Over the last century there have not been significant changes in the anatomical location of obstruction.

The age of
presentation has increased along with age related co-morbidity. Management has consequently been challenging as risks
keep on increasing with advanced age. Hence, clear decision making has become essential in its management. A selective
review of the literature pertaining to common age related aetiologies, diagnosis methods leading to standard decision
making and treatment of acute intestinal obstruction was done. The same is obtained from randomized controlled studies,
meta-analysis and other related evidence based publications. Predicting the conservative or operative management of
Bowel Obstruction (BO) is difficult. BO in young age, in unscarred abdomen and Large Bowel Obstruction (LBO) needs early
surgery. Decision on surgery should be taken in paediatric patient by second day and preferably between 3-5 days of
admission in adults. Higher American Society of Anaesthesiologists (ASA) grade correlates well with the mortalities. In this
article, the timing of surgery, methods to avoid bowel resection and type of surgery in various causes are stressfully
analysed and discussed.

Introduction
Over the last 100 years, the anatomical location of Bowel Obstruction (BO) has remained unchanged; however,
the aetiological factors in small and large BO have changed significantly. With advance of time more and more
elderly patients are presenting with BO [1]. But still, BO continues to be one of the most common surgical
emergencies [2] encountered in general surgery units and it continues to be a major cause of morbidity and
financial expenditure [3]. Peritoneal adhesions and hernia were the most common causes of BO and contributing
42.3% [4]. All patients of BO are potential candidates for major abdominal surgery with long term morbidity and
possible mortality. Hence, the decision of surgery and its timing is vital.
Various factors are considered for taking the decision on operative or non-operative management. The factors considered
are age of the patients, duration of obstruction, volume of nasogastric aspirate, findings on the radiological imaging,
previous abdominal surgeries and malignancy.

Decision in Small Bowel Obstruction (SBO)

Clinical presentation of pain, vomiting, distension and constipation, laboratory and radiographic factors should all be
considered when making a decision about treatment of BO [5]. One must rule out an abdominal wall hernia as a cause of
BO, which is seen in 26.8% of cases in virgin abdomen [4]. Plain radiograph should be an integral part of management of
patients with clinical suspicion of BO and gastrointestinal perforation [6] [Table/Fig-1]. The diagnosis in most cases will be
confirmed by further imaging studies such as ultrasound, contrast studies or most commonly in contemporary practice, the
Computed Tomography (CT) [7].

The CT scan, besides confirming the diagnosis of BO, it gives information on partial or complete obstruction, it location, it
also provides specific type like closed loop type and helps in deciding early surgery. Contrast Enhanced Computed
Tomography (CECT) give enough information on ischemic bowel and bowel oedema, which requires emergency surgery
and luminal gastrograffin helps in relieving the BO [8,9].

Surgeons find coronal images more helpful than axial images for management [10]. The radiographic transition
zone alone does not increase the likelihood of surgical intervention or identify patients who will fail non-operative
management [11]. The four cardinal features
– intra peritoneal free fluid, mesenteric oedema, presence of the "small bowel faeces sign" and history of vomiting - are
predictive of requiring immediate emergency operative intervention [5].

Decision in large bowel obstruction

In Indian scenario, two common types of Large Bowel Obstructions (LBO) are seen. They are: (a) Acute obstruction due to
Sigmoid volvulus (SV); and (b) Sub-acute or chronic obstruction due to cancer of colon. In suspected volvulus, plain X-rays
may help with diagnosis but MRI is more reliable. However, flexible endoscopy is always diagnostic as well as therapeutic
[12]. Once diagnosed flatus tube, hydrostatic enema or colonoscopic reduction attempt is the choice in vascularized bowel.
No endo-luminal reduction to be attempted with the sign of gangrenous SV. If the above methods succeed, later an
elective sigmoidopexy or preferably sigmoid colectomy is required to avoid recurrence. When the endoscopic methods fail,
emergency laparotomy is indicated, where it is untwisted, the definitive and standard therapy, sigmoid resection and
primary anastomosis is the choice [13]. The non-resective alternatives have also been widely used with mixed success, but
a large, randomized controlled trial is needed to compare their efficacy with resection and primary anastomosis.
Laparoscopic surgery in SV management is unwarranted and costly. Complications of SV include haemorrhagic infarction,
perforation, septic shock, and death (14-45%) [14].

Colorectal cancer presents as an emergency with LBO in up to 29% of cases. These patients are often elderly with multiple
co-morbidities and deranged physiological function [15].

Almost 42% of such patients will have anaemia preoperatively [16] and showed worse prognosis [17].
Haematological work up and time permitting iron therapy is useful [16,17]. Pre-operative ferric carboxymaltose
treatment in patients with colon cancer and iron deficiency anaemia significantly reduced RBC transfusion
requirements and hospital length of stay, reaching higher response rates and percentages of normalized
haemoglobin levels both at hospital admission and at 30 days post-surgery [16,17]. But, in an emergency setting
it may not be of much value.
Due to the deranged physiological setting in elderly, staged surgical procedures were advised, but recent trends
have moved towards a primary resection and anastomosis [15].
However, the following options may be considered [18]-
a. Temporary relief by metal stent, bowel preparation and surgery;
b. Primary resection and anastomosis- with or without on table preparation;
c. Initial proximal diversion and staged cancer surgery;
d. Primary resection of the cancer, loaded proximal colon colectomy, end colostomy and Hartman’s pouch
e. Subtotal colectomy [Table/Fig-2] and ileo-rectal anastomosis.

Self-Expanding Metal Colonic Stent (SEMS) is found to be safe and effective in obstructing colorectal cancer and
effective method of alleviating acute and impending BO [18]. The same can be used in LBO either as palliation or
bridge to surgery. They are associated with an overall better outcome and improved quality of life of patients.
Surgery is indicated where SEMS are unavailable or have failed [19]. It gives a better chance of primary
anastomosis and reduce the need for stoma creation and post procedural complications without any effect on
peri-operative morbidity, mortality and long-term survival [20,21]. Delaying the surgery after patency by colonic
stent is found to be having higher local recurrence rate in comparison to emergency subtotal colectomy [22].

