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Decompression Procedures in Abdominal Surgery
Decompression Procedures Abdominal Surgery
.
In
OWEN G. McDONALD, M.D., F.A.C.S.*
Morbidity and mortality following any major surgical procedure involving the gastrointestinal tract and other intra-abdominal organs may be significantly affected by the utilization of proper decompression measures. Decompression implies the removal of air and fluids which have accumulated in excessive amounts-~or are likely to do so-from any portion of the gastrointestinal tract. Decompression is accepted as a standard and vital part of the preoperative preparation in some conditions; in the postoperative patient decompression assumes the role of adjunct or preventive therapy. The choice of procedures is determined by the particular condition or by personal preference of the surgeon. For example, decompression of the stomach and/or small intestine will usually suffice for paralytic ileus but decompression alone will not be adequate in true mechanical obstruction. In the latter condition an aggressive surgical approach is demanded. Similarly, methods that decompress the stomach or small intestine must not be expected to relieve an obstructed colon, especially in the presence of a competent ileocecal valve. Personal preferences are illustrated in the Billroth II anastomosis. Following this operation, some surgeons omit any form of decompression; others favor intubation and position the tube in either the gastric remnant, the proximal limb (for protection of the duodenal closure), or in the distal limb of the jejunum for decompression and/or feeding. DECOMPRESSION METHODS 1. Upper gastrointestinal tract A. Gastric 1. Via nasal passage-Levin tube, etc 2. Gastrostomy
* Assistant
Professor of Surgery, University of Illinois College of Medicine, Chicago; Chairman, Department of Surgery, Lake Forest Hospital, Lake Forest, Illinois; Surgical Staff, Research and Educational and Presbyterian-St. Luke's (Adj.) Hospitals, Chicago, Illinois
273
274
OWEN
G.
McDoNALD
B. Intestinal 1. Via nasal passage-Miller-Abbott, Harris, Cantor tubes 2. Enterostomy 3. Trocar, catheter, metallic tips-during laparotomy II. Lower gastrointestinal tract A. Colostomy-cecum, transverse or sigmoid colon B. Rectal tube
UPPER GASTROINTESTINAL TRACT
Gastric Via Nasal Passage-Levin Tube, etc. Levin5 introduced his tube in 1921 and, for a time, surgeons employed intubation with only siphonage drainage. Then Wangensteen 8 ,9 demonstrated the value of continuous suction as a more effective means of decompression. With Paine,6 he proved the prophylactic value of suction against distention-provided suction was initiated before an extreme degree of distention had occurred. Their efforts to deflate a severely distended and paralyzed gut were much less effective than in cases in which peristaltic action was still present. Following the success reported by these investigators there was a general acceptance of the value of intubation and suction in major abdominal surgery. In fact, as with any new idea, intubation was used excessively and without proper indications until an appreciable number of complications were recognized and reported. The most serious of these were ulceration and/or stricture of the esophagus, laryngeal obstruction, inflammatory lesions of the pulmonary system, and perforations of the upper gastrointestinal tract. These unfortunate results brought about more cautious use of tubes and the development of other effective measures. Long and short tubes are still invaluable aids provided they are used in properly selected cases. When intubation is the method of choice, it is worthwhile to instruct the patient about the importance of this therapy. With little time and effort, the surgeon can gain the patient's confidence and, in addition, make his own task easier. This may seem like a minor consideration but it truly provides the surgeon with an opportunity to combine the art and science of medicine. The forceful, and sometimes brutal, passage of a tube in a frightened, uninformed patient only leads to poor cooperation, aspiration of gastric contents, and wound disruption. Most of the air in the stomach and small gut is swallowed; therefore, tense, neurotic and aerophagic patients will create more problems, when using tubes, than the relaxed confident patient. During the preoperative period, casual observation of the patient's habits can provide information suggesting the need for suction. This is helpful because not every patient coming to cholecystectomy, gastric resection or other major abdominal operations requires intubation. Unnecessary use will only incre::tse postoperative discomfort.
