Spiliotis-Farfarelos Maneuver for the Management of Small Bowel Obstruction and Frozen Pelvis in Patients With Peritoneal Metastasis

Abstract

The management of the advanced peritoneal disease is demanding especially in cases of extensive bowel infiltration and the obstruction of the gastrointestinal tract in different sites. Patients with bowel obstruction due to peritoneal carcinomatosis have an overall survival that ranges from three to eight months to four to five weeks based on the operability or not of the disease, respectively. The decision to operate should carefully consider the balance between the probability of symptomatic relief and the risk of severe perioperative complications and survival after surgery. The extent of the disease and postoperative malnutrition could further complicate patients' postoperative course. We aim to present an operative maneuver of bowel preparation and fixation in cases of extensive infiltration of the small bowel by peritoneal carcinomatosis (PC) in order to eliminate the risk of postoperative fistula formation or anastomotic leakage.

Keywords: advanced gynecological cancer; cytoreduction; gastrointestinal cancer; peritoneal carcinomatosis; surgical maneuver.

Figure 1. Recognition of the ligament of Treitz.

Figure 2. Identification of the small bowel loops that are located ≥150 cm from the Treitz ligament.

Blue arrows indicate the inspection and preservation of the first loops of the small bowel (150 cm).

Figure 3. Preparation of the colon from the middle part of the transverse colon to the rectum.

Blue arrow 1 indicates the mobilization of the transverse colon prior to transection. Blue arrow 2 indicates the potential mobilization of the splenic flexure in order to facilitate the jejunal-transverse anastomosis.

Figure 4. Removal of the affected small bowel along with the right and transverse colon and side-to-side jejunocolic anastomosis.