Physiologic effect of massive small intestinal resection and colectomy

PHYSIOLOGIC EFFECT OF MASSIVE SMALL INTESTINAL RESECTION AND COLECTOMY * J.

E. MCCLENAHAN, M.D. AND BERNARD FISHER, M.D. Pittsburgh, Pennsylvania

T

HE remarkabIe fashion in which nature compensates for removal of massive portions of the intestinal tract has always been of great interest to the surgeon. With the advent of improved technics more tota and nearIy total colectomies are being done for chronic ulcerative colitis, muItipIe congenital poIyposes and megacoIon. At times Iarge sections of smaI1 bowe1 are removed for mesenteric thrombosis,’ segmental iIeitis, trauma to major mesenteric vesseIs and sundry reasons. What effect, if any, is there upon the body economy by such surgicaI procedures? This question prompted us to make the following genera1 review of the probIem of massive intestina1 resection and to present the resuIts obtained from a detaiIed study on two of our patients in this group, nameIy a man upon whom a11 but approximately ~$4 feet of smaII bowel was removed and a young girI upon whom a total coIectomy was done. For a review of the anatomy and physioIogy of the smaI1 and Iarge bowe1 apphcabIe to this probIem, special reference is made to the work of Haymond,2 Treves,3 Lamb,4 and Cori and Cori.5 There is yet no definite answer as to how much smaI1 bowe1 can safeIy be removed and stiI1 aIIow the patient to Iive and return to heaIth. Haymond, in his compIete anaIysis of the probIem, concIuded from 122 cases of resection that with remova of 33 per cent of smaI1 intestine the digestive tract couId be expected to return to norma function. RemovaI of 50 per cent of the bowe1 constituted the upper Iimit of safety and above 50 per cent poor resuIts were the ruIe, aIthough an occasiona case wouId do weI1. Observations of FIint6 show that dogs * From Department

toIerate the remova of as much as 60 per cent of the smaI1 intestine. However, they are unabIe to handIe much fat. Apparently, then, it is important to have a certain amount of intestina1 mucosa present as we11 as biIe and pancreatic juice. The effects of coIectomy or coIonic excIusion, as observed by us on a recent series of five tota coIectomies and severa ileostomies for uIcerative coIitis, are simiIar to those reported by Whittaker and Bargen’ on a series of forty-five cases. For approximateIy one month folIowing coIectomy or excIusion of the coIon there is a period of metaboIic adjustment during which time the patient appears to do poorIy. The excreta from the iIeostomy or rectum (iIiosigmoidostomy having been done) move aImost constantIy, being approximateIy 90 per cent water; the physica or menta1 attitude of the patient is very poor; examination of the bIood shows some reduction in serum calcium which returns to normal within a month and some reduction of chIorides8 but no gross disturbance of the equiIibrium of the chemica1 constituents of the bIood. After the first month there is an increase in strength and weight and within two to three months these are practicahy normaI. The watery discharge thickens so that within a short period of time the stooIs are soft and occasionaIIy formed. It is the genera1 opinion that no permanent deficiencies in metaboIism occur foIIowing coIectomy or coIonic excIusion. CLINICAL OBSEBVATIONS The folIowing two cases typify the findings in patients upon whom massive smaI1

of Surgery, Mercy HospitaI, and University of Pittsburgh,

684

School of Medicine, Pittsburgh,

American

Journal

Pa.

of Surgery

McCIenahan,

Fisher-IntestinaI

Resection

CASE I. G. O., a white maIe aged sixty-one, was admitted to Mercy HospitaI, Pittsburgh, PennsyIvania, on October I 4, I 946, with aching pain in the right lower abdomen and right flank. He had had one episode of nausea and vomiting about two weeks previousIy but was in no acute distress. A Iarge, firm mass could be palpated in the mid-abdomen. X-ray examination showed the mass to be extrarena and extracoIic. It was believed that he had a retroperitonea1 tumor. On October 24th the abdomen was expIored and a retroperitonea1 lymphosarcoma was found in the mesentery of the smaI1 bowe1. This necessitated remova of a massive segment of smaI1 bowe1 due to the fact that the tumor extended into the root of the mesentery thus impinging on a major portion of the bIood suppIy. An end-to-end anastomosis was performed between the terminal foot of iIeum and the third portion of the duodenum severa inches proximal to the ligament of Treitz. This was accompIished by severing the Iigament and dissecting the retroperitonea1 duodenum so as to make the anastomosis. Postoperatively, his ffuid and eIectroIyte baIance were maintained with intravenous infusions; aIso, protein and vitamin supplements were administered. He was given a May,

1950

685

2

I

FIG. I. Length of small bowel; approximatdy FIG. 2. Site of intestinal anastomoses.

