, 2, 20, 37, 38, 40–44]. Although pathognomonic, Rigler's triad ratios range from 0 to 87% [19]. Careful inspection for pneumobilia should be performed, as it is present in most patients with biliary ileus but is sometimes identified only in retrospective observation [20, 37, 38, 41–43]. Pneumobilia can occur following previous biliary surgery or endoscopic interventions. Therefore, clinical evaluation must be taken into account when evaluating this radiological sign [1, 2, 37, 38, 40–44]. In 1978, Balthazar et al. [45] described a fifth sign, which consists of two hydro-plane levels in the upper right quadrant of the abdominal radiography. The medial air fluid level corresponds to the duodenum and the lateral level to the gallbladder. These authors found that this sign was present in 24% of patients at the time of hospitalization. In Bouveret's syndrome, a dilated stomach is expected to be seen on a

simple abdominal radiograph due to gastric obstruction [37, 42, 43, 46–49]. Cappell et al. [31], in a review of 64 cases of Bouveret syndrome, found pneumobilia (39%), calcified upper right quadrant mass or gallstones (38%), and gastric distension (23%) as relatively common findings and dilated loops of the intestine (14%).

#### **2.2 Abdominal ultrasound**

When the diagnosis is still doubtful, an abdominal ultrasound (US) will be indicated for gallbladder stones, fistula, and gallstones visualization. It can also confirm the presence of choledocholithiasis [1, 2, 50]. The use of ultrasound in combination with abdominal radiography has been recommended to increase the sensitivity of the diagnosis. Ultrasound is more sensitive to the detection of pneumobilia and ectopic gallstones. The combination of abdominal and US radiography increased the sensitivity of the diagnosis of the biliary ileum to 74% [51]. The most frequent findings in Bouveret syndrome are gallstones in the gallbladder (53%), pneumobilia or gallbladder fistula (45%), gallstones in the duodenum (25%), dilated or distended stomach (15%), and a contracted gallbladder (13%) [31, 41, 43, 52, 53].

#### **2.3 Computed tomography**

Computed tomography (CT) is considered superior to abdominal radiography or US in the diagnosis of biliary ileum cases, with a sensitivity of up to 93% [47, 51, 54–57]. The detection frequency of Rigler's triad is higher during the CT exam. In a retrospective study by Lassandro et al. [55–58], the Rigler triad was observed in 77.8% of cases by CT, compared to 14.8% with radiographs and 11.1% with the US. Intestinal loop dilation was observed in 92.6% of cases, pneumobilia in 88.9%, ectopic gallstones in 81.5%, hydroaero levels in 37%, and bilio-digestive fistula in 14.8%. Yu et al. [54, 59] conducted a prospective study in which 165 patients with acute small bowel obstruction were evaluated for biliary ileus, with retrospective identification of three diagnostic criteria: (1) small bowel obstruction; (2) ectopic gallstones, both calcified and removed; and (3) abnormal gallbladder with complete air collection, presence of hydro-aircraft levels, or fluid accumulation with irregular wall. The overall sensitivity, specificity, and precision were 93, 100, and 99%, respectively. Rigler's triad was detected only in 36% of cases. These tomographic diagnostic criteria require further prospective validation. Current CT scanners can describe the position of the fistula, gallstones, and gastrointestinal obstruction with greater precision helping in therapeutic decisions [37, 56–58].

#### **2.4 Esophagogastroduodenoscopy**

In an 81-case review of Bouveret syndrome [37, 43, 59–62] in which esophagogastroduodenoscopy (EGD) was performed, gastroduodenal obstruction was revealed in all, but visualization of gallstones was only possible in 56 (69%). Among these 56 cases, such gallstones were observed in the duodenal bulb in 51.8%, in the postbulbar duodenum in 28.6%, in the pylorus or in the prepilorum in 17.9%, and in one case the position was not reported. Gallstones were not recognized in 31% of cases because they were deeply embedded in the mucosa. When gallstones are not displayed, the diagnosis should be strongly suspected when the observed mass is hard, convex, smooth, non-friable and non-fleshy, which are all characteristics of a biliary calculus and can improve the sensitivity of the EGD. For such cases, US and CT are the preferred noninvasive diagnostic tests to confirm endoscopic diagnosis, delineate gastroduodenal anatomy, and demonstrate a cholecystoduodenal fistula [27, 31, 52, 53, 63–65].

**29**

*Gallstones Ileus*

**3. Treatment**

recommended [12].

stage procedure) or later (two-stage procedure).

relapse rates of 17–33% have also been reported [12, 72, 73].

procedure, further events related to gallstones are avoided [18].

*DOI: http://dx.doi.org/10.5772/intechopen.93576*

before surgery [1, 2, 14, 29, 31, 52, 53, 66–68].

The main therapeutic goal is the relief of intestinal obstruction by extraction of gallstones. Hydroelectrolytic imbalances and metabolic disorders due to intestinal obstruction and preexisting comorbidities are common and require management

There is no unanimous consensus on the surgical procedure. Current surgical procedures are: (1) simple enterolithotomy; (2) enterolithotomy, cholecystectomy and closure of the fistula (one-stage procedure); and (3) enterolithotomy with cholecystectomy performed subsequently (two-stage procedure). Intestinal resec-

Enterolithotomy was the most commonly performed surgical procedure. Through an exploratory laparotomy, the gastrointestinal obstruction site is

located. A longitudinal incision is made on the antimesenteric edge proximal to the site of obstruction of the gallstones [12, 24, 66]. Whenever possible, through light manipulation, the bile stone is brought proximally to a non-edematous segment of the intestine. Most of the time, this is not possible due to the degree of impact of gallstones. Enterotomy is performed over the gallstones and extracted. Careful closure of the enterotomy is necessary to avoid narrowing of the intestinal lumen and cross-closure is recommended. Intestinal resection is sometimes required, particularly in the presence of ischemia, perforation, or underlying stenosis [12, 66]. Manual propulsion of gallstones through the ileocecal valve should be reserved for highly selected situations due to the danger of mucosal injury and intestinal perforation [12, 20, 24, 27, 28, 66]. Likewise, attempts to crush gallstones in situ can damage the intestinal wall and should be avoided [20, 27, 66, 69]. Multiple gallstones can generally be extracted through a single incision freeing the intestines and moving smaller gallstones to larger ones. In case of sigmoid obstruction, resection that removes gallstones and underlying stenosis has been

