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Primary and secondary volvulus of the small bowel
Primary
and Secondary Volvulus Small Bowel CHET R. LULENSKI,
From St. Alexis
Hospital,
Cleveland,
M.D.,
of the
Cleveland, Ohio
days; then a11 the symptoms and signs became exacerbated in spite of the continuance of therapy that had previousIy maintained a satisfactory genera1 condition. This series of events cuIminating in a secondary voIvuIus must be considered in every instance of obstruction. In such situations earIp surgery is imperative. In the excisiona surgery performed in obstruction the technica aspects of anastomosing a large obstructed Iumen to a smaI1 decompressed Iumen present a probIem fraught with the danger of subsequent obstruction, torsion or Ieakage. Various obIique angIes must be made with care to insure adequate circuIation by preserving a Ionger mesenteric and a shorter antimesenteric side. To ahow the Iongest line of anastomosis with adequate circulation, an end to end, ovaI-ovaI, mirror image anastomosis has been fashioned as depicted in Figure I. In the suturing, interrupted No. 2--o or 3-m0 chromic sutures are used for the through and through Hurstlayer. In making a symmetrical approximation it is necessary to rotate the mesenteric edges around about 25 per cent of the circumference of the bowe1. There is additiona sIight torsion of the
Obio.
OLVULUS is mentioned infrequentIy in the literature but it is an important type of intestina1 obstruction [r,z,?]. To my knowledge, secondary volvulus as a distinct entity has not been described. This articIe expIains and portrays its deveIopment. In conjunction with therapy, a modihed technic of end to end intestinal anastomosis appIicabIe in resection in obstruction is graphicaIIy presented. A series of cases of primary and secondary voIvuIus wiI1 be annotated. Experience in the use of the new surgica1 procedure wiI1 be described. VoIvulus of the smaI1 bowe1 is a dramatic type of obstruction in which twisting of a Ioop of the intestine occIudes the Iumen at the entrance and at the exit near the fixed point of the involved segment. Because of this a cIosed loop is established. ProximaIIy there is a simpIe obstruction. The voIvuIus may be a primary deveIopment with simuItaneous torsion, closed-Ioop status and minima1 proximal simple obstruction. The voIvuIus may also be a secondary condition superimposed on a preexisting simple obstruction of twenty-four or more hours’ duration. This condition deveIops by vioIent peristaIsis of the movable bower immediately proxima1 to the fixed point, the stagnant or overloaded and heavy bowel remaining reIativeIy stationary. The proximal bowel then revolves on itself because of the difference in weight and peristalsis. This comprises a secondary type of volvuIus which does not occur in the early stages of simple obstruction. Secondary volvuIus may be overIooked if there is much manipuIation during the operation prior to exposure of the site of obstruction. Review of many cases of small intestina1 obstruction reveals a dehnite number in which an obstruction was present for one or more
V
FIG. I. End to end, ovaI-ovaI, mirror image annstomosis.
453
American
Journal
of Surgery.
Volume
101,
Sep~rmber rdr
LuIenski two ends of the bowe1 with interrupted No. 3-o siIk seromuscuIar sutures used as the outer Iayer. This eventuates in a wavy stitch line with the appearance of buckIing of the Ionger edge of the proxima1 bowe1 end. On compIetion of this the diameter of the anastomosis is Iarger than the diameter of the decompressed or distaI intestine. This Iumen is significantIy greater than can be obtained in the usua1 obIique end to end anastomosis. STATISTICS
During the ten year period 1950 to 1959 incIusive there were IOI cases of smaI1 intestina1 obstruction at St. AIexis HospitaI. Twenty&e were due to voIvuIus. Since 91,366 patients were admitted to the hospita1 during this period, voIvuIus was found once in every 3,654 admissions. FINDINGS
AND
THERAPY
Of twenty-five patients with voIvuIus two did not have surgery. The diagnosis was made at autopsy; both were of the primary type. One of these was a two day oId infant for whom a diagnosis of subtentoria1 hemorrhage was made. Postmortem examination discIosed a VOIVUIUS of the entire jejunum and iIeum at the Iigament of Treitz. Proper cIinica1 evaIuation and repeated roentgenograms of the abdomen may have suggested the correct diagnosis. The second patient was a forty-three year oId white female in whom voIvuIus of 6 inches of the dista1 iIeum deveIoped four days after chorecystectomy, death occurring forty hours after the onset of nausea and vomiting. ReaI pathoIogy was unsuspected, adynamic postoperative iIeus being considered as the cause of the symptoms. Patients undergoing abdomina1 operations must be observed cIoseIy, postoperativeIy, for this unfortunate occurrence. Of the twenty-three surgica1 patients, six were treated by untwisting the bowe1 with no resection necessary; a11 had a smooth convaIescence. AI1 these had primary voIvuIus. In the remaining seventeen patients resection of the bowe1 was necessary. EIeven were of the primary type. A seventy-nine year oId white woman in this group died on the seventeenth postoperative day apparentIy of a cerebra1 hemorrhage. In six patients the findings at surgery and the reIativeIy Iong iIIness prior to operation (three days to three weeks) indicated a secondary voIvuIus had been superimposed on 454