intestina1 resection was performed (Case I) and foIIowing coIectomy (Case II):

and CoIectomy

38 inches.

course of deep x-ray therapy and was discharged on November 11th. His prognosis was guarded because it was realized that he had approximateIy onIy 2 to 245 feet of small bowe1 remaining. In August 1948, he came into the hospital so that the metabolic effects of having only approximateIy 38 inches of smaI1 bowe1 from pylorus to cecum as measured on x-ray film could be studied. (Fig. I.) It was interesting to note that hypertrophy and eIongation of the intestine had taken pIace. At the time of operation the termina1 ileum was puIIed straight up to the duodenum with no Ioops of small intestine interposed, as shown on the x-ray picture. The marked hypertrophy of the Iumen of the smaI1 bowe1 may aIso be observed in the same picture. This is most noticeabIe in the segment of smaI1 intestine fiIIed with barium which resembIes the transverse coIon. ApparentIy, both a compensatory eIongation and hypertrophy had resuIted. Figure 2 demonstrates the site of anastomosis at the tip of the inserted MiIIer-Abbott tube. The tube couId be inserted no further because of narrowing and stricture at this point, not sufficient to cause the patient distress. Aside from a normocytic anemia his bIood and bIood chemistry were essentiaIIy normaI. (TabIe I.) Of great interest were the feca1 fat determinations. (TabIe II.) The patient was given

686

McCIenahan,

Fisher-IntestinaI

Resection

a high fat diet (fat 150.55 gm., carbohydrates 159.7 gm. and protein 76.3 gm.) and three samples of feces were examined. The percentages of fat (which is the summation of neutral fat and fatty acids,) 7.3 per cent, 4. I z per cent and 12.18 per cent, a11 fail within the normal values as given by Fowweatherg which are

1

Total Proteins (mg. oi,)

GIucose ToIerance Test

Subjectively, this man believed that the only thing different about him was that he always hungry” and that he was “aImost ate more often. He maintained a constant weight of 140 pounds during the previous year and was working and feehng well in December, 1948.

TABLE

-

I

Cevitamic acid

Albumin GIobulin

I

Cal-

Ereatinine

Blood Count

‘$7. 0

Fasting

.92

45 min. ,129 2 hr. ,126

Case 11

7.62

3.80

51.3

._.

23.6

7.1

0.8

1.7

I

I ~ 526 ) 92

3.82

Fasting IOI 45 min. ,135 6.73 2 hr. .7*

4.99 2.83

i

I

~

I

.o

I

I .2

7:;

Phosphorus

c

I Case I

and CoIectomy

466

89

.b.c. 3,350,‘99 v.b.c. 6,780’ lb. 9.56 gml

.b.c. 3,980,ooo’ i.b.c. 5,650 10.8 lb. 9.5 gm.

4.4

-

neutral fat 7.3 per cent and free fatty acids 5.6 per cent. Barium reached the Iarge bowe1 approximately one hour folIowing its ingestion at this time. A fluoroscopic examination several months folIowing the operation showed the TABLE II* Case 1

Stool SampIe

I

case II

! I

2

131112~3

Weight of feces in 1.5678.1 77.507.50 sample ._..,.,.. 10.8212.87 (gm.) Weight of tota fat insampIe ._.... 0.79 9.53 0.19 0.90 0.601.59 km.) Per cent of fat in sample ._..,__.. 7.30 4.12 12.19 1.15 0.772.12

/ * Fat determination by Department of Chemistry.

,

,

University

!

of

Pittsburgh

barium to reach the cecum within ten seconds. Iron tablets taken with a meal gave a tarry stool approximately six to eight hours after eating. He noted that the eating of such things as beets and greens simiIarIy discoIored the stool in this length of time. He averaged three to four softly formed stooIs in twenty-four hours.

CASE II. G. B., a white femaIe aged fourteen, came into this hospital on August IO, I 947, with typical Hirschsprung’s disease which she had since birth. (Fig. 3.) The entire colon proximal to the sigmoid was tremendously diIated and there had been no response to prolonged medical therapy. On August 28th a subtotal colectomy was done which brought the termina1 iIeum and sigmoid out through the abdomen in the fashion of a Mikulicz procedure. The resected colon, together with its fecal contents, weighed 20 pounds. FolIowing surgery the patient spent about a month passing through the stage of debiIitation mentioned previously; there was aImost a constant flow of liquid materia1 from the ileostomy. She began to improve; the abdominal opening was closed and she was sent home on December 25th. On JuIy 19, 1948, she returned to the hospita1 in good health (Fig. 4) for the metabolic studies shown on Table II. She also was placed on a high fat diet as was the patient in Case I (fat 150.55 gm., carbohydrates 109.7 gm. and protein 71.3 gm.) and the percentages of fat in her stool were much Iower than in the first patient. She had approximately three to five Iiquid to semi-soft bowe1 movements a day aIthough for two to three months fohowing the operation this number was nine to twelve. FeosoP tabIets ingested with a meal resulted