The main long-standing controversy in biliary ileum management is whether surgery should be performed simultaneously with relief of bowel obstruction (one-

In 1922, Pybus successfully extracted a limestone blocking the ileum, closed the duodenal fistula, and drained the gallbladder after removing two additional gallstones from it. In 1929, Holz extracted a limestone at the sigmoid level, and after removing a second limestone in the duodenum, he closed the gallbladder fistula and removed the gallbladder. The author recommended this procedure for patients in satisfactory general conditions. In 1957, Welch successfully performed a one-stage surgery in a patient who was well prepared after recurrent intestinal gallstone obstruction. The authors suggested the feasibility of the operation under optimal conditions. In 1965, Berliner et al. [70] reported three similarly managed and mentioned cases that when the patient is adequately hydrated with restored serum electrolytes, it does not represent an operational risk and a one-stage surgical procedure should be considered. The authors recommend considering the one-step procedure in selected cases. The incidence of recurrence commonly cited is 2–5%, but a recurrence of up to 8% has also been reported after only enterolithotomy; half of these new onset events occurred within 30 days [71]. It should be considered that

The possibility of recurrent cholecystitis and acute cholangitis [12, 70] in patients with unrepaired gallbladder fistulas or retained gallbladder has been highlighted. Acute cholangitis has been reported in 11% of patients with cholecystoduodenal fistula and in 60% with gallbladder colic fistula [12, 52, 53, 67, 68]. With a one-stage

tion is necessary in some cases after performing the enterolithotomy.

#### **3. Treatment**

*Intestinal Obstructions*

**2.2 Abdominal ultrasound**

**2.3 Computed tomography**

**2.4 Esophagogastroduodenoscopy**

simple abdominal radiograph due to gastric obstruction [37, 42, 43, 46–49]. Cappell et al. [31], in a review of 64 cases of Bouveret syndrome, found pneumobilia (39%), calcified upper right quadrant mass or gallstones (38%), and gastric distension (23%) as relatively common findings and dilated loops of the intestine (14%).

When the diagnosis is still doubtful, an abdominal ultrasound (US) will be indicated for gallbladder stones, fistula, and gallstones visualization. It can also confirm the presence of choledocholithiasis [1, 2, 50]. The use of ultrasound in combination with abdominal radiography has been recommended to increase the sensitivity of the diagnosis. Ultrasound is more sensitive to the detection of pneumobilia and ectopic gallstones. The combination of abdominal and US radiography increased the sensitivity of the diagnosis of the biliary ileum to 74% [51]. The most frequent findings in Bouveret syndrome are gallstones in the gallbladder (53%), pneumobilia or gallbladder fistula (45%), gallstones in the duodenum (25%), dilated or distended stomach (15%), and a contracted gallbladder (13%) [31, 41, 43, 52, 53].

Computed tomography (CT) is considered superior to abdominal radiography

In an 81-case review of Bouveret syndrome [37, 43, 59–62] in which esophagogastroduodenoscopy (EGD) was performed, gastroduodenal obstruction was revealed in all, but visualization of gallstones was only possible in 56 (69%). Among these 56 cases, such gallstones were observed in the duodenal bulb in 51.8%, in the postbulbar duodenum in 28.6%, in the pylorus or in the prepilorum in 17.9%, and in one case the position was not reported. Gallstones were not recognized in 31% of cases because they were deeply embedded in the mucosa. When gallstones are not displayed, the diagnosis should be strongly suspected when the observed mass is hard, convex, smooth, non-friable and non-fleshy, which are all characteristics of a biliary calculus and can improve the sensitivity of the EGD. For such cases, US and CT are the preferred noninvasive diagnostic tests to confirm endoscopic diagnosis, delineate gastroduodenal anatomy, and demonstrate a cholecystoduodenal fistula

or US in the diagnosis of biliary ileum cases, with a sensitivity of up to 93% [47, 51, 54–57]. The detection frequency of Rigler's triad is higher during the CT exam. In a retrospective study by Lassandro et al. [55–58], the Rigler triad was observed in 77.8% of cases by CT, compared to 14.8% with radiographs and 11.1% with the US. Intestinal loop dilation was observed in 92.6% of cases, pneumobilia in 88.9%, ectopic gallstones in 81.5%, hydroaero levels in 37%, and bilio-digestive fistula in 14.8%. Yu et al. [54, 59] conducted a prospective study in which 165 patients with acute small bowel obstruction were evaluated for biliary ileus, with retrospective identification of three diagnostic criteria: (1) small bowel obstruction; (2) ectopic gallstones, both calcified and removed; and (3) abnormal gallbladder with complete air collection, presence of hydro-aircraft levels, or fluid accumulation with irregular wall. The overall sensitivity, specificity, and precision were 93, 100, and 99%, respectively. Rigler's triad was detected only in 36% of cases. These tomographic diagnostic criteria require further prospective validation. Current CT scanners can describe the position of the fistula, gallstones, and gastrointestinal obstruction with greater precision helping in therapeutic decisions [37, 56–58].

**28**

[27, 31, 52, 53, 63–65].

The main therapeutic goal is the relief of intestinal obstruction by extraction of gallstones. Hydroelectrolytic imbalances and metabolic disorders due to intestinal obstruction and preexisting comorbidities are common and require management before surgery [1, 2, 14, 29, 31, 52, 53, 66–68].

There is no unanimous consensus on the surgical procedure. Current surgical procedures are: (1) simple enterolithotomy; (2) enterolithotomy, cholecystectomy and closure of the fistula (one-stage procedure); and (3) enterolithotomy with cholecystectomy performed subsequently (two-stage procedure). Intestinal resection is necessary in some cases after performing the enterolithotomy.

Enterolithotomy was the most commonly performed surgical procedure. Through an exploratory laparotomy, the gastrointestinal obstruction site is located. A longitudinal incision is made on the antimesenteric edge proximal to the site of obstruction of the gallstones [12, 24, 66]. Whenever possible, through light manipulation, the bile stone is brought proximally to a non-edematous segment of the intestine. Most of the time, this is not possible due to the degree of impact of gallstones. Enterotomy is performed over the gallstones and extracted. Careful closure of the enterotomy is necessary to avoid narrowing of the intestinal lumen and cross-closure is recommended. Intestinal resection is sometimes required, particularly in the presence of ischemia, perforation, or underlying stenosis [12, 66]. Manual propulsion of gallstones through the ileocecal valve should be reserved for highly selected situations due to the danger of mucosal injury and intestinal perforation [12, 20, 24, 27, 28, 66]. Likewise, attempts to crush gallstones in situ can damage the intestinal wall and should be avoided [20, 27, 66, 69]. Multiple gallstones can generally be extracted through a single incision freeing the intestines and moving smaller gallstones to larger ones. In case of sigmoid obstruction, resection that removes gallstones and underlying stenosis has been recommended [12].

