Br. J. Surg. Vol. 65 (1978) 123-127
Operative intubation in the treatment of complicated small bowel obstruction A L E X A N D E R M U N R O A N D P E T E R F. J O N E S * SUMMARY
Case report
Intestinal intubation carried out at laparotomy for complicated small bowel obstruction is not yet agenerally accepted technique. Experience in 32 patients has shown that it is safe and effective. The procedure was initially described in North America for use in recurrent adhesive small intestinal obstruction but the indications have been extended and it has proved of value in other dificult situations. A techniquefor intubation is described and the results obtained in various clinical situations are given.
Ten years ago, Mrs J. S. was 57 years old when she was treated in a cottage hospital for a strangulated femoral hernia. After resection of gangrenous ileum, intestinal Obstruction recurred, requiring two further laparotomies, at the second of which an ileoileostomy was made to bypass an obstructed loop. Over the next 5 years she suffered recurrent obstructive episodes which settled spontaneously on conservative treatment, but she then had a further episode of obstruction which did not resolve and she was admitted to hospital under our care. At laparotomy the ileum was released from a number of adhesions but obstruction recurred, and at another laparotomy 3 weeks later there were dense generalized adhesions; the only feasible procedure was to perform a gastrostomy and insert a tube into the lowest loop of distended small bowel as an enterostomy. The patient was fed intravenously for 5 weeks and she slowly recovered but over the following year episodes of obstruction came and went and X-rays always showed some dilated loops of bowel containing fluid levels. One year after her last operation an abscess formed on the abdominal wall, discharged and proved to be a small bowel fistula. Because it was clear that the patient would not improve without further surgery another laparotomy was undertaken and this time we decided to try out the method of intestinal intubation described by Baker (1968). At operation the peritoneal cavity appeared to be obliterated by adhesions but the small intestine was freed completely, the blind ileal loop excised, five holes in the intestine repaired and a fresh ileoileal anastomosis made. Finally, a Miller-Abbott tube was inserted through a high jejunostomy and passed down the whole length of the small intestine. Recovery was slow but uneventful and the tube was withdrawn after 3 weeks. There has been no recurrence of obstruction.
RECURRINGsmall intestinal obstruction due to adhesions is a familiar and unpleasant problem for the abdominal surgeon. Each time a laparotomy is undertaken the procedure becomes more difficult and the outcome for the unfortunate patient less certain. There is no reliable method as yet of preventing the formation of adhesions, so attempts to forestall further episodes of obstruction must be aimed at producing ‘controlled adhesions’, which will allow loops of the small intestine to adhere permanently to each other in an orderly pattern. These adhesions can be promoted in two ways: by sutures which hold adjacent loops of intestine in contact for long enough to allow them to adhere to each other (Noble, 1937; Childs and Phillips, 1960); or by threading a tube down the whole length of the small intestine, which will, by its intrinsic stiffness, prevent kinking whilst adhesions form (White, 1956; Baker, 1968). The suture method is not without risks of immediate Method and later complications. The intubation method The tube appears to be both safe and effective and has been The intestinal tube should be at least 300 cm (10 ft) long so used by a number of surgeons in North America, but that when the small intestine is threaded on to it there is no it does not seem to be much practised in this country. pleating of the bowel. In adults an 18 FG tube is suitable. The Intubation of the intestine via an abdominal incision pliability of the tubing must be such that it will bend readily was first suggested by Devine in 1946 for the treatment into a semicircle 5 cm in diameter without kinking. The material for the tubing should not deteriorate in contact with of patients with unremitting paralytic ileus. White, in used intestinal secretions. 1956, threaded a Miller-Abbott tube through the We found that the tube made to Baker’s (1968) specifications whole length of the small intestine when operating for was not available in this country and we therefore used a recurrent adhesive intestinal obstruction with the Miller-Abbott tube (H. W. Andersen Products Inc.). This object of forming ‘controlled adhesions’ by main- tube is not ideal because the balloon is too large and delicate, but the size of the balloon can be altered by tying a piece of taining internal splintage. In 1959 Baker described a Foley-type catheter, 40 in thread around it just distal to the end of the tube and cutting long, which was introduced through a jejunostomy off the remainder of the balloon. When inflated the balloon be tense and measure 1.5-2 cm in diameter. and used to keep obstructed bowel decompressed. In should have recently tested a prototype tube made specifically 1968 Baker made a detailed report on the use of this to We our requirements. This tube has proved satisfactory and is tube to promote controlled adhesions in 52 obstructed essentially a very long Foley-type catheter made of PVC. It is patients, with a very low recurrence rate. At the same similar to the tube designed by Baker (1968) but is slightly time, Whelan reported from Vietnam on the value of longer and small side holes are cut at 15 cm intervals along the Baker’s tube in the management of penetrating ab- distal half.? dominal injuries (Whelan, 1968). The present authors first used the technique 44 years ago in the case * Alexander Munro, Aberdeen Hospitals; Peter F. Jones, General Hospital and Royal Aberdeen Children’s reported below and were impressed with the heIp it Woodend Hospital, Aberdeen. provided in a difficult situation. Since then, the Correspondence to P. F. Jones, Woodend General Hospital, indications have been extended. This paper reviews Aberdeen. previous reports on intestinal intubation and describes t This tube is now being manufactured by J. G. Franklin and our own experience. Sons (Code no. 463018).
124
Alexander Munro and Peter F. Jones
Sutures
/I / /
Fig. 1. Line diagram to show the principal features of the intestinal tube. Note the double-lumen tube, with the balloon inflated in the caecum; the side holes to decompress the small intestine; the sutures attaching the jejunostomy site to parietal peritoneum.
