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Early Postoperative Motor Response of the Small Intestine to Jejunal Feedings
EARLY POSTOPERATIVE MOTOR RESPONSE OF THE SMALL INTESTINE TO JEJUNAL FEEDINGS STEPHAN ROSENAK,
M.D.,"
AND FRANKLIN HOLLANDER,
PH.D.t
THE importance of intrajejunal alimentation in surgery of the gastrointestinal tract has long been recognized, and the current literature reveals a renewed interest in this procedure. s A major factor in the increased use of surgical jejunostomy and orojejunal intubation for this purpose is the improvement in the feeding mixtures employed. Such modifications have eliminated in great part, the diarrhea, cramps and other gastrointestinal disturbances associated with the administration of early types of feeding mixture. 5 ,l.0 Experimental evidence as well as clinical observations have shown that tissue healing is influenced in major degree by nutritional status, and also by fluid and electrolyte balance. Hence, it is important, whenever jejunostomy is performed for alimentation, that such feeding be instituted as soon after the operation as physiological considerations permit. There is considerable evidence that during the first days after abdominal operations, patients suffer some impairment in the threefold activity of the gastrointestinal tract: secretion and digestion, absorption, and motility. However, in jejunostomy patients, it is not known whether the extent of such impairment is great enough to invalidate the use of· intrajejunal feeding during this period. In anticipation of deficiencies in secretion and digestion, we previously advocated the use of a predigested synthetic aliment. 5 It was the purpose of the present study to evaluate the small bowel motility in such patients during the first two days following operation. Data on intestinal absorption are not available at present, but this problem must await later investigation. MOTOR ACTIVITY OF GASTROINTESTINAL TRACT FOLLOWING JEJUNOSTOMY
In order to study motor activity of the gastrointestinal tract, a series of radiographs were taken, employing only. patients with surgical From the Gastroenterology Research Laboratory, Mount Sinai Hospital, New York City. The authors wish to express their thanks to Dr. Ralph Colp and his staff for permission to study the cases cited, to Dr. Marcy L. Sussman for the radiographs, and to Wyeth, Inc., for a grant under which this work was done . .. Clinical Assistant in Surgery and Research Assistant, Mount Sinai Hospital. t Associate in Gastrointestinal Physiology, Mount Sinai Hospital.
345
846
STEPHAN ROSENAK, FRANKLIN HOLLANDER
jejunostomy; motility during orojejunal intubation was not investigated. It was our objective to determine whether the massive introduction into the jejunum of 100 cc. of aliment (with barium added) distends the bowel unduly, or whether the material is transported aborally at a rate sufficient to permit its routine administration. The radiopaque suspension was prepared from the predigested aliment by replacing the small volume of cream with an equal volume of a sterile mixture of 80 gm. of barium sulfate in water. The resulting suspension was stable enough so that only negligible sedimentation occurred within two hours following preparation. In conformity with our routine practice, the mixture was warmed to body temperature, and injected over a five-minute interval. All subjects were in a fasting condition. However, in the early postoperative studies isotonic saline or glucose or both were given intravenously. In control studies performed three to five weeks after operation, the fasting period was never less than fourteen hours. Radiographs were taken at one, two, three, five to ten, and twenty to twenty-four hours following injection. In all, five patients were studied in this investigation. Two of these (J.B. and M.M.) were studied immediately after preliminary jejunostomy. In two others, jejunostomy was performed simultaneously with major gastric surgery. The fifth patient (J.L.) was studied only after a gastric resection following a preliminary jejunostomy. The results are summarized in Tables 1 and 2. One illustrative series of four radiographs is also presented. The clinical histories and a brief description of the observations are as follows: CASE I.