The main long-standing controversy in biliary ileum management is whether surgery should be performed simultaneously with relief of bowel obstruction (onestage procedure) or later (two-stage procedure).

In 1922, Pybus successfully extracted a limestone blocking the ileum, closed the duodenal fistula, and drained the gallbladder after removing two additional gallstones from it. In 1929, Holz extracted a limestone at the sigmoid level, and after removing a second limestone in the duodenum, he closed the gallbladder fistula and removed the gallbladder. The author recommended this procedure for patients in satisfactory general conditions. In 1957, Welch successfully performed a one-stage surgery in a patient who was well prepared after recurrent intestinal gallstone obstruction. The authors suggested the feasibility of the operation under optimal conditions. In 1965, Berliner et al. [70] reported three similarly managed and mentioned cases that when the patient is adequately hydrated with restored serum electrolytes, it does not represent an operational risk and a one-stage surgical procedure should be considered. The authors recommend considering the one-step procedure in selected cases. The incidence of recurrence commonly cited is 2–5%, but a recurrence of up to 8% has also been reported after only enterolithotomy; half of these new onset events occurred within 30 days [71]. It should be considered that relapse rates of 17–33% have also been reported [12, 72, 73].

The possibility of recurrent cholecystitis and acute cholangitis [12, 70] in patients with unrepaired gallbladder fistulas or retained gallbladder has been highlighted. Acute cholangitis has been reported in 11% of patients with cholecystoduodenal fistula and in 60% with gallbladder colic fistula [12, 52, 53, 67, 68]. With a one-stage procedure, further events related to gallstones are avoided [18].

A potential long-term complication of biliary enteric fistula could be gallbladder cancer. Bossart et al. [74] found an incidence of 15% of gallbladder carcinoma in 57 patients undergoing surgery for these fistulas, compared with 0.8% among all patients with cholecystectomy.

On the other hand, simple enterolithotomy has long been associated with lower mortality [13]. It should be taken into account that the severity of each case affects the outcome of a particular surgical procedure and that mortality is not an absolute consequence of the surgical procedure itself. In the Clavien et al.'s [12] report, when patients were comparable in terms of age, concomitant disease, and APACHE II score, operational mortality and morbidity rates were not significantly different.

In 2003, Doko et al. [75] reported a series of 30 patients with morbidity of 27.3% in patients undergoing enterolithotomy alone and 61.1% for a one-stage procedure. Mortality was 9% after enterolithotomy and 10.5% after a one-stage procedure. The American Society of Anesthesiologists (ASA) scores were similar between the two groups, but operating times were significantly longer for the one-step procedure. Urgent fistula repair was significantly associated with postoperative complications. The authors concluded that enterolithotomy is the procedure of choice, with a onestage procedure reserved for patients with acute cholecystitis, gallbladder gangrene, or residual gallstones [12].

In 2008, Riaz et al. [76] reported their retrospective experience with 10 patients diagnosed with bileous ileus. The choice of surgical procedure was largely determined by the patient's clinical condition. Five patients underwent enterolithotomy only (group 1), while the remaining five patients underwent cholecystectomy and fistula repair (group 2). In group 1, all patients were hypertensive and diabetic. All patients were hemodynamically unstable, with metabolic acidosis and prerenal azotemia. The ASA score was III or higher in all patients. In group 2, only two patients were hypertensive and all were hemodynamically stable at presentation with an ASA score of II. There was no operational mortality in both groups.

Many patients with biliary ileus are elderly, with comorbidities, in poor general conditions and have a delayed diagnosis, which leads to dehydration, shock, sepsis, or peritonitis. Relief of gastrointestinal obstruction with simple enterolithotomy is the safest procedure for these patients [19, 21].

At laparotomy, examination and careful palpation of the entire intestine, gallbladder, and extrahepatic bile duct is recommended in order to rule out gallstones, bile loss, abscesses, or necrosis [1, 2, 9, 14, 18, 77]. Cholecystectomy and fistula repair reduce the need for reoperation and the incidence of complications related to the persistence of the fistula, including recurrent ileus, cholecystitis, or cholangitis, but are justified only in selected patients who are adequately stabilized in good general condition, with good reserve cardiorespiratory and metabolic, and are able to withstand a more prolonged operation, unless it has been clearly demonstrated that gallstones do not remain in the gallbladder [10, 12, 21, 67, 78, 79].

According to several authors, enterolytictomy alone is the best option for most patients with biliary ileus. The one-step procedure should only be offered to highly selected patients with absolute indications for biliary surgery at the time of presentation and who have been adequately reanimated [6, 7, 13, 21, 29, 31, 52, 53, 67].

The demonstration of gallstones, the appearance of symptoms, or a persistent cholecystointeric fistula indicates the need for cholecystectomy, closure of the fistula, and exploration of the common duct [18]. It has been pointed out that delayed cholecystectomy as a second procedure is clearly justified only in cases of persistence of symptoms [13, 21]. Cholecystectomy and fistula closure are recommended 4–6 weeks later [7, 13, 29, 80]. A 2.94% mortality rate has been reported in this group of patients [25].

**31**

surgery.

**6. Conclusions**

*Gallstones Ileus*

**4. Morbidity**

**5. Mortality**

*DOI: http://dx.doi.org/10.5772/intechopen.93576*

and urinary tract infections [12, 21, 80].

influence the results of the treatment [1].

