R. Douard

Background: Determining the cause of acute small bowel obstruction (SBO) in patients previously treated for cancer is necessary for adequate management, especially to avoid incorrectly classing the patient as palliative. We aimed to identify predictive factors for a malignant or a benign origin of SBO.Methods: We retrospectively studied data for all patients with a prior history of cancer who had undergone operations for SBO between January 2002 and December 2011. Of the 124 patients included, 36 patients had a known cancer recurrence before surgery for SBO, whereas 88 had none.Results: Causes of SBO were benign (post‐operative adhesions, post‐irradiation strictures) in 68 patients (54.8 %) and malignant in 56 (45.2 %). Incomplete obstruction, acute clinical onset, non‐permanent abdominal pain, a shorter period between primary cancer surgery and the first episode of obstruction, and a known cancer recurrence were significant predictors of a malignant SBO. Benign causes of SBO were observed in 72.8 % of patients who had no known cancer recurrence, but were observed in only 11.1 % of patients whose recurrences were known. In patients with cancer recurrence‐related SBO, post‐operative mortality was 28.6 %, with a median overall survival of 120 days. 1 month after surgery, 38 (67.8 %) of these patients tolerated oral intake.Conclusion: A benign cause of SBO was observed in half of the patients with a prior history of cancer and in two‐thirds of those without known recurrence. Even in the absence of bowel strangulation, surgery must be considered soon after failure of medical management to treat a possible adhesion‐related SBO.

In laparoscopic colorectal resection, the medial-to-lateral approach has been largely adopted. This approach can be initiated by the division of either the inferior mesenteric artery (IMA) or the inferior mesenteric vein (IMV). This cadaveric study aimed to establish the feasibility of IMV dissection as the initial landmark of medial-to-lateral left colonic mobilization for evaluating the size of the peritoneal window between the IMV at the lower part of the pancreas and the origin of the IMA (IMA-IMV distance) and the point of origin of the IMA compared to the lower edge of the third part of the duodenum (IMA-D3 distance). These distances were recorded on 30 fresh cadavers. The IMA-D3 distance was 0.4 ± 2.2 cm (mean ± SD). The IMA originated from the aorta at the level of or below the D3 in 21 cases (70%). The IMA-IMV distance was 5.5 ± 1.8 cm and was greater or equal to 5 cm (large window) in 21 cases (70%). IMA-IMV distance was correlated with IMA-D3 showing that a large window was inversely correlated with a low IMA origin (P < 0.001). IMA-D3 distance was not correlated with weight, height and sex. IMA-IMV distance was largerin male (6.7 ± 0.9 vs. 4.9 ± 1.8, P = 0.001) and correlated with weight, (r = 0.60, 95%CI = 0.03–0.10, P < 0.001) and height (r = 0.54, 95%CI = 0.05–0.21, P = 0.002). IMV can be used as the initial landmark for laparoscopic medial-to-lateral dissection in two-thirds of cases. A too-small window can require first IMA division. The choice between the two different medial-to-lateral approaches could be made by evaluating the anatomical relationship between IMA, IMV, and D3. Clin. Anat., 2013.