-S. H., a man 38 years old, was admitted for substernal pains of a year's duration and a weight loss of 35 pounds. Previous x-ray examination elsewhere yielded the diagnosis of a duodenal ulcer with 50 per cent retention after six hours. Operation (January 2, 1945) revealed a duodenal ulcer for which a subtotal gastrectomy with antecolic terminolateral gastroenterostom}, of the Hofmeister type was performed. A supplementary tube jejunostomy of the Kader-Stamm type was done simultaneously. The first radiograph for the present study was taken twenty-four hours after operation. The one-hour film showed a filling without distention of the injected loop and its adjacent segments. These coils had a normal pattern with well defined segmentation. Neither the duodenum nor stomach contained any contrast material. The two-hour picture showed a wider distribution of radiopaque material; intestinal tonus and segmentation appeared to be somewhat lessened. The fivehour picture revealed a more uniform distribution throughout the small bowel; some of the loops displayed spasticity, others relaxation. After twenty-four hours all of the contrast material was in the last 2 inches of ileum, cecum and the lower ascending colon. These studies were repeated twel,lty days after operation. At one hour the
POSTOPERATIVE MOTOR RESPONSE OF SMALL INTESTINE
347
contrast material was distributed throughout the jejunum below the fistula. By the second hour the aliment was already in the upper ileum and by the third hour it had reached the lower -ileum. The ten hour picture showed most of the contrast material in the ileum and cecum, with some of it in the ascending colon. CASE II.-J. L., a man 47 years old, was admitted with a fifteen year history of pyloric ulcer; at exploration (March 9, 1944) the ulcer was found embedded in a huge inflammatory mass extending into the lesser omentum. Because of the technical difficulties which this presented for radical surgery, only a preliminary jejunostomy was performed for alimentation and relief of the inflammation. The patient was maintained on the predigested aliment for two months, during which he gained weight and became symptom-free. Subsequently (May 8, 1944) the patient was re-examined and a subtotal gastric resection was performed. Both the ulcer and the inflammatory reaction had diminished considerably, which greatly simplified the technical aspects of the surgical procedure. Radiography was started twenty-four hours after operation. In the one hour picture only a few jejunal coils were visible, but a greater number of loops were outlined after two hours. All of these showed a normal pattern. One hour later, the small intestine was uniformly radiopaque. In five hours, the upper jejunum was empty and the contrast material had reached the cecum. The twenty hour radiograph showed contrast material extending from the last ileal coil to the transverse colon. CASE 111.-1. G., a man 70 years old, was admitted with a short history of nausea and vomiting. The gastrointestinal series disclosed a prepyloric obstructive lesion. Operation (January 2, 1945) revealed the presence of a prepyloric gastric ulcer, for which a retrocolic isoperistaltic gastrojejunostomy was performed and a tube jejunostomy established. The first series of radiographs was taken twenty-four hours after operation. In this series, the one hour film showed a rather atonic jejunal loop with poor segmentation; the transverse colon and rectum contained some opaque material from a previous barium enema. The two hour picture visualized the lower jejunal loops, but after three hours both jejunum and ileum showed scattered filling. Tonus of the upper loops appeared to be increased. No substantial change was noted after five hours, but after twenty hours only the cecum, ascending and transverse colons were visualized. The second series, twenty-seven days after operation, afforded a control on the earlier one. One hour after injection, the contrast material was scattered from the level of the jejunostomy down to the upper ileum, with traces in the cecum and ascending colon. It is interesting that the residual stomach was partially filled with contrast material, but the duodenum was not. Two hours after injection, some aliment was still present in the stomach and upper jejunum, but some of it had traveled down as far as the transverse colon. CASE IV.- J. B., a man 43 years old, was admitted with a five year history of peptic ulcer, diagnosed by gastrointestinal series. The picture was typical of a duodenal ulcer which had perforated ten days previously. On admission, the epigastrium and right hypogastrium were still tender to the touch; x-ray examination confirmed the diagnosis of a perforated prepyloric ulcer. An exploratory operation (June 27, 1946) revealed a recent upper abdominal peritonitis, with thin, friable,
348
STEPHAN ROSENAK, FRANKLIN HOlLANDER
i ~ ~ ~
~
! [{l
~ U>
~
I 3 hours.
5 hours.
Fig. 160.~Serial radiographs of the intestinal tract forty hours after operation for preliminary jejunostomy (M. M.) ,to show the rate of transport of the predigested aliment. The time under each radiograph indicates the number of hours after injection through the jejunostomy tube.
