Small Bowel Obstruction

Copyright 2007 Eastern Association for the Surgery of Trauma
1

PRACTICE MANAGEMENT GUIDELINES
FOR SMALL BOWEL OBSTRUCTION
EAST Practice Parameter Workgroup for Management of Small Bowel Obstruction

2

J ose J . Diaz, J r. MD; Co-Chair
Vanderbilt University Medical Center
Nashville, TN
E-mail: jose.diaz@vanderbilt.edu

Faran Bokhari, MD; Vice-Chair
Stroger Hospital of Cook County
Chicago, IL
fbokhari2000@yahoo.com

Nathan T. Mowery, MD
Nashville, TN
nate.mowery@vanderbilt.edu

J ose A. Acosta, MD
San Diego, CA
macosta@centennialpr.net

Ernest F.J , Block, MD
Orlando Regional Healthcare System
Orlando, FL
eblock@orhs.org

William J . Bromberg, MD
Memorial Health University Medical Center
Savannah, GA
brombwi1@memorialhealth.com

3
Bryan R. Collier, DO
Nashville, TN
Bryan.collier@vanderbilt.edu

Daniel C. Cullinane, MD
Mayo Clinic
Rochester, MN
cullinane.daniel@mayo.edu

Kevin M. Dwyer, MD
Inova Fairfax Hospital
Falls Church, VA
kevin.dwyer@inova.com

Margaret M. Griffen, MD
SHANDS J acksonville
J acksonville, FL
maggie.griffen@jax.ufl.com

J ohn C. Mayberry, MD
Oregon Health & Science University
Portland, OR
mayberrj@ohsu.edu

Rebecca J erome
Nashville, TN
rebecca.jerome@vanderbilt.edu

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Practice Management Guidelines for Small Bowel Obstruction

I. Statement of the Problem
The description of patients presenting with small bowel obstruction dates back to the
third or fourth century, when early surgeons created enterocutaneous fistulas to relieve a
bowel obstruction. Despite this success with operative therapy, the nonoperative
management of these patients with attempted reduction of hernias, laxatives, ingestion of
heavy metals (e.g., lead or mercury), and leeches to remove toxic agents from the blood
was the rule until the late 1800s, when antisepsis and aseptic surgical techniques made
operative intervention safer and more acceptable. A better understanding of the
pathophysiology of bowel obstruction and the use of isotonic fluid resuscitation,
intestinal tube decompression, and antibiotics have greatly reduced the mortality rate for
patients with mechanical bowel obstruction.
1, 2
However, the means for determining when
a period of observation is warranted versus early surgical intervention continues to be an
area of debate. With the advances in imaging techniques additional information can be
supplied to the clinical information obtained from the history and physical. The question
of whether these technological advancements have allowed a more sophisticated
evaluation of these patients is yet to be determined. In addition which tests supply the
most information has yet to be clearly described.
Additionally the optimal length of observation continues to be debated. In the era
of a push toward shorter hospital stays correctly identifying patients who are to fail
observation is even more important. It is important to determine if clinical or
radiographic clues can increase our sensitivity in determining such patients.
Finally, as minimally invasive surgery grows and finds new applications are there
reproducible benefits to the patients in pursuing these intervention as both a diagnostic
and therapeutic intervention.

II. Process
A computerized search of the National Library of Medicine MEDLINE database was
undertaken using the PubMed Entrez interface. English language citations during the
period of 1991 through 2006 using the primary search strategy:
5

intestinal obstruction[mh] AND intestine, small[mh] AND humans[mh] NOT
(case reports[pt] OR letter[pt] OR comment[pt] OR news[pt])

Review articles were also excluded. The PubMed Related Articles algorithm was also
employed to identify additional articles similar to the items retrieved by the primary
strategy. Of approximately 550 articles identified by these two techniques, those dealing
with either prospective or retrospective studies examining small bowel obstruction were
selected, comprising 131 institutional studies evaluating diagnosis and management of
adult patients with suspected or proven small bowel obstruction. The articles were
reviewed by a group of eleven trauma / critical care surgeons who collaborated to
produce this practice management guideline. (Table 1)

The correlation between the evidence and the level of recommendations is as follows:
Level 1: This recommendation is convincingly justifiable based on the available scientific
information alone. It is usually based on Class I data, however, strong Class II evidence
may form the basis for a level 1 recommendation, especially if the issue does not lend
itself to testing in a randomized format. Conversely, weak or contradictory Class I data
may not be able to support a level 1 recommendation.
Level 2: This recommendation is reasonably justifiable by available scientific evidence
and strongly supported by expert critical care opinion. It is usually supported by Class II
data or a preponderance of Class III evidence.
Level 3: This recommendation is supported by available data but adequate scientific
evidence is lacking. It is generally supported by Class III data. This type of
recommendation is useful for educational purposes and in guiding future studies.
3

III. Recommendations (Figure 1 Flow diagram)
Diagnosis:
6
1. All patients being evaluated for small bowel obstruction should have plain films
due to the fact that plain films are as sensitive as CT to differentiate obstruction
vs. non-obstruction. LEVEL III
2. All patients with inconclusive plain films for complete or high grade SBO should
have a CT as CT scan gives incremental information over plain films in regard to
differentiating grade of obstruction and etiology of small bowel obstruction
leading to changes in planned management. LEVEL I
3. Multiple signs on CT suggesting strangulation should suggest a low threshold for
operative intervention (Table 2). LEVEL II
4. MRI and ultrasound are an alternative to CT with similar sensitivity and
identification of etiology, but have several logistical limitations. LEVEL III
5. There is a variety of literature that contrast studies should be considered in
patients who fail to improve after 48 hours of conservative management as a
normal contrast study can rule out operative small bowel obstruction. LEVEL II
6. Nonionic low osmolar weight contrast is an alternative to barium for contrast
studies to evaluate for SBO for diagnostic purposes. LEVEL I

Management:
1. Patients with plain film finding of small bowel obstruction and Clinical markers
(fever, leukocytosis, tachycardia, metabolic acidosis and continuous pain) or
peritonitis on physical exam warrant exploration. LEVEL I
2. Patients without the above mentioned clinical picture, and a partial SBO or a
complete SBO can undergo non-operative management safely; although, complete
obstruction has a higher level of failure. LEVEL I
3. Patients without resolution of the there SBO by day 3-5 of non-operative
management should undergo water soluble study or surgery. LEVEL III
4. There is no significant difference with regard to the decompression achieved, the
success of nonoperative treatment, or the morbidity rate after surgical intervention
comparing long tube decompression with the use of nasogastric tubes. LEVEL I
7
5. Water soluble contrast (Gastrograffin) given in the setting of partial SBO can
improve bowel function (time to BM), decrease length of stay, and is both therapeutic
and diagnostic. LEVEL II
6. In a highly selected group of patients the laparoscopic treatment of small bowel
obstruction should be considered and leads to a shorter hospital length of stay.
LEVEL II

Scientific Foundation
A. Historical Background
Mechanical small-bowel obstruction is the most frequently encountered surgical disorder
of the small intestine. Although a wide range of etiologies for this condition exist, intra-
abdominal adhesions related to prior abdominal surgery is the etiologic factor in up to
75% of cases of small-bowel obstruction. More than 300,000 patients are estimated to
undergo surgery to treat adhesion-induced small-bowel obstruction in the United States
annually.
4

B. Diagnostic Evaluation of Small Bowel Obstruction
The diagnostic evaluation should focus on the following goals: distinguishing mechanical
obstruction from ileus; determining the etiology of the obstruction; discriminating partial
(low grade) from complete (high grade) obstruction; and discriminating simple from
strangulating obstruction.
Important elements to obtain on history include prior abdominal operations (suggesting
the presence of adhesions) and the presence of abdominal disorders (e.g., intra-abdominal
cancer or inflammatory bowel disease) that may provide insights into the etiology of
obstruction. Upon examination, a meticulous search for hernias (particularly in the
inguinal and femoral regions) should be conducted. The stool should be checked for
gross or occult blood, the presence of which is suggestive of intestinal strangulation.

