Experiences with intraluminal small intestinal intubation

Seventy-six patients were treated for postoperative ileus of the small intestine, between 1983 and 1987. Forty-four of them received intraluminal intestinal intubation, with indications being established by stringent criteria. One case of recurrent ileus was recorded eight weeks after removal of the Miller-Abbott tube, but no tube-related lethality was observed. The average age of our patients was as low as 49 years. Post-operative lethality amounted to 21.2 percent (eight in 44). Ileus was not removed until death in three cases. Intraluminal intestinal intubation may be recommended after long-distance lysis of adhesions for postoperative ileus of the small intestine as well as in cases of severe ileus in concomitance with controllable peritonitis.     

Emergency interventions in complicated colonic diverticulosis

An account is given in this paper of 480 patients who had been hospitalised for colonic diverticulosis or diverticulitis in the surgical department of the Municipal Waid Hospital of Zurich, between 1970 and 1986. Laparotomy had to be performed on 219 of them (45.6 per cent), among them 84 emergency interventions. The average age of these patients was 70.7 years. Indications for emergency surgery included diffuse or locally delimited peritonitis with abscess development in 72 patients, ileus in ten cases, and massive colon haemorrhage in two. The latter two cases were handled with good success by subtotal colectomy with ileorectostomy and, one of them with the source of bleeding known, by colotomy and suturing of that source of bleeding. Sigmaincontinence resection according to Hartmann has been considered the optional approach since 1977 to diffuse peritonitis and to many cases of ileus (n = 39). In more recent time, anastomosis has been used as primary approach to some patients who survived fibrinous abdominal peritonitis (n = 4). The mortality rate associated with drainage operations according to expectation, has been clearly higher than that following resection, the comparable figures being 32.3 and 17.2 per cent. That has been attributable to non-removal of the septic focus. After all, nowadays combined antibiotic therapy is commonly used for seven to ten days for simultaneous control of both aerobic and anaerobic pathogens. This has become routine practice and involves aminoglycoside, metronidazole, and ampicillin. Overall mortality associated with emergency interventions is clearly higher than that after planned operations, the figures being 22.6 and 4.4 per cent.(ABSTRACT TRUNCATED AT 250 WORDS)     

Transmesenteric small bowel plication or intraluminal tube stenting. Indications and contraindications.

Controversy exists as to the efficacy of transmesenteric intestinal plication or long tube stenting of the small bowel in the treatment of severe intestinal adhesions and in late small bowel obstruction.We reviewed our experience with these procedures over a 12 year period with complete follow-up data on 92 per cent of the patients. There were 28 modified Childs-Phillips plications and 37 intraluminal tube decompressions and stenting. For comparison we reviewed 107 cases of small bowel obstruction treated by simple lysis of adhesions.Three deaths and one small bowel fistula were associated with the modified Childs-Phillips procedure; none was directly related to the plication. Three patients required reoperation within the 1st postoperative week for technical reasons. No late operations for recurrent small bowel obstruction were required.One death and one reoperation for bowel obstruction were associated with but not directly related to the Baker tube stenting.Four deaths were associated with simple lysis. Seven patients required reoperation for late recurrent small bowel obstruction.Modified Childs-Phillips transmesenteric plication using nonabsorbable sutures is recommended in cases of severe visceral and parietal peritoneal damage but not in cases of distention and severe ileus of the small bowel or acute generalized peritonitis.Baker tube jejunostomy with decompression and splinting of the small bowel is recommended with massive distention and ileus of the small bowel. Peritonitis is not a contraindication. In our experience fewer short-term complications have occurred after long tube decompression and stenting than after modified Childs-Phillips plication. Measures to avoid these complications are presented. With proper indications, modified Childs-Phillips plication and intraluminal tube stenting are safe and efficient in preventing reobstruction.     

Incidence of postoperative adhesion obstruction following neonatal laparotomy

Of 649 neonates undergoing laparotomy in a 10 year period, 54 (8.3 per cent) developed adhesion related intestinal obstruction requiring surgical treatment. In 16 infants the obstruction followed a period of prolonged postoperative ileus, while the remaining 38 had completely recovered from the previous surgical procedure before the development of obstruction. The adhesion obstruction occurred after a single neonatal laparotomy in 35 cases but the remaining 19 had undergone subsequent laparotomies; 75 per cent of the obstructions developed within 6 months and 90 per cent within 1 year of surgery. The highest risk groups were infants undergoing correction of gastroschisis (15.4 per cent) and malrotation (15 per cent). There were nine deaths, two of which were a direct consequence of the adhesion obstruction.     

