Nonoperative management of small-bowel obstruction with endoscopic long intestinal tube placement

Intestinal obstruction remains a major cause of morbidity and mortality in surgical patients. We reviewed the records of 77 patients with mechanical small-bowel obstruction who were treated with endoscopically and fluoroscopically placed Leonard long intestinal tube decompression. Most patients (59%) had failed a trial of nasogastric tube or Miller-Abbott tube decompression. Overall, 29 per cent of patients were able to resolve their obstruction with Leonard tube decompression alone. Subdivision of patients on the basis of the etiology of their obstruction demonstrated a much higher rate of success for tube decompression in adhesive obstruction (37%) versus malignant obstruction (12%) or inflammatory obstruction (no successes). Patients with radiographic and clinical evidence of complete intestinal obstruction were significantly less likely to respond to long intestinal tube treatment (13%). The long intestinal tube was easily passed in all patients. There were no complications of the intubation procedure in our series, and the incidence of tube-related complications was four per cent. We conclude that an initial period of long intestinal tube decompression allows a significant percentage of patients with mechanical small-bowel obstruction to be treated nonoperatively, particularly if a partial obstruction from postoperative adhesions is present. Patients who have failed a trial of nasogastric tube decompression and are poor operative risks should also be considered for long intestinal tube placement.     

Specific oral medications decrease the need for surgery in adhesive partial small-bowel obstruction

BACKGROUND: Nothing by mouth (NPO) is the standard treatment for small-bowel obstruction. Whether oral medications should be prohibited during treatment of adhesive, partial small-bowel obstruction is unclear. The goal of this study was to determine whether a combination of specific oral medications in adhesive, partial small-bowel obstruction will decrease the need for operative intervention. METHODS: Of 266 consecutive adult patients with partial small-bowel obstruction admitted at a tertiary medical center, 236 were randomized into 2 groups. Group I patients were treated with intravenous hydration, nasogastric tube decompression, and NPO. Group II patients were placed on intravenous hydration, nasogastric tube decompression, and oral fluids incorporating an oral laxative, a digestant, and a defoaming agent. We compared differences between the groups in (1) the number of patients having a successful nonoperative treatment, (2) complications, and (3) recurrence of symptoms. RESULTS: A total of 116 and 120 patients comprised groups I and II, respectively. The number of patients treated successfully by a nonoperative approach was less in group I than in group II (77% vs 90%, P < .01). The complications and recurrence rate for groups I and II did not differ (4% vs 5% and 5% vs 4%, respectively). CONCLUSIONS: The NPO status for patients with adhesive, partial small-bowel obstruction may not be necessary. This cocktail of oral medications can decrease the need for operative intervention in patients with presumed adhesive, partial small-bowel obstruction.     

A simple technique for diagnosing oesophageal intubation

Undiagnosed oesophageal intubation during anaesthesia is a major cause of anaesthetic-related morbidity and mortality. A test was devised and evaluated to distinguish between placing an endotracheal tube in the trachea and in the oesophagus. The test involves threading a lubricated nasogastric tube through the endotracheal tube, applying continuous suction to the nasogastric tube and then attempting to withdraw the nasogastric tube. Four aspects distinguish an endotracheal tube in the trachea from one in the oesophagus: 1. the length of nasogastric tube inserted and the feel of the final obstruction to further insertion. 2. the ability to maintain unobstructed suction through the nasogastric tube, 3. the ease of withdrawal of the nasogastric tube during continuous suction, 4. the nature of any aspirate (i.e. mucus or gastric contents). An evaluation was performed on twenty patients in whom both the trachea and oesophagus were intubated simultaneously. In all twenty cases, each of the two endotracheal tubes was correctly identified as being either tracheal or oesophageal. The ability to maintain suction and the ease of withdrawal most clearly distinguished between the two positions.     

A prospective randomized study of abdominal aortic surgery without postoperative nasogastric decompression

Nasogastric decompression following abdominal aortic aneurysmectomy or bypass, for 3–4 days, is a routine part of postoperative care in many centers. A prospective randomized study of 80 patients undergoing abdominal aortic surgery was performed in order to determine the necessity of prolonged nasogastric decompression. Patients were divided evenly between removal of the nasogastric tube upon tracheal extubation and retention of the tube until the passage of flatus. Preoperative risk factors, aortic cross-clamp time, estimated blood loss, length of procedure, length of intensive care unit stay, numbers of days with nasogastric tube, number of days until clear liquid and regular diets commenced, and the length of hospital stay were recorded for all patients. There were no significant differences in any of the measured variables between the two groups. The length of hospital stay was similar in both groups and three patients in each group required a nasogastric tube or reinsertion of one. In conclusion, the routine postoperative use of nasogastric tubes for abdominal aortic procedures is unnecessary. Copyright © 1996 The International Society for Cardiovascular Surgery.     