Ravitch and Cherry (1968). In the absence of a balloon which could be inflated in the caecum, we secured the distal end of the tube by bringing it out through a caecotomy. In patients aged about 8 years and upwards an adult-size tube can be used. Operutiue technique (Fig. I ) After the division of all adhesions, any injuries to the intestine are repaired with interrupted Gambee (1951) sutures of 3/0 silk. The obstructed bowel is then decompressed by retrograde stripping into the stomach (Jones and Matheson, 1968). A small incision is now made in the abdominal wall in the left flank and the tube is pulled through into the peritoneal cavity. A purse-string suture of 2/0 chromic catgut is placed o n the antimesenteric border of the jejunum 10-15 cm distal to the duodenojejunal flexure, the bowel wall incised, the tube fed into the jejunum and the suture tightened around it. The balloon is now inflated and is used to draw the tube down the whole length of the small intestine. The ballon is usually of most help if it is blown up hard, so that it can be easily manipulated along the intestine. Especially in obstructed bowel, the process of intubation can be rapid, taking only 5 min, but if the bowel is of normal calibre the process can take 15-20min. As the balloon is advanced small areas kinked by unnoticed adhesions may require straightening. In all cases (with the exception of those who have had right hemicolectomy performed) we have manipulated the deflated balloon through the ileocaecal valve and then reinflated the balloon t o prevent retraction. When the length is satisfactorily adjusted, so that there is neither pleating of the bowel through failure to introduce sufficient tubing nor coiling of an excess of tubing in the bowel, the purse-string suture is finally tied. A second purse-string suture is inserted and tied around the first, to invaginate it, and left long. The tubing is gently drawn out of the stab incision until the jejunum comes to lie against parietal peritoneum. The needle on the second purse-string suture is then passed through the peritoneum at this point and the suture tied, so holding the jejunum firmly up against the abdominal wall; we often insert an extra stitch to reinforce this suture. Finally, the tubing is secured firmly by a skin suture. It is important to ensure that the proximal jejunum at the site of intubation lies well, without kinking, and that the intestines lie in an orderly manner. Postoperatice care
The nasogastric tube need not be left in position for more than 12-24 h after operation. The jejunostomy tube is attached to a closed drainage bag and put on gravity drainage. After a period of 24-48 h the tube often begins to produce intestinal contents. These are very variable in quantity and have ranged from 150 to 1200 m1/24 h. When normal peristaltic sounds are heard and flatus is being passed per rectum, oral fluids can be given and the tube spigotted off. Before removal of the tube, in a number of cases, radiographs were taken to demonstrate the position of the bowel loops (Fig. 2). The jejunostomy tube was left in situ for a period of 10-18 days, most being removed around 12 days from the time of operation. Withdrawal of the tube takes about 5 min, with gentle sustained traction ; although patients may be apprehensive, this has not proved to be an uncomfortable procedure. There is often leakage of small bowel contents around the jejunostomy tube after it has been in place for about 10 days but this has always ceased after withdrawal of the tube, and the skin wound has healed within a week. Fig. 2. Plain X-ray film of the abdomen 10 days after operation. Infants and children
When performing this procedure on babies and infants a smaller tube must be used. Our youngest patient was a baby 9 months old who suffered a mid-gut volvulus for the third time. I n this case we used I2 FG Portex tubing and to assist in drawing the tube through the bowel, l cm of the tip of the tube was turned back through 180" and tied tightly with thread to produce a knuckle on which gentle traction could be applied. The tube was introduced via a gastrostomy, as suggested by
Indications for use Recurrent small bowel obstruction We have used this procedure on 8 patients who had required at least one previous operation for adhesive intestinal obstruction; 3 had undergone multiple previous laparotomies for this reason (Table Z). Two patients had undergone a Noble's plication in our unit, 7 years and 1 year respectively before the intubation operation; 3 required a resection of the small intestine at the time of intubation. Some of these operations
Operative intubation in complicated small bowel obstruction Table I: INTUBATION IN RECURRENT ADHESIVE SMALL BOWEL OBSTRUCTION Previous episodes of Laparotomy findings and procedure Patient Primary operation obstruction * 1972 Adhesive obstruction; K. C. 1970 Intussusception 1971 Small bowel obstruction due to adhesions; laparotomy; intubation of small bowel (6 yr) reduced small bowel resection J. S. 1967 Strangulated 1967 Two laparotomies for 1972 Adhesive obstruction; adhesive obstruction; bypass laparotomy ; resection of (65 yr) femoral hernia; small bowel of distal ileum bypassed area of ileum with end-to-end anastomosis; resection 1970 Small bowel obstruction; intubation of small bowel conservative treatment 1971 Laparotomy for small bowel obstruction. Noble plication; 2 weeks later further laparotomy, gastrostomy and jejunostomy 1976 Laparotomy for adhesive E. F. 1963 Colectomy with June 1969 Intestinal obstruc(50 yr) ileorectal tion; conservative treatment obstruction; separation of 1969 Laparotomy with division adhesions; intubation of anastomosis small bowel of adhesions; 2 weeks later still obstructed; Noble plication 1976 Chronic incomplete small bowel obstruction V. F. 1932 Appendicitis 1953 Adhesive obstruction; 1973 Laparotomy for adhesive laparotomy obstruction; intubation of (53 yr) 1960 Adhesive obstruction; small bowel laparotomy 1963 Small bowel obstruction; Conservative treatment 1965 Adhesive obstruction; laparotomy 25.1 1.74 Admitted with small 30.1 I .74 Obstruction recurred; bowel obstruction; small bowel freed; intubalaparotomy; adhesions to tion of small intestine; abscess around sigmoid sigmoid resection colon; small bowel separated; transverse colostomy D. D. 1948 Ileotransverse 1970 Laparotomy for small April 1975 Jejunal resection (51 yr) colostomy for bowel obstruction; and right hemicolectomy; Crohn's disease adhesions and small bowel intubation of small intestine 1958 Attempted enterolith hysterectomy; 1974 Small bowel obstruction; abandoned because conservative treatment of adhesions 1975 Small bowel obstruction; conservative treatment G. S. 12.3.76 Laparotomy for small 23.3.76. Obstruction recurred; bowel obstruction; adhesions numerous fibrinous (56 yr) to terminal ileum adhesions divided; small bowel intubation D. K. Appendicectomy in December 1975 Adhesive 1977 Adhesive obstruction; (43 yr) childhood obstruction ; laparotomy adhesions divided; small March 1975 August 1976 Adhesive bowel intubation Hysterectomy obstruction ; laparotomy August 1976 Ovarian cystectomv
Outcome Tube removed at 10 d Good recovery Tube removed at 3 wk Good recovery
125 FollowUP
Tube removed at 10 d Good recovery
Tube removed at 12 d Uneventful recovery
Colostomy closed few months later Good recovery
Tube removed at 10 d Good recovery
Tube removed at 10 d Uneventful recovery Tube removed at 12 d Slow recovery and occasional attacks of colic
* Including operations for adhesive obstruction. were tedious and difficult, and in 2 patients holes were accidentally made in the obstructed small bowel during dissection. It was reassuring to know that the side holes in the tubing would allow decompression of the damaged bowel while it healed and that, if intubation achieved its objective, it would not be necessary to repeat such operations. The longest follow-up is 4+ years and the average is 2+ years; so far there has been no recurrence of intestinal obstruction, but one patient has intermittent episodes of intestinal colic. These good results suggested that it would be worth offering the advantages of intubation to a wider range of patients and we recognize four other indications.
