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Tube decompression in intestinal obstruction
Tube
Decompression in Intestinal 0 bstruction GRAFTON A. SMITH, M.D., PH.D., Columbia, Missouri
NTESTINAL intubation as an adjunct in the management of patients with intestinal obstruction has proved to be of definite vaIue during the Iast three decades. The major problems have been the rapid passage of the Iong intestinal tube into the jejunum and rapid relief of distention. Many of the earher tubes had an inadequate design to occasion the rapid transit of the upper gastrointestina1 tract and, aIso, the gage of the lumen was insuffrcient to offer a satisfactory egress of the intestinal gases and content. The advent of controlled anesthesia and antibiotics have, therefore, led many surgeons to disregard the use of long intestina1 tubes for preoperative decompression and reIy principaIIy on surgica1 endeavors for correction. The author too would have succumbed to such management; however, the enormous foIds and Iengths of gut and the inherent continued factor of peritonea1 soilage and Ieakage in the absence of preoperative decompression have sufficed to direct the continued use of intestinal decompression as a major adjunct in the care of patients with intestina1 obstruction. In 1948, a fIexibIe stylet was developed to guide a Iong intestinal tube into the upper part of the small bowel [r-5]. This apparatus has now been used in over I ,000 triaIs at intubation at fIuoroscopy for preoperative or nonoperative treatment of intestinal obstruction. In addition, in over 300 patients in whom operation is beIieved to be the best form of treatment, intubation at operation for immediate decompression and the contro1 of postoperative ileus has proved to be quite he!pfuI. During development and use of this method, several variations in technic have been helpfu1 and warranted under special circumstances. It must be pointed out that there are herein described two definite and distinctIy different methods of intubation: first, an apparatus built to intubate patients
at Auoroscopy; secondly, an apparatus to be used for the insertion of the long intestinal tube at surgery to reIieve distention in patients requiring earIy or immediate surgical intervention.
I
TECHNIC The Intubation witb the Aid of Fluoroscopy. mechanical principIes of the apparatus and its clinica appIication are given in Figures I, 2 and 3. Variations in technic are warranted under specia1 circumstances. Here, changing the position of the patient piays a relatively minor roIe, but turning the patient on his right side can be heIpfu1. This position shows the close relationship of the tube to the spine when the stainIess stee1 tip Iies at or within the lirst portion of the duodenum. Occasionally, it has been heIpfuI to place the patient upon his abdomen whiIe traversing the stomach. The upright position can, in some instances, afford easier passage through the pyIorus and shouId be very helpful among patients who have undergone previous gastroenterostomies, with or without concomitant gastrectomy. the passageway into and Furthermore, through the first portion of the duodenum can be di&uIt because of its position and tortuosity. The controhable tip and tubing may lack sufficient AexibiIity to slip into and through these angles and turns without a flexible leading finger. However, lvhen the styIet is retracted 6 cm. from the stainIess tip, the tubing wiI1 easily act as a leading, flexible finger for transgressing the tortuous duodenum. The fixed position of the duodenum in patients with a large stomach can be troublesome. In these patients, the redundant stomach is easily displaced into the lower part of the abdomen or pelvis as the semi-rigid stylet and tube traverse the greater curvature. The gloved
419
American Journal oj Surgery,
Volume rag, September 1962
Smith
B
A
FIG. I. Flexible stylet with a controHabIe tip and plastic tube. The stylet and tube are constructed to enable controIIed rapid intubation of the smaI1 bowel. The styIet is designed to serve two functions: (I) to direct the Iong intestinal tube toward the pyIorus by manipulation of the controIIabIe tip and (2) to enabIe advancement of the tube into the smaI1 bowe1 through the transformation of the AexibIe styIet into a semi-rigid shaft. A, the stylet is illustrated and diagrammaticaIIy shows the deflection of the tip when the director Iever (a) of the handle is turned. Movement of the director Iever to the right (b) shortens one of two smaI1 wires traversing the flexible shaft (e and f) connecting with the controIIabIe tip (g). This maneuver curves the tip to the right. On the director Iever (a) is a knurIed sliding sIeeve for fine adjustment of the tension imposed upon the smaI1 wire attached to the controIlabIe tip. Rotation of this sIeeve to the Ieft increases maneuverability of the tip (g) and slightty stiffens the smaI1 shaft (f). Increased ffexibiIity of the Ieading portion of the styIet is afforded by turning the sIeeve to the right for passage through the duodenum and smaI1 bowe1. The thumb lever (c) is attached to a flat wire which terminates at the junction of the Iarger (e) and smaIIer (f) portions of the shaft. Pressure exerted on the thumb Iever transforms the proximal segment of the flexible shaft (e) into a semirigid column without affecting the flexibility of the dista1 IO cm. of the stylet. This maneuver enabIes the operator to transform the flexible styIet into a semi-rigid shaft w-ith “Aexible leading finger” and affords a safe instrument for passage into the intestine. The air adaptor (d) is attached to the tube for inflation of the stomach prior to manipuIating the tip. B, the tube is 9 feet Iong and is made of plastic. A stainless stee1 tip (a) is cemented and tied into its end. Two holes, one on each side of the plug, connect with the Iumen of the tube and serve as the avenue of suction distal to the Iatex baIIoon (b). The baIIoon is inflated with air through the smaI1 plastic tubing (c). A hoIe is cut into the waI1 of the Iarge tube 4 feet from the balloon for insertion of the styIet (e). A short segment of intravenous tubing (f) serves as a connection to the suction apparatus. The syringe (g) in pIace for inAation or deflation of the balloon.
