Intestinal obstruction is significant mechanical impairment or complete arrest of the passage of contents through the intestine. Symptoms include cramping pain, vomiting, constipation, and lack of flatus. Diagnosis is clinical, confirmed by abdominal xrays. Treatment is fluid resuscitation, nasogastric suction, and, in most cases of complete obstruction, surgery.
Background •A small-bowel obstruction (SBO) is caused by a variety of pathologic processes. The leading cause of SBO in developed countries is postoperative adhesions (60%) followed by malignancy, Crohn disease, and hernias, although some studies have reported Crohn disease as a greater etiologic factor than neoplasia. Surgeries most closely associated with SBO are appendectomy, colorectal surgery, and gynecologic and upper gastrointestinal (GI) procedures. • One study reported a higher frequency of SBO after colorectal surgery, followed by gynecologic surgery, hernia repair, and appendectomy. •Lower abdominal and pelvic surgeries lead to obstruction more often than upper GI surgeries. •SBOs can be partial or complete, simple (i.e. nonstrangulated) or strangulated. Strangulated obstructions are surgical emergencies. •If not diagnosed and properly treated, vascular compromise leads to bowel ischemia and further morbidity and mortality. Because as many as 40% of patients have strangulated obstructions, differentiating the characteristics and etiologies of obstruction is critical to proper patient treatment.
l. Depending upon the nature of obstruction: A. Mechanical obstruction(dynamic obstruction) 1.Obstructed a: fecalith b: helminthic c: foreign body 2. Strangulated obstruction a: volvulus b: hernia strangulated c: bundle 3. Mixed obstruction(obstructed + strangulated obstruction) a: Intussusception b: Adhesive obstruction B. Adynamic obstruction 1. Paralytic obstruction 2. Spastic obstruction ll. Depending upon the localization of obstruction 1. Intestinal (high; low) 2. Colon lll. Genealogically ( Congenital, Acquired) lV. Clinically 1. Partial 2. Complete(Acute, Subacute, Chronic and Recurrent))
MECHANICAL OBSTRUCTION(DYNAMIC OBSTRUCTION):Classified as 2 types AObtructedit includes the obstruction of the lumen from inside with the inflammation, fecallith, gall stones, food bolus, foreign bodies, obstructed carcinoma, etc. Pressure on the intestine from outside with the inflammations, increased lymphatic nodes, soldering occlusion of the obturator type can also be the reasons for development of the obstructed mechanical obstruction. It is important to know that the blood supply is not seriously impaired in this type of obstruction. The conservative treatment is carried on in 1 hour. BStrangulatedmay include volvulus,srangulated hernia, bundle necrosis. The blood supply is seriously impaired in such a type of obstruction. Conservative treatment in 45 hours.
Left Bowel (mechanical)Obstruction Strangulated bowel obstruction
Intussusception is the invagination
Intussusception of intestine
INTUSSUSCEPTION It is the invagination of one segment of intestine within the other(usually the proximal into the distal)is called intussusception. TYPES (1)Simple ileocolicthe most commom followed by the ileoileal,colocolic,etc (2)Compoundileoileocolic. (3)Retrograde jejunogastric intussusception, a complication of gastrojejunostomy that is rare but an interesting type of intussusception. PARTS (1)INTUSSUSCIPIENSIt is the outer tube(distal bowel that receives the intestine). (2)INTUSSUSCEPTURNproximal bowel(inner tube)that enters inside. (3)APEXis the part that advances further into the distal bowel. (4)NECKthe narrowest portion of intussusception, is the junction of the entering layer whole the mass. The whole mass that develops is called intussusception.
Figure 1 Anatomy of the digestive tract showing the relationship of the small bowel (duodenum, jejunum and ileum) to the stomach and colon
Figure 2 Anatomy of a typical intussusception of ileum into the colon. The leading proximal, small bowel segment (intussusceptum) telescopes into the distal, colon segment (intussuscipens)
AETIOPATHOGENESIS IDIOPATHIC INTUSSUSCEPTION: Actual cause unknown. Seen in infants. Possible factors(a)Dietary factoraround the age of 69 months weaning of the breast milk is done. Weaning causes alteration in the bacterial flora in the gastro intestinal tract, causing swelling of the Peyer’s patches. These protrude into the terminal ileum and may precipitate intussusception. (b)Infective factorusually follows upper respiratory tract infection with the virus that produces inflammation of the Peyer’s patches.