Plain Films
The diagnosis of small-bowel obstruction is usually confirmed with radiographic
examination. The abdominal series consists of a radiograph of the abdomen with the
8
patient in a supine position, a radiograph of the abdomen with the patient in an upright
position, and a radiograph of the chest with the patient in an upright position. There is
class III evidence to suggest that plain films are as sensitive as CT for the detection of a
high grade bowel obstruction (86% vs. 82%).
5
Data also suggests that plain films are less
sensitive in the setting of low grade or partial bowel obstruction. The sensitivity of
abdominal radiographs in the detection of small-bowel obstruction ranges from 70 to
86%.
6, 7
Despite these limitations, abdominal radiographs remain an important study in
patients with suspected small-bowel obstruction because of their widespread availability
and low cost.

Computed tomographic (CT)
There is numerous Class II data to suggest that CT provides incremental information over
other imaging forms to the level, etiology and accuracy at differentiating low grade from
high grade bowel obstruction leading to changes in planned management.
8-10
Computed
tomographic (CT) scanning is 80 to 90% sensitive and 70 to 90% specific in the detection
of small-bowel obstruction.
11
The findings of small-bowel obstruction include a discrete
transition zone with dilation of bowel proximally, decompression of bowel distally,
intraluminal contrast that does not pass beyond the transition zone, and a colon
containing little gas or fluid.
There is class II data to suggest that CT is 85 -100% sensitive for ischemia and
strangulation later confirmed by surgery.
12-15
Ischemia was suggested on CT with:
serrated beak, unusual course of mesenteric vasculature, mesenteric haziness, reduced
wall enhancement, wall thickening, mesenteric fluid, mesenteric venous congestion, and
ascites.
16-18
CT scanning also offers a global evaluation of the abdomen and may
therefore reveal the etiology of obstruction.
19-21
The global picture afforded is especially
relevant when evaluating the acute abdomen when multiple etiologies are on the
differential diagnosis.

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Enteroclysis
A limitation of CT scanning is its low sensitivity (<50%) in the detection of low-grade or
partial small-bowel obstruction. A subtle transition zone or unsuspected closed loop
obstruction may be difficult to identify in the axial images obtained during CT scanning.
In such cases, contrast examinations of the small bowel, either small-bowel series (small-
bowel follow-through) or enteroclysis, can be helpful.
22
Nonionic low osmolar weight
contrast is an alternative to barium for contrast studies to evaluate for SBO.
23
These
examinations are more labor intensive and less-rapidly performed than CT scanning, but
may offer greater sensitivity in the detection of luminal and mural etiologies of
obstruction, such as primary intestinal tumors, with sensitivity and specificity
approaching 100% when coupled with CT.
24
Enteroclysis is rarely performed in the acute
setting, but offers greater sensitivity than small-bowel series in the detection of lesions
that may be causing partial small-bowel obstruction.
25

Ultrasound
Class II data suggests ultrasound is comparable to plain film for the diagnosis, etiology
and strangulation in small bowel obstruction and can better identify free fluid which may
signal the need for operative intervention.
26-30

MRI
Class II data reports the accuracy MRI at least approaches that of CT with both
differentiating obstruction vs no obstruction at an almost 100% sensativity.
31
MRI has
also been shown to be effective in defining location and etiology of obstruction with at
least equivalent accuracy of CT.
32-34
Limitations of MRI include: lack of availability
after hours, poor definition of mass lesions, and poor visualization of colonic obstructions
did not show inflammation as well as CT, and does not show viability.
35, 36

C. Evaluation of the Evidence Supporting Early Operative Management
The standard therapy for small-bowel obstruction is expeditious surgery. The rationale
for this approach is to minimize the risk for bowel strangulation, which is associated with
10
an increased risk for morbidity and mortality. The literature would suggest that clinical
signs supported by simple imaging studies can identify the vast majority of patients
presenting with surgical small bowel obstruction.
37, 38
Early operative intervention in
patients with fever, leukocytosis, peritonitis, tachycardia, metabolic acidosis, and
continuous pain will identify strangulation 45% of the time
39-41
Complete SBO should be
operated on early as the primary mode of therapy. Studies would suggest that 31-43% of
patients with complete SBO or peritonitis will resolve without requiring some form of
bowel resection.
42, 43

Other reported benefits of the operative management of SBO is the description by class II
data that reports lower reoccurrence rate and longer disease free intervals with operative
intervention when compared to conservative management.
44-47

D. Evaluation of the Evidence Supporting Conservative Management
Exceptions to the recommendation for expeditious surgery for intestinal obstruction
include partial small-bowel obstruction, obstruction occurring in the early postoperative
period, intestinal obstruction as a consequence of Crohn's disease, and carcinomatosis.
Progression to strangulation (3-6% with conservative management) is unlikely to occur
with partial small-bowel obstruction, and an attempt at nonoperative resolution is
warranted.
48
Level II data suggests that nonoperative management has been documented
to be successful in 65 to 81% of patients with partial small-bowel obstruction or in
patients without peritonitis.
1
Of those successfully treated non-operatively, only 5 to 15%
have been reported to have symptoms that were not substantially improved within 48
hours after initiation of therapy.
49-52
Therefore, most patients with partial small
obstruction whose symptoms do not improve within 48 hours after initiation of
nonoperative therapy should undergo surgery. There has been some level III data to
suggest that this time period can be safely lengthened to 5 days without increase the
likelihood of strangulation necessitating bowel resection although definite data to support
these claims is not available.
2
Patients undergoing non-operative therapy should be
11
followed with serial abdominal exams for signs of peritonitis which would necessitate
immediate operative intervention.
Adjuncts to Conservative Management
Hypertonic contrast in PSBO
The administration of hypertonic water-soluble contrast agents, such as Gastrografin used
in upper GI and small-bowel follow-through examinations, causes a shift of fluid into the
intestinal lumen, thereby increasing the pressure gradient across the site of obstruction.
Level II data suggests that this effect may speed the return of bowel function (time to
bowel movement) and decrease the length of stay of patients undergoing non-operative
management of partial small bowel obstruction.
53-58

E. Operative Approach
Successful laparoscopic surgery for bowel obstruction is being reported with greater
frequency. Reported data suggest that up to 60% of small-bowel obstruction cases caused
by adhesions may be amenable to laparoscopic therapy.
59
The reported conversion rate is
20-51.9%
60-67
and the complication rate (bowel injury) is 6.5-18.0%.
60, 68
Conversion to
open procedure have been reported secondary to density of adhesions, inability to fix the
obstruction, cause of obstruction not amenable to laparoscopic therapy, intestinal
necrosis, and intestinal perforation. Factors that favor laparoscopic success are SBO post
appendectomy, with bands as cause, with less then two previous surgeries, and shorter
time of symptoms.
69
It has been reported that conversion rate can be decreased to as low
as 6.9% when the surgery is guided by preoperative enteroclysis.
70
The laparoscopic
treatment of small bowel obstruction appears to be effective and leads to a shorter
hospital stay in a highly selected group of patients.
71, 72
There has also been literature to
support that patients treated with laparoscopic intervention have lower hernia rate and
SBO but require the same amount of operative intervention.
73
Patients fitting the criteria
for consideration of laparoscopic management include those with (1) mild abdominal
distention allowing adequate visualization, (2) a proximal obstruction, (3) a partial
obstruction, and (4) an anticipated single-band obstruction. Currently, patients who have
advanced, complete, or distal small bowel obstructions are not candidates for
laparoscopic treatment. Unfortunately, the majority of patients with obstruction are in this
12
group. Similarly, patients with matted adhesions or those who remain distended after
nasogastric intubation should be managed with conventional laparotomy. Therefore, the
future role of laparoscopic procedures in the treatment of these patients remains to be
defined.