DECOMPRESSION PROCEDURES IN ABDOMINAL SURGERY
275
A nasogastric tube should be positioned before operation, or with the patient anesthetized, so as to avoid the struggle with a gagging, distended, ill patient in the postoperative period. However, if a temporary gastrostomy is to be used, this can be established in conjunction with the primary surgical procedure. When using long or short tubes through the nose, these precautions are worthwhile: 1. When passing the tube (a) minimize trauma-use topical anesthesia, lubrication, etc.; (b) prevent aspiration of gastric contents. 2. The position of the tube is determined by (a) effective removal of air and fluids and (b) radiographic evidence. 3. Regular inspection of mechanical suction equipment is essential. 4. Irrigate the tube as indicated. Gastrostomy. During the past ten years there has been an appreciable increase in the use of temporary gastrostomy for decompression of the stomach and small intestine. Advantages of this method have been reported by Farris and Smith,2. 7 Gilchrist,3 Holder and Gross,4 and others. Gastrostomy is a simple but effective procedure which eliminates the complications and annoying discomfort of nasogastric tubes. It is especially valuable in (1) patients needing suction for a long time, (2) aged and very young patients, (3) patients with pulmonary disease-bronchitis, emphysema, etc., and (4) cardiac patients-recent occlusion, decompensation, etc. Understandably, the aged come to operation with a higher percentage of pulmonary and cardiac problems. They are more intolerant and antagonistic to nasal tubes and nowhere is the value of gastrostomy more apparent than in this group. The hazards of retained secretions in the air passages, aspiration, and cardiac strain are all reduced. The most striking single advantage of gastrostomy is the relative comfort enjoyed by the patient. The very young are also ideal candidates for gastrostomy. In this group the surgeon usually deals with sick, frail and premature infants. Their intolerance to tubes in the pharynx and esophagus is general knowledge. All too often these tubes are ineffective because of a small lumen; this is correctible by using the larger tubes permitted with a gastrostomy opening. In tracheo-esophageal fistula where regurgitation of gastric contents into the lungs, via the fistula, is so disastrous, a gastrostomy may be life-saving. Although complications following nasal intubation are quite proportional to the duration of usage, gastrostomy may be employed for long periods with little concern. Technique of Gastrostomy. A temporary gastrostomy may be performed as a separate surgical procedure or combined with most abdominal operations. After making a stab wound in the midportion of the anterior wall of the stomach, bleeders are clamped and ligated. We prefer a No. 20 Foley catheter with a lO-cc. bag. The stab wound should be closed around the catheter with two or three concentrically placed purse-string sutures, the outermost of which incorporates a bite of the tubing. This last suture is also used to bring gastric serosa against the peritoneum of the abdominal
276
OWEN G. McDoNALD
wall. Four to six additional nonabsorbable sutures supplement this fixation. The catheter is always brought out through a separate stab wound and, after inflation of the balloon, the stomach is snugged against the abdominal wall. Externally, one can fix the tube with special clamps or use a heavy silk ligature, which incorporates skin and tubing, to strengthen the fixation. Some surgeons prefer tubes that will decompress the upper gastrointestinal tract as well as the stomach. This requires a longer tip than is available on the standard Foley catheter but special tubes can be purchased for this purpose or one can use a large Levin tube, altered by additional openings. The equipment used for nasogastric suction is satisfactory for a gastrostomy and decompression is continued until liquids or feedings are tolerated. The operation is so simple that attention to details may be slighted. The most frequent complications are: (1) bleeding from the stab wound, (2) leakage at the site of fixation to the abdominal wall, (3) wound infections and (4) skin digestion. I am aware of two deaths at one of our hospitals caused by generalized peritonitis resulting from leakage around the tube.
