53 yo male,came to ER last week with a clear clinical picture of SBO. No previous pathologies nor operations. Underwent an open exploratory laparotomy and 360 small bowel volvulus was detected. Devolvulated,and observed thoroughfully, the loops seemed viable and the surgeon reckoned that the abdo could be closed and so he did. Next day,the abdo was not quiet and we thought that a second look was needed. At exploration, necrosis was observed and extending from the first yeyunal loop through all the yeyunum, starting at almost the Treitz angle and extending to good part of the ileum. Resection was performed and a Foley drain introduced backwards towards the duodenum through the first residual yeyunal loop,closing the loop with seperated stitches (obviously a bad procedure). The aim was to keep well drained the doudenum. A sort of "retrograde duodenostomy". The distal ileal end was exteriorized as a mucosal fistulae.The abdo was left open.
During the week,two reexplorations have been performed and last Tuesday,the abdo was closed. The general condition of the pt is very good though a small leakage of biliary fluid has been appreciated around the way out of the supposed doudenostomy.
He is on TPN and the problem arises now :
What to do next?...No matter what we do,the pt will remain at last with no more than 20 to 25 cms of ileon but what should be done prior to remaking the transit?
Hope you will help us in this diffcult case live.