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Intestinal prolapse through enterostomy following Rammstedt operation
INTESTINAL PROLAPSE THROUGH ENTEROSTOMY FOLLOWING RAMMSTEDT OPERATION JOSEPH K.
NARAT,
M.D.
AttendingSurgeon,St. ElizabethHospital CHICAGO
A
four weeks oId, breast fed infant was admitted to the St. Elizabeth HospitaI, service of Dr. E. H. Flinn, because of projectiIe vomiting which began twelve days previousIy. The baby’s abdomen was round and firm; after feedings peristaltic waves were visible passing along the fundus and the cardia, and ending abruptly at the pyIoric end. The infant’s weight was 6y4 pounds (2.81 kg). AI1 non-essential features are omitted for the sake of brevity. The x-ray study of the gastrointestina1 tract showed a marked retention of the barium suspension in the stomach, such as would be due to a hypertrophic pyloric stenosis. As the the S.M.A. formula given by ,..““*_:,. g;avag;r; ,..n-?n-_,,_.rn_ -r\+ “,,r Uc;llaU”LLll* L.Il,,J,..“, g;aswX. WaZ¶ ll”L ,.,%cn:..-rl IeLcLIIIcXlallU had no effect, the infant was referred for operation. A typica Rammstedt operation was performed under IocaI anesthesia, care being taken not to injure the mucosa. The patient was given father’s blood intramuscuIarIy, in addition to subcutaneous injections of glucose and saIine soIution. The vomiting, no more projectile in character, occurred a few times in course of the next two days and then ceased compIeteIy. As the mother’s milk was very scanty, it was supplemented by human miIk furnished by the Health Department of the city of Chicago. Eight days after the operation the abdomen became distended and the compIexion of the infant turned saIIow. In Course of the folIowing day the distention assumed threatening dimensions; the overIying skin was as thin as tissue paper and Iarge subcutaneous veins were visible on the chest and abdomen. FIatus were passed freeIy, defecation was normaI, vomiting was absent, the temperature never rose above 100.5 degrees. In spite of such a confusing picture, a suspicion of a paraIytic ireus was considered as justified and after a consultation an iIeostomy was performed under IocaI anesthesia nine days after the Rammstedt operation. The aftertreatment consisted of repeated bIood transfusions, hypodermocIysis, injections of pitressin and prostigmin and instiIIations of saIine solution through the catheter pIaced into the enterMALE,
ostomy opening. The infant was exposed daiIy to uItravioIet Iight and was given drysdo1. The operation apparentry did not accomplish a decompression. The abdomen remained extremeIy distended aIthough fIatus and feces were passing freeIy through the artificia1 stoma and not through the rectum. The respirations were labored. A Aat x-ray picture of the abdomen taken eight days after the second operation was reported as foIIows: “There is a sharpIy delined pocket of gas in the right upper quadrant, which appears to be free air under the right diaphragm; the pocket dispIaces the liver downward. The loops of bowel are all cohapsed. As a second guess, the findings may ,. a rIL+,..JaJ ,Ltrllntna ,,I,.. :, *L LO UK.A.., UUC L” UIJCLII”LU,“U3CIUCLL.U L”I”II 111 Llle hepatic Bexure, but the pocket seems too sharpIy defined.” As various conservative measures did not bring any improvement and the infant became highIy dehydrated, sixteen days after the enterostomy a needIe was inserted under Auoroscopic control under the Costa1 arch in the right axihary region and thick pus aspirated. An incision was immediateIy made and a rubber drain inserted into the subphrenic abscess cavity. The Iatter graduahy became obIiterated and the fistma closed spontaneousIy after the puruIent discharge disappeared. As the distention of the abdomen subsided only partially and the rectal examination revealed an obstruction 5 cm. above the anus, a diagnosis of a peIvic abscess was made. Four days after the drainage of the subphrenic abscess a mosquito forceps was inserted through the rectum and a cavity opened, from which thick pus escaped. In the course of the foIIowing few days the same procedure was repeated several times to maintain drainage. The puruIent discharge per rectum stopped after a few days but no feces were passing through the anus. A recta1 examination disclosed a stricture, apparentIy caused by adhesions. Daily gentIe diIatations of the stenosis with Hegar’s cervica1 dilators were instituted. Feces began passing through both the rectum
729
??