~
~
350
STEPHAN ROSENAK, FRANKLIN HOLLANDER
residual adhesions between the viscera and the abdominal wall. An ulcer was embedded in an inflammatory mass near the pylorus. Only a preliminary jejunostomy was performed. The first x-ray series was started one day after operation. Unfortunately, the earliest picture was taken five hours after the injection, at which time there was no contrast material around the jejunostomy tube. Only a lo()p of the I,lpper ileum was well defined, but some contrast material was sca,ttered throughout the jejunum. The ileum showed poor tonus but definite segmentation. The twenty-four hour picture revealed the bulk of the aliment filling the lowermost ileum, cecum and ascending colon. A second intestinal series was taken thirty-five days after operation. One and one half hours after injection, the head of the contrast material had reached the ascending colon, but there also was extensive scattering throughout the small bowel. By the third hour, the jejunum and upper ileum were completely empty, and the aliment extended from the lowermost portion of the ileum to the transverse colon. By the sixth hour it had left the small bowel and entered the splenic flexure. In the twenty-four hour film, the small bowel appeared to be completely empty. CASE V.-M. M., a woman 70 years old, was admitted with a twenty-five year history of duodenal ulcer, leading to pylOric obstruction. Because of her poor general condition, only jejunostomy for alimentation was performed (January 14, 1946). The small bowel was examined forty hours follOwing operation (see illustrative series [Fig. 160]). One hour after injection of the barium aliment, the contJ;ast material, deeply segmented, was present in the lower jejunum and upper ileum. The traces of radiopacity in the transverse colon presumably derived from previous x~ray examination. The two hour picture showed a lessening of tonicity and further propulsion of contrast material into the ileum. The three hour picture showed a somewhat wider distribution, and after five hours the upper jejunum was empty and the contrast material had advanced into the cecum.
COMMENT
Table 1 contains a summary of resu)ts obtained in the present study. On the second day after operation, in three of the five patients, the jejunum was practically devoid of radiopaque aliment by the fifth hour after injection. By the twenty-fourth hour, the ileum contained little if any (0 or +) contrast material in four. cases, and the jejunum was completely empty in the fifth. The aliment first appeared in the cecum in three to five hours in two cases, but in all five it was present in the cecum and ascending colon by the twenty-fourth hour. For a proper evaluation of these observations, it must be remembered that the time normally required fQr the chyme to travel through the small bowel is highly variable. Besid~s individual differences, the type and quantity of food, and the mode and site of its introduction (oral ingesting, intubation or fistula feeding) are important factors.
351
POSTOPERATIVE MOTOR RESPONSE OF SMALL INTESTINE
In postoperative patients, the rate of transport is subject also to influence by medication. It is currently stated that three to five hours TABLE 1 SERIAL RADIOGRAPHIC OBSERVATIONS OF THE INTESTINAL TRACTS OF JEJUNOSTOMY PATIENTS WITHIN Two DAYS OF OPERATION, TO SHOW THE RATE OF TRANSPORT OF PREDIGESTED ALIMENT
Number of Hours after Injection of Radiopaque Aliment* Section of Bowel
Patient 1
2
3
5
Jejunum
M.M. S.H. I. G. J. L. J.B.
+++ +++ +++ +++
++ +++ +++ +++
++ +++ ++ ++
++ ++
+
Ileum
M.M. S.H. I. G. J. L. J.B.
++ + 0 0
++ + ++ ++
Cecum
M.M. S.H. I. G. J. L. J.B.
0 0 0 0
0 0 0 0
0 0 0 0
0
0 0 0 0
I
0 0 0
..
20-24
0
0 tr. 0
++ ++ +++ +++ ++
0 0 0 0
+ 0 + ++
0 0 tr. 0
+++ + +++ ++
0 0 0 0
0 0 0 0 0
+ +++ ++ ++
Ascending Colon
M.M. S.H. I. G. J. L. J.B.
Transverse Colon
M.M. S.H. I. G. J. L. J. B.
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0 0
++
Descending Colon
M.M. S.H. I. G. J. L. J.B.
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0 0
0 tr. 0 0
o. 0 0 .-.
0
tr. 0
* All of these x-ray series were started about twenty-four hours after operatlOn, with the exception of one (M. M.) when the time was forty hours. Plus marks indicate the relative density of radiopacity. A blank space indicates that no radiograph was taken. are required for a suspension of barium sulfate to pass through the normal small bowel, following oral ingestion. l • 6 However, 500 to 1000
352
STEPHAN ROSENAK, FRANKLIN HOLLANDER
ce. of a thin barium sulfate suspension, allowed to flow freely into the duodenum by oral intubation, frequently reached the cecum in fifteen minutes 3 , 4, 7, 9 and in a few cases only five minutes have been required. Comparison of our results with rates cited from the literature is not valid, since previous workers employed five to ten times as much opaque suspension as was used in this study. Furthermore, our rate TABLE 2 SERIAL RADIOGRAPHIC OBSERVATIONS OF THE INTESTINAL TRACTS OF JEJUNOSTOMY PATIENTS THREE TO FIVE WEEKS AFTER OPERATION, TO SHOW THE RATE OF TRANSPORT OF PREDIGESTED ALIMENT
Number of Hours after Injection of Radiopaque Aliment. Section of Bowel
Patient 1
Jejunum
S.H. I.G. J.B.
lleum
S.H. I. G. J.B.
