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The Management of Small Bowel Obstruction
THE MANAGEMENT OF SMALL BOWEL OBSTRUCTION
W. Ross MCCARTY, M.D., F.A.C.S.* INTESTINAL obstruction has always been a major problem on surgical services. Because of the frequency of abdominal wounds during the war and the large number of young men who have recovered from operation and injury, this condition may be seen more often in the future. The approach to the problem should be physiological as well as surgical. Small bowel obstructions can be classified simply as external and internal. These two groups may be further subdivided into those in which the diagnosis has been established early and physiological changes are minimal, and those in which the diagnosis has been delayed and the distention and electrolyte imbalance are marked. External obstructions, are those in which the intra-abdominal contents, usually omentum and small intestine, protrude through congenital or acquired defects of the abdominal wall and become irreducible. Ventral, inguinal and femoral hernias compose most of this group, and as such are easily recognized not only by the physician but by the patient. Internal obstructions, as the term implies, are those obstructions of small bowel occurring within the abdomen secondary to congenital malrotations, defects or bands; adhesions; internal hernias; volvuli; intrinsic lesions of the small intestine, such as benign tumors, neoplasms, gallstones, or other foreign bodies. DIAGNOSIS
,; l I
j
The early diagnosis of external incarcerated hernias can be made readily. In most instances there has been a hernia present for some time, and any change is appreciated by the patient and the physician. A reducible hernia in which obstruction occurs usually becomes irreducible, firm and painful; an irreducible hernia previously soft and asymptomatic may also become firm and painful. Accompanying these local findings there is an increase in the pulse rate, elevation of temperature, abdominal discomfort, anorexia and vomiting. These generalized signs and symptoms increase as the time element increases, until a full-blown picture of acute intestinal obstruction is present. Leukocytosis may be
* Associate Professor of Surgery, New York University College of Medicine; Associate Visiting Surgeon, Third Surgical (New York University) Division, Bellevue Hospital, New York City. 307
308
w.
ROSS MCCARTY
an indication of change in the bowel wall secondary to an embarrassed blood supply. The early diagnosis of internal obstruction involving the small inintestine is more difficult. The inception may occur as the. classical picture: intermittent peristaltic pain increasing in frequency and severity, and associated with vomiting. Many of these patients have previously been subjected to abdominal surgery. These signs and symptoms together with a roentgenogram of the abdomen showing dilated loops of small intestine with or without fluid levels, make an early diagnosis comparatively simple. The possibility of intestinal obstruction must be borne in mind in all cases of ill-defined abdominal pain, whether intermittent or constant, especially where previous abdominal surgery has been performed. Frequently, vague intermittent abdominal pain is disregarded by the patient and misinterpreted by the physician as being of little significance. The presence of bowel sounds or the history of bowel movements should never be taken as an indication that obstruction is not present. The importance of early symptoms may not be realized fully until distention, vomiting or even peritonitis develops. Here again early roentgenographic studies of the abdomen with the patient in prone, upright and lateral decubitus positions is of extreme importance. Dilated loops with fluid levels are diagnostic. Severe abdominal pain and shock frequently accompany the onset of a sudden volvulus or internal herniation. Many of these patients are explored for an undiagnosed acute abdominal catastrophe and only at operation is the true cause ascertained. However, some patients following the onset of severe abdominal pain are comparatively free of symptoms and physical signs later when admitted to the hospital. If the patient is placed under surgical observation, and the cause of the abdominal pain was due to a volvulus or internal herniation, the true nature of the syndrome would not be appreciated until the abdominal pain had recurred or distention and vomiting appeared. A flat x-ray film of the abdomen of these patients taken soon after admission usually reveals a hairpin or horseshoe type dilatation of a closed loop of obstructed intestine. Check films will show this dilated loop to be consistently present but occasionally shifting to various parts of the abdominal cavity. These findings are indicative of a closed loop obstruction secondary to a volvulus or internal herniation (Fig. 144 and 145). The diagnosis of late intestinal obstruction can be readily made. The clinical picture of marked distention, vomiting and dehydration is well known. The x-ray studies of the abdomen reveal the typical distended loops of small intestine with multiple fluid levels (Fig. 146). Paralytic ileus secondary to surgical manipulation, or reflex, usually shows on x-ray a uniform distention of both small and large bowel.