SECONDARY INTUSSUSCEPTION: In adults there is always a cause for intussusception. For e.g.: Meckel’s diverticulum. Polyps. Carcinoma in the caecum or the transverse colon. Submucous lipoma of the terminal ileum. Purpura with submucosal hemorrhages causing swelling of the intestine. CLINICAL FEATURES (1)First born male infants between 69 months commonly affected. (2)Child screams with abdominal pain which is associated with facial pallor. (3)One attack of ”red currant jelly stools” !Bleeding is due to mucosal ulcer. !Mucous is due to irritation of the intestines followed by absolute constipation. (4)Vomiting 34 times, initially due to pylorospasm and later due to obstruction. (5)In between the spasms, the child sleeps but wakes up suddenly with pain.
SIGNS The mother is asked to feed the baby in sitting position and the examination should be done with the left hand, standing in front of the mother. (1)A contracting, hardening mass in and around the umbilical region can be felt(sausage shaped). (2)Emptiness in the right iliac fossa ” Signe De Dance”. (3)There may be a visible step ladder peristalsis. (4)Rarely, Intussusception can be seen outside the anus due to long mesentery. (5)Rectal examination reveals blood stained mucous. DIAGNOSIS ~BARIUM ENEMA: Claw(pincer) ending is the diagnostic of intussusception. This is also called as meniscus sign. If there is any suspicion of gangrene, this test should not be done.
TREATMENT (A)CONSERVATIVE TREATMENT: Hydrostatic reduction can be attempted when the gangrene is ruled out as in early intussusception. A lubricated catheter is introduced into the rectum and 12 liters of saline from height of 12 meters is allowed to run. Catheter is removed and buttocks are pressed together,50 70% of cases are reduced by this method,1:3barium sulfate in warm, isotonic saline can also be used. HYDROSTATIC REDUCTION IS SUCCESSFUL WHEN: (1)Passage of flatus and feaces with barium. (2)Symptomfree, comfortable child. (3)Small bowel loops are filled with contrast. AdvantagesEasy, nonoperative method. ComplicationRarely, colonic perforation. ContraindicationPeritonitis with shock, Total intestinal obstruction.
(B)SURGICAL TREATMENT: ~Laparotomy and reduction of Intussusception. ~Intussusception is reduced by milking or squeezing the colon in opposite direction, which is facilitated by breaking the adhesions at the neck using the little finger. Appendectomy is also done. Fixing the caecum is not necessary because idiopathic intussusception rarely reoccurs ~If the loop is gangrenous, resection and ileocolic anastomosis is done. ~Recurrent intussusception is rare, If it occurs, terminal ileum is sutured to the side of ascending colon.
VOLVULUS OF THE SIGMOID COLON: The precipitating factors are: long mesentery of the pelvic colon. :narrow attachment at the base. :long redundant, pendulous sigmoid. :feaces loaded colon due to high residuous diet :diverticulitis with a band or adhesions. CLINICAL FEATURES : Usually after straining at stools. Volvulus is usually in an anti clockwise direction and after one and a half turns, the entire loop becomes gangrenous. :Enormous distension of the abdomen takes place that gives a tympanitic note all over the abdomen which is due to the diffusion of carbon dioxide gas. Severe hypovolaemic shock develops in 68 hours of volvulus and setting in of gangrene gives rise to features of strangulation. A dilated loop can be seen and felt too. Within 12 days features of peritonitis can be seen. :In case of chronic recurrent sigmoid volvulusoccurrence is due to partial twisting and untwisting of the bowel. Elderly patients have pain in the left side, distension of the abdomen which is relieved on passing large amounts of flatus.
Volvulus is a twisting of the colon around itself, sometimes causing strangulation with ischemia and necrosis. Occasionally, the rotation can be reduced noninvasively with an endoscope.
