Value of enterostomy in intestinal surgery

VALUE

ENTEROSTOMY

OF

IN INTESTINAL SURGERY *

RAYMOND

L.

WARSAW,

T

HE vaIue of enterostomy in intestina surgery is a subject of dispute and it is the aim of this paper to present a rationa expIanation of its indications and its Iimitations. Enterostomy has been used in simpIe intestina1 obstruction, stranguIation obstruction, IocaI and genera1 peritonitis, postoperative adynamic iIeus, resection of the bowe1, and in various conditions for feeding purposes, as in widespread uIceration of the stomach, ulcer of the cardiac end of the stomach, and obstruction between the mouth and the stomach. To advocates of enterostomy, the operation is “ Iife saving” ; to its opponents, the operation is unnecessary and harmfu1. An expIanation of these opposing opinions wiI1 be attempted from a physioIogica1, experimental and cIinica1 pathoIogica1, viewpoint. The enormous voIume of the digestive secretions which in the course of twentyfour hours enters the upper intestine and is reabsorbed from the Iower intestine, is usuaIIy not appreciated. Rowntree has estimated that for an aduIt the secretion of digestive fluids amounts to between 5 and 7 liters daily. The norma intrajejuna1 pressure is 2 to 4 c.c of water. Gas is normaIIy present throughout the intestina1 cana1. One important source for certain of the gases is found in the decomposition of the intestinal contents, a second source in the diffusion of bIood gases into the intestina1 lumen, a third and Iess acknowIedged source in the swaIIowed atmospheric air normaIIy present in the stomach.

EVANS,

M.D.

N. Y.

Whereas gas is normaIIy present throughout the intestina1 cana1, it is visuaIized in roentgenograms of the aduIt”s abdomen in only the stomach and &on. The intimate admixture of gas and fluid in the smaI1 bowe1 precIudes its demonstration. During the first two years of Iife, gas may be reguIarIy identified in the smaI1 intestine by roentgen-ray fiIms, but visibIe gas in the smaI1 intestine of the aduIt is synonymous with intestina! stasis. NormaIIy the gases contained within the intestine are absorbed into the bIood stream and eliminated by the Iungs. OnIy a smaI1 portion, about one-tenth of the tota gas, escapes through the anus. Any interference with the bIood supply of the gut diminishes absorption of the gas, thereby producing distention of the intestine. There are three main types of activity of the bowe1, IocaI swaying movements or rhythmic segmentations which serve to knead the intestina1 contents and to mix the food with the digestive juices; sIow changes in tone; and peristaItic waves, which begin in the region of highest rhythmicity, the duodenum, as shown by the roentgenographic rush of barium in the duodenum, and run to the region of lowest rhythmicity, the iIeum. ACUTE

INTESTINAL

OBSTRUCTIOK

A patient with simpIe intestinal obstruction of two to three days’ duration seems to be in fairIy good condit.ion. He compIains bitterIy of pain and frequent The temperature, puIse, and vomiting. respiration are practicaIIy normaI. The

* From the Department of Surgery, Graduate School of Medicine, IJniversity of PennsyIvania. 53

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bIood pressure is norma or onIy sIightIy lowered. Another patient with acute stranguIation obstruction of six to eight hours’ duration appears to be in profound coIIapse. Vomiting is profuse, fou1 smeIIing, and preceded by abdomina1 pain. The bIood pressure is low, 60 to 70 systoIic. The first gross pathoIogica1 change in simpIe obstruction is a distention of the bowe1 above and a coIIapse beIow the obstruction. The intestines appear normal except for the increase in size, the gIistening pearIy color of the intestine changes to a more opaque tint. The peristaltic contractions become excessive in their effort to prope1 the content past the obstruction and thus marked kinking, twisting, and distention resuIt, so that secondary points of obstruction may occur. The intestina1 contents change from a norma yeIIow, mucoid Iiquid to an abundant dark, often bIood-tinged, granuIar, foul-smeIIing substance. In the pure type of obstruction, uncompIicated by stranguIation, the patient wiI1 succumb before gangrene deveIops. In acute stranguIation with its attendant interference with the venous, arteria1 and Iymphatic circuIation, the coiIs of bowe1 become reddish, then darker, and finaIIy as gangrene supervenes approaches bIack. The fluid within the intestina1 Ioop is bIack and stinking. Acute stranguIation produces substances encountered in moist gangrene. Infectious and toxic materia1 from the intestina1 waI1 in stranguIation go directIy into Iymph channeIs or the genera1 bIood stream. Schijnbauer demonstrated that it is possibIe for substances to pass through the waI1 of compromised gut and be absorbed by the norma peritoneum. In stranguIation obstruction are incIuded a11 intestina1 obstructions accompanied by impaired bIood suppIy, whether this impairment is due to strangulation, mesenteric thrombosis, voIvuIus, or to intussusception, or foIIows simpIe obstruction of forty-eight to seventy-two hours’ duration, with distention.

