Colonic interposition in a patient with short bowel syndrome: a case report

Introduction: Short bowel syndrome is secondary to massive reduction in intestinal length due to surgical resection, compromising absorption of fluids and nutrients necessary for adequate growth in children and weight maintenance in adults. The main etiology is acute mesenteric ischemia. Other causes are atresia and volvulus, traumatic injury, necrotizing enterocolitis, neoplasms and Crohn's disease. Isoperistaltic or antiperistaltic interposition delays transit time and provides better absorption of water and electrolytes, increasing the concentration and viscosity of the fecal bolus. Objectives: To report a case of colonic interposition in a patient with short bowel syndrome, its clinical presentation and treatment. Methodology: This is a descriptive observational study based on the analysis of the patient's medical record and literature review. Results: A 63-year-old woman presented with diffuse abdominal pain that had started 20 days previously and worsened suddenly, associated with nausea and vomiting. Personal history of colon adenocarcinoma, hypertension, acute myocardial infarction and former smoker. Surgical history: rectosigmoidectomy with primary anastomosis. On physical examination, the patient was in a regular general state, discolored, dehydrated, with a distended abdomen, tympanic on percussion and painful on superficial and deep palpation with signs of peritonitis. Acute abdominal radiography showed hydroaerial level, coin stacking and absence of air in rectal ampulla. Contrast-enhanced abdominal CT showed hydroaerial distention of small bowel loops with gas collections, rotation of the mesentery root with abrupt tapering point in the distal ileum and small amount of free fluid in the abdominal cavity. An exploratory laparotomy was performed which visualized extensive ischemia of the small bowel due to internal hernia and moderate amount of hematic fluid and bridles in the fundus, integral colorectal anastomosis, presence of wide mesenteric ischemia extending 50 cm from the Treitz angle to 30 cm from the ileocecal valve. After these findings, a resection of the entire ischemic area and latero-lateral anastomosis with linear stapler was performed. . The patient evolved to an intensive care unit bed for a few weeks and then to a ward bed, where he remains until now, receiving parenteral diet with progression to enteral diet. The anatomopathological examination showed segmental ischemic necrosis of the mucosa and transmural area of the small intestine, with areas of hemorrhage, in addition to regional acute exudative peritonitis and proximal and distal surgical margins with ischemic changes of the mucosa and areas of recent hemorrhage with lymph nodes. Conclusion: Our work reports a case of difficult approach that represents a great challenge to surgeons. The therapeutic possibility of intestinal transplantation increases patient survival and should be individualized.