Intestinal Obstruction Shekeeb Sufian, MD, Philadelphia, Pennsylvania Teruo Matsumoto, MD, PhD, FACS, Philadelphia, Pennsylvania
Acute intestinal obstruction is one of the most common conditions requiring emergency laparotomy. Management of this problem has gone through several evolutions. Fitz [I] advocated medical treatment and delayed surgery in the nineteenth century and Wangsteen [2] in 1931 reported on the successful management of patients by primary intestinal decompression. In the first quarter of the twentieth century, Deaver and Ross [3], Richardson [4], and others started advocating early diagnosis and operation, and for the last thirty years this doctrine has been well established. Scudder [5] in 1908 reported a mortality rate of 60 per cent; this rate declined steadily to about 20 per cent in the next thirty years [6,7] and to about 10 per cent in the 1950’s [8,9]. Although Smith, Perry, and Yonehiro [IO] reported a mortality of 12.5 per cent in a large series of 1,252 cases, overall mortality rates as high as 24 per cent have been reported in recent publications [11,12]. The objective of this study was to review cases of intestinal obstruction in our hospital during a three year period. Material and Methods Case records of patients admitted to the Hahnemann Medical College and Hospital from January 1, 1970 to January 1, 1973 with the diagnosis of intestinal obstruction were reviewed. Of the 329 cases, the records for 18 could not be located. Not included in this study were 102 cases either without sufficient evidence of obstrucFrom the Department of Surgery. Hahnemann Medical College and Hospital, Philadelphia, Pennsylvania. Reprint requests should be addressed to Teruo Matsumoto, MD, Department of Surgery, Hahnemann Medical College and Hospital, Philadelphia, Pennsylvania 19102.
Volume 130. July 1975
tion, with a diagnosis of esophageal or pyloric obstruction, or with external hernia in which only the omentum was found to be incarcerated at operation. Thirty-three cases of paralytic ileus and five cases of mesenteric vascular occlusion were also excluded. This study, therefore, represents 171 patients with mechanical intestinal obstruction either admitted directly to the general surgical services or transferred from other services. In each of these cases the diagnosis had been made by history, physical examination, and radiologic examinations. In those patients who underwent operation the diagnosis was substantiated at surgery.
Results Causes of Obstruction. Of the 171 cases of obstruction studied, 115 (67.3 per cent) were localized in the small intestine and the remaining 56 cases (32.7 per cent) were in the large bowel. Further localization of the level of obstruction was not possible. The most common causes of obstruction were adhesion (32.7 per cent), neoplasm (18.1 per cent), and external hernia (17.5 per cent). (Table I.) Adhesions were the most common cause of small intestinal obstruction and neoplasms were by far the most frequent cause of colonic obstruction. Adhesion: There were 56 cases of obstruction due to adhesion among 171 cases (32.7 per cent) and only a single obstruction was located in the large bowel. In the majority of cases the obstruction due to adhesion was in the small intestine. There was no significant difference in the numbers of males and females. Of the fifty-six patients, five (8.9 per cent) had had no previous operation. The majority had had one or more operations. There was no preponderance of any single type of intraperitoneal surgery prior to obstruction. Contrary
9
Sufian and Matsumoto
TABLE I
Causes of Intestinal
Types of Obstruction Adhesion External Hernia Internal Hernia Neoplasm Impaction volvulus lntussusception Diverticulitis Crohn’s disease Congenital anomalies Miscellaneous Undetermined Total
Total No.
Per Cent
Obstruction
and Mortality
No. of Patients Undergoing
Per Cent of 171 Patients Undergoing
Per Cent of Total Undergoing
No. of Deaths in Patients Undergoing
Mortality in 105 Patients Undergoing Operation
No. of Deaths Related to
Mortality Related to Surgery
Total No. of Deaths
(per cent)
Operation
Operation
Operation
Operation
(per cent)
Surgery
(per cent)
Mortality
56 30 7 31 13 7 2 6 3 3
32.7 17.5 4.1 18.1 7.6 4.1 1.2 3.5 1.8 1.8
2 5 1 18 0 0 1 1 0 1
1.2 2.9 0.6 10.5 0 0 0.6 0.6 0 0.6
29 27 7 23 1 6 2 5 2 0
16.9 15.7 4.1 13.5 0.6 3.5 1.2 2.9 1.2 0
51.8 90.0 100.0 74.2 7.8 85.7 100.0 83.3 66.7 0
2 4 1 11 0 0 1 1 0 0
1.90 3.81 0.95 10.48 0 0 0.95 0.95 ... ..i
... 2 1 ... ... ... 1 1 ... ...
... 1.90 0.95 ... ... ... 0.95 0.95 ... ...
4 9 171
2.3
0
0
3
1.8
75.0
0
...
...
...
5.3 100.0
3 32
1.8 18.7
0 105
0 61.4
. 0. .
