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Treatment of small bowel obstruction by jejunal enterolith
surgery Volume 122, Number 5
Letters to the editors
may be ultimately used in this technique to achieve the same whole bowel cleansing effect. It was the intent of this small case report to simply flush out the intestinal contents until which time a clear effluent was seen indicating that most of the intestinal contents were cleared. The determination of whether this can be achieved at a lower infusion rate will require more patients and most likely an extended period of time. We wish to point out that as indicated in the packet insert for polyethylene glycol, this solution is meant to be taken at high infusion rates to create an osmotic effect. Low infusion rates of this agent will most likely not produce the same flushing effect as a high infusion rate. Furthermore, it should be recognized that much higher infusion rates for polyethylene glycol have been used to treat drug overdoses in comatose patients. These infusion rates have been in excess of 500 ml/hr. Drs. Powell and Siriwardena are correct in pointing out that if hypomotility is a significant clinical problem at the time of contemplation of whole gut washout, this technique may not be feasible. They point out that a dedicated nursing team, repeat x-ray films, and perhaps ultrasonographic techniques are important to accurately assess intestinal debilitation. We agree that this is important and have not encountered any difficulty in obtaining or interpreting plain films of the abdomen in these patients. We are not concerned about colonoscopic decompression of patients who are immobile and ventilated. It is our experience that with a skilled colonoscopist this can be performed safely and effectively. Regarding the possibility that the change in temperature was due to the cooling effect of the large infusion, this seems unlikely given that the five patients studied remained afebrile many hours after the infusion. The polyethylene glycol was mixed with microwaved sterile water that had a temperature of 37” C; therefore it is unlikely that the solution itself led to the fall in temperature. Finally, Drs. Powell and Siriwardena point out that large-scale clinical trials are necessary before the safety and efficacy of this technique are adopted. As was mentioned numerous times in the article, we agree and to that end are involved in a prospective trial to evaluate this technique. John Alverdy, MD Associate Professor of Surgery Giancarlo Piano, MD University of Chicago 5841 S. Maryland Ave. MC 6090 Chicago, IL 60637 11/59/85784
Treatment enterolith
of small
bowel
obstruction
by jejunal
To the Editors: Phelan et al.’ presented a case of acute small bowel obstruction from an enterolith that they inferred was
977
being formed within a jejunal diverticulum and subsequently extruded into the small bowel, thus producing a bezoarlike mechanical obstruction. True enteroliths are rare and are of two main types: choleic acid, containing stones (radiolucent) usually formed in the upper small intestine in association with duodenal or jejunal diverticula; and calcium, containing stones (radiopaque) that are more often formed in the lower small bowel or colon. True or primary enteroliths warrant the title only when the “stone” has been thoroughly analyzed for its chemical and biochemical contents.* Although an enterolith is known to form within a diverticulum, a food bolus/bezoar (false enterolith2) can produce a similar clinical presentation of small bowel obstruction. Classically, patients who have had previous gastric surgery and those who are edentulous are predisposed to food bolus small bowel obstruction.3,4 However, Swift et a1.j reported that those with an intact gastrointestinal tract (GIT) were not immune and accounted for 0.3% to 4.0% of small bowel obstructions. In our series of 31 patients with food bolus/bezoar small bowel obstruction during a period of 6 years, 13 (42%) had an intact GIT with no previous history of gastric or abdominal surgery. The median age of these patients was 67 years (range, 48 to 89 years). It is important that a thorough search along the whole GIT for synchronous bezoar/enterolith is performed at the time of laparotomy; otherwise, missed bezoar/enterolith leading to recurrent obstruction can occur.6 Synchronous food bolus was found in five (16%) of our 31 patients. Several authors have suggested enterotomy as the surgical treatment of enterolith.2,7,s We, like Davies and Lewis,3 would recommend a trial of milking and fragmentation before resorting to an enterotomy. Milking the enterolith/bezoar into the cecum is not possible in all cases, but in our experience the chances of success are highest when the enterolith/bezoar is lodged within the ileum. Milking was successful in 50% of all our cases. C. K. Leow, MD, FRCS W Y Lau, .MD, FRCS The Chinese University ofHong Kong Department of Surgery Prince of Wales Hospital Shatin, New Twritories Hong Kong
References 1. Phelan M, Kaufman H, Becker J, Fitzpatrick G. Small bowel obstruction by jejunal enterolith. Surgery 1997;121:229-30. 2.Bewes PC, Haslewood GAD, Roxburgh RA. Bile-acid enteroliths and jejunal diverticulosis. Br J Surg 1966;53:709-11. 3. Davies DGL, Lewis RH. Food obstruction of the small intestine. Br Med J 1959;26:545-8. 4. Hayes GP, Ori 0. Gastrointestinal phytobezoars: presentation and management. Can J Surg 1986;29:41920.