F. Adjuncts to Surgery
Antibiotics
Broad-spectrum antibiotics are commonly administered because of concerns that
bacterial translocation may occur in the setting of small-bowel obstruction; however,
there are no controlled data to support or refute this approach.
74

Long Tube
Prospective randomized trials demonstrated no significant differences with regard to the
decompression achieved, the success of nonoperative treatment, or the morbidity rate
after surgical intervention compared with the use of nasogastric tubes. Furthermore, the
use of these long tubes has been associated with a significantly longer hospital stay,
duration of postoperative ileus, and postoperative complications in some series.
Therefore, it appears that long intestinal tubes offer no benefit in the preoperative setting
over nasogastric tubes.
75, 76

Hyaluronic acid-carboxycellulose membrane (Seprafilm)
The overall rate of post-operative SBO showed no difference with or without Seprafilm.
However, Seprafilm did have lower (1.8 vs 3.4%) of SBO requiring reoperation.
77-80

V. Summary
To summarize, plain abdominal radiographs are usually diagnostic of bowel obstruction
in more than 60% of the cases, but further evaluation (possibly by CT or barium
radiography) may be necessary in 20% to 30% of cases. CT examination is particularly
useful in patients with a history of abdominal malignancy, in postsurgical patients, and in
patients who have no history of abdominal surgery and present with symptoms of bowel
13
obstruction. Barium studies are recommended in patients with a history of recurring
obstruction or low-grade mechanical obstruction to precisely define the obstructed
segment and degree of obstruction.

VI. Future Investigations
Future studies should be conducted in a prospective, randomized fashion concentrating
on the timing of operative intervention for small bowel obstruction.
14
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27

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v
e
l

o
f

o
b
s
t
r
u
c
t
i
o
n

6
0
%
,

7
0
%
,

a
n
d

9
3
%
.

C
a
u
s
e

o
f

o
b
s
t
r
u
c
t
i
o
n

7
%
,

2
3
%
,

a
n
d

8
7
%
.

C
o
p
y
r
i
g
h
t

2
0
0
7

E
a
s
t
e
r
n

A
s
s
o
c
i
a
t
i
o
n

f
o
r

t
h
e

S
u
r
g
e
r
y

o
f

T
r
a
u
m
a

T
a
o
u
r
e
l

P
G

1
9
9
5

V
a
l
u
e

o
f

C
T

i
n

t
h
e

d
i
a
g
n
o
s
i
s

a
n
d

m
a
n
a
g
e
m
e
n
t

o
f

p
a
t
i
e
n
t
s

w
i
t
h

s
u
s
p
e
c
t
e
d

a
c
u
t
e

s
m
a
l
l
-
b
o
w
e
l

o
b
s
t
r
u
c
t
i
o
n
.

A
J
R

A
m

J

R
o
e
n
t
g
e
n
o
l
.

1
9
9
5

N
o
v
;
1
6
5
(
5
)
:
1
1
8
7
-
9
2
.

I
I

(
N
=
5
7
;

P
r
o
s
p
e
c
t
i
v
e
)

P
a
t
i
e
n
t
s

w
i
t
h

s
u
s
p
i
c
i
o
n

o
f

S
B
O

(
1
9
9
1

-

1
9
9
4
)
.

T
h
e

s
u
r
g
e
o
n

w
a
s

i
n
t
e
r
v
i
e
w
e
d

p
r
i
o
r

t
o

t
h
e

C
T

s
c
a
n
.

I
n

3
3

p
t
s

t
h
e

c
l
i
n
i
c
i
a
n

w
a
n
t
e
d

t
o

d
i
f
f
e
r
e
n
t
i
a
t
e

b
e
t
w
e
e
n

S
B
O

o
r

i
l
e
u
s

a
n
d

i
n

2
4

p
t
s

t
h
e

c
l
i
n
i
c
i
a
n

w
a
n
t
e
d

t
o

k
n
o
w

t
h
e

c
a
u
s
e

o
f

S
B
O
.

C
T

c
o
r
r
e
c
t
l
y

c
h
a
n
g
e
d

t
h
e

d
i
f
f
e
r
e
n
t
i
a
t
i
o
n

b
e
t
w
e
e
n

S
B
O

&

i
l
e
u
s

i
n

2
1
%

o
f

c
a
s
e
s
.

C
T

c
h
a
n
g
e
d

t
h
e

d
i
a
g
n
o
s
i
s

(
c
a
u
s
e
)

o
f

S
B
O

i
n

4
3
%

a
n
d

c
o
r
r
e
c
t
l
y

c
h
a
n
g
e
d

p
r
e
s
e
n
c
e

o
r

a
b
s
e
n
c
e

o
f

s
t
r
a
n
g
u
l
a
t
i
o
n

i
n

2
3
.

C
a
t
a
l
a
n
o

O

1
9
9
7

T
h
e

f
a
e
c
e
s

s
i
g
n
.

A

C
T

f
i
n
d
i
n
g

i
n

s
m
a
l
l
-
b
o
w
e
l

o
b
s
t
r
u
c
t
i
o
n
.

R
a
d
i
o
l
o
g
e
.

1
9
9
7

M
a
y
;
3
7
(
5
)
:
4
1
7
-
9
.

I
I
I

(
N
=
9
4
;

R
e
t
r
o
s
p
e
c
t
i
v
e
)

F
e
c
e
s

s
i
g
n

w
a
s

o
n
l
y

p
r
e
s
e
n
t

i
n

7
%

o
f

c
a
s
e
s
,

o
n
l
y

1

o
f

w
h
i
c
h

h
a
d

s
t
r
a
n
g
u
l
a
t
i
o
n
.

C
h
o
u

C
K

2
0
0
0

D
i
f
f
e
r
e
n
t
i
a
t
i
o
n

o
f

o
b
s
t
r
u
c
t
i
v
e

f
r
o
m

n
o
n
-
o
b
s
t
r
u
c
t
i
v
e

s
m
a
l
l

b
o
w
e
l

d
i
l
a
t
a
t
i
o
n

o
n

C
T
.

E
u
r

J

R
a
d
i
o
l
.

2
0
0
0

S
e
p
;
3
5
(
3
)
:
2
1
3
-
2
0
.

I
I
I

(
N
=
1
4
6
;

R
e
t
r
o
s
p
e
c
t
i
v
e
)

E
v
a
l
u
a
t
e
d

4

c
r
i
t
e
r
i
a
:

c
o
n
t
i
n
u
i
t
y

o
f

p
r
o
x
i
m
a
l

S
B
,

t
r
a
n
s
i
t
i
o
n

z
o
n
e
,

i
n
t
r
a
l
u
m
i
n
a
l

f
l
u
i
d
,

&

c
o
l
o
n
i
c

c
o
n
t
e
n
t
s
.

T
h
e

p
r
o
b
a
b
i
l
i
t
y

o
f

t
r
u
e

o
b
s
t
r
u
c
t
i
o
n

w
a
s

c
a
l
c
u
l
a
t
e
d

f
o
r

e
a
c
h

s
i
g
n
.

C
o
n
t
i
n
u
i
t
y

6
9
%
,

T
r
a
n
s
i
t
i
o
n

z
o
n
e

a
b
r
u
p
t

8
0
%
,

h
i
g
h

a
m
o
u
n
t

o
f

S
B

f
l
u
i
d

7
9
%
,

m
i
n
i
m
a
l

c
o
l
o
n
i
c

c
o
n
t
e
n
t
s

9
0
%
.

D
a
n
e
s
h
m
a
n
d

S

1
9
9
9

T
h
e

u
t
i
l
i
t
y

a
n
d

r
e
l
i
a
b
i
l
i
t
y

o
f

c
o
m
p
u
t
e
d

t
o
m
o
g
r
a
p
h
y

s
c
a
n

i
n

t
h
e

d
i
a
g
n
o
s
i
s

o
f

s
m
a
l
l

b
o
w
e
l

o
b
s
t
r
u
c
t
i
o
n
.

A
m

S
u
r
g
.

1
9
9
9

O
c
t
;
6
5
(
1
0
)
:
9
2
2
-
6
.

I
I
I

R
e
t
r
o
s
p
e
c
t
i
v
e

s
t
u
d
y

o
f

1
0
3

p
t
s

(
1
9
9
7
-
8
)

w
i
t
h

s
u
s
p
e
c
t
e
d

S
B
O
.