730
AmericanJournaIofSurgery
Narat-IntestinaI
and the artificia1 stoma in approximateIy equa1 amounts but a new comphcation appeared. The posterior waI1 of the intestina1 loop, ,.*c”_l.,.~ ,.L~_-:_,I L,_“_ __,I,_ aLLa.~‘ ICUC^ L” *I__ LUGa”U”‘ lll‘lal _..“TI wan uegall p,uu%psing through the enterostomy every time the child cried. Within a short time the evisceration not onIy became stationary but increased in size. After a few days the sausage-shaped protrusion in the right Iower quadrant of the abdomen was 6 cm. long; it had the coIor of the intestinal mucosa and was covered with mucus. A round opening was visible on either end of the mass, which seemed to be only sIightIy congested and showed no signs of inflammation. The general condition of the patient was not affected and the infant was gaining weight. No diffrcuIty was experienced in reducing the proIapse but tight bandaging did not prevent repeated eventrations. A few minute erosions appeared on the surface of the proIapsed mucosa. FecaI masses continued being expeIIed through the enterostomy as we11 as through the rectum but the proIapse recurred every day. Three unsuccessfu1 attempts were made to overcome the recurrences by approximating the edges of the wound with deep siikworm sutures. The skin surrounding the stoma was highIy macerated in spite of appIications of Iatex, kaoIin, etc., and the stitches wouId not hoId. FinaIIy, a rubber sponge was applied to the wound, which immediateIy stopped the recurrences of the proIapse. The surrounding skin graduaIIy assumed a norma appearance and the enterostomy cIosed spontaneousIy. Two and half months after the first operation the chiId weighed 9 Ib. 2 oz. (4.61 kg.), i.e. it had gained three pounds (I .35 kg.). DISCUSSION
The first observation which attracts attention in this case is the deveIopment of peritonitis and paralytic ileus after the Rammstedt operation, in spite of the fact that no visibIe perforation of the pyIoric mucosa was produced. As the pus from the subphrenic abscess contained coIon baciIIi, it is reasonabIe to assume that the infection was caused not by an accidental contamination but by a minute Ieakage of the gastric contents through the exposed mucosa of the pyIorus.
ProIapse
JUNE. 1937
Another interesting feature is the faiIure of the roentgenogram to revea1 a shadow indicating the subphrenic abscess, aIthough the overiying gas bubbie was visuaiized. it foIIows that in suspicious cases an expIoratory aspiration or incision is justified even if the x-ray findings are negative. The most important compIication was the eventration of invaginated intestina1 Ioops. B&rard and ChaIier,l who were the first to describe a proIapse of intestines through an artificia1 anus, distinguish two stages of the condition: (I) eversion of the mucosa and (2) formation of a mucous cyIinder. MaIIet and Martin2 reported 7 cases and ascribed the proIapse to thesuction exerted by Reverdin’s receptacIe, worn by a11 their patients. RecentIy Jaeger” observed a similar condition. AI1 cases reported in the Iiterature deveIoped in aduIts with coIostomies of Iong standing. The mechanism of the deveIopment of such a proIapse is iIIustrated beIow (Figs. I and 2). A vis a tergo, i.e., an increased intraabdominai pressure pushes the posterior waI1 of the attached intestina1 Ioop in the direction of the Ieast resistance. GraduaIIy a cyIinder forms; it has two orifices, one Ieading to the afferent, the other to the efferent Ioop. The externa1 waI1 of the sausage-shaped mass is formed by the everted mucosa, the internal waI1 by the serosa, and the stem by the mesentery. If the pressure is suffIcientIy strong, the cyIinder is transformed into a pouch which may serve as a hernia1 sac for other intestinal coiIs. A stranguIation may deveIop in such a pouch. As to the pathogenesis of such combined evisceration and intussusception, the foIIowing conditions are the determining factors: (I) wide stoma; (2) reIaxation or atrophy of the abdomina1 muscIes; (3) vivid motor activity of the opened and fixed intestina1 Ioop;
1BLRARD
L.
