Acute intestinal obstruction

ACUTE

INTESTINAL OBSTRUCTION MONROE

A. McIVER,

EIGHTH PART

M.D.,

F.A.C.S.

INSTALLMENT

II: DIAGNOSIS

AND TREATMENT

_ CONTENTS [This

Number] VOL.

CHAPTER xx. Treatment: XXI. Treatment XXII. Treatment:

Preoperative (Cont.): The Operation. The Operation (Cont.).

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xx1 PAGE

308 317 . . . . . . . . . . 326 .,

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(Previously IssuedJj I: THE DISEASE

PART

Var. XIX . . . . I63 Introduction . . _ . . _ . . . . . . . . Genera1 Considerations . . . . . . . . . . . , . . I 72 Varieties of Obstruction . . . . . . . . . . . . . . . . Igr Varieties of Obstruction (Continued): Bands and Membranes 365 Varieties of Obstruction (Continued): VolvuIus. . . . . 378 Varieties of Obstruction (Continued): Intussusception . 387 Varieties of Obstruction (Continued): InternaI Hernias . . . . 581 VOL.xx VIII. Varieties of Obstruction (Continued): NeopIasms . . . . . _ 171 IX. Varieties (Continued): StranguIated ExternaI Hernia . . . 182 (Continued) : OccIusion of the Mesenteric VesseIs . 194 X. Varieties The CIinicaI and PathoIogicaI Picture: Morbid Anatomy . . . 476 XI. PathoIogicaI Picture (Continued) : Genera1 Findings 483 XII. CIinicaI Picture (Cont.): Changes in Body FIuids 489 XIII. CIinicaI PathoIogicaI Picture (Cont.) : Mechanism of Cardinal XIV. CIinicaI PathoIogicaI Symptoms . . . . . . . , . . $00 Obstructions . . . . . . . . 8 I2 xv. Functiona XVI. Functiona Obstructions (Continued): Varieties. 823 Obstructions (Continued) : Preventive Measures. 833 XVII. Functional

I. II. III. IV. V. VI. VII.

XVIII. Diagnosis: XIX. Diagnosis

Genera1 Considerations. (Cont.): SpeciaI Points

. & DifferentiaI

. . 145 Diagnosis . . 159

CHAPTER XX TREATMENT The genera1 principIes governing the treatment of a case of acute mechanica obstruction of the intestine are simpIe: they consist of reIief of the obstruction, and correction as far as possibIe of the systemic effects of the obstruction. The need for prompt operation has Iong been stressed; but realization of the importance of the treatment of the secondary effects of obstruction is a reIativeIy recent advance.le2 It is now generaIIy recognized that many of the signs and symptoms shown by the patient are due not soIeIy to the absorption of a toxin, as formerIy thought, but aIso to loss of water and sodium and chIoride ions from the body by vomiting. The restoration of these substances is an extremeIy important factor in the treatment,3 aIthough the amount of repIacement needed is, of course, in proportion to the amount of Auid Iost, which varies greatIy in different types of obstruction.4-5 * The management and treatment may be chronoIogicaIIy considered under three heads: treatment before operation; operation; and after care. PREOPERATIVE TREATMENT Since promptness in operating is of paramount importance, no preparatory procedure that materiaIIy deIays surgical reIief shouId be considered. UsuaIIy, however, after the decision to operate has been reached there is an interva1, whiIe the necessary arrangements for operating are being made, which can be utiIized to good advantage in preparing the patient. Proper treatment at this time wiI1 often put the patient into much better condition for operation. RELIEF OF PAIN. If the pain is severe, morphine shouId be administered. Since the diagnosis has been made, morphine * See

May

instaIIment,

p.

486. 308

Book Page 230

TREATMENT

309

is no Ionger contraindicated for fear of masking symptoms, and even partiaI reIief from the agonizing types of pain wilI often materiaIIy improve the patient’s genera1 condition and reIieve the menta1 anxiety that is often an important feature. MAINTENANCE OF BODY TEMPERATURE. It is important that any patient prior to operation be adequateIy protected against exposure. It is especiaIIy important in the type of case which shows signs of coIIapse or is in danger of deveIoping such a condition after operation that the normaI body temperature be maintained as a prophyIactic against shock.” The physician and nurse shouId be careful to avoid undue exposure during examinations, or whiIe the skin preparation for operation is being carried out, during the administration of enemas, etc. If indicated, the patient may be wrapped in warm blankets and heat appIied to the extremities. TREATMENT OF DEHYDRATION. One of the most striking cIinica1 features of many cases of obstruction is a marked dehydration. This is proportionate to the amount of vomiting that has taken place; for in the vomitus is Iost not onIy water but aIso the eIectroIytes sodium and chIoride, which are essentia1 in maintaining the norma voIume of body fluids. These substances are best returned to the body by the administration of norma saIt soIution;* as has aIready been shown in the chapter on body fluids,? no other type of soIution wiI1 take the place of one containing sodium and chIoride.ll As demonstrated experimentaIIy by Haden and Orr7 and White and Bridge,l’ water aIone, or gIucose alone, is without benefit. Not infrequentIy, however, it may be desirabIe to add gIucose to the saIt soIution, for the patient may have been starving for some time and the gIycogen reserve of the Iiver be exhausted. GIucose * In their early work, Haden and Orr advocated the administration of hypertonic saline? on the theory that the bIood chIorides were Iow, due to the fact that they w-ere called upon to neutraIize a toxin .* These authors have abandoned this theory,” and it seems physioIogicaIIy more correct to use an isotonic solution, which also permits the administration of large voIumes of fluid. The work of HughsonLo on the markedly stimuIating effect of hypertonic saIt soIution on intestina1 peristalsis is of interest; it would seem unwise, however, to increase peristaItic activity before reIief of the obstruction. t This appeared in the May instaIIment, p. 486. Book t’:tgr 231