First episode of'intestinal obstruction due to dense small bowel adhesions When intubation proved to be useful in our earlier patients it was decided to extend its use to patients who required a first laparotomy for small bowel obstruction with extensive adhesions. We hoped that future adhesive obstruction would thus be prevented. In 10 of the 11 cases in this group the adhesions were presumed to be secondary to previous surgery and in the eleventh patient, who had no previous operation, the whole small bowel was matted together by dense adhesions. In several patients, when separation had been completed, large areas of the small intestine were denuded of serosa.
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All these patients have pursued an uncomplicated postoperative course and none has developed further episodes of intestinal obstruction. Four of the operations have been carried out in the past few months but the average follow-up of the others is 26 years. General peritonitis When general peritonitis occurs there is always a marked fibrinous exudate over the surface of exposed bowel, there is often a degree of intestinal obstruction which may be both paralytic and mechanical in origin, and it is common to find loculi of pus trapped between adherent loops of intestine. We believe that there is a good case for intubation at the time of operation for peritonitis, rather than at a more difficult and dangerous second operation, as suggested by Luck and Eastcott (1961). We have done this in 6 patients, 3 of whom had a perforated colon with widespread faecal contamination. Two other patients were operated on for neglected perforated appendicitis with established interloop abscesses containing large quantities of pus. Following colonic resection or appendicectomy the whole of the small bowel was freed and the entire intestine and peritoneal cavity, including the subdiaphragmatic spaces, were thoroughly washed with several litres of solution containing 0 1 per cent tetracycline in normal saline. Intubation of the small bowel was carried out in the usual way. The intestinal tube was removed 10 days after the operation in 4 cases and in 2 cases the tube was left in situ for 14 and 17 days respectively because of continued ileus. All made a complete recovery and we did not experience recurrent intestinal obstruction in any of these patients, nor was residual intraperitoneal sepsis encountered.
Prophylactic intubation Our encouraging experience of intubation in obstructed patients led us to consider this procedure as a prophylactic measure in patients who appeared to be at particular risk of later adhesive obstruction, even when there was no evidence of this at the time of operation. We have carried out such intubation in two groups of patients. 1. Patients who, at laparotomy, are found to have dense multiple adhesions which have to be separated in the course of carrying out the operation. There were 6 patients in this group; 5 had had a previous operation for peritonitis due to colonic perforation and 4 were undergoing a restorative anastomosis of colon to rectum after an emergency Hartmann’s resection for perforated diverticular disease. The sixth patient was having a very large incisional hernia repaired and it seemed particularly important that his abdomen should not become distended postoperatively (White, 1956). 2. Patients who, though having no evidence of adhesion formation, are undergoing surgery which carries a particularly high later risk of adhesive obstruction, e.g. proctocolectomy for colitis. We have been impressed by the speedy recovery of intestinal function in these patients. There have been no subsequent obstructive episodes.
Discussion Fibrinous adhesions form after every laparotomy and it has been suggested that some may be lysed by the
action of proteolytic enzymes (Jackson, 1958); those that remain tend to become organized. Experience suggests that many of these remain quite silent ; that some patients have a marked ability to absorb adhesions, but that others are particularly able to produce and maintain them. The only preventive action appropriate at present is to select patients in whom it is wise to promote the formation of ‘controlled adhesions’ (White, 1956). Noble (1937) suggested that when a loop of small bowel was dissected free of adhesions with loss of serosa, this area should be covered by suturing it to the adjacent loop of bowel; this process, when repeated, led to the small intestine being sutured together in an orderly ladder pattern. The major objections to this method are that it is time-consuming, unreliable and has a high complication rate. Wilson (1964) reported 7 deaths and 24 recurrent obstructions among 127 Noble procedures. The modification introduced by Childs and Phillips (1960) takes less time but it may also be associated with complications, and when used in patients with peritonitis carries a high mortality (McCarthy, 1975). Thus, a safer and quicker operation would be welcome, and intestinal intubation seems a worthwhile alternative. The only animal experiments designed to show the effects of intubation of the small intestine (Heydinger et al., 1960) suggest that adequate adhesions will have formed between loops of small intestine in 10 days, and clinical experience of this technique has also led surgeons to recommend leaving the tube in situ for about 10 days (White, 1956; Baker, 1968; Grosfield et al., 1975). We generally leave the tube in situ for 10-14 days and the radiographs taken with the tube in situ suggest that a favourable position of the bowel is maintained during that time. Small bowel barium studies carried out several years after intubation would be of interest, but so far such studies have not been required. The upper jejunum is the site favoured by most surgeons for insertion of the intestinal tube (Baker, 1968; Behrend and Piezas, 1969; Markee and Uhlig, 1971). One case of obstruction at the site of the Witzel jejunostomy has been described (Baker, 1968), and Baker (1968) and Markee and Uhlig (1971) mentioned persistent jejunal fistulas after removal of the jejunal tube in 2 patients, one of which closed off spontaneously after one month while the other patient died. However, we have now used the proximal jejunum as the site for insertion of the tube in 31 patients and so far we are satisfied that it is troublefree, and of particular importance is the fact that in each case the jejunostomy site has healed over within 1 week of removal of the tube. Other surgeons (Richard and Green, 1969) have preferred to insert the intestinal tube through a gastrostomy, but we d o not favour this procedure except in neonates and small children, when we would agree with Grosfield et al. (1975) that the stomach is the site of choice. In our experience gastrostomy is much easier to perform and carries a lower complication rate in children than in adult patients. We have placed more emphasis than other surgeons on the value of continued decompression of the small intestine. Baker’s tube has holes only at the end of the tube beyond the balloon so that the bowel can be decompressed at the time of operation, but we feel that if this tube is fed into the distal ileum or into the
