Multi-level bowel obstruction in a patient with previous truncal vagotomy

Abstract text (incl. references and figure legends)

Case history:A 78-year-old gentleman attended the emergency department with a 5 day history of severe persistent epigastric pain, nausea, and vomiting. He had a medical history of hypertension, coronary artery bypass graft, renal stones, truncal vagotomy and spinal stenosis.

Clinical findings:The abdomen was distended but soft with generalised tenderness, worse in the epigastric region. There were reduced bowel sounds and the PR examination identified hard stools in the rectum.

Investigations:Vital signs were within normal range, with mildly raised CRP and lactate. A CT abdomen and pelvis revealed a high-grade small bowel (SB) obstruction; the stomach, duodenum and proximal jejunum were grossly distended above the level of a transition point.

Diagnosis:The initial impression was of SB obstruction, likely adhesional in origin, secondary to previous abdominal surgery.

Therapy:The patient underwent an emergency laparotomy. A food bolus was identified in the proximal SB, beyond which the bowel was collapsed. A 5 cm enterotomy was performed to deliver the bolus. Postoperatively, the patient experienced a post operative ileus. A repeat CT scan indicated a similar pattern of bowel dilation with no definite obstructing cause. Decision for a relook laparotomy was made. A large firm food bolus was found proximally to the previous enterotomy site, with multiple additional boluses in the jejunum and colon. Two further enterotomies were needed. Patient recovered slowly and discharged the 25th post operative day.

Comments:This was a case of a multi-level SB obstruction secondary to food bolus, likely related to the previous truncal vagotomy. The gastroparesis and the contents of the dilated stomach were the reason of the second episode of SB obstruction, soon after the initial emergency laparotomy. This was a challenging and very rare event which should be in mind of all the emergency surgeons who deal with similar cases.

References: Seeras K, et al. Truncal Vagotomy. 2021

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