Cecum
S.H. I. G. J.B.
2
3
5-10
++ +
++
+
0
0
0
+ ++
++ +++ ++
++ ++
++
0
0
0
+++ ++ tr.
. tr.
0
tr.
++
+ ++
Ascending Colon
S.H. I.G. J.B.
0 tr.
0 tr.
+
+
++ ++ + ++
Transverse Colon
S.H. I. G. J.B.
0 0 0
0 tr. 0
0
0
tr.
+
Descending Colon
S.H. I.G. J.B.
0 0 0
0 0 0
0
0
0
0
+
+++ 0
20-24
0
0
tr.
tr.
+++ tr.
• Plus marks indicate the relative density of radiopacity. A blank space indicates no radiograph was taken.
of administration was invariably 100 cc. per five minutes, whereas the others reported rates considerably greater than this-e.g., as much as 1000 cc. per fifteen minutes. And finally, other investigators have used a wholly inert medium, whereas we suspended the barium sulfate in the predigested aliment. Hence, it was necessary to establish control values under essentially the same conditions as those employed in the tests. For this
POSTOPERATIVE MOTOR RESPONSE OF SMALL INTESTINE
353
purpose, serial radiography was repeated in three of the patients, three to five weeks after operation, when it was assumed that the rate of propulsive activity had returned to normal. Also, at that time, medication was no longer a disturbing factor. Comparison of Tables 1 and 2 reveals a generally higher rate of propulsion several weeks after operation than during the second day. The head of the contrast material was already present in the cecum by the end of the first hour in two of the three patients, but in the third it required over three hours to reach this level. Complete emptying of the small bowel required three to five hours in at least one case, and probably in a second as well; the third case required well over ten hours. Thus, the rate of transport was below normal shortly after operation, but the observations indicate that it was sufficiently rapid to obviate the accumulation of aliment near the site of injection. This is confirmed by the absence of any sign of jejunal distention in the one-hour films. The presence of segmentation in all of the radiographs supports the view that the aliment is transported through the bowel by active peristalsis. Retrograde movement of the aliment was never observed in the five early postoperative studies; neither the duodenum nor the stomach was visualized in this series. In one of the control series, on whom a gastroenterostomy had been performed, some of the contrast material was carried into the stomach through the stoma; even in this case, however, the duodenum was not visualized. CONCLUSIONS
It may be concluded that jejunal feeding with our predigested aliment may be instituted as early as twenty-four hours following operation, provided certain precautions are adhered to. Even in the presence of an upper abdominal peritonitis, such as was encountered in patient lB., early alimentation is feasible. This has already been recognized by Charrier.2 Furthermore, because of the absence of retrograde movement of the aliment, it seems likely that this feeding procedure does not jeopardize the weak spot of gastric surgery, the duodenal stump. Nevertheless, special precautions concerning volume and rate of administration of aliment, previously described,5 must be taken during the early days following operation. REFERENCES
1. Bargen, J. A.: J.A.M.A., 182:313, 1946. 2. Charrier, J.: Arch. d. mal. de l'App. Digestif., 25:288, 1925. 3. Gershon-Cohen, J. and Shay, H.: Am. J. Roentgenol., 42:456, 1939.
354 4. 5. 6. 7. 8. 9. 10.
STEPHAN ROSENAK, FRANKLIN HOLLANDER
Ghelew, B. and Mengis, 0.: Presse Med., 46:444, 1938. Ilollander, F., Rosenak, S., and Colp, R.: Surgery, 17:754, 1945. Nash, J.: Surgical Physiology. Springfield, Ill., Charles C Thomas, 1942, p. 145. Pesquera, G. S., Am. J. Roentgenol., 22:254, 1929. Rosenak, S. and Hollander, F.: Clinics, 3:638, 1944. Schatzki, R.: Am. J. Roentgenol., 50:743, 1943. Scott, H. G. and Ivy, A. C.: Ann. Surg., 93:1197, 1931.