a simpIe obstruction. There was one death in this series, a seventy-two year oId white woman who died on the eighth postoperative day. Autopsy reveaIed obstruction at the ordinary end to end ileoileostomy. In addition to the fatalities, three patients had prolonged, stormy courses with hospitaIization for three to four weeks after surgery. The two fataIities among the twenty-three surgica1 patients produced a mortaIity of 8.7 per cent in this group but the over-a11 death incidence is 16 per cent when the deaths of two nonsurgica1 patients are incIuded. VoIvuIus can be a hidden deveIopment in unusua1 circumstances as exemplified by the two cases undiagnosed unti1 autopsy. Frequent examinations and abdominal roentgenograms at six hour intervaIs wiI1 heIp soIve the probIem and aIIow for immediate surgery. In simpIe obstructipn one must constantIy watch for possibIe superimposed secondary voIVUIUS needing immediate surgery. In therapy of the cIosed-loop obstruction earIy diagnosis and operation are mandatory. In the actua1 resection and anastomosis an obIique, ovalovaI, mirror image, end to end arrangement aIIows the best possibIe connection. This particuIar technic was empIoyed in six cases with success. The same principIe has been used in transverse coIon and sigmoid anastomoses. SUMMARY
VoIvuIus of the smaI1 bowel is present in a Iow percentage of patients admitted to the average genera1 hospita1. It necessitates prompt surgica1 intervention. The mortaIity in twentyfive cases presented here is 16 per cent. If surgery is performed sufIicientIy earIy so that resection is not necessary, morbidity and mortality are much decreased. There are two types of voIvuIus, primary and secondary. The secondary voIvuIus must be suspected whenever there is a sudden change in a previously stabiIized simpIe obstruction. If resection is done, care must be taken to use the Iongest Iine of end to end anastomosis such as the obIique mirror image connection described. REFERENCES
I. FINE, J. The cause of death in acute intestinal obstruction. Surg. Gynec. ti Obst., I IO: 628, 1960. 2. MORETZ, W. H. and MORTON, J. J. Acute voIvuIus of smaII intestine. Ann. Swg., 132: 899, Igp. 3. SMITH, G. A. and PERRY, J. E., JR. Small bowe1 voIvuIus. Missouri Med., 1049, ,937.
and Secondary Volvulus Small Bowel CHET R. LULENSKI,
From St. Alexis
Hospital,
Cleveland,
M.D.,
of the
Cleveland, Ohio
days; then a11 the symptoms and signs became exacerbated in spite of the continuance of therapy that had previousIy maintained a satisfactory genera1 condition. This series of events cuIminating in a secondary voIvuIus must be considered in every instance of obstruction. In such situations earIp surgery is imperative. In the excisiona surgery performed in obstruction the technica aspects of anastomosing a large obstructed Iumen to a smaI1 decompressed Iumen present a probIem fraught with the danger of subsequent obstruction, torsion or Ieakage. Various obIique angIes must be made with care to insure adequate circuIation by preserving a Ionger mesenteric and a shorter antimesenteric side. To ahow the Iongest line of anastomosis with adequate circulation, an end to end, ovaI-ovaI, mirror image anastomosis has been fashioned as depicted in Figure I. In the suturing, interrupted No. 2--o or 3-m0 chromic sutures are used for the through and through Hurstlayer. In making a symmetrical approximation it is necessary to rotate the mesenteric edges around about 25 per cent of the circumference of the bowe1. There is additiona sIight torsion of the
Obio.
OLVULUS is mentioned infrequentIy in the literature but it is an important type of intestina1 obstruction [r,z,?]. To my knowledge, secondary volvulus as a distinct entity has not been described. This articIe expIains and portrays its deveIopment. In conjunction with therapy, a modihed technic of end to end intestinal anastomosis appIicabIe in resection in obstruction is graphicaIIy presented. A series of cases of primary and secondary voIvuIus wiI1 be annotated. Experience in the use of the new surgica1 procedure wiI1 be described. VoIvulus of the smaI1 bowe1 is a dramatic type of obstruction in which twisting of a Ioop of the intestine occIudes the Iumen at the entrance and at the exit near the fixed point of the involved segment. Because of this a cIosed loop is established. ProximaIIy there is a simpIe obstruction. The voIvuIus may be a primary deveIopment with simuItaneous torsion, closed-Ioop status and minima1 proximal simple obstruction. The voIvuIus may also be a secondary condition superimposed on a preexisting simple obstruction of twenty-four or more hours’ duration. This condition deveIops by vioIent peristaIsis of the movable bower immediately proxima1 to the fixed point, the stagnant or overloaded and heavy bowel remaining reIativeIy stationary. The proximal bowel then revolves on itself because of the difference in weight and peristalsis. This comprises a secondary type of volvuIus which does not occur in the early stages of simple obstruction. Secondary volvuIus may be overIooked if there is much manipuIation during the operation prior to exposure of the site of obstruction. Review of many cases of small intestina1 obstruction reveals a dehnite number in which an obstruction was present for one or more
V
FIG. I. End to end, ovaI-ovaI, mirror image annstomosis.