One stage primary resections with anastomosis of the large bowel can be performed safely in case of emergency whenever
patient co-morbidities and local conditions do not stand as major restrictions [23]. Possibly due to gross faecal loading this
is not suitable in South East Asia. Options with stomas are not preferred by the patients and also give poor quality of life
more so in elderly people. The last option of subtotal colectomy and primary ileo-rectal anastomosis in a semi-emergency
basis is a safe and efficient procedure in the management of acutely obstructed neoplasm of the left colon [24]. Despite
the difficult pre-operative conditions, subtotal colectomy for left colonic obstruction is found to have lower anastomotic
leak rate than the segmental colectomy [25]. The advantages of the last options are many: (a) No bowel preparation, as all
the loaded bowel are removed and per anal rectal wash can be given to clean the rectum; (b) It allows to treat in one stage
the cancer and theobstruction [24]; (c) Biggest advantage is no stoma; (d) Pre-surgery chronic constipation get relieved; (d)
No need of follow up repeated screening colonoscopy; (e) No compromise on the proximal cut margin; (f) Proximal
Synchronous lesions are taken care of. The disadvantages are: (a) Technically difficult surgery in presence of grossly dilated
and loaded colon [26]. This can be made easier once the mobilized right colon is kept outside the abdomen; (b) Increased
frequency of motion for 6-8 months and peri-anal excoriation. In spite of frequent loose motions many patients become
happy, because it is a great relief for them after a long period of chronic constipation.

Laparoscopic resectional surgery in acute LBO is feasible and safe option with a low complication rate that enables early
hospital discharge [27]. In view of the various alternatives and the lack of high-grade evidence, the treatment of distal
colonic obstruction should be individually tailored to each patient [28].

Age related – Decision making in newborn, young and old

Age is one of the important factors in decision making in BO. Extremes of age have a low body reserve and are liable for
higher morbidity and mortality and hence, an early decision is needed for surgery or otherwise [4]. BO in the newborn is a
common reason for admission to neonatal ICUs. The incidence is estimated to be approximately 1 in 2000 live births. There
are 4 cardinal features of intestinal obstruction in new-borns: (1) Pre-natal maternal polyhydramnios; (2) Bilious vomiting;
(3) No passage of meconium; and (4) Abdominal distension. Massive abdominal distension with respiratory distress and
cardiovascular collapse is common in neglected megacolon [Table/Fig-3]. A detailed history from the mother and periodic
physical examination and X-ray abdomen clinches the diagnosis [29]. Internal hernia and Meckel’s diverticulum related BO
[Table/Fig-4] is rare but important. Meckel's diverticulum can be overlooked in many cases hence, it is recommended that
the small bowel be assessed in all cases of appendectomy [30]. 16.4% of children and adolescents undergoing operative
management require bowel resections [Table/Fig-5]. To avoid potentially increasing risk for bowel loss, intervention should
be considered by the second day in patients who do not exhibit signs of improvement [31].

As old age is significantly associated with an increased incidence of strangulation, operative mortality and complications,
this group of patients should be managed with extra caution to avoid unfavourable outcome of surgery [4]. Electrolyte
imbalance, mostly hyponatraemia and hypokalaemia needs correction before any decision.

Virgin abdomen vs. scarred abdomen

BO in a virgin abdomen is non-adhesive and mostly due to congenital bands and internal hernia. It is rare but, may be a life-
threatening surgical emergency. A high index of suspicion based on the patient's history and response to conservative
management
[Table/Fig-3]: Neglected megacolon. [Table/Fig-4]: Meckel’s Diverticulum causing obstruction. [Table/Fig-5]: Meckel’s
related BO needing resection.

is required to achieve early diagnosis so that surgical treatment can be rapidly instituted [32]. Peritoneal
adhesions causing SBO is the commonest cause contributing 42.3% [4]. The rate of recurrent obstruction is
around 15.9% and 5.8% requiring surgical management [33]. The general impression is that laparoscopic surgery
causes less adhesions. But a single centre study has reported no difference in the incidence of post-operative
adhesive intestinal obstruction between laparoscopic and open colorectal resection [34]. Surgically treated
patients had a lower frequency of recurrence and a longer time interval to recurrence; at the cost of longer
hospital stay. There is no predictor of adhesive BO either before or after surgery or any variables predicting the
success of a particular treatment [35]. However, patients with matted adhesions have a higher recurrence rate
than those with band adhesions. Non-operative treatment for adhesions in stable patients results in a shorter
hospital stay and similar recurrence and re-operation rates, but a reduced interval to re-obstruction when
compared with operative treatment [3]. These patients need close observation and repeated abdominal
examination for evidence of impending bowel ischemia, in the form of raised C-Reactive Protein (CRP) serum
lactate, raised total leucocytes count besides guarding.
Recurrent BO
Recurrent bowel obstruction- common causes are given in [Table/Fig-6]. Recurrent BO is seen in three clinical
scenario. The first is on an unscarred abdomen, mostly due to internal hernia, secondly during an early post-
operative period, where there is likely confusion of post-operative ileus/ BO. The third scenario being adhesive
obstruction. All these three situations are discussed below.

a. Recurrent BOin virgin abdomen

Often, they present at recurrent BO and keep resolving on conservative management. A CT scan with oral
contrast and even a barium study of small bowel is usually diagnostic. Para-duodenal hernia constitute 50% of
internal herniation [Table/Fig-7] [36,37]. A small bowel barium study/ CT-scan may be diagnostic [38].
Laparoscopy continues to be a safe diagnostic and therapeutic tool in the management of pediatric initial BO and
recurrent small BO [39]. In case of any difficulty, an open surgical reduction [Table/Fig-8] can be undertaken.
b. Early post-operative BO or early recurrence BO after relieve of BO/ paralytic ileus

This is the most serious condition, as the patients has been fasting and still vomiting. This leads to malnutrition and
electrolyte imbalance. When this state of post-operative ileus remains longer than usual, patient continues to have
distended abdomen and continues to vomit. It is important to rule out any intestinal leak. It is mostly localized due to the
adhesion [Table/Fig-9] and rarely leads to peritonitis. Any form of drainage will lead to a faecal fistula and, hence the
critical decision can be taken on laparotomy and closure or create a fistula. Whatever may be the decision, parenteral
nutrition must be instituted in this state of bowel failure. In case a stoma is created in jejunum or mid bowel, the distal
bowel can be utilized in the way of distal feeding of the output [40]. This type of chyme re-infusion or enteroclysis are less
expensive, well tolerated, and easy-to-use nutrition support techniques, which may allow reducing parenteral nutrition-
related healthcare costs and lifesaving [40].