The most common postoperative complication was wound infection. In 1961, Raiford [5] observed an overall wound infection rate of 75%. Localized peritonitis, respiratory complications, phlebitis, and recurrent obstruction due to residual gallstones and cholangitis have also been observed. Wound infection continues to be the most common complication, with rates of 27 and 42.5%, as reported by Clavien et al. [12] and Rodríguez Hermosa et al. [19], respectively. Several authors have reported no significant differences in postoperative complications between patients treated with enterolithotomy or enterolithotomy, cholecystectomy, and closure of fistulas [12, 21, 67, 80]. The least common complications were wound dehiscence, cardiopulmonary and vascular complications, sepsis, intestinal and biliary fistulas,

Biliary ileum is predominantly a geriatric disease and as many as 80–90% of patients have concomitant medical diseases. Hypertension, diabetes, congestive heart failure, chronic lung disease, and anemia are the most common comorbidities [25]. These associated conditions must be taken into consideration, as they can

Mortality rates were reported up to 44% in the late 1800s, while in the first half of the twentieth century, these rates remained between 40 and 50% [14, 22]. In the 1990s, significant reductions in mortality were observed at 15–18%, at current rates of less than 7% [13, 25]. In particular, simple enterolithotomy has long been associated with a mortality of 11.7% compared to 16.9% for the one-stage procedure (enterolithotomy plus cholecystectomy and fistula closure) [13]. As described by Kirchmayr et al. [79], four main reasons could be responsible for the high number of lethal courses. First of all, the biliary ileum is a disease of the elderly. Second, concomitant diseases such as cardiorespiratory diseases and/or diabetes mellitus are frequent. Third, due to uncommon symptoms, the diagnosis is difficult and an average delay of 4 days from the start of symptoms to hospitalization is reported. Fourth, postoperative recovery is also hampered; age-related complications such as pneumonia or heart failure are more frequent than complications associated with

The authors noted that fistula closure, performed during the initial procedure, was independently associated with a higher mortality rate than enterolithotomy alone. When intestinal resection was indicated, it was also associated with a higher mortality rate than with enterolithotomy alone. However, if you consider the fact that intestinal resection is not exactly an option but a requirement due to the conditions of the intestinal segment, the mortality for those patients who underwent

Biliary ileum or gastrointestinal obstruction from gallstones accounts for less than 1% of cases of gastrointestinal obstruction, with a higher frequency among the elderly. Computed tomography has proven to be the most accurate diagnostic modality, but validation of diagnostic criteria is required. Surgical relief of the obstruction is the cornerstone of the treatment. Given the high incidence of comorbidity in these patients, a good judgment is needed in the choice of the

enterolithotomy alone or intestinal resection is actually 6.53%.

### **4. Morbidity**

*Intestinal Obstructions*

different.

patients with cholecystectomy.

or residual gallstones [12].

A potential long-term complication of biliary enteric fistula could be gallbladder cancer. Bossart et al. [74] found an incidence of 15% of gallbladder carcinoma in 57 patients undergoing surgery for these fistulas, compared with 0.8% among all

In 2003, Doko et al. [75] reported a series of 30 patients with morbidity of 27.3% in patients undergoing enterolithotomy alone and 61.1% for a one-stage procedure. Mortality was 9% after enterolithotomy and 10.5% after a one-stage procedure. The American Society of Anesthesiologists (ASA) scores were similar between the two groups, but operating times were significantly longer for the one-step procedure. Urgent fistula repair was significantly associated with postoperative complications. The authors concluded that enterolithotomy is the procedure of choice, with a onestage procedure reserved for patients with acute cholecystitis, gallbladder gangrene,

In 2008, Riaz et al. [76] reported their retrospective experience with 10 patients diagnosed with bileous ileus. The choice of surgical procedure was largely determined by the patient's clinical condition. Five patients underwent enterolithotomy only (group 1), while the remaining five patients underwent cholecystectomy and fistula repair (group 2). In group 1, all patients were hypertensive and diabetic. All patients were hemodynamically unstable, with metabolic acidosis and prerenal azotemia. The ASA score was III or higher in all patients. In group 2, only two patients were hypertensive and all were hemodynamically stable at presentation with an

Many patients with biliary ileus are elderly, with comorbidities, in poor general conditions and have a delayed diagnosis, which leads to dehydration, shock, sepsis, or peritonitis. Relief of gastrointestinal obstruction with simple enterolithotomy is

At laparotomy, examination and careful palpation of the entire intestine, gallbladder, and extrahepatic bile duct is recommended in order to rule out gallstones, bile loss, abscesses, or necrosis [1, 2, 9, 14, 18, 77]. Cholecystectomy and fistula repair reduce the need for reoperation and the incidence of complications related to the persistence of the fistula, including recurrent ileus, cholecystitis, or cholangitis, but are justified only in selected patients who are adequately stabilized in good general condition, with good reserve cardiorespiratory and metabolic, and are able to withstand a more prolonged operation, unless it has been clearly demonstrated

According to several authors, enterolytictomy alone is the best option for most patients with biliary ileus. The one-step procedure should only be offered to highly selected patients with absolute indications for biliary surgery at the time of presentation and who have been adequately reanimated [6, 7, 13, 21, 29, 31, 52, 53, 67]. The demonstration of gallstones, the appearance of symptoms, or a persistent cholecystointeric fistula indicates the need for cholecystectomy, closure of the fistula, and exploration of the common duct [18]. It has been pointed out that delayed cholecystectomy as a second procedure is clearly justified only in cases of persistence of symptoms [13, 21]. Cholecystectomy and fistula closure are recommended 4–6 weeks later [7, 13, 29, 80]. A 2.94% mortality rate has been reported in this group

ASA score of II. There was no operational mortality in both groups.

that gallstones do not remain in the gallbladder [10, 12, 21, 67, 78, 79].

the safest procedure for these patients [19, 21].

On the other hand, simple enterolithotomy has long been associated with lower mortality [13]. It should be taken into account that the severity of each case affects the outcome of a particular surgical procedure and that mortality is not an absolute consequence of the surgical procedure itself. In the Clavien et al.'s [12] report, when patients were comparable in terms of age, concomitant disease, and APACHE II score, operational mortality and morbidity rates were not significantly

**30**

of patients [25].

The most common postoperative complication was wound infection. In 1961, Raiford [5] observed an overall wound infection rate of 75%. Localized peritonitis, respiratory complications, phlebitis, and recurrent obstruction due to residual gallstones and cholangitis have also been observed. Wound infection continues to be the most common complication, with rates of 27 and 42.5%, as reported by Clavien et al. [12] and Rodríguez Hermosa et al. [19], respectively. Several authors have reported no significant differences in postoperative complications between patients treated with enterolithotomy or enterolithotomy, cholecystectomy, and closure of fistulas [12, 21, 67, 80]. The least common complications were wound dehiscence, cardiopulmonary and vascular complications, sepsis, intestinal and biliary fistulas, and urinary tract infections [12, 21, 80].

#### **5. Mortality**

Biliary ileum is predominantly a geriatric disease and as many as 80–90% of patients have concomitant medical diseases. Hypertension, diabetes, congestive heart failure, chronic lung disease, and anemia are the most common comorbidities [25]. These associated conditions must be taken into consideration, as they can influence the results of the treatment [1].

