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Spontaneous resolution of intestinal obstruction while receiving home parenteral nutrition
Spontaneous Resolution of Intestinal Obstruction While Receiving Home Parenteral Nutrition
Rick Ft. Selby, MD, Phoenix, Arizona George H. Mertz, MD, FACS, Phoenix, Arizona Robert B. Giisdorf, MD, PhD, FACS, Phoenix, Arizona
Matted, dense, and vascular adhesions of the intestine producing obstruction can create an edematous friable bowel that cannot be freed. Even after extensive dissection the obstruction persists and, if a second operation is performed too soon, the condition becomes even worse. Previously, an extensive resection was performed in many patients and in others, the only recourse was to close the abdomen. In the latter situation, the patient can not eat and must be placed on total parenteral nutrition. Six postoperative patients were referred for home total parenteral nutrition because of such persistent intestinal obstruction. Our original plan was to maintain these patients for a period of time so the surgeon could make another attempt at freeing the small intestine. In the course of 2 to 4 months, however, we were pleasantly surprised to observe spontaneous resolution of the obstruction in four of the six patients. In the two other patients in whom the surgeon had divided the bowel and created a formal stoma, an operation was required to reestablish gastrointestinal continuity. In the latter two patients, we found filmy, nonvascular, easily divisible adhesions and other areas where the bowel was entirely free. This is a report of our observations in these six patients. Material
and Methods
The patients, who ranged in age from 35 to 68 years, began receiving total parenteral nutrition because of persistent intestinal obstruction after at least two attempts at enterolysis. None had malignant disease (Table I), and all had two to eight previous operations. In each patient, From the Department of Surgery, Veterans Administration Medical Center and the Phoenix Nutritional Support Group, Phoenix, Arizona. Requests for reprints should be addressed to Robert B. Gilsdorf, MD, Phoenix Nutritional Support Group, 1010 East McKowell Road, Phoenix, Arizona 85006. Presented at the 35th Annual Meeting of the Southwestern Surgical Congress, Phoenix, Arizona, May 2-5, 1983.
742
the last operation performed was for intestinal obstruction due to adhesions. An average of 2i/z weeks postoperatively, at the time of operation, the surgeon was unable to free the loops of bowel. During the course of the dissection, all patients had at least one enterotomy. In two patients, the bowel was divided and the proximal end brought out of the abdomen as a stoma to bypass the multiple enterotomies in the distal bowel. In the four patients without a formal stoma, enterocutaneous fistulas were present secondary to leakage at one or more of the enterotomy repair sites. At the time the decision was made to begin long-term nutritional support, all patients had nasogastric tubes or gastrostomy tubes in place and on suction. Also, all had clinical and radiologic evidence of complete small bowel obstruction. None of the patients was severely malnourished (Table II). A central venous silicone catheter was inserted for home total parenteral nutrition [I], and the patients were given 2,000 to 2,500 calories per day. Formulas were designed to provide a 15O:I calorie to nitrogen ratio, with 95 percent of the nonprotein calories from glucose. Lipids were given only once a week. The patients received all of the solution during a 10 to 12 hour nocturnal infusion and were ambulatory during the day. They were trained in catheter care, fistula care, and parenteral solution mixing before being discharged from the hospital an average of 10 to 14 days later. Before discharge, the nasogastric and gastrostomy tubes were removed from all of the patients and they were allowed only occasional sips of clear liquid for the first month [2]. The patients were followed frequently as outpatients until their enterocutaneous fistulas closed and signs of obstruction disappeared. One week after obstruction had subsided, as evidenced by passage of flatus, the patients were given a clear liquid diet. The diets were advanced as tolerated over a 2 week period. Two of the patients had upper gastrointestinal series that showed nonobstructed small bowel before they were given oral alimentation. One week after tolerating a solid diet, the central venous catheters were removed. Subsequently, all patients have been observed for the possibility of recurrent obstruction. The two patients with intentional stomas underwent reoperation 6 and 8 months after discharge to reestablish intestinal continuity. Blood loss and technical problems were as-
The American
Journal of Surgery
Resolution
TABLE I
TABLE II
Patient Data Age
Patient
(yr) & Sex
1
53,F
2 3
4 5 6
Cause of Obstruction
Diverticulitis surgery with leak 5 1 ,M Adhesions after cholecystectomy 67,M Bowel perforation after abdominal radiation 68,M Adhesions after aortic graft 65,M Afferent loop leak after gastrectomy 34.M Adhesions from gunshot wound
Fistula Present
Previous Operations
Stoma ileostomy Jejunum to wound Jejunostomy
a
Jejunum to wound Duodenum to drain site Jejunum to drain site
4
4 3
2
Intestinal
Patients With Spontaneous Resolution of Obstruction
Patient
Time Fistula Remained Open (mo)
Time Until Obstruction Opened (mo)
1 2 3 4
2.5 1.5 0.5 1
3 3 3.5 2
4.5 3 3.5 2
1.4
2.9
3.3
Average
Obstruction
Total Parenteral Nutrition Duration Complications (mo) None Catheter infection Catheter infection None
TPN = total parenteral nutrition.