Intestinal Via Nasal Passage-Long or Intestinal Tubes. When the value of continuous suction and the prevention of distention were proved, long tubes (Miller-Abbott, Harris, Cantor, etc.) came into use for intestinal decompression. These proved to be very successful in cases of paralytic ileus and in partial obstructions which so often accompany the plastic exudate and fibrinous adhesions of peritonitis and intra-abdominal trauma. However, long tubes never attained the wide acceptance I believe they deserve, possibly because of (1) increased trauma-more complications, (2) difficulty in advancing tube through pylorus, (3) the need for greater attention and effort and (4) added fluid and electrolyte problems. In using the long tube there will be greater success if the tube is passed under fluoroscopic guidance. Although this requires transportation of a sick patient to the x-ray department it may, in the long run, be welldirected effort. The easier procedure of inserting the tube into the stomach, placing the patient on his right side, and then obtaining a series of films with a portable x-ray machine generally leads to failure and loss of valuable time in the relief of distention. Unless the tip is properly directed one can rarely look for more than gastric emptying and criticism from colleagues about the merits of these tubes. When successfully passed and faithfully attended, these tubes have prevented many laparotomies, permitted time for correction of fluid and electrolyte problems, and converted emergencies into elective operations. Enterostomy. This form of decompression, extensively used years ago, is less commonly employed as a primary procedure today because of the effectiveness of other measures. Infection, leakage, skin digestion,
r I
t
I I
I
I r
I II I
I II
I
DECOMPRESSION PROCEDURES IN ABDOMINAL SURGERY
277
retraction and other limitations have all contributed to lesser usage. However, the method described by Allen and Donaldson! for decompression after a high gastric resection has much to recommend it. When the gastric remnant does not lend itself to a safe gastrostomy, they employ a technique in which the catheter is passed in retrograde fashion through the afferent loop of the jejunum, across the anastomosis, and into the high stomach pouch. Trocar, Metallic Suction Tips, etc. On occasion, the surgeon is forced to decompress distended small bowel during a laparotomy, before proceeding with a safe and complete search for a site of obstruction. At other times, having relieved the obstruction, he may wish to decompress the small bowel to facilitate closure of the incision and promote more prompt return of intestinal function. For this, we pass a large needle, subserosally, for several centimeters before penetrating the mucosa. When suction is attached to the needle it decompresses a short segment of gut so that bowel clamps may be applied with safety and security. Then a trocar or metal suction tip may be used in the deflated gut without the leakage which is so common when larger instruments are inserted into distended intestine.
LOWER GASTROINTESTINAL TRACT
Colostomy In this discussion we are concerned with colostomy only as it is used to relieve an acute or chronically distended colon, to prevent distention following resection or closure of a perforation, or when progressive obstruction is anticipated. A distended obstructed colon must be decompressed to prevent perforation proximal to or at the site of a lesion. The artificial opening can be placed in the cecum or transverse or sigmoid colon, each site having particular advantages and disadvantages related to purpose, permanency, ease of performance, etc. Cecostomy. An opening in this portion of the colon may be satisfactory when relief or prevention of distention is the prime purpose or when a safety valve is indicated, as in anastomoses and perforations distal to the cecum. It is never totally diversionary and should not be performed when complete side-tracking of intestinal contents is indicated. TheRe are advantages of cecostomy: 1. It is easy to perform-with minimal trauma. 2. It can be accomplished with local anesthesia. 3. It is acceptable for irrigations and cleansing of distal colon. 4. It results in decrease of edema and release of distal obstruction. 5. It causes less interference with wide resection of left colon. 6. Tube cecostomy may not require formal closure.
278
OWEN G. McDoNALD
In considering a cecostomy, one must also weigh these disadvantages: 1. It provides decompression but not diversion. 2. Skin care presents more problems. 3. It is not adaptable to use of appliances. 4. The usual incision is not conducive to wide exploration. Technique. In the simplest technique, the cecum is approached through a muscle-splitting incision. If a tube cecostomy is planned, the procedure is similar to that described for gastrostomy except that a much larger tube is necessary and the tube may be brought out through the primary incision. It is important that the tube extend well into the right colon. This method permits the escape of gas and fluids and protects a distal anastomosis. Unfortunately, it is more prone to leakage. For more complete diversion it is better to mobilize enough cecum to protrude 4 to 6 cm. above the skin level. In fixation, avoid sutures in the cecum at the peritoneal and fascial levels for fear of leakage; however, several fine stitches may be used to suture the cecum to the skin edges. Twelve to 24 hours should elapse before opening the cecum unless the danger of perforation demands immediate decompression. As a general rule, cecostomy should probably be reserved for those patients too ill to tolerate surgery of greater magnitude, for obese patients in whom there may be difficulty and danger in exteriorization of the transverse colon, and for the purpose of protecting a suture line more distally. Transverse Colon Colostomy. This is undoubtedly the most utilitarian method of decompressing bowel obstructed by low-lying lesions. When properly constructed, it provides thorough decompression and diversion, is away from the field of most left-sided resections, is easily combined with exploration, and is adaptable to appliances. However, in obese patients with a short mesentery, and in the presence of severe distention, it may be impossible to adequately mobilize the transverse colon without danger of perforation. If exteriorization is incomplete, retraction will follow and result in a colostomy which is difficult to manage and unsatisfactory for itR intended purpose. Technique. The abdomen may be entered through a transverse or right vertical incision of sufficient length to permit exploration. The right transverse colon is grasped and a segment freed of its omentum. A small rent is created in the mesentery to permit passage of a latex rubber drain or a strip of bias tape. With traction and manipulation, a 4 to 6 inch segment of colon is exteriorized and the incision closed in layers from each end with caution to avoid constriction of the blood supply. A glass rod or similar device is then substituted for the traction tape to prevent retraction of the colon. If urgent, this colostomy may be opened immediately. In cases of severe distention, we insert a tube into the proximal limb through a small stab wound in the exteriorized loop and then snug the bowel around the tube with purse-string sutures, to minimize leakage. However, we prefer to delay opening the bowel for 12 to 24 hours because this enables
279
DECOMPRESSION PROCEDURES IN ABDOMINAL SURGERY
!
