Understanding the bowel obstruction problem

GREAT IDEAS IN SURGERY

Understanding the Bowel Obstruction Problem Owen H. Wangensteen, MD, Minneapolis,

Minnesota

I feel a special sense of privilege to be included amongst an illustrious group of surgeons invited here to summarize briefly the essence of their life’s work. Some of the participants will address themselves to new ventures in twentieth century surgery. I come to you with the management of a problem that Praxagoras dealt with successfully in the fourth century BC, the Iliac Passion of strangulated external hernia; he incised the inguinal swelling and cured his patient by establishment of an external intestinal fistula. Aspects of bowel obstruction have been an absorbing theme of my professional life, extending back for more than fifty years (1925-19X!), during which period I dealt with both its experimental and clinical aspects. You will readily appreciate that a portrayal of the problem over this interval suggests definitely how much more sophisticated are the available therapeutic technics of today contrasted with those of the mid 1920s. Present-day achievement with acute intestinal obstruction too reflects improved understanding of the condition. The Beginnings

All of life’s problems are better understood in retrospect than in prospect, to which understanding the bowel obstruction problem is no exception. Early skirmishes of surgeons in exploratory ventures with Regents’ Professor and Chairman Emeritus, Department of Surgery, University of Minnesota, Minneapolis, Minnesota. This work has received modest support over many years from a number of sources including the National Institutes of Health, grateful patients and friends, and in recent years from the Alice M. O’Brien, the Margaret Weyerhaeuser Harmon, and the Ralph and Marian Falk Research Foundations. Reprint requests should be addressed to 0. H. Wangensteen, MD, University of Minnesota Medical School Complex, Box 610. Minneapolis, Minnesota 55455. Presented as part of the Inaugural F’rogramof the A. Webb Roberts Center for Continuing Education in the Health Sciences, Baylor University Medical Center, Dallas, Texas, November 3-4, 1972

Volume 135, February 1976

lesions of the abdomen were rather discouraging. Ephraim McDowell of Danville, Kentucky, successfully excised a large ovarian cyst in 1809, for that period an extraordinary accomplishment. Yet, a century earlier, French surgeons at the Hotel-Dieu in Paris had successfully operated for strangulated hernia with advanced intestinal gangrene. Mery (1701), La Peyronie (1723,1743), Louis (1757,1768), Pipelet (1768), Regnauld (1787), and others had recorded successful instances of operations for both internal intestinal strangulation as well as strangulated external hernia. These surgeons excised the dead bowel and established an external bowel fistula; occasionally both proximal and distal stomas when left in the wound were subsequently approximated with suture so that intestinal continuity was reestablished. Pierre Franc0 (1561) usually is regarded as the originator of the planned, direct attack upon strangulated hernia. He made an incision over the swelling and divided the constricting band. Pigray of Rouen (1615) operated with similar success. Even so, the surgery of acute intestinal obstruction, as of most other acute lesions of the abdomen, lagged badly. Maunoury (1819) reports that Dupuytren of Paris exhausted all agencies of depletion, including phlebotomy, leeches, and purging before resorting to operation for strangulated hernia. The great English surgeon, Astley Cooper (1823), advised taxis, the inverted posture, and tobacco enemas for the relief of acute intestinal obstruction [IO]. For strangulated external hernias he also invoked these measures before recourse to the knife. He merely incised the dead bowel, making no effort to excise it, and left the patient with an external fistula. Even so, his achievement, a mortality of 42.4 per cent among

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thirty-three operations for strangulated hernia, does not compare too badly with present-day mortality for intestinal strangulations demanding excision of dead bowel, as indicated in publications over the last two decades from some of America’s finest surgical clinics. Two Centuries of Conservative Measures for Relief of Obstructlon

Sydenham (1676) had been an ardent advocate of opium in the management of acute obstruction, a thesis ardently supported by Hugh Owen Thomas of Liverpool (1879) two centuries later. Thomas was of the impression that bowel obstruction was usually functional rather than mechanical in nature. In his defense of conservative management he was sustained by the high current mortality of operative management. Throughout much of the nineteenth century, metallic mercury was recommended as a helpful agent in bypassing the obstructive lesion in the bowel. The extreme mobility of quicksilver is well known. However, the method had its limitations. Pillore of Rouen (1776) performed a successful ceco&my for the relief of acute obstruction occasioned by a cancer of the distal colon, but his patient died twenty-eight days later. In the earlier management of the situation, Pillore had administered 2 pounds of metallic mercury over a period of a month. The heavy mercury caused the terminal coils of the small intestine to drop into the pelvis; the mercury failed to ascend and could not be evacuated. Perhaps here the inverted posture might have been of some help. Electrical stimulation as a means of activating the paretic bowel was used increasingly after Duchenne (1855) reported successes attending employment of the faradic current for intestinal obstruction. Bilgutay (1963), employing an indwelling duodenal electrode on the tip of a duodenal catheter, indicated he had succeeded in stimulating intestinal peristalsis attending abdominal operations by this maneuver. However, having failed to employ controls, Bilgutay encountered no suggestion of acceptance of his proposal. Kussmaul(l869) had advocated gastric lavage for pyloric obstruction and by 1884 had become enthusiastic over its use as a therapeutic device for acute intestinal obstruction. In a conference on the condition, the German internist, Curschmann (1889), said that gastric lavage was second only to opium in the management of acute intestinal obstruction. As late as 1891 the Philadelphia physicians, Martin and

132

Hare, continued to extol1 the virtues of gastric lavage in dealing with such problems. Percutaneous intestinal puncture, an eighteenth century innovation, concerning which Mensching of Restock (1756) was enthusiastic, continued to be popular for more than a century. The Boston clinicians, Blake and Bigelow (1876), treated a patient with intestinal obstruction over a period of eighteen weeks by periodic frequent puncture of the distended bowel through the abdominal wall, employing a Potain aspirator to remove gas and fluid. The patient eventually died of starvation and continued obstruction without recourse having been taken to operation over a period of eighteen weeks, a therapeutic device that Martin and Hare also endorsed. Reluctance of Nineteenth Century Surgeons to Operate for Intestinal Obstruction

The Scats, Annandale (1870-71) and Buchanan (1871), in publishing their successes attending surgical intervention, suggested that serious consideration be lent surgical exploration in instances of bowel obstruction. However, at the 1878 meeting of the British Medical Association, Jonathan Hutchinson, prominent London surgeon, was outspoken in his criticism of early operation, indicating that many obstructions would relent and that the hazard of surgery was great. At that same meeting, Allbutt (1878) shared Hutchinson’s views and indicated he had gone only so far as to employ percutaneous intestinal puncture in dealing with obstruction. However, within a year Allbutt (1879) capitulated to operative intervention, largely because of the circumstance that his surgical colleague, Teale in Leeds, had one operative success among six interventions. In a session of the British Medical Association in 1883, the Liverpool surgeon, Parker, urged extension of conservative modes of treatment. In protest, the Birmingham surgeon, Lawson Tait, remarked that an accurate diagnosis of intestinal obstruction can “only be made by exploration, which is better performed before than after death.” In a paper presented at the Liverpool Medical Institute, 1884, Greves lent operative intervention a strong forward thrust. He had treated a patient for five days with taxis, enemas, and intestinal insufflation, without success. Then he called a local surgeon, Mr Pughe, who operated under antiseptic precautions and divided a hand obstructing the terminal ileum, with recovery of the patient. In the discussion, Hugh Owen Thomas was ardent in his advocacy of opium management and published shortly thereafter a monograph entitled The Colle-