C
o
m
p
a
r
i
s
o
n

o
f

p
l
a
i
n

r
a
d
i
o
g
r
a
p
h
s

w
i
t
h

C
T

i
n

d
e
t
e
r
m
i
n
i
n
g

p
a
r
t
i
a
l

v
s

c
o
m
p
l
e
t
e

S
B
O

a
n
d

i
n

d
e
t
e
r
m
i
n
i
n
g

c
a
u
s
e
.

P
l
a
i
n

f
i
l
m
s

w
e
r
e

7
5
%

s
e
n
s
i
t
i
v
e

a
n
d

5
3
%

s
p
e
c
i
f
i
c

f
o
r

p
a
r
t
i
a
l

v
s

c
o
m
p
l
e
t
e
.

C
T

w
a
s

9
2
%

s
e
n
s
i
t
i
v
e

a
n
d

7
1
%

s
p
e
c
i
f
i
c
.

C
a
u
s
e

w
a
s

c
o
r
r
e
c
t
l
y

d
e
t
e
r
m
i
n
e
d

o
r

i
n
f
e
r
r
e
d

t
o

b
e

a
d
h
e
s
i
o
n
s

b
y

C
T

i
n

9
1
%

o
f

c
a
s
e
s
.

G
o
l
l
u
b

M
J

2
0
0
6

D
o
e
s

t
h
e

C
T

w
h
i
r
l

s
i
g
n

r
e
a
l
l
y

p
r
e
d
i
c
t

s
m
a
l
l

b
o
w
e
l

v
o
l
v
u
l
u
s
?
:

E
x
p
e
r
i
e
n
c
e

i
n

a
n

o
n
c
o
l
o
g
i
c

p
o
p
u
l
a
t
i
o
n
.

J

C
o
m
p
u
t

A
s
s
i
s
t

T
o
m
o
g
r
.

2
0
0
6

J
a
n
-
F
e
b
;
3
0
(
1
)
:
2
5
-
3
2
.

I
I
I

R
e
t
r
o
s
p
e
c
t
i
v
e

a
n
a
l
y
s
i
s

o
f

1
2
0
0
+

C
T

s
c
a
n
s

o
f

p
t
s

w
i
t
h

s
u
s
p
e
c
t
e
d

S
B
O

a
t

a

c
a
n
c
e
r

c
e
n
t
e
r
.

W
h
i
r
l

s
i
g
n

w
a
s

f
o
u
n
d

i
n

3
3

p
t
s

b
y

a

s
e
n
i
o
r

r
a
d
i
o
l
o
g
i
s
t

a
n
d

1
4

p
t
s

b
y

a

s
e
n
i
o
r

r
a
d
i
o
l
o
g
y

r
e
s
i
d
e
n
t
.

T
h
e

w
h
i
r
l

s
i
g
n

h
a
d

a

s
e
n
s
i
t
i
v
i
t
y

o
f

6
4
%

f
o
r

v
o
l
v
u
l
u
s

b
y

t
h
e

s
e
n
i
o
r

r
a
d
i
o
l
o
g
i
s
t

a
n
d

m
u
c
h

l
e
s
s

b
y

t
h
e

r
e
s
i
d
e
n
t
.

T
h
e
y

c
o
n
c
l
u
d
e
d

t
h
a
t

t
h
e

w
h
i
r
l

s
i
g
n

i
s

a

r
e
l
a
t
i
v
e
l
y

p
o
o
r

p
r
e
d
i
c
t
o
r

o
f

v
o
l
v
u
l
u
s

i
n

t
h
i
s

p
o
p
u
l
a
t
i
o
n

H
a

H
K

1
9
9
7

D
i
f
f
e
r
e
n
t
i
a
t
i
o
n

o
f

s
i
m
p
l
e

a
n
d

s
t
r
a
n
g
u
l
a
t
e
d

s
m
a
l
l
-
b
o
w
e
l

o
b
s
t
r
u
c
t
i
o
n
s
:

u
s
e
f
u
l
n
e
s
s

o
f

k
n
o
w
n

C
T

c
r
i
t
e
r
i
a
.

R
a
d
i
o
l
o
g
y
.

1
9
9
7

A
u
g
;
2
0
4
(
2
)
:
5
0
7
-
1
2
.

I
I
I

(
N
=
8
4
;

R
e
t
r
o
s
p
e
c
t
i
v
e
)

P
a
t
i
e
n
t
s

w
i
t
h

k
n
o
w
n

o
u
t
c
o
m
e
s
,

s
i
m
p
l
e

v
s

s
t
r
a
n
g
u
l
a
t
e
d

S
B
O

(
1
9
9
1
-
1
9
9
6
)
.

T
h
e
y

i
d
e
n
t
i
f
i
e
d

6

C
T

f
i
n
d
i
n
g
s

a
s

b
e
s
t

a
t

d
e
t
e
r
m
i
n
i
n
g

s
t
r
a
n
g
u
l
a
t
i
o
n
:

r
e
d
u
c
e
d

w
a
l
l

e
n
h
a
n
c
e
m
e
n
t
,

s
e
r
r
a
t
e
d

b
e
a
k
,

a
s
c
i
t
e
s
,

a
n
d

u
n
u
s
u
a
l

c
o
u
r
s
e

o
f

m
e
s
e
n
t
e
r
i
c

v
a
s
c
u
l
a
t
u
r
e
,

m
e
s
e
n
t
e
r
i
c

h
a
z
i
n
e
s
s
,

a
n
d

m
e
s
e
n
t
e
r
i
c

v
e
n
o
u
s

e
n
g
o
r
g
e
m
e
n
t
.

U
s
i
n
g

t
h
e
s
e

s
i
g
n
s

t
h
e
y

w
e
r
e

a
b
l
e

t
o

f
i
n
d

8
5
%

o
f

s
t
r
a
n
g
u
l
a
t
i
o
n
s

J
a
f
f
e

T
A

2
0
0
6

S
m
a
l
l
-
b
o
w
e
l

o
b
s
t
r
u
c
t
i
o
n
:

c
o
r
o
n
a
l

r
e
f
o
r
m
a
t
i
o
n
s

f
r
o
m

i
s
o
t
r
o
p
i
c

v
o
x
e
l
s

a
t

1
6
-
I
I
I

R
e
t
r
o
s
p
e
c
t
i
v
e

a
n
a
l
y
s
i
s

o
f

a
d
d
e
d

v
a
l
u
e

o
f

c
o
r
o
n
a
l

r
e
f
o
r
m
a
t
i
o
n
s

C
o
p
y
r
i
g
h
t

2
0
0
7

E
a
s
t
e
r
n

A
s
s
o
c
i
a
t
i
o
n

f
o
r

t
h
e

S
u
r
g
e
r
y

o
f

T
r
a
u
m
a

s
e
c
t
i
o
n

m
u
l
t
i
-
d
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R
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d
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g
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2
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4
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2
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u
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.

I
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c

l
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c
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O
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h
u
n
g

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C

1
9
9
6

A

p
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r
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n

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n
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A
u
s
t

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r
g
.

1
9
9
6

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e
p
;
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6
(
9
)
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5
9
8
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6
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1
.

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I

S
a
f
e

p
r
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c
e
d
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r
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e
a
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l
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e
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s
h
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o
c
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s
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e
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4

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s
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e
r
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y
c
e

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1
9
9
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h
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v
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e

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f

w
a
t
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r
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s
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g
y

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n

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m
a
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m
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o
f

a
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s
m
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s
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t
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n
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n
n

R

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o
l
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r
g

E
n
g
l
.

1
9
9
2

N
o
v
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4
(
6
)
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4
2
2
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5
.

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I

W
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t
e
r
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O
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l

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.

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e
c
k

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J

1
9
9
9

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h
e

r
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l
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f

c
o
m
p
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t
e
d

t
o
m
o
g
r
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p
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y

w
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t
h

c
o
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t
r
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a
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s
m
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b
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f
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t
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n

m
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t

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n
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m

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S
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g
.

1
9
9
9

M
a
y
;
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7
7
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5
)
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3
7
5
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8
.

I
I
I

W
i
t
h

e
q
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a
l

f
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d
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f
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T

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a
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d

s
p
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c
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t
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a
r
e

9
5
%

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n
d

8
6
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r
e
s
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t
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h
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g
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r

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e
a
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h

a
l
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.