Mortality rates were reported up to 44% in the late 1800s, while in the first half of the twentieth century, these rates remained between 40 and 50% [14, 22]. In the 1990s, significant reductions in mortality were observed at 15–18%, at current rates of less than 7% [13, 25]. In particular, simple enterolithotomy has long been associated with a mortality of 11.7% compared to 16.9% for the one-stage procedure (enterolithotomy plus cholecystectomy and fistula closure) [13]. As described by Kirchmayr et al. [79], four main reasons could be responsible for the high number of lethal courses. First of all, the biliary ileum is a disease of the elderly. Second, concomitant diseases such as cardiorespiratory diseases and/or diabetes mellitus are frequent. Third, due to uncommon symptoms, the diagnosis is difficult and an average delay of 4 days from the start of symptoms to hospitalization is reported. Fourth, postoperative recovery is also hampered; age-related complications such as pneumonia or heart failure are more frequent than complications associated with surgery.

The authors noted that fistula closure, performed during the initial procedure, was independently associated with a higher mortality rate than enterolithotomy alone. When intestinal resection was indicated, it was also associated with a higher mortality rate than with enterolithotomy alone. However, if you consider the fact that intestinal resection is not exactly an option but a requirement due to the conditions of the intestinal segment, the mortality for those patients who underwent enterolithotomy alone or intestinal resection is actually 6.53%.

#### **6. Conclusions**

Biliary ileum or gastrointestinal obstruction from gallstones accounts for less than 1% of cases of gastrointestinal obstruction, with a higher frequency among the elderly. Computed tomography has proven to be the most accurate diagnostic modality, but validation of diagnostic criteria is required. Surgical relief of the obstruction is the cornerstone of the treatment. Given the high incidence of comorbidity in these patients, a good judgment is needed in the choice of the

surgical procedure. Enterolithotomy remains the mainstay of surgical treatment. A one-stage cholecystectomy and fistula repair are justified only in selected patients in good general condition and adequately stabilized preoperatively. Two-stage surgery is an option for patients with persistent symptoms after an enterolithotomy. Extensive prospective studies of laparoscopic and endoscopic guided procedures are planned.

## **Author details**

Giovanni Petracca\*, Francesco Zappia and Fabrizio Silvaggio Ospedale "G. Jazzolino" – Vibo Valentia, Azienda Sanitaria Provinciale di Vibo Valentia, Vibo Valentia, Italy

\*Address all correspondence to: doc37@virgilio.it

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**33**

*Gallstones Ileus*

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rgmx.2016.07.006

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[12] Clavien PA, Richon J, Burgan S, Rohner A. Gallstone ileus. The British Journal of Surgery. 1990;**77**:737-742

[13] Reisner RM, Cohen JR. Gallstone ileus: A review of 1001 reported cases. The American Surgeon.

[14] Rogers FA, Carter R. Gallstone intestinal obstruction. California Medicine. 1958;**88**:140-143

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planned.

**32**

**Author details**

Valentia, Vibo Valentia, Italy

Giovanni Petracca\*, Francesco Zappia and Fabrizio Silvaggio

\*Address all correspondence to: doc37@virgilio.it

provided the original work is properly cited.

Ospedale "G. Jazzolino" – Vibo Valentia, Azienda Sanitaria Provinciale di Vibo

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

surgical procedure. Enterolithotomy remains the mainstay of surgical treatment. A one-stage cholecystectomy and fistula repair are justified only in selected patients in good general condition and adequately stabilized preoperatively. Two-stage surgery is an option for patients with persistent symptoms after an enterolithotomy. Extensive prospective studies of laparoscopic and endoscopic guided procedures are

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[2] Martin F. Intestinal obstruction due to gall-stones: With report of three successful cases. Annals of Surgery. 1912;**55**:725-743

[3] Fox PF. Planning the operation for cholecystoenteric fistula with gallstone ileus. The Surgical Clinics of North America. 1970;**50**:93-102

[4] VanLandingham SB, Broders CW. Gallstone ileus. The Surgical Clinics of North America. 1982;**62**:241-247

[5] Raiford TS. Intestinal obstruction due to gallstones. (Gallstone ileus). Annals of Surgery. 1961;**153**:830-838

[6] Nakao A, Okamoto Y, Sunami M, Fujita T, Tsuji T. The oldest patient with gallstone ileus: Report of a case and review of 176 cases in Japan. The Kurume Medical Journal. 2008;**55**:29-33

[7] Ayantunde AA, Agrawal A. Gallstone ileus: diagnosis and management. World Journal of Surgery. 2007;**31**:1292-1297

[8] Masannat Y, Masannat Y, Shatnawei A. Gallstone ileus: A review. Mount Sinai Journal of Medicine. 2006;**73**:1132-1134

[9] Beltran MA, Csendes A. Mirizzi syndrome and gallstone ileus: An unusual presentation of gallstone disease. Journal of Gastrointestinal Surgery. 2005;**9**:686-689

[10] Ploneda-Valencia CF, Gallo-Morales M, Rinchon C, Navarro-Muñiz E, Bautista-López CA, de la Cerda-Trujillo LF, et al. Gallstone ileus: An overview of the literature.

Revista de Gastroenterología de México. 2017;**82**(3):248-254. DOI: 10.1016/j. rgmx.2016.07.006

[11] Abbasi S-U-N, Khan DB, Khandwala K, Raza R, Memon WA. Cholecystocolonic fistula. Case Reports. 2019;**11**(6):e4874

[12] Clavien PA, Richon J, Burgan S, Rohner A. Gallstone ileus. The British Journal of Surgery. 1990;**77**:737-742

[13] Reisner RM, Cohen JR. Gallstone ileus: A review of 1001 reported cases. The American Surgeon. 1994;**60**:441-446

[14] Rogers FA, Carter R. Gallstone intestinal obstruction. California Medicine. 1958;**88**:140-143

[15] Dias AR, Lopes RI. Biliary stone causing afferent loop syndrome and pancreatitis. World Journal of Gastroenterology. 2006;**12**:6229-6231

[16] Micheletto G, Danelli P, Morandi A, Panizzo V, Montorsi M. Gallstone ileus after biliointestinal bypass: Report of two cases. Journal of Gastrointestinal Surgery. 2013;**17**:2162-2165