310

ACUTE INTESTINAL

OBSTRUCTION

is usually added in the concentration of 3 or IO per cent; it is better to use the former concentration if the solution is to be given subcutaneously, for it should be borne in mind that the ffuid is not taken up so rapidly from the tissues when it contains gIucose, especially if the soIution be hypertonic. iZletbod of Administering the Fluids. Administration of fluids by mouth is contraindicated: they bring on vomiting, which increases the loss of chlorides, and produce distention of the intestinal tract above the point of obstruction (Foster-l3 and Gatch et al.). There are a number of methods by which fluids can be given satisfactorily, and these are discussed in the order of ease of administration: (I) by rectum; (2) by hypodermoclysis; (3) intravenously. Where the dehydration is severe, all three methods of administering fluids may be used. The Iarge amount of fluid that will be absorbed from the rectum when the body is depleted is well known. There is usually no contraindication to administration by rectum, either in the form of a continuous Murphy drip, or by injections of I 20 to 180 C.C. (4 to 6 oz.) repeated every three or four hours. Normal salt solution should be used. The subcutaneous administration of salt solution is one of the simplest and most effective methods for supplying large volumes of fluid to a patient with intestinal obstruction. It may be used alone or in conjunction with the rectal and intravenous methods. It is customary to inject the fluids under the breast or into the subcutaneous tissues of the thigh. It is usually possible in the adult to give IOOO to 2000 C.C. in the course of a singIe injection without producing too great distention of the tissues: the flow of fluid must be clamped off from time to time when the rate of entrance markedly exceeds the rate of absorption. Injection of normal salt soIution (with or without the addition of 5 to I o per cent glucose) directIy into the venous circulation, is the most rapid and often the most satisfactory method for administering fluids. The usual and well-known precautions for intravenous injection of any fIuid should be observed; the Book Page 232

TREATMENT

311

soIution shouId, of course, be steriIe, chemicaIIy pure, and free from any particuIate matter; and it is desirabIe that it be made up onIy a short time before its injection. The fluid shouId be injected at body temperature; and care shouId be taken that it be not given too rapidIy. The amount to be injected depends upon the extent of the dehydration, the size of the individual and his toIeration of the treatment. If the fIuid is to be given during a short period of time (within haIf an hour, for exampIe) it is perhaps best to limit the amount to Iarger from joo to IOOO C.C. If a Ionger time is avaiIabIe, voIumes can be given. GASTRIC LAVAGE. Patients with obstruction who are having the regurgitant type of vomiting, or where there are other reasons for suspecting a diIated stomach, should have a tube passed and the stomach emptied. Often this not onIy temporarily improves the genera1 condition of the patient, but renders vomiting during the operation Iess IikeIy. This Iatter point is of particular importance if a genera1 anesthetic is to be used, for the patient may regurgitate and aspirate the septic material into the Iungs, thus setting up a diffuse, fulminating pneumonia; or he may even aspirate so much materia1 that he dies on the tabIe from asphyxia. The danger from this serious compIication is not compIeteIy removed by emptying the stomach before operation, since the stomach may rapidly fiI1 again from a dilated intestine. In the more serious cases a smaI1 tube may be passed into the stomach through the nose and be left there during the operation. A&ESTHETIC. The anesthetic to be used must be fitted to the individua1 case. In TabIe XIII are shown the types of anesthesia used in cases of intestina1 obstruction (excIusive of stranguIated externa1 hernia and neopIasms) at the Massachusetts Genera1 HospitaI during the twenty-year period 1908-I 927 incIusive, and the attendant mortality. The Iow mortaIity shown by the cases receiving ether is in agreement with the figures recentIy reported by MiIIer.‘” As regards the Massachusetts Genera1 HospitaI figures, the high mortaIity

ACUTE INTESTINAL

312

OBSTRUCTION

attending IocaI anesthesia as contrasted with general, is probabIy expIained on the basis of the fact that the cases received earIy for operation were generaIIy done under ether; whereas the more desperate types of cases, usuaIIy those received Iate, were usuaIIy operated upon under novocaine anesthesia. Ether. There are many earIy cases where ether is a safe anesthetic, and the compIete muscuIar reIaxation that it produces is desirabIe from the point of view of a thorough expIoration. In the Iater stages of the obstruction, when the patient is beginning to show systemic manifestations of the disease, ether has a number of drawbacks. In the first pIace, shock and coIIapse are much more frequent after the use of ether, even in patients who seemed to be in reasonabIy good condition at the time the operation was started. Its action in these cases resembIes its effect on patients with severe traumatic injuries, where its use often tends to induce shock if this is not aIready present, or to depress further the patient who aIready shows signs of shock. An interesting study of the effects of ether in shock was made by CatteII.15 This investigator found that a condition of sensitiveness to ether was brought about by any circumstances which tended to depress the genera1 condition of the animaIs. Upon etherizing the experimental animaIs there occurred a prehminary drop in bIood pressure, probabIy due to the depressing action of ether on the heart. In normal animaIs, this was quickly compensated for by the vasoconstrictor action of ether on the periphera1 vesseIs; but when the animaIs were in shock, no such compensation occurred and the bIood pressure continued to faI1, reaching zero before the eye reffexes disappeared. SecondIy, the IocaI effects of ether on the bowe1 may be injurious. Ether normaIIy inhibits the peristaItic activity and decreases the tone of the intestine; and the bowel which is distended and fatigued from obstruction may not resume its activity after operation, even though the obstruction has been relieved. In the Iess extreme cases, the convalescence may Book