DIAGNOSIS: Plain xray of the abdomen in erect position shows a huge dilated sigmoid loop that is called as “bent inner tube sign”. The dilated loop may be visible on the right side, centre and to the left of the abdomen having two fluid levels ;one on the right and the other on the left. TREATMENT:(1)A successful passage of flatus tube or sigmoidoscope results in release of large amount of flatus and fluid and obstruction is relieved. If the obstruction is completely relieved and there is no gangrene general condition of patient improved then elective resection done in 7 days. (2)If the loop is gangrenous ; resection is followed by end to end anastomosis after giving on table lavage using saline washes till the contents of the colon are clear. (3)If the loop is gangrenous and proximal bowel is loaded with fecal matter resection of the sigmoid colon is done . Proximal descending colon is brought out as end colostomy and rectum is closed(Hartmann’s procedure).After 6 weeks colon rectal anastomosis is done. (4)If the loop is not gangrenous, untwist the sigmoid loop and fix the sigmoid to the posterior abdominal wallSigmoidopexy . If the mesentery is long, it can be made short by plication. (5)Exteriorisation : done when the general condition of the patient is poor, elderly patients, severely dehydrated with impending septicaemia. In such cases, the gangrenous loop is brought outside and resected with a proximal colostomy and a distal mucous fistula.
SPASTIC OBSTRUCTION: Occurs rarely. The main causes may be (1)Retroperitional irritationrenal colic, gall stone colic, fracture of spine and pelvis. (2)Within bowelsirritation ,bulky food, foreign body, worms. (3)Intoxicationplumbic intoxication, nicotinic intoxication, helminthic toxins (4)Diseases of the central nervous systemhysteria, neurasthenia, amyelotrophy. CLINICAL FEATURES : Dynamic ileus describes acute colicky pain throughout the abdomen, anxious patient. Frequent vomit, stool retention and flatulences. :Soft abdomen, painful palpation, normal pulse, blood pressure may rise. :Failure to pass flatus and feaces for several days. :Tachypnoea due to elevation of the diaphragm. DIAGNOSTICS: Rectal examination reveals some feaces. :Plain xray of the abdomen in erect position may or may not show one or two air fluid levels. Distension mainly colonic. TREATMENT: Conservative treatment is recommended by paranephric blocking, spasmolytics, enema provided that acute abdomen is ruled out.
Pathophysiology
1.Obstruction of small bowel leads to proximal dilatation of the intestine due to accumulation of GI secretions and swallowed air. Bowel dilatation stimulates cell secretory activity resulting in more fluid accumulation. This leads to increased peristalsis both above and below the obstruction with frequent loose stools and flatus early in its course. 2.Vomiting occurs if the level of obstruction is proximal. Increasing smallbowel distention leads to increased intraluminal pressures. This cause compression of mucosal lymphatics leading to bowel wall lymphedema. With even higher intraluminal hydrostatic pressures, increased hydrostatic pressure in the capillary beds results in massive third spacing of fluid, electrolytes, and proteins in intestinal lumen. The fluid loss and dehydration that ensue may be severe and contribute to increase morbidity and mortality. 3.Strangulated SBOs are most commonly associated with adhesions and occur when a loop of distended bowel twists on its mesenteric pedicle. The arterial occlusion leads to bowel ischemia and necrosis. If left untreated, this progresses to perforation, peritonitis, and death. 4.Bacteria in the gut proliferate proximal to the obstruction. Microvascular changes in the bowel wall allow translocation to the mesenteric lymph nodes. This is associated with an increase in incidence of bacteremia due to Escherichia coli, but the clinical significance is unclear
P A T H O P H Y S I O L O G Y
OBSTRUCTION DISTENSION VENOUS COMPRESSION BANDS AND VOLVULOUS PROGRESSIVE ARTERIAL COMPROMISE GANGRENE
PROLIFERATION OF BACTERIA
TOXINS
TRANSMIGRATION
PERITONIAL CAVITY
SEPTIC SHOCK
Causes of Intestinal Obstruction Location Causes Colon Tumors (usually in left colon), diverticulitis (usually in sigmoid), volvulus of sigmoid or caecum, fecal impaction, Hirschsprung's disease Duodenum Cancer of the duodenum or head of Adults pancreas, ulcer disease Artesia, volvulus, bands, annular pancreas Neonates Jejunum and ileum Adults
Neonates
Hernias, adhesions (common), tumors, foreign body, Meckel's diverticulum, Crohn's disease (uncommon),Ascaris infestation, midgut volvulus, intussusception by tumor (rare) Meconium ileus, volvulus of a malrotated gut,
Frequency SBO accounts for 20% of all acute surgical admissions.