Long tube decompression is successful in 90% of patients with adhesive small bowel obstruction

BACKGROUND: For patients with small bowel obstruction (SBO), who do not have strangulation obstruction or other contraindications, long tube decompression has been successful in 75% in two studies. In a 1995 prospective randomized study, comparing nasogastric suction (short tube) with long tube decompression, the short tube was successful in 51% and the long tube was successful in 75%. Using upper gastrointestinal endoscopy, a long tube can be advanced into the jejunum in 20 minutes, so the delay in function has been eliminated. METHODS: There were 35 patients with 37 episodes of SBO. From 1983 to 1988, three tubes then available were advanced endoscopically into the jejunum in 17 patients. From 1989 to 2002, an improved tube designed for endoscopic placement was used in 20 patients. RESULTS: From 1983 to 1988 using three tubes, long tube decompression was successful in 12 of 17 (70%); from 1989 to 2002 with the improved tube, decompression was successful in 18 of 20 (90%). CONCLUSIONS: For patients with SBO due to adhesions, a trial with long tube decompression for 48 to 72 hours is recommended. For those who fail a trial with the long tube, laparotomy with enterolysis or bowel resection is indicated. If the operative findings indicate a high risk for recurrent obstruction, then long tube splinting of the small bowel should be considered.     

肠内全程导管减压法用于术后早期炎性肠梗阻治疗的研究

目的评价经鼻置入导管行肠内全程减压在术后早期炎症性肠梗阻保守治疗中的作用。方法回顾性分析北京大学第三医院2005年3—8月收治的8例腹部手术后早期炎症性肠梗阻的病人，使用鼻胃管减压等常规保守治疗无效后，经鼻置入导管行肠内全程减压，并进行胃肠减压治疗，观察其治疗效果。结果与鼻胃管相比，使用肠内全程导管减压后，病人的胃肠减压量明显增加、腹围和腹腔内压力明显降低；通过3～10d的经鼻置入导管减压等保守治疗后，8例病人的肠梗阻症状均缓解，未再接受手术治疗。结论经鼻肠内全程导管减压用于治疗术后早期肠梗阻安全有效，且可能使病人免于再次急诊手术。     

Treatment alternatives in renal failure and renal transplantation patients with nonobstructive colonic dilatation

The incidence of nonobstructive colonic dilatation (NCD) is unknown, but the attendant mortality associated with perforation is nearly 50%. Patients with chronic renal failure and transplant recipients may manifest many of the conditions that have been implicated in the development of NCD. Mechanical obstruction and ischemic bowel disease must be eliminated as causes for colon dilatation. Over a four-year period eight patients (mean age 50 years) were treated for presumed NCD. Six patients with a mean cecal diameter of 12.8 cm were treated initially with colonoscopy. Five patients (83%) had successful endoscopic decompression; of the three remaining patients, one underwent urgent ileocolectomy for cecal ischemia after unsuccessful endoscopic decompression, a second (cecal diameter 13 cm) had a tube cecostomy performed as an initial procedure, and the third (cecal diameter 9 cm) was managed successfully with enemas and nasogastric suction. Two deaths occurred in the series (25%), but both were unrelated to colon distension. No complications of colonoscopy were observed. The sequelae of massive NCD (cecal ischemia, perforation, and protracted sepsis) are poorly tolerated in the immunocompromised patient. Conservative management may be employed in patients with a cecal diameter of 9 cm, but urgent diagnostic and therapeutic colonoscopy is recommended for patients with a cecal diameter of 12 cm or greater. Operative tube cecostomy may be necessary if colonoscopic decompression is unsuccessful or cannot be performed.     

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在缤纷的礼花和欢快的节日乐曲中，我们已经迎来了崭新而豪迈的2006年。在新的一年到来之际，我们谨代表《中国实用外科杂志》编辑委员会和编辑部，向所有关心和支持《中国实用外科杂志》的外科界同仁致以诚挚的谢意和亲切的问候。并借此机会向多年来给予《中国实用外科杂志》关心和帮助的各级领导、诸位专家和广大读者、作者表示衷心的感谢和美好的祝福!     