The American Journal of Surgery

Great Ideas in Surgery: Bowel Obstruction

gian of 1666 and the Collegians

of 1885. This is a diatribe against surgical intervention in which Sydenham was the Collegian of 1666 and obviously Hugh Owen Thomas, one of the Collegians of 1885. Thomas must bear some of the burden of responsibility for retarding acceptance of operative intervention for bowel obstruction in Britain. However, similar expressions were heard outside Britain. The Philadelphia surgeon, Ashhurst, who was mildly enthusiastic over operation for intestinal obstruction in 1874, had a change of heart by 1886; chastened by his own experience, we find him extolling the old remedies of bleeding, leeching, opium, and enemas. At the 1887 German Surgical Congress, Madelung sounded a note of caution relative to operations for intestinal obstruction, stating that he had hurried a number of patients to their death thereby. Mikulicz agreed, adding he had receded from a former more aggressive surgical attitude and that his experience had taught him that operation often offered no hopeful prospect. Similarly, at the First American Congress of Physicians and Surgeons (1888) Reginald Fitz of Boston insisted that even after acute intestinal obstruction was diagnosed, conservative management should be continued for an additional 48 to 72 hours before calling in the surgeon. Nicholas Senn,* presenting the surgical aspects of the problem, was in general agreement. In the 1899 edition of his monograph on intestinal obstructions, Treves of the London Hospital strongly advocated operation. Yet he enumerated all the conservative measures alluded to above. Diagnosis of Bowel Obstruction

Over a period of more than fifty years, aspects of the bowel obstruction problem have been a major concern of mine. It is unlikely, therefore, that this presentation will reveal any views that my colleagues and I have not already committed to print. In a sense, therefore, I appear before you to indicate how long and difficult my learning lessons have been in the University of Experience. Its tuition fees are the highest of any school in the land, and every enrollee * Two years later (1890) at the Tenth International Medical Congress held in Berlin, Senn was allotted an hour in which to demonstrate the effectiveness of insufflating gaseous hydrogen through the rectum to detect an intestinal leak. A dog was shot through the abdomen and laid out on the table. The hour went by, but no evidence of inflation of the dog’s abdomen occurred and the demonstration had to be abandoned. Senn had been outwitted by an assistant, deficient in knowledge of comparative anatomy: there were two orifices beneath the dogs tail! No account of the frustrating mishap appeared in the Transactions of the Berlin Conference. This episode was related by G. W. Broom (Medical Pickwick

1: 430,1915).

Volume 135, F&ruary 1979

learns that he is both student and teacher, being taught by his own experience. The young clinician must adopt Caesar’s technic: divide and conquer, taking one facet of the problem at a time, learning from his own experience and from that of others. One reason the bowel obstruction problem remained in a confused state for so long a time was that Semmelweis’ principle of preventive antisepsis (1847-49,1861) had to await Lister’s demonstration of its utility in surgical wound management (1867-1880) before surgery’s great expansion included the body cavities. The technics of dealing with the obstructed bowel had to be learned and acquired. During Lister’s Glasgow professorship (1860-69), his coachman was run over near the Royal Infirmary by Lister’s brougham when the skittish horses became frightened and toppled the carriage. Lister made a diagnosis of injury to the bowel but failed to open his coachman’s abdomen. Exploration for suspected bowel injury had not yet become a regular therapeutic device. At autopsy Lister observed small bowel leakage from a perforation. As late as 1888 in this country, when a diagnosis of acute intestinal obstruction was made, it was agreed by both physicians and surgeons that two days should be devoted to conservative therapy, consisting primarily of enemas, before the patient was submitted to surgery. In the mid 1920s when I had an opportunity to enter the lists to wrestle with the problem, the overall mortality of the situation in the hands of the best clinics in the land varied between 40 and 60 per cent. C. Jeff Miller (1929) announced that the mortality of operative management of acute intestinal obstruction at the Charity Hospital in New Orleans was 65 per cent. He lamented the difficulty in making the diagnosis. The diagnosis of acute intestinal obstruction is essentially clinical. The finding of intestinal colic serves to indicate its presence.+ Obviously food indiscretions and abdominal distention, unaccompanied by intestinal colic, need to be excluded. In my experience, regurgitant vomiting of brownish materials with a feculent odor suggests obstruction of the small intestine, probably a lowlying one. (Figures l-4.) When my interest in the problem developed in the mid 192Os,the thesis prevailed that feculent vomiting was a phenomenon connoting obstruction of the colon. How this theory came about is difficult to t Intestinal colic is attended by gaseous borborygmi generating metallic sounding tinkles in acute obstruction at the acme of recurrent gas pains; after 48 hours intestinal colic is characterized by gurgling due to delayed absorption of fluid from the bowel.

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Figure 7. X-ray films of air-inflated segments of intestine. A, jejunum siightiy distended. B, jejunum more distended. C, ileum. D, colon. Distinguishing colon and jejunum may occasionally be troublesome. Figure 2. Scout film suggests this to be a complete obstruction, yet the obstruction relented completely after tow enterostomy. The fluid drainage is to be seen in Table ii. Figure 3. Scout film indicates an incomplete obstruction (gas in colon after enemas). Decompressed by suction applied to an iniying duodenal tube. Figure 4. Leff, scout film, supine, denotes gasless area in lower abdomen. Right, pneumoperitoneum, 650 ml air (no barium). Venous infarcted segments appear like sausages. Ninety cm viable bowel excised; patient at age seventy-three years had undergone total gastrectomy for gastric cancer several weeks earlier. Patient survived until age ninety years and died after hip fracture.

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Great Ideas in Surgery:

know. However, it is to be remembered that the ills of the abdomen were almost solely in the hands of physicians until the waning fifteen years of the nineteenth century. For more than a century, texts of surgery and medicine too had been written by authors often having before them two or three honored texts of an earlier period. The authors, writing beyond the ken of their own experience, unable to distinguish fact from fiction, copied both into their own compilation. Since the days of Ambroise Pare, surgeons might well be divided into two classes. Those who believe what they have been told or have read, and those who believe what they see. There is a world of difference in this philosophic distinction. A realistic observer having once seen an orange cannot mistake it. When he sees another, he will immediately identify it. Such too was my experience in recognizing the symptomatic differences between obstruction of the small bowel and of the large intestine. In my experience obstructions of the distal colon, though accompanied by great distention, almost. invariably fail to provoke feculent vomiting. The competent ileocecal valve and the lips of the sphincter in more than 60 per cent of instances delimit the distention of the colon (Dennis, 1944). Even when vomiting occurs in obstruction of the colon attended by great distention, it is far more likely to be gastric or biliary in nature. X-ray findings are, of course, helpful in verifying the location of the obstruction. The stethoscope is the most important instrument* in making a clinical diagnosis affirming the presence of intestinal colic. The experienced clinician on seeing a patient will therefore know (1) that obstruction is present and (2) the location of the obstruction, whether in the small intestine or in the colon. Scout x-ray films of the abdomen lend corroborative evidence and provide reasonably reliable information of the site of the obstruction. The surgeon cannot tell, however, how the bowel is obstructed; nor can he differentiate reliably whether the obstruction is simple or strangulating in nature. (Figures 5-7.) The enema has only one function in the management of intestinal obstruction: to differentiate between complete and incomplete obstruction of the small intestine. With complete obstruction, a repetition of enemas fails to expel additional gas or feces beyond that achieved by the first enema, and a second scout, x-ray film indicates no migration of the gaseous distention into the colon. * During the administration of an enema, Treves (1899) placed a stethoscope over the area of the cecum; if the rush of fluid into the cecum was heard, he inferred the obstruction was not in the colon. Vohme 135, February 1979