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2
0
0
1

C
o
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t

r
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d
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r
a
p
h
y

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n

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i
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t
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s
t
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n
a
l

o
b
s
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u
c
t
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o
n
,

a

v
a
l
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a
b
l
e

d
i
a
g
n
o
s
t
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c

t
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l
?

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u
r

J

S
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g
.

2
0
0
1

F
e
b
;
1
6
7
(
2
)
:
1
2
0
-
4
.

I
I
I

T
h
e

o
u
t
c
o
m
e

o
f

o
r
a
l

c
o
n
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s
t
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d
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e
s

c
a
n

b
e

p
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d
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b
y

p
l
a
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.

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o
n
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s
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c
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D
i
x
o
n

P
M

1
9
9
3

T
h
e

s
m
a
l
l

b
o
w
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l

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m
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t
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e
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.

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l
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n

R
a
d
i
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l
.

1
9
9
3

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a
n
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6
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I
I
I

R
o
u
t
i
n
e

u
s
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o
f

s
m
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b
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v
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r
y

h
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g
h

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n
s
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t
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v
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t
y

(
9
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%
)

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n
d

s
p
e
c
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f
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c
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t
y

(
9
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.
9
%
)

a
n
d

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b
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o
n

h
a
d

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s
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n
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t
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v
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t
y

o
f

9
8
%
.

C
o
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s
e
r
v
a
t
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v
e

M
a
n
a
g
e
m
e
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t

G
e
n
e
r
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l

C
o
n
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d
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t
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C
o
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e
r
v
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t
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v
e

M
a
n
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g
e
m
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n
t

C
l
i
n
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c
a
l

I
n
d
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c
a
t
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r
s
/
T
i
m
e

P
e
r
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d

M
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l
l
e
r

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2
0
0
0

N
a
t
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r
a
l

h
i
s
t
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r
y

o
f

p
a
t
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e
n
t
s

w
i
t
h

a
d
h
e
s
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v
e

s
m
a
l
l

b
o
w
e
l

o
b
s
t
r
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c
t
i
o
n
.

B
r

J

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u
r
g
.

2
0
0
0

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e
p
;
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7
(
9
)
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1
2
4
0
-
7
.

I
I
I

P
a
t
i
e
n
t
s

a
r
e

n
e
v
e
r

f
r
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f

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o
p

o
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s

2
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d

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d
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e
s
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n
s

(
1
4
%

p
r
e
s
e
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t

>
2
0

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r
s

p
o
s
t
-
o
p
)
.

R
a
t
e

o
f

r
e
c
u
r
r
e
n
c
e

w
a
s

3
3
%

C
o
p
y
r
i
g
h
t

2
0
0
7

E
a
s
t
e
r
n

A
s
s
o
c
i
a
t
i
o
n

f
o
r

t
h
e

S
u
r
g
e
r
y

o
f

T
r
a
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m
a

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v
e
r
a
l
l

(
3
2
%

f
o
r

o
p
e
r
a
t
i
o
n
,

3
4
%

(
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S
)

f
o
r

c
o
n
s
.

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g
m
t
)
,

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a
c
h

r
e
c
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r
r
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n
c
e

r
a
i
s
e
d

r
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s
k

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f

f
u
t
u
r
e

r
e
c
u
r
r
e
n
c
e
.

C
o
l
o
r
e
c
t
a
l

p
r
o
c
e
d
u
r
e
s

w
e
r
e

m
o
r
e

l
i
k
e
l
y

t
o

r
e
s
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t

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n

m
a
t
t
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d

a
d
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e
s
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n
s

v
.

s
i
n
g
l
e

b
a
n
d
s

a
n
d

r
e
s
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l
t

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n

m
o
r
e

r
e
a
d
m
i
t
s
.

R
e
c
u
r
r
e
n
c
e

r
a
t
e
s

b
/
w

o
p

a
n
d

n
o
n
-
o
p

w
e
r
e

s
i
m
i
l
a
r
.

N
a
u
t
a

R
J

2
0
0
5

A
d
v
a
n
c
e
d

a
b
d
o
m
i
n
a
l

i
m
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g
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n
g

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s

n
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t

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e
q
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d

t
o

e
x
c
l
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d
e

s
t
r
a
n
g
u
l
a
t
i
o
n

i
f

c
o
m
p
l
e
t
e

s
m
a
l
l

b
o
w
e
l

o
b
s
t
r
u
c
t
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o
n
s

u
n
d
e
r
g
o

p
r
o
m
p
t

l
a
p
a
r
o
t
o
m
y
.

J

A
m

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o
l
l

S
u
r
g
.

2
0
0
5

J
u
n
;
2
0
0
(
6
)
:
9
0
4
-
1
1
.

I
I
I

P
a
p
e
r

v
a
l
i
d
a
t
e
s

t
h
a
t

c
o
m
p
l
e
t
e

S
B
O

w
a
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r
a
n
t
s

n
o

a
d
d
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t
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n
a
l

i
m
a
g
i
n
g

o
t
h
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r

t
h
a
n

p
l
a
i
n

f
i
l
m
s
.

7
1
%

o
f

P
S
B
O

b
y

p
l
a
i
n

f
i
l
m

w
i
t
h
o
u
t

p
e
r
i
t
o
n
i
t
i
s

r
e
s
o
l
v
e
d

w
i
t
h

c
o
n
s
e
r
v
a
t
i
v
e

m
a
n
a
g
e
m
e
n
t
.

I
n

p
a
t
i
e
n
t
s

w
i
t
h

c
o
m
p
l
e
t
e

S
B
O
,

t
h
e
r
e

w
a
s

a

v
e
r
y

h
i
g
h

r
a
t
e

o
f

b
o
w
e
l

r
e
s
e
c
t
i
o
n

(
3
1
%
)
.

T
h
i
s

s
u
g
g
e
s
t
s

t
h
a
t

a

c
o
m
p
l
e
t
e

S
B
O

i
s

a

s
u
r
g
i
c
a
l

d
i
s
e
a
s
e
.

S
e
r
o
r

D

1
9
9
3

H
o
w

c
o
n
s
e
r
v
a
t
i
v
e
l
y

c
a
n

p
o
s
t
o
p
e
r
a
t
i
v
e

s
m
a
l
l

b
o
w
e
l

o
b
s
t
r
u
c
t
i
o
n

b
e

t
r
e
a
t
e
d
?

A
m

J

S
u
r
g
.

1
9
9
3

J
a
n
;
1
6
5
(
1
)
:
1
2
1
-
5
;

d
i
s
c
u
s
s
i
o
n

1
2
5
-
6
.

I
I
I

7
3
%

r
e
s
p
o
n
s
e

t
o

c
o
n
s
e
r
v
a
t
i
v
e

t
x

i
n

a
l
l

S
B
O

(
C
o
m
p
l
e
t
e

a
n
d

P
a
r
t
i
a
l
)
.

N
o

d
i
f
f
e
r
e
n
c
e

i
n

W
B
C
,

f
e
v
e
r
,

p
u
l
s
e

i
n

t
h
o
s
e

w
h
o

r
e
q
u
i
r
e
d

s
u
r
g
e
r
y
.

N
o

w
o
r
s
e

o
u
t
c
o
m
e

i
n

t
h
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2
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2

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a

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r
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g
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7
7
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1
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I
I
I

(
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=
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1
6
)

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s
e

o
f

l
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p
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p
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f
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r

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g
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2
0
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e
p
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)
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1
4
7
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5
1
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I
I
I

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s
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e
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r
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t
i
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o
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v
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r
s
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d

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r

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e

t
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m
e
s
.

P
o
s
t
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o
p
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r
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t
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c
o
m
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c
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t
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n
s
,

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e
t
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r
n

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f

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a
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d

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O
S

l
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s

f
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r

l
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p
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r
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s
c
o
p
y
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L
e
o
n

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L

1
9
9
9

L
a
p
a
r
o
s
c
o
p
i
c

m
a
n
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g
e
m
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n
t

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m
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l

b
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b
s
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r
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:

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n
d
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c
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t
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s

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u
t
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a
s
t
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t

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g
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1
9
9
8

M
a
r
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p
r
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)
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3
2
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4
0
.