The next step is to differentiate between prolonged paralytic ileus and mechanical BO. One should suspect mechanical
obstruction when: Patient had passed flatus/stool and then it stopped again, noisy peristalsis and no flatus, colicky pain, X-
ray/CT-scan/contrast study abdomen suggests obstruction [41]. The incidences of re-surgery are given in [Table/Fig-10].
Once it is established as mechanical obstruction and bowel is non gangrenous, a gastrograffin trail can be given and if it
fails, then surgery can be done as per the algorithm.

Then only one can think of using alvimopan and methylnaltrexone, the peripherally acting μ-opioid receptor antagonists
can be used to accelerate gastrointestinal recovery. In another randomized trial administration of Bisacodyl demonstrated
significantly earlier bowel movements than those who received placebo (25 h vs. 56 h) [42]. Even in early post-operative
adhesion the management protocol should follow the algorithm [Table/Fig-11].
c. Late post-operative recurrence
Recurrent BO is a real challenge in adhesive type. The common causes are given in [Table/Fig-6]. There are many more rare
and uncommon causes besides given in the table. The initial management remains the same as applicable in the algorithms.
In recurrent adhesive SBO, not resolving even after gastrograffin trail, surgery is indicated. During surgery, after
adhesiolysis, it is better to do a plication of the bowel to avoid next attack [Table/Fig-12] [45]. The plication can be done by
fixing the mesentery (The Noble plication) by Protective fibrin-sealed application [46]. Trans- mesenteric plication can also
be done in a state of peritonitis [47]. But in the

adhesion prevention effectiveness without restrictions concerning mode of application and compatibility and, thus, is a
promising strategy to prevent abdominal adhesions [49].

However, In a cochrane database systematic review, the positive results are refuted [50]. Similar, negative result is
reported for icodextrin as an anti-adhesive intraperitoneal fluid [51]. In fact the cause of the recurrent obstruction must be
found out and addressed once the acute obstruction resolves. Such cases are common in internal hernias. A barium study
or CT scan with enteral contrast clinches the diagnosis. If both go without a diagnosis, a diagnostic laparoscopy will
culminate to therapy as well.

If surgery is needed during the acute attack, laparotomy the not only gives the diagnosis but curative surgery can be done.
The case of abdominal cocoon is challenging to the surgeon plain X-ray shows hardly any dilated small bowel to the
inquisitive surgeon. At times it might be cocoon which covers the entire small bowel. It is mostly due to tuberculosis in
India [52]. Occasionally it may be due to fibrosis of the peritoneum [53]. Tricky adhesiolysis by an experienced surgeon is
needed.

Gastrograffin trial

Data showed that, the use of gastrograffin in adhesive small intestine obstruction is safe and reduces the operative rate
and the time to resolution of obstruction. One study has reported the resolution of obstruction in 81.5% after a mean time
of 6.4 hours [54]. When it resolves, it reduces the hospital stay with adhesive SBO [54-56] and failure to resolve is an
effective indication in predicting the need for surgery [55]. It is better to do a CT scan with oral contrast to know the
location and cause of obstruction so that it can be dealt with during this attack or be prepared in case of any recurrence.

Ovarian cancer related bowel obstruction

Ovarian cancer needs special mention due to the high incidence of BO in these patients. Nearly 20% of women developed
BO after they are diagnosed with cancer. There is associated increased risk of subsequent obstructions [57]. Un-dilated
bowel in presence of features of SBO does not benefit from operative intervention [Table/Fig-14]. Estimation of CA-125
may be helpful. Diligent discussion with the primary team and frank discussions with the patient and his or her family are
essential to formulate an appropriate plan [58].

Timing and decision for surgery

Timing is crucial to avoid gangrenous bowel resection and obvious electrolyte imbalance. Identifying patients who may
safely undergo non operative management remains difficult [59]. In a large study of 1613 patients 56.6% required surgery
and 43.4% could be managed non-operatively [59]. There was an associated higher incidence of bowel resection in patients
who took increased time to reach the operating room. Among the patients in whom the admission to operating room was
less than 24 hours, 12% patients had bowel resection as compared to 29% in patients who took greater than 24 hours [59].
To avoid potentially increasing risk for bowel loss, intervention should be considered by the second day in a paediatric
patient with low threshold in those who do not exhibit signs of improvement [31] and no more than 5 days in adults [60].
BO in young age and patients having virgin abdomen are more likely to under go operation [59]. Patients with a CT reading
of complete obstruction, dilated small bowel and free fluid were operated on 77%, 66%, and 65% of the time, respectively
[61].

Patients on conservative treatment for BO, where drainage volume through the nasogastric tube on day 3 is > 500mL,
mostly required surgery [62]. CT scan of abdomen with oral gastrograffin not only gives the location of BO but also adds to
the gastrograffin trial and avoids an abdominal surgery [63]. When a procedure is needed for adhesiolysis, laparoscopic
adhesiolysis in expert hand in selected patients, reduced overall complication rate. It is found to be advantageous in
studies [64]. The post-operative hospital stay was significantly shorter in the Laparoscopic Adhesiolysis (LA) group
compared to converted (3 vs. 9 days). LA is safe and feasible for the management of BO and should be offered to all
patients with BO unless there is an absolute contraindication to laparoscopic surgery [65,66]. It is also suitable in paediatric
age group [67]. It is an excellent diagnostic tool and, in most cases, a therapeutic modality in patients with SBO. However, a
significant number of patients will require conversion [66]. Open adhesiolysis is faster than laparoscopic adhesiolysis (LA)
[68]. A previous upper abdominal surgical incision and a transition zone outside of the pelvis on CT scan were pre-operative
predictors of a successful laparoscopic adhesiolysis. The laparoscopic group had shorter length of stay [69]. LA in presence
of dilated bowel leads to less dolmen for the play of the instruments and hence, it is not advisable. It is ideal, where BO
caused by post-operative adhesion had resolved earlier on conservative management and the patient comes with
recurrence, where LA to be attempted early before gross dilatation of the bowel [70]. Conversion to mini-laparotomy or
laparotomy should be considered in patients with dense or pelvic adhesion [71].
Once the diagnosis of BO is established clinically and confirmed by radiological investigation; then comes the decision.
There are two decisions conservative or operative. If conservative is chosen, the responsibility of the treating team is to
operate before the bowel becomes gangrenous. Hence, repeating X-ray/CT scan and radiating the patient looks non-
academic. Secondly clinical diagnosis of resolution of BO is quite evident clinically.