3
sessed and compared with those at previous operations by the operating surgeon. No histologic sections or special studies were carried out. Results The four patients without intentional stomas had spontaneous resolution of their obstructions an average of 2.9 months after the last operation (range 2 to 3.5 months) (Table II). The fistulas closed in all of the patients from 2 to 10 weeks after laparotomy while they were receiving on home total parenteral nutrition. The follow-up period in these four patients ranged from 1 month to 2 years. In that time, only one of the patients had symptoms of partial small bowel obstruction; however, they were mild and did not require reoperation. The two patients who were operated on for stoma closure were found to have adhesions that. were filmy, relatively avascular, and technically easy to dissect. The bowel was neither edematous nor friable and was not entered during enterolysis. On the program of home total parenteral nutrition, there was an average weight gain of 4.5 lb and an average increase in the serum albumin level of 0.5 g/100 ml (Table 111). There were no metabolic complications. All patients ret.urned to relatively normal activity during their time receiving home total parenteral nutrition. One patient returned to work as a mail carrier. Comments The successful management of small bowel obstruction due to adhesions bv long-term narenteral feedings and complete gas;trointestuinal rest, suggests that there is a resolution of adhesions that results in a nonobstructed state. Schade and Williamson [3] found that early adhesions are made up of fibrin. As the fibrin is removed by tissue macrophages, the adhesions become compact, dense bundles of collagen [3,4]. The clearance of the fibrinous adhesions may be accelerated by the presence of local plas-
Volume 146, December 1963
of Adhesive
minogen activators found in substantial concentrations in the serosa [5]. The mature adhesion probably represents a permanent state in which the collagen has the microscopic appearance of long collagen fibers with little or no vascularity or inflammatory cells [6]. It is unclear whether complete gastrointestinal rest contributes to the resolution of adhesions or merely minimizes symptoms while maturation is under way. The operative findings in this series indicated complete resolution of the edema and inflammatory reaction. We theorize that spontaneous resolution of the obstruction is due to the maturation of the adhesions into the long loose collagen fibers and that this process of maturation occurs in the absence of the inflammatory response that normally occurs if a patient with partial or total obstruction is allowed to continue to eat. Based on our admittedly small series, we believe that if enterolysis has been performed because of adhesive intestinal obstruction and the gastrointestinal tract does not open up in the early postoperative period, reoperation is not advised. The frozen abdomen or abdominal cocoon encountered in this early postoperative period represents an immature stage of adhesions. Maturation of the adhesions, we suggest, will result in resolution of the obstruction and gastrointestinal patency within an average of 3 months. Should reoperation be necessary, a waiting period of at least 3 months is recommended. Full maturation is reached about 6 months postoperatively but, because we observed spontaneous resolution of obstruction after 3 months of gastrointestinal rest, we have assumed that reasonable matuTABLE III
Results of Total Parenteral Nutrition
Patient
Calories Per Day