I
I
I

(
N
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4
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)

L
a
p
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s
c
o
p
y

s
u
c
c
e
s
s
f
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l

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5
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a
s
s
i
s
t
e
d

3
0
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a
n
d

3
5
%

c
o
n
v
e
r
s
i
o
n
.

.

R
e
a
s
o
n
s

f
o
r

c
o
n
v
e
r
s
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n

i
n
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l
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d

d
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d
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s
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n
s
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n
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e
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t
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r
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h
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n
c
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.

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h
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o
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r

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.

L
e
v
a
r
d

H

2
0
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1

L
a
p
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r
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s
c
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c

t
r
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t
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f

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c
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s
m
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2
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v
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1
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6
.

I
I
I

(
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)

L
a
p
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s
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y

c
o
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v
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a
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h
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r

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O

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s
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h
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n
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t

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d

h
a
d

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r

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r

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r
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t

2
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a
s
t
e
r
n

A
s
s
o
c
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t
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n

f
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f

T
r
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i
a
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w

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J

2
0
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5

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a
p
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s
c
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p
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c

m
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e
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s
m
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n
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s
i
a
n

J

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u
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g
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2
0
0
5

J
u
l
;
2
8
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)
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1
8
5
-
8
.

I
I
I

(
N
=
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)

C
o
n
v
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r
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n

r
a
t
e

o
f

2
2
%
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t
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r

M

2
0
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p
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c
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m
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u
c
c
e
s
s

o
r

f
a
i
l
u
r
e
?

S
u
r
g

E
n
d
o
s
c
.

2
0
0
0

M
a
y
;
1
4
(
5
)
:
4
7
8
-
8
3
.

I
I
I

(
N
=
1
5
)

E
n
t
e
r
o
c
l
y
s
i
s

g
u
i
d
e
d

l
a
p
a
r
o
s
c
o
p
y

c
o
n
v
e
r
s
i
o
n

r
a
t
e

o
f

6
.
7
%
.

S
u
z
u
k
i

K

2
0
0
3

E
l
e
c
t
i
v
e

l
a
p
a
r
o
s
c
o
p
y

f
o
r

s
m
a
l
l

b
o
w
e
l

o
b
s
t
r
u
c
t
i
o
n
.

S
u
r
g

L
a
p
a
r
o
s
c

E
n
d
o
s
c

P
e
r
c
u
t
a
n

T
e
c
h
.

2
0
0
3

A
u
g
;
1
3
(
4
)
:
2
5
4
-
6
.

I
I
I

(
N
=
4
0
)

L
a
p
a
r
o
s
c
o
p
y

c
o
n
v
e
r
s
i
o
n

r
a
t
e

o
f

4
0
%
.

I
n
t
r
a
o
p

e
n
t
e
r
o
t
o
m
i
e
s

1
0
%
.

L
a
t
e

r
e
c
u
r
r
e
n
c
e

2
.
5
%

T
s
u
m
u
r
a

H

2
0
0
4

L
a
p
a
r
o
s
c
o
p
i
c

a
d
h
e
s
i
o
l
y
s
i
s

f
o
r

r
e
c
u
r
r
e
n
t

p
o
s
t
o
p
e
r
a
t
i
v
e

s
m
a
l
l

b
o
w
e
l

o
b
s
t
r
u
c
t
i
o
n
.

H
e
p
a
t
o
g
a
s
t
r
o
e
n
t
e
r
o
l
o
g
y
.

2
0
0
4

J
u
l
-
A
u
g
;
5
1
(
5
8
)
:
1
0
5
8
-
6
1
.

I
I
I

(
N
=
8
3
)

5
7
%

i
n
i
t
i
a
l

s
u
c
c
e
s
s

r
a
t
e

w
i
t
h

d
u
r
a
t
i
o
n

o
f

s
u
r
g
e
r
y

(
>
1
2
0
m
i
n
)

a
n
d

b
o
w
e
l

d
i
a
m
e
t
e
r

(
>
4
c
m
)

p
r
e
d
i
c
t
i
v
e

o
f

c
o
n
v
e
r
s
i
o
n
.

R
e
o
p
e
r
a
t
i
o
n

r
a
t
e

o
f

9
%
.

B
o
w
e
l

p
e
r
f
o
r
a
t
i
o
n

a
n
d

n
e
e
d

f
o
r

c
o
n
v
e
r
s
i
o
n

i
n
c
r
e
a
s
e
d

p
o
s
t
-
o
p

c
o
m
p
l
i
c
a
t
i
o
n
s
.

P
e
k
m
e
z
c
i

S

2
0
0
2

E
n
t
e
r
o
c
l
y
s
i
s
-
g
u
i
d
e
d

l
a
p
a
r
o
s
c
o
p
i
c

a
d
h
e
s
i
o
l
y
s
i
s

i
n

r
e
c
u
r
r
e
n
t

a
d
h
e
s
i
v
e

s
m
a
l
l

b
o
w
e
l

o
b
s
t
r
u
c
t
i
o
n
s
.

S
u
r
g

L
a
p
a
r
o
s
c

E
n
d
o
s
c

P
e
r
c
u
t
a
n

T
e
c
h
.

2
0
0
2

J
u
n
;
1
2
(
3
)
:
1
6
5
-
7
0
.

I
I
I

(
N
=
2
1
)

5
7
%

l
a
p
a
r
o
s
c
o
p
y

o
n
l
y
,

2
4
%

a
s
s
i
s
t
e
d
,

1
9
%

c
o
n
v
e
r
s
i
o
n

r
a
t
e
.

U
t
i
l
i
z
i
n
g

l
a
p
a
r
o
s
c
o
p
y

(
+
/
-

a
s
s
i
s
t
e
d
)

d
i
m
i
n
i
s
h
e
d

t
i
m
e

f
o
r

b
o
w
e
l

f
u
n
c
t
i
o
n

a
n
d

L
O
S
.

S
t
r
i
c
k
l
a
n
d

P

1
9
9
9

I
s

l
a
p
a
r
o
s
c
o
p
y

s
a
f
e

a
n
d

e
f
f
e
c
t
i
v
e

f
o
r

t
r
e
a
t
m
e
n
t

o
f

a
c
u
t
e

s
m
a
l
l
-
b
o
w
e
l

o
b
s
t
r
u
c
t
i
o
n
?

S
u
r
g

E
n
d
o
s
c
.

1
9
9
9

J
u
l
;
1
3
(
7
)
:
6
9
5
-
8
.

I
I
I

(
N
=
2
5
)

C
o
m
p
l
e
t
e

a
d
h
e
s
i
o
l
y
s
i
s

7
2
%
.

L
a
p

a
s
s
i
s
t
e
d

2
4
%
.

O
p
e
n

4
%
.

U
t
i
l
i
z
i
n
g

l
a
p
a
r
o
s
c
o
p
y

(
+
/
-

a
s
s
i
s
t
e
d
)

d
i
m
i
n
i
s
h
e
d

t
i
m
e

f
o
r

b
o
w
e
l

f
u
n
c
t
i
o
n

a
n
d

L
O
S
.

O
p
e
r
a
t
i
v
e

A
p
p
r
o
a
c
h

A
d
j
u
n
c
t
s

F
a
z
i
o

V
W

2
0
0
6

R
e
d
u
c
t
i
o
n

i
n

a
d
h
e
s
i
v
e

s
m
a
l
l
-
b
o
w
e
l

o
b
s
t
r
u
c
t
i
o
n

b
y

S
e
p
r
a
f
i
l
m

a
d
h
e
s
i
o
n

b
a
r
r
i
e
r

a
f
t
e
r

i
n
t
e
s
t
i
n
a
l

r
e
s
e
c
t
i
o
n
.

D
i
s

C
o
l
o
n

R
e
c
t
u
m
.

2
0
0
6

J
a
n
;
4
9
(
1
)
:
1
-
1
1
.

I

(
N
=
1
7
9
1
)

P
t

b
l
i
n
d
e
d

r
a
n
d
o
m
i
z
e
d

m
u
l
t
i
c
e
n
t
e
r

t
r
i
a
l

t
o

e
v
a
l

S
e
p
r
a
f
i
l
m
.