Mortality/Morbidity Mortality and morbidity are dependent on the early recognition and correct diagnosis of obstruction. If untreated, strangulated obstructions cause death in 100% of patients. If surgery is performed within 36 hours, the mortality rate decreases to 8%. The mortality rate is 25% if the surgery is postponed beyond 36 hours in these patients.
History
•Obstruction can be characterized as either partial or complete versus simple or strangulated. •Abdominal pain (characteristic with most patients) 1. Pain, often described as crampy and intermittent, is more prevalent in simple obstruction. 2. Often, the presentation may provide clues to the approximate location and nature of the obstruction. Usually, pain that occurs for a shorter duration of time and is colicky and accompanied by bilious vomiting may be more proximal. Pain lasting as many as several days, which is progressive in nature and with abdominal distention, may be typical of a more distal obstruction. 3. Changes in the character of the pain may indicate the development of a more serious complication (ie, constant pain of strangulated or ischemic bowel). •Nausea •Vomiting, which is associated more with proximal obstructions •Diarrhea (an early finding) •Constipation (a late finding) as evidenced by the absence of flatus or bowel movements •Fever and tachycardia Occur late and may be associated with strangulation •Previous abdominal or pelvic surgery, previous radiation therapy, or both (may be part of patient's medical history) •History of malignancy (particularly ovarian and colonic)
Physical Abdominal distention •Duodenal or proximal small bowel has less distention when obstructed than the distal bowel has when obstructed. •Hyperactive bowel sounds occur early as GI contents attempt to overcome the obstruction. •Hypoactive bowel sounds occur late. •Exclude incarcerated hernias of the groin, femoral triangle, and obturator foramina. •Proper genitourinary and pelvic examinations are essential. •Look for the following during rectal examination: 1. Gross or occult blood, which suggests late strangulation or malignancy 2. Masses, which suggest obturator hernia •Check for symptoms commonly believed to be more diagnostic of intestinal ischemia, including the following: 1. Fever (temperature >100°F) 2. Tachycardia (>100 beats/min) 3. Peritoneal signs •No reliable way exists to differentiate simple from early strangulated obstruction on physical examination. Serial abdominal examinations are important and may detect changes early.
Causes •The most common cause of SBO is postsurgical adhesions. 1. Postoperative adhesions can be the cause of acute obstruction within 4 weeks of surgery or of chronic obstruction decades later. 2. The incidence of SBO parallels the increasing number of laparotomies performed in developing countries. 3. The second most common identified cause of SBO is an incarcerated groin hernia. •Other etiologies of SBO include malignant tumor (20%), hernia (10%), inflammatory bowel disease (5%), volvulus (3%), and miscellaneous causes (2%). •The causes of SBO in pediatric patients include congenital atresia, pyloric stenosis, and intussusception.
CLASSIC TRIAD OF OBSTRUCTION . COLICKY PAIN . DISTENDED ABDOMEN . CONSTIPATION
GENERAL SIGNS OF OBSTRUCTION: (1)General signs of dehydrationdry skin, dry tongue sunken eyes, feeble pulse, low urinary output due to persistent vomit and sequestration of fluid and electrolytes. (2)Abdominal Findings(a)Distension, tympanitic note on percussion. (b)Step ladder peristalsis in the terminal ileal obstruction. ©Right to left colonic peristalsis in the left sided colonic obstructionlarge bowel obstruction. (d)On auscultationloud, noisy, intestinal sounds are heard that are called as Borborygmi. (3)Hernial orifices have to be looked for, especially a small femoral hernia in females. (4)Look for any kind of surgical scars(adhesion disease or cancer).
LOCAL SIGNS OF OBSRUCTION: (1)Abnormal configuration and asymmetry are special for occlusion. Asymmetry, signified distension when seen isOblique abdomen or BAYER’S symptom. (2)VAL’S symptomextended intestinal loop with the zone of tympanic resonance. (3)SHLANGE’S symptomis the visual peristalsis of the intestine that appears simultaneously or after a light percussion on the abdomen. It is the main sign for mechanical obstruction. (4)SKLYAROV’S symptomalso called as the splashing sound symptom that appears in case of shaking of the abdomen wall or light percussion, it is caused by one or several intestinal loops filled with liquid or gas. (5)GANGOLF’S symptomPercussion of the abdomen defines the tympanic sound, which is not localized regularly and changes with the areas of bluntness (bluntness is the sloping places of the abdomen).
