From the Guidelines
The most suitable treatment option for this case is surgical intervention with a right hemicolectomy and resection of the terminal ileum. This procedure would involve removing the affected ileal segment with the stricture, the ileocecal valve, and the ascending colon containing the necrotic-like areas, followed by creation of an ileocolonic anastomosis. Preoperative management should include bowel rest, nasogastric tube decompression, intravenous fluid resuscitation, and broad-spectrum antibiotics (such as piperacillin-tazobactam 3.375g IV every 6 hours or ceftriaxone 1g IV daily plus metronidazole 500mg IV every 8 hours) 1. The presence of a stricture, lymph node enlargement, and necrotic areas suggests possible malignancy or advanced inflammatory bowel disease, making surgical resection necessary rather than conservative management. The resected specimen should be sent for pathological examination to determine the underlying etiology, which will guide further treatment. Postoperatively, the patient will require continued antibiotics for 5-7 days, gradual advancement of diet, pain management, and close monitoring for complications such as anastomotic leak, wound infection, or recurrent obstruction. Early mobilization should be encouraged to prevent postoperative complications. According to the 2017 WSES guidelines on colon and rectal cancer emergencies, right colectomy with primary anastomosis is the preferred option for right-sided colon cancer causing acute obstruction 1. In this case, the ileal stricture is located 10 cm from the ileocecal valve, and the presence of lymph node enlargement and necrotic areas in the lower ascending colon suggests a possible malignant or advanced inflammatory process, making right hemicolectomy and resection of the terminal ileum the most suitable treatment option. The ECCO-ESCP consensus on surgery for Crohn's disease also supports the use of stricturoplasty as a safe alternative to resection in jejuno-ileal Crohn's disease, but this is not applicable in this case due to the presence of necrotic areas and lymph node enlargement, which suggests a possible malignant process 1. Therefore, the most suitable treatment option is a right hemicolectomy and resection of the terminal ileum, as it addresses the possible malignant or advanced inflammatory process and prevents further complications.
From the Research
Treatment Options for Small Bowel Obstruction
The case presents a small bowel obstruction with an ileal stricture 10 cm from the ileocecal valve, lymph node enlargement, and necrotic-like areas in the lower ascending colon. Considering the evidence, the most suitable treatment option would be:
- Right hemicolectomy: This procedure is supported by studies 2, 3, 4, which highlight the importance of surgical resection in treating colon cancer and lymph node metastasis. Right hemicolectomy is a common surgical procedure for treating right colon cancer, and it may be necessary for removing the affected portion of the ileum and the enlarged lymph nodes.
Rationale for Right Hemicolectomy
The rationale for choosing right hemicolectomy is based on the following points:
- The presence of an ileal stricture and lymph node enlargement suggests a possible malignant process, which requires surgical resection 2, 3.
- The location of the stricture, 10 cm from the ileocecal valve, and the presence of necrotic-like areas in the lower ascending colon, indicate that the disease process may involve the cecum and the ascending colon, making right hemicolectomy a suitable option 4.
- The study by 5 highlights the importance of considering rare causes of small bowel obstruction, such as endometriosis, but in this case, the presence of lymph node enlargement and necrotic-like areas suggests a more sinister process.
Other Options
The other options, such as stricturoplasty and nodal biopsy 3, ileotransverse anastomosis and biopsy, and biopsy and close, may not be suitable for this case, as they may not address the underlying disease process adequately. Stricturoplasty may be considered for benign strictures, but in this case, the presence of lymph node enlargement and necrotic-like areas suggests a possible malignant process. Ileotransverse anastomosis and biopsy may not be necessary, as the disease process appears to be localized to the ileum and the ascending colon. Biopsy and close may not be sufficient, as it may not address the underlying disease process, and the patient may require further surgical intervention.