hand in pIacing pressure upon the abdomen and aIong the greater curvature of the stomach maintains a smaIIer area with the upper part of the abdomen and therefore aIIows the stylet to reach the region of the pyIorus and duodenum. If a11 of these efforts fai1, the technic described in Figure 3 shouId be most heIpfu1. This technic is highly recommended for use in a
cascade or sharpIy transverse type of stomach. Jntubation at Operation. The apparatus and technic of intubation at operation are given in Figures 4, 5A and 5B. This technic offers, with IittIe training, an exceIIent method of decompression at operation without perforation of the bowe1 by enterostomy or external methods of decompressive procedure. Further, this particuIar technic is of advantage over the 420
Tube
Decompression
in Intestinal
Obstruction
FIG. 2. Diagram of the technic of intubation using the flexible styIet with a controllable tip. The long intestinal tube is inserted into the stomach (a). Passage along the greater curvature toward the right simplifies the procedure and the operator proceeds directly to intubate the smaI1 boweI. When the tube coiIs in the fundus, it is retracted to the position indicated. The stomach is distended with 700 to 1,000 cc. of air and the controllable tip is turned toward the pylorus (b). The semi-rigid stylet and tubing are advanced to exert pressure on the pylorus (c). Here, the styIet may be withdrawn to the position indicated (insert) to take advantage of the greater Aexibility of the Leading tip of the tube, alone, in traversing the tortuous first portion of the duodenum. It is then passed into the third portion of the duodenum (d). In the event that progression of the tube through the third portion of the duodenum is not rapid, the duodenum may aIso be inflated with air (insert d) as was accomplished within the stomach. Previous to advancement of the tube, the marked angularity or kinking of the tube within the stomach is decreased by the removal of excess tubing and then the stylet may be partiaIIy extracted from the tubing unti1 its tip is within the region of the pyIorus (e). The stylet and tubing are advanced together until the tip of the tube is within the jejunum and the tip of the styIet in the second portion of the duodenum (f). FoIlowing repeated partia1 removal of the styIet and then insertion of the tube and styIet, as shown in (e) and (f), the long intestinal tube is we11 into the jejunum Cgj. The stylet is then removed and the baIIoon is inflated with IO cc. of air.
hesions which cause obstruction in the patient. This simple procedure can be performed with a minimum of trauma to the intestine, and, of course, excessive traction on the mesentery of the intestine is afforded during all manipulations. SpiIIage from definitive surgery is minimized and also rapid bowel steriIization
larger tubes, more recentIy described, in that this tube may be left within the bowel for five or six days quite safely and yet the caIiber of lumen is such that it wiI1 effectively decompress most patients with bowel obstructions. In this way, one has an effective spIint postoperativeIy to avoid the recurrence of ad4.21
Smith
FIG. 3. This shows an alternate technic of intubation using the AexibIe stylet with a controllable tip with the addition of mercury within the balIoon to serve as a gravity director. The Iong intestinat tube is inserted into the stomach (a). Then the stomach is distended with 700 to 1,000 cc. of air, and the tip of the stylet is positioned so as to rest approximateIy 6 cm. from the end of the tube as shown by Auoroscopy. The patient is turned on his right side and the semi-rigid styIet and tube are advanced until they cross the midIine (b). The patient’s head is ako lowered so the merckry-weighted baIIoon wiI1 pass toward the duodena1 buIb (c). At this point continuous pressure by the semirigid styIet affords rapid passage into the upper second portion of the duodenum. The patient assumes a new position by Iying supine with the head eIevated above the feet to afford rapid passage through the second portion of the duodenum (d). The duodenum is then inflated so as to become distended with air to afford passage of the weighted tip into the third portion (e). Further rapid advancement is aided by placing the patient on his Ieft side (f). This is accompIished by insertion of the tube and semi-rigid stylet together into the Iower reaches of the bowel (g). Finally, the patient is placed in the upright position and the mercury-weighted tube faIIs into the jejunum (h). The baIIoon is then inflated with IO cc. of air and the st.yIet is extracted. Attachment to suction is afforded as described in Figure I.
can be afforded after the tube is inserted one so chooses at operation.
if
approximateIy a go per cent chance of rapid intubation of the upper parts of the bowel at fluoroscopy and that the rehef of distention of patients with simpIe bowe1 obstructions shouId be achieved within the next thirty-six to forty hours. The relief of distention at operation by insertion of the Iong intestinal tube has been appIied in over 300 additiona patients. This
COMMENTS
In generaI, the resuIts of these methods of intubation have been appIied in we11 over 1,000 patients. The appIication of intubation at IIuoroscopy wouId indicate that there is 422
Tube
Decompression
in Intestinal
Obstruction
FIG. 4. Plastic tube and flexible stylet without controllabk tip, for operative intubation of the small intestine. The intestina1 tube is 9 feet Iong and made of plastic (Mayon). A stainless steel tip (a) is cemented and tied into its end. Two hates, one on each side of the plug, connect with the lumen of the tube and serve as the avenue of suction d&a1 to the latex baIIoon (b). The balIoon is inflated with air through the small plastic tubing (c). A hole is cut in the waII of the Iarge tube 4 feet from the baIIoon for insertion of the stylet (d). A steel adapter is used to occlude the opening after remova of the styIet (e). A short segment of intravenous tubing (f) serves as a connection to the suction apparatus. The syringe is in pIace for inflation or deflation of the balloon (g). The stylet is so constructed as to enable rapid advancement of the tube into the small intestine through the transformation of the flexible stylet into a semi-rigid shaft. The thumb lever (h) on the handIe is attached to a Aat wire that terminates at the junction of the larger (i) and smaIIer (j) portions of the shaft. Pressure exerted on the thumb Iever transforms the proxima1 segment of the ffexibIe shaft (i) into a semi-rigid column without affecting the flexibility of the distal 8 cm. of the stylet (smaIIer diameter shaft). This maneuver enabIes the operator to transform the fIexibIe stylet into a semi-rigid shaft with a “fIexibIe leading finger” and affords a safe instrument for passage into the intestine.