Fig. 144 Fig. 145 Figs. 144 and 145.-Illustrating a closed loop obstruction due to volvulus. This gasfilled loop shifted about the abdominal cavity, but its general configuration remained the same. Similar closed loops due to internal hernia are more likely to remain in a fixed position.
Fig. 146.-Illustrating multiple fluid levels in distended loops of small bowel. This is a late state of the process. The patient was not seen until four days after the onset of intestinal obstruction. 309
310
W. ROSS MCCARTY
EARLY INTESTINAL OBSTRUCTION
The management of early and late intestinal obstruction will be described separately. There is general agreement that patients with early intestinal obstruction admitted to the hospital free of distention and in electrolyte balance should be operated upon immediately. It seems logical that an indwelling intestinal tube should be passed on all patients, whether early or late. Many early cases with histories of recurrent attacks of intestinal obstruction have been relieved previously by intubation; patients presenting the possibilities of multiple adhesions, or those in whom there is partial obstruction aggravated by torsion or angulation may be completely relieved by means of the tube. Surgery can be avoided in many of these cases. The frequently reported difficulty in passing the intestinal tube often arises from the relegation of this important task to an inexperienced or untrained individual. Most of the failures can be corrected by having trained personnel manage the initial and subsequent course of intubation. It is not sufficient merely to pass the tube successfully and then expect the tube together with suction apparatus to overcome all obstructions by some magic formula. In properly managed cases distention and excessive intestinal contents of the small intestine proximal to the blockage will be relieved, and normal intestinal tone and peristalsis restored. The progress of the tube and relative position of the tip must be followed closely by repeated prone or upright x-ray studies taken every six to eight hours. In certain cases the tip will be observed to be approximately in the same position on succeeding x-ray plates with an increasing length of tube in the intestines. These findings represent the stoppage of the tube at the point of obstruction and with the feeding of the tube into the nostril of the patient an increasing length whips back and forth in the intestines (Figs. 147 and 148). The term "whipping of the tube" has been coined for this condition. Failure to note this fact in the earlier studies of intestinal obstruction has resulted in unnecessary delay in surgical intervention. This danger signal should not be overlooked. Confirmation of complete or almost complete block can be obtained by the introduction, without pressure, of a small amount of dilute solution of barium into the aspirating side of the intestinal tube. If a block is present the barium will be observed on the fluoroscopic screen to strike the impasse and flow upward along the tube (Fig. 149). Lack of gaseous distention beyond this point is taken as an indication of a simple mechanical block. Fluoroscopic or x-ray evidence of a distended hairpin loop, or a distended long loop beyond the stoppage of
MANAGEMENT OF SMALL BOWEL OBSTRUCTION
311
Fig. 147 Fig. 148 Figs. 147 and 148.-Illustrating "whipping of the tube." In .Figure 147, the end of the tube has reached the site of obstruction. In Figure 148 the position of the end of the tube is unchanged but further tubing fed through the nose has coiled or "whipped" in the small intestine.
Fig. 149.-Illustrating the localization of the obstructed site, in this case a large gallstone, by the instillation of thin barium mixture into the intestinal tube.
312
w.