Page

234

TREATMENT

313

be rendered more serious by the depressing effect of ether on intestina1 activity and tone. ThirdIy, the postoperative puImonary comphcations after ether anesthesia shouId be remembered. AIthough statisticaIIy they are not more common foIIowing ether than after other forms of anesthesia, it should be recaIIed that the more serious cases, which might be expected to have a higher incidence of puImonary compIications, are usuaIly done under IocaI anesthesia. For a recent anaIysis of postoperative puImonary compIications, see King’s articIe. l6 Novocaine. Local anesthesia is often the anesthetic of choice in obstruction, particuIarIy in the more serious cases where no extensive exploration is contemplated. There is no depressing effect, either genera1 or IocaI, on any of the bodiIy functions; and since the reflexes about the throat are intact, the danger of aspirating vomitus is avoided. It has the disadvantage that compIete muscuIar reIaxation is not obtained, so that expIoration may be diffrcuIt; aIso intestina1 manipuIation requiring traction upon the mesentery may be painfu1. It is a form of anesthetic, however, that has a wide heId of usefuIness in obstruction. Most of the operative procedures required can be carried out satisfactoriIy without empIoying supplementary anesthetics. It is particuIarIy indicated in the very sick individual requiring onIy an enterostomy; and practica1Iy a11 cases of stranguIated externa1 hernia can be operated upon satisfactoriIy without resort to other anesthetics. Its use is by no means Iimited, however, to those two types of case. Nitrous Oxide. Nitrous oxide with oxygen is occasionaIIy a satisfactory anesthetic. The gas has IittIe or no depressing action, and actuaIly raises the blood pressure. Unless skiIfuIIy given, relaxation of the abdominal muscIes is poor, and the straining is IikeIy to push distended coiIs of intestine out of the wound, and render expIoration difficuIt and dangerous; at times, however, it may be usefu1 as an adjunct to IocaI anesthesia. Because of the danger of aspirating vomitus, the mask shouId not be strapped on. Book

Page

23s

ACUTE

3’4

INTESTINAL

OBSTRUCTION

EthyIene has proved a satisfactory anesthetic in many cases of obstruction. In some cIinics, however, it is not used because of the expIosion hazard. Its advantage lies in the fact that it gives better reIaxation than nitrous oxide, without having the depressing effect of ether. This anesthetic aIso may be used advantageousIy to suppIement Iocal anesthesia. Ethylene.

TABLE TYPES

OF

XIII

ANESTHESIA*

1go8-Igr7

II

IgI8-Igz7

1

T

Type of Anesthesia

Ether.

Number

Number

Number

of Deaths

Mortality (Per Cent)

Number

of Cases

of Cases

of Deaths

41

41

99

35

35

I

14

I

0

0

2

29

20

69

gg

Mortality (Per Cent)

-I-

SpinaI anesthesia..

7 _I.

Local (novocaine)

4 -I-

Spinal and general.

z

I

0

0

0

Novocaine

and general.

4

4

IO

6

60

.

2

0

8

6

75

0

9t

I

Gas-oxygen. EthyIene..

..

.

o _~___

~TotaI.

118

Richardson;‘? McIver.18 t The use of ethylene has been abandoned hazard.

II --

.

I56

*

at this clinic because of the explosion

Spinal Anesthesia. SpinaI anesthesia is increasing in popuIarity in many types of gastrointestina1 surgery.lg It is at times a satisfactory and desirabIe anesthesia in obstruction: it gives good muscuIar reIaxation and has the advantage that under its influence intestina1 peristaIsis and tone are stimuIated. It has, however, certain disadvantages. It interrupts the vasoconstrictor impuIses passing by way of the spIanchnic nerves Book

Page

236

TREATMENT to the blood vessels of the abdominal viscera, often producing considerable fall in blood pressure. In the deeply toxic patient this drop in blood pressure may be profound and serious, for considerable strain on the splanchnic circulation may already exist and anything that tends to abolish the compensator? mechanism may be disastrous. If, therefore, the patient shows any sign of shock or is in such a precarious condition that the onset of shock seems likely, spinal anesthesia should be given only after careful consideration of its dangers. REFERENCES

TO CHAPTER

XX

I. HARTWELL, J. A., and HOGLJET,J. P. Experimenta intestinal obstruction in dogs with special reference to cause of death and treatment by Iarge amounts of normal saline solution. J. A. M. A., 59: 82-87, 1912. 2. HADEN, R. L., and ORR, T. G. Cause of certain acute symptoms foIlowing gnstroenterostomy. Bull. Jobns Hopkins Hosp., 34: 26-30, 1923. 3. WHIPPLE, A. 0. Safety factors in treatment of acute intestinal obstruction. Boston M. @ S. J., 197: 218-222, 1927. 4. MCIVER, M. A., and GAMBLE, J. L. Body fluid changes due to upper intestinal obstruction. J. A. M. A., 91: 1589-1592, 1928. 5. WHITE, J. C., and FENDER, F. A. Cause of death in UncompIicated high intestinal obstruction; experimentat evidence to show that death is due not to toxemia, but to Ioss of digestive fluids and saIts. Arch. Surg., 20: 897-905, 1930. 6. CANNON, W. B. Traumatic shock. N. Y., AppIeton, 1923, p. 169. 7. ORR, T. G., and HADEN, R. L. Reducing surgical risk in some gastro-intestinal conditions. J. A. M. A., 85: 813-814, 1925. 8. HADEN, R. L., and ORR, T. G. Effect of sodium chIoride on chemical changes in bIood of dog after pyIoric and intestina1 obstruction. J. Exper. 12/led.,38: 5j-7 I, 1923. 9. ORR, T. G., and HADEN, R. L. ChemicaI factors in toxemia of intestina1 obstruction. J. A. M. A., 91: 1529-1530, 1928. IO. HUGHSON, W., and SCARFF, J. E. Influence of intravenous sodium chIoride on intestinaI absorption and peristalsis. Bull. Johns Hopkins Hosp., 35: 197-201, 1924. 11. HADEN, R. L., and ORR, T. G. Effect of inorganic saIts on chemica1 changes in bIood of dog after obstruction of duodenum. J. hper. Med., 39: 321-330, 1924. 12. WHITE, J. C., and BRIDGE, E. M. Loss of chIoride and water from tissues and bIood in acute high intestina1 obstruction; experimental study on dogs with duodenal obstruction. Boston M. ~3’s. J., 196: 893-897, 1927. 13. FOSTER, W. C. Acute intestina1 obstruction; correIation of recent experimental studies and cIinicaI apphcations. J. A. M. A., 91: 1523-1529, 1928. 14. MILLER, C. J. Study of 343 surgical cases of intestinal obstruction. Ann. Surg., 89: 91-107, 1929. 15. CATTELL, McK. Studies in experimental traumatic shock; action of ether on circulation in traumatic shock. Arch. Surg.. 6: 41-84, 1923. Book Page zj,

316

ACUTE INTESTINAL

OBSTRUCTION

16. KING, D. S. Postoperative puImonary comphcations; I. statistica study based on two years’ persona1 observation. Surg. Gynec. Obsl., 56: 43-50, 1933. 17. RICHARDSON, E. P. Acute intestinal obstruction; study of second series of cases from Massachusetts Genera1 Hospital. Boston M. @ S. J., 183: 288-298, rgzo. 18. MCIVER, M. A. Acute intestinal obstruction. Arch. Surg., 25: rog8-1134, 1932. 19. MCKI-ITRICK, L. S., MCCLURE, W. L., and SWEET, R. H. SpinaI anesthesia in abdominal surgery. Surg. Gynec. Oh., 52: 898-09, 1931.