HartweII and Cooper stated that it is rare to see simpIe obstruction without the compIication of toxemia. TrusIer stated that, unfortunateIy, simpIe obstruction is rare. It occurs CharacteristicaIIy at or near the pyIorus, but eIsewhere in the intestine an obstruction soon becomes compIicated by circuIatory injury. Foster and HausIer said that 30 to 40 per cent of cases of acute iIeus are simpIe obstructions, but if negIected, stranguIation supervenes. Morton reported that strangulation obstruction commonIy foIIows simpIe obstruction of forty-eight to seventy-two hours’ duration. Van Beuren found that the third twentyfour hours is a critica period in the course of acute simple obstruction. The gut becomes distended to three to four times its norma diameter, with a resuItant arithmetica increase in its circumference and a geometrica increase in its voIume. Necrosis begins in the intestina1 mucosa and extends through the waI1. If the distention is reIieved earIy enough, necrosis of the waI1 may remain superficia1, and hea by scar formation, or adhesion to omentum or other viscera. In a comprehensive review of simple high obstruction, HartweII and Cooper concIuded that there were primariIy a disturbance in the acid-base mechanism with aIkaIosis and dehydration and, secondarily, a definite toxemia. The dehydration is a resuIt of persistent vomiting and is directIy proportiona to it. The decrease in the bIood chIorides is directIy proportiona to the vomiting. Many methods demonstrate a toxic property of the intestina1 content above an obstruction. The identity and the source of the toxin are not known. ApparentIy the toxin reaches the bIood stream and is responsibIe for the toxemia, but there is no evidence that toxins circulate in the bIood of animaIs or patients dying of intestina1 obstruction. The toxin is not absorbed by a norma mucosa but any process which damages the mucosa Ieads to absorption of toxic Ioop content.

N,.u

Stnr~s

VOL.

XXIV, No.

1

Evans-Enterostomy

The process most often concerned in promoting absorption of the toxin is the interference with the bIood supply of the obstructed Ioop of gut by stranguIation or distention. Five causes for accumuIation of gas in the obstructed bowe1 are: Separation of the intimate admixture of gas and intestina1 contents; faiIure of absorption of intestina1 gases into the bIood stream; dif‘fusion of bIood gases into the intestina1 activity of intestina1 bacteria, Iumen; and the swaIIowing of atmospheric air. In simpIe obstruction, gas accumuIates in the proxima1 bowe1 in far greater amount than within cIosed-Ioop or stranguIated segments. McIver showed experimentaIIy, that the reIativeIy smaI1 amount of gas in the closed Ioop is due to the excIusion of swaIIowed air, and concluded that the oral source accounts for the greater amount in simple obstruction. The degree of pressure within the lumen of the bowe1 in obstruction is greatIy increased over the normaI. The maximum pressure rises above 50 C.C. of water, and sustained pressure measures 6 to 8 C.C. of water, but the norma intrajejuna1 pressure is 2 to 4 c.c of water. With retching, vomiting or straining, the pressure is greatIy increased and may exceed IOO C.C. of water. Mounting pressure within the Iumen is an important factor in the absorption of toxins. This pressure, however, deIays the circuIation and SIOWS the dissemination of the poisonous materia1. A Iatent period of from ten to twenty hours is necessary before sufficient fluid accumulates in the bowe1 to increase intra-intestina1 pressure. The toxic properties as a ruIe require more than thirty-six hours to deveIop. The antimesenteric border of the bowe1 wall is entirely bIanched when the gas pressure is equa1 to the bIood pressure. On reIease of the gas pressure, the bIood flow through the bowe1 waI1 is at times greater than normal. Dragstedt and others found that the circuIation is more susceptibIe of impair-