M.D.,"
AND FRANKLIN HOLLANDER,
PH.D.t
THE importance of intrajejunal alimentation in surgery of the gastrointestinal tract has long been recognized, and the current literature reveals a renewed interest in this procedure. s A major factor in the increased use of surgical jejunostomy and orojejunal intubation for this purpose is the improvement in the feeding mixtures employed. Such modifications have eliminated in great part, the diarrhea, cramps and other gastrointestinal disturbances associated with the administration of early types of feeding mixture. 5 ,l.0 Experimental evidence as well as clinical observations have shown that tissue healing is influenced in major degree by nutritional status, and also by fluid and electrolyte balance. Hence, it is important, whenever jejunostomy is performed for alimentation, that such feeding be instituted as soon after the operation as physiological considerations permit. There is considerable evidence that during the first days after abdominal operations, patients suffer some impairment in the threefold activity of the gastrointestinal tract: secretion and digestion, absorption, and motility. However, in jejunostomy patients, it is not known whether the extent of such impairment is great enough to invalidate the use of· intrajejunal feeding during this period. In anticipation of deficiencies in secretion and digestion, we previously advocated the use of a predigested synthetic aliment. 5 It was the purpose of the present study to evaluate the small bowel motility in such patients during the first two days following operation. Data on intestinal absorption are not available at present, but this problem must await later investigation. MOTOR ACTIVITY OF GASTROINTESTINAL TRACT FOLLOWING JEJUNOSTOMY
In order to study motor activity of the gastrointestinal tract, a series of radiographs were taken, employing only. patients with surgical From the Gastroenterology Research Laboratory, Mount Sinai Hospital, New York City. The authors wish to express their thanks to Dr. Ralph Colp and his staff for permission to study the cases cited, to Dr. Marcy L. Sussman for the radiographs, and to Wyeth, Inc., for a grant under which this work was done . .. Clinical Assistant in Surgery and Research Assistant, Mount Sinai Hospital. t Associate in Gastrointestinal Physiology, Mount Sinai Hospital.
345
846
STEPHAN ROSENAK, FRANKLIN HOLLANDER
jejunostomy; motility during orojejunal intubation was not investigated. It was our objective to determine whether the massive introduction into the jejunum of 100 cc. of aliment (with barium added) distends the bowel unduly, or whether the material is transported aborally at a rate sufficient to permit its routine administration. The radiopaque suspension was prepared from the predigested aliment by replacing the small volume of cream with an equal volume of a sterile mixture of 80 gm. of barium sulfate in water. The resulting suspension was stable enough so that only negligible sedimentation occurred within two hours following preparation. In conformity with our routine practice, the mixture was warmed to body temperature, and injected over a five-minute interval. All subjects were in a fasting condition. However, in the early postoperative studies isotonic saline or glucose or both were given intravenously. In control studies performed three to five weeks after operation, the fasting period was never less than fourteen hours. Radiographs were taken at one, two, three, five to ten, and twenty to twenty-four hours following injection. In all, five patients were studied in this investigation. Two of these (J.B. and M.M.) were studied immediately after preliminary jejunostomy. In two others, jejunostomy was performed simultaneously with major gastric surgery. The fifth patient (J.L.) was studied only after a gastric resection following a preliminary jejunostomy. The results are summarized in Tables 1 and 2. One illustrative series of four radiographs is also presented. The clinical histories and a brief description of the observations are as follows: CASE I.