Rapid long tube intubation of the jejunum by a new endoscopic device.

Despite the advantages of aseptic nonoperative intubation of the small intestine for decompression of obstructed loops, 48% of the attempts lead to failure to pass the tube through the pylorus. The difficulty and inconvenience of passage beyond the stomach have been overcome by the development of a special tube attachment adapted to a fiberoptic duodenoscope (Olympus Model GIF-K). Under direct endoscopic vision the tube can be carried into the second and third portion of the duodenum, released from the scope, and then further prodded into the jejunum. The entire procedure takes less than 15 minutes. Rapid intubation has now been easily carried out in five patients. Three patients had mechanical bowel obstruction. Rapid and effective decompression allowed adequate time for stabilization of concomitant serious problems such as (1) marked cardiopulmonary dysfunction secondary to a near fatal pulmonary embolus, (2) severe peritonitis post appendectomy, and (3) acidosis and dehydration. Surgical correction of the obstructing lesions was safely deferred for up to one week until the concomitant problems improved. The fourth patient, who was a renal transplant recipient, had chronic gastric ileus secondary to duodenal ulcer. Rapid passage of the long tube into the jejunum allowed restoration of nutrition and avoidance of gastrostomy. The fifth patient, with an ileus secondary to an infected abdominal aortic graft, underwent successful decompression but died of sepsis. He represents the only mortality. We propose that jejunal intubation using our technic is not only rapid but relatively easy and should encourage the wider acceptance of aseptic long tube intestinal decompression.     

Peritonitis: Pathologic physiology involved in treatment

Peritonitis can usually be divided into an early formative or absorptive stage during which bacteriemia and bacterial toxemia preponderate, and the fully developed later stage in which circulatory disturbances and inhibition ileus preponderate.The most important factors that enter into the production of symptoms are: (a) bacteriemia and toxemia; (b) dehydration and demineralization; (c) reflex symptoms of nausea, anorexia and general depression; (d) inhibition ileus; (e) circulatory disturbances; (f) anoxemia, and (g) starvation.The most important local defensive factors against peritoneal infection are phagocytosis, formation of a fibrinous exudate and early localized intestinal inhibition. The general antibacterial activities are interfered with by anhydremia, demineralization, disturbances of the acidbase balance, anoxemia and circulatory disturbances.The surgical treatment involves the early removal of the focus of infection, with constant consideration of the importance of not disturbing the local defensive mechanisms.Dehydration and demineralization are treated by means of normal saline, Ringer's and Hartmann's solutions.The anoxemia is treated by correcting circulatory disturbances and by the early use of oxygen inhalations.To increase the colloid osmotic pressure of the plasma when a shock syndrome exists, 6 per cent acacia solution with minute doses of pitressin are to be used. (Suprarenal cortex extract may be of some value.)Fluids are not to be administered by mouth during any stage of peritonitis because they stimulate gut activity. However fluids may be given by mouth during the time that duodenal intubation with suction is applied.Proctoclysis and enemas are contraindicated in the early cases of peritonitis due to gangrenous appendicitis, when physiologic rest of the cecum is most desirable.Morphine is needed to control pain. It is doubtful whether deep morphinization has any specific beneficial effect in peritonitis and its deleterious effect upon the respiratory mechanism as well as upon the immune reactions must be borne in mind.The splanchnic vasomotor paralysis may be treated in the early stages only by means of small doses of ephedrine. Ephedrine also probably lessens “weeping” from the peritoneum and plasma loss into the intestine, and its inhibitory effect upon gut motility is of advantage during the early stages.Inhibition ileus and distention are treated by means of duodenal intubation and hypertonic salt solution intravenously. The stimulating effect of hypertonic salt solution upon propulsive intestinal motility contraindicates its use in the early formative stages.Glucose solutions are especially indicated during the starvation stage.Fowler's position is of definite value during the early, formative stages. Later the state of the circulation and the patient's comfort should determine the position of the patient.Mild x-ray treatment during the early formative stages of peritonitis is probably indicated because it raises the antibacterial defense mechanisms.The possibility of a mechanical obstruction occurring in peritonitis, from kinking of the bowel, localized abscess, or from a plastic exudate is to be borne in mind. Enterostomy is indicated only after the simple method of duodenal intubation with suction has been given a trial.Spinal anesthesia is contraindicated during the early absorptive stages of peritonitis because of its stimulating effect upon peristalsis. Ether is contraindicated during any stage of peritonitis.The inefficacy of drainage in general peritonitis cases is briefly discussed.     