American

Journal

of Surgery

$5

ment in the duodenum than in the jejunum and iIeum, and in the Iatter two, more than in the coIon. At a certain Iow, apparentry minima1 effective pressure, varying degrees of infarction may be produced in the duodenum with IittIe disturbance elsewhere. Raine and Perry found that rabbits recover more rapidIy from intestinal obstruction if they are permitted to re-absorb the contents of the obstructed intestine than when such contents are removed. The bIood chIorides are increased within one hour after reIease of the obstruction. PresumabIy, if toxins were present in the intestinal Iumen of the obstructed gut, they were not absorbed by the norma mucosa below the obstruction. They found that diminishing intra-intestina1 pressure in obstructed bowe1 proIongs the Iife of rabbits because it diminishes secretion and promotes reabsorption; increasing intraintestina1 pressure in obstructed bowe1 shortens the Iife of rabbits because it stimuIates secretion and diminishes reabsorption. The therapeutic vaIue of soIutions of sodium chIoride parenteraIIy increases as the intra-intestina1 pressure in the obstructed bowe1 diminishes and, conversely, the vaIue diminishes as intraintestina1 pressure increases. Jenkins found that high obstruction in the dog is compatibIe with Iife as Iong as a month, if the biIiary, pancreatic and duodena1 secretions are transferred to a point beIow the obstruction. Loss of digestive juices is prevented, hence dehydration and aIkaIosis do not occur. Distention is prevented by shunting the digestive juices to a point beIow the obstruction. Without distention the circuIation is maintained; injury to the intestina1 mucosa does not deveIop and secondary toxemia does not occur. Roger found that piIocarpine, even in smaI1 doses, hastens the fata termination, by increasing the Auid distention in experimenta animaIs with small bower obstruction. Haden and Orr found that jejunostom? does not prevent the chemical changes

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Jwrnalot

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Evans-Enterostomy

in the bIood characteristic of obstruction of the jejunum in the dog; that jejunostomy foIIowing experimental obstruction of the jejunum has no beneficia1 effect upon the duration of Iife, and that Iife may be shortened by earIy jejunostomy. TrusIer stated that the dog has a high percentage of hydrochIoric acid in the gastric juice, therefore, severe hypochIoremia occurs more readily in the dog than in man. Morton and Pearse reported that a striking simiIarity in the cIinica1 picture, bIood chemical changes and Iife expectancy, exists in animaIs with simpIe high obstruction and those with compIete fistuIa at the same Ievel. The syndrome is due to a deficiency of essentia1 secretions through Ioss from the upper gastrointestina1 tract. In the treatment of simple obstruction of twenty-four to forty-eight hours’ duration, the dehydration and imminent aIkaIosis require reIief by the administration of sodium chloride solution. The patient’s condition is usuaIIy good and the obstructive Iesion may be removed. In simpIe obstruction of more than forty-eight hours’ duration, dehydration and imminent or actua1 aIkaIosis is associated with secondary toxemia. Dehydration and aIkaIosis shouId be combated; the distention relieved by drainage of the boweI; and if the patient’s condition permits, the obstruction shouId be removed. Haden and Orr state that it is diffIcuIt to refute the cIinica1 evidence in favor of high jejunostomy. Prompt reIief from pain, and a sense of oppression are nausea, often noted by the patient soon after the bowe1 is drained. The duration and type of the obstruction, the technique of enterostomy, and the individual surgeon’s indications for enterostomy account IargeIy for the statistica1 differences and the opposing viewpoints of the vaIue of enterostomy. By auscultation of the abdomen it may be determined, to an extent, whether an enterostomy in a case of simple obstruc-