0 20
*.* 19.04
‘F
... 4.75
to other reports [ll], gynecologic surgery, comprising 21 per cent of all previous operations, was not the most common previous operation. Of the fifty-six cases, twenty-nine (51.8 per cent) were treated surgically. Eight of the twentynine patients had lysis of adhesions and the rest required bowel resection. There were two deaths in the group, both of whom had had more than two previous operations and were over sixty years of age. Interestingly, in both the obstruction developed in the hospital. One patient was a seventyeight year old white female who was being treated for metastatic carcinoma of the lung, and the other was a sixty-four year old white male who had undergone aortic aneurysmectomy two weeks prior to obstruction. Both underwent operation; the first had lysis of adhesions and the second had lysis and resection of small bowel. In neither was the cause of death related to the obstruction. Hernia: Of the thirty cases of external hernia, only three caused large bowel obstruction. The majority of cases of external hernia and all the cases of internal hernia caused small bowel obstruction. As a cause of obstruction only adhesion was more frequent than the various types of hernia. Right inguinal hernia was the cause of obstruction in 32.5 per cent of the cases. Internal hernia was next in frequency, followed by as many cases of femoral as incisional hernia. No diaphragmatic or other rare types of hernia were noted. Because it was not possible to determine the number of di-
10
in 171 Cases with 32 Deaths
rect inguinal hernias, all were categorized as inguinal. Twenty-seven of the thirty patients with external hernia and all patients with internal hernia underwent operation. Most had reduction and repair of hernia and nine required bowel resection. Death occurred in five patients with external hernia and one with internal hernia. Only one patient died preoperatively, from a ruptured thoracic aneurysm on the night of admission. Of the remaining five who died postoperatively, two died of myocardial infarction, two of sepsis, and one of pulmonary edema and renal failure. Only in the last three patients was death related to surgery. Admission was delayed an average of seven days among those who died. Neoplasm: There were thirty-one cases of obstruction due to neoplastic diseases. Carcinoma was the most common cause of large bowel obstruction, with seventeen cases of obstruction of the colon. In about half the cases the tumor originated in the colon. Most of the patients with neoplasm. causing small bowel obstruction had disseminated carcinomatosis. Twenty-three of the thirty-one were treated surgically. Primary resection was performed in six, resection and diversion colostomy in five, diversion alone in nine, bypass in one, and one was inoperable. The overall number of deaths in this group was eighteen (58.1 per cent of cases of obstruction due to neoplasm and 10.5 per cent of all cases of intestinal obstruction studied). This group accounts for half of the total
The American
Journal
of Surgery
Intestinal Obstruction
deaths. The operative mortality was eleven deaths (10.5 per cent of all postoperative mortality). Impaction: Impaction was a cause of obstruction in thirteen cases (7.6 per cent). Only one patient required operation for barium impaction, and fecal diversion and colostomy was performed. No death occurred in this group. The average age was 61.2 years, which was greater than the overall average. VoZuulus: Of the seven cases of volvulus (4.1 per cent), one was of the small intestine. Two patients had cecal volvulus and both were treated surgically; one underwent resection, and the other had surgical reduction, appendectomy, and cecostomy. Both patients were young (thirty-nine and twentythree years). Four patients had sigmoid volvulus, one of whom had conservative management with sigmoidoscopy and tube decompression alone. One patient underwent tube decompression followed by resection. The remaining two had surgical reduction and underwent resection in stages. All four were older than sixty years. No death occurred in this group. Intussusception: In each of the two cases of intussusception carcinoma was the lead point at the ileocecal region. Right hemicolectomy was performed in both patients, each of whom was older than sixty years of age. There was one postoperative death of an eighty-two year old white male. Autopsy revealed perforated gastric ulcer and diffuse peritonitis. Diverticulitis: Of the six patients with diverticulitis (3.5 per cent), five underwent operation. One of the patients undergoing operation died after left hemicolectomy, aortic aneurysmectomy, appendectomy, and cecostomy. The other four underwent diversion colostomy. Crohn’s disease: Of the three patients with Crohn’s disease, all were young (thirty, twentyone, and eighteen years). Two underwent small bowel resection. No death occurred in this group. Congenital anomalies: Only three patients (1.8 per cent) presented with congenital anomalies in our study. These were due to meconium plug, cystic fibrosis with inspissated bowel, and Hirschsprung’s disease. The patient with cystic fibrosis died. None of the three underwent operation. Miscellaneous: Four cases (2.3 per cent) were classified as miscellaneous. These were due to loop obstruction, ileostomy dysfunction, anastomotic stricture at the sigmoid colon, and obstruction of the transverse colon by an afferent loop. No death occurred.
Volume 130, July lB75
MORTALITY
AS RELATED TO SEX
IOOr 40.5% 80 -
08 83
60 40
-
20 -
56.3%
43.6%
0’ TOTAL DIED -Male
TOTAL DIED Female
65.5% 100
r
112 MORTALITY
80 -
TO RACE
n 60
32.7 % 56
-
40 20 -
White
TOTAL DIED Me Black
TOTAL DIED Others
Figure 1. Mortality related to sex and race in 177 patients with intestinal obstruction.