[17] Mondragón Sánchez A, Berrones Stringel G, Tort Martínez A, Soberanes Fernández C, Domínguez Camacho L, Mondragón Sánchez R. Surgical management of gallstone ileus: Fourteen year experience. Revista de Gastroenterología de México. 2005;**70**:44-49

[18] Warshaw AL, Bartlett MK. Choice of operation for gallstone intestinal obstruction. Annals of Surgery. 1966;**164**:1051-1055

[19] Rodríguez Hermosa JI, Codina Cazador A, Gironès Vilà J, Roig García J, Figa Francesch M, Acero Fernández D. Gallstone ileus: Results of analysis of a

series of 40 patients. Gastroenterología y Hepatología. 2001;**24**:489-494

[20] Luu MB, Deziel DJ. Unusual complications of gallstones. The Surgical Clinics of North America. 2014;**94**:377-394

[21] Rodríguez-Sanjuán JC, Casado F, Fernández MJ, Morales DJ, Naranjo A. Cholecystectomy and fistula closure versus enterolithotomy alone in gallstone ileus. The British Journal of Surgery. 1997;**84**:634-637

[22] Courvoisier LG. Casuistischstatistische Beitrage zur Pathologic und Chirurgie der gallenwege. XII Leipzig: FCW Vogel; 1890

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[25] Halabi WJ, Kang CY, Ketana N, Lafaro KJ, Nguyen VQ, Stamos MJ, et al. Surgery for gallstone ileus: A nationwide comparison of trends and outcomes. Annals of Surgery. 2014;**259**:329-335

[26] Kasahara Y, Umemura H, Shiraha S, Kuyama T, Sakata K, Kubota H. Gallstone ileus. Review of 112 patients in the Japanese literature. American Journal of Surgery. 1980;**140**:437-440

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complications. American Journal of Surgery. 2007;**193**:73-78

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[36] Sertkaya M, Emre A, Akbulut S, Vicdan H, §anh AN. A typical gallstone ileus: Clinical, radiological and operational findings. Turkish Journal of Gastroenterology 2019; 30: 377-380

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**35**

*Gallstones Ileus*

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DOI: 10.1007/s10140-017-1568-5

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Imaging. 2001;**26**:401-405

Surgery. 1968;**167**:377-383

Mendes CA, Boteon YL, de

[52] Cooperman AM, Dickson ER, ReMine WH. Changing concepts in the surgical treatment of gallstone ileus: A review of 15 cases with emphasis on diagnosis and treatment. Annals of

[53] de Alencastro MC, Cardoso KT,

Carvalho RB, Fraga GP. Acute intestinal obstruction due to gallstone ileus. Revista do Colégio Brasileiro de Cirurgiões. 2013;**40**:275-280

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Surgery 2015;7(8):152-159.

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#### *Gallstones Ileus DOI: http://dx.doi.org/10.5772/intechopen.93576*

in thè deep: Imaging findings and diagnostic pearls in gallstone. Surgery Research and Practice. 2020;**1421753**

*Intestinal Obstructions*

2014;**94**:377-394

Surgery. 1997;**84**:634-637

FCW Vogel; 1890

[22] Courvoisier LG. Casuistischstatistische Beitrage zur Pathologic und Chirurgie der gallenwege. XII Leipzig:

[23] Bouveret L. Stenose du pylore adherent a la vesicule calculeuse. Revolution Medicines. 1896;**16**:1-16

[24] Kurtz RJ, Heimann TM, Beck AR, Kurtz AB. Patterns of treatment of gallstone ileus over a 45-year period. The American Journal of Gastroenterology. 1985;**80**:95-98

[25] Halabi WJ, Kang CY, Ketana N, Lafaro KJ, Nguyen VQ, Stamos MJ, et al. Surgery for gallstone ileus: A nationwide comparison of trends and outcomes. Annals of Surgery. 2014;**259**:329-335

[26] Kasahara Y, Umemura H, Shiraha S, Kuyama T, Sakata K, Kubota H. Gallstone ileus. Review of 112 patients in the Japanese literature.

American Journal of Surgery.

[27] Habib E, Elhadad A. Digestive complications of gallstones lost during laparoscopic cholecystectomy. HPB: The Official Journal of the International Hepato Pancreato Biliary Association.

[28] Zehetner J, Shamiyeh A, Wayand W.

Lost gallstones in laparoscopic cholecystectomy: All possible

1980;**140**:437-440

2003;**5**:118-122

series of 40 patients. Gastroenterología

complications. American Journal of

Complications of gallstones: The Mirizzi syndrome, gallstone ileus, gallstone pancreatitis, complications of "lost" gallstones. The Surgical Clinics of North

Surgery. 2007;**193**:73-78

[29] Zaliekas J, Munson JL.

America. 2008;**88**:1345-1368

[31] Cappell MS, Davis M. Characterization of Bouveret's syndrome: A comprehensive review of 128 cases. The American Journal of Gastroenterology. 2006;**101**:2139-2146

[30] Koulaouzidis A, Moschos J.

[32] Jakubauskas M, Luksaite R,

ileus: Management and clinical outeomes. Medicina. 2019;**55**(9):598

2018;**43**:18-23

Case Reports. 2016;**17**:301

[35] Ramirez-Ramirez MM,

2016;**81**(2):103-104

Sileikis A, Strupas I, Poskus T. Gallstone

[33] De Monti M, Cestaro G, Alkayyali S, Galafassi J, Fasolini F. Gallstone ileus: A possible cause of bowel obstruction in thè elderly population. International Journal of Surgery Case Report.

[34] Al-Mudares S, Kurer M, Koshy RM, El-Menyar A. An unusual presentation of gallstone ileus: A red-herring or missed diagnosis. American Journal of

Villanueva-Saenz E, Zubieta-Ófarril G. Rigler's triad in gallstone ileus: A rare form of bowel obstruction. Revista di Gastroenterología de México.

[36] Sertkaya M, Emre A, Akbulut S, Vicdan H, §anh AN. A typical gallstone

[37] Aldo IO, Lorenzo M, Olgerta L, Alberto C, Licia U, Melchiore G. Rolling

operational findings. Turkish Journal of Gastroenterology 2019; 30: 377-380

ileus: Clinical, radiological and

Bouveret's syndrome. Narrative review. Annals of Hepatology. 2007;**6**:89-91

y Hepatología. 2001;**24**:489-494

[20] Luu MB, Deziel DJ. Unusual complications of gallstones. The Surgical Clinics of North America.

