One discussion this week involved small bowel obstruction and sclerosing encapsulating peritonitis (SEP).
Reference: Liberale G, Sugarbaker PH. Sclerosing encapsulating peritonitis as a potential complication of cytoreductive surgery and HIPEC: clinical features and results of treatment in 4 patients. Surgical Oncology. 2018 Dec;27(4):657-662.
Summary: Liberale and Sugarbaker (2018) define SEP as “a rare entity characterized by encapsulation of the small bowel and/or the colon by fibrous tissue forming a shell” (p.657). It is iatrogenic, idiopathic, or secondardy, and its pathophysiology is uncertain. The most common symptoms are abdominal pain, discomfort, and partial or complete obstruction.
In this article, the authors present 4 cases of SEP, all of which required additional surgery to alleviate recurrent episodes of small bowel obstruction.
In discussion, they provide some advice (p.661):
- An adverse event to avoid is small bowel fistula following surgery.
- The prevention of fistulization which results in enteric contamination of the peritoneal space is of utmost importance in reoperative surgery.
- Careful marking of seromuscular tears and their repair prior to closing the abdomen is important.
- A major problem that may occur in follow-up is the difficulty of distinguishing recurrence of peritoneal metastases from benign causes of bowel obstruction.
There are two types of SEP (p.661):
- Type I: a fibrous membrane sheathing the bowel loops together without a clearly separated dissection plane. Surgery is challenging and the surgeon needs to open the plane between bowel loops while avoiding causing serosal tears.
- Type II: a fibrous membrane forming an enterocele or ‘pseudocyst-like’ structure. These are easier to manage as, once the pouch is open, the small bowel can be dissected and separated easily from the surrounding sheath.