Book Page 238

CHAPTER XXI TREATMENT

(Continued)

THE OPERATION GENERAL CONSIDERATIONS. The location and character of the obstruction (particuIarIy as to whether the Iarge or smaI1 intestine is invoIved and whether or not stranguIation is present) having first been determined as exactly as possibIe, it is important to form as accurate an opinion as possibIe in regard to the patient’s genera1 condition. It shouId be reahzed that a patient with intestina1 obstruction is often a much poorer risk than might be supposed from the objective findings: the compensation that these patients have been abIe to establish is easily broken by anesthesia and operative procedure, and once this is broken they quickIy pass into a state of colIapse and shock from which recovery may be diffrcuIt or impossible. With this in mind, the type and extent of operation must be fitted to the individual patient. The chance of recovery for the extremeIy ilI patient is better if the minimum amount of operative procedure be carried out; and it is easy to be Ied into doing too much. Excessive manipuIation of the abdomina1 viscera, especiaIIy traction on the mesentery, or evisceration, is to be avoided. Speed is desirabIe; but precision and gentIeness are essential. In performing the operation the greatest care shouId be used in attempting to free adhesions or to dehver an adherent Ioop: a friabIe, inflamed, distended Ioop of bowe1 may be aImost as easiIy torn or punctured as wet paper; and if this accident occurs the result is usuaIIy fataI. Even if no gross perforation occurs, many surgeons beheve that the permeabihty of an obstructed bowe1 is at times so increased that a peritonitis may resuIt from undue handIing. OrdinariIy, as soon as the peritoneum is opened diIated co& of intestine present themseIves in the wound. Great care is 317 Book Page 230

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OBSTRUCTION

necessary that they do not escape, especiaIIy if the patient makes a sudden straining movement, for not onIy is such an accident conducive to shock, but the diIated co&s may be extremely difhcuIt to return to the abdomen. Care shouId be taken to cover immediately with warm, moist toweIs or large gauze sponges any co&s of intestine that are exposed. CHOICE OF PROCEDURE. The first important question to decide is whether the abdomen is to be expIored, or whether some simpIe procedure such as an enterostomy shaI1 be carried out without expjoration. The answer to this question may be cIear from the preoperative study of the patient; or it may depend upon the operative findings, as for exampIe evidence upon opening the peritonea1 cavity of strangmation, which had not been suspected beforehand. In the seriousIy sick patients, if there is no evidence of stranguIation and the obstruction is in the smaI1 intestine, an enterostomy aIone is usuaIIy sufficient without any exploration; the intestine shouId not be ahowed to come out of the abdomen. If it has been determined before operation that the obstruction is in the Iarge intestine, a cecostomy should be done with a Iarge tube (unIess the obstruction is in the ascending colon or at the iIeoceca1 vaIve, which can easiIy be determined) ; no expIoration shouId be done, and the intestine shouId not be ahowed to come out of the abdomen. In doing either an enterostomy or a cecostomy, if the intestine is much distended an aspirating needIe attached to a suction apparatus shouId be inserted to empty the loop that is to be opened. Aside from the foregoing group of cases, there is the Iarger group where an expIoration is indicated. The hand shouId be inserted into the abdomina1 cavity and the experienced surgeon should be able to feel any band, growth or voIvuIus, in fact anything where there is IocaI distention and thickening of the intestine. In certain instances a colIapsed intestina1 coiI may be foIIowed up to the point of bIockage, or a coi1 of diIated intestine foIIowed down to the obstruction, and the nature of the pathoIogy determined. The situation may be very simpIe, Book

Page

uo

TREATMENT

3°C)

as in the case of a single band compressing a Ioop of gut, or of an annuIar carcinoma of the coIon. On the other hand, it ma) be extremeIy puzzIing, as for exampIe in cases where the intestine is snarIed and rotated around some point fixed by a mass of adhesions. Tracing a section of coIIapsed intestine may Iead one to an opening of an abdomina1 fossa where an internal stranguIation has occurred, or to some hole in the mesenteq or omentum through which herniation and stranguIation has occurred; paIpation in the region of the termina1 iIeum ma3 reveal an impacted gaIIstone or an inflammatory reaction around a MeckeI’s diverticuIum which may be responsible for the obstruction; or the characteristic mass of an intussusception may be feIt. The intestine shouId not be aIIowed to come out of the abdomina1 cavity during the expIoration. If by this conservative method of expIoration it is impossibIe to Iocate the obstruction, and if it is imperative that it be found, it may be necessary to resort to partia1 or compIete evisceration. Cheever’ suggests that the intestines, as they are brought out of the peritoneal cavity, be pIaced in a large sheet of rubber dam and covered with pads wet with warm saIine soIution. D. F. Jones2 says that onIy in cases of absolute necessity should the intestines ever be brought out of the abdomina1 cavity, for he believes that even with the utmost precautions this procedure is dangerous to the Iife of the patient. LOCATION OF THE INCISION. As regards the incision in a case of intestina1 obstruction, in genera1 it may be said that when no definite indication exists as to where this shouId be made, it had best be Iocated over the Iower abdomen or near the midIine.3 A right para-umbiIica1 incision which can be extended upward or downward is often useful and furnishes access to a large area of the abdomen. 4 The great majority of obstructions invoIve the Iower howe and are to be found in the lower abdomen or peIvis, and the incision should furnish ready approach to this region. The incision shouId be of sufficient Iength to permit expIoration to be carried on with ease and rapidity.

