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Whatever happened to the long tube?
Whatever Happened to the Long Tube? Leon Morgenstern, MD, Los Angeles, Califomia
nce upon a time, there were long intestinal tubes known as the Miller-Abbott tube, and its more popular descendant, the Cantor tube. 1 Both were mainstays in the management of small-intestinal obstruction 2 and were as common on a surgical ward as junior residents. Successful intubation of the dilated small intestine was mostly art, partly science. The art was in passing the tube through the nares and traversing the no man's land of the stomach; the science was in proper positioning of the patient and proper timing of the application of the suction. When the tubes worked well, they worked wonders, as the tube tip, weighted with a mercury-filled bag (which characterized both tubes) moved robot-like down to the point of obstruction. When the tubes didn't work, frustration was rife in all ranks from attending to intern, not to mention the exhausted patient. Then quite suddenly, like the extinction of the dinosaurs by the calamitous comet of yore, the long tube disappeared. Current house staff have not even heard of, much less utilized, the long tube. It has been relegated to the obscurity of obsolescent surgical maneuvers along with Wangensteen suction and hypodermal clysis. Is this obsolescence warranted? Is the long tube not only not to be remembered, but also not to be missed? The demise of the long tube was decreed by the outlawing of metallic mercury as a "toxic" chemical and "extremely hazardous waste" in the 1991 Federal Register. 3 Initially, some mercury was bootlegged to the bedside by a few diehard devotees of the long tube. Then some futile efforts were made to substitute barium for the mercury, but barium came nowhere near replacing the magical properties of metallic mercury. Finally, in desperation, theconcept took hold that gastric decompression served the purpose just as well and with much less trouble for all concerned. But did it? True, there were some studies that purported to show that it did. 4'5 But what of that intrepid gatekeeper, the pylorus, when it failed to open the floodgates to the fluidfilled small intestine? And was it not more logical to carry the remedy to the problem, that is, get the tube to the point of obstruction, rather than hope the problem, the dammedup gas and fluids, would find the tube, which often coiled in the stomach?
O
As one diehard who was raised and rewarded over many decades by the artfully placed long tube, I mourn its demise and am saddened by a generation of house staff who know not that it even existed. There is no question in my mind that it saved many miles of intestine destined for the pathologist's pail and that it handled the dilated fluid-filled small intestine infinitely more efficiently than the nasogastric tube. But alas, there is no longer a possibility of a rigorously controlled clinical trial to provide an answer one way or the other. Perhaps metallic mercury, with its magical properties of overweight liquidity, will again be released for medical use as a controlled substance, rigorously regulated just as is morphine, for example. Or perhaps some reliable means will be found to attach a micro-robotic replacement for the mercury at the tube tip, guiding it by remote control into the far reaches of the bowel. Rumor has it that such a development is already in the testing stage. But until the (improbable) return of mercury or the (remotely probable) arrival of the robotic tip, let us not forget that once there was a long intestinal tube, which sometimes worked wonders in the obstructed small intestine.
REFERENCES 1. Welch CE. Intestinal Obstruction. Chicago, Ill: Year Book Medical Publishers; 1958:107-109. 2. Wolfson PJ, Bauer JJ, Gelernt IM, et al. Use of the long tube in the management of patients with small-intestinal obstruction due to adhesions. Arch Surg. 1985;120:1001-1006. 3. FederalRe~ster. 1991;22:686. 4. Brolin RE, Krasna MJ, Mast BA. Use of tubes and radiographs in the management of small bowel obstruction. Ann Surg. 1987;206: 126-133.. 5. Wrenn K. The lowly nasogastric tube: still appropriate after all these years (at times). AmJ Emerg Med. 1993;11:84-89.
From the Division of General Surgery, Department of Surgery, Cedars-Sinai Research Institute, Cedars-Sinai Medical Center, Los Angeles, California. Am J Surg. 1995;170:237. Requests for reprints should be addressed to Leon Morgenstern, MD, UCLA Medical School, 444 S. San Vicente Blvd., Los Angeles, California 90048-1869. Manuscript submitted October 3, 1994 and accepted February 9, 1995.