Operative intubation in complicated small bowel obstruction Table 11: RESULTS OF OPERATIVE INTUBATION OF THE SMALL INTESTINE Mortality No. of cases related to Recurrence of small bowel operation obstruction Authors operated on Reason for intubation 46 Recurrent small bowel 4 1 Requiring operation Baker (1968) obstruction 3 No operation 49 33 Small bowel obstruction 1 2 1 Requiring operation Markee and 11 Prophylactic 1 No operation Uhlig (1971) 5 Decompression White (1956) 16 4 Recurrent obstruction 1 1 1 Requiring operation 12 First laparotomy for ( ? pulmonary obstruction embolus) 18 Acute and chronic I Richard and obstructions Green (1969) 10 7 Small bowel obstruction Heydinger et al. None (1960) 3 Small bowel obstruction associated with peritonitis 32 6 Peritonitis Present series None 8 Recurrent obstruction 11 First laparotomy for obstruction 7 Prophylactic
caecum then the rest of the bowel may be incompletely emptied in the postoperative period. By cutting small side holes along the length of our tubes we feel that more adequate decompression can be achieved in the postoperative period. There is no convincing evidence that decompression of the bowel will expedite the return of intestinal motility, but it may be of help in reducing the kinking associated with gross intestinal distension and also in allowing healing to take place when bowel anastomoses are made in adverse circumstances. The value of intubation in preventing recurrent small bowel obstruction is not easily proved, and only long term follow-up of these patients and comparison with a control group could give a definite answer. From the results collected in Table ZZ, it can be seen that 139 patients have had intubation carried out for adhesive intestinal obstruction. There were 2 deaths possibly related to the operation and 8 patients with possible recurrent obstruction in the follow-up period. Three of the patients with recurrent obstruction required operation but only 1 of these was found to have recurrent adhesive obstruction at operation. The length of follow-up since operation is in many cases still short, but considering the complexity of many of the cases, the results of intubation are very encouraging. The extension of the indications for intubation to patients with peritonitis is more controversial but the basis of the procedure appears to be sound, and we have been impressed, as were Heydinger et al. (1960) and Luck and Eastcott (1961), with the absence of signs of prolonged ileus and the smooth recovery of these patients. Whether intubation should be extended to patients undergoing, for example, panproctocolectomy, needs further examination. There is no doubt that the incidence of postoperative adhesive obstruction after this operation is exceptionally high (Ritchie, 1971). Operative intubation has now been used by the authors in 32 patients of all ages and has proved to be safe and free of complications. These results, and those of other surgeons, suggest that the technique should be recognized as a useful addition to surgical practice.
127
Length of follow-up 2-15 yr 0-4 yr 0-6 yr Not stated Short term
0-5 yr
References w. (1959) A long jejunostomy tube for decompressing intestinal obstruction. Surg. Gynecol. Obstet. 109, 519-520. BAKER J. w. (1968) Stitchless plication for recurring obstruction of the small bowel. Am. J. Surg. 116, 316-324. BEHREND A. and PIEZAS M. c. (1969) Treatment of complicated intestinal obstructions by use of the Baker tube. Znt. Surg. 52, 63-67. CHILDS w. A. and PHILLIPS R. B. (1960) Experience with intestinal plication and a proposed modification. Ann. Surg. 152, 258-265. DEVINE J. (1946) A concept of paralytic ileus: a clinical study. Br. J. Surg. 34, 158-179. GAMBEE L. P. (1951) A single-layer open intestinal anastomosis applicable to the small as well as the large intestine. West. J. Surg. Obstet. Gynecol. 59, 1-5. GROSFIELD L. J., COONEY D. R. and CSICSKO J F. (1975) Gastrointestinal tube stent plication in infants and children Arch. Surg. 110, 594-599. HEYDINGER D . K., TAYLOR P. H. and ROETTIG L. C. (1960) Recurrent intestinal obstruction. Arch. Surg. 80, 670-676. JACKSON B. B. (1958) Observations on intraperitoneal adhesions. Surgery 44, 507-514. JONES P. F. and MATHESON N. A. (1968) Operative decompression in intestinal obstruction. Lancer 1, 1197-1 198. LUCK R. J. and EASTCOTT H. H . G. (1961) Intubated jejunostomy for recurrent small-bowel obstruction due to peritonitis. Br. Med. J. 1, 1200-1202. MCCARTHY J. D. (1975) Further experience with the ChildsPhillips plication operation. Am. J. Surg. 130, 15-19. MARKEE R. K. and UHLIG B. E. (1971) Baker tube jejunostomy. Minn. Med. 54, 981-984. NOBLE T. B. (1937) Plication of the small intestine as prophylaxis against adhesions. Am. J. Surg. 35, 41-44. RAVITCH M. M. and CHERRY J. (1968) Intestinal intubation to prevent recurrence of midgut volvulus. Am. J. Surg. 116, 101-102. RICHARD N. P. and GREEN w. L. (1969) A non-suture method of plication of the small bowel. Int. Surg. 52, 489-493. RITCHIE J. K. (1971) Ileostomy and excisional surgery for chronic inflammatory disease of the colon. A survey of one hospital region. Gut 12, 528-540. WHITE R. R. (1956) Prevention of recurrent small bowel obstruction due to adhesions. Ann. Surg. 143, 714-719. WILSON N. D. (1964) Complications of the Noble procedure. Am. J. S U ~ Z108, . 264-269. WHELAN T. J. (1968). Quoted by Baker (1968). BAKER J.
Paper accepted 7.9.1977.