320

ACUTE INTESTINAL

OBSTRUCTION

CHARACTER OF THE PERITONEAL FLUID. As soon as the peritoneum is opened, most valuabIe information may be obtained from the character of the peritonea1 fluid. In cases of obstruction there is an increased amount of cIear, straw-coIored fluid; if the Auid is of a dark, bIoody coIor, a stranguIation must be suspected and sought for. In the recent series of 335 cases at the Massachusetts Genera1 HospitaI there were 21 instances in which bIood-stained fIuid was present and a gross interference with the mesenteric bIood suppIy found; in a number of instances the fluid was described as fouI-smeIIing, indicating extreme damage to the bowe1. There were 4 cases in which bIood-stained Auid was present but no definite interference with the mesenteric circuIation found; the fIuid in these cases was probabIy the resuIt of the great distention and congestion of the obstructed intestine. There were aIso a few cases in which, aIthough there was interference with the mesenteric circuIation, it was definiteIy stated that there was no bIoody fluid. Its presence must depend upon the degree and duration of the strangulation. It represents an important operative finding; but its absence, particuIarIy in cases brought earIy to operation, does not preclude the possibihty of stranguIation. At times the character of the peritonea1 contents may suggest that a mistake in diagnosis has been made: the puruIent Auid may suggest some inflammatory disease, or the escape of gas and Auid indicate the perforation of an uIcer. ORIENTATION. The immediate probIem is to obtain some idea as to the IeveI of the obstruction. This may be easy or may be diffrcuIt. If a coIIapsed smaI1 intestine can be Iocated, it is obvious that the obstruction is in the smaI1 intestine and that it must be sought for at a IeveI higher than the coIIapsed portion. On the other hand, if, in addition to diIated coiIs of smaI1 intestine, distended coIon (easiIy identified by the characteristic bands and appendices epipIoicae or the attachment of the omentum) is found, the obstruction is presumably situated in the colon dista1 to the distended portion. It is sometimes timeBook Page 2~

TREATMENT

321

saving to examine the cecum and terminal iIeum first. These structures serve to orient one for further expIoration, whiIe their distention or cohapse at once furnishes evidence as to

FIG. 32. Broken Iine is approximatety Iine of mesenteric root as located on abdominaI wall. ObIique solid Iines divide abdomen into three compartments containing upper, middle and Iower thirds of smaI1 intestines. (&210nks.5)

whether the obstruction is Iocated in the Iarge or smaI1 intestine. Monks, in 1903~ on the basis of the attachment of the mesentery

and certain

distinctive

anatomica

features

of the

intestine and its bIood suppIy, caIled attention to a number of points that are usefu1 in determining approximateIy to which portion of smal1 intestine any given loop beIongs. Diagrams from his articIe are reproduced here. In Figure 52 the broken Iine is approximateIy the line of the mesenteric root as Iocated on the abdomina1 waI1. The obIique soIid lines drawn at right

53‘4

53B

FIG. 53 A, B and c.

u34 Book Page 244

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angIes to this Iine divide the abdomen into three compartments containing the upper, middIe and Iower thirds of the smaI1 intestine. The correspondence between the different parts of the smaI1 intestine and the oblique attachment of the mesentery is obvious. The upper 6 feet or so of the tube are generaIIy confined to the Ieft hypochondriac region. The upper smaI1 intestine is in genera1 of Iarger diameter than the Iower portion of the intestine; the waIIs are thicker, and due to greater vascuIarity the coIor is pinker. These distinctive features, however, may be IargeIy obIiterated or obscured by the effects of distention. The size and arrangement of the mesenteric blood vesseIs offer characteristic points and may furnish a cIue as to the identity of an intestinaI Ioop; Figure 53 A, B, c illustrates these points. The mesenteric vesseIs opposite the upper part of the bowe1 are Iarger than at any other point, and diminish in size unti1 the lower third of the gut is reached. In generaI, the mesentery of the upper intestine is thinner and more transIucent than that of the Iower intestine. The foregoing points in regard to the approximate identification of any given portion of the smaI1 intestine may or may not be heIpfu1 in a particuIar case. They may, however, furnish vaIuabIe hints, and the student would do we11 to note at the autopsy table, in the dissecting room, or during the course of genera1 abdomina1 work, the smaI1 anatomica variations that distinguish different IeveIs; for at times the information may be vaIuabIe and prevent unnecessary manipulation in an emergency. Distention of the coiIs is a factor which often renders expIoration diffIcuIt in cases of obstruction. In some of the

FIG. 53. A. Loop of intestine at 6 feet, showing vasa recta. Secondary loops are a prominent feature. (Monks.“) B. Loop of intestine at 17 feet. Mesentery is opaque, and smal1 tabs of fat begin to appear along mesenteric border of gut. VesseIs are represented by a somewhat compIicated network and are seen with difTicuIty in thick fat of mesentcry. c. Loop of intestine at 20 feet. Gut appears to be thick and large. Mesentery is quite fat and opaque, and Iarge and numerous fat tabs are present. Vessels, which are complicated, are seen with difficulty and are represented by mere grooves in fat. Book