453
American
Journal
of Surgery.
Volume
101,
Sep~rmber rdr
LuIenski two ends of the bowe1 with interrupted No. 3-o siIk seromuscuIar sutures used as the outer Iayer. This eventuates in a wavy stitch line with the appearance of buckIing of the Ionger edge of the proxima1 bowe1 end. On compIetion of this the diameter of the anastomosis is Iarger than the diameter of the decompressed or distaI intestine. This Iumen is significantIy greater than can be obtained in the usua1 obIique end to end anastomosis. STATISTICS
During the ten year period 1950 to 1959 incIusive there were IOI cases of smaI1 intestina1 obstruction at St. AIexis HospitaI. Twenty&e were due to voIvuIus. Since 91,366 patients were admitted to the hospita1 during this period, voIvuIus was found once in every 3,654 admissions. FINDINGS
AND
THERAPY
Of twenty-five patients with voIvuIus two did not have surgery. The diagnosis was made at autopsy; both were of the primary type. One of these was a two day oId infant for whom a diagnosis of subtentoria1 hemorrhage was made. Postmortem examination discIosed a VOIVUIUS of the entire jejunum and iIeum at the Iigament of Treitz. Proper cIinica1 evaIuation and repeated roentgenograms of the abdomen may have suggested the correct diagnosis. The second patient was a forty-three year oId white female in whom voIvuIus of 6 inches of the dista1 iIeum deveIoped four days after chorecystectomy, death occurring forty hours after the onset of nausea and vomiting. ReaI pathoIogy was unsuspected, adynamic postoperative iIeus being considered as the cause of the symptoms. Patients undergoing abdomina1 operations must be observed cIoseIy, postoperativeIy, for this unfortunate occurrence. Of the twenty-three surgica1 patients, six were treated by untwisting the bowe1 with no resection necessary; a11 had a smooth convaIescence. AI1 these had primary voIvuIus. In the remaining seventeen patients resection of the bowe1 was necessary. EIeven were of the primary type. A seventy-nine year oId white woman in this group died on the seventeenth postoperative day apparentIy of a cerebra1 hemorrhage. In six patients the findings at surgery and the reIativeIy Iong iIIness prior to operation (three days to three weeks) indicated a secondary voIvuIus had been superimposed on 454
a simpIe obstruction. There was one death in this series, a seventy-two year oId white woman who died on the eighth postoperative day. Autopsy reveaIed obstruction at the ordinary end to end ileoileostomy. In addition to the fatalities, three patients had prolonged, stormy courses with hospitaIization for three to four weeks after surgery. The two fataIities among the twenty-three surgica1 patients produced a mortaIity of 8.7 per cent in this group but the over-a11 death incidence is 16 per cent when the deaths of two nonsurgica1 patients are incIuded. VoIvuIus can be a hidden deveIopment in unusua1 circumstances as exemplified by the two cases undiagnosed unti1 autopsy. Frequent examinations and abdominal roentgenograms at six hour intervaIs wiI1 heIp soIve the probIem and aIIow for immediate surgery. In simpIe obstructipn one must constantIy watch for possibIe superimposed secondary voIVUIUS needing immediate surgery. In therapy of the cIosed-loop obstruction earIy diagnosis and operation are mandatory. In the actua1 resection and anastomosis an obIique, ovalovaI, mirror image, end to end arrangement aIIows the best possibIe connection. This particuIar technic was empIoyed in six cases with success. The same principIe has been used in transverse coIon and sigmoid anastomoses. SUMMARY
VoIvuIus of the smaI1 bowel is present in a Iow percentage of patients admitted to the average genera1 hospita1. It necessitates prompt surgica1 intervention. The mortaIity in twentyfive cases presented here is 16 per cent. If surgery is performed sufIicientIy earIy so that resection is not necessary, morbidity and mortality are much decreased. There are two types of voIvuIus, primary and secondary. The secondary voIvuIus must be suspected whenever there is a sudden change in a previously stabiIized simpIe obstruction. If resection is done, care must be taken to use the Iongest Iine of end to end anastomosis such as the obIique mirror image connection described. REFERENCES
I. FINE, J. The cause of death in acute intestinal obstruction. Surg. Gynec. ti Obst., I IO: 628, 1960. 2. MORETZ, W. H. and MORTON, J. J. Acute voIvuIus of smaII intestine. Ann. Swg., 132: 899, Igp. 3. SMITH, G. A. and PERRY, J. E., JR. Small bowe1 voIvuIus. Missouri Med., 1049, ,937.