ROSS MCCARTY
barium, is indicative of a closed loop type of obstruction. Armed with these facts the surgeon knows exactly what type and where the obstruction is located. In the first type the release of a simple mechanical block will usually relieve the obstruction and in the second type surgery is facilitated by the fact that the intestine above and below the obstructed loop is collapsed, and collapse of the obstructed loop can be readily managed at operation by the use of an aspirating syringe or suction catheter. To repeat, early cases, in the absence of distention and electrolyte imbalance, are best operated upon soon. When patients are managed by the intubation method, supportive treatment must be adequately supervised. LATE INTESTINAL OBSTRUCTION
When one is confronted with the problem of management of a patient in the late stages oi,obstruction, the philosophy of immediate surgical intervention does not apply. The mortality following immediate operation in this group is prohibitive, not because of the obstruction per se, but because of the superimposed derangement in fluid and electrolytes which at this point is the most lethal factor. This deduction was the result of several observations: 1. The hopeless task of a surgeon trying to battle a mass of distended coils of small intestine in an attempt to relieve obstruction or close the abdomen. ~. The successful management by the intubation method of a large number of acute small bowel obstructions in soldiers with severe abdominal wounds where further surgery at the time would have resulted in increased mortality rate. 3. A ten year survey was made of the cases of intestinal obstruction admitted to the Third Surgical (New York University) Division of Bellevue Hospital, New York, between the years of 1935 and 1946. In this series of small bowel obstruction from all causes there were: 147 cases .......... 54 deaths .......... mortality of 36.7 per cent
A six year breakdown showed that from 1935 to 1940 there were: 65 cases .......... 29 deaths .......... mortality of 44.6 per cent
From 1941 to 1946 there were: 82 cases .......... 25 deaths .......... mortality of 30.4 per cent
Further analysis of those admitted seventy-two hours or more from onset of symptoms showed the following:
313
MANAGEMENT OF SMALL BOWEL OBSTRUCTION
From 1935 to 1940 there were: 25 cases .... 62 operated upon .... 15 deaths .... mortality 60 per cent
From 1940 to 1945 there were: 35 cases .... 33 operated upon .... 18 deaths .... mortality 51.4 per cent
Therefore in this latter group there were: 60 cases .... 55 operations ........ 33 deaths .... mortality 55 per cent
-
CL. HeT. P.P.
Qf..
zzzz:
1
120 45 9.2 110 43 8.4 100 41
7.6
90 39 6.8 80 37 6.0 70 35
5.2~
______________
~
__
~~_
27 28 29 30 1 2 3 4 5 6 7 8 9 10 11 Fig. 1.50.-Graph illustrating relative values of blood chlorides, hematocrit and plasma proteins when first seen and on subsequent days of preparation for operation.
These observations and study caused a change in the policy of handling cases seen late in the course of intestinal obstruction on the Third Surgical (New York University) Division, Bellevue Hospital. Since 1946 an organized system was instituted to insure when possible that all patients with late intestinal obstruction be relieved of distention, and that fluid and electrolytes be brought into balance prior to operation. A mimeographed copy of detailed instructions in the management of . such cases was issued to each member of the resident staff. From 1946 to 1947 there have been seventeen cases of late small bowel obstruction coming to surgical care seventy-two hours or more after onset. In this series there were thirteen operations with four operative deaths. There was also one non operative death in a patient admitted iu extremis.
314
W. ROSS MCCARTY
The relief of distention and the adequate correction of fluid and electrolyte balance required a prolonged preoperative period in most of these cases. Herewith is an abstract of the history of one of the fatal cases: An 85 year old woman was admitted with signs and symptoms of acute intestinal obstruction preceded by right upper quadrant pain. X-rays revealed gallstones lying within the abdominal cavity which on subsequent examinations were shown to be within the intestinal tract. The management was complicated by irrationality, incontinence, and the fact that the Miller-Abbott tube was removed by the patient on three different occasions in the early stages of treatment. Finally the patient was decompressed, electrolyte balance was attained and the site of obstruction was localized (Fig. 150), At operation, the stone was located easily and removed by a simple longitudinal incision in the terminal ileum. The proximal intestine was only slightly edematous showing that decompression had been adequate. There was no evidence of embarrassed blood supply. The patient was out of bed on the second postoperative day. Signs of cerebral vascular accident developed and death occurred four days postoperatively. This death was due to complications of the obstruction, the operation, and the patient's general condition. The obstruction itself was relieved. SUMMARY
The number of cases of late (seventy-two hours or more) small bowel obstruction treated in this manner are too few to compare with the larger series in which operative procedures were performed before the distention was relieved or fluid and electrolyte imbalance corrected. But it would appear even in this small series of seventeen cases that careful preoperative preparation has lowered the mortality rate in this distressing condition. 1. The classification of external and internal obstruction of small intestine has been outlined. ~. The management of early and late cases of intestinal obstruction has been reviewed. 3. The importance of x-ray observation of the progress of the tube and localization of the obstructive site has been emphasized. 4. Attention has been drawn to the early diagnosis of acute volvulus and internal herniation. 5. A statistical study of the cases of small bowel obstruction admitted to the Third Surgical (New York University) Division, Bellevue Hospital, with the mortality rate is analyzed. 6. The advisability of early operation in acute intestinal obstruction when the patient is free of distention and in electrolyte balance is affirmed.