has been successful in 95 per cent of the patients and earIy decompression at operation has been achieved among those successfuhy intubated. These methods have proved to be not onIy rapid but safe. There was onIy one puncture of the gastrointestinal tract which occurred at the ligament of Treitz during passage of the intestinal tube at operation. This was incumbent by a kinking just distal to the Iigament of Treitz. The indications and contraindications of the application of intestina1 suction in the management of patients with obstruction have received great coverage in the Iiterature during the past decades. The attempt has been to establish a form of therapy which is safe for the patient and also to expedite the reIief of distention by the surgeon. SurgicaI intervention has gained
considerable ground as a result of better contro1 of the patient under anesthesia, better contro1 of the effects of infection by antibiotics, a pronounced improvement in electrolyte and fIuid baIance and a genera1 improvement in the training of visceral surgeons. The too great tendency, however, is to ignore the distressing effects of bowel distention and to operate in the face of obstructions. In the total picture this method of intubation has been highly successfu1 in the rehef of distention among patients with a twenty-four to thirty-six hour tria1 of suction. However, the time required for decompression suggests that in patients with simple mechanical obstructions of the small bowe1 and in those with paralytic ileus, the Iong intestinal tube shouId continue to be used for the contro1 of dis423
Smith
FIG. 5. This shows the technic of operative intubation of the smaIl intestine. The Aexible stylet without the controiIable tip, well lubricated with petroIeum jelIy, is introduced through a hole in the side of the intestina1 tube to within 3 cm. of the stee1 tip of the tube. The tube is passed through the mouth into the esophagus with the aid of the Iaryngoscope folIowing an incision in the abdomen as shown in (a). The stylet and tube are advanced unti1 the surgeon is abIe to palpate the tip of the tube through the gastric waI1. The surgeon’s right hand is pIaced aIong the figure greater curvature of the stomach directing and tiIting the tip of the tube toward pylorus as the tube is advanced (b). The Ieft hand of the surgeon directs the tube through the pyIorus (c) as the intubationist appIies pressure on the thumb Iever which stiffens the styIet whiIe the tube is advanced. Passage through the duodenum is facilitated by advancing the styIet and the tube from above, whiIe the surgeon’s Ieft hand supports the greater curvature of the stomach and the right hand moves aIong the duodenum Iigament and then beIow the transverse mesocolon aIong the duodena1 margins at the origin of the transverse mesocoIon (d). This maneuver prevents the tube from coiIing within the stomach and affords rapid transit through the duodenum. The baIIoon is then inflated with IO cc. of air and the tube is heId stationary in the jejunum during extraction of the styIet (e); however, frequentIy the surgeon asks that the styIet be Ieft in position during intubation in the upper half of the jejunum because migration of the catheter down the intestine appears to be faciIitated thereby (f and g). The catheter is then threaded into the intestine by holding the proximal intestine stationary and advancing the baIIoon tipped catheter as it is heId between the index and third fingers. At this juncture the tube is Iaying we11 within the jejunum and if rapid decompression is desirabIe the tube may be attached to a motor driven suction through a Y adapter. The Y adapter provides the opportunity for frequent intermittent interruption of the high negative pressure facilitating evacuation of the intestina content (h). Further migration down the intestinal tract is accompIished by accordian pIeating the intestine and drawing it out in a position to lengthen the tube that is present and thereby rapidIy pulling the tube down into the intestina1 tract without direct trauma to the bowe1. This is done within the abdomen without extensive traction on the base of the mesentery of the smaI1 bowe1 (i). With descent of the catheter, suction is appIied intermittentIy to evacuate the bowel and, at the juncture of the adhesion then easiIy visuaIized with bowe1 decompressed, Iysis of the adhesion or the obstructive mechanism is treated definitiveIy by surgery (j).