tion wiI1 be of vaIue. Loud intestinal noises concomitant with the height of the intermittent pains are easiIy audibIe in mechanica obstruction, They persist even after the pain has been assuaged A metaIIic tinkIe signiby morphine. fies that the bowe1 is under tension, and is imparted onIy by a distended intestine. If the mechanical obstruction continues unreIieved, distention becomes a prominent factor and the peristaItic rushes become infrequent and weaker. AuscuItation of the abdomen reveaIs fewer metaIIic tinkIes at Ionger intervaIs of time. In the far advanced cases, peristaIsis ceases and the abdomen is siIent. PeristaItic activity of the bowe1 i&uences the vaIue of enterostomy. HorsIey states that enterostomy without peristalsis can empty onIy a smaI1 Ioop of bowe1. Lewis beIieves that if the case is so advanced that there is no peristaIsis above the point of obstruction, not much can be expected from an enterostomy. With auscuItatory evidence of peristaIsis in simpIe obstruction of Iong duration, reIief of distention by enterostomy may be expected; without auscuItatory evidence not much reIief results. of peristaIsis, An enterostomy shouId be performed in these Iatter cases because the reIief of distention of even a small loop of bowe1 may occasionaIIy permit reabsorption of secretions with return of muscular tone Remaining cognizant of and peristaIsis. the Iimitations of enterostomy, the procedure shouId not be condemned when it faiIs. Enterostomy is done to reIieve excess pressure, but compIete drainage of gastric and duodena1 secretions shouId be prevented because this is as disastrous as the obstruction. Too rapid reIief of distention should be guarded against for the re&stabIishment of bIood and Iymphatic circuIation, usuaIIy may rapidIy wash out with hyperemia, the retained toxins and the sudden release of an enormousIy diIated bowe1 of Iongstanding obstruction may Iead to a rapidIy fata outcome. GraduaI decompression of

the distended intestine is advocated for these reasons. Enterostomy is preferably done under local or gas anesthesia. Ether is contraindicated because it inhibits peristaIsis. The technical points of importance in the operation of enterostomy have been stressed b,v Guthrie. Man!; surgeons sew the tube into the intestine by two pursestring inverting sutures, others prefer the method of WitzeI which tends to prevent fist& on withdrawa of the tube. The size of the tube v-aries, a smaII recta1 tube or a catheter being used. Hendon advocates the use of the Pezzer catheter. Long preferred the cautery to the knife or scissors because a burnt wound does not made by burning breed; a perforation tends to contract rather than get Iarger; the heat sears the various coats of the intestine; and there is notabIe absence of eversion of the mucosa. The tube is irrigated at Ieast hourIy with water injected without pressure. Constant attention to the tube beginning immediateIy after drainage is necessary. If too much fluid is being Iost through the tube it may be cIamped for two or three hours every four hours. Drainage Iasts onIy as Iong as peristaIsis is reversed; when norma peristaIsis is estabIished drainage practicaIIy ceases. The tube is cIamped about the fourth day, if distention and vomiting occur, the tube is uncIamped; if not, the tube remains cIamped and if gas and feces are passed by rectum the intestina1 tract is open, and the tube may be safeIy removed. The tube usuaIIy remains six to eight days. After remova of the tube, there may be a sIight amount of drainage from the incision but the opening in the intestine cIoses rapidIy. FistuIa occurs very rareIy. STRANGULATION

OBSTRUCTION

The treatment of StranguIation obstruction is an entireIy different probIem. The offending intestina1 segment which is giving rise to the toxemia must be removed. The danger of deIay is of overwheIming

absorption of toxins; or impending rupture with rapidIy fata peritonitis. If the toxin is widely disseminated, no remedy h,as any value. If the duration of the disease is short; if the stranguIated segment is not ganand if the patient’s condition grenous; permits, an immediate resection with an intestina1 anastomosis is done. If #a ganIoop is found, excision of the grenous necrotic segment by the double-barre1 method is advocated by several authors. After the patient has recovered, an intestina1 anastomosis can be established El man recommends simple with safety. exteriorization for Iater resection and pIastic repair and gradua1 decompression of the obstructed bowe1 by fractiona drainage of its contents. ExperimentaIIy, if the Ioops are extraperitonea1 in position, drainage of them has IittIe effect; if intraperitoneak it quickIy kiIIs. In the presence of great distention of the bowe1, it is exceedingIy dangerous to do a one-stage resection and anastomosis. The seminecrotic tissues are diffrcuIt to suture and the fresh surfaces opened invite rapid absorption of toxic materia1. Enterostomy is not indicated in StranguIation obstruction. LOCAL