Palliation in BO

In palliative care patients with nausea and vomiting, 5HT3 receptor antagonists can be used if treatment with other
antiemetics, such as metoclopramide and neuroleptics is not sufficient.

There is a trend that steroids in combination with other antiemetic improve symptom relief.

Cannabinoids have a status as a second line antiemetic. As a palliative care in malignant obstruction, long acting octreotide
remains the first choice and butyl-scopolammonium bromide, the second to palliate the symptoms [72]. In a small study of
only 12 cases, (patients with malignant BO/ bowel dysfunction), most of the patients improved with combination of anti-
inflammatory (Dexamethasone), anti-secretory (Octriotide), and prokinetic (metoclopramide).

Post-operative prognosis

The early post-operative mortality is strongly linked with the age and the American Society of Anesthesiologists (ASA)
grade and the long-term mortality with post-operative complications [73]. More frequent bowel resections might be
suggested for patients featuring 10 or more obstructive strictures and an intestinal wall injury, especially when associated
with a reversible intestinal ischemia [74].

Conclusi on

Predicting the conservative or operative management in BO is difficult. Decision on surgery should be taken in paediatric
patient by 24 hours, in young age, in virgin abdomen and large BO by 48hrs and within 3-5 days of admission in adults, if
the oral gastrografin fails to resolve the BO more so the adhesive obstruction with high (>500ml) gastric tube aspirate
(Algorithm). In recurrent BO some form of plication may be considered during surgery. The early post-operative mortality is
strongly linked with the age and the ASA grade whereas the long-term mortality is associated with post-operative
complications.

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Selama seabad terakhir belum ada perubahan signifikan dalam lokasi anatomi terjadinya obstruksi.
Presentasi usia menunjukkan peningkatan usia seiring dengan peningkatan komorbiditas.
Manajemen akibatnya menantang karena risiko terus meningkat dengan usia lanjut. Oleh karena itu,
pengambilan keputusan yang jelas menjadi sangat penting dalam manajemennya. Sebuah tinjauan
selektif literatur yang berkaitan dengan etiologi terkait usia umum, metode diagnosis yang
mengarah ke pengambilan keputusan standar dan pengobatan obstruksi usus akut dilakukan. Hal
yang sama diperoleh dari studi terkontrol acak, meta-analisis dan publikasi berbasis bukti terkait
lainnya. Memprediksi manajemen konservatif atau operasi Obstruksi Usus (BO) sulit. BO di usia
muda, di perut yang tidak diacak dan Obstruksi Usus Besar (LBO) membutuhkan operasi dini.
Keputusan tentang operasi harus diambil pada pasien anak pada hari kedua dan sebaiknya antara 3-
5 hari masuk pada orang dewasa. Kelas American Society of Anaesthesiologists (ASA) yang lebih
tinggi berkorelasi baik dengan kematian. Dalam artikel ini, waktu operasi, metode untuk
menghindari reseksi usus dan jenis operasi dalam berbagai penyebab dianalisis dan dibahas secara
stres.

Selama 100 tahun terakhir, lokasi anatomi Obstruksi Usus (BO) tetap tidak berubah; Namun, faktor
etiologi dalam BO kecil dan besar telah berubah secara signifikan. Dengan kemajuan waktu semakin
banyak pasien lanjut usia yang hadir dengan BO [1]. Tapi tetap, BO terus menjadi salah satu keadaan
darurat bedah yang paling umum [2] ditemui di unit operasi umum dan terus menjadi penyebab
utama morbiditas dan pengeluaran keuangan [3]. Adhesi peritoneum dan hernia adalah penyebab
paling umum dari BO dan berkontribusi 42,3% [4]. Semua pasien BO adalah kandidat potensial untuk
operasi perut besar dengan morbiditas jangka panjang dan kemungkinan kematian. Oleh karena itu,
keputusan operasi dan waktunya sangat penting.
Berbagai faktor dipertimbangkan untuk mengambil keputusan tentang manajemen operatif atau
non-operatif. Faktor-faktor yang dipertimbangkan adalah usia pasien, durasi obstruksi, volume
aspirasi nasogastrik, temuan pada pencitraan radiologis, operasi perut sebelumnya dan keganasan.

Keputusan dalam Obstruksi Usus Kecil (SBO)

Presentasi klinis nyeri, muntah, distensi dan konstipasi, laboratorium dan faktor radiografi semua
harus dipertimbangkan ketika membuat keputusan tentang pengobatan BO [5]. Seseorang harus
mengesampingkan hernia dinding perut sebagai penyebab BO, yang terlihat pada 26,8% kasus di
perut perawan [4]. Foto polos harus menjadi bagian integral dari penatalaksanaan pasien dengan
kecurigaan klinis pada perforasi gastrointestinal dan BO [6] [Tabel / Gambar-1]. Diagnosis dalam
banyak kasus akan dikonfirmasi oleh penelitian pencitraan lebih lanjut seperti USG, studi kontras
atau paling umum dalam praktik kontemporer, Computed Tomography (CT) [7].
CT scan, selain mengkonfirmasi diagnosis BO, juga memberikan informasi mengenai obstruksi parsial
atau lengkap, lokasinya, juga menyediakan tipe spesifik seperti tipe loop tertutup dan membantu
dalam memutuskan operasi dini. Contrast Enhanced Computed Tomography (CECT) memberikan
informasi yang cukup mengenai iskemik usus dan usus edema, yang memerlukan operasi darurat
dan bantuan luminal gastrograffin dalam mengurangi BO [8,9].
Ahli bedah menemukan gambar koronal lebih membantu daripada gambar aksial untuk manajemen
[10]. Zona transisi radiografi saja tidak meningkatkan kemungkinan intervensi bedah atau
mengidentifikasi pasien yang akan gagal manajemen non-operatif [11]. Keempat fitur utama
- cairan intra peritoneal gratis, edema mesenterika, kehadiran "tanda usus usus kecil" dan riwayat
muntah - adalah prediksi membutuhkan intervensi operasi darurat segera [5].