Age Distribution. The age distribution ranged from birth to 85 years of age, with an average age of 52.7 years. Over 40 per cent of the patients were older than sixty years. As in other reports [10,11,13], mortality was related to age, and in our series 60 per cent of the deaths occurred in the patients older than sixty years. Sex and Race. There was no significant difference in the numbers of males and females (48.5 and 51.5 per cent, respectively). Although there were a few more deaths among females, the difference was not statistically significant. As seen in Figure 1, there were exactly twice as many whites as blacks, but the relative mortality was significantly higher among blacks. History and Physical Findings. The most common symptom in patients with small or large bowel obstruction was abdominal pain. In cases of small intestinal obstruction, abdominal pain was followed by vomiting, but in cases of large bowel obstruction, constipation was more frequent. The
11
Sufian and Matsumoto
physical sign most frequently present in patients with small bowel obstruction was tenderness followed by distention and hyperactive bowel sounds, whereas for the patients with large bowel obstruction it was distention followed by tenderness, hyperactive bowel sounds, and palpable abdominal mass. The great majority of our patients had had symptoms for over twenty-four hours, and only forty-eight patients (28 per cent) presented within twenty-four hours of the onset of symptoms. The mortality rate was greatly increased among patients admitted more than five days from the onset of symptoms. X-Ray and Laboratory Studies. In the great number of our patients, plain films of the abdomen led to a diagnosis of mechanical obstruction. Although we have not been able to determine the diagnostic accuracy of abdominal films, Lo, Evans, and Carey [II] have reported that only in 60 per cent of their cases were they able to diagnose mechanical intestinal obstruction conclusively by abdominal x-ray films. Gastrograffin swallows or barium enemas were performed as a secondary diagnostic procedure in some of our patients and, according to the previously cited report, proved helpful in 50 per cent. Laboratory studies, as expected, were not of diagnostic value except to assess the degree of dehydration. Treatment. Initial therapy was directed towards replacement of fluid and electrolytes and gastric decompression with a Levin tube or nasogastric tube. Long tubes (Miller-Abbott or Cantor) were employed successfully in ten of the sixty-six patients who had conservative management. The length of time of initial therapy ranged from 1 to 7 days, with an average of 4.5 days. The exact number of patients in whom long tubes could not be advanced was not determined. The amount of parenteral fluids and/or blood used also could not be determined. One hundred five patients (61.4 per cent) were treated surgically. This low percentage is explained by the large number of patients with impaction (thirty patients, 17 per cent) and those in whom the cause was undetermined (nine patients, 5.3 per cent). Of these nine patients, three died in a moribund state before operation could be performed. The most common operations performed were lysis of adhesion, reduction and repair of hernia, bowel resection, and various procedures for fecal diversion. Postoperative Complications. The only two postoperative complications we were able to assess
12
were wound infection and pulmonary complications. There were twenty-four patients (22.9 per cent) with wound infection. Eighteen had small bowel obstruction and the remaining six had large bowel obstruction. The majority had bowel resection and in only six of the patients was no part of the intestine opened. Most of the infections were mixed, most commonly with Escherichia coli, Proteus, Klebsiella, and staphylococci. There were sixteen cases of major pulmonary complications (15.2 per cent). Hospital Stay. The average hospital stay was 20.8 days. This is similar to the 21.1 days reported by Bollinger and Fowler [13]. For those patients undergoing operation the length of hospitalization was prolonged, being an average of 25.4 days compared with 13.5 days in the nonoperative group. Comments The etiologic factors of mechanical intestinal obstruction have undergone some changes in the last sixty years, although the primary causes have remained the same. In a large collected series (1940 to 1953) reported by Waldron and Hampton [14], adhesion ranks first in this country as a cause of obstruction (38.2 per cent), followed by hernia (24.1 per cent), and carcinoma (16.6 per cent). Our figures show similar frequency with slightly decreased incidence of adhesion and hernia, but increased incidence of carcinoma. In the underdeveloped countries, as reported by Gill and Eggleston [15], the incidence of adhesion is low and that of hernia high, mainly becauSe of lack of acceptance of elective surgery. However, Kaltiala, Lenkkeri, and Larmi [16] have reported that the most common cause of intestinal obstruction in Finland continues to be strangulation of external hernia (37.2 per cent), followed by adhesion (27.8 per cent). Carcinoma caused obstruction in 18.1 per cent of our series, which may be due to the very active radiation therapy program in the Department and Division of Medical Oncology at our institution. Bramlitt, Hardy, and Wilson [17] reported a 5.9 per cent incidence of neoplastic obstruction in 1,287 cases, and Bollinger and Fowler [13] reported the same incidence in 205 cases. However, Smith, Perry, and Yonehiro [IO], in 1,252 cases, reported a 27.4 per cent incidence of neoplastic obstruction, which was second in frequency only to adhesion. Nemir [9] in 358 cases reported an incidence of 20.2 per cent. The small but steady increase in the incidence of carcinoma can be very significant because of the
The American Journal of Surgery
Intestinal Obstruction