(6)KIWULL’S symptomDuring the percussion with the lpessimeter it is sometimes possible to hear the mild metallic sounds. (7)AUSCULTATION SIGNSfirst of all the strengthened intestine noises are heardone time gurgling and one time roaring. as the paralysis progresses, the intestine noises weakenn,it is possible to hear “the sound of a falling drop”. In the late stages, in case of complete paralysis of the intestines, it is possible to hear complete quietness in the abdominal cavity. In these cases the hearing of breathing noises and heart tones is called BAILY’S symptom. (8)RECTAL EXAMINATION: In small bowel obstruction, it is empty and ballooned out. :Carcinomatous growth with or without stools can be felt. :Finger may be stained with blood. :During the rectal examination the empty or the dilated ampoule of the rectum is calledOBUKHOV HOSPITAL symptom
Lab Studies Essential laboratory tests •Serum chemistries: Results are usually normal or mildly elevated. •BUN level: If the BUN level is increased, this may indicate decreased volume state (e.g., dehydration). •Creatinine level: Creatinine level elevations may indicate dehydration. •CBC: WBC count may be elevated with a left shift in simple or strangulated obstructions. Increased hematocrit is an indicator of volume state (ie, dehydration). •Lactate dehydrogenase tests •Urinalysis •Type and cross match: The patient may require surgical intervention. Laboratory tests to exclude biliary or hepatic disease •Phosphate level •Creatine kinase level •Liver panels
Plain radiography
1. Obtain plain radiographs first for patients in whom SBO is suspected. 2. At least 2 views, supine or flat and upright, are required. 3. Plain radiographs are diagnostically more accurate in cases of simple obstruction; however, diagnostic failure rates of as much as 30% have been reported. In one small study, the sensitivity of plain radiographs was reported as 75%, and specificity was reported to be 53%. Similar findings were reported in a second study. 4. In one study, plain films were more accurate in the detection of an acute SBO and the accuracy was higher if interpreted by more experienced radiologists. 5. Plain radiography is of little assistance in differentiating strangulation from simple obstruction. A study by Lappas et al proposed that 2 findings were more predictive of a higher grade or complete SBO: presence of airfluid differential height in the same smallbowel loop and presence of a mean level width greater than 25 mm. The study found that when the 2 findings are present, the obstruction is most likely high grade or complete. When both are absent, a lowgrade (partial) SBO is likely or nonexistent.
• • •
• • • • •
Dilated smallbowel loops with air fluid levels indicate SBO. Absent or minimal colonic gas indicates SBO. The limitations of the plain abdominal Xray in small bowel obstruction are well recognized. • In a study of 117 patients, a normal or nonspecific appearance on the plain film was associated with surgically proven small bowel obstruction in 22% of patients, whereas signs of probable or definite obstruction on plain Xray were confirmed at surgery in only 58% of patients. However, the plain film is valuable for imaging triage and it has been recommended that where the initial Xray suggests complete or highgrade obstruction and a trial of conservative management is contemplated, additional imaging with CT has the potential to modify the patient’s management. Ultrasound also contributes useful information, particularly in the context of the ‘gasless abdomen’, where the bowel is filled with fluid.5
Upright abdominal xray showing obstruction of the small bowel. Note multiple air/fluid levels.
Supine abdominal xray showing obstruction of the small bowel. Note dilated loops of small bowel.
Figure 1. Small bowel obstruction in the proximal ileum demonstrated by (a) water soluble contrast study, with (b) computed tomography scan demonstrating anterior adhesions as the underlying cause.
Enteroclysis
1. Enteroclysis is valuable in detecting the presence of obstruction and in differentiating partial from complete blockages. 2. This study is useful when plain radiographic findings are normal in the presence of clinical signs of SBO or if plain radiographic findings are nonspecific. 3. It distinguishes adhesions from metastases, tumor recurrence, and radiation damage. 4. Enteroclysis offers a high negative predictive value and can be performed with 2 types of contrast. 5. Barium is the classic contrast agent used in this study. It is safe and useful when diagnosing obstructions provided no evidence of bowel ischemia or perforation exists. Barium has been associated with peritonitis and should be avoided if perforation is suspected. 6. Enteroclysis with multiplanar CT is being used to overcome the limitations of use of either modality (enteroclysis or CT individually) and may ultimately simplify the understanding of the obstructive process and assist with management.