THE AMERICAN JOURNAL OF S U R G E R Y ® VOLUME 170 SEPTEMBER 1995
237
nce upon a time, there were long intestinal tubes known as the Miller-Abbott tube, and its more popular descendant, the Cantor tube. 1 Both were mainstays in the management of small-intestinal obstruction 2 and were as common on a surgical ward as junior residents. Successful intubation of the dilated small intestine was mostly art, partly science. The art was in passing the tube through the nares and traversing the no man's land of the stomach; the science was in proper positioning of the patient and proper timing of the application of the suction. When the tubes worked well, they worked wonders, as the tube tip, weighted with a mercury-filled bag (which characterized both tubes) moved robot-like down to the point of obstruction. When the tubes didn't work, frustration was rife in all ranks from attending to intern, not to mention the exhausted patient. Then quite suddenly, like the extinction of the dinosaurs by the calamitous comet of yore, the long tube disappeared. Current house staff have not even heard of, much less utilized, the long tube. It has been relegated to the obscurity of obsolescent surgical maneuvers along with Wangensteen suction and hypodermal clysis. Is this obsolescence warranted? Is the long tube not only not to be remembered, but also not to be missed? The demise of the long tube was decreed by the outlawing of metallic mercury as a "toxic" chemical and "extremely hazardous waste" in the 1991 Federal Register. 3 Initially, some mercury was bootlegged to the bedside by a few diehard devotees of the long tube. Then some futile efforts were made to substitute barium for the mercury, but barium came nowhere near replacing the magical properties of metallic mercury. Finally, in desperation, theconcept took hold that gastric decompression served the purpose just as well and with much less trouble for all concerned. But did it? True, there were some studies that purported to show that it did. 4'5 But what of that intrepid gatekeeper, the pylorus, when it failed to open the floodgates to the fluidfilled small intestine? And was it not more logical to carry the remedy to the problem, that is, get the tube to the point of obstruction, rather than hope the problem, the dammedup gas and fluids, would find the tube, which often coiled in the stomach?
O
As one diehard who was raised and rewarded over many decades by the artfully placed long tube, I mourn its demise and am saddened by a generation of house staff who know not that it even existed. There is no question in my mind that it saved many miles of intestine destined for the pathologist's pail and that it handled the dilated fluid-filled small intestine infinitely more efficiently than the nasogastric tube. But alas, there is no longer a possibility of a rigorously controlled clinical trial to provide an answer one way or the other. Perhaps metallic mercury, with its magical properties of overweight liquidity, will again be released for medical use as a controlled substance, rigorously regulated just as is morphine, for example. Or perhaps some reliable means will be found to attach a micro-robotic replacement for the mercury at the tube tip, guiding it by remote control into the far reaches of the bowel. Rumor has it that such a development is already in the testing stage. But until the (improbable) return of mercury or the (remotely probable) arrival of the robotic tip, let us not forget that once there was a long intestinal tube, which sometimes worked wonders in the obstructed small intestine.
REFERENCES 1. Welch CE. Intestinal Obstruction. Chicago, Ill: Year Book Medical Publishers; 1958:107-109. 2. Wolfson PJ, Bauer JJ, Gelernt IM, et al. Use of the long tube in the management of patients with small-intestinal obstruction due to adhesions. Arch Surg. 1985;120:1001-1006. 3. FederalRe~ster. 1991;22:686. 4. Brolin RE, Krasna MJ, Mast BA. Use of tubes and radiographs in the management of small bowel obstruction. Ann Surg. 1987;206: 126-133.. 5. Wrenn K. The lowly nasogastric tube: still appropriate after all these years (at times). AmJ Emerg Med. 1993;11:84-89.
From the Division of General Surgery, Department of Surgery, Cedars-Sinai Research Institute, Cedars-Sinai Medical Center, Los Angeles, California. Am J Surg. 1995;170:237. Requests for reprints should be addressed to Leon Morgenstern, MD, UCLA Medical School, 444 S. San Vicente Blvd., Los Angeles, California 90048-1869. Manuscript submitted October 3, 1994 and accepted February 9, 1995.
THE AMERICAN JOURNAL OF S U R G E R Y ® VOLUME 170 SEPTEMBER 1995
237