Early diagnosis of diffuse peritonitis

Treatment for diffuse peritonitis was applied to 62 patients at the Surgical Clinic of Münster University, between 1983 and mid-1985. Mortality accounted for 46.8 per cent. Therapeutic approaches depended on both clinical patterns and intraoperative findings. Repetitive laparotomy with abdominal lavage and generous drainage was predominant. Only five cases were given treatment with opened abdominal cavity. With early diagnosis and immediate laparotomy, 17.7 per cent of all patients were cured, and no further operation was required. A second operation was necessary for 19.3 per cent, and several laparotomies were needed by another 16.1 per cent. Twenty of the above 62 patients (32.3 per cent) died in spite of several laparotomies. Nine patients (14.5 per cent) had been received in moribund and thus inoperable condition. The mean interval between first and second laparotomies was 5.3 days. Repeated abdominal lavage became necessary in cases in which the start of therapeutic action was delayed to 6.4 days on average. This interval had been 8.3 days for patients who died despite repeated surgery. Early diagnosis was found to be the decisive prerequisite to lower peritonitis lethality. Clinical parameters in conjunction with routine laboratory checks have proved to be sufficient for adequate diagnosis in 95 per cent of all cases. High-risk patients have to be identified long time in advance. They require early surgery and intensive postoperative supervision and monitoring, if the fatal vicious circle of peritonitis is to be overcome.     

Stellenwert der intraluminalen Darmdekompression durch eine endoskopisch plazierte Dennis-Sonde in der Therapie des Ileus

For determination of the efficacy of intraluminal bowel decompression by an endoscopically placed Dennis tube, 174 patients with paralytic ileus or different kinds of partial small bowel obstruction were reviewed retrospectively. There were 66 cases (37.9%) of early post-operative ileus (A), 27 (15.5%) of late postoperative ileus (B), 38 (21.8%) of paralytic ileus (C), 31 (17.8%) with obstruction due to advanced intraabdominal tumors (D), and 12 (6.8%) of obstructive ileus caused by inflammatory stenosis of the small bowel in Crohn's disease (E). Successful endoscopic placement of the intestinal tube was achieved in 97.2% of patients. Placement of the tube was impossible in 5 cases. A total of 95 patients (54.6%) were successfully managed by long intestinal tube decompression. Success rates for the individual groups were 71.2% (A), 18.5% (B), 86.8% (C), 16.1% (D), and 41.7% (E). Some 75 patients (43.1%) had to be operated on because of insufficient conservative therapy. Four patients with advanced intraabdominal tumors died during the treatment with the intestinal tube; 13 patients died postoperatively. There was no tube-related mortality, but tube-related complications occurred in 6.9%. We conclude that intraluminal intestinal tube decompression after endoscopic placement provides a therapeutic tool with a concomitant low complication and high success rate in paralytic and early postoperative ileus.     

Role of resection and primary anastomosis of the left colon in the presence of peritonitis

BACKGROUND: Classically a primary colonic anastomosis is not performed in the presence of left colonic peritonitis. Recently there has been a trend towards resection and anastomosis in selected patients, but no prospective study concerning the safety of this approach has been published. The objective of this study was to define the role of intraoperative colonic lavage with resection and primary anastomosis (RPA) in left colonic peritonitis, and to evaluate the differences in outcome in patients with diffuse or localized peritonitis. METHODS: Between January 1994 and December 1998, 127 patients underwent emergency operation for a distal large bowel perforation. RPA was the operation of choice and was performed in 61 patients, 38 with localized and 23 with diffuse peritonitis. Septic shock, faecal peritonitis, immunocompromised status and American society of Anesthesiologists grade IV were contraindications to the one-stage procedure. Alternative operations used in high-risk patients were Hartmann's procedure in 55 patients, subtotal colectomy in eight and colostomy in three. RESULTS: There were two deaths (3 per cent) among 61 patients treated by RPA and one (2 per cent) case of clinical anastomotic dehiscence. Overall morbidity was 39 per cent and the overall mean(s.d.) hospital stay was 18(15) days. No statistical differences were observed between patients with localized and diffuse peritonitis treated by RPA. CONCLUSION: RPA may be the operation of choice in selected patients with left colonic diffuse peritonitis.     