t.,
I,: 1
US to bring a portable cautery to the bedside for a more thorough division of the loop. The latter method requires no anesthesia but an occasional bleeder will need ligation. Sigmoid Colostomy. Although effective, this segment of colon is not as satisfactory when it is expected that decompression will be followed at a later date by a resection. It is the most desirable location for a colostomy when decompression is necessary for an obstructing nonresectable rectal lesion because the consistency of the stools makes for easier management. The technique here utilizes the same principles described for a transverse colon colostomy.
Rectal Tube Decompression In an anterior resection, with a low-lying anastomosis, excellent decompression can be provided by means of a rectal tube. The tube may be inserted into the rectum before surgery and then drawn upward to extend above the anastomosis, or it may be positioned as shown in Figure 1. In the latter method, and before placement of the final sutures of the anastomosis, a folded rectal tube is inserted so that the rounded end passes distally and the flared end, with supplemental openings, extends above the anastomosis. After abdominal closure, the excess tube protruding from the
Figure 1. Insertion and positioning of rectal tube at operation for protection of low colonic suture line. Note added openings in tube above anastomosis.
3
280
OWEN
G.
McDoNALD
anal canal is cut away to within 2 inches of the rectum. One heavy silk suture fixes the tube to the anal skin. Postoperatively, small amounts of fluid can be instilled to thin colonic contents and to clear the openings above the suture line. I have found this method to be just as effective as a proximal colostomy, easier to manage, and associated with fewer complications.
REFERENCES 1. Allen, A. W. and Donaldson, G.: Jejunostomy for decompression of the postoperative stomach. Surgery 13: 565, 1942. 2. Farris, J. M. and Smith, G K.: An evaluation of temporary gastrostomy: a substitute for nasogastric suction. Tr. Am. S. A. 74: 187, 1956. 3. Gilchrist, R. K.: Gastrostomy tubes. Surg. Gynec. & Obst. 108: 631, 1958. 4. Holder, T. M. and Gross, R. E.: Temporary gastrostomy in pediatric surgery. Pediatrics 26: 36-41, 1960. 5. Levin, A. L.: New gastroduodenal catheter. J.A.M.A. 76: 1007, 1921. 6. Paine, J. R. and Wangensteen, O. H.: Necessity for constant suction to inlying nasal tubes for effectual decompression or drainage of upper gastrointestinal tract. Surg. Gynec. & Obst. 57: 601-611, 1933. 7. Smith. G. K. and Farris, J. M.: Re-evaluation of temporary gastrostomy as a substitute for nasogastric suction. Am. J. Surg. 102: 168, 1961. 8. Wangsteen, O. H. and Paine, J. R.: Nasal catheter suction siphonage: Its uses and technique of employment. Minnesota Med. 16: 96-100,1933. 9. Wangensteen, O. H. and Paine, J. R.: Treatment of acute intestinal obstruction by suction with duodenal tube. J.A.M.A. 101: 1532-1539, 1933. 198 East Westminster Avenue Lake Forest, Illinois
.