Keputusan dalam obstruksi usus besar

Dalam skenario India, dua jenis penghalang usus besar (LBO) yang umum terlihat. Mereka adalah: (a)
Obstruksi akut karena Sigmoid volvulus (SV); dan (b) Obstruksi sub-akut atau kronis karena kanker
kolon. Dalam dugaan volvulus, X-ray polos dapat membantu diagnosis tetapi MRI lebih dapat
diandalkan. Namun, endoskopi fleksibel selalu bersifat diagnostik dan terapeutik [12]. Setelah
didiagnosis tabung flatus, enema hidrostatik atau upaya reduksi kolonoskopi adalah pilihan pada
usus halus. Tidak ada pengurangan endo-luminal yang harus dicoba dengan tanda SV gangren. Jika
metode di atas berhasil, nantinya diperlukan sigmoidopeksi elektif atau kolektomi sigmoid yang
diinginkan untuk menghindari kekambuhan. Ketika metode endoskopi gagal, laparotomi darurat
diindikasikan, di mana itu dipilin, terapi definitif dan standar, reseksi sigmoid dan anastomosis
primer adalah pilihan [13]. Alternatif non-resective juga telah banyak digunakan dengan
keberhasilan yang beragam, tetapi percobaan terkontrol acak yang besar diperlukan untuk
membandingkan efektivitas mereka dengan reseksi dan anastomosis primer. Bedah laparoskopi
pada manajemen SV tidak beralasan dan mahal. Komplikasi SV termasuk infark haemorrhagic,
perforasi, syok septik, dan kematian (14-45%) [14].
Kanker kolorektal hadir sebagai keadaan darurat dengan LBO pada hingga 29% kasus. Pasien-pasien
ini sering tua dengan beberapa komorbiditas dan gangguan fungsi fisiologis [15].

Hampir 42% dari pasien tersebut akan mengalami anemia sebelum operasi [16] dan menunjukkan
prognosis yang lebih buruk [17]. Kerja hematologi dan waktu yang memungkinkan terapi besi
berguna [16,17]. Perawatan carboxymaltose ferrous pra-operasi pada pasien dengan kanker usus
besar dan anemia defisiensi besi secara signifikan mengurangi persyaratan transfusi RBC dan lama
rawat di rumah sakit, mencapai tingkat respons yang lebih tinggi dan persentase tingkat hemoglobin
yang dinormalisasi baik di rawat inap rumah sakit dan pada 30 hari pasca operasi [16, 17]. Namun,
dalam keadaan darurat mungkin tidak banyak nilainya.
Karena pengaturan fisiologis gila pada orang tua, prosedur bedah dipentaskan yang disarankan,
tetapi tren baru-baru ini telah bergerak menuju reseksi primer dan anastomosis [15].
Namun, opsi berikut dapat dipertimbangkan [18] -
Sebuah. Relief sementara dengan stent logam, persiapan usus dan operasi;
b. Reseksi primer dan anastomosis - dengan atau tanpa persiapan meja;
c. Pengalihan proksimal awal dan operasi kanker bertahap;
d. Reseksi primer kanker, kolonisasi kolon proksimal, kolostomi akhir, dan kantong Hartman
e. Kolektomi subtotal

[Table/Fig-2] and ileo-rectal anastomosis.

Stet Colonic Standing Otomatis (SEMS) ditemukan aman dan efektif dalam menghalangi
kanker kolorektal dan metode efektif untuk mengurangi BO akut [18]. Hal yang sama dapat
digunakan dalam LBO baik sebagai paliatif atau jembatan untuk operasi. Mereka terkait
dengan hasil yang lebih baik secara keseluruhan dan peningkatan kualitas hidup pasien.
Pembedahan diindikasikan di mana SEMS tidak tersedia atau gagal [19]. Ini memberikan
kesempatan yang lebih baik untuk anastomosis primer dan mengurangi kebutuhan untuk
pembuatan stoma dan pasca komplikasi prosedural tanpa efek pada morbiditas perioperatif,
mortalitas dan kelangsungan hidup jangka panjang [20,21]. Menunda operasi setelah patensi
oleh stent kolon ditemukan memiliki tingkat kekambuhan lokal yang lebih tinggi
dibandingkan dengan kolostomi subtotal darurat [22].

Satu tahap reseksi primer dengan anastomosis usus besar dapat dilakukan dengan aman
dalam keadaan darurat setiap kali pasien komorbiditas dan kondisi lokal tidak berdiri sebagai
pembatasan utama [23]. Mungkin karena pemuatan feses kotor ini tidak cocok di Asia
Tenggara. Pilihan dengan stoma tidak disukai oleh pasien dan juga memberikan kualitas
hidup yang lebih buruk pada orang lanjut usia. Pilihan terakhir dari kolektomi subtotal dan
anastomosis ileo-rectal primer secara semi-darurat adalah prosedur yang aman dan efisien
dalam penatalaksanaan neoplasma obstruktif akut pada kolon kiri [24]. Meskipun kondisi
pra-operasi sulit, kolektomi subtotal untuk obstruksi kolon kiri ditemukan memiliki tingkat
kebocoran anastomosis yang lebih rendah daripada kolektomi segmental [25]. Keuntungan
dari pilihan terakhir adalah banyak: (a) Tidak ada persiapan usus, karena semua usus yang
diambil diangkat dan per pencucian dubur dubur dapat diberikan untuk membersihkan
rektum; (B) Ini memungkinkan untuk mengobati dalam satu tahap kanker dan theobstruction
[24]; (c) Keuntungan terbesar adalah tidak ada stoma; (d) Konstipasi kronis pra-operasi
menjadi lega; (D) Tidak perlu tindak lanjut screening kolonoskopi berulang; (e) Tidak ada
kompromi pada margin potongan proksimal; (f) Lesi Synchronous proksimal dirawat.
Kerugiannya adalah: (a) Secara teknis operasi sulit di hadapan usus besar yang membesar dan
terangkat [26]. Ini dapat dibuat lebih mudah setelah kolon kanan dimobilisasi disimpan di
luar perut; (b) Peningkatan frekuensi gerak selama 6-8 bulan dan ekskoriasi peri-anal.
Terlepas dari seringnya gerakan yang longgar, banyak pasien menjadi bahagia, karena itu
sangat melegakan bagi mereka setelah lama konstipasi kronis.