poor prognosis when these two diseases occur together. The increase in the average life span of the population may account for the increased incidence. Perhaps equally important is the increased number of bowel resections for carcinoma of the colon followed by local recurrence or diffuse carcinomatosis. The incidence of obstruction secondary to congenital anomalies is misleadingly low in our series (1.8 per cent). Most other studies report a 7 to 10 per cent incidence [6,10,14]. This is due to the relatively small number of pediatric patients undergoing operation in our institution between 1970 and 1972. Our mortality rate could be favorably affected by this low incidence because it is known that this group has a high mortality. Conversely, our mortality could be unfavorably affected by the high incidence of neoplastic disease in our series. Conspicuously absent in our study are cases of obstruction caused by obturation, particularly gallstones. Gallstone ileus is rather uncommon and most large series report a 1 to 2 per cent incidence [10,13,14]. Unlike other reports [12] with over 60 per cent females, the numbers of males and females was not significantly different in our series. Blacks had relatively higher mortality rates. This may be due to delay in admission, which was significantly longer in blacks than in whites. Nationally, the magnitude of the problem of intestinal obstruction is great. It is estimated that there are approximately 9,000 deaths due to small bowel obstruction yearly in this country [19]. Compared with other series [10,14], our overall mortality of 18.7 per cent is alarmingly high. However, further analysis reveals that the single most important contributing factor in our series is the high mortality in patients with advanced carcinoma. These deaths accounted for 10.5 per cent of all deaths, occurring in 58 per cent of the patients with obstruction caused by malignant lesions. Other series [14,17,18], including those that reported a high incidence of neoplasm [9,10], have reported a much lower mortality rate of 15 to 30 per cent for this group. It is interesting to note that overall mortality rates have been reported as high as 24 per cent in recent studies 111,121. &her contributing factors that were found sianificant in our study are a high proportion of elderly patients and delay in admission and/or operation. As shown by Bollinger and Fowler [13], any delay in operation of twelve hours or more doubles the mortality rate. Other major factors that adversely influence survival but were not tested in
Volume 130, July 1975
our study are gangrenous perforation of bowel and severe bowel distention. The rate of wound infection in our series was surprisingly high (22.9 per cent) compared with other series [13,20] that have reported figures of 6 to 12 per cent. Larsen and Pories [21], however, have recently reported a wound infection rate of 20 per cent after operation for small bowel obstruction. They found no correlation between wound infection and either the age or sex of the patient or the location of obstruction. However, there was a definite correlation between wound infection and delay in operation. Entry into the bowel also was associated significantly with wound infection, as was the case in our series. It should be emphasized that early operation is the treatment of mechanical intestinal obstruction. In a few selected cases, however, delay for twenty-four hours may be justified, as in the case of multiple recurrent obstructions secondary to adhesion, postoperative obstruction, inflammatory bowel disease, or abdominal carcinomatosis, when long tubes could greatly benefit the patient. Summary
One hundred seventy-one cases of mechanical intestinal obstruction were studied. One hundred fifteen had small bowel obstruction and fifty-six had large bowel obstruction. Adhesion (32.8 per cent), hernia (21.6 per cent), and neoplasm (18.1 per cent) were the cause of obstruction in more than 70 per cent of all cases. More than 40 per cent of patients were older than 60 years and the average age was 52.7. The numbers of males and females were approximately equal. There were twice as many whites as blacks, and the mortality rate was higher among blacks. The overall uncorrected mortality rate was 18.7 per cent. Operation was performed in 105 patients (61.4 per cent), with a postoperative mortality of 19 per cent and corrected postoperative mortality of 4.5 per cent. Contributing factors that were significant were high incidence of metastatic diseases, elderly patients, and delay in admission. References 1. Fitz R: The diaanosis and medical treatment of acute intestinal obstructi&. Trans Cong Ann Phys Surg 1: 1. 1888. 2. Wangsteen OH: Early diagnosis of intestinal obstruction with comments on pathology and treatment with report of successful decompression of three cases of mechanical bowel obstruction by nasal catheter suction siphonage. West J Surg 40: 1, 1932. 3. Deaver JB, Ross GB: Mortality statistics of 276 cases of acute intestinalobstruction.Ann Surg 61: 198, 1915.
13
Sufian and Matsumoto
4. Richardson EP: Acute intestinal obstruction. Study of second series of cases from Massachusetts General Hospital. Boston A&d Sci J 183: 288, 1920. 5. Scudder CL: Principles underlying treatment of acute intestinal obstruction. Trans NH Med Sot p 234. 1908. 6. Wangsteen OH, Rea CR, Smith BA Jr, et al: Experiences with employment of suction in the treatment of acute intestinal obstruction. Surg Gynecol Obstet 68: 851, 1939. 7. McKattrick LS, Sarris SP: Acute mechanical obstruction of small bowel: its diagnosis and treatment. N Engl J Med 222: 611, 1940. 8. Moses WR: Acute obstruction of small intestine. N Engl J Med 234: 78, 1946. 9. Nemir P: Intestinal obstruction: ten year statistical survey at the hospital of the University of Pennsylvania. Ann Surg 135: 367, 1952. 10. Smith GA, Perry JF Jr. Yonehiro EG: Mechanical intestinal obstruction: a study of 1,252 cases. Surg Gynecol Obstet 100: 651. 1955. 11. Lo AM. Evans WE, Carey LC: Review of small bowel obstruction at Milwaukee County General Hospital. Am J Surg 111: 884. 1966. 12. Giuffre JC: Intestinal obstruction: ten years experience. Dis Colon Rectum 15: 426, 1972.
14
13. Bollinger JA, Fowler EF: Results of treatment of acute small bowel obstruction: clinical study of 205 consecutive cases. Arch Surg 66: 888, 1953. 14. Waldron GW, Hampton JM: Intestinal obstruction: a half century comparative analysis. Ann Surg 153: 839. 1961. 15. Gill SS, Eggleston FC: Acute intestinal obstruction. Arch Surg 91: 589, 1965. 16. Kaltiala EH, Lenkkeri H. Larmi TKI: Mechanical intestinal obstruction: an analysis of 577 cases. Ann Chiv Gynecol fenn 61: 87, 1972. 17. Bramlitt EE, Haidy JD, Wilson H: Intestinal obstruction. Analysis of 1287 admissions over a ten year period. Am Surg 21: 1091, 1955. 18. Welch JP. Donaldson GA: Management of severe obstruction of the large bowel due to malignant diseases. Am J Surg 127: 492, 1974. 19. Statistical Abstracts of the United States, 1963, Ed. 84. Washington, DC, US Bureau of Census, 1963, p 65. 20. Plyforth RH, Holloway JB. Griffen WO: Mechanical small bowel obstruction: a plea for earlier surgical intervention. Ann Surg 171: 783, 1970. 21. Larson E, Pories NJ: Frequency of wound complication after surgery of small bowel obstruction. Am J Surg 122: 384, 1971.