1 2 3 4 5 6
2,000 2,000 2,000 2,000 2,000 2,500
Weight (lb) Beginning End 120 149 139 137 135 236
121 161 148 143 135 235
Albumin (g/dl) Beginning End 3.6 3.2 3.5 3.7 2.8 3.6
3.2 4.6 4.5 4.6 3.3 3.2
743
Selby
et al
ration must have occurred at 3 months. Should reoperation be required, it probably can safely be performed at that time. In the event a surgeon does operate on an obstructed gut and encounters a cemented mass, we believe he should refrain from prolonged bloody disse‘ction with the inevitable enterotomies. Certainly one should not, in frustration, perform an extensive resection. Gastrostomy, if the stomach is readily accessible, should be performed. Enterotomies should be repaired, but the area of the enterotomy should be drained since most will leak. Dividing the bowel and creating a stoma will result in obligatory reoperation with its inherent risk. We found that gastric decompression could be stopped as long as the gastrointestinal tract was maintained at complete rest. All fistulas closed spontaneously despite initial copious drainage of succus entericus, and only rarely were antispasmodic medications necessary for cramps. It appears that once the gastrointestinal tract opens due to maturation of the adhesions it will stay open. None of our patients has had significant obstructive symptoms in the follow-up period. Whether these observations hold for subsequent patients or for the reported group with a longer follow-up period remains to be seen. This experience certainly suggests that it is safer to wait before reoperating for persistent intestinal obstruction. Summary Six patients with intestinal obstruction secondary to benign adhesions so dense and vascular that the operating surgeon could not free them, were placed on a home total parenteral nutrition program. Four patients had enterocutaneous fistulas, and two had their bowels divided and stomas created to divert intestinal contents from distal enterotomies made during the attempt to free the intestine. The enterocutaneous fistulas closed in four patients within 2 weeks to 5 months and the obstructions spontaneously resolved in 2 to 3.5 months. At reoperation on the two patients whose intestinal tracts were purposely divided, the previously matted bowels with dense adhesions were easily freed. We believe complete gastrointestinal rest allows adhesions to mature into long avascular collagen fibers in the absence of a persistant inflammatory reaction that accompanies partial or total small bowel obstruction. We recommend that patients receive 3 months of home total parenteral nutrition before a second operation for persistent obstruction after recent enterolysis should be considered. Spontaneous resolution should occur, but if not, reoperation can be perfoimed safely after the 3 month interval. References 1. Hiekman RO, Buckner CD, Clift RA, et al. A modified right atrial catheter for access to the venous system in marrow transplant recipients. Surg Gynecol Obstet 1979;148:871-5.
744
2. Gilsdorf RB, Rosado IR, Cartmill A. Home total parenteral nutrition: clinical experience and observa%ons. Samaritan Medicine 1983;1:5-12. 3. Schade DS, Williamson MD. The pathogenesis of peritoneal adhesions: an ultrastructural study. Ann Surg 1968;167: 500-10. 4. Ryan GB, Grobety J, Majno G. Postoperative peritoneal adhesions. Am J Pathol 1971;65:117-35. 5. Myhre-Jensen 0, Astrup T. Fibrinolytic activity in serosal and synovial membranes. Arch Pathol Lab Med 1969;88:62330. 6. Weibel MA, Majno G. Peritoneal adhesions and their relation to abdominal surgery. Am J Surg 1973;126:345-53.