Bedah reseksi laparoskopi pada LBO akut adalah opsi yang layak dan aman dengan tingkat
komplikasi rendah yang memungkinkan pelepasan rumah sakit awal [27]. Mengingat berbagai
alternatif dan kurangnya bukti bermutu tinggi, pengobatan obstruksi kolon distal harus secara
individual disesuaikan untuk setiap pasien [28].

Terkait usia - Pengambilan keputusan pada bayi baru lahir, muda dan tua
Usia adalah salah satu faktor penting dalam pengambilan keputusan di BO. Ekstrem usia memiliki
cadangan tubuh yang rendah dan bertanggung jawab atas morbiditas dan mortalitas yang lebih
tinggi dan karenanya, keputusan awal diperlukan untuk operasi atau sebaliknya [4]. BO pada bayi
baru lahir adalah alasan umum untuk masuk ke ICU neonatal. Kejadiannya diperkirakan sekitar 1 dari
2000 kelahiran hidup. Ada 4 ciri kardinal obstruksi usus pada bayi baru lahir: (1) polihidramnion
maternal pra-natal; (2) muntah bilasan; (3) Tidak ada bagian mekonium; dan (4) Distensi abdomen.
Distensi abdomen besar-besaran dengan distres pernapasan dan kolaps kardiovaskular sering terjadi
pada megakolon terabaikan [Tabel / Gambar-3]. Riwayat rinci dari ibu dan pemeriksaan fisik berkala
dan abdomen X-ray memastikan diagnosis [29]. Hernia internal dan divertikulum Meckel terkait
dengan BO [Tabel / Gambar-4] jarang tetapi penting. Diverticulum Meckel dapat diabaikan dalam
banyak kasus karenanya, direkomendasikan bahwa usus kecil harus dinilai dalam semua kasus
apendektomi [30]. 16,4% anak-anak dan remaja yang menjalani manajemen operasi membutuhkan
reseksi usus [Tabel / Gambar-5]. Untuk menghindari kemungkinan peningkatan risiko kehilangan
usus, intervensi harus dipertimbangkan pada hari kedua pada pasien yang tidak menunjukkan tanda-
tanda perbaikan [31].

[Table/Fig-3]: Neglected megacolon. [Table/Fig-4]: Meckel’s Diverticulum causing obstruction. [Table/Fig-5]: Meckel’s
related BO needing resection.

Karena usia lanjut secara signifikan terkait dengan peningkatan insidensi strangulasi, mortalitas
operasi dan komplikasi, kelompok pasien ini harus dikelola dengan ekstra hati-hati untuk
menghindari hasil operasi yang tidak menguntungkan [4]. Ketidakseimbangan elektrolit, kebanyakan
hiponatremia dan hipokalemi perlu koreksi sebelum keputusan apa pun.

Perut perawan vs perut yang terluka

BO di perut perawan adalah non-perekat dan sebagian besar karena band bawaan dan hernia
internal. Jarang terjadi, tetapi bisa menjadi keadaan darurat yang mengancam jiwa. Indeks
kecurigaan yang tinggi berdasarkan riwayat pasien dan tanggapan terhadap manajemen konservatif
diperlukan untuk mencapai diagnosis dini sehingga perawatan bedah dapat dengan cepat dilakukan
[32]. Adhesi peritoneal yang menyebabkan SBO adalah penyebab tersering yang berkontribusi 42,3%
[4]. Tingkat obstruksi berulang sekitar 15,9% dan 5,8% membutuhkan manajemen bedah [33]. Kesan
umum adalah bahwa operasi laparoskopi menyebabkan kurang adhesi. Tetapi satu pusat studi telah
melaporkan tidak ada perbedaan dalam kejadian obstruksi usus pasca operasi usus antara
laparoskopi dan reseksi kolorektal terbuka [34]. Pasien yang diobati dengan operasi memiliki
frekuensi kekambuhan yang lebih rendah dan interval waktu yang lebih lama untuk kekambuhan;
dengan biaya tinggal di rumah sakit lebih lama. Tidak ada prediktor BO perekat baik sebelum atau
setelah operasi atau variabel memprediksi keberhasilan pengobatan tertentu [35]. Namun, pasien
dengan adhesi kusut memiliki tingkat kekambuhan yang lebih tinggi dibandingkan dengan adhesi
pita. Perawatan non-operasi untuk adhesi pada pasien yang stabil menghasilkan waktu rawat inap
yang lebih singkat dan tingkat kekambuhan dan operasi ulang yang serupa, tetapi interval yang
berkurang untuk obstruksi ulang bila dibandingkan dengan terapi operatif [3]. Pasien-pasien ini
memerlukan observasi ketat dan pemeriksaan perut berulang untuk bukti iskemia usus yang akan
datang, dalam bentuk peningkatan laktat serum C-Reactive Protein (CRP), meningkatkan jumlah
leukosit total selain menjaga.

Recurrent BO
Obstruksi usus berulang - penyebab umum diberikan dalam [Tabel / Gambar-6]. BO berulang terlihat
dalam tiga skenario klinis. Yang pertama adalah pada abdomen yang tidak diukir, sebagian besar
karena hernia internal, kedua selama periode pasca operasi awal, di mana ada kemungkinan
kebingungan ileus pasca operasi / BO. Skenario ketiga adalah obstruksi perekat. Ketiga situasi ini
dibahas di bawah ini.
a. Recurrent BOin virgin abdomen
Seringkali, mereka hadir di BO berulang dan terus menyelesaikan pada manajemen konservatif. CT
scan dengan kontras oral dan bahkan studi barium usus kecil biasanya bersifat diagnostik. Hernia
Para-duodenal merupakan 50% dari herniasi internal [Tabel / Gambar-7] [36,37]. Sebuah studi
barium usus kecil / CT-scan mungkin diagnostik [38]. Laparoskopi terus menjadi alat diagnostik dan
terapeutik yang aman dalam pengelolaan BO awal pada anak dan BO kecil berulang [39]. Dalam hal
kesulitan apa pun, operasi reduksi terbuka [Tabel / Gambar-8] dapat dilakukan.

b. Early post-operative BO or early recurrence BO after relieve of BO/ paralytic ileus