MANAGEMENT OF SMALL BOWEL OBSTRUCTION
315
7. The high mortality rate in patients admitted seventy-two hours or more after the onset of obstructed symptoms is noted. 8. The importance of restoration of electrolyte balance and relief from distention prior to surgical interference in late cases of intestinal obstruction is discussed. REFERENCES 1. Abbott, W. O. and Johnston, C. G.: Intubation Studies of the Human Intestine. Surg.
Gynec. & Obst. 66: 691, 1938. 2. Wangensteen, O. H.: Intestinal Obstruction. Charles C. Thomas, Springfield, Illinois, 1942. 3. Hunt, Claude J.: Early Diagnosis and Management of Small Intestinal Obstruction. Surgery 19: 237-250, 1946. 4. Eliason, E. L. and Welty, Robert F.: A Ten Year Survey of Intestinal Obstruction. Ann. Surg. 1125: 57-65, 1947. 5. Foisie, Philip S.: Intestinal Obstruction Following Abdominal Battle Wounds. New England J. Med. 1234: 498-500, 1946. 6. McCarty, W. Ross, Mulholland, John H. and Sze, Kenneth C.: The Problem of Late Small Bowel Obstruction. Abst. Bull. American College of Surgeons 312 (3) Sept. 1947.
W. Ross MCCARTY, M.D., F.A.C.S.* INTESTINAL obstruction has always been a major problem on surgical services. Because of the frequency of abdominal wounds during the war and the large number of young men who have recovered from operation and injury, this condition may be seen more often in the future. The approach to the problem should be physiological as well as surgical. Small bowel obstructions can be classified simply as external and internal. These two groups may be further subdivided into those in which the diagnosis has been established early and physiological changes are minimal, and those in which the diagnosis has been delayed and the distention and electrolyte imbalance are marked. External obstructions, are those in which the intra-abdominal contents, usually omentum and small intestine, protrude through congenital or acquired defects of the abdominal wall and become irreducible. Ventral, inguinal and femoral hernias compose most of this group, and as such are easily recognized not only by the physician but by the patient. Internal obstructions, as the term implies, are those obstructions of small bowel occurring within the abdomen secondary to congenital malrotations, defects or bands; adhesions; internal hernias; volvuli; intrinsic lesions of the small intestine, such as benign tumors, neoplasms, gallstones, or other foreign bodies. DIAGNOSIS
,; l I
j
The early diagnosis of external incarcerated hernias can be made readily. In most instances there has been a hernia present for some time, and any change is appreciated by the patient and the physician. A reducible hernia in which obstruction occurs usually becomes irreducible, firm and painful; an irreducible hernia previously soft and asymptomatic may also become firm and painful. Accompanying these local findings there is an increase in the pulse rate, elevation of temperature, abdominal discomfort, anorexia and vomiting. These generalized signs and symptoms increase as the time element increases, until a full-blown picture of acute intestinal obstruction is present. Leukocytosis may be
* Associate Professor of Surgery, New York University College of Medicine; Associate Visiting Surgeon, Third Surgical (New York University) Division, Bellevue Hospital, New York City. 307
308
w.
