PARENTERAL NUTRITION INSTEAD OF EARLY REOPERATION IN THE MANAGEMENT OF PERSISTENT EARLY POSTOPERATIVE SMALL BOWEL OBSTRUCTION
Dominykas Burneikis*, Luca Stocchi, Ezra Steiger, Denise Jezerski, Sherief Shawki
Cleveland Clinic, Cleveland, OH
Background:
In the majority of patients, early postoperative small bowel obstruction (EPSBO) resolves with nasogastric decompression and bowel rest alone, while in some patients symptoms persist without urgent indications for surgery. In such cases elective repeat laparotomy may occur during the worst phase of intraabdominal adhesion formation. The purpose of this study was the evaluation of home parenteral nutrition (HPN) instead of elective surgery as initial approach to persistent EPSBO.
Methods:
Patients developing EPSBO between 2005 and 2017 receiving HPN without reoperation within 6 weeks after index intestinal surgery were identified from an institutional HPN registry and compared with patients undergoing elective reoperation for EPSBO within the same time periods. Inclusion criteria required radiological and clinical evidence of EPSBO despite nasogastric decompression. HPN administration elsewhere and urgent reoperations were excluded. Electronic medical charts were reviewed to assess comparative patient characteristics, hospital course, morbidity and readmission data.
Results:
34 patients for the HPN group and 27 patients in elective reoperative (REOP) group met the inclusion criteria. Overall, the most common index operations preceding EPSBO were laparotomy for small bowel obstruction (n = 16) and takedown of diverting loop ileostomy (n = 18).
In the HPN group, the mean interval between surgery and PN initiation was 11 days and the mean postoperative length of stay (LOS) was 20 days. HPN duration ranged from 17 to 244 days with a median of 60 days. Thirty-one patients (91%) successfully recovered bowel function and resumed enteral nutrition without the need for reoperation while 3 patients required reoperation > 6 weeks after index surgery due to HPN failure. Four HPN patients required intensive care unit readmission due to line sepsis.
Patient characteristics in the REOP group were similar, except for more common use of laparoscopic surgery at their index operation (33% vs. 9%, p=0.039). The mean interval between index surgery and reoperation was 17 days and the mean overall LOS was 21 days. Morbidity and readmission rates were comparable between groups. However, the REOP group included 12 patients requiring bowel resection, 5 having incidental enterotomies, and 3 requiring new stoma creation at the time of reoperation. Postoperatively after reoperation, 2 patients developed enterocutaneous fistulas, 1 experienced an anastomotic leak and another had a fascial dehiscence.
Conclusion:
HPN is a valid alternative to elective surgery in clinically stable patients with persistent EPSBO. This approach avoids hazardous reoperation during the recovery phase when adhesions are at their worst.
EPSBO Outcomes and Complications
| HPN (n=34) | REOP (n=27) | p | |
| Mean LOS | 20 (13) | 21 (8) | 0.868 |
| Median PN Duration [IQR] | 60 [35.5, 84] | 10 [7.5, 17] | <0.001 |
| Readmissions | 16 (47) | 7 (26) | 0.154 |
| Recurrent SBO at 12 Months | 5 (15) | 1 (4) | 0.317 |
| Complications | |||
| Clavien-Dindo Grade I | 5 | 3 | 0.993 |
| Clavien-Dindo Grade II | 36 | 27 | 0.831 |
| Clavien-Dindo Grade III | 0.816 | ||
| Upper GI Bleed | 1 | 0 | |
| Organ Space SSI | 4 | 0 | |
| Pouch Dysfunction | 1 | 0 | |
| DVT/PE | 1 | 1 | |
| Seroma | 1 | 0 | |
| Pericardial Effusion | 1 | 0 | |
| Cystitis | 0 | 1 | |
| Bladder Injury | 0 | 1 | |
| Enterocutaneous Fistula | 0 | 2 | |
| High Output Ileostomy | 0 | 1 | |
| NSTEMI | 0 | 1 | |
| Fascial Dehiscence | 0 | 1 | |
| Clavien-Dindo Grade IV | 0.110 | ||
| Line Sepsis | 4 | 1 | |
| Anastomotic Leak | 0 | 1 | |
| Mortality | 0 | 1 | 0.907 |
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