Rapid resolution of small-bowel obstruction with the long tube, endoscopically advanced into the jejunum

BACKGROUND: Long-tube decompression has achieved a 75% to 80% success rate in 5 studies, and the short tube had a 40% success rate in 3 studies. METHODS: From 1984 to 1991, an endoscope-advanced long intestinal tube was placed into the jejunum in 17 patients, and from 1992 to 2004 an improved long tube was used in 23 patients. Costs were calculated for each type of procedure. RESULTS: In the first group, decompression was successful in 12 of 17 patients (70%). In the second group, decompression was successful in 21 of 23 patients (90%). The average charges were as follows: for the short tube the average charge was 21,687 dollars, and for the long tube the average charge was 11,316 dollars. CONCLUSIONS: First, by using the improved long tube, which was advanced endoscopically into the jejunum, the success rate was 90% with procedures that are standard in every hospital. Second, most patients who fail the short-tube procedure are candidates for the long tube. Third, the improved long tube, endoscopically advanced into the jejunum, is recommended strongly because it provides significant advantages, both clinically and economically, over the short-tube approach. A prospective randomized study comparing the short tube for 3 days versus the long tube for 3 days is recommended to prove the superiority of the long tube in patients with small-bowel obstruction.     

Is routine postoperative nasogastric decompression really necessary?

Controversy exists regarding the need for nasogastric tube decompression and the incidence of complications resulting from its use following major intra-abdominal surgery. To determine the value of such tubes, 100 patients were managed after surgery with a nasogastric tube in situ until the passage of flatus per rectum (Group I). In a second group of 100 patients, no nasogastric tube was placed after surgery unless vomiting, gross distention, or overt obstruction occurred (Group II). In Group I, the nasogastric tube remained in place an average of 6 days and five patients required replacement of the tube after its initial removal. In Group II, nasogastric intubation was required at some point after surgery in six patients. No aspiration pneumonia, nasal septum necrosis, anastomotic leak, or wound dehiscence was seen in either group. There were three wound infections in Group I and two in Group II. The most obvious difference was the increased comfort and mobility of the group of patients treated without routine nasogastric decompression (Group II). Routine use of the nasogastric tube adjunct to patient care following gastrointestinal tract surgery may be safely eliminated.     

善宁联合泛影葡胺治疗老年人黏连性小肠梗阻

目的　探讨老年人黏连性小肠梗阻保守治疗安全有效方法。方法　 6 7例老年黏连性小肠梗阻病人 ,随机分成A组 35例 ,加用善宁 0 .1mg皮下注射q8h,并经胃管注入 76 %的泛影葡胺10 0ml;B组 32例为对照组。结果　A组保守治疗成功者 32例 ,B组 2 6例 ;A组胃肠引流量少于B组 ;第一次排气排便时间短于B组 ;住院时间短于B组。A组 3例 ,B组 6例中转手术治疗 ;A组无死亡 ,未发生因保守治疗延误病情 ,B组一例因术后肺部感染加重而死亡。结论　善宁联合泛影葡胺治疗老年人黏连性小肠梗阻 ,安全有效 ,临床上可以推广。     

Routine omission of nasogastric intubation after gastrointestinal surgery.

The need for routine nasogastric-tube decompression after gastrointestinal surgery has been challenged repeatedly for several years. To determine whether nasogastric intubation can be omitted routinely, 101 consecutive patients who underwent gastrointestinal surgery were managed prospectively without nasogastric tubes. Excluded were patients with complete bowel obstruction and those who required prolonged endotracheal intubation. These patients were compared with 101 retrospective controls who had nasogastric decompression routinely. There were four protocol violations in the prospective group (nasogastric tubes were left in place postoperatively) and one in the retrospective group (no nasogastric tube postoperatively), leaving 97 and 100 patients, respectively, for follow-up. The mean duration of hospitalization in comparable patients was 10.6 days in patients without decompression and 11.9 days in those with routine decompression. Subsequent nasogastric-tube insertion was required in nine patients who did not undergo routine decompression, compared with two patients who had routine decompression. There were no statistically significant differences in the rates of anastomotic leaks, wound disruptions and pulmonary or other complications between the two groups. The authors conclude that nasogastric decompression can be safely omitted as a routine part of postoperative care after gastrointestinal surgery.     