Bowel Obstruction

My Early Exposure to the Problem

I was requested in this presentation to stress my personal involvement with troublesome aspects of intestinal obstruction. In consequence, I have attempted to relive my successive encounters with the problem and the lessons learned therefrom. As a young surgical house officer at the University of Minnesota in the mid 192Os,I noted with dismay that in performing enterostomy, some of our staff surgeons placed the catheter, often disproportionately large, upon the bowel wall, without taking pains to decompress the distended gut, merely burying it in the bowel wall with running or pursestring sutures, spillage usually occurring at virtually every needle hole. At that time the surgeons of my area in Minnesota were much influenced by the writings of Victor Bonney (1910, 1916) of the Middlesex Hospital in London and of his surgical colleague, W. Sampson Handley (1925), who stressed intestinal toxemia as the primary cause of death in both intestinal obstruction and peritonitic states [51]. For the relief of these situations, high jejunostomy was advised. It often fell to my lot to close the persistent intestinal fistulas attending such operative procedures. My first contribution to the problem in our own hospital, therefore, was to isolate the distended segment of the bowel upon which enterostomy was to be performed between two intestinal clamps, after milking out its content. Within less than 60 seconds after this maneuver the paper-thin bowel wall acquired substance and thickness, making it possible to introduce a catheter into the bowel wall by the technic that Oscar Witzel of Bonn (1890) had used upon the stomach, and without leakage in the performance; no catheter larger than 14 French gauge is used in making the enterostomy. Contrary to the advice of those who favored high jejunostomy, I always selected a low-lying distended loop for the enterostomy. Even when the catheter remained in situ for a long time, neither leakage nor fistula was observed on withdrawal. Within the past decade, I chanced to see a long-standing intestinal fistula in a physician resulting from a technically poorly constructed enterostomy in the hands of a professor of surgery in the same institution. Van Beuren (1927, 1929) of the Columbia Presbyterian Hospital stressed the great hazards of enterostomy as a therapeutic device for acute obstruction, pointing out that the mortality of the enterostomy group for the 1916-1919 period was 90.9 per cent; for the 1920-1923 period, 77.7 per cent, a risk that had fallen in the 1924-1927 period to 24.2 per cent. This experience undoubtedly represents 135

Wangensteen

Figure 5. Obsttuct~nat distal coion. Competent iieocecai valve and sphincter made this a closed-loop obstruction. The measured intraiuminai ten&n was 24 cm HzO. The resuttant tension upon bowel wail is indicated in circles. Figure 6. Manner in which iieocecai valve and sphincter act as check vaive, a/rowing fhdd and gas to enter but not return into ileum. Figure 7. Neopiastic stricture of ascending colon, in presence of competent proximal iieocecai valve and sphincter, causedperforation of cecum. The patient, a well known local surgeon, and his physician had diagnosed the doctor’s problem as “intestinal influenza. ”

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Great Ideas in Surgery: Bowel Obstruction

protracted use of faulty technics in performing enterostomy. Kocher’s (1916) and Moynihan’s (1925) published illustrations indicate clearly that methods of enterostomy, inviting trouble, were employed by some of the keenest exponents of abdominal surgery during the first quarter of the twentieth century. In 1938 the mortality of enterostomy at the Columbia Presbyterian Hospital Center was reported to be 70 per cent in patients with complete obstruction [78]. By 1942 at the University of Minnesota operative decompressive enterotomy had replaced enterostomy, which in many instances was obviously an incomplete operation. Over the 1925-1940 period enterostomy at Minnesota had been a favored, useful, and safe operation, with a risk of 10 per cent. Being an incomplete operation for complete obstruction,

it was abandoned for something better. This procedure made it possible to locate and deal in a definitive manner with the obstructive mechanism, upon an empty bowel. In this clinic, operative enterotomy also came to be supplanted in the 1960s by sophisticated technics of per oral intestinal intubation prior to and/or at operation in the hands of my surgical colleagues, Arnold Leonard and Richard Edlich. Demise of Autointoxication Theory (Figure 8)

The origin of the concept of autointoxication as the principal cause of death in bowel obstruction traces back to Amussat (1839). According to his Parisian colleagues, Amussat formulated this theory after the death of his friend and patient, the famous French

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FJgure 8. A, hype&mph&d intestine of dog fifty-seven days afJer complete Meal obstruction and prior cervical eso~omy to exciude swallowed air: oniy 125 cc of fiuld and 100 cc of gas in bo wei at amy. Dog sustainedby daiiy intravenous giucose andsaline solutions. 6, loss of viability and increased permeabiiity of ciosed intestinai ioops are &pendent upon intraiuminai pressure and its duration: 20 cm sustained intraiuminai Hz0 pressure apparently well toierat* for 10 hours; impaired viability at 22 hours; ioop nonviabk permitting transperlfona~absorpllorr, at28hdum.C,mesentericvenousocciustonindogs is attended by sho~I survival, great blood ioss, and increase of bowel density by aimost 300 per cent. t&gs with arterial occlusion (A) live longer. No increase in density of bowel. Death + owing to loss of viability and transperitoneai absorption.

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Wangensteen

clinician Broussais, the keenest exponent of thorough depletion including leeches, phlebotomy, purging, and emetics for every trying medical situation. Broussais suffered a rectal hemorrhage and died following fulguration by Amussat of a low-lying rectal cancer. In extenuation of the unfortunate outcome, Amussat reported that death was caused by absorption of noxious materials from the obstructed colon, a theory that surgeons eagerly invoked to explain their poor accomplishment in the management of bowel obstruction. George Whipple and his associates (1913-1917) isolated a toxic proteose from filtrates of intestinal content from obstructed intestinal loops, a finding that lent renewed credence to the seventy-five year old theory of autointoxication. Hartwell’s and Hoguet’s discovery (1912) that dogs with high jejunal obstruction given saline solution could be kept alive for three weeks constituted the first indictment of the autointoxication thesis. Haden and Orr (1923-24) subscribed to Amussat’s theory, stating that saline solution rendered the absorbed toxin of bowel obstruction inert. Even astute investigators find it difficult to abandon completely time-honored theories. Clarification of the mystery came when Gamble and his associates (1925) showed very nicely that saline solution provided an excellent substitute for fluid and electrolytes lost by vomiting. Such, of course, had been the therapeutic thesis of O’Shaughnessy (1831-32) and of Schmidt (1850) for the severe diarrhea of cholera and dysentery. The significant observations of Gamble and his associates initiated studies of fluid and electrolyte requirements of surgical patients that have long been a great boon in almost every sphere of the surgeon’s activity. Effects of Obstruction

The miracle-like role of saline solution in high jejunal obstructions has no counterpart in low ileal obstruction, an observation which led to more than a decade of concentrated research in the laboratory (1928-1940) by myself and a large number of associates investigating the effects of obstruction upon functional roles of the bowel. The significant blood loss factor in venous mesenteric occlusions was revealed in experiments by Scott and myself (1932). It was shown that when the venous return in dogs was occluded to 4 feet of small bowel, death occurred in 5 hours, primarily from hemorrhage, with a 283 per cent increase in density of the bowel. In arterial mesenteric occlusion, however, blood loss is minimal. Scott (1932) observed that dogs with occlusion of the terminal arteries to a segment of bowel 4 feet in length survive consid138

erably longer, death occurring because of transperitoneal migration of noxious substances from the bowel lumen. As a consequence of the work of a large number of competent investigators in many laboratories concerned with various facets of the problem of intestinal obstruction, the following have come to be recognized as the significant features in management: fluid and electrolyte therapy; replacement of blood loss; decompression and release of the obstruction; and the earliest possible identification of strangulating obstructions and excision of devitalized bowel. When the continuity of the bowel is blocked, a swell in the intestinal current dilates the elastic walls of the intestinal cylinder. Resistance of the bowel wall to dilatation causes pain as peristalsis attempts to propel the stagnant content forward. With increase in volume of the intestinal content, antiperistaltic activity, in the presence of an intestinal block, causes regurgitation of intestinal content into the stomach, provoking a copious regurgitant yellowish brown vomit with a feculent odor. It is estimated that normally about 7,000 cc of fluid are dumped into the intestinal canal daily from the following sources: saliva; gastric and pancreatic juice; bile; and succus entericus. Under the influence of obstruction the total amount apparently increases the response of the gut to distention. Moreover, a number of experiments demonstrate considerable decrease in absorption of fluid from the bowel in the presence of obstruction. The source of gaseous distention of the obstructed bowel is largely swallowed air. By transecting the cervical esophagus in dogs and inverting the aboral end, Rea and I (1933-1939) observed that dogs with obstruction in the terminal ileum not infrequently survived for eight weeks when supported by intravenous glucose and saline solutions. At autopsy the gut wall was considerably thickened but contained only small amounts of fluid and gas. Small amounts of amorphous materials accumulated just proximal to the obstruction. lntraenteric Pressure in Bowel Obstruction (Figures 9-11)

The effect of distention upon the obstructed bowel is best assayed in terms of increased intraluminal tension. It is evident that intraenteric pressure may influence absorption from the bowel, its blood supply, and its viability. The intraenteric pressure in experimental obstructions of the small intestine in the dog and in a number of patients with obstruction of both small intestine and colon was measured at

The American Journal of Surgery

Great Ideas in Surgery: Bowel Obstruction

Figure 9. Technics of operative decompress~n of the distended bowel kmg employed in this clinic: A, isdattng a kop for enterosfomy. 6, dealing wtth a distended dubious& viabie Wp that cannot be mobil&d. t2, enterostomy. D, decompressing the distended colon.