The American Journal of Surgery
Acute intestinal obstruction is one of the most common conditions requiring emergency laparotomy. Management of this problem has gone through several evolutions. Fitz [I] advocated medical treatment and delayed surgery in the nineteenth century and Wangsteen [2] in 1931 reported on the successful management of patients by primary intestinal decompression. In the first quarter of the twentieth century, Deaver and Ross [3], Richardson [4], and others started advocating early diagnosis and operation, and for the last thirty years this doctrine has been well established. Scudder [5] in 1908 reported a mortality rate of 60 per cent; this rate declined steadily to about 20 per cent in the next thirty years [6,7] and to about 10 per cent in the 1950’s [8,9]. Although Smith, Perry, and Yonehiro [IO] reported a mortality of 12.5 per cent in a large series of 1,252 cases, overall mortality rates as high as 24 per cent have been reported in recent publications [11,12]. The objective of this study was to review cases of intestinal obstruction in our hospital during a three year period. Material and Methods Case records of patients admitted to the Hahnemann Medical College and Hospital from January 1, 1970 to January 1, 1973 with the diagnosis of intestinal obstruction were reviewed. Of the 329 cases, the records for 18 could not be located. Not included in this study were 102 cases either without sufficient evidence of obstrucFrom the Department of Surgery. Hahnemann Medical College and Hospital, Philadelphia, Pennsylvania. Reprint requests should be addressed to Teruo Matsumoto, MD, Department of Surgery, Hahnemann Medical College and Hospital, Philadelphia, Pennsylvania 19102.
Volume 130. July 1975
tion, with a diagnosis of esophageal or pyloric obstruction, or with external hernia in which only the omentum was found to be incarcerated at operation. Thirty-three cases of paralytic ileus and five cases of mesenteric vascular occlusion were also excluded. This study, therefore, represents 171 patients with mechanical intestinal obstruction either admitted directly to the general surgical services or transferred from other services. In each of these cases the diagnosis had been made by history, physical examination, and radiologic examinations. In those patients who underwent operation the diagnosis was substantiated at surgery.
Results Causes of Obstruction. Of the 171 cases of obstruction studied, 115 (67.3 per cent) were localized in the small intestine and the remaining 56 cases (32.7 per cent) were in the large bowel. Further localization of the level of obstruction was not possible. The most common causes of obstruction were adhesion (32.7 per cent), neoplasm (18.1 per cent), and external hernia (17.5 per cent). (Table I.) Adhesions were the most common cause of small intestinal obstruction and neoplasms were by far the most frequent cause of colonic obstruction. Adhesion: There were 56 cases of obstruction due to adhesion among 171 cases (32.7 per cent) and only a single obstruction was located in the large bowel. In the majority of cases the obstruction due to adhesion was in the small intestine. There was no significant difference in the numbers of males and females. Of the fifty-six patients, five (8.9 per cent) had had no previous operation. The majority had had one or more operations. There was no preponderance of any single type of intraperitoneal surgery prior to obstruction. Contrary
9
Sufian and Matsumoto
TABLE I
Causes of Intestinal
Types of Obstruction Adhesion External Hernia Internal Hernia Neoplasm Impaction volvulus lntussusception Diverticulitis Crohn’s disease Congenital anomalies Miscellaneous Undetermined Total
Total No.
Per Cent
Obstruction
and Mortality
No. of Patients Undergoing
Per Cent of 171 Patients Undergoing
Per Cent of Total Undergoing
No. of Deaths in Patients Undergoing
Mortality in 105 Patients Undergoing Operation
No. of Deaths Related to
Mortality Related to Surgery
Total No. of Deaths
(per cent)
Operation
Operation
Operation
Operation
(per cent)
Surgery
(per cent)
Mortality
56 30 7 31 13 7 2 6 3 3
32.7 17.5 4.1 18.1 7.6 4.1 1.2 3.5 1.8 1.8
2 5 1 18 0 0 1 1 0 1
1.2 2.9 0.6 10.5 0 0 0.6 0.6 0 0.6
29 27 7 23 1 6 2 5 2 0
16.9 15.7 4.1 13.5 0.6 3.5 1.2 2.9 1.2 0
51.8 90.0 100.0 74.2 7.8 85.7 100.0 83.3 66.7 0
2 4 1 11 0 0 1 1 0 0
1.90 3.81 0.95 10.48 0 0 0.95 0.95 ... ..i
... 2 1 ... ... ... 1 1 ... ...
... 1.90 0.95 ... ... ... 0.95 0.95 ... ...
4 9 171
2.3
0
0
3
1.8
75.0
0
...
...
...
5.3 100.0
3 32
1.8 18.7
0 105
0 61.4
. 0. .