In
OWEN G. McDONALD, M.D., F.A.C.S.*
Morbidity and mortality following any major surgical procedure involving the gastrointestinal tract and other intra-abdominal organs may be significantly affected by the utilization of proper decompression measures. Decompression implies the removal of air and fluids which have accumulated in excessive amounts-~or are likely to do so-from any portion of the gastrointestinal tract. Decompression is accepted as a standard and vital part of the preoperative preparation in some conditions; in the postoperative patient decompression assumes the role of adjunct or preventive therapy. The choice of procedures is determined by the particular condition or by personal preference of the surgeon. For example, decompression of the stomach and/or small intestine will usually suffice for paralytic ileus but decompression alone will not be adequate in true mechanical obstruction. In the latter condition an aggressive surgical approach is demanded. Similarly, methods that decompress the stomach or small intestine must not be expected to relieve an obstructed colon, especially in the presence of a competent ileocecal valve. Personal preferences are illustrated in the Billroth II anastomosis. Following this operation, some surgeons omit any form of decompression; others favor intubation and position the tube in either the gastric remnant, the proximal limb (for protection of the duodenal closure), or in the distal limb of the jejunum for decompression and/or feeding. DECOMPRESSION METHODS 1. Upper gastrointestinal tract A. Gastric 1. Via nasal passage-Levin tube, etc 2. Gastrostomy
* Assistant
Professor of Surgery, University of Illinois College of Medicine, Chicago; Chairman, Department of Surgery, Lake Forest Hospital, Lake Forest, Illinois; Surgical Staff, Research and Educational and Presbyterian-St. Luke's (Adj.) Hospitals, Chicago, Illinois
273
274
OWEN
G.
McDoNALD
B. Intestinal 1. Via nasal passage-Miller-Abbott, Harris, Cantor tubes 2. Enterostomy 3. Trocar, catheter, metallic tips-during laparotomy II. Lower gastrointestinal tract A. Colostomy-cecum, transverse or sigmoid colon B. Rectal tube
UPPER GASTROINTESTINAL TRACT
Gastric Via Nasal Passage-Levin Tube, etc. Levin5 introduced his tube in 1921 and, for a time, surgeons employed intubation with only siphonage drainage. Then Wangensteen 8 ,9 demonstrated the value of continuous suction as a more effective means of decompression. With Paine,6 he proved the prophylactic value of suction against distention-provided suction was initiated before an extreme degree of distention had occurred. Their efforts to deflate a severely distended and paralyzed gut were much less effective than in cases in which peristaltic action was still present. Following the success reported by these investigators there was a general acceptance of the value of intubation and suction in major abdominal surgery. In fact, as with any new idea, intubation was used excessively and without proper indications until an appreciable number of complications were recognized and reported. The most serious of these were ulceration and/or stricture of the esophagus, laryngeal obstruction, inflammatory lesions of the pulmonary system, and perforations of the upper gastrointestinal tract. These unfortunate results brought about more cautious use of tubes and the development of other effective measures. Long and short tubes are still invaluable aids provided they are used in properly selected cases. When intubation is the method of choice, it is worthwhile to instruct the patient about the importance of this therapy. With little time and effort, the surgeon can gain the patient's confidence and, in addition, make his own task easier. This may seem like a minor consideration but it truly provides the surgeon with an opportunity to combine the art and science of medicine. The forceful, and sometimes brutal, passage of a tube in a frightened, uninformed patient only leads to poor cooperation, aspiration of gastric contents, and wound disruption. Most of the air in the stomach and small gut is swallowed; therefore, tense, neurotic and aerophagic patients will create more problems, when using tubes, than the relaxed confident patient. During the preoperative period, casual observation of the patient's habits can provide information suggesting the need for suction. This is helpful because not every patient coming to cholecystectomy, gastric resection or other major abdominal operations requires intubation. Unnecessary use will only incre::tse postoperative discomfort.