-S. H., a man 38 years old, was admitted for substernal pains of a year's duration and a weight loss of 35 pounds. Previous x-ray examination elsewhere yielded the diagnosis of a duodenal ulcer with 50 per cent retention after six hours. Operation (January 2, 1945) revealed a duodenal ulcer for which a subtotal gastrectomy with antecolic terminolateral gastroenterostom}, of the Hofmeister type was performed. A supplementary tube jejunostomy of the Kader-Stamm type was done simultaneously. The first radiograph for the present study was taken twenty-four hours after operation. The one-hour film showed a filling without distention of the injected loop and its adjacent segments. These coils had a normal pattern with well defined segmentation. Neither the duodenum nor stomach contained any contrast material. The two-hour picture showed a wider distribution of radiopaque material; intestinal tonus and segmentation appeared to be somewhat lessened. The fivehour picture revealed a more uniform distribution throughout the small bowel; some of the loops displayed spasticity, others relaxation. After twenty-four hours all of the contrast material was in the last 2 inches of ileum, cecum and the lower ascending colon. These studies were repeated twel,lty days after operation. At one hour the
POSTOPERATIVE MOTOR RESPONSE OF SMALL INTESTINE
347
contrast material was distributed throughout the jejunum below the fistula. By the second hour the aliment was already in the upper ileum and by the third hour it had reached the lower -ileum. The ten hour picture showed most of the contrast material in the ileum and cecum, with some of it in the ascending colon. CASE II.-J. L., a man 47 years old, was admitted with a fifteen year history of pyloric ulcer; at exploration (March 9, 1944) the ulcer was found embedded in a huge inflammatory mass extending into the lesser omentum. Because of the technical difficulties which this presented for radical surgery, only a preliminary jejunostomy was performed for alimentation and relief of the inflammation. The patient was maintained on the predigested aliment for two months, during which he gained weight and became symptom-free. Subsequently (May 8, 1944) the patient was re-examined and a subtotal gastric resection was performed. Both the ulcer and the inflammatory reaction had diminished considerably, which greatly simplified the technical aspects of the surgical procedure. Radiography was started twenty-four hours after operation. In the one hour picture only a few jejunal coils were visible, but a greater number of loops were outlined after two hours. All of these showed a normal pattern. One hour later, the small intestine was uniformly radiopaque. In five hours, the upper jejunum was empty and the contrast material had reached the cecum. The twenty hour radiograph showed contrast material extending from the last ileal coil to the transverse colon. CASE 111.-1. G., a man 70 years old, was admitted with a short history of nausea and vomiting. The gastrointestinal series disclosed a prepyloric obstructive lesion. Operation (January 2, 1945) revealed the presence of a prepyloric gastric ulcer, for which a retrocolic isoperistaltic gastrojejunostomy was performed and a tube jejunostomy established. The first series of radiographs was taken twenty-four hours after operation. In this series, the one hour film showed a rather atonic jejunal loop with poor segmentation; the transverse colon and rectum contained some opaque material from a previous barium enema. The two hour picture visualized the lower jejunal loops, but after three hours both jejunum and ileum showed scattered filling. Tonus of the upper loops appeared to be increased. No substantial change was noted after five hours, but after twenty hours only the cecum, ascending and transverse colons were visualized. The second series, twenty-seven days after operation, afforded a control on the earlier one. One hour after injection, the contrast material was scattered from the level of the jejunostomy down to the upper ileum, with traces in the cecum and ascending colon. It is interesting that the residual stomach was partially filled with contrast material, but the duodenum was not. Two hours after injection, some aliment was still present in the stomach and upper jejunum, but some of it had traveled down as far as the transverse colon. CASE IV.- J. B., a man 43 years old, was admitted with a five year history of peptic ulcer, diagnosed by gastrointestinal series. The picture was typical of a duodenal ulcer which had perforated ten days previously. On admission, the epigastrium and right hypogastrium were still tender to the touch; x-ray examination confirmed the diagnosis of a perforated prepyloric ulcer. An exploratory operation (June 27, 1946) revealed a recent upper abdominal peritonitis, with thin, friable,
348
STEPHAN ROSENAK, FRANKLIN HOlLANDER
i ~ ~ ~
~
! [{l
~ U>
~
I 3 hours.
5 hours.
Fig. 160.~Serial radiographs of the intestinal tract forty hours after operation for preliminary jejunostomy (M. M.) ,to show the rate of transport of the predigested aliment. The time under each radiograph indicates the number of hours after injection through the jejunostomy tube.
