Case history
This is the case of a 81 year-old woman with a past medical history of transperitoneal open right nephrectomy for clear cell carcinoma.
Clinical findings
The patient referred to the Emergency Departmet (ED) complaining of abdominal distension, pain, nausea and constipation. Vital signs and labs were normal.
Investigation/Results
Contrast enhanced CT-scan showed adhesive small bowel obstruction (ASBO) without signs of bowel ischemia.
Diagnosis
The diagnosis was non complicated ASBO
Therapy and Progressions
The patient was treated with fluids, nihil per os and gastric tube decompression. Gastrografin challenge was tried and, at the 8-hour abdominal plain film, the contrast was in the rectum. Therefore, she started and tolerated solid oral feeding and was discharged. Ten days later, she was readmitted complaining of the same symptoms and nonoperatively treated at first after a CT-scan not showing signs of ischemia. This time we noticed a failure in non operative approach so that the patient was taken to the OR. A laparoscopic approach was chosen. Intraoperative findings were significant for a long right ureter stump at the level of the right iliac vessels acting as a band and responsible for a closed loop obstruction. The band was divided with immediate resolution of the obstruction. The post-operative course was uneventful and the patient was discharged 3 days afterwards.
Comments
ASBO is commonly caused by postoperative peritoneal adhesions. Non-operative management is the preferred choice when no bowel ischemia is detected. When surgery is needed, in absence of contraindications, laparoscopic approach showed to be safe and feasible. To our knowledge, this is the first reported case of a ureter residual causing ASBO.
Fig 1 Intraoperative findings: ureter stump causing loop obstruction
References
Regan JP, Cho ES, Flowers JL. Small bowel obstruction after laparoscopic donor nephrectomy. Surg Endosc. 2003 Jan;17(1):108-10
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