Discussion Edward T. Peter (Oakland, CA): The problem of adhesive small bowel obstruction can be a major source of anguish for the general surgeons as we all know. Several reports have been presented to this society in recent years. McCarthy has reported good results with the use of the Childs plication, having no recurrent obstructions in 31 patients. Weigelt reported a 9 percent incidence of recurrent obstruction with the use of the Baker tube. Brightwell and his associates from San Antonio, in a comparative but not randomized study, actually found better results with lysis of the adhesions only rather than in combination with tube plication. The authors have reported a period of 3 to 8 months for resolution of the adhesions. I wonder if they have some way of telling how long it is going to take in an individual patient, and if they would speculate on the mechanisms. Is it merely a reduction in the inflammatory process? Dennis Weiland (Scottsdale, AZ): Were any samples of peritoneum taken and was talc peritonitis seen? Do the authors do a gastrostomy to keep the patient’s intestinal tract at rest, thereby avoiding the long-term use of a nasogastric tube? Ronald Elkins (Oklahoma City, OK): Can the authors give us some idea of the actual dollar cost to the patient? Secondly, would you tell us what commercial preparation your patients used? Craig Wilkinson (Salt Lake City, UT): Do your patients manage their own total parenteral nutrition at home or is a visiting nurse necessary? Is the total parenteral nutrition given at night only or throughout the day? Lawrence H. Wilkinson (Albuquerque, NM): Just one comment about the technique of taking down adhesions that are probably not as severe as the ones just described. We have found that the Shaw knife or the so-called hot blade will often save time and blood and will decrease the chances of penetrating the bowel lumen. Robert Selby (closing): Our general administration consists of a 2 liter compounded bag. We have our bags compounded on the outside with a solution that contains 500 g of dextrose and about 85 g of protein plus the additives of electrolytes. We teach the patients in the hospital after their Broviac catheters are placed, how to take care of the cap on the end of the catheter and how to administer heparin and change dressings. We gradually taper them from a strictly 24 hour to a strictly nighttime delivery system where they receive 100 ml of total parenteral nu-
The American Journal of Surgery
Resolution of Adhesive Intestinal Obstruction
trition the first hour and 200 ml every hour thereafter for a total of 10 hours; then back off to 100 ml, and then they cap the system. The cost to the patient is probably around $200 a day which is roughly a third of the total hospital cost for total parenteral nutrition. It is helpful to place a gastrostomy tube in the patients if the stomach is accessible at the time of laparotomy. In fact, most of our patients mainly have partial small bowel obstruction
and would tolerate
Volume 146, December 1963
clamping
of the gastros-
tomy tube or nasogastric tube shortly after placement of the Broviac catheter. We do not have anv histologic evidence of talc peritonitis in any of our patients. Dr. Peter asked how long it takes for the adhesions to resolve in t.he individual patient. That correlates fairly well with the development of collagen adhesions. Collagen is laid down for the first 10 to 30 days aft.er injury, and it takes another 1 to 3 months for the collagen 1o mature and become more compact and easier to dissect.
745
Rick Ft. Selby, MD, Phoenix, Arizona George H. Mertz, MD, FACS, Phoenix, Arizona Robert B. Giisdorf, MD, PhD, FACS, Phoenix, Arizona
Matted, dense, and vascular adhesions of the intestine producing obstruction can create an edematous friable bowel that cannot be freed. Even after extensive dissection the obstruction persists and, if a second operation is performed too soon, the condition becomes even worse. Previously, an extensive resection was performed in many patients and in others, the only recourse was to close the abdomen. In the latter situation, the patient can not eat and must be placed on total parenteral nutrition. Six postoperative patients were referred for home total parenteral nutrition because of such persistent intestinal obstruction. Our original plan was to maintain these patients for a period of time so the surgeon could make another attempt at freeing the small intestine. In the course of 2 to 4 months, however, we were pleasantly surprised to observe spontaneous resolution of the obstruction in four of the six patients. In the two other patients in whom the surgeon had divided the bowel and created a formal stoma, an operation was required to reestablish gastrointestinal continuity. In the latter two patients, we found filmy, nonvascular, easily divisible adhesions and other areas where the bowel was entirely free. This is a report of our observations in these six patients. Material
and Methods
The patients, who ranged in age from 35 to 68 years, began receiving total parenteral nutrition because of persistent intestinal obstruction after at least two attempts at enterolysis. None had malignant disease (Table I), and all had two to eight previous operations. In each patient, From the Department of Surgery, Veterans Administration Medical Center and the Phoenix Nutritional Support Group, Phoenix, Arizona. Requests for reprints should be addressed to Robert B. Gilsdorf, MD, Phoenix Nutritional Support Group, 1010 East McKowell Road, Phoenix, Arizona 85006. Presented at the 35th Annual Meeting of the Southwestern Surgical Congress, Phoenix, Arizona, May 2-5, 1983.