Figure 10. Technic of decompressive suction enterotomy that came to supplant enterostomy in this clinic in 194 7. ‘Thesite Ibrthe~~yis~asdnF~lA.Ankntsstbraltrochar,~a~~~a~a#l4duodenaitcnbe~vered with a iong +rose drain, kpemployed to empty the bowel. Only when the entire distended bo wei is completely empty is thes#ed~~eougMioranddeaAlwWh.Thelhsert(i)ahowsdheslrorttrensverseenterotomy~~cksed.DYvlskn of the adhesive band, accompanied by gentle tractton, broke the fibrinous seal and the bowel opened wkteiy; the bowel being empty, no harm was &me (see insert). 77~ case motfaiity of enterostomy (Figure 9) over the prior two years was 10.5 per cent. The case mortalfty after decompressive suction enterotomy replaced blind enterostomy. was 7.4 per cent.

Vohma 199, February 1979

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Figure 7 7. Outmoded technics of enferostomy. A, a loop of disfended bowel is sutured in the wound ( Kocher, 19 7 7- 19 16); on compielion of the operation the bowel is incised. This method of draining the distended bowel is essentially the technic of Ndaton ( 1657). 6, Kocher’s ailernaNve scfteme of draining the distended small bowel. C, Moynihan’s melhod ( 7926) of emptying the obstructed small bowel af operafion. None of these technics are acceptable operative procedures, nor is Ihe Stamm-Kader hype of enteroitomy.

operation. The proximal competent ileocecal valve and sphincter, in colic obstructions, behave as a check-valve in more than 60 per cent of cases, thus converting the obstructed colon into a virtual closed loop with resultant increase in intraluminal pressure. I have observed pressures varying between 12 and 52 cm Hz0 in clinical cases of acute obstruction of the colon, with a mean value of about 25 cm. In clinical cases of obstruction of the small intestine, as well as in simple ileal obstructions in dogs, because of the greater length of the gut participating in the distention, the intraluminal pressures invariably have considerably lower values. Readings in a large number of obstructed dogs varied between 4 and 19 cm H20, the average and mean value being 9 cm. In four patients with obstruction of the small bowel persisting 48 to 96 hours, sustained pressures varied between 4 and 14 cm H,O; at the height of peristaltic activity occasional pressure of 20 to 30 cm were noted. However, these are not sustained pressures. The tension upon any part of the distended gut wall is the product of circumference X the sustained intraenteric pressure. In complete obstructions of the distal colon, perforation of the large and thin-walled cecum is occasionally observed in cases with great distention when timely decompression is postponed. Even though the intraluminal pressure is the same throughout the distended gut, because of the greater diameter of the cecum the force exerted on its walls is greater than in any other section of the distended bowel. In simple obstruction of the distended lower ileum, it is apparent that the distal coils of the gut can never be completely evacuated through the action of antiperistaltic activity and vomiting. The effect on the 140

bowel wall with long-continued distention, therefore, will be considerably greater than on the more proximal reaches of the bowel, from which area intestinal contents are more easily’ regurgitated.

Effects of Obstruction on Absorption

The three possible avenues for absorption from the obstructed bowel are (1) the mesenteric veins, (2) the mesenteric lymphatics, and (3) the transperitoneal route. There is no reason to believe that any absorption occurs normally through the latter. From the bowel which has been obstructed for 48 to 96 hours, it may be readily shown that there is less than normal absorption for a given unit of time of water, strychnine, glucose, and other substances, to which the normal bowel is permeable. Similarly, increases in intraenteric pressure delay venous absorption from the bowel. After the introduction of dyes such as gentian violet or trypan blue into the lumen of the obstructed bowel, staining of the mesenteric lymph nodes occurs, a finding not observed after the intraenteric introduction of such dyes into the unobstructed bowel. The arrest of the intestinal current provides greater opportunity for the absorption of such dyes. It is significant that bacteria may be demonstrated in the mesenteric lymph nodes in far greater numbers after obstruction of the bowel. Transperitoneal absorption is a manifestation of impaired viability of the gut wall in obstruction. Strychnine, intioduced into a short segment of canine ileum deprived of its blood supply, shows no early signs of absorption. Later, when obvious signs of loss of viability are in evidence, fluid recovered from the peritoneal cavity on injection into the dorsal The American Journal of Surgery

Great Ideas in

lymph sac of frogs provides unmistakable of strychnine poisoning.

evidence

Effect of Sustained Pressure

By employing the Perusse pressure bottle, Sperling and I (1935) subjected closed ileal loops in the dog to sustained increases of intraluminal pressure. Levels were maintained for hours at 10,20, and 40 cm Hz0 within the range of pressures observed clinically. Placement of 30 cc of a 5 per cent solution of potassium ferrocyanide into the lumen of the closed loop prior to distention afforded an opportunity to test for evidence of abnormal permeability in the wall of the distended bowel. At intervals, the abdomen of the dog was reopened and the surfaces of the distended loop were sponged with a 1 per cent solution of ferric chloride. Penetration of the potassium ferrocyanide through the gut wall was heralded by the appearance of a definite blue color. At the time of reopening the abdomen, the viability of the distended loops was tested by faradic stimulation. Failure of the bowel wall to contract when stimulated with two dry cells with the coils 8 cm apart was taken as evidence of impaired viability. The time over which the intraluminal pressure operates is very significant. Pressures approaching capillary blood pressure are invariably hazardous when continued for more than 20 hours. Neither abnormal permeability nor impaired viability was noted at 20 cm saline pressure (approximately 15 mm Hg) continuing for 10 hours; at 28 hours the bowel wall was nonviable and exhibited evidences of abnormal permeability. At 40 cm saline pressure (approximately 30 mm Hg), a pressure observed not uncommonly in colon obstructions, areas of bowel necrosis together with evidences of abnormal permeability were observed at 17 hours.

Surgery: Bowel Obstruction

small intestine that persuaded me that application of suction to an inlying duodenal catheter might accomplish what an enterostomy does when placed just proximal to the obstruction. When this is performed in the presence of incomplete obstruction, after an initial period of a few days of drainage, the continuity of the intestinal canal is reestablished and diminishing quantities of fluid escape from the enterostomy catheter. Similarly, studies indicated that the gas escape through the intestinal catheter paralleled that of the fluid drainage. With incomplete obstructions, after the initial escape of fluid and gas, the enterostomy catheter ceased to serve a useful purpose. A series of observations made on such fluid and gas escape attending enterostomy for incomplete obstruction (1930-31) led to attempts at relieving mechanical obstruction of the small bowel by suction applied to an inlying duodenal catheter. Together with my late associate, Doctor John R. Paine, I was able to show that an active source of suction was far more efficient in the removal of gas and fluid in patients who had undergone abdominal operations than was siphonage, a procedure employed by Rudolph Matas in 1924. After many hours of siphonage during which som? gas and fluid were aspirated, application of an active source of suction in the distended patient invariably removed far greater quantities of both gas and fluid than did mere siphonage. (Tables I and II.)

TABLE

I

Alternating Siphonage and Suction

Time 8 hr 30 min 10 min 4 hr 55 min 10 min 5 hr 50 min 10 min

Siphonage Fluid Gas ICC) (cc) 25

75

0

0

0

0

Gas kc)

Suction Fluid (cc)

50

250

500

200

400

500

Origins of lntubation in This Clinic to Achieve Intestinal Decompression

I must now return to my mandate in this special presentation to relate the nature of the observations that led to efforts of achieving decompression by an inlying duodenal tube. From the very beginning of my clinical experience with obstruction, I was very enthusiastic over enterostomy as a therapeutic procedure. In instances of incomplete obstruction of the small bowel, it was almost uniformly successful; in complete obstructions, secondary entry was invariably necessary to deal with the obstructing mechanism. It was these observations on patients who had undergone enterostomy for acute obstruction of the Volume 135, February 1978

TABLE II Postoperative Dav

Fluid Drainage Attending Enterostomy Catheter (cc) Case I Case II Case Ill 375 200 85 0 0

l

250 15 5 20 200 150 100 75 50’

20 65 180 60’

Subsequent recovery.