‘909. 2 MALLET-GUY
and CHALIER,
A. Lyon
P. and MARTIN,
E. Journ. de Cbir.,
34: 425, 1929. 3 JAEGER, F. Bruns’ Beitr. z. Klin.
1936.
Cbir., 2: 96,
Cbir.,
163: 539,
NEW
SERIES VOL. XXXVI.
No. 3
Narat-IntestinaI
(4) increased intra-abdomina1 pressure; and (3) long mesentery. Contrary to other observations described in the Iiterature, the complication devei-
Prolapse
American
Journal
of Surgery
73’
SUMMARY
A Rammstedt operation for a pyloric stenosis was performed on a four weeks
Fi$ure
1
Fi@_mz 2
FIG. I. Prolapse
of intestines through an artificial anus. a, enterostomy; posterior wall begins to bulge; b, eventration more pronounced; c, compIete eventration of both stomata. FIG. 2. Intussusception and evisceration through an artificial anus. a, intussusception of the afferent and efferent Ioops; b, intussusception combined with incipient evisceration; c, intussusception and evisceration completed. Note: This mechanism results in a protrusion of a much Iarger loop than a simple bulging of the posterior waII of the attached gut, as ilmstrated in Figure I.
oped in an infant and not in an ad&; in an iieostomy and not in a colostomy; in a reIativeIy recent stoma and not in an artificia1 orifice of a Iong standing. Pads and tight dressings, recommended by writers on this subject, proved useIess in the author’s case. A rubber sponge accomplished the desired effect, probabIy by exerting a continuous elastic pressure and absorbing moisture, thus preventing maceration and contributing to an increased strength of the abdomina1 waI1.
oId infant. One week Iater a paraIytic ireus necessitated an enterostomy. Six days after this second operation a subphrenic abscess and four days Iater a peIvic abscess were drained. On the top of a11 these compIications a prolapse of invaginated afferent and efferent Ioops deveIoped through the enterostomy opening. A rubber sponge apphed over the stoma proved effective in the prevention of recurrences of this intussusception and eventration. A spontaneous closure of the enterostomy foIIowed.
NARAT,
M.D.
AttendingSurgeon,St. ElizabethHospital CHICAGO
A
four weeks oId, breast fed infant was admitted to the St. Elizabeth HospitaI, service of Dr. E. H. Flinn, because of projectiIe vomiting which began twelve days previousIy. The baby’s abdomen was round and firm; after feedings peristaltic waves were visible passing along the fundus and the cardia, and ending abruptly at the pyIoric end. The infant’s weight was 6y4 pounds (2.81 kg). AI1 non-essential features are omitted for the sake of brevity. The x-ray study of the gastrointestina1 tract showed a marked retention of the barium suspension in the stomach, such as would be due to a hypertrophic pyloric stenosis. As the the S.M.A. formula given by ,..““*_:,. g;avag;r; ,..n-?n-_,,_.rn_ -r\+ “,,r Uc;llaU”LLll* L.Il,,J,..“, g;aswX. WaZ¶ ll”L ,.,%cn:..-rl IeLcLIIIcXlallU had no effect, the infant was referred for operation. A typica Rammstedt operation was performed under IocaI anesthesia, care being taken not to injure the mucosa. The patient was given father’s blood intramuscuIarIy, in addition to subcutaneous injections of glucose and saIine soIution. The vomiting, no more projectile in character, occurred a few times in course of the next two days and then ceased compIeteIy. As the mother’s milk was very scanty, it was supplemented by human miIk furnished by the Health Department of the city of Chicago. Eight days after the operation the abdomen became distended and the compIexion of the infant turned saIIow. In Course of the folIowing day the distention assumed threatening dimensions; the overIying skin was as thin as tissue paper and Iarge subcutaneous veins were visible on the chest and abdomen. FIatus were passed freeIy, defecation was normaI, vomiting was absent, the temperature never rose above 100.5 degrees. In spite of such a confusing picture, a suspicion of a paraIytic ireus was considered as justified and after a consultation an iIeostomy was performed under IocaI anesthesia nine days after the Rammstedt operation. The aftertreatment consisted of repeated bIood transfusions, hypodermocIysis, injections of pitressin and prostigmin and instiIIations of saIine solution through the catheter pIaced into the enterMALE,