742
the last operation performed was for intestinal obstruction due to adhesions. An average of 2i/z weeks postoperatively, at the time of operation, the surgeon was unable to free the loops of bowel. During the course of the dissection, all patients had at least one enterotomy. In two patients, the bowel was divided and the proximal end brought out of the abdomen as a stoma to bypass the multiple enterotomies in the distal bowel. In the four patients without a formal stoma, enterocutaneous fistulas were present secondary to leakage at one or more of the enterotomy repair sites. At the time the decision was made to begin long-term nutritional support, all patients had nasogastric tubes or gastrostomy tubes in place and on suction. Also, all had clinical and radiologic evidence of complete small bowel obstruction. None of the patients was severely malnourished (Table II). A central venous silicone catheter was inserted for home total parenteral nutrition [I], and the patients were given 2,000 to 2,500 calories per day. Formulas were designed to provide a 15O:I calorie to nitrogen ratio, with 95 percent of the nonprotein calories from glucose. Lipids were given only once a week. The patients received all of the solution during a 10 to 12 hour nocturnal infusion and were ambulatory during the day. They were trained in catheter care, fistula care, and parenteral solution mixing before being discharged from the hospital an average of 10 to 14 days later. Before discharge, the nasogastric and gastrostomy tubes were removed from all of the patients and they were allowed only occasional sips of clear liquid for the first month [2]. The patients were followed frequently as outpatients until their enterocutaneous fistulas closed and signs of obstruction disappeared. One week after obstruction had subsided, as evidenced by passage of flatus, the patients were given a clear liquid diet. The diets were advanced as tolerated over a 2 week period. Two of the patients had upper gastrointestinal series that showed nonobstructed small bowel before they were given oral alimentation. One week after tolerating a solid diet, the central venous catheters were removed. Subsequently, all patients have been observed for the possibility of recurrent obstruction. The two patients with intentional stomas underwent reoperation 6 and 8 months after discharge to reestablish intestinal continuity. Blood loss and technical problems were as-
The American
Journal of Surgery
Resolution
TABLE I
TABLE II
Patient Data Age
Patient
(yr) & Sex
1
53,F
2 3
4 5 6
Cause of Obstruction
Diverticulitis surgery with leak 5 1 ,M Adhesions after cholecystectomy 67,M Bowel perforation after abdominal radiation 68,M Adhesions after aortic graft 65,M Afferent loop leak after gastrectomy 34.M Adhesions from gunshot wound
Fistula Present
Previous Operations
Stoma ileostomy Jejunum to wound Jejunostomy
a
Jejunum to wound Duodenum to drain site Jejunum to drain site
4
4 3
2
Intestinal
Patients With Spontaneous Resolution of Obstruction
Patient
Time Fistula Remained Open (mo)
Time Until Obstruction Opened (mo)
1 2 3 4
2.5 1.5 0.5 1
3 3 3.5 2
4.5 3 3.5 2
1.4
2.9
3.3
Average
Obstruction
Total Parenteral Nutrition Duration Complications (mo) None Catheter infection Catheter infection None
TPN = total parenteral nutrition.
