What is the treatment for small intestine intertwining?

Treatment for Small Intestine Intertwining (Volvulus)

Surgical intervention is the definitive treatment for small intestine intertwining (volvulus), with exploratory laparoscopy or laparotomy recommended within the first 12-24 hours in stable patients presenting with persistent abdominal pain. 1

Diagnostic Approach

• CT scan is the preferred imaging technique to confirm diagnosis, identify the location of obstruction, and detect signs requiring immediate surgery
• Plain abdominal X-rays have limited diagnostic value (50-60% accuracy) and may be inconclusive in 20-30% of cases 2
• Laboratory tests should include complete blood count, renal function, electrolytes, serum bicarbonate, and lactic acid to identify signs of ischemia 2

Pre-operative Management

1. Nasogastric tube decompression
2. IV fluid resuscitation with correction of electrolyte abnormalities
3. NPO status
4. Broad-spectrum antibiotics if signs of ischemia or perforation are present 2

Surgical Management Algorithm

Step 1: Surgical Approach Selection

• Laparotomy: Standard approach for high-grade small bowel obstruction with optimal exposure for complete assessment 2
• Laparoscopy: May be considered in selected cases with:
  • ≤2 previous laparotomies
  • No previous median laparotomy
  • Suspected single adhesive band 2

Step 2: Intraoperative Assessment

• Begin exploration from the ileocecal junction (distal to obstruction) and work proximally 1
• Assess intestinal viability thoroughly - look for:
  • Color changes
  • Absent peristalsis
  • Absent mesenteric pulsations
  • Mesenteric hemorrhage 1
• Indocyanine green (ICG) fluorescence angiography may be used to evaluate bowel perfusion when available 1

Step 3: Definitive Treatment Based on Findings

• For viable bowel with volvulus: Detorsion (untwisting) of the affected segment 1
• For non-viable bowel: Resection of the affected segment with primary anastomosis in hemodynamically stable patients 1
• For extensive ischemia/peritonitis in unstable patients: Damage control approach with resection and temporary abdominal closure 1
• For intussusception: Reduction if bowel is viable, but resection of the affected segment is recommended to prevent recurrence 1

Post-operative Management

• Continue nasogastric decompression until return of bowel function
• Progressive diet advancement once bowel function returns
• Early mobilization to prevent post-operative complications
• Close monitoring for signs of recurrent obstruction or anastomotic leak 2

Special Considerations

• In pregnant women, diagnostic laparoscopy for small bowel obstruction is effective and associated with good maternal and fetal outcomes 1
• Post-bariatric surgery patients require specialized evaluation, starting with inspection of potential internal hernia sites: traverse mesocolon, Petersen's space, and jejuno-jejunostomy mesenteric defect 1
• If an internal hernia is found, closure of the mesenteric defect should be performed with non-absorbable material 1

Outcomes

• Surgical management has a lower recurrence rate compared to non-operative management (8% vs 16% at 1 year) 2
• Morbidity rates after surgical exploration range from 10-39% 2
• Mortality is generally low with prompt surgical intervention, but increases with delayed treatment 2

Early recognition and prompt surgical intervention are critical to prevent progression to intestinal necrosis, which significantly increases morbidity and mortality.