141

At the time, attempting decompression in acute intestinal obstruction by suction applied to an indwelling duodenal tube did appear to be a bold effort. Despite the circumstance that studies of enterostomy drainage provided strong support for the thesis, it found very little or no evidence of general acceptance by surgeons. In fact, a paper outlining both experimental and clinical aspects of the thesis was rejected for publication by both an experimental and a clinical journal. Finally, by submerging the report of three successful cases under the innocent title of “Diagnosis and Treatment of Acute Intestinal Obstruction,” the suggestion was published (1932). A few years later (1935), the observations, summarized in the Samuel D. Gross Prize Essay, were submitted for publication as a monograph. Despite the blessing lent the effort by a Committee of the Philadelphia Academy of Surgery, it was necessary to consult four publishers before it was possible to reproduce the essay in print (1937). Whereas in the view of conservative surgeons it did seem a rather unorthodox innovation and departure, in retrospect it is clear that my enthusiasm for observations upon, and success with, enterostomy in simple acute obstruction of the small intestine constituted ample justification of the proposal to achieve by use of an inlying duodenal tube what could be readily achieved by enterostomy in instances of incomplete obstruction of the small bowel. Over the years the method was destined to undergo wide trial and encountered acceptance in many areas. Obviously the method can be overused. Its chief indications, of course, were instances of incomplete obstruction of the small bowel in which removal of gas and fluid from the upper reaches of the jejunum automatically reestablished intestinal continuity. From the very beginning it was appreciated that strangulating and colic obstructions constituted strict contraindications to its use in achieving decompression. Experience also indicated that for complete obstructions of the small bowel it was only a temporary expedient and that early operation was in order. van der Reis and Schembra (1926) had found that the functional length of the intestine was considerably shorter than its anatomic length, an observation that McClendon had made at Minnesota on two freshman medical students (1918, 1925). In 1934 Miller and Abbott found that intubation of the small intestine was hastened by attaching a small balloon to a two-way long duodenal tube. By 1938 Abbott and Johnston of Philadelphia were able to report instances of decompression of mechanical obstruction by the Miller-Abbott tube. In 1941 Sivertsen, a

142

Minneapolis surgeon, suggested to me that mobile mercury be placed in a small balloon attached to the distal end of the duodenal tube to encourage its descent into the distended bowel. A large number of clinicians toyed with the Sivertsen suggestion, which was included in the second edition (1942) of my monograph on bowel obstruction. Presently Wild (1944), Harris (1945), Cantor (1947), and a number of others developed variants of the Sivertsen principle [96,97]. For a long span of years little interest was manifested in the principle of effecting quick decompression of the distended intestine in mechanical obstructions by suction applied to inlying duodenal tubes. My late colleague, Grafton Smith, with a very clever device was able to hasten intubation of the duodenum, passing the catheter beyond the duodenojejunal ligament beyond which point the tube rarely progressed. In 1961, another colleague, Arnold Leonard, reintroduced the Einhorn stylet by which a catheter of the Levin type with an accessory distal balloon could be made to descend far more quickly than by other available technics into distal reaches of the distended bowel. My instrument maker, John A. Phelan, first incorporated a coiled spring into the wall of a duodenal tube. He had an obstructive duodenal ulcer and emptied his own stomach by this means, a disorder for which he accepted partial gastrectomy in 1942. Leonard persuaded Phelan to provide him with such a catheter and a long stylet to assess its utility in decompressing the distended bowel. In Leonard’s experienced hands, the method met with great success and for the first time a means of facilitating descent of long intestinal tubes for decompression into the distended bowel became available. My erstwhile associate, Doctor Richard F. Edlich, developed a maneuverable controlled tip that could be bent like a finger and brought readily through the pylorus into the duodenum under fluoroscopy-a technic which in Edlich’s practiced hands achieved quicker transit into lower reaches of distended intestinal coils.

Need for Team Effort (Figures 12 and 13)

Management of acute intestinal obstruction is essentially a team-effort responsibility. Success with tube intubation demands that the team have an enthusiastic and experienced intestinal intubator. In fact, our experience at Minnesota, up until my retirement in 1967, showed it was feasible to decompress many distended bowels in patients with incomplete obstruction of the small intestine quite

The American Journal of Surgery

Great Ideas in Surgery: Bowel Obstruction

Figure 12. Long intestinal decompression tubes. Leonard’s TOP, Arnold coiled-spring tube for decompress/on of the distended small intestine. bliddie, decompression at operation of an incomplete obsttxxtion with Leonard tube. Scout film priorto operation on Mt. Situation on compktlon of operation: the tube is temporartiy left in situ, at left. Bottom, long intestinal tube when remaining in situ for several days Mates the effect of the No6ie p//cation procedure.

Vdume 135, February 1978

(that patient was found to have a perforated bowel at operation), a mortality of less than 2 per cent, a measure of the progress made in the management of some aspects of acute intestinal obstruction since the days of C. Jeff Miller (1929). In twelve patients in this series in whom nonviable bowel was encountered the mortality was 25 per cent.

Decompression in Colic Obstructions

Figure 13. Richard Edlich’s maneuverable and controllable tip facilitates ready passage of tube through pytonts. M, too, like the Leonard tube achieves ready descent with the aid of a distal balloon and a sty/et employed to urge the tube an. _...

effectively prior to operation. One cannot know how the bowel is obstructed; in consequence operation is necessary. At such operations the bowel, in most instances, is found empty and quite well decompressed save for a few distended loops just proximal to the obstructing agent. Moreover, the inlying catheters can be quickly advanced to decompress completely any remaining distended coils, making it possible to deal directly with the obstructing agent. Whereas it was my experience and enthusiasm for enterostomy that provoked my interest in effecting intestinal decompression with an inlying duodenal tube, it was the expertise of some of my associates in extending the technics of intestinal intubation that made it possible to decompress distended bowel effectively prior to or at operation and without recourse to external drainage. In a series of ninety-seven patients treated during the four year interval from 1961 to 1965, no enterostomy was performed and operative decompression failed only three times. In seventythree patients with simple obstruction (excluding cases of carcinomatosis) only one death occurred

144

Over four decades in this clinic, the choice of procedure in acute obstruction of the colon with enormous distention has been colostomy proximal to the obstruction, the site for decompression being guided by the scout x-ray film. (Figure 9D.) Inasmuch as the obstruction most frequently concerns the sigmoid, splenic flexure, or descending colon, the operation is usually performed upon the transverse colon. It probably can be done with less risk than any other decompressive procedure. To be certain, if the cecum is not greatly distended, cecostomy succeeds in decompressing the bowel without spillage. In this clinic, Dennis (1944) found that the mortality of transverse colostomy for acute obstruction of the colon in thirty-eight patients was 7.8 per cent. Of the three deaths. two occurred in natients in whom nerforation was already present ai operation. Grafion Smith reviewed the experience of this clinic over the twelve year period from 1942 to 1953 and observed the mortality of transverse colostomy as a method for decomnression of the obstructed large bowel to be 3.7 per cent. There were three deaths among eighty-one patients; two died of perforation distal to the transverse colostomy, a circumstance that points up the need of effecting operative decompression near the obstruction. On this score cecostomy for obstruction in the distal colon is definitely an incomplete operation. The other patient died of pulmonary embolus. For primary resection in the presence of great distention, the mortality was 14.2 per cent (5 deaths in 35 patients). My thesis in dealing with acute intestinal obstruction is to rectify the threat by the simplest means. The situation is comparable to that of a drowning man: he is brought to shore; it is not the proper time for a swimming Iesson.