3
sessed and compared with those at previous operations by the operating surgeon. No histologic sections or special studies were carried out. Results The four patients without intentional stomas had spontaneous resolution of their obstructions an average of 2.9 months after the last operation (range 2 to 3.5 months) (Table II). The fistulas closed in all of the patients from 2 to 10 weeks after laparotomy while they were receiving on home total parenteral nutrition. The follow-up period in these four patients ranged from 1 month to 2 years. In that time, only one of the patients had symptoms of partial small bowel obstruction; however, they were mild and did not require reoperation. The two patients who were operated on for stoma closure were found to have adhesions that. were filmy, relatively avascular, and technically easy to dissect. The bowel was neither edematous nor friable and was not entered during enterolysis. On the program of home total parenteral nutrition, there was an average weight gain of 4.5 lb and an average increase in the serum albumin level of 0.5 g/100 ml (Table 111). There were no metabolic complications. All patients ret.urned to relatively normal activity during their time receiving home total parenteral nutrition. One patient returned to work as a mail carrier. Comments The successful management of small bowel obstruction due to adhesions bv long-term narenteral feedings and complete gas;trointestuinal rest, suggests that there is a resolution of adhesions that results in a nonobstructed state. Schade and Williamson [3] found that early adhesions are made up of fibrin. As the fibrin is removed by tissue macrophages, the adhesions become compact, dense bundles of collagen [3,4]. The clearance of the fibrinous adhesions may be accelerated by the presence of local plas-
Volume 146, December 1963
of Adhesive
minogen activators found in substantial concentrations in the serosa [5]. The mature adhesion probably represents a permanent state in which the collagen has the microscopic appearance of long collagen fibers with little or no vascularity or inflammatory cells [6]. It is unclear whether complete gastrointestinal rest contributes to the resolution of adhesions or merely minimizes symptoms while maturation is under way. The operative findings in this series indicated complete resolution of the edema and inflammatory reaction. We theorize that spontaneous resolution of the obstruction is due to the maturation of the adhesions into the long loose collagen fibers and that this process of maturation occurs in the absence of the inflammatory response that normally occurs if a patient with partial or total obstruction is allowed to continue to eat. Based on our admittedly small series, we believe that if enterolysis has been performed because of adhesive intestinal obstruction and the gastrointestinal tract does not open up in the early postoperative period, reoperation is not advised. The frozen abdomen or abdominal cocoon encountered in this early postoperative period represents an immature stage of adhesions. Maturation of the adhesions, we suggest, will result in resolution of the obstruction and gastrointestinal patency within an average of 3 months. Should reoperation be necessary, a waiting period of at least 3 months is recommended. Full maturation is reached about 6 months postoperatively but, because we observed spontaneous resolution of obstruction after 3 months of gastrointestinal rest, we have assumed that reasonable matuTABLE III
Results of Total Parenteral Nutrition
Patient
Calories Per Day
1 2 3 4 5 6
2,000 2,000 2,000 2,000 2,000 2,500
Weight (lb) Beginning End 120 149 139 137 135 236
121 161 148 143 135 235
Albumin (g/dl) Beginning End 3.6 3.2 3.5 3.7 2.8 3.6
3.2 4.6 4.5 4.6 3.3 3.2
743
Selby
et al
ration must have occurred at 3 months. Should reoperation be required, it probably can safely be performed at that time. In the event a surgeon does operate on an obstructed gut and encounters a cemented mass, we believe he should refrain from prolonged bloody disse‘ction with the inevitable enterotomies. Certainly one should not, in frustration, perform an extensive resection. Gastrostomy, if the stomach is readily accessible, should be performed. Enterotomies should be repaired, but the area of the enterotomy should be drained since most will leak. Dividing the bowel and creating a stoma will result in obligatory reoperation with its inherent risk. We found that gastric decompression could be stopped as long as the gastrointestinal tract was maintained at complete rest. All fistulas closed spontaneously despite initial copious drainage of succus entericus, and only rarely were antispasmodic medications necessary for cramps. It appears that once the gastrointestinal tract opens due to maturation of the adhesions it will stay open. None of our patients has had significant obstructive symptoms in the follow-up period. Whether these observations hold for subsequent patients or for the reported group with a longer follow-up period remains to be seen. This experience certainly suggests that it is safer to wait before reoperating for persistent intestinal obstruction. Summary Six patients with intestinal obstruction secondary to benign adhesions so dense and vascular that the operating surgeon could not free them, were placed on a home total parenteral nutrition program. Four patients had enterocutaneous fistulas, and two had their bowels divided and stomas created to divert intestinal contents from distal enterotomies made during the attempt to free the intestine. The enterocutaneous fistulas closed in four patients within 2 weeks to 5 months and the obstructions spontaneously resolved in 2 to 3.5 months. At reoperation on the two patients whose intestinal tracts were purposely divided, the previously matted bowels with dense adhesions were easily freed. We believe complete gastrointestinal rest allows adhesions to mature into long avascular collagen fibers in the absence of a persistant inflammatory reaction that accompanies partial or total small bowel obstruction. We recommend that patients receive 3 months of home total parenteral nutrition before a second operation for persistent obstruction after recent enterolysis should be considered. Spontaneous resolution should occur, but if not, reoperation can be perfoimed safely after the 3 month interval. References 1. Hiekman RO, Buckner CD, Clift RA, et al. A modified right atrial catheter for access to the venous system in marrow transplant recipients. Surg Gynecol Obstet 1979;148:871-5.