ostomy opening. The infant was exposed daiIy to uItravioIet Iight and was given drysdo1. The operation apparentry did not accomplish a decompression. The abdomen remained extremeIy distended aIthough fIatus and feces were passing freeIy through the artificia1 stoma and not through the rectum. The respirations were labored. A Aat x-ray picture of the abdomen taken eight days after the second operation was reported as foIIows: “There is a sharpIy delined pocket of gas in the right upper quadrant, which appears to be free air under the right diaphragm; the pocket dispIaces the liver downward. The loops of bowel are all cohapsed. As a second guess, the findings may ,. a rIL+,..JaJ ,Ltrllntna ,,I,.. :, *L LO UK.A.., UUC L” UIJCLII”LU,“U3CIUCLL.U L”I”II 111 Llle hepatic Bexure, but the pocket seems too sharpIy defined.” As various conservative measures did not bring any improvement and the infant became highIy dehydrated, sixteen days after the enterostomy a needIe was inserted under Auoroscopic control under the Costa1 arch in the right axihary region and thick pus aspirated. An incision was immediateIy made and a rubber drain inserted into the subphrenic abscess cavity. The Iatter graduahy became obIiterated and the fistma closed spontaneousIy after the puruIent discharge disappeared. As the distention of the abdomen subsided only partially and the rectal examination revealed an obstruction 5 cm. above the anus, a diagnosis of a peIvic abscess was made. Four days after the drainage of the subphrenic abscess a mosquito forceps was inserted through the rectum and a cavity opened, from which thick pus escaped. In the course of the foIIowing few days the same procedure was repeated several times to maintain drainage. The puruIent discharge per rectum stopped after a few days but no feces were passing through the anus. A recta1 examination disclosed a stricture, apparentIy caused by adhesions. Daily gentIe diIatations of the stenosis with Hegar’s cervica1 dilators were instituted. Feces began passing through both the rectum
729
??
730
AmericanJournaIofSurgery
Narat-IntestinaI
and the artificia1 stoma in approximateIy equa1 amounts but a new comphcation appeared. The posterior waI1 of the intestina1 loop, ,.*c”_l.,.~ ,.L~_-:_,I L,_“_ __,I,_ aLLa.~‘ ICUC^ L” *I__ LUGa”U”‘ lll‘lal _..“TI wan uegall p,uu%psing through the enterostomy every time the child cried. Within a short time the evisceration not onIy became stationary but increased in size. After a few days the sausage-shaped protrusion in the right Iower quadrant of the abdomen was 6 cm. long; it had the coIor of the intestinal mucosa and was covered with mucus. A round opening was visible on either end of the mass, which seemed to be only sIightIy congested and showed no signs of inflammation. The general condition of the patient was not affected and the infant was gaining weight. No diffrcuIty was experienced in reducing the proIapse but tight bandaging did not prevent repeated eventrations. A few minute erosions appeared on the surface of the proIapsed mucosa. FecaI masses continued being expeIIed through the enterostomy as we11 as through the rectum but the proIapse recurred every day. Three unsuccessfu1 attempts were made to overcome the recurrences by approximating the edges of the wound with deep siikworm sutures. The skin surrounding the stoma was highIy macerated in spite of appIications of Iatex, kaoIin, etc., and the stitches wouId not hoId. FinaIIy, a rubber sponge was applied to the wound, which immediateIy stopped the recurrences of the proIapse. The surrounding skin graduaIIy assumed a norma appearance and the enterostomy cIosed spontaneousIy. Two and half months after the first operation the chiId weighed 9 Ib. 2 oz. (4.61 kg.), i.e. it had gained three pounds (I .35 kg.). DISCUSSION
The first observation which attracts attention in this case is the deveIopment of peritonitis and paralytic ileus after the Rammstedt operation, in spite of the fact that no visibIe perforation of the pyIoric mucosa was produced. As the pus from the subphrenic abscess contained coIon baciIIi, it is reasonabIe to assume that the infection was caused not by an accidental contamination but by a minute Ieakage of the gastric contents through the exposed mucosa of the pyIorus.