978
Letters to the editor5
5.Swift RI, obstruction trointestinal 9. 6.Chisholm Phytobezoar: obstruction.
surgmy November 1997
Wood CB, Hershman due to phytobezoars tract. J R Co11 Surg
HJ. Small bowel in the intact gasEdinb 1989;34:267-
EM,
Leong HT, Chung SC, Li AK. an uncommon cause of small bowel Ann R Co11 Surg 1992;74:342-4.
7. Palder SP, Frey CB. Jejunal diverticulosis. Arch Surg 1988;123:889-94. 8. Lopez PV, Welch JP. Enterolith intestinal obstruction owing to acquired and congenital diverticulosis. Dis Colon Rectum 1991;34:941-4. 11/59/85716
CORRECTION In the article “In Vivo Depletion of Host CD4’ and CD@ Cells Permits Engraftment of Bone Marrow Stem Cells and Tolerance Induction with Minimal Conditioning” (Exner BG, Colson YL, Li H, Ildstad ST. Surgery 1997;122:221-7) the incorrect illustration for Fig. 1 on page 222 was published. The correct illustration for that figure is shown below. UNMANIPULATED
ANTIBODY PRB-TREATED
P 4 e
Fig. 1. To con!rirm adequacy of anti-CD4 and anti-CD8 pretreatment, PBLs were obtained from animals on day 3 after antibody pretreatment (day 0 for bone marrow transplantation) and stained with phycoerythrin-conjugated anti-CD4 and anti-CD8 antibodies. Percentage of CD4 (A, B) and CD8 (C, D) cells is shown for unmanipulated control (A, C) and representative depleted (B, D) animals. Percentages listed are cells staining positive of all cells in analyzed region (lymphoid gate).
Letters to the editors
may be ultimately used in this technique to achieve the same whole bowel cleansing effect. It was the intent of this small case report to simply flush out the intestinal contents until which time a clear effluent was seen indicating that most of the intestinal contents were cleared. The determination of whether this can be achieved at a lower infusion rate will require more patients and most likely an extended period of time. We wish to point out that as indicated in the packet insert for polyethylene glycol, this solution is meant to be taken at high infusion rates to create an osmotic effect. Low infusion rates of this agent will most likely not produce the same flushing effect as a high infusion rate. Furthermore, it should be recognized that much higher infusion rates for polyethylene glycol have been used to treat drug overdoses in comatose patients. These infusion rates have been in excess of 500 ml/hr. Drs. Powell and Siriwardena are correct in pointing out that if hypomotility is a significant clinical problem at the time of contemplation of whole gut washout, this technique may not be feasible. They point out that a dedicated nursing team, repeat x-ray films, and perhaps ultrasonographic techniques are important to accurately assess intestinal debilitation. We agree that this is important and have not encountered any difficulty in obtaining or interpreting plain films of the abdomen in these patients. We are not concerned about colonoscopic decompression of patients who are immobile and ventilated. It is our experience that with a skilled colonoscopist this can be performed safely and effectively. Regarding the possibility that the change in temperature was due to the cooling effect of the large infusion, this seems unlikely given that the five patients studied remained afebrile many hours after the infusion. The polyethylene glycol was mixed with microwaved sterile water that had a temperature of 37” C; therefore it is unlikely that the solution itself led to the fall in temperature. Finally, Drs. Powell and Siriwardena point out that large-scale clinical trials are necessary before the safety and efficacy of this technique are adopted. As was mentioned numerous times in the article, we agree and to that end are involved in a prospective trial to evaluate this technique. John Alverdy, MD Associate Professor of Surgery Giancarlo Piano, MD University of Chicago 5841 S. Maryland Ave. MC 6090 Chicago, IL 60637 11/59/85784
Treatment enterolith
of small
bowel
obstruction
by jejunal
To the Editors: Phelan et al.’ presented a case of acute small bowel obstruction from an enterolith that they inferred was