A prospective randomized trial of routine postoperative nasogastric decompression in patients with bowel anastomosis.

Until relatively recently, the nasogastric (NG) tube has been used routinely for decompression in the patient with small- or large-bowel anastomosis. To determine if routine postoperative NG decompression benefited such patients, 102 patients were randomized prospectively to either NG decompression or no-NG tube. Excluded were patients with chronic bowel obstruction, peritonitis, gross fecal contamination or spillage, and previous abdominal or pelvic irradiation. There were 52 patients in the no-NG group and 50 in the NG group. Patients in the no-NG group had earlier bowel sounds, return of flatus, oral intake and first bowel movement. Four patients (8%) in the no-NG group, compared with one patient (2%) in the NG group, required subsequent decompression. Length of hospital stay was significantly (p < 0.001) shorter in the no-NG group. There were no significant differences in the presence of atelectasis, postoperative fever, wound infections and anastomotic leaks between the two groups. The authors conclude that routine nasogastric decompression is not warranted after elective surgery involving small- or large-bowel anastomosis.     

Gastric fluid volume in infants for pyloromyotomy

Purpose

To quantify gastric fluid volumes in infants with pylonc stenosis presenting for pyloromyotomy and to demonstrate endoscopically the efficacy of blind aspiration for gastric fluid recovery. We hypothesized that previous diagnostic contrast studies, preoperative nasogastric suction, and fasting interval would not affect these volumes.

Methods

Seventy-five infants scheduled for pyloromyotomy were given atropine before induction of anaesthesia. For those who had undergone preoperative nasogastric suction, the nasogastric tube was aspirated and removed. A 14 F multionficed orogastric catheter was blindly passed to aspirate gastric fluid for measurement. Following tracheal intubation. I 5/75 subjects underwent gastroscopy to measure residual gastric fluid.

Results

Gastric fluid volume removed by blind aspiration averaged 4.8 ± 4.3 ml·kg^?1 with 83% of patients having > 1.25 ml·kg^?1. Although 14 of the 15 patients evaluated by endoscope had ≤ 1 ml residual gastric fluid, one had 1.8 ml·kg^?1. Recovery of total gastric fluid volume by blind aspiration averaged 96 ± 7%. The large gastric fluid volumes were independent of a history of banum study, preoperative nasogastric suction, and fasting interval.

Conclusion

Infants with pylonc stenosis have large gastric fluid volumes which are not substantially reduced by preoperative nasogastric suction. Blind aspiration of gastric contents prior to induction of anaesthesia provides a reliable estimate of total gastric fluid for most of these infants, although the occasional infant may retain a small amount of gastric fluid. The clinical importance of such a residual volume is uncertain.     

Laparoscopy for acute small-bowel obstruction secondary to adhesions

BACKGROUND AND PURPOSE: Postoperative adhesions are the leading cause of small-bowel obstruction in developed countries. Several arguments suggest that laparoscopy may lead to fewer adhesions than does laparotomy. We report here the short-term results of laparoscopy in patients admitted on an emergency basis for acute small-bowel obstruction secondary to adhesions. PATIENTS AND METHODS: This prospective trial included 134 consecutive patients: 39 underwent emergency surgery, and 95 had laparoscopic adhesiolysis shortly after resolution of the obstruction with nasogastric suction. Of the previous operations for which the dates were known, 16% had taken place within 1 year of the obstruction and 33.5% within 5 years. In all, 27% of the patients had open laparoscopy, and 16% had conversions: 7% after elective laparoscopy and 36% after emergency laparoscopy. RESULTS: There were no operative deaths. One patient underwent a reoperation the following day for fistula after incomplete adhesiolysis attributable to multiple adhesions found during elective laparoscopy. If laparoscopy is considered to have failed when adhesiolysis was incomplete or conversion or reoperation was necessary, our success rate was 80% after elective laparoscopy and 59% after emergency laparoscopy. CONCLUSION: Emergency situations in acute small-bowel obstruction combine several circumstances unfavorable for laparoscopy: a limited work area and a distended and fragile small bowel. Laparoscopic adhesiolysis after the crisis has passed may produce better results, but only long-term follow-up can confirm the role of elective laparoscopy for this indication.     