tention. In patients with postoperative iIeus, even with insertion of the tube in the upper parts of the jejunum, rapid decompression was thwarted; however, experience has shown that eventua1 reIief of distention has been most successful in these patients. Obstruction of the Iarge bowe1 is principaIIy a surgica1 probIem in
management. The onIy rationa therapy to be folIowed is to maintain the patient and to secure the best possibIe condition of the patient prior to definitive surgica1 treatment. RationaI and effective treatment can best be based on current pathoIogic concepts. The vicious cycle initiated by stoppage of the 424
Tube
Decompression
in Intestinal
bowel and its principal hazard of peritonitis is explained best by the mechanical theory, viz., dilation of the intestine and subsequent loss of viability and then peritoneal soilage. The usua1 terminal appearance of peritonitis can be avoided by either contro1 of distention using a long intestinal tube for intestina1 decompression until the obstruction has relented or early operation when the obstruction has not been relieved or signs of strangulation have occurred. Patients with late mechanica obstructions in whom bowel sounds are absent shouId be operated upon as soon as dehydration has been corrected, since rapid decompression of the intestine by intestinal suction alone is slow. When gangrene is encountered even under the protective influences of modern antibiotics, only definitive bowel resection following operative rehef of distention shouId be performed. This is accomplished best by closed methods of anastomosis. Actually, the newer antibiotics have some hazards for they do potentiate or cause mutinous enterocohtis and thus somewhat negate their possibIe corrective influences. Of special interest is the current trend toward the belief that postoperative obstruction in patients to prevent distention and other complications is not advisable with the advent of current methods of surgical management. Personal experiences would indicate that patients are more comfortabIe and best protected following large abdominal incisions when distention incident to reduced intestinal motility and swallowed air is controlled by effective gastrointestinal suction. The exclusion of swahowed air obviates the distention factor and its sequelae of decreased viabihty of the bowel and separation of the anastomotic site. Better healing afforded by pIacing the bowel at rest far outweighs the complication of intestinal intubation which only becomes manifest following the necessity of prolonged suction attending complications of abdominal surgery. Among reports of patients with improperly instituted catheter suction is the rare report of injury to the nasal passages, upper intestinal tract and more frequent occurrence of fluid and electrolyte depletion. Chronic irritation to the nasopharynx is found infrequently among patients treated with suction for periods of one to two days. When irritation becomes manifest, cIeansing and movement of the tube from one nostril to the other prevent com-
Obstruction
phcations. Electrolyte balance, the more important consideration, can frequentIy be controlled with a schedule of daily weights of the patient, daily intake and output records, and cIose surveihance of the extracellular electrolytes by readily availabIe chemical analysis. When ileus does occur, large doses of fluid and eIectroIyte collect within the bowel. Physiologically they are Iost to the body; they are not determinable and contribute an unknown amount of body weight. If suction is used, the Iosses are aspirated into a bottIe where they can be measured in an electroIyte concentration and determined with any desired degree of accuracy. Also, the weight is a reliable determination onIy when the bowel is relatively empty. In brief, fluid and electrolyte losses need be feared only if they are not known. These considerations indicate that correctly managed suction is helpfu1 and can be used safeIy. Therefore, it wouId appear that prophyIactic decompression would be in order among patients in whom ileus was likely to occur. In addition to the relief of distention and control of the bowel motility during the postoperative period, a long tube threaded through the bowe1 at surgery has other applications. In the event that resection of the intestine is necessary- in the absence of preoperative preparation of the intestines, the tube offers an avenue for the injection of an antibiotic to reduce bacterial content of the intestine. Also, the placement of a lcng tube proximal to all smaI1 intestinal and ileocolic anastomosis is justified. Especially heIpfu1 is the use of the long intestinal tube as a splint for the bowel for protection and maintenance of a lumen during the recovery period among those patients with recurrent adhesive bowel obstructions. The tube in this instance acts as a guide to maintain the Iumen of the bowel during the earIy healing period. As a suggestion, when the long tube is used during the postoperative period, one should also use gastric suction for the control of proxima1 distention of the bowe1. With the return of peristalsis among those patients with operations for adhesions, the gastric tube is removed first and the long intestinal tube is clamped for a period of twelve hours. If orallg administered fluids are we11 tclerated by the patient, the long tube may be safeIy removed. These suggestions and precautions against post425
Smith Patients with simoIe obstruction of the small bowe1 deserve a trial of suction for a period of thirty-six hours. If the obstruction has not reIented, surgery shouId foIIow. Postoperative ileus is best managed by intestinal suction and the resuIts have been generaIIy satisfactory. Rapid reIief at operation may be achieved by the insertion of the tube to contro1 peritonea1 soiIage. The contro1 of intestina1 distention by catheter suction remains the primarv objective in the treatment of patients w:th bowe1 obstruction.
operative iIeus offer the best chance of success by pIacing the intestine at rest and assuring a norme. intestina1 circuIation during the healing period. Intubation of the intestine has both diagnostic as we11 as therapeutic impIications. The continued high mortaIity in patients with stranguIated and postoperative obstructions could be much improved if earIy treatment couId be instituted. AIthough even the most carefu1 physica examination and Iucid history fai1 to be heIpfu1, abdominal fiIms and those taken in conjunction with thin mixtures of barium given through a Iong tube pIaced into the smaI1 bowel can often identify the area of obstruction. In addition, scout fiIms following pneumoperitoneum could be heIpfu1. However, suspicion of the occurrence of obstruction by the surgeon remains the single most important factor in the early recognition of bowe1 obstructions. Tube decompression of the patient with obstruction remains a satisfactory method of management. A technic of intubation with the aid of huoroscopy and also a technic for intubation at operation have been described.
REFERENCES
I. SMITH, G. A. A study of intestinal intubation using a AexibIe styIet with controIIabIe tip. Surgery, 32: 17, 19% 2. SMITH, G. A. and BRACKNEY, E. L. Preliminary report on a new method of intestina1 intubation with the aid of a AexibIe stvIet with controIIabIe tip. Surgery, 27: 817, 1950. _ 3. SMITH. G. A. A studv of intestinal intubation usinn a ffexibIe stylet with a controIIabIe tip. Surg. Gynec. CT Obst., Iog: 639, 1939. 4. WANGENSTEEN, 0. H. Intestinal Obstructions. SpringfieId, III., 1955. CharIes C Thomas. 5. SMITH, G. A. Long intestina1 tubes for operative decompression and post-operative iIeus. J. A. M. A., 160: 266, 1956.