Strangulating Obstructions (Table Ill)

Strangulating types of intestinal obstruction constitute an area in which a high mortality still persists [97]. Both physicians and surgeons need to be alert to the rapidity with which loss of viability and gangrene can occur in strangulated external

The Amerlcan Journal of Surgery

Great ideas in Surgery: Bowel Obstruction

hernias. This progression is notably rapid in strangulated femoral hernia in which the rigid ligaments of Poupart, Gimbernat, and Cooper cause loss of viability of the bowel in a surprisingly short period of time [20,33,72]. The Clinical Research Committee of the London County Hospital (1948) reported that within 6 hours of the commencement of symptoms 8 per cent of strangulated femoral hernias will require inversion of devitalized areas or intestinal resection; at 12 hours 10 per cent will be in need of such additional surgery; at 24 hours 13 per cent; at 48 hours 30 per cent; and beyond 48 hours 54 per cent will require aggressive surgery. The overall mortality for 336 strangulated hernias reported by the Council was 20.2 per cent; when intestinal resection was necessary, 52 per cent. The obvious conclusion is that any delay is attended with grave risk and that serious heed must be paid signs of strangulated external hernia accompanied by immediate operation to disengage the bowel from the constriction. The primary difficulty with internal strangulating obstructions is that they are difficult to recognize. The increased density of the bowel in mesenteric venous occlusion described by Scott and myself (1932) was put to practical use by Perry (1956) in my laboratory. Perry observed that attending inflation of the peritoneal cavity with 500 to 700 ml of air, the infarcted hemorrhagic loops stood out prominently like sausages. (Figure 4.) Inasmuch as arterial mesenteric occlusions are not attended by increase in density of the bowel, pneumoperitoneum is of no value in their recognition. More recent studies in this laboratory (Ghanem et al, 1970) have shown that arterial mesenteric oc-

TABLE III

Hours after Surgery 6 8 10 12 14

Average Peritoneal Leukocytosis (cells per cubic millimeter) in Dogs after Superior Mesenterlc Artery Ligation Control Dogs* Average Peritoneal No. of WBC &SD Dogs 1 3

500 1.800 f216 4.450 f550 2,800 f260 2,150 Al,350

2 3 2

Test Dogs Average Peritoneal No. of WBC &SD Dogs 3.900 13,400 f2.698.14 24,800 f4.000 42,333 f3.470.19 69,900 f&950

p Value

1 3

<0.05

2


3


3


* Control dogs had laparotomy and passage of untied suture around superior mesenteric artery.

Voiumo 135, February

1978

elusions can be recognized by the simple expedient of a peritoneal tap, a procedure which my colleague, Doctor Root, and his associates have used to advantage in ascertaining whether intestinal perforation is present in penetrating or blunt injuries of the abdominal wall. My surgical colleagues, Ghanem and Goodale, noted that when the arterial blood supply to short or long segments of gut in the dog, rat, or mouse is interrupted, surprisingly high peritoneal leukocyte counts are observed in the peritoneal fluid within 6 to 8 hours; on the contrary, leukocyte counts of the peripheral blood, both capillary and venous, exhibit only modest increases at 6 hours, especially in the dog; great increase in leukocytosis in the peritoneal fluid is regularly observed at 8 hours. This marked contrast between leukocyte counts of the peripheral blood and the striking leukocytosis observed in the peritoneal fluid is virtually diagnostic of strangulating obstructions.* The constricting mechanism in internal strangulations rarely devitalizes the bowel as rapidly as do the unyielding ligaments in strangulated external hernias. Every clinician must maintain a high index of suspicion in the recognition of all threatening obscure acute abdominal disorders; internal intestinal strangulations notably have long been difficult to recognize. Early recognition, obviously, is of the greatest importance. There would appear to be little if any justification for not employing peritoneal tap to establish the presence of internal intestinal strangulations. In my judgment the method is superior to and more reliable than mesenteric arteriography. When strangulated external hernias are operated on regularly within 4 hours after onset of symptoms, and when patients harboring likely internal strangulations are regularly subjected to peritoneal tap through a short subumbilical midline incision not more than 2 cm in length within 6 to 8 hours after onset of symptoms, the forbidding and persistent high mortality of arterial mesenteric infarction hopefully will cease to exist. More frequent recourse to pneumoperitoneum for early recognition of the more frequent venous mesenteric infarctions also is urgently needed. Somewhat more than one third of the overall mortality of acute intestinal obstruction is owing to mesenteric infarction [93]. Strangulated external hernias are responsible for 20 per cent of the deaths. In other words, 53 per cent of the overall mortality of acute intestinal obstruction is owing to strangu* Jenson and Smith (1956) in this clinic had urged peritoneal tap for the recognition of internal strangulating obstructions.

145

Wangensteen

zE

2 x 0 8 0’ 0

16.0I14.0I-

Ulcer of Stomach and Duodenum Appendicitis intestinal Obstruction and Hernia

12.0 10.0I-

&

8.0

ZZ

6.0

8

4.0

-

-

W g

f g n

2.0 1930

32

34

36

38

40

42

44

46

48

50

Time in Years Ftgure 14. The death rate per 100,000 population from ktestkal obstructfon, appendicifs, andpeptic ulcer in the United States from 1930 to 1967. A 95 per cent reduction in morta/Ity of acute appendkttis has occurred over the past thirty-seven years. Perforation of the appendix ts obstructive in nature too, occasioned by a fecaffth and the high secretory power of the appendix, the highest of all glandular and tubular strictures in the body. A 57 per cent decrease in the mortality due to intestinal obstructfon has occurred over the same interval. A better achievement w/th strangulating obst~ctions can add new dimensions to current accomplishment. The tools are available; they need to be used. The 1967 mortality rate for peptic ulcer has decreased llper cent since 1930; inclusion of mortality from stress ulcer indicates an increase of 15 per cent over the 1930 situation ( Vital Statistics, US, 1967). In recent years there has been a deflntte decrease in the mortality of peptic ulcers owing to more effective control of hermorrhage. More recent data (Monthly Vital Statistics, August 30, 1972) suggest a 97per cent decrease in mortaftty due to a~ndkftis ( 1977) since 1930; and an approwimate 66 per cent decrease in mortality due to intestinal obstruction over the same period of time; 45 per cent of mortaltty from hernia involves hernia without obstruction.

lating varieties of obstruction. The remedy is clear: early recognition and immediate operation.* Attempts at taxis must cease and inattentiveness to the time factor must be corrected. When our profession takes greater heed of currently available methods by which mesenteric infarction can be recognized, whether venous or arterial in character, a significant impress upon this segment of the problem for the better will be in evidence. Moreover, immediate surgical intervention lies at the root of the matter. Misplaced Reliance Obstructions

on Antibiotics

for Strangulating

A number of publications have stressed the beneficial effect of antibiotics on prolongation of life in experimental strangulating intestinal obstructions [3,17,101], suggesting that such therapy could prove

* Notable improvement has occurred in management of intussusception-only eighty-five deaths in the Vital Statistics of the United States in 1967. Similar improvement is attending the surgery of congenital intestinal atresia.