PERITONITIS

LocaI peritonitis is an important cause of intestina1 obstruction folIowing operations for ruptured appendices and infected peIvic cases. If gastric Iavage or nasa1 catheter suction-siphonage proves unsatisfactory, if the distention sIowIy increases, neither ffatus nor feca1 matter is passed and the patient’s condition becomes worse, Enterostomy enterostomy is necessary. for an apparent compIete bowe1 obstruction often wiI1 aIIow fluid and gas to pass by rectum. Haggard beIieved that the cause or point of obstruction shouId not be sought and the operative heId shouId not be reentered in IocaI peritonitis iIeus, if it can possibIy be avoided. More recoveries foIIow jejunostomy without expk~ration, than with exploration and an extensive

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piece of surgery. C. Mayo beIieved that if the obstruction has foIIowed a peIvic operation, an iIeostomy may afford marked reIief but a high obstruction demands jejunostomy for drainage purposes. Haden and Orr stated that if the peritonitis is chiefly in the Iower part of the abdomen with obstructive symptoms and spasmodic wiI1 undoubtedIy cramps, enterostomy resuIt in much benefit. Morton differentiates dynamic obstruction from paralytic iIeus in IocaI peritonitis and no Ionger hesitates to attack the obstruction at its source. Spasmodic cramps and auscuItatory evidence of peristaIsis usuaIIy indicate a good resuIt with jejunostomy. Their absence indicates paraIytic iIeus or ffatgradient iIeus. Even in the Iatter cases a good resuIt usuaIIy occurs with enterostomy, provided the peritonitis is IocaIized to the Iower abdomen. The majority of writers advocate enterostomy for intestina1 obstruction in IocaI peritonitis, and do not attack the origina operative site. GENERAL

PERITONITIS

Both PringIe and HandIey believed that in acute peritonitis, death is usuaIIy not due to absorption of the products of suppurative peritonitis but to intestina1 toxemia secondary to paresis of the inAamed intestine. David and Sparks concIuded from their experiments that in the earIy hours of peritonitis absorption of toxins and bacteria into the circuIation directIy and via the Iymphatics is the dominant factor of danger, whiIe Iater, absorption from the peritoneum becomes Iess important and a IocaI condition, such as paraIytic iIeus, gains the ascendancy in the picture. Hiibener heId the opinion that enterostomy shouId be done in peritonitis after conservative means have faiIed to reestabIish peristaIsis. CIute beIieved that by drainage of the intestine in peritonitis, some patients may be saved who otherwise wouId die.

Haden and Orr showed experimentaIIy that if the entire abdomina1 cavity is invoIved in the infection with free fluid and if much damage is done to the tonicity of the waI1 of the bowe1, enterostomy wiI1 be of no value. They concIuded that sufficient evidence has not been presented to justify the beIief that the cause of death in genera1 peritonitis is intestina1 obstruction; but that in doubtfu1 cases of peritonitis enterostomy shouId be used. In genera1 peritonitis, absorption of toxins and bacteria occurs earIy and paraIytic ileus Iater. The abdomen is spIinted and does not move with respiration; auscuItation reveaIs a siIent abdomen. From a cIinica1 and pathoIogica1 physioIogicaI viewpoint, it seems concIusive that an enterostomy has IittIe vaIue in these cases but in doubtfu1 cases it may be used with a fuI1 reaIization of its Iimitations. POSTOPERATIVE