ROSS MCCARTY
an indication of change in the bowel wall secondary to an embarrassed blood supply. The early diagnosis of internal obstruction involving the small inintestine is more difficult. The inception may occur as the. classical picture: intermittent peristaltic pain increasing in frequency and severity, and associated with vomiting. Many of these patients have previously been subjected to abdominal surgery. These signs and symptoms together with a roentgenogram of the abdomen showing dilated loops of small intestine with or without fluid levels, make an early diagnosis comparatively simple. The possibility of intestinal obstruction must be borne in mind in all cases of ill-defined abdominal pain, whether intermittent or constant, especially where previous abdominal surgery has been performed. Frequently, vague intermittent abdominal pain is disregarded by the patient and misinterpreted by the physician as being of little significance. The presence of bowel sounds or the history of bowel movements should never be taken as an indication that obstruction is not present. The importance of early symptoms may not be realized fully until distention, vomiting or even peritonitis develops. Here again early roentgenographic studies of the abdomen with the patient in prone, upright and lateral decubitus positions is of extreme importance. Dilated loops with fluid levels are diagnostic. Severe abdominal pain and shock frequently accompany the onset of a sudden volvulus or internal herniation. Many of these patients are explored for an undiagnosed acute abdominal catastrophe and only at operation is the true cause ascertained. However, some patients following the onset of severe abdominal pain are comparatively free of symptoms and physical signs later when admitted to the hospital. If the patient is placed under surgical observation, and the cause of the abdominal pain was due to a volvulus or internal herniation, the true nature of the syndrome would not be appreciated until the abdominal pain had recurred or distention and vomiting appeared. A flat x-ray film of the abdomen of these patients taken soon after admission usually reveals a hairpin or horseshoe type dilatation of a closed loop of obstructed intestine. Check films will show this dilated loop to be consistently present but occasionally shifting to various parts of the abdominal cavity. These findings are indicative of a closed loop obstruction secondary to a volvulus or internal herniation (Fig. 144 and 145). The diagnosis of late intestinal obstruction can be readily made. The clinical picture of marked distention, vomiting and dehydration is well known. The x-ray studies of the abdomen reveal the typical distended loops of small intestine with multiple fluid levels (Fig. 146). Paralytic ileus secondary to surgical manipulation, or reflex, usually shows on x-ray a uniform distention of both small and large bowel.
Fig. 144 Fig. 145 Figs. 144 and 145.-Illustrating a closed loop obstruction due to volvulus. This gasfilled loop shifted about the abdominal cavity, but its general configuration remained the same. Similar closed loops due to internal hernia are more likely to remain in a fixed position.
Fig. 146.-Illustrating multiple fluid levels in distended loops of small bowel. This is a late state of the process. The patient was not seen until four days after the onset of intestinal obstruction. 309
310
W. ROSS MCCARTY
EARLY INTESTINAL OBSTRUCTION
The management of early and late intestinal obstruction will be described separately. There is general agreement that patients with early intestinal obstruction admitted to the hospital free of distention and in electrolyte balance should be operated upon immediately. It seems logical that an indwelling intestinal tube should be passed on all patients, whether early or late. Many early cases with histories of recurrent attacks of intestinal obstruction have been relieved previously by intubation; patients presenting the possibilities of multiple adhesions, or those in whom there is partial obstruction aggravated by torsion or angulation may be completely relieved by means of the tube. Surgery can be avoided in many of these cases. The frequently reported difficulty in passing the intestinal tube often arises from the relegation of this important task to an inexperienced or untrained individual. Most of the failures can be corrected by having trained personnel manage the initial and subsequent course of intubation. It is not sufficient merely to pass the tube successfully and then expect the tube together with suction apparatus to overcome all obstructions by some magic formula. In properly managed cases distention and excessive intestinal contents of the small intestine proximal to the blockage will be relieved, and normal intestinal tone and