146

to be lifesaving in clinical intestinal strangulations [36,102]. The problem, apart from the arrest of intestinal continuity, is the great hazard of a dying or dead intestinal cylinder containing extremely noxious substances. Morgagni (1769) knew that intestine mortified more quickly than other tissues. No surgeon would think of relying upon antibiotics in the management of strangulated external hernias or devitalized tissue from trauma. Early release of the obstructing mechanism or excision of the dead tissue obviously is indicated. Despite the unrealistic enthusiasm of some experimentalists for antibiotics in strangulated internal obstructions, there is no factual evidence that antibiotics have any protective value in the presence of dying or dead tissues. Emphasis needs to be shifted to the significant item of early detorsion or excision of nonviable bowel. (Figure 14.) Summary

Tools to cope more effectively with the bowel obstruction problem have been gradually evolving over The American Journal of Surgery

Great Ideas in Surgery:

the past four decades. It is possible to recognize most varieties of acute intestinal obstruction early enough to salvage the patient from the threat of a disorder that a few decades ago commanded a forbidding mortality. Great intestinal distention does not loom as difficult a problem today as it did four decades ago. The large residual mortality of intestinal obstruction today concerns primarily strangulating varieties. In fact, more than half the deaths from intestinal obstruction derive from the profession’s failure to deal promptly with strangulated hernias and with internal strangulations before the bowel becomes nonviable. The current achievement with intussusception contrasts strikingly with our failure to deal competently with other strangulating varieties of intestinal obstruction. So similarly, the accomplishment with congenital intestinal atresia bespeaks the finesse of modern-day surgeons in coping with anastomoses of small tubular structures. The profession needs to take a more serious interest in intubation technics in dealing with intestinal distention, to which developments my colleagues, Doctors Arnold Leonard and Richard Edlich, have made significant contributions. The team approach to the problem of intestinal obstruction is essential. Every hospital with an interest in intestinal obstruction should have on its Bowel Obstruction Team an intestinal intubator with both interest and expertise. Leonard and Edlich and others who have achieved striking success with intestinal decompression by per oral intubation have a responsibility to train intubators and to transmit their expertise to others who can carry on. The problem in many respects is not unlike the history of utilization of gastroscopy for diagnosis. Only within the past decade have most American hospitals enjoyed ready access to competent gastroscopists, despite the fact that Mikulicz’s first effort with gastroscopy traces back more than a century. It is important to preserve the skill and expertise that experienced intubators have acquired. Their lessons and experience will be lost unless transmitted to younger professional associates. Early diagnosis, prompt surgical management of all strangulated hernias, and per oral decompression of the distended small bowel prior to and/or at operation in all simple obstructions are fundamental criteria for success in any plan of treatment. When the obstruction is complete, after operative decompression, the obstructing mechanism must be removed surgically. For incomplete simple obstructions of the small intestine following adequate decompression, operation may not be necessary. Most instances of paralytic ileus, not septic in nature, reVolume 135, February 1978

Bowel Obstruction

spond favorably to conservative management. In colic obstructions, early decompression proximal to the obstruction is indicated. Effective intestinal decompression, preserving the sterility of the peritoneal cavity lies at the root of the matter. This recounting of a long experience in attempting to understand the bowel obstruction problem suggests that clinical observation, reinforced by experimental studies, is a useful tool in lending a forward thrust to improved accomplishment. References 1. Abbott WO, Johnston CG: lntubation studies of the human small intestine. X. A non-surgical method of treating, localizing and diagnosing the nature of obstructive lesions. Surg Gynecol Obstet 66: 69, 1936. 2. Allbutt TC: Some remarks on obstruction of the bowels. Br Med J 1: 40, 1679. 3. Amundsen E, Gustafsson BE: Results of experimental intestinal strangulation obstruction in germ-free rats. J Exp h&d 117: 623, 1963. 4. Amussat J-Z: Quelques reflexions pratiques sur les obstructions du rectum, faisant suite a la relations de la maladie de Broussais. Gaz MedParis series 2, 7: 1, 1639. 5. Annandale T: Case in which an intestinal obstruction was removed by the operation of gastrotomy. Edinb A&d Surg J 16: 700, 1670-71. 6. Ashhurst J: The Principles and Practice of Surgery. Philadelphia, Lea, 1671, p 790. 9. Ashhurst J: Treatment of intestinal obstruction, p 60. International Encyclopedia of Surgery, ~016, revised ed. New York, Wm Wood, 1666. 10. Beard GM, Rockwell AD: A Practical Treatise on the Medical and Surgical Uses of Electricity, 2nd ed. New York, Wm Wood, 1676. p 579. 11. Bilgutay AM, Wingrove R, Griffen WO, Bonnabeau RC, Lillehei CW: Gastrointestinal pacing, a new concept in the treatment of ileus. Biomed Sci lnstrumentafion 1: 377, 1963. 12. Blake JG: A case of intestinal obstruction of eighteen weeks’ duration, with remarks. Boston Med Surg J 95: 601. 1876. 13. Bonney V: Fecal and intestinal vomiting and jejunostomy. Br MedJ 1: 563, 1916. 14. Buchanan G: On gastrotomy; with a case of intestinal obstruction, in which the operation was followed by relief of the symptoms and cure of the patient, Lancef June 10, 1671, p 776. 15. Cantor MO: Mercury-its role in intestinal decompression tubes. Am J Surg 73: 690, 1947. 16. Clinical Research Committee of the Public Health Department of the London County Council: Viability of strangulated bowel. Br A&d J 1: 43, 1946. 17. Cohn I Jr: Strangulation Obstruction. Springfield, Illinois, Charles C Thomas, 1961. 18. Cooper A: A Series of Lectures on the Most Approved Principles and Practice of Modern Surgery: Principally Derived from the Lectures Delivered by Astley Cooper . . by Charles Williams Jones, 1st American ed from 2nd London ed, by Charles Mingay Syder. Boston, Charles Ewer, 1823, p 281. 19. Duchenne de Boulogne G-B: De I’electrisation IocalisCteet de son application a la physiologie a la pathologie, et a la therapeutique. Paris, JB Bailliere. 1855. 20. Dunphy JE: The diagnosis and surgical management of strangulated femoral hernia. JAMA 114: 394, 1940. 21. Edlich RF, Gedgaudas E, Leonard AS, Wangensteen OH: New long intestinal tube for rapid nonoperative intubation: a preliminary report. Arch Surg 95: 443, 1967.

147

22. Fik I?: The diagnosis and medical treatment of acute intestinal obstruction. Trans Cong Am phvs Surg 1: 1, 1888. 23. Franc0 P: Petit trait6 contentant une des parties principalles de chirurgie. Lyon, 1561. 24. Frankau C: Strangulated hernia: a review of 1487 cases. Br JSurg 19: 176, 1931. 25. Gamble JL, Mclver MA: A study of the effects of pyloric obstruction in rabbits. J C/in Invest 1: 531, 1925. 26. Ghanem M, Goodale RL, Spanos P, Tsung MS, Wangensteen OH: Value of leukocyte counts in the recognition of mesenteric infarction and strangulation of shorter intestinal lengths. An experimental study. Surgery 68: 635, 1970. 27. Goodale RL, Gedgaudas E, Wangensteen OH: Studies of the mucosal pattern attending mesenteric arterial occlusion in dogs with Thiry fistula. (Studies in progress.) 28. Haden RL, Orr TG: Chemical changes in blood of man after acute intestinal obstruction. Surg Gynecol Obsfet 37: 465, 1923. 29. Handley WS: Acute “general” peritonitis and its treatment. Br J Surg 12: 417, 1925. 30. Harris FI: Intestinal intubation in bowel obstruction. Technic with new single lumen mercury weighted tube. Surg Gynecol Obstet 81: 671. 1945. 31. Hartwell JA, Hoguet JP: Experimental intestinal obstruction in dogs with special reference to cause of death and treatment by large amounts of normal saline solution. JAMA 59: 82, 1912. 32. Hutchinson J: Notes on intestinal obstruction: its diagnosis and treatment. Br A&d J 2: 305, 1878. 33. Jarboe JP, Pratt JH: Strangulated femoral hernia: surgical management. Surg Gynecol Obstet 85: 185, 1947. 34. Kocher T: Text-book of Operative Sugary, 3rd ed, vol2 (Stiles HJ, Paul CB, translators). New York, Macmillan, 1911, p 613. 35. La Peyronie F de: Observations avec des reflexions SIX la cure des hernies avec gangrene. Mmoires Acad Roy de Chir 1: 337, 1743. 36. Leffall LD Jr, Quander J, Syphax B: Strangulation Intestinal obstruction: a clinical appraisal. Arch Surg 91: 592, 1965. 37. Leonard AS, Nicoloff DM, Griffen WO Jr, Root HD, Salmon PA, Wangensteen OH: Intestinal decompression: use of a long tube with a coiled spring which achieves relief of distension without enterotomy or enterostomy. Surgery 49: 440, 1961. 38. Leonard AS. Nicoloff DM, Griffen WO Jr, Peter ET, Wangensteen OH: Long coiled spring tube for operative intestinal decompression. Am J Surg 104: 427, 1962. 39. Leonard AS, Wangensteen OH: Operative intestinal decompression by means of a long coiled-spring intestinal tube. Surgery57: 491, 1965. 40. Louis A: Sur la cure des hernies intestinales avec gangrene. Wmoires Acad Roy de Chir 3: 145,170 (La Peyronie), 188 (Duverger), 1757. 41. Louis A: Reflexions sur I’operation de la hernie. Memoires Acad Roy de Chir 4: 28 1, 1768. 42. Louw JH: Resection and end-to-end anastomosis in the management of atresia and stenosis of the small bowel. Surgery 62: 740,1987. 43. Madelung OW: Zur Frage der operativen Behandlung der inneren Darmeinklemmungen. Verh Dtsch Ges Chir 16 (2): 63, 1889 (discussion by Mikulicz reported, pt 1, p 67). 44. Martin E, Hare HA: The Surgical Treatment of Wounds and Obstruction of the Intestines. Philadelphia, WB Saunders, 1891, p 91 (lavage). p 107 (puncture). 45. Matas R: A clinical report on intravenous saline infusion in the wards of the New Orleans Charity Hospital from June 1, 1888 to June 1891. New Orleans &fed Surg J 19: 1, 81, 1891. 46. Matas R: Continued intravenous “drip” with remarks on value of continued gastric drainage and irrigation by nasal intu-