Ini adalah kondisi yang paling serius, karena pasien telah berpuasa dan masih muntah. Ini
menyebabkan malnutrisi dan ketidakseimbangan elektrolit. Ketika keadaan ileus pasca operasi ini
tetap lebih lama dari biasanya, pasien terus mengalami distensi perut dan terus muntah. Penting
untuk menyingkirkan kebocoran usus. Hal ini sebagian besar terlokalisasi karena adhesi [Tabel /
Gambar-9] dan jarang menyebabkan peritonitis. Setiap bentuk drainase akan menyebabkan fistula
faecal dan, karenanya keputusan kritis dapat diambil pada laparotomi dan penutupan atau membuat
fistula. Apapun keputusannya, nutrisi parenteral harus diberikan dalam keadaan gagal usus. Jika
stoma dibuat di jejunum atau pertengahan usus, usus distal dapat digunakan untuk memberi makan
distal dari output [40]. Jenis reus infus atau enteroclysis ini lebih murah, ditolerir dengan baik, dan
teknik-teknik dukungan nutrisi yang mudah digunakan, yang memungkinkan mengurangi biaya
perawatan kesehatan yang berhubungan dengan nutrisi parenteral dan menyelamatkan nyawa [40].

Langkah selanjutnya adalah membedakan antara ileus paralitik berkepanjangan dan BO mekanik.
Seseorang harus menduga obstruksi mekanik ketika: Pasien telah melewati flatus / tinja dan
kemudian berhenti lagi, peristaltik yang bising dan tidak ada kentut, nyeri kolik, X-ray / CT-scan /
kontras perut studi menunjukkan obstruksi [41]. Insiden operasi ulang diberikan dalam [Tabel /
Gambar-10]. Setelah ditetapkan sebagai obstruksi mekanik dan usus tidak ber-gangren, lintasan
gastrograffin dapat diberikan dan jika gagal, maka pembedahan dapat dilakukan sesuai algoritma.

Maka hanya satu yang dapat memikirkan penggunaan alvimopan dan methylnaltrexone, antagonis
reseptor μ-opioid perifer dapat digunakan untuk mempercepat pemulihan gastrointestinal. Dalam
administrasi percobaan acak lain Bisacodyl menunjukkan secara signifikan gerakan usus lebih awal
daripada mereka yang menerima plasebo (25 jam vs 56 jam) [42]. Bahkan dalam adhesi pasca
operasi awal protokol manajemen harus mengikuti algoritma [Tabel / Gambar-11].

c. Late post-operative recurrence

BO berulang adalah tantangan nyata dalam jenis perekat. Penyebab umum diberikan dalam [Tabel /
Gambar-6]. Ada banyak lagi penyebab yang jarang dan jarang selain diberikan dalam tabel.
Manajemen awal tetap sama seperti yang berlaku dalam algoritma. Dalam SBO rekat rekuren, tidak
teratasi bahkan setelah lintasan gastrograffin, pembedahan diindikasikan. Selama pembedahan,
setelah adhesiolysis, lebih baik untuk melakukan pembekuan usus untuk menghindari serangan
berikutnya [Tabel / Gambar-12] [45]. Penyembuhan dapat dilakukan dengan memperbaiki
mesenterium (The Noble plication) dengan aplikasi pelindung fibrin-disegel [46]. Implikasi trans-
mesenteric juga dapat dilakukan dalam keadaan peritonitis [47]. Tetapi dalam efektivitas
pencegahan adhesi tanpa pembatasan mengenai mode aplikasi dan kompatibilitas dan, dengan
demikian, adalah strategi yang menjanjikan untuk mencegah adhesi perut [49].

Namun, dalam tinjauan sistematik database kochrane, hasil positif disanggah [50]. Serupa, hasil
negatif dilaporkan untuk icodextrin sebagai cairan antaperadangan intaperitoneal [51]. Sebenarnya
penyebab obstruksi berulang harus ditemukan dan ditangani setelah obstruksi akut hilang. Kasus-
kasus seperti itu biasa terjadi pada hernia interna. Studi barium atau CT scan dengan kontras enteral
menentukan diagnosis. Jika keduanya pergi tanpa diagnosis, laparoskopi diagnostik akan berujung
pada terapi juga.

Jika operasi diperlukan selama serangan akut, laparotomi tidak hanya memberikan diagnosis tetapi
operasi kuratif dapat dilakukan. Kasus kepompong perut menantang bagi dokter bedah, sinar X
polos menunjukkan hampir tidak ada usus kecil yang melebar ke dokter bedah yang ingin tahu.
Kadang-kadang mungkin kepompong yang menutupi seluruh usus kecil. Sebagian besar disebabkan
oleh tuberkulosis di India [52]. Kadang-kadang mungkin karena fibrosis peritoneum [53]. Tricky
adhesiolysis oleh ahli bedah yang berpengalaman diperlukan.
Gastrograffin trial

Data menunjukkan bahwa, penggunaan gastrograffin dalam obstruksi usus halus perekat aman dan
mengurangi tingkat operasi dan waktu untuk resolusi obstruksi. Satu penelitian telah melaporkan
resolusi obstruksi di 81,5% setelah waktu rata-rata 6,4 jam [54]. Ketika terputus, mengurangi masa
tinggal di rumah sakit dengan perekat SBO [54-56] dan kegagalan untuk menyelesaikan adalah
indikasi efektif dalam memprediksi kebutuhan untuk operasi [55]. Adalah lebih baik untuk
melakukan CT scan dengan kontras oral untuk mengetahui lokasi dan penyebab obstruksi sehingga
dapat ditangani selama serangan ini atau disiapkan jika terjadi kekambuhan.

Ovarian cancer related bowel obstruction

Kanker ovarium membutuhkan perhatian khusus karena tingginya insiden BO pada pasien ini.
Hampir 20% wanita mengembangkan BO setelah mereka didiagnosis mengidap kanker. Ada
peningkatan risiko obstruksi berikutnya [57]. Dilepas usus di hadapan fitur SBO tidak
mendapat manfaat dari intervensi operasi [Tabel / Gambar-14]. Estimasi CA-125 dapat
membantu. Diskusi yang tekun dengan tim utama dan diskusi jujur dengan pasien dan
keluarganya sangat penting untuk merumuskan rencana yang tepat [58].