ADYNAMIC

ILEUS

Adynamic iIeus, or paraIytic iIeus, may be defined as a disorganization and impairment of the motor function of the gastrointestina1 tract, sometimes resuIting in compIete cessation of motor activity with consequent functiona obstruction, bIood chemistry changes and toxemia. The onset of adynamic iIeus is brought about by a pecuIiar nervous reaction in the “nervous type” individuaIs who are more susceptibIe to direct and reffex stimuIation of the spIanchnic sympathetic nerves. The digestive tract is highIy autonomous, hence it seems unIikeIy that a withdrawa of nervous stimuIi couId produce paraIytic iIeus. It is more probabIe that postoperative adynamic iIeus wouId be produced by a stream of inhibitory stimuIi arising in the brain or cord, or in tissues cut or injured during the operation. It is not paraIytic because the muscIe is active and in good working order, and it is not dynamic in the sense that there are no white, ring-Iike contractions that sometimes obstruct the bowe1 in children. Peritonitis, Iesions within the centra1 or sympathetic nervous system, certain types

NEW SERIES VOL. XXIV,

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of abdomina1 trauma and nerve Iesions, and certain types of toxemias are frequent causes of adynamic iIeus. anaIgesia or spina TheoreticaIIy, splanchnic anaIgesia is effective in reIieving adynamic iIeus, as either procedure produces a chemica1 section of the spIanchnit nerves, that is, spIanchnic inhibitory reflexes are bIocked and vagus motor reflexes have fuI1 power. CIinicaIIy, spina anaIgesia has been used more frequentIy than spIanchnic analgesia for this purpose. Spinal anesthesia wiI1 not be effective if the patient is under the influence of morphine. ParaIysis of the intestine does not, per se, cause much distention. The accumuIation of gas and swaIIowed atmospheric air raises the intra-intestina1 pressure norma and produces distenabove tion. MucosaI damage resuIts as distention progresses, and absorption of toxins begins. SpinaI anesthesia has been proposed by many in the treatment of paraIytic iIeus. If the intra-intestinal pressure has distended the muscuIar waI1 to a point where it produces exhaustion and Ioss of muscuIar elasticity, the use of spina anesthesia is of no vaIue. Its influence can be of importance onIy as a therapeutic measure in the earIy treatment of adynamic ileus before the muscuIar waI1 itseIf is exhausted. In the use of jejunostomy in the paraIytic type of iIeus, various authors report good resuIts, aIthough the majority quaIify this with the Iimitation that the jejunum must show active peristaIsis. BartIett stated that enterostomy has proved in his experience a most vaIuabIe resource as an emergency for the relief of intestina1 obstruction. The high mortaIity reported foIlowing enterostomy is the inevitable concomitant of its use in dying patients. It has been natura1 to deIay interference unti1 sufficient time has elapsed for the patient’s condition to make operation imperative. BartIett beIieves that the response to spina anesthesia gives a true indication for or against enterostomy.

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If, within fifteen minutes after the injection of the spina anesthetic, passage of gas and feces and disappearance of distention be not obtained, enterostomy should be performed immediately, advantage thus being taken of the anesthesia aIready produced. Longer deIay permits progressive depIetion of saIt and water reserves, interference with circuration of the gut and subsequent toxemia. If spinal anesthesia faiIs, expectant treatment aIone, regardless of all attempts to meet the patient’s physioIogica1 needs, onIy deIays the inevitabIe. EarIy treatment of paraivtic i1eu.s consists of the parentera injection of sodium chIoride soIution to prevent dehydration. An indweIIing Levine tube or nasa1 catheter suction-siphonage to keep the stomach and duodenum free of gas and secretions is used; heat is appIied to the abdomen; and psychica support to the highest degree is given. The abdomen shouId be JUSCUItated at frequent intervaIs; the appearance of norma peristaItic sound is generalIy a harbinger of prompt improvement. If the overffow of gastric and duodena1 secretions continues, the green, biIe-stained ffuid changes to a dark brown, foursmeIIing fluid; and if the abdomina1 distention increases, with Ioss of peristaItic sounds, the subsequent treatment varies with different surgeons. One surgeon may give drugs Iike pituitrin or eserine to stimuIate peristalsis; if peristaIsis fails to return, he may or may not perform an enterostomy. A second surgeon performs an enterostomy to reIieve distention, hoping that peristaIsis wiI1 return but an enterostomy without peristaIsis wiI1 empty only- a smaI1 100~ of intestine. A third surgeon earIy injects a spinal anesthetic to induce peristaIsis but if it does not return, he performs an enterostomy. The enterostomy may relieve the distention sufFicientIy to restore muscuIar tone of a smaI1 Ioop of intestine with a return of peristaIsis through effective vagus impuIses, the spIanchnic inhibitory reflexes having been bIocked by the spina