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more extreme cases one wiII have to decide whether or not to abandon the idea of expIoration and simpIy do an enterostomy; if there is reason to suspect stranguIation the expIoration must, naturaIIy, be continued. In the course of expIoration in very distended cases it may be desirabIe to empty certain of the more diIated coiIs. This may be necessary in order to reach the desired portion of the abdomen, to make it possibIe to bring out a portion of the bowe1 for purposes of an enterostomy or cecostomy, or to return to the abdomina1 cavity coils that have been drawn out onto the surface of the abdomen. Owing to the highIy septic nature of the intestina1 contents in obstruction, however, this is aIways a dangerous procedure and must not be undertaken IightIy. The procedure is best carried out with a needle or smaI1 trocar attached by rubber tubing to a suction apparatus; if the aspirating needle is put into the iptestine and aIIowed to drain without suction, Ieakage around the needIe is IikeIy to occur. The puncture wound may be cIosed with a purse-string suture; gauze packing shouId be carefuIIy placed to absorb any unavoidabIe Ieakage. Codman,B Cheeverl and ot,hers advise in seIected cases (in generaI, Iate cases of smaI1 intestina1 obstruction) the insertion into the intestine above the point of obstrSuction of a “Monks tube” or a stiff, woven catheter, over which the bowe1 may be “threaded” and the distended intestine emptied of its contents. This procedure is carried out, not onIy with the idea of reducing the distention, but aIso in order to draw off the toxic contents of the obstructed intestine as a therapeutic measure. The method, however, is not used in most clinics, and shouId certainIy not be attempted by anyone who has not had wide experience in abdomina1 surgery. REFERENCES I. CHEEVER, D. Operative evacuation

J. Med.,

TO CHAPTER

XXI

of smaI1 intestine in paraIytic stasis. New England

207: 1125-I 131, 1932.

2. JONES, D. F. Persona1 communication to author. 3. WHIPPLE, A. 0. Safety factors in treatment of acute intestina1 obstruction. M. e+ S. J., 197: 218-222, 1927. Book Page 246

Boston

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325

4. FLINT, E. R. Acute intestina1 obstruction; series of 282 cases. Brit. M. J., I : 729-731, 1921. 5. MONKS, G. H. Intestinal IocaIization: study on cadaver for purpose of determining to what extent various parts of small intestine may be identified through abdominal wound. Ann. Surg., 38: 574-592, 1903. 6. CODMAN, E. A. Intestinal obstruction. Boston M. CY S. J., 182: 420-424; 451-458, 1920.

CHAPTER XXI I TREATMENT

(Continued)

THE OPERATION (CONTINUED) PROCEDURES FOR RELIEVING THE OBSTRUCTION.Depending upon the pathology found at expIoration, there is great Iatitude as to the choice of operative procedures. In certain cases, the cause of the obstruction may be directIy removed: the division of a constricting band, the untwisting of a voIvuIus, the reduction of a strangmated hernia or intussusception, may be aII that is required and may be very easiIy carried out. When a direct attack is inadvisabIe or impossibIe, the bIockage may be indirectIy reIieved by estabIishing drainage above the o,bstruction through an enterostomy or, occasionahy, by anastomosis of the intestina1 Ioop above the obstruction to one below, thus side-tracking the intestina1 stream around a benign or maIignant stricture. Where the intestine has suffered considerabIy from the effects of obstruction and is diIated and atonic above the bIockage, an enterostomy may be indicated in addition to direct remova of the cause of the obstruction, in order temporarily to divert the intestina1 stream and prevent overIoading and further distention of a portion of bowe1 that is functionahy incapacitated. In cases where extensive interference with the circuIation of the bowe1 exists, resection of the gangrenous bowel and reestabhshment of the intestina1 continuity may be required in addition to reIief of the obstruction. The operations in the recent Massachusetts General Hospita1 series were grouped somewhat arbitrarily under the foIIowing heads: rehef of the obstruction onIy; rehef of the obstruction and drainage; drainage onIy; resection with immediate or deIayed anastomosis; miscehaneous procedures which couId not be grouped under the foregoing headings. The resuhs are shown in TabIe XIV. 326 Book

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It wiII be noted that those cases in which relief of the obstruction aIone was carried out had by far the Iowest mortality. These cases were, in general, those that came to operation earIy in the disease. Resection. Question as to the viabiIity of a segment of intestine comes up frequentIy in operations for acute obstruction. The cyanotic, engorged appearance of a stranguIated It may be easy or difhcuIt to Ioop of gut is characteristic. decide whether it is viabIe and shouId be returned to the abdomina1 cavity or whether it shouId be resected. A wrong decision usuaIIy means a fataIity. There are a number of points that heIp one to decide whether the intestine has been damaged beyond the point where it may safeIy be conserved. The appearance of the peritoneal coat shouId be observed: if this has Iost its norma sheen and gIisten and is of a duI1, grayish coIor with fibrin on the surface, the outIook is not good. PaIpation is heIpfu1, for the viabIe intestine has a certain tone which can be feIt and which is repIaced in the Iater stages by a reIaxed, sodden feeIing. Any evidence of peristaIsis shouId be carefuIIy Iooked for: if it occurs, either spontaneousIy or after pinching, it is of course a favorabIe sign and indicates that the neuromuscuIar apparatus has not undergone serious degeneration. * The mesentery of the invoIved segment shouId be paIpated for puIsations in the mesenteric arteries, incIuding the vasa recta at the mesenteric b0rder.l The veins shouId be examined for the presence of cIot. If the circuIation is obviousIy inadequate,? the bowe1 should be resected; or, in the desperate * Eisberg,’ however, reports a case in which atthough peristalsis was noted at operation, the gut later became gangrenous. t ConsiderabIe experimental work has been carried out on animaIs to determine how much interference with the mesenteric circmation couId be produced without resuItant gangrene of the bowe1. There have also been numerous experiments to determine the point at which Iigations of the mesenteric vesseIs couId best be carried out without fataIIy interrupting the circulation of the bowe1. The earIy anatomica and pathoIogica1 studies of MaII,2 WeIch,3 and Dwight4 Iaid the foundation for subsequent work on this subject, particularly as regards the working out of the anastomotic connections in the mesentery and bowe1. Most of the more recent experiments have consisted of stripping the mesentery from varying lengths of intestine, or of Iigating various mesenteric vessels, and observing the surviva1 period of the animal Book