~
~
350
STEPHAN ROSENAK, FRANKLIN HOLLANDER
residual adhesions between the viscera and the abdominal wall. An ulcer was embedded in an inflammatory mass near the pylorus. Only a preliminary jejunostomy was performed. The first x-ray series was started one day after operation. Unfortunately, the earliest picture was taken five hours after the injection, at which time there was no contrast material around the jejunostomy tube. Only a lo()p of the I,lpper ileum was well defined, but some contrast material was sca,ttered throughout the jejunum. The ileum showed poor tonus but definite segmentation. The twenty-four hour picture revealed the bulk of the aliment filling the lowermost ileum, cecum and ascending colon. A second intestinal series was taken thirty-five days after operation. One and one half hours after injection, the head of the contrast material had reached the ascending colon, but there also was extensive scattering throughout the small bowel. By the third hour, the jejunum and upper ileum were completely empty, and the aliment extended from the lowermost portion of the ileum to the transverse colon. By the sixth hour it had left the small bowel and entered the splenic flexure. In the twenty-four hour film, the small bowel appeared to be completely empty. CASE V.-M. M., a woman 70 years old, was admitted with a twenty-five year history of duodenal ulcer, leading to pylOric obstruction. Because of her poor general condition, only jejunostomy for alimentation was performed (January 14, 1946). The small bowel was examined forty hours follOwing operation (see illustrative series [Fig. 160]). One hour after injection of the barium aliment, the contJ;ast material, deeply segmented, was present in the lower jejunum and upper ileum. The traces of radiopacity in the transverse colon presumably derived from previous x~ray examination. The two hour picture showed a lessening of tonicity and further propulsion of contrast material into the ileum. The three hour picture showed a somewhat wider distribution, and after five hours the upper jejunum was empty and the contrast material had advanced into the cecum.
COMMENT
Table 1 contains a summary of resu)ts obtained in the present study. On the second day after operation, in three of the five patients, the jejunum was practically devoid of radiopaque aliment by the fifth hour after injection. By the twenty-fourth hour, the ileum contained little if any (0 or +) contrast material in four. cases, and the jejunum was completely empty in the fifth. The aliment first appeared in the cecum in three to five hours in two cases, but in all five it was present in the cecum and ascending colon by the twenty-fourth hour. For a proper evaluation of these observations, it must be remembered that the time normally required fQr the chyme to travel through the small bowel is highly variable. Besid~s individual differences, the type and quantity of food, and the mode and site of its introduction (oral ingesting, intubation or fistula feeding) are important factors.
351
POSTOPERATIVE MOTOR RESPONSE OF SMALL INTESTINE
In postoperative patients, the rate of transport is subject also to influence by medication. It is currently stated that three to five hours TABLE 1 SERIAL RADIOGRAPHIC OBSERVATIONS OF THE INTESTINAL TRACTS OF JEJUNOSTOMY PATIENTS WITHIN Two DAYS OF OPERATION, TO SHOW THE RATE OF TRANSPORT OF PREDIGESTED ALIMENT
Number of Hours after Injection of Radiopaque Aliment* Section of Bowel
Patient 1
2
3
5
Jejunum
M.M. S.H. I. G. J. L. J.B.
+++ +++ +++ +++
++ +++ +++ +++
++ +++ ++ ++
++ ++
+
Ileum
M.M. S.H. I. G. J. L. J.B.
++ + 0 0
++ + ++ ++
Cecum
M.M. S.H. I. G. J. L. J.B.
0 0 0 0
0 0 0 0
0 0 0 0
0
0 0 0 0
I
0 0 0
..
20-24
0
0 tr. 0
++ ++ +++ +++ ++
0 0 0 0
+ 0 + ++
0 0 tr. 0
+++ + +++ ++
0 0 0 0
0 0 0 0 0
+ +++ ++ ++
Ascending Colon
M.M. S.H. I. G. J. L. J.B.
Transverse Colon
M.M. S.H. I. G. J. L. J. B.
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0 0
++
Descending Colon
M.M. S.H. I. G. J. L. J.B.
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0 0
0 tr. 0 0
o. 0 0 .-.
0
tr. 0
* All of these x-ray series were started about twenty-four hours after operatlOn, with the exception of one (M. M.) when the time was forty hours. Plus marks indicate the relative density of radiopacity. A blank space indicates that no radiograph was taken. are required for a suspension of barium sulfate to pass through the normal small bowel, following oral ingestion. l • 6 However, 500 to 1000
352
STEPHAN ROSENAK, FRANKLIN HOLLANDER
ce. of a thin barium sulfate suspension, allowed to flow freely into the duodenum by oral intubation, frequently reached the cecum in fifteen minutes 3 , 4, 7, 9 and in a few cases only five minutes have been required. Comparison of our results with rates cited from the literature is not valid, since previous workers employed five to ten times as much opaque suspension as was used in this study. Furthermore, our rate TABLE 2 SERIAL RADIOGRAPHIC OBSERVATIONS OF THE INTESTINAL TRACTS OF JEJUNOSTOMY PATIENTS THREE TO FIVE WEEKS AFTER OPERATION, TO SHOW THE RATE OF TRANSPORT OF PREDIGESTED ALIMENT
Number of Hours after Injection of Radiopaque Aliment. Section of Bowel
Patient 1
Jejunum
S.H. I.G. J.B.
lleum
S.H. I. G. J.B.