结直肠癌性肠梗阻术前经肛门置肠梗阻导管的临床研究

为探讨结直肠癌性肠梗阻患者术前经肛门置肠梗阻导管的应用价值,对2008年3月至2013年3月我院收治的70岁以下且未合并严重慢性病的60例结直肠癌性肠梗阻患者,于内镜引导下经肛门放置肠梗阻导管,引流肠内容物并行肠道准备,拟行一期结直肠癌切除肠管吻合术。结果显示,60例患者中,58例肠梗阻导管放置成功,另2例因肿瘤处肠腔过度狭窄,且位于肠管弯曲处,导管无法通过而致治疗失败。成功放置肠梗阻导管的58例患者经4～5d治疗肠梗阻完全缓解,再经2～3d肠道准备拟行一期结直肠癌根治肠管吻合术,术中发现2例患者肠道准备欠佳,遂行预防性肠造口,其中1例术后发生吻合口漏,经保守治疗治愈,其他患者一期手术成功,术后未发生并发症。结果表明,结直肠癌性肠梗阻患者术前经肛门置肠梗阻导管可解除肠梗阻,为一期手术治疗创造条件,避免或减少患者二次手术机会,减轻患者痛苦及经济负担,具有较高的应用价值。     

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.     

Randomized clinical trial evaluating the need for routine nasogastric decompression after elective hepatic resection

BACKGROUND: The value of routine nasogastric tube (NGT) decompression after elective hepatic resection has not been investigated. METHODS: Of 200 patients who had elective hepatic resection, including 68 who had previously had colorectal surgery, 100 were randomized to NGT decompression, where the NGT was left in place after surgery until the passage of flatus or stool, and 100 to no decompression, where the NGT was removed at the end of the operation. RESULTS: There was no difference between patients who had NGT decompression and those who did not in terms of overall surgical complications (15.0 versus 19.0 per cent respectively; P = 0.451) medical morbidity (61.0 versus 55.0 per cent; P = 0.391), in-hospital mortality (3.0 versus 2.0 per cent; P = 0.640), duration of ileus (mean(s.d.) 4.3(1.5) versus 4.5(1.7) days; P = 0.400) or length of hospital stay (14.2(8.5) versus 15.8(10.8) days; P = 0.220). Twelve patients randomized to no NGT decompression required reinsertion of the tube 3.9(1.9) days after surgery. Previous abdominal surgery had no influence on the need for NGT reinsertion. Severe discomfort was recorded in 21 patients in the NGT group and premature removal of the tube was required in 19. Pneumonia (13.0 versus 5.0 per cent; P = 0.047) and atelectasis (81 versus 67 per cent; P = 0.043) were significantly more common in the NGT group. CONCLUSION: Routine NGT decompression after elective hepatectomy had no advantages. Its use was associated with an increased risk of pulmonary complications.     

Application of transcatheter detoxication therapy as a combined treatment of intestinal obstruction and diffuse peritonitis

Causes of death of 65 patients with ileus and 43--with diffuse peritonitis for 1998-2000 period were analyzed. Considering the data obtained the improved programme of the via intubation probe treatment was used. Application of elaborated treatment charts have allowed to lower the mortality in ileus--down to 9.4%, in diffuse peritonitis--to 6.6%.     