DECOMPRESSION PROCEDURES IN ABDOMINAL SURGERY
275
A nasogastric tube should be positioned before operation, or with the patient anesthetized, so as to avoid the struggle with a gagging, distended, ill patient in the postoperative period. However, if a temporary gastrostomy is to be used, this can be established in conjunction with the primary surgical procedure. When using long or short tubes through the nose, these precautions are worthwhile: 1. When passing the tube (a) minimize trauma-use topical anesthesia, lubrication, etc.; (b) prevent aspiration of gastric contents. 2. The position of the tube is determined by (a) effective removal of air and fluids and (b) radiographic evidence. 3. Regular inspection of mechanical suction equipment is essential. 4. Irrigate the tube as indicated. Gastrostomy. During the past ten years there has been an appreciable increase in the use of temporary gastrostomy for decompression of the stomach and small intestine. Advantages of this method have been reported by Farris and Smith,2. 7 Gilchrist,3 Holder and Gross,4 and others. Gastrostomy is a simple but effective procedure which eliminates the complications and annoying discomfort of nasogastric tubes. It is especially valuable in (1) patients needing suction for a long time, (2) aged and very young patients, (3) patients with pulmonary disease-bronchitis, emphysema, etc., and (4) cardiac patients-recent occlusion, decompensation, etc. Understandably, the aged come to operation with a higher percentage of pulmonary and cardiac problems. They are more intolerant and antagonistic to nasal tubes and nowhere is the value of gastrostomy more apparent than in this group. The hazards of retained secretions in the air passages, aspiration, and cardiac strain are all reduced. The most striking single advantage of gastrostomy is the relative comfort enjoyed by the patient. The very young are also ideal candidates for gastrostomy. In this group the surgeon usually deals with sick, frail and premature infants. Their intolerance to tubes in the pharynx and esophagus is general knowledge. All too often these tubes are ineffective because of a small lumen; this is correctible by using the larger tubes permitted with a gastrostomy opening. In tracheo-esophageal fistula where regurgitation of gastric contents into the lungs, via the fistula, is so disastrous, a gastrostomy may be life-saving. Although complications following nasal intubation are quite proportional to the duration of usage, gastrostomy may be employed for long periods with little concern. Technique of Gastrostomy. A temporary gastrostomy may be performed as a separate surgical procedure or combined with most abdominal operations. After making a stab wound in the midportion of the anterior wall of the stomach, bleeders are clamped and ligated. We prefer a No. 20 Foley catheter with a lO-cc. bag. The stab wound should be closed around the catheter with two or three concentrically placed purse-string sutures, the outermost of which incorporates a bite of the tubing. This last suture is also used to bring gastric serosa against the peritoneum of the abdominal
276
OWEN G. McDoNALD
wall. Four to six additional nonabsorbable sutures supplement this fixation. The catheter is always brought out through a separate stab wound and, after inflation of the balloon, the stomach is snugged against the abdominal wall. Externally, one can fix the tube with special clamps or use a heavy silk ligature, which incorporates skin and tubing, to strengthen the fixation. Some surgeons prefer tubes that will decompress the upper gastrointestinal tract as well as the stomach. This requires a longer tip than is available on the standard Foley catheter but special tubes can be purchased for this purpose or one can use a large Levin tube, altered by additional openings. The equipment used for nasogastric suction is satisfactory for a gastrostomy and decompression is continued until liquids or feedings are tolerated. The operation is so simple that attention to details may be slighted. The most frequent complications are: (1) bleeding from the stab wound, (2) leakage at the site of fixation to the abdominal wall, (3) wound infections and (4) skin digestion. I am aware of two deaths at one of our hospitals caused by generalized peritonitis resulting from leakage around the tube.