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anesthetic. Recorded statistics in these cases seem to be simpIy a record of surgeon’s impressions and experiences. COMPLETE OF

INTESTINAL THE

LARGE

OBSTRUCTION BOWEL

In compIete intestina1 obstruction from carcinoma of the coIon with unIocaIized obstruction, the bIind cecostomy, under IocaI anesthesia without exproration, is the procedure of choice according to Haggard and to Rankin. Cheever, however, prefers a transverse coIostomy through the right rectus muscIe on the theory that the great majority of cases of coIonic carcinoma wiI1 be found dista1 to that point and that a proxima1 Iesion is not IikeIy to produce obstruction. Pfeiffer and Smyth advocate compIete diversion of the feca1 stream by coIostomy in preference to a temporary coIostomy or cecostomy made with a tube which necessariIy diverts onIy a part of the feca1 current aIthough it does act as a safety vaIve to prevent gaseous distention. COMPLEMENTAL

ENTEROSTOMY

MacKinnon found that a tube introduced into the upper end of the jejunum at the cIose of some serious abdomina1 operations for perforated uIcer, peritonitis, and intestina1 obstruction, prevents postoperative iIeus. The name compIementa1 jejunostomy was given to this procedure which acts as a safety vaIve against an increase of intra-intestina1 pressure. Heyd advised compIementa1 jejunostomy in cases of gastric resection in which Ioss of gastric waI1 is so great as to prohibit an exceIIent or anatomic cIosure; in widespread uIceration of the stomach, where compIete gastric rest for a Iong period is imperative; in duodena1 perforations or gastric resection to take the strain off the suture line; and in that group of patients in which a detour is made in the aIimentary tract because of obstruction, between the mouth and stomach, such as infiltration stenosis, stricture, or carcinoma. For the treatment of obstruction between the

mouth and stomach, many surgeons prefer gastrostomy. Judd and Rankin stated that deIiberate iIeostomy in a11 resections of the coIon reduces gas distention to the minimum; reIieves tension on the suture Iine; and makes ConvaIescence as uneventfu1 as possibIe, in striking contrast to the persistent and Iess successfu1 use of enemata. CONCLUSION

Enterostomy is of vaIue in various conditions encountered in intestina1 surgery. The duration of an obstruction, the type of obstruction, the amount of peritonea1 irritation and inff ammation, the presence or absence of peristaIsis, and the genera1 condition of the patient determine to a Iarge extent the indications and Iimitations of enterostomy. Enterostomy is done primariIy to reIieve the distention and peristaIsis is necessary for the uItimate success of the procedure. With the above considerations, it is concIuded that: I. Enterostomy is of vaIue in simpIe obstruction of more than forty-eight hours’ duration. 2. Enterostomy is of no vaIue in stranguIation obstruction. 3. Enterostomy is of value in intestinal obstruction with IocaI peritonitis of the Iower abdomen or peIvis. 4. Enterostomy is of IittIe or doubtfu1 vaIue in genera1 peritonitis. 5. Enterostomy can be of definite vaIue in postoperative adynamic ileus. 6. Enterostomy is of vaIue foIIowing resection of the colon, and in operations for perforated uIcer, peritonitis, and intestina1 obstruction when used as a secondary or compIementary procedure. 7. Enterostomy may be used for feeding purposes in widespread uIceration of the stomach, gastric uIcer of the cardiac end of the stomach, and obstruction between the mouth and stomach. REFERENCES

ALVAREZ, W. C., and KIYOSHI, H. What has happened to the unobstructed bowe1 that faiIs to transport fluid and gas? Am J. SURG., n.s. 6: 569, Igzg.

LV. JR. An indication for early operation in intestinal obstruction. Surg. Gynec. Obst., 49: 719,

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