Timing and decision for surgery

Pengaturan waktu sangat penting untuk menghindari reseksi usus besar dan jelas
ketidakseimbangan elektrolit. Mengidentifikasi pasien yang mungkin dengan aman menjalani
manajemen non operatif tetap sulit [59]. Dalam studi besar 1613 pasien 56,6% diperlukan
operasi dan 43,4% dapat dikelola non-operatif [59]. Ada insiden terkait reseksi usus yang
lebih tinggi pada pasien yang membutuhkan waktu lebih lama untuk mencapai ruang operasi.
Di antara pasien yang masuk ke ruang operasi kurang dari 24 jam, 12% pasien memiliki
reseksi usus dibandingkan dengan 29% pada pasien yang mengambil lebih dari 24 jam [59].
Untuk menghindari potensi peningkatan risiko kehilangan usus, intervensi harus
dipertimbangkan pada hari kedua pada pasien anak dengan ambang batas rendah pada mereka
yang tidak menunjukkan tanda-tanda perbaikan [31] dan tidak lebih dari 5 hari pada orang
dewasa [60]. BO di usia muda dan pasien yang memiliki perut perawan lebih mungkin
menjalani operasi bawah [59]. Pasien dengan CT scan obstruksi lengkap, usus kecil melebar
dan cairan bebas dioperasikan pada 77%, 66%, dan 65% dari waktu, masing-masing [61].

Pasien dengan pengobatan konservatif untuk BO, di mana volume drainase melalui tabung
nasogastrik pada hari ke 3 adalah> 500mL, sebagian besar membutuhkan pembedahan [62]. CT scan
perut dengan gastrograffin oral tidak hanya memberikan lokasi BO tetapi juga menambah percobaan
gastrograffin dan menghindari operasi perut [63]. Ketika prosedur diperlukan untuk adhesiolysis,
adhesiolysis laparoskopi di tangan ahli pada pasien yang dipilih, mengurangi tingkat komplikasi
secara keseluruhan. Hal ini ditemukan menguntungkan dalam penelitian [64]. Rumah sakit pasca
operasi secara signifikan lebih pendek pada kelompok Laparoscopic Adhesiolysis (LA) dibandingkan
dengan konversi (3 vs 9 hari). LA aman dan layak untuk manajemen BO dan harus ditawarkan kepada
semua pasien dengan BO kecuali ada kontraindikasi absolut untuk operasi laparoskopi [65,66]. Ini
juga cocok pada kelompok usia anak-anak [67]. Ini adalah alat diagnostik yang sangat baik dan,
dalam banyak kasus, modalitas terapeutik pada pasien dengan SBO. Namun, sejumlah besar pasien
akan memerlukan konversi [66]. Buka adhesiolysis lebih cepat daripada laparoscopic adhesiolysis
(LA) [68]. Insisi bedah abdomen atas sebelumnya dan zona transisi di luar panggul pada CT scan
adalah prediktor pra-operasi dari adhesiolysis laparoskopi yang berhasil. Kelompok laparoskopi
memiliki durasi tinggal yang lebih pendek [69]. LA di hadapan usus melebar menyebabkan kurang
dolmen untuk memainkan instrumen dan karenanya, itu tidak dianjurkan. Ini sangat ideal, di mana
BO yang disebabkan oleh adhesi pasca-operasi telah diselesaikan sebelumnya pada manajemen
konservatif dan pasien datang dengan kekambuhan, di mana LA harus dicoba lebih awal sebelum
dilatasi kotor usus [70]. Konversi ke mini-laparotomi atau laparotomi harus dipertimbangkan pada
pasien dengan adhesi padat atau pelvis [71].

Setelah diagnosis BO ditegakkan secara klinis dan dikonfirmasi dengan pemeriksaan radiologi; maka
muncullah keputusan. Ada dua keputusan yang konservatif atau operatif. Jika konservatif dipilih,
tanggung jawab tim yang merawat adalah untuk beroperasi sebelum usus menjadi gangren. Oleh
karena itu, mengulangi X-ray / CT scan dan memancarkan pasien terlihat non-akademik. Kedua
diagnosis klinis dari resolusi BO cukup jelas secara klinis.

Palliation in BO

Pada pasien perawatan paliatif dengan mual dan muntah, antagonis reseptor 5HT3 dapat digunakan
jika pengobatan dengan antiemetik lainnya, seperti metoclopramide dan neuroleptik tidak cukup.

Ada kecenderungan bahwa steroid dalam kombinasi dengan antiemetik lainnya meningkatkan
bantuan gejala.
Cannabinoids memiliki status sebagai antiemetik baris kedua. Sebagai perawatan paliatif pada
obstruksi ganas, oktreotida aksi panjang tetap pilihan pertama dan butil-skopolammonium bromide,
yang kedua untuk meringankan gejala [72]. Dalam sebuah penelitian kecil hanya 12 kasus, (pasien
dengan disfungsi BO / usus yang ganas), sebagian besar pasien membaik dengan kombinasi anti-
inflamasi (Dexamethasone), anti-sekretori (Octriotide), dan prokinetik (metoclopramide).

Post-operative prognosis

Mortalitas pasca operasi awal sangat terkait dengan usia dan American Society of Anesthesiologists
(ASA) grade dan mortalitas jangka panjang dengan komplikasi pasca-operasi [73]. Reseksi usus lebih
sering mungkin disarankan untuk pasien yang memiliki 10 atau lebih striktur obstruktif dan cedera
dinding usus, terutama bila dihubungkan dengan iskemia intestinal reversibel [74].

Conclusi on

Memprediksi manajemen konservatif atau operatif dalam BO sulit. Keputusan tentang operasi harus
diambil pada pasien anak-anak dengan 24 jam, di usia muda, di perut perawan dan BO besar dengan
48 jam dan dalam 3-5 hari masuk pada orang dewasa, jika gastrografin oral gagal untuk
menyelesaikan BO lebih sehingga obstruksi perekat dengan aspirasi saluran lambung (> 500ml) yang
tinggi (Algoritma). Dalam BO berulang beberapa bentuk plikasi dapat dipertimbangkan selama
operasi. Mortalitas pasca operasi dini sangat terkait dengan usia dan tingkat ASA sedangkan
mortalitas jangka panjang dikaitkan dengan komplikasi pasca-operasi.