426
Decompression in Intestinal 0 bstruction GRAFTON A. SMITH, M.D., PH.D., Columbia, Missouri
NTESTINAL intubation as an adjunct in the management of patients with intestinal obstruction has proved to be of definite vaIue during the Iast three decades. The major problems have been the rapid passage of the Iong intestinal tube into the jejunum and rapid relief of distention. Many of the earher tubes had an inadequate design to occasion the rapid transit of the upper gastrointestina1 tract and, aIso, the gage of the lumen was insuffrcient to offer a satisfactory egress of the intestinal gases and content. The advent of controlled anesthesia and antibiotics have, therefore, led many surgeons to disregard the use of long intestina1 tubes for preoperative decompression and reIy principaIIy on surgica1 endeavors for correction. The author too would have succumbed to such management; however, the enormous foIds and Iengths of gut and the inherent continued factor of peritonea1 soilage and Ieakage in the absence of preoperative decompression have sufficed to direct the continued use of intestinal decompression as a major adjunct in the care of patients with intestina1 obstruction. In 1948, a fIexibIe stylet was developed to guide a Iong intestinal tube into the upper part of the small bowel [r-5]. This apparatus has now been used in over I ,000 triaIs at intubation at fIuoroscopy for preoperative or nonoperative treatment of intestinal obstruction. In addition, in over 300 patients in whom operation is beIieved to be the best form of treatment, intubation at operation for immediate decompression and the contro1 of postoperative ileus has proved to be quite he!pfuI. During development and use of this method, several variations in technic have been helpfu1 and warranted under special circumstances. It must be pointed out that there are herein described two definite and distinctIy different methods of intubation: first, an apparatus built to intubate patients
at Auoroscopy; secondly, an apparatus to be used for the insertion of the long intestinal tube at surgery to reIieve distention in patients requiring earIy or immediate surgical intervention.
I
TECHNIC The Intubation witb the Aid of Fluoroscopy. mechanical principIes of the apparatus and its clinica appIication are given in Figures I, 2 and 3. Variations in technic are warranted under specia1 circumstances. Here, changing the position of the patient piays a relatively minor roIe, but turning the patient on his right side can be heIpfu1. This position shows the close relationship of the tube to the spine when the stainIess stee1 tip Iies at or within the lirst portion of the duodenum. Occasionally, it has been heIpfuI to place the patient upon his abdomen whiIe traversing the stomach. The upright position can, in some instances, afford easier passage through the pyIorus and shouId be very helpful among patients who have undergone previous gastroenterostomies, with or without concomitant gastrectomy. the passageway into and Furthermore, through the first portion of the duodenum can be di&uIt because of its position and tortuosity. The controhable tip and tubing may lack sufficient AexibiIity to slip into and through these angles and turns without a flexible leading finger. However, lvhen the styIet is retracted 6 cm. from the stainIess tip, the tubing wiI1 easily act as a leading, flexible finger for transgressing the tortuous duodenum. The fixed position of the duodenum in patients with a large stomach can be troublesome. In these patients, the redundant stomach is easily displaced into the lower part of the abdomen or pelvis as the semi-rigid stylet and tube traverse the greater curvature. The gloved
419
American Journal oj Surgery,
Volume rag, September 1962
Smith
B
A
FIG. I. Flexible stylet with a controHabIe tip and plastic tube. The stylet and tube are constructed to enable controIIed rapid intubation of the smaI1 bowel. The styIet is designed to serve two functions: (I) to direct the Iong intestinal tube toward the pyIorus by manipulation of the controIIabIe tip and (2) to enabIe advancement of the tube into the smaI1 bowe1 through the transformation of the AexibIe styIet into a semi-rigid shaft. A, the stylet is illustrated and diagrammaticaIIy shows the deflection of the tip when the director Iever (a) of the handle is turned. Movement of the director Iever to the right (b) shortens one of two smaI1 wires traversing the flexible shaft (e and f) connecting with the controIIabIe tip (g). This maneuver curves the tip to the right. On the director Iever (a) is a knurIed sliding sIeeve for fine adjustment of the tension imposed upon the smaI1 wire attached to the controIlabIe tip. Rotation of this sIeeve to the Ieft increases maneuverability of the tip (g) and slightty stiffens the smaI1 shaft (f). Increased ffexibiIity of the Ieading portion of the styIet is afforded by turning the sIeeve to the right for passage through the duodenum and smaI1 bowe1. The thumb lever (c) is attached to a flat wire which terminates at the junction of the Iarger (e) and smaIIer (f) portions of the shaft. Pressure exerted on the thumb Iever transforms the proximal segment of the flexible shaft (e) into a semirigid column without affecting the flexibility of the dista1 IO cm. of the stylet. This maneuver enabIes the operator to transform the flexible styIet into a semi-rigid shaft w-ith “Aexible leading finger” and affords a safe instrument for passage into the intestine. The air adaptor (d) is attached to the tube for inflation of the stomach prior to manipuIating the tip. B, the tube is 9 feet Iong and is made of plastic. A stainless stee1 tip (a) is cemented and tied into its end. Two holes, one on each side of the plug, connect with the Iumen of the tube and serve as the avenue of suction distal to the Iatex baIIoon (b). The baIIoon is inflated with air through the smaI1 plastic tubing (c). A hoIe is cut into the waI1 of the Iarge tube 4 feet from the balloon for insertion of the styIet (e). A short segment of intravenous tubing (f) serves as a connection to the suction apparatus. The syringe (g) in pIace for inAation or deflation of the balloon.