148

bation with gastroduodenal tube (Jutte) in surgical practice. Ann Surg 79: 643, 1924. 47. Matignon A.: Dur traitement de I’occlusion intestinale par le mercure metallique a haute dose, Paris thesis, 1879. 48. Maunoury LJ: Considerations sur I’entranglement interne du canal intestinal, Paris thesis, 1819. 49. McClendon JF, Bissell FS, Lowe ER, Meyer PF: Hydrogen-ion concentration of the contents of the small intestine. JAMA 75: 1638. 1920. 50. McClendon JF, Medes G: physical Chemistry in Biology and Medicine. Philadelphia, WB Saunders, 1925, p 202. 51. McGregor AL: Triumph of Sampson Handley. Med J South Africa 20: 292, 1925. 52. McKittrick LS, Sarris SP: Acute mechanical obstruction of the small bowel; its diagnosis and ireatment. N Engl J A&d 222: 611, 1940. 53. Mery J: Observations sur les hernies. Histoire Acad Roy des SC. . . . 1701, Amsterdam, Gerard Kuyper, 1707. p 356. 54. Miller CJ: A study of three hundred forty-three surgical cases of intestinal obstruction. Ann Surg 89: 91, 1929. 55. Miller LD, Mackie JA, Rhoads JE: The pathophysiology and management of intestinal obstruction. Surg C/in North Am 42: 1285, 1962. 56. Miiler TG, Abbott WO: Intestinal intubation: a practical technique. Am J SC 187: 595, 1934. 57. Moynihan BA: Abdominal Operations, vol 1,4th ed. Philadelphia, WB Saunders, 1926, p 489. 58. Moqagni JP: The Seats and Causes of Diseases . . . (translated from the Latin by Alexander B) 3 vol, London, 1789. Facsimile ediiion, New York, Hafner, 1960, vol 2, book 2, letter 35, article 5, p 167. 59. NBlaton A, Veillard L: Une observation de r&r&issement et d’obliteration du colon ascendant: operation de I’enterotomie suivie de mort-deux autres observations d’enterotomie suivie guerison. Union Med 11: 383, 371, 379, 1857. 60. Nemir P Jr: Intestinal obstruction: ten-year statistical survey at the Hospital of the University of Pennsylvania. Ann Surg 135: 367, 1952. 61. O’Reilly J: Hints on the Treatment of Strangulated Hernia. New York, Wm Wood, 1863, p 20. 62. O’Shaughnessy WB: Proposal of a new method of treating the blue epidemic cholera by the injection of highly-oxygenised salts into the venous system. Lancet, 1831. p. 366. 63. O’Shaughnessy WB: Report on the chemical pathology of the malignant cholera. London, 1832. 64. Parker R: Intestinal obstruction. Br A&d J 2: 669, 1683. 65. Perry JF Jr, VonDrashek SC, Wangensteen OH: Studies in the recognition of strangulating intestinal obstructions with special reference to the value of pneumoperitoneography. Surgery 39: 725, 1956. 66. Petit JL: Trait6 des maladies chirurgicales et des operations qui leur conviennent, ouvrage posthume, 3 vol. Paris, M& quignon I’ain6, 1790, vol 2, p 273. 67. Pigray P: Epitome des Preceptes de Medecine et Chirurgie. Rouen, Adrien Ovyn, 1615, p 257. 88. Pillore de Rouen: Opbration d’anus artificiel. oar la methede de Littre , p 85 in Amussat, 1839, op. cit. 69. Pipelet I’ain& Sur la rCtunion de I’intestin aui a souffert [email protected] de substance, dans une hernie avec gangrene. Memoires Acad Roy de Chir 4: 164, 1768. 70. Pughe RN: Remarks on the case described by Doctor Greves, Liverpool. MChir J 5: 130, 1885. 71. Root HD, Hausar CW, McKinlay CR, LaFave JW, Mendiola RP Jr: Diagnostic peritoneal lavage. Surgery 57: 633, 1965. 72. Saltzstein EC, Marshall WJ, Freeark FJ: Gangrenous intestinal obstruction. Surg Gynecol Obstet 114: 694, 1982. 73. Schmidt K: Characteristik der epidemischen Cholera gegeniiber verwandten Transudations Anomalien. Leipzig, A. Reyer, 1850. 74. Scott HG, Wangensteen OH: Length of life following various

The American Journal of Surgery

Great Ideas in Surgery:

75.

78.

77. 78.

79. 80. 81. 82.

83.

84.

85. 86.

87.

88.

types of strangulation obstruction in dogs. Proc Sot Exp Biol Med 29: 424, 1932. Scott HG, Wan$ensteen OH: Blood losses in experimental strangulation; relation to degree of shock and death. Proc Sot Exp Brbl Med 29: 748, 1932. Scott HG, Wangensteen OH: Absorption of strychnine from strangulated segments of bowel. Proc Sot Exp Biol Med 30: 287, 1932. Scott HG: Intestinal obstruction; experimental evidence on loss of blood in strangulation. Arch Surg 38: 818, 1938. Scudder J, Zwemer RL, Whipple AO: Acute intestinal ob: struction; evaluation of results in 2150 cases; with detailed studies qf 25 showing potassium & toxic factor. Ann Surg 107: 161, l&38. Senn N: The surgical treatment of intestinal obstruction. Ttans Cong Am FfhysSurg 1: 43, 1888. Sperting L: Role of ileocecal sphiccter in cases of obstruction of large bowel. Arch Surg 32: 22, 1938. Sperling L: Mechanics of simple obstruction; experimental study. Arch Surg 36: 778, 1938. Sperling L, Wangensteen OH: Trtisperitoneal absorption. VI. Significance of impaired viability and the influence oj djstention on its occurrence. Proc Sot Exp Biol Med 32: 1385, 1935. Sperling L, Wangensteen OH: Lymphatic absorption in simple obstructi&; significance of distention upon its occurrence. Proc Sot Exp Biol Med 33: 23, 1935. Sydenham T: The Works of Thomas Sydenham (translated from the Latin edition of Doctor Greenhill with a life of the author by Latham RG) 2 vol. London, 1848, 1850, vol 1, p 194, vol2, p 68. Teale TP: On exploration of the abdomen in obstruction of the bowels. BrMJ 1: 41, 1879. Thomas HO: Diet and opium: the past and present treatment of intestinal obstructions, reviewed, with an improved treatment indicated. London, HK Lewis, 1879, p 2. Thomas HO: The collegian of 1666 and the collegians of 1885; or what is recognised treatment? London, HK Lewis, 1885. Treves F: Intestinal Obstruction; its varieties with their pathology, diagnosis, and treatment, new and revised tiition.

Bowel

Obstruction

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