American Journal of Surgery

McCIenahan,

Fisher-IntestinaI

3

FIG. 3. Before coIectomy. FIG. 4. After colectomy.

in a tarry stoo1 seven hours and forty-five minutes later. Her bIood calcium level was normaI, apparentIy having become adjusted to the coIectomy. Of specia1 interest w-as the discrepancy of urinary output as compared with measured intake. On three successive days her intake by mouth was 1,300 cc., 1,850 cc. and 1,350 cc. Her urinary output was 500 cc., 800 cc. and 800 cc. No record was kept of tota volume of feces which were liquid. However, as she appeared cIinicaIIy to be in norma water balance, it might be presumed that the urine volume was Iess because of water Ioss in the feces. SUMMARY

AND

CONCLUSION

Nature’s abihty to compensate for tissue Ioss is demonstrated in massive remova of portions of intestinal tract just, as in the remova of part of numerous other organs of the body. Two cases upon which rather detaiIed study was done folIowing resection of a11 but 38 inches of smaI1 bowel and a subtota1 coIectomy were presented with the foIIowing tenabIe concIusions : I. Massive resection of smaI1 bowe1 is physioIogicaIIy feasibIe in an unpredictable May,

1950

Resection

and Colectomy

687

4

number of cases and, therefore, shouId be done when it may be Iife-saving, i.e., mesenteric thrombosis, tumor. 2. Although a11 but approximately 2 to 2% feet of smaI1 bowel were removed at operation, compensatory elongation and hypertrophy have taken place so that two years Iater there are about 38 inches demonstrable by x-ray. 3. By chemica1 and Iaboratory examination no serious metaboIic derangement has occurred in a man upon whom a11 but 2 to 234 feet of smaI1 bowe1 were removed. This is admittedIy very unusua1. 4. CoIectomy or colonic excIusion is attended by immediate serious metaboIic derangement. 5. SeveraI months foIIowing coIectomy the chemical and Iaboratory studies are essentiaIIy normaI. REFERENCES I. MCCLENAHAN, J. E. and FISHER, BERNARD. Mesenteric thrombosis. Surgery, 23: 778, 1948.

2. HAYMOND, H. E. Massive resection of smaII intestine-an anaIysis of 257 coIIected cases. Surg., Gynec. # Obst., 61: 693, 1935.

688

McClenahan,

3. Gray’s

Anatomy.

24th ed., p.

Fisher-IntestinaI I 188. PhiIadeIphia,

~942. Lea & Febiger.

4. Quoted by BRYANT, J. Observations upon the growth and length of the human intestine. Am. J. M. Sr., 167: 499 j20, 1924. 5. CORI, C. F. and CORI, G. T. The rate of absorption of fresoses and pentoses from the intestinal tract. J. Biol. Chem., 66: 691, 1925. 6. FLINT, J. M. Compensatory hypertrophy of small intestine following resection of large portions of

Resection

and CoIectomy

jejunum and iIeum. Proc. Connecticut &f. Sot., p. 283, 1909-1910. WHITTAKER, LOUIS, D. and BARGEN. J. ARNOLD. Observations one the human being folIowing coIectomy or coIonic excIusion with ileostomy. Surg., GJmec. c~ Obst., 64: 849, 1937. 8. CATTELL, R. B. The surgical treatment of uIcerative colitis. J. A. M. A., 104: ro4-ro9, r935. 9. CANTAROW, A. and TRUMPER, M. CIinicaI Biochemistry. P. 135. Philadelphia, 1945. W. B. Saunders Co.

PANCREATIC caMi were first described by DeGraaf in 1667; only ~$0 cases have since been reported. The condition is probabIy not rare but is frequently overIooked or forgotten. This possibiIity should be suspected in diabetics with abdomina1 pain or steatorrhea, or those with enlargement of the Iiver and associated vague pains in the upper abdomen. One characteristic of this epigastric pain is that it is often spasmodic and colicky in character, severe in intensity and may radiate to the Ieft side of the abdomen to the back and to either shoulder, especially the left one. The indicated treatment is surgery but only in cases in which the pancreatic caIculi are apparently causing severe enough symptoms to warrant taking such risks. There should be no operation for the so-caIIed “silent” stones in the pancreatic ducts which are accidentaIIy found by x-ray examination and are not causing symptoms. (Richard A. Leonardo, M.D.)

American

Journal

of Surgery