A staged surgical approach to save ischemic bowel

A 15-year-old girl developed bowel strangulation of 80% of her small intestine by an omental sling. At exploration, only 100 cm of proximal jejunum remained clearly viable and the remaining small bowel looked necrotic. The transitional bowel between normal and ischemic segments was exteriorized to form a double-barreled jejunostomy. Twelve hours later a "second look" operation was performed. The bowel distal to the exteriorization appeared still seminecrotic but blood flow recovery was demonstrated along the mesenteric border by Doppler oxymeter. No bowel resection was performed. Two months later the jejunostomy was converted to a Bishop-Koop type side-to-end jejunostomy. In the ensuing 2 months, the patient passed both gas and stool per rectum, and oral feedings were gradually increased, retaining the jejunal stoma as a "safety valve." Later, the stoma was taken down, stenotic bowel segments were resected, and the bowel was finally reconstructed by an end-to-end anastomosis, preserving approximately 80% of the small intestine. This management strategy provides an alternative approach to the conventional practice of simple resection of severely ischemic bowel, allowing maximal salvage of bowel with reversible high-grade ischemic change in selected patients.