小肠内支撑排列术治疗多次术后广泛粘连性肠梗阻

目的总结小肠内支撑排列术治疗多次术后广泛粘连性肠梗阻的临床经验与疗效。方法回顾分析1995～2003年间采用小肠内支撑排列术治疗多次术后广泛粘连性肠梗阻21例患者的临床资料。结果20例患者术后无并发症发生,顺利康复。1例肠坏死肠切除病例术后发生肠瘘,经内支撑管持续低负压引流后迅速痊愈。19例患者经1～7年随访,均未出现肠粘连和肠梗阻。结论对多次手术(2次以上)后出现广泛粘连性肠梗阻患者,小肠内支撑排列术是一种操作简单、安全而有效的术式。     

Recurrent ileus in jejunal diverticulitis

Jejunal diverticula are in most cases acquired lesions of the intestinal wall, which are caused by abnormalities of smooth muscle or myenteric plexus. They may lead to more complications than previously expected. The described patient developed an acute abdomen 8 years after an ileus due to jejunal diverticulitis with enterolith formation and resection of two jejunal diverticula. Immediate laparotomy had demonstrated again an ileus, partly induced mechanically by an obstruction due to 2 enteroliths, partly induced paralytically due to local peritonitis. The surgical significance of jejunal diverticula is discussed.     

Experiences in small intestine intubation in pediatric surgery

An account is given in this paper of intestinal intubation, the most promising approach at present to postoperative ileus. Reference is made to causes and to preventive methods used in the past. Classical techniques and their variants are described, with peculiarities being mentioned together with possible complications. Positive results have enlarged the list of intraabdominal diseases in which cases intubation should be justified. Fifteen children died out of 55 with intestinal intubation. However, those deaths could not be attributed to intubation, since no ileus was recordable on post-mortem from any of these cases. They were rather attribute to pre-existence of general damage or to postoperative complications which had unfavourable effects primarily on prematurely born children, newborns, and infants up to one month of age. Hence, intestinal intubation may be considered to be the most effective and least risky approach to the control of mechanical or combined paralytico-mechanical ileus.     

El íleo biliar como causa de abdomen agudo. Importancia del diagnóstico precoz para el tratamiento quirúrgico

Gallstone ileus is an uncommon type of mechanical intestinal obstruction caused by an intraluminal gallstone, and preoperative diagnosis is difficult in the Emergency department. This study is a retrospective analysis of the clinical presentation of 5 patients with gallstone ileus treated between 2000-2010. Clinical features, diagnostic testing, and surgical treatment were analyzed. Five patients were included: 2 cases showed bowel obstruction; 2 patients presented a recurrent gallstone ileus with prior surgical intervention; and one patient presented acute peritonitis due to perforation of an ileal diverticula. In all cases CT confirmed the preoperative diagnosis. In our experience, gallstone ileus may present with clinical features other than intestinal obstruction. In suspicious cases CT may be useful to decrease diagnostic delay, which is associated with more complications.     

Disordered postoperative course. A retrospective analysis

A brief definition of the term of "relaparotomy" is followed by reference to some causes of erroneous or delayed decisionmaking on re-operation. The background of postoperative disorders is, basically, one and the same throughout acute surgery: haemorrhage, peritonitis, ileus. Relaparotomy was necessary in 0.6 per cent of the authors' cases, in the course of five years. Lethality amounted to 31 per cent at an average age of 50 years. Colorectal carcinoma was the most common cause of relaparotomy, with ileus of the small intestine being the most important of all indications. The average intervals between primary surgery and relaparotomy were seven days for ileus, 3.5 days for peritonitis, and up to 24 hours for postoperative bleeding. A lethality analysis after the first operation showed that only two of 96 deaths were attributable to omission of relaparotomy. Finally, reference is made to some clinical peculiarities in postoperative developments as well as to evaluation and interpretation of paraclinical data.     

Adhesion obstruction following Nissen fundoplication in children

The incidence of postoperative adhesion intestinal obstruction among 156 children who had undergone Nissen fundoplication for intractable gastro-oesophageal reflux was determined. There were 18 episodes of obstruction in 16 patients (10.3 per cent). The mean interval between fundoplication and adhesion obstruction was 10 months (range 10 days-4 years). Additional procedures performed at the original laparotomy substantially increased the risk of developing obstruction. Relaparotomy for adhesion obstruction was required by 21 per cent of patients who had a Ladd's procedure and 12 per cent who had appendicectomy. Presenting symptoms were not typical of intestinal obstruction because many of these children were unable to vomit. Only three did vomit but all had radiological appearance suggestive of small bowel obstruction. There were two deaths directly related to adhesion obstruction.