Operative intubation in the treatment of complicated small bowel obstruction A L E X A N D E R M U N R O A N D P E T E R F. J O N E S * SUMMARY
Case report
Intestinal intubation carried out at laparotomy for complicated small bowel obstruction is not yet agenerally accepted technique. Experience in 32 patients has shown that it is safe and effective. The procedure was initially described in North America for use in recurrent adhesive small intestinal obstruction but the indications have been extended and it has proved of value in other dificult situations. A techniquefor intubation is described and the results obtained in various clinical situations are given.
Ten years ago, Mrs J. S. was 57 years old when she was treated in a cottage hospital for a strangulated femoral hernia. After resection of gangrenous ileum, intestinal Obstruction recurred, requiring two further laparotomies, at the second of which an ileoileostomy was made to bypass an obstructed loop. Over the next 5 years she suffered recurrent obstructive episodes which settled spontaneously on conservative treatment, but she then had a further episode of obstruction which did not resolve and she was admitted to hospital under our care. At laparotomy the ileum was released from a number of adhesions but obstruction recurred, and at another laparotomy 3 weeks later there were dense generalized adhesions; the only feasible procedure was to perform a gastrostomy and insert a tube into the lowest loop of distended small bowel as an enterostomy. The patient was fed intravenously for 5 weeks and she slowly recovered but over the following year episodes of obstruction came and went and X-rays always showed some dilated loops of bowel containing fluid levels. One year after her last operation an abscess formed on the abdominal wall, discharged and proved to be a small bowel fistula. Because it was clear that the patient would not improve without further surgery another laparotomy was undertaken and this time we decided to try out the method of intestinal intubation described by Baker (1968). At operation the peritoneal cavity appeared to be obliterated by adhesions but the small intestine was freed completely, the blind ileal loop excised, five holes in the intestine repaired and a fresh ileoileal anastomosis made. Finally, a Miller-Abbott tube was inserted through a high jejunostomy and passed down the whole length of the small intestine. Recovery was slow but uneventful and the tube was withdrawn after 3 weeks. There has been no recurrence of obstruction.
RECURRINGsmall intestinal obstruction due to adhesions is a familiar and unpleasant problem for the abdominal surgeon. Each time a laparotomy is undertaken the procedure becomes more difficult and the outcome for the unfortunate patient less certain. There is no reliable method as yet of preventing the formation of adhesions, so attempts to forestall further episodes of obstruction must be aimed at producing ‘controlled adhesions’, which will allow loops of the small intestine to adhere permanently to each other in an orderly pattern. These adhesions can be promoted in two ways: by sutures which hold adjacent loops of intestine in contact for long enough to allow them to adhere to each other (Noble, 1937; Childs and Phillips, 1960); or by threading a tube down the whole length of the small intestine, which will, by its intrinsic stiffness, prevent kinking whilst adhesions form (White, 1956; Baker, 1968). The suture method is not without risks of immediate Method and later complications. The intubation method The tube appears to be both safe and effective and has been The intestinal tube should be at least 300 cm (10 ft) long so used by a number of surgeons in North America, but that when the small intestine is threaded on to it there is no it does not seem to be much practised in this country. pleating of the bowel. In adults an 18 FG tube is suitable. The Intubation of the intestine via an abdominal incision pliability of the tubing must be such that it will bend readily was first suggested by Devine in 1946 for the treatment into a semicircle 5 cm in diameter without kinking. The material for the tubing should not deteriorate in contact with of patients with unremitting paralytic ileus. White, in used intestinal secretions. 1956, threaded a Miller-Abbott tube through the We found that the tube made to Baker’s (1968) specifications whole length of the small intestine when operating for was not available in this country and we therefore used a recurrent adhesive intestinal obstruction with the Miller-Abbott tube (H. W. Andersen Products Inc.). This object of forming ‘controlled adhesions’ by main- tube is not ideal because the balloon is too large and delicate, but the size of the balloon can be altered by tying a piece of taining internal splintage. In 1959 Baker described a Foley-type catheter, 40 in thread around it just distal to the end of the tube and cutting long, which was introduced through a jejunostomy off the remainder of the balloon. When inflated the balloon be tense and measure 1.5-2 cm in diameter. and used to keep obstructed bowel decompressed. In should have recently tested a prototype tube made specifically 1968 Baker made a detailed report on the use of this to We our requirements. This tube has proved satisfactory and is tube to promote controlled adhesions in 52 obstructed essentially a very long Foley-type catheter made of PVC. It is patients, with a very low recurrence rate. At the same similar to the tube designed by Baker (1968) but is slightly time, Whelan reported from Vietnam on the value of longer and small side holes are cut at 15 cm intervals along the Baker’s tube in the management of penetrating ab- distal half.? dominal injuries (Whelan, 1968). The present authors first used the technique 44 years ago in the case * Alexander Munro, Aberdeen Hospitals; Peter F. Jones, General Hospital and Royal Aberdeen Children’s reported below and were impressed with the heIp it Woodend Hospital, Aberdeen. provided in a difficult situation. Since then, the Correspondence to P. F. Jones, Woodend General Hospital, indications have been extended. This paper reviews Aberdeen. previous reports on intestinal intubation and describes t This tube is now being manufactured by J. G. Franklin and our own experience. Sons (Code no. 463018).
124
Alexander Munro and Peter F. Jones
Sutures
/I / /
Fig. 1. Line diagram to show the principal features of the intestinal tube. Note the double-lumen tube, with the balloon inflated in the caecum; the side holes to decompress the small intestine; the sutures attaching the jejunostomy site to parietal peritoneum.
