Laparotomy under high spinal anaesthesia: Is it the way out for the anaesthetically high-risk patient with small bowel obstruction?

Abstract text (incl. references and figure legends)

Case history:We discuss management of two frail patients with significant pulmonary disease and acute small bowel obstruction (SBO) requiring surgery. First patient was 78yrs old with atrial fibrillation, heart failure & hypothyroidism. Second patient was 75yrs old with hypertension, pulmonary fibrosis & previous MI. He had recently completed radical chemoradiotherapy for oesophago-gastric cancer and had an indwelling gastrostomy feeding tube.Clinical findings:Both patients had abdominal pain & persistent bilious vomiting. There were no signs of peritonitis on examination. The first patient presented 2 days after onset of symptoms and appeared to have aspiration pneumonitis necessitating intravenous antibiotics.Investigations:CT scan in the first patient revealed high-grade SBO with transition within the mid ileum in keeping with adhesional obstruction. In the second patient, CT showed SBO with two transition points likely due to adhesive bands within the mid ileum & the terminal ileum along with mesenteric oedema and thickening raising concern about closed loop obstruction.Diagnosis: adhesive SBO.Therapy: First patient was treated conservatively for 3 days with close monitoring but there was no resolution of obstruction, so surgery was carried out on day 4. In the second case, urgent surgery was planned shortly after presentation in view of CT findings. In both cases, patients were not fit for GA due to their chest conditions, therefore, decision made to operate under high spinal anaesthesia. In the first case, tight adhesional-band was found causing gangrenous constriction-ring in the bowel, however without perforation or contamination. This was divided & limited resection re-anastomosis performed. In the second case, adhesions causing a closed loop were released.Comment:Regional anaesthesia can enable surgery for the fragile patient with SBO. Technique is key & decision to operate has to be timely as this approach can"t be adopted when contamination is present.

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