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cases, the gangrenous intestine may be drawn out onto the abdomina1 walI and a catheter inserted in the proxima1 (oraI) portion as advocated by Eisberg.’ In doubtfu1 cases the Ioop shouId be wrapped in a sponge with warm saline, and a IittIe time ahowed for the circulation to be re-estabIished. Improvement in coIor and other convincing signs of returning circuIation may appear promptIy ; if they do not appear after a reasonabIe time, resection shouId be carried out. There may be an occasiona borderIine case where one is Ioath to return to the abdominal cavity a Ioop of questionabIe viabiIity, but equaIIy reluctant to carry out the radica1 procedure of resection of gut that might survive. In such a case, the Ioop in question may be Ieft outside the abdomina1 cavity and the peritoneum carefuIIy cIosed around it. Under these conditions the Ioop could be promptIy removed if it did not survive, and the and the pathoIogica1 reactions of the invoIved segment of bowe1. Eisberg’ points out that the Iigation of the vesseIs of the second mesenteric arcades (see Monks’ iIIustration, p. 322), has proved safest in experimental work.*This author also feeIs that trauma to the vesseIs and proIonged spastic muscular contracture of the gut waI1 is important in preventing the return of adequate coIIatera1 circutation. Another factor pointed out as important is the speed with which vascuIar occlusion takes pIace, the gut suffering severely when it occurs rapidIy, even though a short segment is involved, while interference with the bIood supply to considerable areas is much better tolerated if the vascutar occlusion takes place slowly. Bostb and Rothschild,6 repeating oIder experiments by various investigators,’ separated the mesentery from varying lengths of intestine and found that the animal survived (in one instance, where 8 inches of the intestine had been separated from its mesentery;s the mesentery was sutured back in place and the omentum wrapped about its attachment to the bowe1.) It is an oId cIinica1 practice to wrap the omentum around intestines whose viability is questionable. The experiments of Scudde? and I concIuded that WiIkieQ deaIt with this point. WiIkie says: “From these experiments the wrapping of a portion of the intestine, the viabiIity of which is doubtful, in the great omentum is of some value in preventing gangrene and perforation; but it is a practice whose range of usefuIness is distinctIy limited.” Scudder came to essentiaIIy the same conclusion. ApparentIy in some cases vascuIar connections are made between the omentum and the damaged gut; but in most cases probabIy the chief vaIue of the omentum is in preventing the spread of peritonitis. In regard to the clinica appIication of this experimental work it shouId be remembered that most of the Iieations of bIood vessels and seoarations of the mesenterv were carried out on healthy intestines, whiIe in acute stranguIation in humans not only is the mesenteric circuIation impaired, but often, also, the capiIIary circutation in the bowel waI1 is handicapped by congestion and distention due to the intestina1 obstruction. Book Page 230

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amount of toxic absorption in the meantime wouId be smaII;* if on the other hand it proved viabIe, it couId at a suitable time be returned to the abdomina1 cavity. Where a smaI1, IocaIized area of necrotic bowe1 is found, such, for exampIe, as might resuIt from the direct pressure of a band upon the bowe1 wal1, the damaged area may be infolded Wrhere it is not possibIe without resorting to resection.12”3 to infoId the necrotic area, at times a IocaI excision may be carried out without cutting across the mesenteric border of the intestine; the wound is cIosed as in an end-to-end anastomosis. In cases requiring resection, great precaution shouId be taken (by walIing off the operative heId with gauze and by careful appIication of clamps) to avoid spilling any of the intestina1 contents and so setting up a rapidIy fata peritonitis. A suction apparatus to remove any Auid may be used to advantage. After a gangrenous segment has been removed and a11 bIeeding controIIed, the question as to the re-establishment of the continuity of the intestine arises. In a number of cases it may be safe, even highIy desirabIe, to proceed at once with an appropriate anastomosis (either end-to-end or side-to-side) by means of suture, or, where time is especiaIIy important, by using a Murphy or a JabouIay button. High LstuIae are often poorIy toIerated, especiaIIy by young chiIdren; and at times an immediate anastomosis, aIthough a risky procedure, is better than a delay and secondary operation. In certain cases, however, particuIarIy in deaIing with a very sick individual or when technica diffrcuIties to anastomosis exist (as for exampIe when there is great disproportion between the diIated gut above and the contracted portion beIow), it is wiser not to attempt to carry out an immediate anastomosis but to bring the severed ends outside the peritoneal cavity, closing the peritoneum around them, and wait unti1 the patient has recovered SUITIcientIy before restoring the intestinal continuity. It may be * The experiments by Travers’O and White and 1LlcI~er,~~ show that toxic absorption under these conditions is small even when gangrene is present. (See also Eisberg’s case.‘) Book

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usefu1 to tie into the ends ffanged gIass tubes (“Mixter tubes”; “ PauI tubes”) to Iead off the drainage. In certain cases where drainage is profuse, it is possibIe Iater to connect the ends of

FIG. 54. Device joining enterostomy tubes, permitting secretions from intestine above an obstruction to pass into coIIapsed gut below. (Wilkie.“)

the tubes so that the intestina1 stream from above passes into the Iower bowe1 for absorption, and dehydration and maInutrition are diminished (see Fig. 54).14 Or, one may colIect the drainage and inject it into the Iower segment. These procedures are particuIarIy appIicabIe to a high fistuIa; if the fistuIa is Iow, so that there is a large absorbing surface above, they are usuaIly not necessary. The secondary operation may be postponed for days or weeks, depending upon the condition of the patient or upon how satisfactoriIy the fistuIa can be managed. Shedden l5 has recently caIIed attention to the fact that an extraperitonea1 Mikulicz type of operation, where the dividing waIIs between the Ioops of gut are graduaIIy cut through with an appropriate cIamp, may be utiIized in estabIishing the continuity of the smaI1 as we11 as of the Iarge intestine. Book