hand in pIacing pressure upon the abdomen and aIong the greater curvature of the stomach maintains a smaIIer area with the upper part of the abdomen and therefore aIIows the stylet to reach the region of the pyIorus and duodenum. If a11 of these efforts fai1, the technic described in Figure 3 shouId be most heIpfu1. This technic is highly recommended for use in a
cascade or sharpIy transverse type of stomach. Jntubation at Operation. The apparatus and technic of intubation at operation are given in Figures 4, 5A and 5B. This technic offers, with IittIe training, an exceIIent method of decompression at operation without perforation of the bowe1 by enterostomy or external methods of decompressive procedure. Further, this particuIar technic is of advantage over the 420
Tube
Decompression
in Intestinal
Obstruction
FIG. 2. Diagram of the technic of intubation using the flexible styIet with a controllable tip. The long intestinal tube is inserted into the stomach (a). Passage along the greater curvature toward the right simplifies the procedure and the operator proceeds directly to intubate the smaI1 boweI. When the tube coiIs in the fundus, it is retracted to the position indicated. The stomach is distended with 700 to 1,000 cc. of air and the controllable tip is turned toward the pylorus (b). The semi-rigid stylet and tubing are advanced to exert pressure on the pylorus (c). Here, the styIet may be withdrawn to the position indicated (insert) to take advantage of the greater Aexibility of the Leading tip of the tube, alone, in traversing the tortuous first portion of the duodenum. It is then passed into the third portion of the duodenum (d). In the event that progression of the tube through the third portion of the duodenum is not rapid, the duodenum may aIso be inflated with air (insert d) as was accomplished within the stomach. Previous to advancement of the tube, the marked angularity or kinking of the tube within the stomach is decreased by the removal of excess tubing and then the stylet may be partiaIIy extracted from the tubing unti1 its tip is within the region of the pyIorus (e). The stylet and tubing are advanced together until the tip of the tube is within the jejunum and the tip of the styIet in the second portion of the duodenum (f). FoIlowing repeated partia1 removal of the styIet and then insertion of the tube and styIet, as shown in (e) and (f), the long intestinal tube is we11 into the jejunum Cgj. The stylet is then removed and the baIIoon is inflated with IO cc. of air.
hesions which cause obstruction in the patient. This simple procedure can be performed with a minimum of trauma to the intestine, and, of course, excessive traction on the mesentery of the intestine is afforded during all manipulations. SpiIIage from definitive surgery is minimized and also rapid bowel steriIization
larger tubes, more recentIy described, in that this tube may be left within the bowel for five or six days quite safely and yet the caIiber of lumen is such that it wiI1 effectively decompress most patients with bowel obstructions. In this way, one has an effective spIint postoperativeIy to avoid the recurrence of ad4.21
Smith
FIG. 3. This shows an alternate technic of intubation using the AexibIe stylet with a controllable tip with the addition of mercury within the balIoon to serve as a gravity director. The Iong intestinat tube is inserted into the stomach (a). Then the stomach is distended with 700 to 1,000 cc. of air, and the tip of the stylet is positioned so as to rest approximateIy 6 cm. from the end of the tube as shown by Auoroscopy. The patient is turned on his right side and the semi-rigid styIet and tube are advanced until they cross the midIine (b). The patient’s head is ako lowered so the merckry-weighted baIIoon wiI1 pass toward the duodena1 buIb (c). At this point continuous pressure by the semirigid styIet affords rapid passage into the upper second portion of the duodenum. The patient assumes a new position by Iying supine with the head eIevated above the feet to afford rapid passage through the second portion of the duodenum (d). The duodenum is then inflated so as to become distended with air to afford passage of the weighted tip into the third portion (e). Further rapid advancement is aided by placing the patient on his Ieft side (f). This is accompIished by insertion of the tube and semi-rigid stylet together into the Iower reaches of the bowel (g). Finally, the patient is placed in the upright position and the mercury-weighted tube faIIs into the jejunum (h). The baIIoon is then inflated with IO cc. of air and the st.yIet is extracted. Attachment to suction is afforded as described in Figure I.
can be afforded after the tube is inserted one so chooses at operation.
if
approximateIy a go per cent chance of rapid intubation of the upper parts of the bowel at fluoroscopy and that the rehef of distention of patients with simpIe bowe1 obstructions shouId be achieved within the next thirty-six to forty hours. The relief of distention at operation by insertion of the Iong intestinal tube has been appIied in over 300 additiona patients. This
COMMENTS
In generaI, the resuIts of these methods of intubation have been appIied in we11 over 1,000 patients. The appIication of intubation at IIuoroscopy wouId indicate that there is 422
Tube
Decompression
in Intestinal
Obstruction
FIG. 4. Plastic tube and flexible stylet without controllabk tip, for operative intubation of the small intestine. The intestina1 tube is 9 feet Iong and made of plastic (Mayon). A stainless steel tip (a) is cemented and tied into its end. Two hates, one on each side of the plug, connect with the lumen of the tube and serve as the avenue of suction d&a1 to the latex baIIoon (b). The balIoon is inflated with air through the small plastic tubing (c). A hole is cut in the waII of the Iarge tube 4 feet from the baIIoon for insertion of the stylet (d). A steel adapter is used to occlude the opening after remova of the styIet (e). A short segment of intravenous tubing (f) serves as a connection to the suction apparatus. The syringe is in pIace for inflation or deflation of the balloon (g). The stylet is so constructed as to enable rapid advancement of the tube into the small intestine through the transformation of the flexible stylet into a semi-rigid shaft. The thumb lever (h) on the handIe is attached to a Aat wire that terminates at the junction of the larger (i) and smaIIer (j) portions of the shaft. Pressure exerted on the thumb Iever transforms the proxima1 segment of the ffexibIe shaft (i) into a semi-rigid column without affecting the flexibility of the distal 8 cm. of the stylet (smaIIer diameter shaft). This maneuver enabIes the operator to transform the fIexibIe stylet into a semi-rigid shaft with a “fIexibIe leading finger” and affords a safe instrument for passage into the intestine.