Intestinal Via Nasal Passage-Long or Intestinal Tubes. When the value of continuous suction and the prevention of distention were proved, long tubes (Miller-Abbott, Harris, Cantor, etc.) came into use for intestinal decompression. These proved to be very successful in cases of paralytic ileus and in partial obstructions which so often accompany the plastic exudate and fibrinous adhesions of peritonitis and intra-abdominal trauma. However, long tubes never attained the wide acceptance I believe they deserve, possibly because of (1) increased trauma-more complications, (2) difficulty in advancing tube through pylorus, (3) the need for greater attention and effort and (4) added fluid and electrolyte problems. In using the long tube there will be greater success if the tube is passed under fluoroscopic guidance. Although this requires transportation of a sick patient to the x-ray department it may, in the long run, be welldirected effort. The easier procedure of inserting the tube into the stomach, placing the patient on his right side, and then obtaining a series of films with a portable x-ray machine generally leads to failure and loss of valuable time in the relief of distention. Unless the tip is properly directed one can rarely look for more than gastric emptying and criticism from colleagues about the merits of these tubes. When successfully passed and faithfully attended, these tubes have prevented many laparotomies, permitted time for correction of fluid and electrolyte problems, and converted emergencies into elective operations. Enterostomy. This form of decompression, extensively used years ago, is less commonly employed as a primary procedure today because of the effectiveness of other measures. Infection, leakage, skin digestion,
r I
t
I I
I
I r
I II I
I II
I
DECOMPRESSION PROCEDURES IN ABDOMINAL SURGERY
277
retraction and other limitations have all contributed to lesser usage. However, the method described by Allen and Donaldson! for decompression after a high gastric resection has much to recommend it. When the gastric remnant does not lend itself to a safe gastrostomy, they employ a technique in which the catheter is passed in retrograde fashion through the afferent loop of the jejunum, across the anastomosis, and into the high stomach pouch. Trocar, Metallic Suction Tips, etc. On occasion, the surgeon is forced to decompress distended small bowel during a laparotomy, before proceeding with a safe and complete search for a site of obstruction. At other times, having relieved the obstruction, he may wish to decompress the small bowel to facilitate closure of the incision and promote more prompt return of intestinal function. For this, we pass a large needle, subserosally, for several centimeters before penetrating the mucosa. When suction is attached to the needle it decompresses a short segment of gut so that bowel clamps may be applied with safety and security. Then a trocar or metal suction tip may be used in the deflated gut without the leakage which is so common when larger instruments are inserted into distended intestine.
LOWER GASTROINTESTINAL TRACT
Colostomy In this discussion we are concerned with colostomy only as it is used to relieve an acute or chronically distended colon, to prevent distention following resection or closure of a perforation, or when progressive obstruction is anticipated. A distended obstructed colon must be decompressed to prevent perforation proximal to or at the site of a lesion. The artificial opening can be placed in the cecum or transverse or sigmoid colon, each site having particular advantages and disadvantages related to purpose, permanency, ease of performance, etc. Cecostomy. An opening in this portion of the colon may be satisfactory when relief or prevention of distention is the prime purpose or when a safety valve is indicated, as in anastomoses and perforations distal to the cecum. It is never totally diversionary and should not be performed when complete side-tracking of intestinal contents is indicated. TheRe are advantages of cecostomy: 1. It is easy to perform-with minimal trauma. 2. It can be accomplished with local anesthesia. 3. It is acceptable for irrigations and cleansing of distal colon. 4. It results in decrease of edema and release of distal obstruction. 5. It causes less interference with wide resection of left colon. 6. Tube cecostomy may not require formal closure.
278
OWEN G. McDoNALD
In considering a cecostomy, one must also weigh these disadvantages: 1. It provides decompression but not diversion. 2. Skin care presents more problems. 3. It is not adaptable to use of appliances. 4. The usual incision is not conducive to wide exploration. Technique. In the simplest technique, the cecum is approached through a muscle-splitting incision. If a tube cecostomy is planned, the procedure is similar to that described for gastrostomy except that a much larger tube is necessary and the tube may be brought out through the primary incision. It is important that the tube extend well into the right colon. This method permits the escape of gas and fluids and protects a distal anastomosis. Unfortunately, it is more prone to leakage. For more complete diversion it is better to mobilize enough cecum to protrude 4 to 6 cm. above the skin level. In fixation, avoid sutures in the cecum at the peritoneal and fascial levels for fear of leakage; however, several fine stitches may be used to suture the cecum to the skin edges. Twelve to 24 hours should elapse before opening the cecum unless the danger of perforation demands immediate decompression. As a general rule, cecostomy should probably be reserved for those patients too ill to tolerate surgery of greater magnitude, for obese patients in whom there may be difficulty and danger in exteriorization of the transverse colon, and for the purpose of protecting a suture line more distally. Transverse Colon Colostomy. This is undoubtedly the most utilitarian method of decompressing bowel obstructed by low-lying lesions. When properly constructed, it provides thorough decompression and diversion, is away from the field of most left-sided resections, is easily combined with exploration, and is adaptable to appliances. However, in obese patients with a short mesentery, and in the presence of severe distention, it may be impossible to adequately mobilize the transverse colon without danger of perforation. If exteriorization is incomplete, retraction will follow and result in a colostomy which is difficult to manage and unsatisfactory for itR intended purpose. Technique. The abdomen may be entered through a transverse or right vertical incision of sufficient length to permit exploration. The right transverse colon is grasped and a segment freed of its omentum. A small rent is created in the mesentery to permit passage of a latex rubber drain or a strip of bias tape. With traction and manipulation, a 4 to 6 inch segment of colon is exteriorized and the incision closed in layers from each end with caution to avoid constriction of the blood supply. A glass rod or similar device is then substituted for the traction tape to prevent retraction of the colon. If urgent, this colostomy may be opened immediately. In cases of severe distention, we insert a tube into the proximal limb through a small stab wound in the exteriorized loop and then snug the bowel around the tube with purse-string sutures, to minimize leakage. However, we prefer to delay opening the bowel for 12 to 24 hours because this enables
279
DECOMPRESSION PROCEDURES IN ABDOMINAL SURGERY
!