T
h
e

o
v
e
r
a
l
l

r
a
t
e

o
f

p
o
s
t
-
o
p
e
r
a
t
i
v
e

S
B
O

s
h
o
w
e
d

n
o

d
i
f
f
e
r
e
n
c
e

w
i
t
h

o
r

w
i
t
h
o
u
t

S
e
p
r
a
f
i
l
m
.

H
o
w
e
v
e
r
,

S
e
p
r
a
f
i
l
m

d
i
d

h
a
v
e

l
o
w
e
r

(
1
.
8

v
s

3
.
4
%
)

o
f

S
B
O

r
e
q
u
i
r
i
n
g

r
e
o
p
e
r
a
t
i
o
n

(
N
=
9
0
)
.

K
i
e
f
f
e
r

R
W

1
9
9
3

I
n
d
i
c
a
t
i
o
n
s

f
o
r

i
n
t
e
r
n
a
l

s
t
e
n
t
i
n
g

i
n

i
n
t
e
s
t
i
n
a
l

o
b
s
t
r
u
c
t
i
o
n
.

M
i
l

M
e
d
.

1
9
9
3

J
u
l
;
1
5
8
(
7
)
:
4
7
8
-
9
.

I
I
I

(
N
=
1
6
)

U
s
i
n
g

i
n
t
e
r
n
a
l

s
t
e
n
t
i
n
g

w
i
t
h

B
a
k
e
r

j
e
j
u
n
a
l

t
u
b
e
,

r
e
c
u
r
r
e
n
t

r
a
t
e

o
f

o
b
s
t
r
u
c
t
i
o
n

w
a
s

2
5
%
.

N
o
n
-
o
b
s
t
r
u
c
t
i
v
e

i
n
t
r
a
-
a
b
d
o
m
i
n
a
l

c
o
m
p
l
i
c
a
t
i
o
n

r
a
t
e

1
8
.
7
%
.

M
e
i
s
s
n
e
r

K

2
0
0
0

E
f
f
e
c
t
i
v
e
n
e
s
s

o
f

i
n
t
e
s
t
i
n
a
l

t
u
b
e

s
p
l
i
n
t
i
n
g
:

a

p
r
o
s
p
e
c
t
i
v
e

o
b
s
e
r
v
a
t
i
o
n
a
l

s
t
u
d
y
.

D
i
g

S
u
r
g
.

2
0
0
0
;
1
7
(
1
)
:
4
9
-
5
6
.

I
I

(
N
=
1
8
6
)

W
i
t
h

i
n
t
e
r
n
a
l

s
p
l
i
n
t
i
n
g
,

9
%

c
o
m
p
l
i
c
a
t
i
o
n
s
,

2
%

p
r
o
c
e
d
u
r
a
l

c
o
m
p
l
i
c
a
t
i
o
n
s
,

3
%

r
e
o
p
e
r
a
t
i
o
n
.

N
o

e
a
r
l
y

S
B
O
.

L
o
w
e
r

l
a
t
e

S
B
O

c
o
m
p
a
r
e
d

t
o

h
i
s
t
o
r
i
c
a
l

o
u
t
c
o
m
e

d
a
t
a
.

K
u
d
o

F
A

2
0
0
4

U
s
e

o
f

b
i
o
r
e
s
o
r
b
a
b
l
e

m
e
m
b
r
a
n
e

t
o

p
r
e
v
e
n
t

p
o
s
t
o
p
e
r
a
t
i
v
e

s
m
a
l
l

b
o
w
e
l

o
b
s
t
r
u
c
t
i
o
n

i
n

t
r
a
n
s
a
b
d
o
m
i
n
a
l

a
o
r
t
i
c

a
n
e
u
r
y
s
m

s
u
r
g
e
r
y
.

S
u
r
g

T
o
d
a
y
.

2
0
0
4
;
3
4
(
8
)
:
6
4
8
-
5
1
.

I
I
I

(
N
=
5
1
)

E
a
r
l
y

S
B
O

w
a
s

l
o
w
e
r

w
i
t
h

S
e
p
r
a
f
i
l
m

e
v
i
d
e
n
t

b
y

e
a
r
l
i
e
r

d
i
e
t

i
n
t
a
k
e

a
n
d

l
e
s
s

a
b
d
o
m
i
n
a
l

c
o
m
p
l
a
i
n
t
s
.

N
o

r
e
o
p
e
r
a
t
i
o
n
s

w
e
r
e

r
e
q
u
i
r
e
d

i
n

e
i
t
h
e
r

g
r
o
u
p
.

M
e
i
s
s
n
e
r

K

2
0
0
1

S
m
a
l
l

b
o
w
e
l

o
b
s
t
r
u
c
t
i
o
n

f
o
l
l
o
w
i
n
g

e
x
t
e
n
d
e
d

r
i
g
h
t

h
e
m
i
c
o
l
e
c
t
o
m
y

a
n
d

s
u
b
t
o
t
a
l

c
o
l
e
c
t
o
m
y
:

a
s
s
e
s
s
i
n
g

t
h
e

b
e
n
e
f
i
t

o
f

p
r
o
p
h
y
l
a
c
t
i
c

t
u
b
e

s
p
l
i
n
t
i
n
g
.

D
i
g

S
u
r
g
.

2
0
0
1
;
1
8
(
5
)
:
3
8
8
-
9
2
.

I
I
I

(
N
=
3
4
)

I
n
t
e
s
t
i
n
a
l

t
u
b
e

s
p
l
i
n
t
i
n
g

s
h
o
w
e
d

n
o
n
-
s
t
a
t
i
s
t
i
c
a
l

f
e
w
e
r

e
a
r
l
y

a
n
d

l
a
t
e

S
B
O

M
o
h
r
i

Y

2
0
0
5

H
y
a
l
u
r
o
n
i
c

a
c
i
d
-
c
a
r
b
o
x
y
c
e
l
l
u
l
o
s
e

m
e
m
b
r
a
n
e

(
S
e
p
r
a
f
i
l
m
)

r
e
d
u
c
e
s

e
a
r
l
y

I
I
I

(
N
=
1
8
4
)

I
n
c
i
d
e
n
c
e

o
f

e
a
r
l
y

S
B
O

l
o
w
e
r

w
i
t
h

S
e
p
r
f
i
l
m
.

N
o

C
o
p
y
r
i
g
h
t

2
0
0
7

E
a
s
t
e
r
n

A
s
s
o
c
i
a
t
i
o
n

f
o
r

t
h
e

S
u
r
g
e
r
y

o
f

T
r
a
u
m
a

p
o
s
t
o
p
e
r
a
t
i
v
e

s
m
a
l
l

b
o
w
e
l

o
b
s
t
r
u
c
t
i
o
n

i
n

g
a
s
t
r
o
i
n
t
e
s
t
i
n
a
l

s
u
r
g
e
r
y
.

A
m

S
u
r
g
.

2
0
0
5

O
c
t
;
7
1
(
1
0
)
:
8
6
1
-
3
.

d
i
f
f
e
r
e
n
c
e

i
n

s
u
r
g
i
c
a
l

s
i
t
e

i
n
f
e
c
t
i
o
n
.

S
p
r
o
u
s
e

L
R

2
n
d

2
0
0
1

T
w
e
l
v
e
-
y
e
a
r

e
x
p
e
r
i
e
n
c
e

w
i
t
h

t
h
e

T
h
o
w

l
o
n
g

i
n
t
e
s
t
i
n
a
l

t
u
b
e
:

a

m
e
a
n
s

o
f

p
r
e
v
e
n
t
i
n
g

p
o
s
t
o
p
e
r
a
t
i
v
e

b
o
w
e
l

o
b
s
t
r
u
c
t
i
o
n
.

A
m

S
u
r
g
.

2
0
0
1

A
p
r
;
6
7
(
4
)
:
3
5
7
-
6
0
.