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In the group of resections in Table VIII, the mortality was high. Once the bowel has become gangrenous there is only a short time interval in which surgery can save the patient; if many hours elapse before operation, so much toxic absorption takes place that removal of the damaged gut is without avail. There were 22 resections in the recent Massachusetts General Hospital series, with 16 deaths, a mortality of 73 per cent. In 9 of these patients the anastomosis re-establishing the continuity of the intestinal tract was carried out immediately; there were 7 deaths. In 13 instances the ends of the intestine brought out and anastomosis reserved for future operation; there were 9 deaths. Enterostomy was combined with resection in 4 instances. “Sidetracking” Operations. Indirect operations for relieving the obstruction have already been mentioned. Before taking up the principal one of these, enterostomy, the question of “sidetracking” operations will be considered. Short-circuiting the intestinal stream around a point of obstruction is particularly indicated where the obstruction is the result of some inoperable neoplasm. Certain cases where the obstruction is caused by such a mass of adhesions and inflammatory reactions that it is unwise to attempt to deal comes with it directly,16a17 and others where the obstruction about from some benign stricture, may also be advantageously treated by this meth0d.l” At times the sidetracking operation is useful as a first step in a two-stage operation, the attack upon the primary cause of obstruction being reserved for a secondary operation after all obstructive symptoms have subsided. Turner-l9 draws attention to the dangers of certain types of exclusion operations, where by IateraI anastomosis the ileum is joined to the transverse or left side of the coIon because of a malignant growth in the proximal portion of the colon. The author makes the point that a cecostomy should be carried out in this case; for occasionally the cecum, Iacking a vent (the ileocecal valve at times preventing any discharge back into Book Page 253

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the iIeum), wilI be so greatly distended that it becomes gangrenous or bursts. (See aIso Morison’s articIe.20) Stretton21 reports a case where, following the transpIantation of iIeum into the sigmoid, a bIind pouch composed of cecum and a portion of colon became so distended that resection was required. Codman’s case22 where a permanent cecostomy was Ieft is of interest. TABLE XIV OPERATIVE PROCEDURES (156 CASES, MASSACHUSETTSGENERAL HOSPITAL TEN-YEAR SERIES) * Type of Operation

Relief of obstruction, onIy. Relief of obstruction and drainage of the bowel. Drainage of the bowe1, onIy.. Immediate anastomosis. _ Resection DeIayed anastomosis. i MiscelIaneoust . TotaI.......................................

9 13 6

7

73

9 5

83

156

68

44

* It wiII be noted that those cases in which relief of the obstruction aIone was carried out had by far the Iowest mortality: these cases were for the most part those that came to operation earIy in the disease. The higher mortaIity in the other groups indicates in genera1 the seriousness of the condition found at operation and is not due to poor choice of operative procedure. (McIver.) t There were 2 cases in which because of the condition of the patient the operation was abandoned; and one case in which due to a diagnostic error the obstruction was not relieved. REFERENCES I.

EISBERG, H. B. In viabibty

TO

of intestine

CHAPTER

XXII

in intestinal

obstruction.

Ann.

Surg.,

81:

926-938, 1925. 2. MALL, J. P. Die BIut-und Lymphwege im Diinndarm des Hundes. Abbandl. d. Math.-pbys. Cl. d. k. Siicbs. Gesellscb. d. Wissenscb., 14:151-189, 1887. WELCH, W. H. Hemorrhagic infarction. Trans. Assoc. Am. Physicians, 2: 121-132, 1887. DWIGHT, T. Branches of superior mesenteric artery to jejunum and iIeum. Proc. Assoc. Am. Anat., IO: 79-81, 1898. BOST, T. C. Mesenteric injuries and intestina1 viability. Ann. Surg., 89: 218-221, 1929. ROTHSCHILD, N. S. Safety 1929.

factors

in mesenteric

Iigations.

Ann.

Surg.,

89: 878-885,

TREATMENT 7. BUNTS, F. E. Separation of coIon from its mesentery: clinica and experimenta study. Ann. Surg., 51: 837-845, 1910. 8. SCUDDER, C. L. Omentopexy to intestine deprived of its mesentcry. Boston M. P’* S. J., 159: 338-339, 1908. g. WILKIE, D. P. D. Some functions and surgica1 uses of omentum. Brit. M. J., 2: 1103-1106, 1911. 10. TRAVERS, B. Inquiry into Process of Nature in Repairing Injuries of Intestines: IlIustrating Treatment of Penetrating Wounds, and StranguIated Hernia. London, Longmans, 1812, p. 338. I I. Quoted by WHITE, .I. C., and FENDER F. A. Cause of death in uncomplicated, high intestina1 obstruction; experimenta evidence to show that death is due not to toxemia, but to Ioss of digestive fluids and salts. Arch. Surg., 20: 897-905, 1930. 12. SUMMERS, J. E. Acute intestina1 obstruction; cause of continued high mortality; how this may be reduced. Ann. Surg., 72: 201-206, 1920. I 3. FLINT, E. R. Acute intestinal obstructiod; series of 282 cases. Brit. M. J., I : 729-73I, 1921.

WILKIE, D. P. D. Some principles in abdomina1 surgery. Surg. Gynec. Obst., 50: 129-138, 1930. 15. SHEDDEN, W. M. Resection of small intestine according to technique of Mikulicz; extraction of Iarge foreign body (cream bottte) from rectum. New England J. Med., 200: 1042-1044, 1929. 16. MIXTER, S. J. Points in surgical treatment of acute intestina1 obstruction. Surf. Gynec. Obst., 20: 268-270, rgr5. 17. HANDLEY, W. S. Acute “generaI” peritonitis and its treatment. Brif. J. Surg., 12: I4.

417-434, 1925. 18. ANSPACH, B. M. Enterostomy and enterocoIostomy in treatment of acute intestinal obstruction folIowing peIvic operations. J. A. M. A., 71: 785-788, 1918. rg. TURNER, G. G. Danger of intestinaI excIusion. Brit. J. Surg., 4: 227-233, 1916. 20. MORISOK, R. Notes on case of intestina1 obstruction; with comments on burst of intestine. Brit. J. Surg., 6: 135-139, 1918. 2 I. STRETTON, J. L. Ultimate fate of disused portions of intestine after compIete shortcircuiting operations. Practitioner, 115: 215-217, 1925. 22. CODMAN, E. A. IntestinaI obstruction. Boston hf. ti s. J., 182: 420-424; 451-458, 1920. 23. MCIVER, M. A. Acute intestinaI obstruction. Arch. Surg., 25: 1098-1134, 1932.