ProIapse
JUNE. 1937
Another interesting feature is the faiIure of the roentgenogram to revea1 a shadow indicating the subphrenic abscess, aIthough the overiying gas bubbie was visuaiized. it foIIows that in suspicious cases an expIoratory aspiration or incision is justified even if the x-ray findings are negative. The most important compIication was the eventration of invaginated intestina1 Ioops. B&rard and ChaIier,l who were the first to describe a proIapse of intestines through an artificia1 anus, distinguish two stages of the condition: (I) eversion of the mucosa and (2) formation of a mucous cyIinder. MaIIet and Martin2 reported 7 cases and ascribed the proIapse to thesuction exerted by Reverdin’s receptacIe, worn by a11 their patients. RecentIy Jaeger” observed a similar condition. AI1 cases reported in the Iiterature deveIoped in aduIts with coIostomies of Iong standing. The mechanism of the deveIopment of such a proIapse is iIIustrated beIow (Figs. I and 2). A vis a tergo, i.e., an increased intraabdominai pressure pushes the posterior waI1 of the attached intestina1 Ioop in the direction of the Ieast resistance. GraduaIIy a cyIinder forms; it has two orifices, one Ieading to the afferent, the other to the efferent Ioop. The externa1 waI1 of the sausage-shaped mass is formed by the everted mucosa, the internal waI1 by the serosa, and the stem by the mesentery. If the pressure is suffIcientIy strong, the cyIinder is transformed into a pouch which may serve as a hernia1 sac for other intestinal coiIs. A stranguIation may deveIop in such a pouch. As to the pathogenesis of such combined evisceration and intussusception, the foIIowing conditions are the determining factors: (I) wide stoma; (2) reIaxation or atrophy of the abdomina1 muscIes; (3) vivid motor activity of the opened and fixed intestina1 Ioop;
1BLRARD
L.
‘909. 2 MALLET-GUY
and CHALIER,
A. Lyon
P. and MARTIN,
E. Journ. de Cbir.,
34: 425, 1929. 3 JAEGER, F. Bruns’ Beitr. z. Klin.
1936.
Cbir., 2: 96,
Cbir.,
163: 539,
NEW
SERIES VOL. XXXVI.
No. 3
Narat-IntestinaI
(4) increased intra-abdomina1 pressure; and (3) long mesentery. Contrary to other observations described in the Iiterature, the complication devei-
Prolapse
American
Journal
of Surgery
73’
SUMMARY
A Rammstedt operation for a pyloric stenosis was performed on a four weeks
Fi$ure
1
Fi@_mz 2
FIG. I. Prolapse
of intestines through an artificial anus. a, enterostomy; posterior wall begins to bulge; b, eventration more pronounced; c, compIete eventration of both stomata. FIG. 2. Intussusception and evisceration through an artificial anus. a, intussusception of the afferent and efferent Ioops; b, intussusception combined with incipient evisceration; c, intussusception and evisceration completed. Note: This mechanism results in a protrusion of a much Iarger loop than a simple bulging of the posterior waII of the attached gut, as ilmstrated in Figure I.
oped in an infant and not in an ad&; in an iieostomy and not in a colostomy; in a reIativeIy recent stoma and not in an artificia1 orifice of a Iong standing. Pads and tight dressings, recommended by writers on this subject, proved useIess in the author’s case. A rubber sponge accomplished the desired effect, probabIy by exerting a continuous elastic pressure and absorbing moisture, thus preventing maceration and contributing to an increased strength of the abdomina1 waI1.
oId infant. One week Iater a paraIytic ireus necessitated an enterostomy. Six days after this second operation a subphrenic abscess and four days Iater a peIvic abscess were drained. On the top of a11 these compIications a prolapse of invaginated afferent and efferent Ioops deveIoped through the enterostomy opening. A rubber sponge apphed over the stoma proved effective in the prevention of recurrences of this intussusception and eventration. A spontaneous closure of the enterostomy foIIowed.