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**34**

[38] Shovkat Ahmad Mir, Zeiad Hussain, Christine Ann Davey, Glenn Vincent Miller, Srinivas Chintapatla. Management and outcome of recurrent gallstone ileus: A systematic review. World Journal of Gastrointestinal Surgery 2015;7(8):152-159.

[39] Rigler LG, Borman CN, Noble JF. Gallstone obstruction: Pathogenesis and roentgen manifestations. Journal of the American Medical Association. 1941;**117**:1753-1759

[40] Haddad FG, Mansour W, Mansour J, Deeb L. From Bouveret's syndrome to gallstone ileus: The journey of a migrating stone! 1 Cureus. 2018;**10**(3):e2370

[41] Rotaru MI, Necula AH, Caraiani CN, Badea AF, Tantau MV, Badea RI. Point-of-care ultrasound in management of Gallstone ileus - A case report. Medical Ultrasonography. 2019;**21**(2):197-199

[42] Saran S, Malik S, Kharbanda A, Sharma Y. Pneumobilia with multiple air-fluid levels on abdominal radiography: A clincher. Annals of African Medicine. 2019;**18**(2):115-116

[43] Ferhatoğlu MF, Kartal A. Bouveret's syndrome: A case-based review, clinical presentation, diagnostics and treatment approaches. SiSli Etfal Hastanesi Tip Bulteni. 2020;**54**(1):1-7

[44] Morosin T, De Robles MSB, Putnis S. Gallstone ileus: An unusual cause of intestinal obstruction. Cureus. 2020;**12**(3):e7284

[45] Balthazar EJ, Schechter LS. Air in gallbladder: A frequent finding in gallstone ileus. AJR. American Journal of Roentgenology. 1978;**131**:219-222

[46] Liew V, Layani L, Speakman D. Bouveret's syndrome in Melbourne. ANZ Journal of Surgery. 2002;**72**:161-163

[47] Brennan GB, Rosenberg RD, Arora S. Bouveret syndrome. Radiographics. 2004;**24**:1171-1175

[48] Chang L, Chang M, Chang HM, Chang AI, Chang F. Clinical and radiological diagnosis of gallstone ileus. Emergency Radiology. 2018;**25**:189-196. DOI: 10.1007/s10140-017-1568-5

[49] Tahashi K, Kashimura H, Konno N, Nakagawa M, Kawahara Y, Munakata A, et al. Gallstone ileus with spontaneous evacuation: A case report. Journal of General and Family Medicine. 2018;**19**(5):173-175

[50] Lasson A, Lorén I, Nilsson A, Nirhov N, Nilsson P. Ultrasonography in gallstone ileus: A diagnostic challenge. The European Journal of Surgery. 1995;**161**:259-263

[51] Ripollés T, Miguel-Dasit A, Errando J, Morote V, Gómez-Abril SA, Richart J. Gallstone ileus: Increased diagnostic sensitivity by combining plain film and ultrasound. Abdominal Imaging. 2001;**26**:401-405

[52] Cooperman AM, Dickson ER, ReMine WH. Changing concepts in the surgical treatment of gallstone ileus: A review of 15 cases with emphasis on diagnosis and treatment. Annals of Surgery. 1968;**167**:377-383

[53] de Alencastro MC, Cardoso KT, Mendes CA, Boteon YL, de Carvalho RB, Fraga GP. Acute intestinal obstruction due to gallstone ileus. Revista do Colégio Brasileiro de Cirurgiões. 2013;**40**:275-280

[54] Yu CY, Lin CC, Shyu RY, Hsieh CB, Wu HS, Tyan YS, et al. Value of CT in the diagnosis and management of gallstone ileus. World Journal of Gastroenterology. 2005;**11**:2142-2147

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[62] Evola G, Caramma S, Caruso G, Dapri G, Evola FR, Reina C, et al. Bouveret's syndrome as a rare complication of Cholelithiasis: Disputes in current management and report of two cases. Surgical Case Reports. 2020;**71**:315-318

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**37**

*Gallstones Ileus*

1998;**68**:755-756

1961;**176**:494-497

1962;**103**:366-369

2003;**27**:400-404

1959;**35**:673-676

2010;**2**:172-176

*DOI: http://dx.doi.org/10.5772/intechopen.93576*

ileus: rare and still controversial. ANZ Journal of Surgery. 2005;**75**:234-238

[80] Tan YM, Wong WK, Ooi LL. A comparison of two surgical strategies for the emergency treatment of gallstone ileus. Singapore Medical Journal.

2004;**45**:69-72

Frizelle FA. Recurrent gallstone ileus: Underestimated. The Australian and New Zealand Journal of Surgery.

[72] Kirkland KC, Croce EJ. Gallstone intestinal obstruction. A review of the literature and presentation of 12 cases, including 3 recurrences. Journal of the American Medical Association.

[73] Ravikumar R, Williams JG. The operative management of gallstone ileus. Annals of the Royal College of Surgeons of England. 2010;**92**:279-281

[74] Bossart PA, Patterson AH, Zintel HA. Carcinoma of the gallbladder. A report of seventy-six cases. American Journal of Surgery.

[75] Doko M, Zovak M, Kopljar M, Glavan E, Ljubicic N, Hochstädter H. Comparison of surgical treatments of gallstone ileus: Preliminary report. World Journal of Surgery.

[76] Riaz N, Khan MR, Tayeb M. Gallstone ileus: Retrospective review of a single centre's experience using two surgical procedures. Singapore Medical

[77] Fiddian RV. Gall-stone ileus. Recurrences and multiple stones. Postgraduate Medical Journal.

Arróniz-Jáuregui J, Moreno-Pérez PA, Chávez-Solís EA, Esparza-Arias N, Hernández-González CI. Gallstone ileus: One-stage surgery in a patient with intermittent obstruction. World Journal of Gastrointestinal Surgery.

[79] Kirchmayr W, Mühlmann G, Zitt M, Bodner J, Weiss H, Klaus A. Gallstone

Journal. 2008;**49**:624-626

[78] Nuño-Guzmán CM,

[71] Doogue MP, Choong CK,

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*Intestinal Obstructions*

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[60] Caldwell KM, Lee SJ,

2018;**11**:69-75

Leggett PL, Bajwa KS, Mehta SS, Shah SIC. Bouveret syndrome: Current management strategies. Clinical and Experimental Gastroenterology.