peristalsis restored. The progress of the tube and relative position of the tip must be followed closely by repeated prone or upright x-ray studies taken every six to eight hours. In certain cases the tip will be observed to be approximately in the same position on succeeding x-ray plates with an increasing length of tube in the intestines. These findings represent the stoppage of the tube at the point of obstruction and with the feeding of the tube into the nostril of the patient an increasing length whips back and forth in the intestines (Figs. 147 and 148). The term "whipping of the tube" has been coined for this condition. Failure to note this fact in the earlier studies of intestinal obstruction has resulted in unnecessary delay in surgical intervention. This danger signal should not be overlooked. Confirmation of complete or almost complete block can be obtained by the introduction, without pressure, of a small amount of dilute solution of barium into the aspirating side of the intestinal tube. If a block is present the barium will be observed on the fluoroscopic screen to strike the impasse and flow upward along the tube (Fig. 149). Lack of gaseous distention beyond this point is taken as an indication of a simple mechanical block. Fluoroscopic or x-ray evidence of a distended hairpin loop, or a distended long loop beyond the stoppage of
MANAGEMENT OF SMALL BOWEL OBSTRUCTION
311
Fig. 147 Fig. 148 Figs. 147 and 148.-Illustrating "whipping of the tube." In .Figure 147, the end of the tube has reached the site of obstruction. In Figure 148 the position of the end of the tube is unchanged but further tubing fed through the nose has coiled or "whipped" in the small intestine.
Fig. 149.-Illustrating the localization of the obstructed site, in this case a large gallstone, by the instillation of thin barium mixture into the intestinal tube.
312
w.
ROSS MCCARTY
barium, is indicative of a closed loop type of obstruction. Armed with these facts the surgeon knows exactly what type and where the obstruction is located. In the first type the release of a simple mechanical block will usually relieve the obstruction and in the second type surgery is facilitated by the fact that the intestine above and below the obstructed loop is collapsed, and collapse of the obstructed loop can be readily managed at operation by the use of an aspirating syringe or suction catheter. To repeat, early cases, in the absence of distention and electrolyte imbalance, are best operated upon soon. When patients are managed by the intubation method, supportive treatment must be adequately supervised. LATE INTESTINAL OBSTRUCTION
When one is confronted with the problem of management of a patient in the late stages oi,obstruction, the philosophy of immediate surgical intervention does not apply. The mortality following immediate operation in this group is prohibitive, not because of the obstruction per se, but because of the superimposed derangement in fluid and electrolytes which at this point is the most lethal factor. This deduction was the result of several observations: 1. The hopeless task of a surgeon trying to battle a mass of distended coils of small intestine in an attempt to relieve obstruction or close the abdomen. ~. The successful management by the intubation method of a large number of acute small bowel obstructions in soldiers with severe abdominal wounds where further surgery at the time would have resulted in increased mortality rate. 3. A ten year survey was made of the cases of intestinal obstruction admitted to the Third Surgical (New York University) Division of Bellevue Hospital, New York, between the years of 1935 and 1946. In this series of small bowel obstruction from all causes there were: 147 cases .......... 54 deaths .......... mortality of 36.7 per cent
A six year breakdown showed that from 1935 to 1940 there were: 65 cases .......... 29 deaths .......... mortality of 44.6 per cent
From 1941 to 1946 there were: 82 cases .......... 25 deaths .......... mortality of 30.4 per cent
Further analysis of those admitted seventy-two hours or more from onset of symptoms showed the following:
313
MANAGEMENT OF SMALL BOWEL OBSTRUCTION
From 1935 to 1940 there were: 25 cases .... 62 operated upon .... 15 deaths .... mortality 60 per cent
From 1940 to 1945 there were: 35 cases .... 33 operated upon .... 18 deaths .... mortality 51.4 per cent
Therefore in this latter group there were: 60 cases .... 55 operations ........ 33 deaths .... mortality 55 per cent
-
CL. HeT. P.P.
Qf..
zzzz:
1
120 45 9.2 110 43 8.4 100 41
7.6
90 39 6.8 80 37 6.0 70 35
5.2~
______________
~
__
~~_
27 28 29 30 1 2 3 4 5 6 7 8 9 10 11 Fig. 1.50.-Graph illustrating relative values of blood chlorides, hematocrit and plasma proteins when first seen and on subsequent days of preparation for operation.
