- Email: [email protected]
Introduction to the third (Boston University) surgical service thirteenth annual seminar
The American Journal of Surgery VOLUME
114
SEPTEMBER
196’7
Symposizlm on Diseuses of the Smd
NUMBER
3
Ititestine
Third (Boston University) Surgical Service Thirteenth Annual Seminar Introduction sions which were found in this organ, and Wangensteen’s [6] great contributions to our knowledge of the diagnosis, physiology, and treatment of intestinal obstruction did much to improve our results with this condition. Antibiotics and public health measures have essentially eliminated tuberculosis and typhoid. Vagotomy with pyloroplasty is performed with increasing frequency for peptic ulcer, and many functional disorders of the denervated small intestine are being reported [7]. On the opposite side of the ledger, the same operation may alleviate some of the distressing sequelae of major intestinal resections [8]. An increasing interest in vascular diseases of the small intestine has been stimulated by the pioneering work of Shaw and Rutledge [9] in removing a superior mesenteric embolism in 1957. Improved radiologic technics are enabling physicians to study the blood supply of the intestine, affording earlier diagnosis of acute vascular insufficiency to avoid major resections of this vital organ as well as to enable the vascular surgeon to diagnose chronic insufliciency accurately so that relief may be obtained by new vascular procedures. Also of interest has been an increase in the number of cases of nonocclusive intestinal gangrene [IO]. Much progress made in the treatment of congenital disorders is due to the great work of Ladd and Gross [II ] as well as to the pioneering work of Dennis [12] relative to the primary anastomosis of the small intestine in children. Our newer knowledge of nutrition enables us to control obesity by bypassing the small
From the Third (Boston University) Surgical Service, Boston City Hospital, and Department of Surgery, Boston University School of Medicine, Boston University Medical Center, Boston, Massachusetts.
S
OF THE SMALL INTESTINE began when Lembert [1] in 1826 introduced his serosa to serosa concept of intestinal suturing, which led to newer and improved technics of intestinal suturing by means of artificial devices, such as buttons and a host of continuous interrupted and combined sutures. One of the pioneering adventures along these lines was a “right angle” continuous intestinal suture developed by Cushing at the Boston City Hospital [Z]. The pain of surgery was eliminated by the development of ether anesthesia [3], but the dangers of operating on the abdominal cavity were not alleviated until Lister’s work on antisepsis which eventually merged into aseptic technics. Note should be made of the fact that Lister’s great work was first announced to the world one hundred years ago, and many centennial celebrations of this epochal work are being carried on throughout the world [4]. Thus armed with anesthesia, technic, and antisepsis or asepsis, the surgeon began his attack on the small intestine. The conditions that occupied his attention were traumatic injuries, tumors, congenital abnormalities, obstructions, vascular catastrophies, tuberculosis, and perforations from typhoid. Crohn’s [5] contribution in 1932 did much to distinguish some of the perplexing stenotic leURGERY
351
Byrne
352
bowel, and there is good evidence that atherosclerosis might be controlled in a similar manner. The small bowel is also used as a conduit for urine or bile, is interposed in various locations for control of the dumping syndrome, or is used as a replacement of the gastroesophageal junction. Although the possibility of replacing the small bowel by a substitute prosthesis is not even close, transplantation is feasible [13]. The small bowel, although not a paired organ, offers sufficient length so that segments could be borrowed for transplantation after further immunologic advances are made. The following Symposium will review old problems, critically analyze new areas, and give us hints of things to come. JOHN
J. BYRNE, M.D.
Boston, Massachusetis REFERENCES 1. LEMBERT, A. M&moire sur l’enterographie. Rep. Gen. Anat. Physiol. Path., 2: 100, 1826. 2. GUSHING, H. W. The “right angle” continuous intestinal suture. Medical and Surgical Reports of the City Hospital of the City of Boston, Fourth Series, p. 81-101, 1889.
3. BIGELO~, H. J. Insensibility during surgical operations produced by inhalation. Boston M. b S. J., 35: 309,1846. 4. LISTER, J. On a new method of treating compound fracture, abscess, etc., with observations on the conditions of suppuration. Lancet, 1: 326, 1967. 5. CROHN, B. B. Regional ileitis. J.A.M.A., 99: 1323, 1932. 6. WANGENSTEEN, 0. H. The early diagnosis of acute intestinal obstruction with comments on pathology and treatment. IT’&. J. Surg., 40: 1, 1932. 7. BALLINGER, W. F. The small intestine following vagotomy. Surg. Gynec. 60 CM., 116: 115, 1963. 8. FREDERICK, P. L., SIZER, J. S., and OSBORNE, M. P. Relation of massive bowel resection to gastric secretion. Tr. New England S. Sot., 45: 89, 1964. 9. SHAW, R. S. and RUTLEDGE, R. H. Superior mesenteric embolectomy in treatment of massive mesenteric infarction. New England J. Med., 257: 595, 1957. 10. BERGER, R. L. and BYRNE, J. J. Intestinal gangrene associated with heart disease .Szq. Gynec. & oh-t., 112: 529,196l. 11. GROSS, R. E. The Surgery of Infancy and Childhood. Philadelnhia. 1953. W. B. Saunders Co. 12. DENNIS, C. Resktion and primary anastomosis in the treatment of gangrenous or non-reducible intussusception in children. Ann. Surg., 5: 788, 1947. 13. LILLIHEI, R., GOLDBERG, S., GOOTT, B., and LONGERBEAM, J. K. The present status of intestinal transplantation. Am. J. Surg., 105: 58, 1963.