[61] Yu Y-B, Song Y, Xu J-B, Qi F-Z. Bouveret's syndrome: A rare presentation of gastric outlet obstruction. Experimental and Therapeutic Medicine. 2019;**17**(3):1813-1816

[62] Evola G, Caramma S,

2020;**71**:315-318

Caruso G, Dapri G, Evola FR, Reina C, et al. Bouveret's syndrome as a rare complication of Cholelithiasis: Disputes in current management and report of two cases. Surgical Case Reports.

Mazzeo R. Gallstone ileus analysis of radiological findings in 27 patients. European Journal of Radiology.

[63] Halter F, Bangerter U,

Endoscopy. 1981;**13**:88-89

[64] Chavalitdhamrong D, Donepudi S, Pu L, Draganov PV. Uncommon and rarely reported adverse

Endoscopy. 2014;**26**:15-22

[65] Yamauchi Y, Wakui N,

2014;**2014**:271571

1955;**142**:52-65

events of endoscopic retrograde cholangiopancreatography. Digestive

Asai Y, Dan N, Takeda Y, Ueki N, et al. Gallstone ileus following endoscopic stone extraction. Case Reports in Gastrointestinal Medicine.

[66] Deckoff SL. Gallstone ileus; a report of 12 cases. Annals of Surgery.

[67] Martínez Ramos D, Daroca José JM, Escrig Sos J, Paiva Coronel G, Alcalde Sánchez M, Salvador Sanchís JL. Gallstone ileus: Management options and results on a series of 40 patients. Revista Española de Enfermedades Digestivas. 2009;**101**:117-120

[68] Yakan S, Engin O, Tekeli T, Calik B, Deneçli AG, Coker A, et al. Gallstone ileus as an unexpected complication of cholelithiasis: Diagnostic difficulties and treatment. Ulusal Travma ve Acil Cerrahi Dergisi. 2010;**16**:344-348

[69] Aguilar-Espinosa F,

rgmx.2016.10.010

1965;**90**:313-316

Maza-Sánchez R, Vargas-Solís F,

Guerrero-Martínez GA, Medina-Reyes JL, Flores-Quiroz PI. Cholecystoduodenal fistula, an infrequent complication of Cholelithiasis: Our experience in its surgical management. Revista de Gastroenterología de México. 2017;**82**(4):287-295. DOI: 10.1016/j.

[70] Berliner SD, Burson LC. One-stage repair for cholecyst-duodenal fistula and gallstone ileus. Archives of Surgery.

Gigon JP, Pusterla C. Gallstone ileus after endoscopic sphincterotomy.

**36**

[71] Doogue MP, Choong CK, Frizelle FA. Recurrent gallstone ileus: Underestimated. The Australian and New Zealand Journal of Surgery. 1998;**68**:755-756

[72] Kirkland KC, Croce EJ. Gallstone intestinal obstruction. A review of the literature and presentation of 12 cases, including 3 recurrences. Journal of the American Medical Association. 1961;**176**:494-497

[73] Ravikumar R, Williams JG. The operative management of gallstone ileus. Annals of the Royal College of Surgeons of England. 2010;**92**:279-281

[74] Bossart PA, Patterson AH, Zintel HA. Carcinoma of the gallbladder. A report of seventy-six cases. American Journal of Surgery. 1962;**103**:366-369

[75] Doko M, Zovak M, Kopljar M, Glavan E, Ljubicic N, Hochstädter H. Comparison of surgical treatments of gallstone ileus: Preliminary report. World Journal of Surgery. 2003;**27**:400-404

[76] Riaz N, Khan MR, Tayeb M. Gallstone ileus: Retrospective review of a single centre's experience using two surgical procedures. Singapore Medical Journal. 2008;**49**:624-626

[77] Fiddian RV. Gall-stone ileus. Recurrences and multiple stones. Postgraduate Medical Journal. 1959;**35**:673-676

[78] Nuño-Guzmán CM, Arróniz-Jáuregui J, Moreno-Pérez PA, Chávez-Solís EA, Esparza-Arias N, Hernández-González CI. Gallstone ileus: One-stage surgery in a patient with intermittent obstruction. World Journal of Gastrointestinal Surgery. 2010;**2**:172-176

[79] Kirchmayr W, Mühlmann G, Zitt M, Bodner J, Weiss H, Klaus A. Gallstone

ileus: rare and still controversial. ANZ Journal of Surgery. 2005;**75**:234-238

[80] Tan YM, Wong WK, Ooi LL. A comparison of two surgical strategies for the emergency treatment of gallstone ileus. Singapore Medical Journal. 2004;**45**:69-72

**39**

ment process.

**Chapter 4**

**Abstract**

Obstructions

obstructions caused by foreign bodies.

discusses foreign body ingestion and outcomes.

**1. Introduction**

**Keywords:** foreign body, ingestion, obstruction, intestine, bowel

Foreign body ingestion encompasses a wide range of objects. Most often, the patients that have ingested a foreign body are in the pediatric population, which can lead to its own challenges in management. In adults, there is even less literature that

Foreign bodies can become lodged in various areas of the upper and lower gastrointestinal tracts. There are specific characteristics of objects and certain anatomic and physiologic regions of the gastrointestinal tract that create unique problems regarding management of the ingested foreign body. As is demonstrated in the pediatric literature, an algorithmic approach should be utilized to manage adults who have ingested an object. This approach includes systematic evaluation and work-up, determining appropriate management based on the clinical evaluation, and ultimately addressing complications as they may arise during the manage-

Foreign Bodies and Bowel

Foreign body ingestion most commonly occurs in the pediatric population, with approximately 80–90% of objects passing spontaneously in individuals who are evaluated by medical professionals. Objects may be lodged in a variety of anatomic locations. Only about 10% of foreign bodies progress past the stomach. Of the 10–20% of objects that fail to pass, less than 1% requires surgical intervention. Small bowel obstructions are a rare presentation of foreign body ingestions. There are case reports, guidelines, and retrospective reviews in the literature regarding the management of ingested foreign bodies. In patients who do not have spontaneous passage of foreign bodies, endoscopic and surgical techniques have been utilized for successful retrieval. The timing and indication for endoscopic intervention is dependent upon several factors, including the type and location of the foreign body and is also contingent upon patient symptoms. Numerous case reports and studies describe the successful endoscopic removal of foreign bodies in the upper and lower gastrointestinal tract. Although the type and location of an ingested object is critical for determining the success of endoscopic intervention, the patient's clinical exam and stability is also an aspect to consider when deciding on management of bowel

*Jessica Elizabeth Taylor and Devin Clegg*

#### **Chapter 4**