has been successful in 95 per cent of the patients and earIy decompression at operation has been achieved among those successfuhy intubated. These methods have proved to be not onIy rapid but safe. There was onIy one puncture of the gastrointestinal tract which occurred at the ligament of Treitz during passage of the intestinal tube at operation. This was incumbent by a kinking just distal to the Iigament of Treitz. The indications and contraindications of the application of intestina1 suction in the management of patients with obstruction have received great coverage in the Iiterature during the past decades. The attempt has been to establish a form of therapy which is safe for the patient and also to expedite the reIief of distention by the surgeon. SurgicaI intervention has gained
considerable ground as a result of better contro1 of the patient under anesthesia, better contro1 of the effects of infection by antibiotics, a pronounced improvement in electrolyte and fIuid baIance and a genera1 improvement in the training of visceral surgeons. The too great tendency, however, is to ignore the distressing effects of bowel distention and to operate in the face of obstructions. In the total picture this method of intubation has been highly successfu1 in the rehef of distention among patients with a twenty-four to thirty-six hour tria1 of suction. However, the time required for decompression suggests that in patients with simple mechanical obstructions of the small bowe1 and in those with paralytic ileus, the Iong intestinal tube shouId continue to be used for the contro1 of dis423
Smith
FIG. 5. This shows the technic of operative intubation of the smaIl intestine. The Aexible stylet without the controiIable tip, well lubricated with petroIeum jelIy, is introduced through a hole in the side of the intestina1 tube to within 3 cm. of the stee1 tip of the tube. The tube is passed through the mouth into the esophagus with the aid of the Iaryngoscope folIowing an incision in the abdomen as shown in (a). The stylet and tube are advanced unti1 the surgeon is abIe to palpate the tip of the tube through the gastric waI1. The surgeon’s right hand is pIaced aIong the figure greater curvature of the stomach directing and tiIting the tip of the tube toward pylorus as the tube is advanced (b). The Ieft hand of the surgeon directs the tube through the pyIorus (c) as the intubationist appIies pressure on the thumb Iever which stiffens the styIet whiIe the tube is advanced. Passage through the duodenum is facilitated by advancing the styIet and the tube from above, whiIe the surgeon’s Ieft hand supports the greater curvature of the stomach and the right hand moves aIong the duodenum Iigament and then beIow the transverse mesocolon aIong the duodena1 margins at the origin of the transverse mesocoIon (d). This maneuver prevents the tube from coiIing within the stomach and affords rapid transit through the duodenum. The baIIoon is then inflated with IO cc. of air and the tube is heId stationary in the jejunum during extraction of the styIet (e); however, frequentIy the surgeon asks that the styIet be Ieft in position during intubation in the upper half of the jejunum because migration of the catheter down the intestine appears to be faciIitated thereby (f and g). The catheter is then threaded into the intestine by holding the proximal intestine stationary and advancing the baIIoon tipped catheter as it is heId between the index and third fingers. At this juncture the tube is Iaying we11 within the jejunum and if rapid decompression is desirabIe the tube may be attached to a motor driven suction through a Y adapter. The Y adapter provides the opportunity for frequent intermittent interruption of the high negative pressure facilitating evacuation of the intestina content (h). Further migration down the intestinal tract is accompIished by accordian pIeating the intestine and drawing it out in a position to lengthen the tube that is present and thereby rapidIy pulling the tube down into the intestina1 tract without direct trauma to the bowe1. This is done within the abdomen without extensive traction on the base of the mesentery of the smaI1 bowe1 (i). With descent of the catheter, suction is appIied intermittentIy to evacuate the bowel and, at the juncture of the adhesion then easiIy visuaIized with bowe1 decompressed, Iysis of the adhesion or the obstructive mechanism is treated definitiveIy by surgery (j).