Acute pseudo-obstruction of the colon

Fourteen patients with acute pseudo-obstruction of the colon (Ogilvie's syndrome) were treated over a 16-year period. Ten patients (71.4%) had a recent history of mental illness and were treated with hypnotic and sedative drugs uninterruptedly for many months. The clinical picture and abdominal radiographs on admission to hospital were typical of acute mechanical obstruction of the colon; 1 patient had a perforation of the transverse colon. Obstruction was ruled out by barium enema in 9 patients, by colonoscopy in 3 and by immediate laparotomy in 2. Twelve patients were treated conservatively by nasogastric tube, correction of fluid and electrolyte imbalance, enemas, cessation of all hypnotic and sedative drugs, and decompression of the colon using a rigid rectoscope and rectal tube. There were no complications and no deaths. Ogilvie's syndrome should be suspected in patients with symptoms of large-bowel obstruction whose history discloses intake of hypnotic and sedative drugs. After mechanical obstruction is ruled out, conservative management is indicated. It should include cessation of all psychopharmacological agents and decompression of the colon by rectal intubation or colonoscopy. If conservative measures fail and the caecum increases in size, operative decompression by transverse colostomy rather than cecostomy is indicated.     

Tube gastrostomy. Techniques and complications.

For prolonged gastrointestinal decompression or enteral nutrition, gastrostomies are preferable to nasogastric tubes. To assess the safety of tube gastrostomy, the authors reviewed 424 gastrostomies systematically selected from a total of 3,359 done from 1975 through 1980. Feeding gastrostomies composed 22% of the total; the remaining 78% were done for decompression. Complications were rare (6.6% major, 6.6% minor) and were not influenced by patients' age. Perioperative steroid therapy promoted laparotomy wound infections. External and internal leakage of stomach contents, as well as bleeding from the gastrostomy site, were independent of the method of gastrostomy and the type of catheter used. Feeding gastrostomies were more likely to leak internally than were decompression gastrostomies. Unless the gastrostomy site was sutured to the anterior abdominal wall, there was a 7% incidence of extravasation of stomach contents into the peritoneal cavity after removal of the tube. The low complication rate justifies use of gastrostomies as an alternative to prolonged nasogastric intubation. Problems are minimized by employing the Stamm technique with a straight catheter and anterior gastropexy.     

A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy.

OBJECTIVE: A meta-analysis of all published clinical trials comparing selective versus routine nasogastric decompression was performed in an attempt to evaluate the need for nasogastric decompression after elective laparotomy. BACKGROUND: Many studies have suggested that routine nasogastric decompression is unnecessary after elective laparotomy and may be associated with an increased incidence of complications. Despite these reports, many surgeons continue to practice routine nasogastric decompression, believing that its use significantly decreases the risk of postoperative nausea, vomiting, aspiration, wound dehiscence, and anastomotic leak. METHODS: A comprehensive search of the English language medical literature was performed to identify all published clinical trials evaluating nasogastric decompression. Twenty-six trials (3964 patients) met inclusion criteria. The outcome data extracted from each trial were subsequently "pooled" and analyzed for significant differences using the Mantel-Haenszel estimation of combined relative risk. RESULTS: Fever, atelectasis, and pneumonia were significantly less common and days to first oral intake were significantly fewer in patients managed without nasogastric tubes. Meta-analysis based on study quality revealed significantly fewer pulmonary complications, but significantly greater abdominal distension and vomiting in patients managed without nasogastric tubes. Routine nasogastric decompression did not decrease the incidence of any other complication. CONCLUSIONS: Although patients may develop abdominal distension or vomiting without a nasogastric tube, this is not associated with an increase in complications or length of stay. For every patient requiring insertion of a nasogastric tube in the postoperative period, at least 20 patients will not require nasogastric decompression. Routine nasogastric decompression is not supported by meta-analysis of the literature.     

Ventilatory failure due to an improperly placed nasogastric tube

A case is described of a 35-yr-old patient who was transferred to the operating room for the repair of a right ventricular laceration. Prior to transfer a nasogastric tube was placed unknowingly beyond the tracheal tube cuff into the trachea. During the surgery, the patient's head was turned to insert a central venous line at which time the ventilator low pressure alarm sounded and effective ventilation ceased. The problem was corrected by turning off the nasogastric tube suction. It is postulated that the nasogastric tube became unkinked when the head was turned and this led to the evacuation of gas from the lungs and breathing circuit through the nasogastric tube suction. Identification of the problem was complicated by the lack of a temporal relationship between the insertion and connection to suction of the nasogastric tube, and the episode of ventilatory failure.