977
being formed within a jejunal diverticulum and subsequently extruded into the small bowel, thus producing a bezoarlike mechanical obstruction. True enteroliths are rare and are of two main types: choleic acid, containing stones (radiolucent) usually formed in the upper small intestine in association with duodenal or jejunal diverticula; and calcium, containing stones (radiopaque) that are more often formed in the lower small bowel or colon. True or primary enteroliths warrant the title only when the “stone” has been thoroughly analyzed for its chemical and biochemical contents.* Although an enterolith is known to form within a diverticulum, a food bolus/bezoar (false enterolith2) can produce a similar clinical presentation of small bowel obstruction. Classically, patients who have had previous gastric surgery and those who are edentulous are predisposed to food bolus small bowel obstruction.3,4 However, Swift et a1.j reported that those with an intact gastrointestinal tract (GIT) were not immune and accounted for 0.3% to 4.0% of small bowel obstructions. In our series of 31 patients with food bolus/bezoar small bowel obstruction during a period of 6 years, 13 (42%) had an intact GIT with no previous history of gastric or abdominal surgery. The median age of these patients was 67 years (range, 48 to 89 years). It is important that a thorough search along the whole GIT for synchronous bezoar/enterolith is performed at the time of laparotomy; otherwise, missed bezoar/enterolith leading to recurrent obstruction can occur.6 Synchronous food bolus was found in five (16%) of our 31 patients. Several authors have suggested enterotomy as the surgical treatment of enterolith.2,7,s We, like Davies and Lewis,3 would recommend a trial of milking and fragmentation before resorting to an enterotomy. Milking the enterolith/bezoar into the cecum is not possible in all cases, but in our experience the chances of success are highest when the enterolith/bezoar is lodged within the ileum. Milking was successful in 50% of all our cases. C. K. Leow, MD, FRCS W Y Lau, .MD, FRCS The Chinese University ofHong Kong Department of Surgery Prince of Wales Hospital Shatin, New Twritories Hong Kong
References 1. Phelan M, Kaufman H, Becker J, Fitzpatrick G. Small bowel obstruction by jejunal enterolith. Surgery 1997;121:229-30. 2.Bewes PC, Haslewood GAD, Roxburgh RA. Bile-acid enteroliths and jejunal diverticulosis. Br J Surg 1966;53:709-11. 3. Davies DGL, Lewis RH. Food obstruction of the small intestine. Br Med J 1959;26:545-8. 4. Hayes GP, Ori 0. Gastrointestinal phytobezoars: presentation and management. Can J Surg 1986;29:41920.
978
Letters to the editor5
5.Swift RI, obstruction trointestinal 9. 6.Chisholm Phytobezoar: obstruction.
surgmy November 1997
Wood CB, Hershman due to phytobezoars tract. J R Co11 Surg
HJ. Small bowel in the intact gasEdinb 1989;34:267-
EM,
Leong HT, Chung SC, Li AK. an uncommon cause of small bowel Ann R Co11 Surg 1992;74:342-4.
7. Palder SP, Frey CB. Jejunal diverticulosis. Arch Surg 1988;123:889-94. 8. Lopez PV, Welch JP. Enterolith intestinal obstruction owing to acquired and congenital diverticulosis. Dis Colon Rectum 1991;34:941-4. 11/59/85716
CORRECTION In the article “In Vivo Depletion of Host CD4’ and CD@ Cells Permits Engraftment of Bone Marrow Stem Cells and Tolerance Induction with Minimal Conditioning” (Exner BG, Colson YL, Li H, Ildstad ST. Surgery 1997;122:221-7) the incorrect illustration for Fig. 1 on page 222 was published. The correct illustration for that figure is shown below. UNMANIPULATED
ANTIBODY PRB-TREATED
P 4 e
Fig. 1. To con!rirm adequacy of anti-CD4 and anti-CD8 pretreatment, PBLs were obtained from animals on day 3 after antibody pretreatment (day 0 for bone marrow transplantation) and stained with phycoerythrin-conjugated anti-CD4 and anti-CD8 antibodies. Percentage of CD4 (A, B) and CD8 (C, D) cells is shown for unmanipulated control (A, C) and representative depleted (B, D) animals. Percentages listed are cells staining positive of all cells in analyzed region (lymphoid gate).