0 20
*.* 19.04
‘F
... 4.75
to other reports [ll], gynecologic surgery, comprising 21 per cent of all previous operations, was not the most common previous operation. Of the fifty-six cases, twenty-nine (51.8 per cent) were treated surgically. Eight of the twentynine patients had lysis of adhesions and the rest required bowel resection. There were two deaths in the group, both of whom had had more than two previous operations and were over sixty years of age. Interestingly, in both the obstruction developed in the hospital. One patient was a seventyeight year old white female who was being treated for metastatic carcinoma of the lung, and the other was a sixty-four year old white male who had undergone aortic aneurysmectomy two weeks prior to obstruction. Both underwent operation; the first had lysis of adhesions and the second had lysis and resection of small bowel. In neither was the cause of death related to the obstruction. Hernia: Of the thirty cases of external hernia, only three caused large bowel obstruction. The majority of cases of external hernia and all the cases of internal hernia caused small bowel obstruction. As a cause of obstruction only adhesion was more frequent than the various types of hernia. Right inguinal hernia was the cause of obstruction in 32.5 per cent of the cases. Internal hernia was next in frequency, followed by as many cases of femoral as incisional hernia. No diaphragmatic or other rare types of hernia were noted. Because it was not possible to determine the number of di-
10
in 171 Cases with 32 Deaths
rect inguinal hernias, all were categorized as inguinal. Twenty-seven of the thirty patients with external hernia and all patients with internal hernia underwent operation. Most had reduction and repair of hernia and nine required bowel resection. Death occurred in five patients with external hernia and one with internal hernia. Only one patient died preoperatively, from a ruptured thoracic aneurysm on the night of admission. Of the remaining five who died postoperatively, two died of myocardial infarction, two of sepsis, and one of pulmonary edema and renal failure. Only in the last three patients was death related to surgery. Admission was delayed an average of seven days among those who died. Neoplasm: There were thirty-one cases of obstruction due to neoplastic diseases. Carcinoma was the most common cause of large bowel obstruction, with seventeen cases of obstruction of the colon. In about half the cases the tumor originated in the colon. Most of the patients with neoplasm. causing small bowel obstruction had disseminated carcinomatosis. Twenty-three of the thirty-one were treated surgically. Primary resection was performed in six, resection and diversion colostomy in five, diversion alone in nine, bypass in one, and one was inoperable. The overall number of deaths in this group was eighteen (58.1 per cent of cases of obstruction due to neoplasm and 10.5 per cent of all cases of intestinal obstruction studied). This group accounts for half of the total
The American
Journal
of Surgery
Intestinal Obstruction
deaths. The operative mortality was eleven deaths (10.5 per cent of all postoperative mortality). Impaction: Impaction was a cause of obstruction in thirteen cases (7.6 per cent). Only one patient required operation for barium impaction, and fecal diversion and colostomy was performed. No death occurred in this group. The average age was 61.2 years, which was greater than the overall average. VoZuulus: Of the seven cases of volvulus (4.1 per cent), one was of the small intestine. Two patients had cecal volvulus and both were treated surgically; one underwent resection, and the other had surgical reduction, appendectomy, and cecostomy. Both patients were young (thirty-nine and twentythree years). Four patients had sigmoid volvulus, one of whom had conservative management with sigmoidoscopy and tube decompression alone. One patient underwent tube decompression followed by resection. The remaining two had surgical reduction and underwent resection in stages. All four were older than sixty years. No death occurred in this group. Intussusception: In each of the two cases of intussusception carcinoma was the lead point at the ileocecal region. Right hemicolectomy was performed in both patients, each of whom was older than sixty years of age. There was one postoperative death of an eighty-two year old white male. Autopsy revealed perforated gastric ulcer and diffuse peritonitis. Diverticulitis: Of the six patients with diverticulitis (3.5 per cent), five underwent operation. One of the patients undergoing operation died after left hemicolectomy, aortic aneurysmectomy, appendectomy, and cecostomy. The other four underwent diversion colostomy. Crohn’s disease: Of the three patients with Crohn’s disease, all were young (thirty, twentyone, and eighteen years). Two underwent small bowel resection. No death occurred in this group. Congenital anomalies: Only three patients (1.8 per cent) presented with congenital anomalies in our study. These were due to meconium plug, cystic fibrosis with inspissated bowel, and Hirschsprung’s disease. The patient with cystic fibrosis died. None of the three underwent operation. Miscellaneous: Four cases (2.3 per cent) were classified as miscellaneous. These were due to loop obstruction, ileostomy dysfunction, anastomotic stricture at the sigmoid colon, and obstruction of the transverse colon by an afferent loop. No death occurred.
Volume 130, July lB75
MORTALITY
AS RELATED TO SEX
IOOr 40.5% 80 -
08 83
60 40
-
20 -
56.3%
43.6%
0’ TOTAL DIED -Male
TOTAL DIED Female
65.5% 100
r
112 MORTALITY
80 -
TO RACE
n 60
32.7 % 56
-
40 20 -
White
TOTAL DIED Me Black
TOTAL DIED Others
Figure 1. Mortality related to sex and race in 177 patients with intestinal obstruction.