744
2. Gilsdorf RB, Rosado IR, Cartmill A. Home total parenteral nutrition: clinical experience and observa%ons. Samaritan Medicine 1983;1:5-12. 3. Schade DS, Williamson MD. The pathogenesis of peritoneal adhesions: an ultrastructural study. Ann Surg 1968;167: 500-10. 4. Ryan GB, Grobety J, Majno G. Postoperative peritoneal adhesions. Am J Pathol 1971;65:117-35. 5. Myhre-Jensen 0, Astrup T. Fibrinolytic activity in serosal and synovial membranes. Arch Pathol Lab Med 1969;88:62330. 6. Weibel MA, Majno G. Peritoneal adhesions and their relation to abdominal surgery. Am J Surg 1973;126:345-53.
Discussion Edward T. Peter (Oakland, CA): The problem of adhesive small bowel obstruction can be a major source of anguish for the general surgeons as we all know. Several reports have been presented to this society in recent years. McCarthy has reported good results with the use of the Childs plication, having no recurrent obstructions in 31 patients. Weigelt reported a 9 percent incidence of recurrent obstruction with the use of the Baker tube. Brightwell and his associates from San Antonio, in a comparative but not randomized study, actually found better results with lysis of the adhesions only rather than in combination with tube plication. The authors have reported a period of 3 to 8 months for resolution of the adhesions. I wonder if they have some way of telling how long it is going to take in an individual patient, and if they would speculate on the mechanisms. Is it merely a reduction in the inflammatory process? Dennis Weiland (Scottsdale, AZ): Were any samples of peritoneum taken and was talc peritonitis seen? Do the authors do a gastrostomy to keep the patient’s intestinal tract at rest, thereby avoiding the long-term use of a nasogastric tube? Ronald Elkins (Oklahoma City, OK): Can the authors give us some idea of the actual dollar cost to the patient? Secondly, would you tell us what commercial preparation your patients used? Craig Wilkinson (Salt Lake City, UT): Do your patients manage their own total parenteral nutrition at home or is a visiting nurse necessary? Is the total parenteral nutrition given at night only or throughout the day? Lawrence H. Wilkinson (Albuquerque, NM): Just one comment about the technique of taking down adhesions that are probably not as severe as the ones just described. We have found that the Shaw knife or the so-called hot blade will often save time and blood and will decrease the chances of penetrating the bowel lumen. Robert Selby (closing): Our general administration consists of a 2 liter compounded bag. We have our bags compounded on the outside with a solution that contains 500 g of dextrose and about 85 g of protein plus the additives of electrolytes. We teach the patients in the hospital after their Broviac catheters are placed, how to take care of the cap on the end of the catheter and how to administer heparin and change dressings. We gradually taper them from a strictly 24 hour to a strictly nighttime delivery system where they receive 100 ml of total parenteral nu-
The American Journal of Surgery
Resolution of Adhesive Intestinal Obstruction
trition the first hour and 200 ml every hour thereafter for a total of 10 hours; then back off to 100 ml, and then they cap the system. The cost to the patient is probably around $200 a day which is roughly a third of the total hospital cost for total parenteral nutrition. It is helpful to place a gastrostomy tube in the patients if the stomach is accessible at the time of laparotomy. In fact, most of our patients mainly have partial small bowel obstruction
and would tolerate
Volume 146, December 1963
clamping
of the gastros-
tomy tube or nasogastric tube shortly after placement of the Broviac catheter. We do not have anv histologic evidence of talc peritonitis in any of our patients. Dr. Peter asked how long it takes for the adhesions to resolve in t.he individual patient. That correlates fairly well with the development of collagen adhesions. Collagen is laid down for the first 10 to 30 days aft.er injury, and it takes another 1 to 3 months for the collagen 1o mature and become more compact and easier to dissect.
745