tention. In patients with postoperative iIeus, even with insertion of the tube in the upper parts of the jejunum, rapid decompression was thwarted; however, experience has shown that eventua1 reIief of distention has been most successful in these patients. Obstruction of the Iarge bowe1 is principaIIy a surgica1 probIem in
management. The onIy rationa therapy to be folIowed is to maintain the patient and to secure the best possibIe condition of the patient prior to definitive surgica1 treatment. RationaI and effective treatment can best be based on current pathoIogic concepts. The vicious cycle initiated by stoppage of the 424
Tube
Decompression
in Intestinal
bowel and its principal hazard of peritonitis is explained best by the mechanical theory, viz., dilation of the intestine and subsequent loss of viability and then peritoneal soilage. The usua1 terminal appearance of peritonitis can be avoided by either contro1 of distention using a long intestinal tube for intestina1 decompression until the obstruction has relented or early operation when the obstruction has not been relieved or signs of strangulation have occurred. Patients with late mechanica obstructions in whom bowel sounds are absent shouId be operated upon as soon as dehydration has been corrected, since rapid decompression of the intestine by intestinal suction alone is slow. When gangrene is encountered even under the protective influences of modern antibiotics, only definitive bowel resection following operative rehef of distention shouId be performed. This is accomplished best by closed methods of anastomosis. Actually, the newer antibiotics have some hazards for they do potentiate or cause mutinous enterocohtis and thus somewhat negate their possibIe corrective influences. Of special interest is the current trend toward the belief that postoperative obstruction in patients to prevent distention and other complications is not advisable with the advent of current methods of surgical management. Personal experiences would indicate that patients are more comfortabIe and best protected following large abdominal incisions when distention incident to reduced intestinal motility and swallowed air is controlled by effective gastrointestinal suction. The exclusion of swahowed air obviates the distention factor and its sequelae of decreased viabihty of the bowel and separation of the anastomotic site. Better healing afforded by pIacing the bowel at rest far outweighs the complication of intestinal intubation which only becomes manifest following the necessity of prolonged suction attending complications of abdominal surgery. Among reports of patients with improperly instituted catheter suction is the rare report of injury to the nasal passages, upper intestinal tract and more frequent occurrence of fluid and electrolyte depletion. Chronic irritation to the nasopharynx is found infrequently among patients treated with suction for periods of one to two days. When irritation becomes manifest, cIeansing and movement of the tube from one nostril to the other prevent com-
Obstruction
phcations. Electrolyte balance, the more important consideration, can frequentIy be controlled with a schedule of daily weights of the patient, daily intake and output records, and cIose surveihance of the extracellular electrolytes by readily availabIe chemical analysis. When ileus does occur, large doses of fluid and eIectroIyte collect within the bowel. Physiologically they are Iost to the body; they are not determinable and contribute an unknown amount of body weight. If suction is used, the Iosses are aspirated into a bottIe where they can be measured in an electroIyte concentration and determined with any desired degree of accuracy. Also, the weight is a reliable determination onIy when the bowel is relatively empty. In brief, fluid and electrolyte losses need be feared only if they are not known. These considerations indicate that correctly managed suction is helpfu1 and can be used safeIy. Therefore, it wouId appear that prophyIactic decompression would be in order among patients in whom ileus was likely to occur. In addition to the relief of distention and control of the bowel motility during the postoperative period, a long tube threaded through the bowe1 at surgery has other applications. In the event that resection of the intestine is necessary- in the absence of preoperative preparation of the intestines, the tube offers an avenue for the injection of an antibiotic to reduce bacterial content of the intestine. Also, the placement of a lcng tube proximal to all smaI1 intestinal and ileocolic anastomosis is justified. Especially heIpfu1 is the use of the long intestinal tube as a splint for the bowel for protection and maintenance of a lumen during the recovery period among those patients with recurrent adhesive bowel obstructions. The tube in this instance acts as a guide to maintain the Iumen of the bowel during the earIy healing period. As a suggestion, when the long tube is used during the postoperative period, one should also use gastric suction for the control of proxima1 distention of the bowe1. With the return of peristalsis among those patients with operations for adhesions, the gastric tube is removed first and the long intestinal tube is clamped for a period of twelve hours. If orallg administered fluids are we11 tclerated by the patient, the long tube may be safeIy removed. These suggestions and precautions against post425
Smith Patients with simoIe obstruction of the small bowe1 deserve a trial of suction for a period of thirty-six hours. If the obstruction has not reIented, surgery shouId foIIow. Postoperative ileus is best managed by intestinal suction and the resuIts have been generaIIy satisfactory. Rapid reIief at operation may be achieved by the insertion of the tube to contro1 peritonea1 soiIage. The contro1 of intestina1 distention by catheter suction remains the primarv objective in the treatment of patients w:th bowe1 obstruction.
operative iIeus offer the best chance of success by pIacing the intestine at rest and assuring a norme. intestina1 circuIation during the healing period. Intubation of the intestine has both diagnostic as we11 as therapeutic impIications. The continued high mortaIity in patients with stranguIated and postoperative obstructions could be much improved if earIy treatment couId be instituted. AIthough even the most carefu1 physica examination and Iucid history fai1 to be heIpfu1, abdominal fiIms and those taken in conjunction with thin mixtures of barium given through a Iong tube pIaced into the smaI1 bowel can often identify the area of obstruction. In addition, scout fiIms following pneumoperitoneum could be heIpfu1. However, suspicion of the occurrence of obstruction by the surgeon remains the single most important factor in the early recognition of bowe1 obstructions. Tube decompression of the patient with obstruction remains a satisfactory method of management. A technic of intubation with the aid of huoroscopy and also a technic for intubation at operation have been described.
REFERENCES
I. SMITH, G. A. A study of intestinal intubation using a AexibIe styIet with controIIabIe tip. Surgery, 32: 17, 19% 2. SMITH, G. A. and BRACKNEY, E. L. Preliminary report on a new method of intestina1 intubation with the aid of a AexibIe stvIet with controIIabIe tip. Surgery, 27: 817, 1950. _ 3. SMITH. G. A. A studv of intestinal intubation usinn a ffexibIe stylet with a controIIabIe tip. Surg. Gynec. CT Obst., Iog: 639, 1939. 4. WANGENSTEEN, 0. H. Intestinal Obstructions. SpringfieId, III., 1955. CharIes C Thomas. 5. SMITH, G. A. Long intestina1 tubes for operative decompression and post-operative iIeus. J. A. M. A., 160: 266, 1956.
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