114
SEPTEMBER
196’7
Symposizlm on Diseuses of the Smd
NUMBER
3
Ititestine
Third (Boston University) Surgical Service Thirteenth Annual Seminar Introduction sions which were found in this organ, and Wangensteen’s [6] great contributions to our knowledge of the diagnosis, physiology, and treatment of intestinal obstruction did much to improve our results with this condition. Antibiotics and public health measures have essentially eliminated tuberculosis and typhoid. Vagotomy with pyloroplasty is performed with increasing frequency for peptic ulcer, and many functional disorders of the denervated small intestine are being reported [7]. On the opposite side of the ledger, the same operation may alleviate some of the distressing sequelae of major intestinal resections [8]. An increasing interest in vascular diseases of the small intestine has been stimulated by the pioneering work of Shaw and Rutledge [9] in removing a superior mesenteric embolism in 1957. Improved radiologic technics are enabling physicians to study the blood supply of the intestine, affording earlier diagnosis of acute vascular insufficiency to avoid major resections of this vital organ as well as to enable the vascular surgeon to diagnose chronic insufliciency accurately so that relief may be obtained by new vascular procedures. Also of interest has been an increase in the number of cases of nonocclusive intestinal gangrene [IO]. Much progress made in the treatment of congenital disorders is due to the great work of Ladd and Gross [II ] as well as to the pioneering work of Dennis [12] relative to the primary anastomosis of the small intestine in children. Our newer knowledge of nutrition enables us to control obesity by bypassing the small
From the Third (Boston University) Surgical Service, Boston City Hospital, and Department of Surgery, Boston University School of Medicine, Boston University Medical Center, Boston, Massachusetts.
S
OF THE SMALL INTESTINE began when Lembert [1] in 1826 introduced his serosa to serosa concept of intestinal suturing, which led to newer and improved technics of intestinal suturing by means of artificial devices, such as buttons and a host of continuous interrupted and combined sutures. One of the pioneering adventures along these lines was a “right angle” continuous intestinal suture developed by Cushing at the Boston City Hospital [Z]. The pain of surgery was eliminated by the development of ether anesthesia [3], but the dangers of operating on the abdominal cavity were not alleviated until Lister’s work on antisepsis which eventually merged into aseptic technics. Note should be made of the fact that Lister’s great work was first announced to the world one hundred years ago, and many centennial celebrations of this epochal work are being carried on throughout the world [4]. Thus armed with anesthesia, technic, and antisepsis or asepsis, the surgeon began his attack on the small intestine. The conditions that occupied his attention were traumatic injuries, tumors, congenital abnormalities, obstructions, vascular catastrophies, tuberculosis, and perforations from typhoid. Crohn’s [5] contribution in 1932 did much to distinguish some of the perplexing stenotic leURGERY
351
Byrne
352
bowel, and there is good evidence that atherosclerosis might be controlled in a similar manner. The small bowel is also used as a conduit for urine or bile, is interposed in various locations for control of the dumping syndrome, or is used as a replacement of the gastroesophageal junction. Although the possibility of replacing the small bowel by a substitute prosthesis is not even close, transplantation is feasible [13]. The small bowel, although not a paired organ, offers sufficient length so that segments could be borrowed for transplantation after further immunologic advances are made. The following Symposium will review old problems, critically analyze new areas, and give us hints of things to come. JOHN
J. BYRNE, M.D.
Boston, Massachusetis REFERENCES 1. LEMBERT, A. M&moire sur l’enterographie. Rep. Gen. Anat. Physiol. Path., 2: 100, 1826. 2. GUSHING, H. W. The “right angle” continuous intestinal suture. Medical and Surgical Reports of the City Hospital of the City of Boston, Fourth Series, p. 81-101, 1889.
3. BIGELO~, H. J. Insensibility during surgical operations produced by inhalation. Boston M. b S. J., 35: 309,1846. 4. LISTER, J. On a new method of treating compound fracture, abscess, etc., with observations on the conditions of suppuration. Lancet, 1: 326, 1967. 5. CROHN, B. B. Regional ileitis. J.A.M.A., 99: 1323, 1932. 6. WANGENSTEEN, 0. H. The early diagnosis of acute intestinal obstruction with comments on pathology and treatment. IT’&. J. Surg., 40: 1, 1932. 7. BALLINGER, W. F. The small intestine following vagotomy. Surg. Gynec. 60 CM., 116: 115, 1963. 8. FREDERICK, P. L., SIZER, J. S., and OSBORNE, M. P. Relation of massive bowel resection to gastric secretion. Tr. New England S. Sot., 45: 89, 1964. 9. SHAW, R. S. and RUTLEDGE, R. H. Superior mesenteric embolectomy in treatment of massive mesenteric infarction. New England J. Med., 257: 595, 1957. 10. BERGER, R. L. and BYRNE, J. J. Intestinal gangrene associated with heart disease .Szq. Gynec. & oh-t., 112: 529,196l. 11. GROSS, R. E. The Surgery of Infancy and Childhood. Philadelnhia. 1953. W. B. Saunders Co. 12. DENNIS, C. Resktion and primary anastomosis in the treatment of gangrenous or non-reducible intussusception in children. Ann. Surg., 5: 788, 1947. 13. LILLIHEI, R., GOLDBERG, S., GOOTT, B., and LONGERBEAM, J. K. The present status of intestinal transplantation. Am. J. Surg., 105: 58, 1963.