t.,
I,: 1
US to bring a portable cautery to the bedside for a more thorough division of the loop. The latter method requires no anesthesia but an occasional bleeder will need ligation. Sigmoid Colostomy. Although effective, this segment of colon is not as satisfactory when it is expected that decompression will be followed at a later date by a resection. It is the most desirable location for a colostomy when decompression is necessary for an obstructing nonresectable rectal lesion because the consistency of the stools makes for easier management. The technique here utilizes the same principles described for a transverse colon colostomy.
Rectal Tube Decompression In an anterior resection, with a low-lying anastomosis, excellent decompression can be provided by means of a rectal tube. The tube may be inserted into the rectum before surgery and then drawn upward to extend above the anastomosis, or it may be positioned as shown in Figure 1. In the latter method, and before placement of the final sutures of the anastomosis, a folded rectal tube is inserted so that the rounded end passes distally and the flared end, with supplemental openings, extends above the anastomosis. After abdominal closure, the excess tube protruding from the
Figure 1. Insertion and positioning of rectal tube at operation for protection of low colonic suture line. Note added openings in tube above anastomosis.
3
280
OWEN
G.
McDoNALD
anal canal is cut away to within 2 inches of the rectum. One heavy silk suture fixes the tube to the anal skin. Postoperatively, small amounts of fluid can be instilled to thin colonic contents and to clear the openings above the suture line. I have found this method to be just as effective as a proximal colostomy, easier to manage, and associated with fewer complications.
REFERENCES 1. Allen, A. W. and Donaldson, G.: Jejunostomy for decompression of the postoperative stomach. Surgery 13: 565, 1942. 2. Farris, J. M. and Smith, G K.: An evaluation of temporary gastrostomy: a substitute for nasogastric suction. Tr. Am. S. A. 74: 187, 1956. 3. Gilchrist, R. K.: Gastrostomy tubes. Surg. Gynec. & Obst. 108: 631, 1958. 4. Holder, T. M. and Gross, R. E.: Temporary gastrostomy in pediatric surgery. Pediatrics 26: 36-41, 1960. 5. Levin, A. L.: New gastroduodenal catheter. J.A.M.A. 76: 1007, 1921. 6. Paine, J. R. and Wangensteen, O. H.: Necessity for constant suction to inlying nasal tubes for effectual decompression or drainage of upper gastrointestinal tract. Surg. Gynec. & Obst. 57: 601-611, 1933. 7. Smith. G. K. and Farris, J. M.: Re-evaluation of temporary gastrostomy as a substitute for nasogastric suction. Am. J. Surg. 102: 168, 1961. 8. Wangsteen, O. H. and Paine, J. R.: Nasal catheter suction siphonage: Its uses and technique of employment. Minnesota Med. 16: 96-100,1933. 9. Wangensteen, O. H. and Paine, J. R.: Treatment of acute intestinal obstruction by suction with duodenal tube. J.A.M.A. 101: 1532-1539, 1933. 198 East Westminster Avenue Lake Forest, Illinois