I
I
I

(
N
=
3
4
)

T
r
a
n
s
g
a
s
t
r
i
c

T
h
o
w

t
u
b
e

h
a
d

n
o

l
o
n
g

t
e
r
m

(
>
4
y
)

w
i
t
h

p
t
s

w
h
o

h
a
d

o
p
e
r
a
t
i
v
e

i
n
t
e
r
v
e
n
t
i
o
n

f
o
r

a
d
h
e
s
i
o
n

S
B
O
.

F
o
l
l
o
w
-
u
p

r
e
c
o
r
d
e
d

v
i
a

p
h
o
n
e

c
a
l
l
s

t
o

p
a
t
i
e
n
t
s

(
2
5

o
f

3
4
)
.

C
o
m
p
l
i
c
a
t
i
o
n
s

a
l
l

r
e
l
a
t
e
d

t
o

g
a
s
t
r
o
s
t
o
m
y

(
2
5
%
)

R
o
d
r
i
g
u
e
z
-
R
u
e
s
g
a

R

1
9
9
5

T
w
e
l
v
e
-
y
e
a
r

e
x
p
e
r
i
e
n
c
e

w
i
t
h

t
h
e

l
o
n
g

i
n
t
e
s
t
i
n
a
l

t
u
b
e
.

W
o
r
l
d

J

S
u
r
g
.

1
9
9
5

J
u
l
-
A
u
g
;
1
9
(
4
)
:
6
2
7
-
3
0
;

d
i
s
c
u
s
s
i
o
n

6
3
0
-
1
.

I
I
I

(
N
=
4
7
)

C
o
m
p
l
e
x

s
u
r
g
i
c
a
l

p
a
t
i
e
n
t

w
i
t
h

m
e
d
i
a
n

4

p
r
e
v
i
o
u
s

l
a
p
a
r
o
t
o
m
i
e
s
.

2
3
.
4
%

r
e
c
u
r
r
e
n
t

S
B
O
,

o
n
l
y

2

r
e
q
u
i
r
e
d

r
e
o
p
e
r
a
t
i
o
n
.

K
o
r
e
n
a
g
a

D

2
0
0
1

F
a
c
t
o
r
s

i
n
f
l
u
e
n
c
i
n
g

t
h
e

d
e
v
e
l
o
p
m
e
n
t

o
f

s
m
a
l
l

i
n
t
e
s
t
i
n
a
l

o
b
s
t
r
u
c
t
i
o
n

f
o
l
l
o
w
i
n
g

t
o
t
a
l

g
a
s
t
r
e
c
t
o
m
y

f
o
r

g
a
s
t
r
i
c

c
a
n
c
e
r
:

t
h
e

i
m
p
a
c
t

o
f

r
e
c
o
n
s
t
r
u
c
t
i
v
e

r
o
u
t
e

i
n

t
h
e

R
o
u
x
-
e
n
-
Y

p
r
o
c
e
d
u
r
e
.

H
e
p
a
t
o
g
a
s
t
r
o
e
n
t
e
r
o
l
o
g
y
.

2
0
0
1

S
e
p
-
O
c
t
;
4
8
(
4
1
)
:
1
3
8
9
-
9
2
.

I
I
I

(
N
=
4
8
)

2
2
.
9
%

p
r
e
s
e
n
t
e
d

w
i
t
h

m
e
c
h
a
n
i
c
a
l

o
b
s
t
r
u
c
t
i
o
n

a
n
d

a
n
t
e
c
o
l
i
c

a
n
a
s
t
o
m
o
s
i
s

f
o
u
n
d

t
o

b
e

p
r
e
d
i
c
t
i
v
e

f
a
c
t
o
r
.

4
5
%

r
e
q
u
i
r
e
d

r
e
o
p
e
r
a
t
i
o
n
.

P
o
o
n

J
T

2
0
0
4

S
m
a
l
l

b
o
w
e
l

o
b
s
t
r
u
c
t
i
o
n

f
o
l
l
o
w
i
n
g

l
o
w

a
n
t
e
r
i
o
r

r
e
s
e
c
t
i
o
n
:

t
h
e

i
m
p
a
c
t

o
f

d
i
v
e
r
s
i
o
n

i
l
e
o
s
t
o
m
y
.

L
a
n
g
e
n
b
e
c
k
s

A
r
c
h

S
u
r
g
.

2
0
0
4

A
u
g
;
3
8
9
(
4
)
:
2
5
0
-
5
.

I
I

(
N
=
2
1
4
)

S
B
O

f
o
l
l
o
w
i
n
g

L
A
R

i
s

1
0
.
3
%
,

t
h
e

m
a
j
o
r
i
t
y

b
e
n
i
g
n

a
n
d

n
o
t

m
a
l
i
g
n
a
n
t

r
e
c
u
r
r
e
n
c
e
.

D
i
v
e
r
t
i
n
g

i
l
e
o
s
t
o
m
y

i
n
c
r
e
a
s
e
s

i
n
c
i
d
e
n
c
e

o
f

e
a
r
l
y

S
B
O
.

H
o
l
m
d
a
h
l

L

1
9
9
7

A
d
h
e
s
i
o
n
s
:

p
r
e
v
e
n
t
i
o
n

a
n
d

c
o
m
p
l
i
c
a
t
i
o
n
s

i
n

g
e
n
e
r
a
l

s
u
r
g
e
r
y
.

E
u
r

J

S
u
r
g
.

1
9
9
7

M
a
r
;
1
6
3
(
3
)
:
1
6
9
-
7
4
.

I
I
I

S
u
r
v
e
y

s
e
n
t

o
u
t

t
o

s
u
r
g
i
c
a
l

d
e
p
a
r
t
m
e
n
t

h
e
a
d
s

i
n

S
w
e
d
e
n
.

8
4
%

(
8
7
u
n
i
t
s
)

r
e
s
p
o
n
s
e

r
a
t
e
.

>
4
7
0
0

a
d
m
i
s
s
i
o
n
s

f
o
r

a
d
h
e
s
i
o
n

S
B
O
,

4
7
%

o
p
e
r
a
t
i
v
e

r
a
t
e
.

O
v
e
r

1
5
0
0

o
p
e
r
a
t
i
o
n
s
/
y

c
o
m
p
l
i
c
a
t
e
d

b
y

p
r
e
v
i
o
u
s
l
y

f
o
r
m
e
d

a
d
h
e
s
i
o
n
s
.

A
u
t
h
o
r

s
u
g
g
e
s
t
s

w
a
s
h
i
n
g

g
l
o
v
e
s

a
n
d

s
u
t
u
r
i
n
g

p
e
r
i
t
o
n
e
u
m

c
o
u
l
d

h
e
l
p

b
u
t

n
o

e
v
i
d
e
n
c
e

p
r
o
v
i
d
e
d
.

S
B
O

i
n

P
r
e
g
n
a
n
c
y

M
e
y
e
r
s
o
n

S

1
9
9
5

S
m
a
l
l

b
o
w
e
l

o
b
s
t
r
u
c
t
i
o
n

i
n

p
r
e
g
n
a
n
c
y
.

A
m

J

G
a
s
t
r
o
e
n
t
e
r
o
l
.

1
9
9
5

F
e
b
;
9
0
(
2
)
:
2
9
9
-
3
0
2
.

I
I
I

9

c
a
s
e
s

o
v
e
r

1
5

y
e
a
r
s

a
n
d

1
5
0
,
3
8
6

d
e
l
i
v
e
r
i
e
s
.

P
r
e
v
i
o
u
s

s
u
r
g
e
r
y

8

o
f

9

c
a
s
e
s
.

O
p
e
r
a
t
i
o
n

r
e
q
u
i
r
e
d

i
n

8

o
f

9

p
a
t
i
e
n
t
s
.

N
o

m
a
t
e
r
n
a
l

d
e
a
t
h
s
.

3

o
f

9

f
e
t
a
l

d
e
a
t
h
s

(
2
2
-
3
0

w
k
s
)

C
o
p
y
r
i
g
h
t

2
0
0
7

E
a
s
t
e
r
n

A
s
s
o
c
i
a
t
i
o
n

f
o
r

t
h
e

S
u
r
g
e
r
y

o
f

T
r
a
u
m
a

Small Bowel Obstruction

Diunggah oleh

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Copyright 2007 Eastern Association for the Surgery of Trauma

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