Ravitch and Cherry (1968). In the absence of a balloon which could be inflated in the caecum, we secured the distal end of the tube by bringing it out through a caecotomy. In patients aged about 8 years and upwards an adult-size tube can be used. Operutiue technique (Fig. I ) After the division of all adhesions, any injuries to the intestine are repaired with interrupted Gambee (1951) sutures of 3/0 silk. The obstructed bowel is then decompressed by retrograde stripping into the stomach (Jones and Matheson, 1968). A small incision is now made in the abdominal wall in the left flank and the tube is pulled through into the peritoneal cavity. A purse-string suture of 2/0 chromic catgut is placed o n the antimesenteric border of the jejunum 10-15 cm distal to the duodenojejunal flexure, the bowel wall incised, the tube fed into the jejunum and the suture tightened around it. The balloon is now inflated and is used to draw the tube down the whole length of the small intestine. The ballon is usually of most help if it is blown up hard, so that it can be easily manipulated along the intestine. Especially in obstructed bowel, the process of intubation can be rapid, taking only 5 min, but if the bowel is of normal calibre the process can take 15-20min. As the balloon is advanced small areas kinked by unnoticed adhesions may require straightening. In all cases (with the exception of those who have had right hemicolectomy performed) we have manipulated the deflated balloon through the ileocaecal valve and then reinflated the balloon t o prevent retraction. When the length is satisfactorily adjusted, so that there is neither pleating of the bowel through failure to introduce sufficient tubing nor coiling of an excess of tubing in the bowel, the purse-string suture is finally tied. A second purse-string suture is inserted and tied around the first, to invaginate it, and left long. The tubing is gently drawn out of the stab incision until the jejunum comes to lie against parietal peritoneum. The needle on the second purse-string suture is then passed through the peritoneum at this point and the suture tied, so holding the jejunum firmly up against the abdominal wall; we often insert an extra stitch to reinforce this suture. Finally, the tubing is secured firmly by a skin suture. It is important to ensure that the proximal jejunum at the site of intubation lies well, without kinking, and that the intestines lie in an orderly manner. Postoperatice care
The nasogastric tube need not be left in position for more than 12-24 h after operation. The jejunostomy tube is attached to a closed drainage bag and put on gravity drainage. After a period of 24-48 h the tube often begins to produce intestinal contents. These are very variable in quantity and have ranged from 150 to 1200 m1/24 h. When normal peristaltic sounds are heard and flatus is being passed per rectum, oral fluids can be given and the tube spigotted off. Before removal of the tube, in a number of cases, radiographs were taken to demonstrate the position of the bowel loops (Fig. 2). The jejunostomy tube was left in situ for a period of 10-18 days, most being removed around 12 days from the time of operation. Withdrawal of the tube takes about 5 min, with gentle sustained traction ; although patients may be apprehensive, this has not proved to be an uncomfortable procedure. There is often leakage of small bowel contents around the jejunostomy tube after it has been in place for about 10 days but this has always ceased after withdrawal of the tube, and the skin wound has healed within a week. Fig. 2. Plain X-ray film of the abdomen 10 days after operation. Infants and children
When performing this procedure on babies and infants a smaller tube must be used. Our youngest patient was a baby 9 months old who suffered a mid-gut volvulus for the third time. I n this case we used I2 FG Portex tubing and to assist in drawing the tube through the bowel, l cm of the tip of the tube was turned back through 180" and tied tightly with thread to produce a knuckle on which gentle traction could be applied. The tube was introduced via a gastrostomy, as suggested by
Indications for use Recurrent small bowel obstruction We have used this procedure on 8 patients who had required at least one previous operation for adhesive intestinal obstruction; 3 had undergone multiple previous laparotomies for this reason (Table Z). Two patients had undergone a Noble's plication in our unit, 7 years and 1 year respectively before the intubation operation; 3 required a resection of the small intestine at the time of intubation. Some of these operations
Operative intubation in complicated small bowel obstruction Table I: INTUBATION IN RECURRENT ADHESIVE SMALL BOWEL OBSTRUCTION Previous episodes of Laparotomy findings and procedure Patient Primary operation obstruction * 1972 Adhesive obstruction; K. C. 1970 Intussusception 1971 Small bowel obstruction due to adhesions; laparotomy; intubation of small bowel (6 yr) reduced small bowel resection J. S. 1967 Strangulated 1967 Two laparotomies for 1972 Adhesive obstruction; adhesive obstruction; bypass laparotomy ; resection of (65 yr) femoral hernia; small bowel of distal ileum bypassed area of ileum with end-to-end anastomosis; resection 1970 Small bowel obstruction; intubation of small bowel conservative treatment 1971 Laparotomy for small bowel obstruction. Noble plication; 2 weeks later further laparotomy, gastrostomy and jejunostomy 1976 Laparotomy for adhesive E. F. 1963 Colectomy with June 1969 Intestinal obstruc(50 yr) ileorectal tion; conservative treatment obstruction; separation of 1969 Laparotomy with division adhesions; intubation of anastomosis small bowel of adhesions; 2 weeks later still obstructed; Noble plication 1976 Chronic incomplete small bowel obstruction V. F. 1932 Appendicitis 1953 Adhesive obstruction; 1973 Laparotomy for adhesive laparotomy obstruction; intubation of (53 yr) 1960 Adhesive obstruction; small bowel laparotomy 1963 Small bowel obstruction; Conservative treatment 1965 Adhesive obstruction; laparotomy 25.1 1.74 Admitted with small 30.1 I .74 Obstruction recurred; bowel obstruction; small bowel freed; intubalaparotomy; adhesions to tion of small intestine; abscess around sigmoid sigmoid resection colon; small bowel separated; transverse colostomy D. D. 1948 Ileotransverse 1970 Laparotomy for small April 1975 Jejunal resection (51 yr) colostomy for bowel obstruction; and right hemicolectomy; Crohn's disease adhesions and small bowel intubation of small intestine 1958 Attempted enterolith hysterectomy; 1974 Small bowel obstruction; abandoned because conservative treatment of adhesions 1975 Small bowel obstruction; conservative treatment G. S. 12.3.76 Laparotomy for small 23.3.76. Obstruction recurred; bowel obstruction; adhesions numerous fibrinous (56 yr) to terminal ileum adhesions divided; small bowel intubation D. K. Appendicectomy in December 1975 Adhesive 1977 Adhesive obstruction; (43 yr) childhood obstruction ; laparotomy adhesions divided; small March 1975 August 1976 Adhesive bowel intubation Hysterectomy obstruction ; laparotomy August 1976 Ovarian cystectomv
Outcome Tube removed at 10 d Good recovery Tube removed at 3 wk Good recovery
125 FollowUP
Tube removed at 10 d Good recovery
Tube removed at 12 d Uneventful recovery
Colostomy closed few months later Good recovery
Tube removed at 10 d Good recovery
Tube removed at 10 d Uneventful recovery Tube removed at 12 d Slow recovery and occasional attacks of colic
* Including operations for adhesive obstruction. were tedious and difficult, and in 2 patients holes were accidentally made in the obstructed small bowel during dissection. It was reassuring to know that the side holes in the tubing would allow decompression of the damaged bowel while it healed and that, if intubation achieved its objective, it would not be necessary to repeat such operations. The longest follow-up is 4+ years and the average is 2+ years; so far there has been no recurrence of intestinal obstruction, but one patient has intermittent episodes of intestinal colic. These good results suggested that it would be worth offering the advantages of intubation to a wider range of patients and we recognize four other indications.