Enteroclysis showing two jejunal stenosis with prestenotic dilatations
Enteroclysis, done during a period of abdominal pain, shows adhesive band (arrow) causing bowel to kink at an acute angle. This adhesive traction and relative fixation of bowel causes pooling and slow movement of contrast medium
Enteroclysis Small Bowel
CT scanning
•CT scanning is useful in making an early diagnosis of strangulated obstruction and in delineating the myriad other causes of acute abdominal pain, particularly when clinical and radiographic findings are inconclusive. It also has proved useful in distinguishing the etiologies of SBO, that is, extrinsic causes such as adhesions and hernia from intrinsic causes such as neoplasms or Crohn disease. It also differentiates the above from intraluminal causes such as bezoars. •CT scanning is about 90% sensitive and specific in detecting SBO. •CT scanning is the study of choice if the patient has fever, tachycardia, localized abdominal pain, and/or leukocytosis. •It is capable of revealing abscess, inflammatory process, extraluminal pathology resulting in obstruction, and mesenteric ischemia. •CT scanning enables the clinician to distinguish between ileus and mechanical small bowel in postoperative patients. •CT scanning does not require oral contrast for the diagnosis of SBO because the retained intraluminal fluid serves as a natural contrast agent.
•Obstruction is present if the smallbowel loop is greater than 2.5 cm in diameter dilated proximal to a distinct transition zone of collapsed bowel less than 1 cm in diameter. •A smooth beak indicates simple obstruction without vascular compromise; a serrated beak may indicate strangulation. •Bowel wall thickening indicates early strangulation. •Portal venous gas indicates early strangulation. •Pneumatosis indicates early strangulation. •CT scanning is useful in identifying abscesses, hernias, and tumors. •CT may be less useful in the evaluation of small bowel ischemia associated with obstruction. •One small series reported a sensitivity of 93%, specificity of 100%, and accuracy of 94% in detecting obstruction. Another reported a sensitivity of 92% and specificity of 71% in correct identification of partial or complete SBO.
Figure 2. (a and b) Highgrade small bowel obstruction with short zone of transition (arrows). The absence of an associated mass or bowel wall abnormality indicates that adhesions are the most likely cause.
Figure 3. (a and b) Highgrade small bowel obstruction caused by a serosal deposit (arrow) from ovarian carcinoma.
Ultrasonography
1. Ultrasonography is less costly and less invasive than CT scanning. 2. It may reliably exclude SBO in as many as 89% of patients. 3. Specificity is reportedly 100%.
Other Tests Studies have been performed to evaluate the use of watersoluble oral contrast as a tool in the management of smallbowel obstruction and as a predictive tool for nonoperative resolution of adhesive SBO. It does not cause resolution of the SBO, but it may reduce the hospital stay in patients not requiring surgery.
Procedures Nasogastric tube placement and suction should be performed for patients with severe nausea and vomiting.
Emergency Department Care •Initial ED treatment consists of aggressive fluid resuscitation, bowel decompression, administration of analgesia and antiemetic as indicated clinically, antibiotics, and early surgical consultation. •Initial decompression can be performed by placement of a nasogastric (NG) tube for suctioning GI contents and preventing aspiration. •Antibiotics are used to cover against gramnegative and anaerobic organisms. •Monitor airway, breathing, and circulation (ABCs). •Blood pressure monitoring •Cardiac monitoring in selected patients (especially elderly patients or those with comorbid conditions)
Consultations General surgeon (early and without delay): Laparoscopy is being used in addition to laparotomy and has been shown to reduce hospital stay, speed recovery, and decrease morbidity.
Complications 1.Sepsis 2.Intraabdominal abscess 3.Wound dehiscence 4.Aspiration 5.Shortbowel syndrome (as a result of multiple surgeries) 6.Death (secondary to delayed treatment)
Prognosis With proper diagnosis and treatment of the obstruction, prognosis is good. Complete obstructions treated successfully nonoperatively have a higher incidence of recurrence than those treated surgically.
Medical/Legal Pitfalls 1.No accurate clinical picture exists to detect early strangulation of obstruction. 2.If the diagnosis is unclear, admission and observation are warranted to detect early obstructions. 3.Some factors associated with death and postoperative complications include age, comorbidity, and treatment delay.