Small Intestinal obstruction: next step?

[minookie]

History of my mother: colon cancer April 1999; had surgery to remove tumor. chemotherapy for 6 months. July 1999, small bowel obstruction: spent 10 days in hospital on IV, obstruction cleared.On Nov 10,2004 my mother had surgery on her small intestine to remove obstruction.Doc found gangrene in sm intest and removed 30 cm. prognosis looked good. was kept on IV with g-tube at hosp until bowel movement. waited for 3 weeks but no movement. doc suspected another obstruction, suggested another surgery:exploratory laparoscopy was done nov.30. this time, doc found severe adhesions of small intestine (as if cement had been poured). during surg, adhesions were cut apart, 10 stitches were made on intestinal walls, in the end 50% of sm intest remained. surgery took nearly 5 hrs. prognosis was not good. if adhesions were to form again, the doctor could not give us another course of action. he said he could NOT do another surgery to remove adhesions, but steps for preventing more adhes were taken during the 2nd surgery (ie. material lined between intestines for preventing adhes). all we can do is wait and hope no more adhes form. after surg, mom was in ICU for a few days, heart rate was high btw 119-139, needed oxygen tube, but returned to normal hospital med/surg unit dec 3rd.  the advice given to us was to keep my mom moving as much as poss. walking was impossible,standing and sitting up very difficult. on dec 6, moms weight was 172lbs (before surg, it was 143lbs) which was why she could not move. her thighs were hard and swollen, stomach completely distended, said it felt as though a boulder was on her stomach. doc gave albumin to reduce swelling. later on dec 6, mom felt something burst, and felt total relief, as if boulder had been lifted. a few minutes later, i noticed fluid coming out. mom lost i think 500cc of fluid (color was dark brownish/red), nurses said it was drainage.doc said that one of the stitches on her intest walls had leaked b/c of fluid build up. colostomy bag is attached to where it leaked (on stomach). still has g=tube on side. after leakage, swelling in thighs gone. little swelling in lower back still. stomach is not as full, but still distended. dec 7, moms weight 157lbs. today, dec 10 147 lbs. mom can move much better,starting to walk today, but legs weak.since leakage(dec 6) output (g-tube and urine) has been high.BUT output in colost bag is LOW, near nothing.input, still no fluids/food, only ice chips. doc waiting for bowel movemnt/passing gas. none so far. intest still not moving, no sounds. vitals good,oxy tube intermit.prognosis re: stitch opening, doc said that colost bag must stay on for 6mths-1yr,if everything else ok, then maybe go back in and stitch it up, OR very smll chance of healing on its own. prognosis re: recovery of sm. intest is unknown. just waiting for bowel movement and NO more adhes. not much we can do now, but have my mom keep moving and exercising.any suggestions?what to do?what if adhes form again?help,mina

[Kevin Pho, MD]

Difficult case.  One option would be placing a long intestinal tube  to prevent reobstruction (i.e. known as a Baker's tube).  It traverses the entire small bowel and can be left in place 14 days post-op to prevent further obstruction.

The use of bioabsorbable barrier membranes can also be considered (although you have seemed to describe something similar).  They are currently in the experimental stage, but seems promising.

Another consideration would be application of dextran to the peritoneal surfaces, which has been shown to slightly decrease adhesions.  The downside is that it has been shown to have an increase in infections.

You may want to discuss these options with your personal physician or surgeon.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
Medical Weblog:
kevinmd_b

[kimbacat]

Mina,

your mom has been thru a lot, but congrats on her surving colon cancer!  you didn't mention how old she is.  the docs can maybe help you with some medical answers but I wanted to respond to you about recovery and adhesions.  your mom has most likely been taking a lot of pain meds and those, along with the repeated surgeries can shut down your bowel.  it doesn't have anything to do with adhesions, it's just due to the side effects of the meds and the fact that the bowel does NOT like to be handled.  time, getting off the pain meds, walking, moving around alot and eventually the bowel will "wake up".  

as far as the adhesions.... no one can predict what will happen, or even if anything will happen.  hopefully the SupraFilm will help inhibit the formation of some.  if she does develop them, it doesn't necessarily mean she'll get obstructed.  some tips that might help if she is worried (mostly common sense stuff):  drink plently of fluids (unless she is fluid restricted for other health reasons), dehydration will slow your gut down and can stop it all together.  CHEW, CHEW, CHEW!  eat slowly and chew your food thoroughly.  I have extensive abdominal/pelvic adhesions and I am always the last one done at every meal by a good 10+ minutes.  the smaller the pieces, the less likely they are to get 'stuck'.  personally, I avoid undigestible foods like corn, mushrooms and celery.  once she is able to eat, start off with smaller, more frequent (4-5) meals per day until she feels comfortable and confident.  just kind of graze throughout the day, it's better for you anyway :)

take care

[surgeon]

It's not a matter of "if" adhesions will form, because they have and will (and, whereas the film they placed might limit formation in a specific area, it won't help much overall). It's a matter of what to do about them. And the answer is, hopefully, nothing. In fact, when they are causing problems early after surgery, as before her second operation, the best thing is to wait them out. Early postop obstructions tend to resolve. The very good and lucky thing in her case is that the output into the bag is low, which means in fact that the odds are extremely high that it will completely heal, and reoperation is very unlikely. Meanwhile, I assume she's getting some form of intravenous nutrition (called "hyperalimentation," or TPN (total parenteral nutrition). That can be done on an in-home basis as well as at the hospital. As frustrating as it is, it sounds like at the moment things are as good as they could be, and in fact could have been much worse. It's lucky the leakage found its way to the surface on its own. And the best approach now is patience and intravenous nutrition. With more luck, it'll resolve without more surgery; and if surgery were ever needed again, the longer the time that's passed the better; three weeks after surgery is absolutely the most difficult and dangerous time to go back. Six months can make a huge difference. But, again, having adhesions per se is not the problem. It's whether they cause blockages. And, in a sense, the more extensive the adhesions, the less likely to form a specific treatable blockage.