First episode of'intestinal obstruction due to dense small bowel adhesions When intubation proved to be useful in our earlier patients it was decided to extend its use to patients who required a first laparotomy for small bowel obstruction with extensive adhesions. We hoped that future adhesive obstruction would thus be prevented. In 10 of the 11 cases in this group the adhesions were presumed to be secondary to previous surgery and in the eleventh patient, who had no previous operation, the whole small bowel was matted together by dense adhesions. In several patients, when separation had been completed, large areas of the small intestine were denuded of serosa.
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Alexander Munro and Peter F. Jones
All these patients have pursued an uncomplicated postoperative course and none has developed further episodes of intestinal obstruction. Four of the operations have been carried out in the past few months but the average follow-up of the others is 26 years. General peritonitis When general peritonitis occurs there is always a marked fibrinous exudate over the surface of exposed bowel, there is often a degree of intestinal obstruction which may be both paralytic and mechanical in origin, and it is common to find loculi of pus trapped between adherent loops of intestine. We believe that there is a good case for intubation at the time of operation for peritonitis, rather than at a more difficult and dangerous second operation, as suggested by Luck and Eastcott (1961). We have done this in 6 patients, 3 of whom had a perforated colon with widespread faecal contamination. Two other patients were operated on for neglected perforated appendicitis with established interloop abscesses containing large quantities of pus. Following colonic resection or appendicectomy the whole of the small bowel was freed and the entire intestine and peritoneal cavity, including the subdiaphragmatic spaces, were thoroughly washed with several litres of solution containing 0 1 per cent tetracycline in normal saline. Intubation of the small bowel was carried out in the usual way. The intestinal tube was removed 10 days after the operation in 4 cases and in 2 cases the tube was left in situ for 14 and 17 days respectively because of continued ileus. All made a complete recovery and we did not experience recurrent intestinal obstruction in any of these patients, nor was residual intraperitoneal sepsis encountered.
Prophylactic intubation Our encouraging experience of intubation in obstructed patients led us to consider this procedure as a prophylactic measure in patients who appeared to be at particular risk of later adhesive obstruction, even when there was no evidence of this at the time of operation. We have carried out such intubation in two groups of patients. 1. Patients who, at laparotomy, are found to have dense multiple adhesions which have to be separated in the course of carrying out the operation. There were 6 patients in this group; 5 had had a previous operation for peritonitis due to colonic perforation and 4 were undergoing a restorative anastomosis of colon to rectum after an emergency Hartmann’s resection for perforated diverticular disease. The sixth patient was having a very large incisional hernia repaired and it seemed particularly important that his abdomen should not become distended postoperatively (White, 1956). 2. Patients who, though having no evidence of adhesion formation, are undergoing surgery which carries a particularly high later risk of adhesive obstruction, e.g. proctocolectomy for colitis. We have been impressed by the speedy recovery of intestinal function in these patients. There have been no subsequent obstructive episodes.
Discussion Fibrinous adhesions form after every laparotomy and it has been suggested that some may be lysed by the
action of proteolytic enzymes (Jackson, 1958); those that remain tend to become organized. Experience suggests that many of these remain quite silent ; that some patients have a marked ability to absorb adhesions, but that others are particularly able to produce and maintain them. The only preventive action appropriate at present is to select patients in whom it is wise to promote the formation of ‘controlled adhesions’ (White, 1956). Noble (1937) suggested that when a loop of small bowel was dissected free of adhesions with loss of serosa, this area should be covered by suturing it to the adjacent loop of bowel; this process, when repeated, led to the small intestine being sutured together in an orderly ladder pattern. The major objections to this method are that it is time-consuming, unreliable and has a high complication rate. Wilson (1964) reported 7 deaths and 24 recurrent obstructions among 127 Noble procedures. The modification introduced by Childs and Phillips (1960) takes less time but it may also be associated with complications, and when used in patients with peritonitis carries a high mortality (McCarthy, 1975). Thus, a safer and quicker operation would be welcome, and intestinal intubation seems a worthwhile alternative. The only animal experiments designed to show the effects of intubation of the small intestine (Heydinger et al., 1960) suggest that adequate adhesions will have formed between loops of small intestine in 10 days, and clinical experience of this technique has also led surgeons to recommend leaving the tube in situ for about 10 days (White, 1956; Baker, 1968; Grosfield et al., 1975). We generally leave the tube in situ for 10-14 days and the radiographs taken with the tube in situ suggest that a favourable position of the bowel is maintained during that time. Small bowel barium studies carried out several years after intubation would be of interest, but so far such studies have not been required. The upper jejunum is the site favoured by most surgeons for insertion of the intestinal tube (Baker, 1968; Behrend and Piezas, 1969; Markee and Uhlig, 1971). One case of obstruction at the site of the Witzel jejunostomy has been described (Baker, 1968), and Baker (1968) and Markee and Uhlig (1971) mentioned persistent jejunal fistulas after removal of the jejunal tube in 2 patients, one of which closed off spontaneously after one month while the other patient died. However, we have now used the proximal jejunum as the site for insertion of the tube in 31 patients and so far we are satisfied that it is troublefree, and of particular importance is the fact that in each case the jejunostomy site has healed over within 1 week of removal of the tube. Other surgeons (Richard and Green, 1969) have preferred to insert the intestinal tube through a gastrostomy, but we d o not favour this procedure except in neonates and small children, when we would agree with Grosfield et al. (1975) that the stomach is the site of choice. In our experience gastrostomy is much easier to perform and carries a lower complication rate in children than in adult patients. We have placed more emphasis than other surgeons on the value of continued decompression of the small intestine. Baker’s tube has holes only at the end of the tube beyond the balloon so that the bowel can be decompressed at the time of operation, but we feel that if this tube is fed into the distal ileum or into the