These observations and study caused a change in the policy of handling cases seen late in the course of intestinal obstruction on the Third Surgical (New York University) Division, Bellevue Hospital. Since 1946 an organized system was instituted to insure when possible that all patients with late intestinal obstruction be relieved of distention, and that fluid and electrolytes be brought into balance prior to operation. A mimeographed copy of detailed instructions in the management of . such cases was issued to each member of the resident staff. From 1946 to 1947 there have been seventeen cases of late small bowel obstruction coming to surgical care seventy-two hours or more after onset. In this series there were thirteen operations with four operative deaths. There was also one non operative death in a patient admitted iu extremis.
314
W. ROSS MCCARTY
The relief of distention and the adequate correction of fluid and electrolyte balance required a prolonged preoperative period in most of these cases. Herewith is an abstract of the history of one of the fatal cases: An 85 year old woman was admitted with signs and symptoms of acute intestinal obstruction preceded by right upper quadrant pain. X-rays revealed gallstones lying within the abdominal cavity which on subsequent examinations were shown to be within the intestinal tract. The management was complicated by irrationality, incontinence, and the fact that the Miller-Abbott tube was removed by the patient on three different occasions in the early stages of treatment. Finally the patient was decompressed, electrolyte balance was attained and the site of obstruction was localized (Fig. 150), At operation, the stone was located easily and removed by a simple longitudinal incision in the terminal ileum. The proximal intestine was only slightly edematous showing that decompression had been adequate. There was no evidence of embarrassed blood supply. The patient was out of bed on the second postoperative day. Signs of cerebral vascular accident developed and death occurred four days postoperatively. This death was due to complications of the obstruction, the operation, and the patient's general condition. The obstruction itself was relieved. SUMMARY
The number of cases of late (seventy-two hours or more) small bowel obstruction treated in this manner are too few to compare with the larger series in which operative procedures were performed before the distention was relieved or fluid and electrolyte imbalance corrected. But it would appear even in this small series of seventeen cases that careful preoperative preparation has lowered the mortality rate in this distressing condition. 1. The classification of external and internal obstruction of small intestine has been outlined. ~. The management of early and late cases of intestinal obstruction has been reviewed. 3. The importance of x-ray observation of the progress of the tube and localization of the obstructive site has been emphasized. 4. Attention has been drawn to the early diagnosis of acute volvulus and internal herniation. 5. A statistical study of the cases of small bowel obstruction admitted to the Third Surgical (New York University) Division, Bellevue Hospital, with the mortality rate is analyzed. 6. The advisability of early operation in acute intestinal obstruction when the patient is free of distention and in electrolyte balance is affirmed.
MANAGEMENT OF SMALL BOWEL OBSTRUCTION
315
7. The high mortality rate in patients admitted seventy-two hours or more after the onset of obstructed symptoms is noted. 8. The importance of restoration of electrolyte balance and relief from distention prior to surgical interference in late cases of intestinal obstruction is discussed. REFERENCES 1. Abbott, W. O. and Johnston, C. G.: Intubation Studies of the Human Intestine. Surg.
Gynec. & Obst. 66: 691, 1938. 2. Wangensteen, O. H.: Intestinal Obstruction. Charles C. Thomas, Springfield, Illinois, 1942. 3. Hunt, Claude J.: Early Diagnosis and Management of Small Intestinal Obstruction. Surgery 19: 237-250, 1946. 4. Eliason, E. L. and Welty, Robert F.: A Ten Year Survey of Intestinal Obstruction. Ann. Surg. 1125: 57-65, 1947. 5. Foisie, Philip S.: Intestinal Obstruction Following Abdominal Battle Wounds. New England J. Med. 1234: 498-500, 1946. 6. McCarty, W. Ross, Mulholland, John H. and Sze, Kenneth C.: The Problem of Late Small Bowel Obstruction. Abst. Bull. American College of Surgeons 312 (3) Sept. 1947.