Age Distribution. The age distribution ranged from birth to 85 years of age, with an average age of 52.7 years. Over 40 per cent of the patients were older than sixty years. As in other reports [10,11,13], mortality was related to age, and in our series 60 per cent of the deaths occurred in the patients older than sixty years. Sex and Race. There was no significant difference in the numbers of males and females (48.5 and 51.5 per cent, respectively). Although there were a few more deaths among females, the difference was not statistically significant. As seen in Figure 1, there were exactly twice as many whites as blacks, but the relative mortality was significantly higher among blacks. History and Physical Findings. The most common symptom in patients with small or large bowel obstruction was abdominal pain. In cases of small intestinal obstruction, abdominal pain was followed by vomiting, but in cases of large bowel obstruction, constipation was more frequent. The
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physical sign most frequently present in patients with small bowel obstruction was tenderness followed by distention and hyperactive bowel sounds, whereas for the patients with large bowel obstruction it was distention followed by tenderness, hyperactive bowel sounds, and palpable abdominal mass. The great majority of our patients had had symptoms for over twenty-four hours, and only forty-eight patients (28 per cent) presented within twenty-four hours of the onset of symptoms. The mortality rate was greatly increased among patients admitted more than five days from the onset of symptoms. X-Ray and Laboratory Studies. In the great number of our patients, plain films of the abdomen led to a diagnosis of mechanical obstruction. Although we have not been able to determine the diagnostic accuracy of abdominal films, Lo, Evans, and Carey [II] have reported that only in 60 per cent of their cases were they able to diagnose mechanical intestinal obstruction conclusively by abdominal x-ray films. Gastrograffin swallows or barium enemas were performed as a secondary diagnostic procedure in some of our patients and, according to the previously cited report, proved helpful in 50 per cent. Laboratory studies, as expected, were not of diagnostic value except to assess the degree of dehydration. Treatment. Initial therapy was directed towards replacement of fluid and electrolytes and gastric decompression with a Levin tube or nasogastric tube. Long tubes (Miller-Abbott or Cantor) were employed successfully in ten of the sixty-six patients who had conservative management. The length of time of initial therapy ranged from 1 to 7 days, with an average of 4.5 days. The exact number of patients in whom long tubes could not be advanced was not determined. The amount of parenteral fluids and/or blood used also could not be determined. One hundred five patients (61.4 per cent) were treated surgically. This low percentage is explained by the large number of patients with impaction (thirty patients, 17 per cent) and those in whom the cause was undetermined (nine patients, 5.3 per cent). Of these nine patients, three died in a moribund state before operation could be performed. The most common operations performed were lysis of adhesion, reduction and repair of hernia, bowel resection, and various procedures for fecal diversion. Postoperative Complications. The only two postoperative complications we were able to assess
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were wound infection and pulmonary complications. There were twenty-four patients (22.9 per cent) with wound infection. Eighteen had small bowel obstruction and the remaining six had large bowel obstruction. The majority had bowel resection and in only six of the patients was no part of the intestine opened. Most of the infections were mixed, most commonly with Escherichia coli, Proteus, Klebsiella, and staphylococci. There were sixteen cases of major pulmonary complications (15.2 per cent). Hospital Stay. The average hospital stay was 20.8 days. This is similar to the 21.1 days reported by Bollinger and Fowler [13]. For those patients undergoing operation the length of hospitalization was prolonged, being an average of 25.4 days compared with 13.5 days in the nonoperative group. Comments The etiologic factors of mechanical intestinal obstruction have undergone some changes in the last sixty years, although the primary causes have remained the same. In a large collected series (1940 to 1953) reported by Waldron and Hampton [14], adhesion ranks first in this country as a cause of obstruction (38.2 per cent), followed by hernia (24.1 per cent), and carcinoma (16.6 per cent). Our figures show similar frequency with slightly decreased incidence of adhesion and hernia, but increased incidence of carcinoma. In the underdeveloped countries, as reported by Gill and Eggleston [15], the incidence of adhesion is low and that of hernia high, mainly becauSe of lack of acceptance of elective surgery. However, Kaltiala, Lenkkeri, and Larmi [16] have reported that the most common cause of intestinal obstruction in Finland continues to be strangulation of external hernia (37.2 per cent), followed by adhesion (27.8 per cent). Carcinoma caused obstruction in 18.1 per cent of our series, which may be due to the very active radiation therapy program in the Department and Division of Medical Oncology at our institution. Bramlitt, Hardy, and Wilson [17] reported a 5.9 per cent incidence of neoplastic obstruction in 1,287 cases, and Bollinger and Fowler [13] reported the same incidence in 205 cases. However, Smith, Perry, and Yonehiro [IO], in 1,252 cases, reported a 27.4 per cent incidence of neoplastic obstruction, which was second in frequency only to adhesion. Nemir [9] in 358 cases reported an incidence of 20.2 per cent. The small but steady increase in the incidence of carcinoma can be very significant because of the
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Intestinal Obstruction