Operative intubation in complicated small bowel obstruction Table 11: RESULTS OF OPERATIVE INTUBATION OF THE SMALL INTESTINE Mortality No. of cases related to Recurrence of small bowel operation obstruction Authors operated on Reason for intubation 46 Recurrent small bowel 4 1 Requiring operation Baker (1968) obstruction 3 No operation 49 33 Small bowel obstruction 1 2 1 Requiring operation Markee and 11 Prophylactic 1 No operation Uhlig (1971) 5 Decompression White (1956) 16 4 Recurrent obstruction 1 1 1 Requiring operation 12 First laparotomy for ( ? pulmonary obstruction embolus) 18 Acute and chronic I Richard and obstructions Green (1969) 10 7 Small bowel obstruction Heydinger et al. None (1960) 3 Small bowel obstruction associated with peritonitis 32 6 Peritonitis Present series None 8 Recurrent obstruction 11 First laparotomy for obstruction 7 Prophylactic
caecum then the rest of the bowel may be incompletely emptied in the postoperative period. By cutting small side holes along the length of our tubes we feel that more adequate decompression can be achieved in the postoperative period. There is no convincing evidence that decompression of the bowel will expedite the return of intestinal motility, but it may be of help in reducing the kinking associated with gross intestinal distension and also in allowing healing to take place when bowel anastomoses are made in adverse circumstances. The value of intubation in preventing recurrent small bowel obstruction is not easily proved, and only long term follow-up of these patients and comparison with a control group could give a definite answer. From the results collected in Table ZZ, it can be seen that 139 patients have had intubation carried out for adhesive intestinal obstruction. There were 2 deaths possibly related to the operation and 8 patients with possible recurrent obstruction in the follow-up period. Three of the patients with recurrent obstruction required operation but only 1 of these was found to have recurrent adhesive obstruction at operation. The length of follow-up since operation is in many cases still short, but considering the complexity of many of the cases, the results of intubation are very encouraging. The extension of the indications for intubation to patients with peritonitis is more controversial but the basis of the procedure appears to be sound, and we have been impressed, as were Heydinger et al. (1960) and Luck and Eastcott (1961), with the absence of signs of prolonged ileus and the smooth recovery of these patients. Whether intubation should be extended to patients undergoing, for example, panproctocolectomy, needs further examination. There is no doubt that the incidence of postoperative adhesive obstruction after this operation is exceptionally high (Ritchie, 1971). Operative intubation has now been used by the authors in 32 patients of all ages and has proved to be safe and free of complications. These results, and those of other surgeons, suggest that the technique should be recognized as a useful addition to surgical practice.
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Length of follow-up 2-15 yr 0-4 yr 0-6 yr Not stated Short term
0-5 yr
References w. (1959) A long jejunostomy tube for decompressing intestinal obstruction. Surg. Gynecol. Obstet. 109, 519-520. BAKER J. w. (1968) Stitchless plication for recurring obstruction of the small bowel. Am. J. Surg. 116, 316-324. BEHREND A. and PIEZAS M. c. (1969) Treatment of complicated intestinal obstructions by use of the Baker tube. Znt. Surg. 52, 63-67. CHILDS w. A. and PHILLIPS R. B. (1960) Experience with intestinal plication and a proposed modification. Ann. Surg. 152, 258-265. DEVINE J. (1946) A concept of paralytic ileus: a clinical study. Br. J. Surg. 34, 158-179. GAMBEE L. P. (1951) A single-layer open intestinal anastomosis applicable to the small as well as the large intestine. West. J. Surg. Obstet. Gynecol. 59, 1-5. GROSFIELD L. J., COONEY D. R. and CSICSKO J F. (1975) Gastrointestinal tube stent plication in infants and children Arch. Surg. 110, 594-599. HEYDINGER D . K., TAYLOR P. H. and ROETTIG L. C. (1960) Recurrent intestinal obstruction. Arch. Surg. 80, 670-676. JACKSON B. B. (1958) Observations on intraperitoneal adhesions. Surgery 44, 507-514. JONES P. F. and MATHESON N. A. (1968) Operative decompression in intestinal obstruction. Lancer 1, 1197-1 198. LUCK R. J. and EASTCOTT H. H . G. (1961) Intubated jejunostomy for recurrent small-bowel obstruction due to peritonitis. Br. Med. J. 1, 1200-1202. MCCARTHY J. D. (1975) Further experience with the ChildsPhillips plication operation. Am. J. Surg. 130, 15-19. MARKEE R. K. and UHLIG B. E. (1971) Baker tube jejunostomy. Minn. Med. 54, 981-984. NOBLE T. B. (1937) Plication of the small intestine as prophylaxis against adhesions. Am. J. Surg. 35, 41-44. RAVITCH M. M. and CHERRY J. (1968) Intestinal intubation to prevent recurrence of midgut volvulus. Am. J. Surg. 116, 101-102. RICHARD N. P. and GREEN w. L. (1969) A non-suture method of plication of the small bowel. Int. Surg. 52, 489-493. RITCHIE J. K. (1971) Ileostomy and excisional surgery for chronic inflammatory disease of the colon. A survey of one hospital region. Gut 12, 528-540. WHITE R. R. (1956) Prevention of recurrent small bowel obstruction due to adhesions. Ann. Surg. 143, 714-719. WILSON N. D. (1964) Complications of the Noble procedure. Am. J. S U ~ Z108, . 264-269. WHELAN T. J. (1968). Quoted by Baker (1968). BAKER J.
Paper accepted 7.9.1977.