Cecum
S.H. I. G. J.B.
2
3
5-10
++ +
++
+
0
0
0
+ ++
++ +++ ++
++ ++
++
0
0
0
+++ ++ tr.
. tr.
0
tr.
++
+ ++
Ascending Colon
S.H. I.G. J.B.
0 tr.
0 tr.
+
+
++ ++ + ++
Transverse Colon
S.H. I. G. J.B.
0 0 0
0 tr. 0
0
0
tr.
+
Descending Colon
S.H. I.G. J.B.
0 0 0
0 0 0
0
0
0
0
+
+++ 0
20-24
0
0
tr.
tr.
+++ tr.
• Plus marks indicate the relative density of radiopacity. A blank space indicates no radiograph was taken.
of administration was invariably 100 cc. per five minutes, whereas the others reported rates considerably greater than this-e.g., as much as 1000 cc. per fifteen minutes. And finally, other investigators have used a wholly inert medium, whereas we suspended the barium sulfate in the predigested aliment. Hence, it was necessary to establish control values under essentially the same conditions as those employed in the tests. For this
POSTOPERATIVE MOTOR RESPONSE OF SMALL INTESTINE
353
purpose, serial radiography was repeated in three of the patients, three to five weeks after operation, when it was assumed that the rate of propulsive activity had returned to normal. Also, at that time, medication was no longer a disturbing factor. Comparison of Tables 1 and 2 reveals a generally higher rate of propulsion several weeks after operation than during the second day. The head of the contrast material was already present in the cecum by the end of the first hour in two of the three patients, but in the third it required over three hours to reach this level. Complete emptying of the small bowel required three to five hours in at least one case, and probably in a second as well; the third case required well over ten hours. Thus, the rate of transport was below normal shortly after operation, but the observations indicate that it was sufficiently rapid to obviate the accumulation of aliment near the site of injection. This is confirmed by the absence of any sign of jejunal distention in the one-hour films. The presence of segmentation in all of the radiographs supports the view that the aliment is transported through the bowel by active peristalsis. Retrograde movement of the aliment was never observed in the five early postoperative studies; neither the duodenum nor the stomach was visualized in this series. In one of the control series, on whom a gastroenterostomy had been performed, some of the contrast material was carried into the stomach through the stoma; even in this case, however, the duodenum was not visualized. CONCLUSIONS
It may be concluded that jejunal feeding with our predigested aliment may be instituted as early as twenty-four hours following operation, provided certain precautions are adhered to. Even in the presence of an upper abdominal peritonitis, such as was encountered in patient lB., early alimentation is feasible. This has already been recognized by Charrier.2 Furthermore, because of the absence of retrograde movement of the aliment, it seems likely that this feeding procedure does not jeopardize the weak spot of gastric surgery, the duodenal stump. Nevertheless, special precautions concerning volume and rate of administration of aliment, previously described,5 must be taken during the early days following operation. REFERENCES
1. Bargen, J. A.: J.A.M.A., 182:313, 1946. 2. Charrier, J.: Arch. d. mal. de l'App. Digestif., 25:288, 1925. 3. Gershon-Cohen, J. and Shay, H.: Am. J. Roentgenol., 42:456, 1939.
354 4. 5. 6. 7. 8. 9. 10.
STEPHAN ROSENAK, FRANKLIN HOLLANDER
Ghelew, B. and Mengis, 0.: Presse Med., 46:444, 1938. Ilollander, F., Rosenak, S., and Colp, R.: Surgery, 17:754, 1945. Nash, J.: Surgical Physiology. Springfield, Ill., Charles C Thomas, 1942, p. 145. Pesquera, G. S., Am. J. Roentgenol., 22:254, 1929. Rosenak, S. and Hollander, F.: Clinics, 3:638, 1944. Schatzki, R.: Am. J. Roentgenol., 50:743, 1943. Scott, H. G. and Ivy, A. C.: Ann. Surg., 93:1197, 1931.