poor prognosis when these two diseases occur together. The increase in the average life span of the population may account for the increased incidence. Perhaps equally important is the increased number of bowel resections for carcinoma of the colon followed by local recurrence or diffuse carcinomatosis. The incidence of obstruction secondary to congenital anomalies is misleadingly low in our series (1.8 per cent). Most other studies report a 7 to 10 per cent incidence [6,10,14]. This is due to the relatively small number of pediatric patients undergoing operation in our institution between 1970 and 1972. Our mortality rate could be favorably affected by this low incidence because it is known that this group has a high mortality. Conversely, our mortality could be unfavorably affected by the high incidence of neoplastic disease in our series. Conspicuously absent in our study are cases of obstruction caused by obturation, particularly gallstones. Gallstone ileus is rather uncommon and most large series report a 1 to 2 per cent incidence [10,13,14]. Unlike other reports [12] with over 60 per cent females, the numbers of males and females was not significantly different in our series. Blacks had relatively higher mortality rates. This may be due to delay in admission, which was significantly longer in blacks than in whites. Nationally, the magnitude of the problem of intestinal obstruction is great. It is estimated that there are approximately 9,000 deaths due to small bowel obstruction yearly in this country [19]. Compared with other series [10,14], our overall mortality of 18.7 per cent is alarmingly high. However, further analysis reveals that the single most important contributing factor in our series is the high mortality in patients with advanced carcinoma. These deaths accounted for 10.5 per cent of all deaths, occurring in 58 per cent of the patients with obstruction caused by malignant lesions. Other series [14,17,18], including those that reported a high incidence of neoplasm [9,10], have reported a much lower mortality rate of 15 to 30 per cent for this group. It is interesting to note that overall mortality rates have been reported as high as 24 per cent in recent studies 111,121. &her contributing factors that were found sianificant in our study are a high proportion of elderly patients and delay in admission and/or operation. As shown by Bollinger and Fowler [13], any delay in operation of twelve hours or more doubles the mortality rate. Other major factors that adversely influence survival but were not tested in
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our study are gangrenous perforation of bowel and severe bowel distention. The rate of wound infection in our series was surprisingly high (22.9 per cent) compared with other series [13,20] that have reported figures of 6 to 12 per cent. Larsen and Pories [21], however, have recently reported a wound infection rate of 20 per cent after operation for small bowel obstruction. They found no correlation between wound infection and either the age or sex of the patient or the location of obstruction. However, there was a definite correlation between wound infection and delay in operation. Entry into the bowel also was associated significantly with wound infection, as was the case in our series. It should be emphasized that early operation is the treatment of mechanical intestinal obstruction. In a few selected cases, however, delay for twenty-four hours may be justified, as in the case of multiple recurrent obstructions secondary to adhesion, postoperative obstruction, inflammatory bowel disease, or abdominal carcinomatosis, when long tubes could greatly benefit the patient. Summary
One hundred seventy-one cases of mechanical intestinal obstruction were studied. One hundred fifteen had small bowel obstruction and fifty-six had large bowel obstruction. Adhesion (32.8 per cent), hernia (21.6 per cent), and neoplasm (18.1 per cent) were the cause of obstruction in more than 70 per cent of all cases. More than 40 per cent of patients were older than 60 years and the average age was 52.7. The numbers of males and females were approximately equal. There were twice as many whites as blacks, and the mortality rate was higher among blacks. The overall uncorrected mortality rate was 18.7 per cent. Operation was performed in 105 patients (61.4 per cent), with a postoperative mortality of 19 per cent and corrected postoperative mortality of 4.5 per cent. Contributing factors that were significant were high incidence of metastatic diseases, elderly patients, and delay in admission. References 1. Fitz R: The diaanosis and medical treatment of acute intestinal obstructi&. Trans Cong Ann Phys Surg 1: 1. 1888. 2. Wangsteen OH: Early diagnosis of intestinal obstruction with comments on pathology and treatment with report of successful decompression of three cases of mechanical bowel obstruction by nasal catheter suction siphonage. West J Surg 40: 1, 1932. 3. Deaver JB, Ross GB: Mortality statistics of 276 cases of acute intestinalobstruction.Ann Surg 61: 198, 1915.
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4. Richardson EP: Acute intestinal obstruction. Study of second series of cases from Massachusetts General Hospital. Boston A&d Sci J 183: 288, 1920. 5. Scudder CL: Principles underlying treatment of acute intestinal obstruction. Trans NH Med Sot p 234. 1908. 6. Wangsteen OH, Rea CR, Smith BA Jr, et al: Experiences with employment of suction in the treatment of acute intestinal obstruction. Surg Gynecol Obstet 68: 851, 1939. 7. McKattrick LS, Sarris SP: Acute mechanical obstruction of small bowel: its diagnosis and treatment. N Engl J Med 222: 611, 1940. 8. Moses WR: Acute obstruction of small intestine. N Engl J Med 234: 78, 1946. 9. Nemir P: Intestinal obstruction: ten year statistical survey at the hospital of the University of Pennsylvania. Ann Surg 135: 367, 1952. 10. Smith GA, Perry JF Jr. Yonehiro EG: Mechanical intestinal obstruction: a study of 1,252 cases. Surg Gynecol Obstet 100: 651. 1955. 11. Lo AM. Evans WE, Carey LC: Review of small bowel obstruction at Milwaukee County General Hospital. Am J Surg 111: 884. 1966. 12. Giuffre JC: Intestinal obstruction: ten years experience. Dis Colon Rectum 15: 426, 1972.
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13. Bollinger JA, Fowler EF: Results of treatment of acute small bowel obstruction: clinical study of 205 consecutive cases. Arch Surg 66: 888, 1953. 14. Waldron GW, Hampton JM: Intestinal obstruction: a half century comparative analysis. Ann Surg 153: 839. 1961. 15. Gill SS, Eggleston FC: Acute intestinal obstruction. Arch Surg 91: 589, 1965. 16. Kaltiala EH, Lenkkeri H. Larmi TKI: Mechanical intestinal obstruction: an analysis of 577 cases. Ann Chiv Gynecol fenn 61: 87, 1972. 17. Bramlitt EE, Haidy JD, Wilson H: Intestinal obstruction. Analysis of 1287 admissions over a ten year period. Am Surg 21: 1091, 1955. 18. Welch JP. Donaldson GA: Management of severe obstruction of the large bowel due to malignant diseases. Am J Surg 127: 492, 1974. 19. Statistical Abstracts of the United States, 1963, Ed. 84. Washington, DC, US Bureau of Census, 1963, p 65. 20. Plyforth RH, Holloway JB. Griffen WO: Mechanical small bowel obstruction: a plea for earlier surgical intervention. Ann Surg 171: 783, 1970. 21. Larson E, Pories NJ: Frequency of wound complication after surgery of small bowel obstruction. Am J Surg 122: 384, 1971.
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