Search

The article presents a clinical case of a 23-year-old patient with an extremely severe congenital form of chronic intestinal pseudoobstruction coupled with a neuromyopathy,colon malrotation, malabsorption, bacterial overgrowth syndrome, cholelithiasis and gastrostasis, which excluded bowel transplantation. Long-term treatment in the intensive care unit with combined, mainly parenteral nutrition for 6 months, using antibiotics, prokinetics, intestinal decompression allowed to achieve partial stabilization of the patients condition and transfer to home treatment with the continuation of adequate complex therapy.Представлено клиническое наблюдение больной 23 лет с крайне тяжелой врожденной формой хронической интестинальной псевдообструкции с нейромиопатией. мальротацией толстой кишки, мальабсорбцией, синдромом избыточного бактериального роста, холелитиазом, гастростазом, исключавшим выполнение трансплантации кишечника. Длительное лечение в отделении интенсивной терапии с комбинированным, преимущественно парентеральным питанием в течение 6 мес, применением антибиотиков, прокинетиков, кишечной декомпрессии позволило добиться частичной стабилизации состояния и перевода пациентки на домашнее лечение с продолжением адекватной комплексной терапии.

Chronic intestinal pseudo-obstruction a rare violation of the motor skills of the gastrointestinal complex, similar to mechanical obstruction, but without a mechanical obstacle. The development of chronic intestinal pseudo-obstruction is caused by a disturbance on the part of the smooth muscles and the nervous system of the gastrointestinal system. Common symptoms include constipation, abdominal pain, nausea, vomiting, bloating. Violation of peristalsis leads to food stagnation in the hinges of the small intestine, their dilation, the development of bacterial insemination syndrome. Eating disorders, bacterial contamination syndrome (CDDs) lead to impaired suction syndrome, cahexia. Treatment is aimed at providing adequate nutrition, the use of drugs that activate motor skills, suppress the growth of microbes in the small intestine, the implementation of intestinal decompression. Surgical treatment: resection of the affected segment of the gut. In the refractory course of the disease intestinal transplantation.

According to literature data acute intestinal obstruction is characterized by a great number of neglected forms comprising 5–70% cases with the given pathology. A number of radiological signs in the way of Kloiber’s bowls and intestinal arches simply confirm this and testify of colon motor activity decompensation. To date there are no objective diagnostic criteria providing indications to intestinal decompression before the operation. Intestinal intubation, its types and indications to its fulfilment are based only on the experience and intuition of the operating surgeon. Aim — to define clinical efficiency of the intestinal wall impaired contractility diagnostics method in the treatment of patients with acute colonic obstruction. Medical histories analysis of 166 patients with obstructive intestinal obstruction was carried out. Assessment of intestinal motor activity compensation was carried out with the help of echographic criteria — the number of enlarged small bowel loops, intestinal lumen width, wall thickness, distance between Kerckring folds, number of peristaltic movements per minute. According to the suggested method 3 groups of patients were distinguished — with compensated motor activity (32 (19%) patients), with sub-compensated motor activity (61 (36.5%) patients) and with intestinal decompensated motor activity (73 (44.4%) patients). Wherein the greater number of patients with obstructive ileus (135 (81%) patients) got into the hospital with sub- and decompensated intestinal motor function. In the group of patients with compensated muscular tone intestinal decompression was not carried out, in the second group with sub-compensated intestinal tone decompression was carried out simultaneously in 13 (7.8%) patients, and in 9 (5.4%) a nasojunal probe was installed for 2–3 days, in the third group intestinal intubation was done in 63 (38%) patients. Post-operative mortality was 3.2%. Thus, echographic criteria allow establishing the degree of intestinal impaired motor function before the operation in patients with acute intestinal obstruction which decompression depends upon its state.

Background Conservative therapy for Crohn’s disease (CD)-related acute bowel obstruction is essential to avoid emergent surgery. The present study aimed to evaluate the efficacy of using a long intestinal decompression tube (LT) in treatment of CD with acute intestinal obstruction. Methods This is a prospective observational study. Comparative analysis was performed in CD patients treated with LT (the LT group) and nasogastric tube (the GT group). The primary outcome was the avoidance of emergent surgery. Additionally, predictive factors for failure of decompression and subsequent surgery were investigated. Results There were 27 and 42 CD patients treated with LT and GT, respectively, in emergent situations. Twelve (44.4%) patients using LT were managed conservatively without laparotomy, while only nine (21.4%) patients in the GT group were spared from emergent surgery (P 500 mL were predictors of unavoidable surgery (both P 0.05). Conclusions Endoscopic placement of LT could improve the emergent status in CD patients with acute bowel obstruction. The drainage output and changes in C-reactive protein after intubation could serve as practical predictive indices for subsequent surgery. Compared to traditional GT decompression, LT decompression was associated with fewer short-term complications and did not appear to affect long-term recurrence.

Pediatric intestinal pseudoobstruction (PIPO) is the "tip of the iceberg" of the most severe gut motility disorders. In patients with PIPO, the impairment of gastrointestinal propulsive patterns is such as to result in progressive obstructive symptoms without evidence of mechanical causes. PIPO is an important cause of intestinal failure and affects growth and pubertal development. Bowel loop and abdominal distension represent one of the main features of intestinal pseudo-obstruction syndromes, hence intestinal decompression is a mainstay in the management of PIPO. So far, pharmacologic, endoscopic, and surgical treatments failed to achieve long-term relief of bowel distension and related symptoms, including pain. Recent data, however, indicated that percutaneous endoscopic gastrojejunostomy (PEG-J) might be a minimally invasive approach for intestinal decompression, thereby improving abdominal symptoms and nutritional status in adult patients with chronic intestinal pseudo-obstruction. Based on these promising results, we treated for the first time a 12-y-old patient affected by PIPO refractory to any therapeutic options to obtain intestinal decompression by PEG-J. We showed that PEG-J yielded sustained small bowel decompression in the reported PIPO patient with considerable improvement of both abdominal symptoms and nutritional status. The positive outcome of the present case provides a basis to test the actual efficacy PEG-J versus other therapeutic approaches to intestinal decompression in patients with PIPO.

BACKGROUND Preoperative intestinal decompression, such as self-expandable metallic stents (SEMS) and transanal decompression tubes (TDT), has been widely used for patients with malignant large-bowel obstruction (MLBO). The aim of this study is to evaluate the clinical outcomes of SEMS for MLBO as a bridge to surgery compared to TDT. METHODS We searched three databases, including PubMed, Embase, and Web of Science from inception until June 12, 2019. Risk ratio (RR) or weight mean difference (WMD) with 95% CIs was used to calculate the data extracted from included studies. RESULTS Five studies with 226 participants were included in this review. SEMS insertion showed significantly higher clinical success rate (RR =1.30, 95% CI: 1.06, 1.60; P=0.012) and technical success rate (RR =1.33, 95% CI: 1.07, 1.65; P=0.011), as well as higher rates of solid food intake (RR =27.15, 95% CI: 8.73, 84.45; P

We present the case of an 89-year-old polymorbid female patient with recurrent acute colonic pseudo-obstruction who was treated by performing percutaneous endoscopic cecostomy as the first procedure of its kind in the Czech Republic. The patient presented repeatedly with ileous conditions without evidence of an organic cause. Surgical colostomy was proposed with a possibility of subtotal colectomy as an ultimum refugium due to an insufficient effect of maximum conservative management and a need for repeated endoscopic decompression. In this particular patient, however, any kind of surgical intervention posed a major risk and was eventually abandoned. Finally, percutaneous endoscopic cecostomy was proposed as an alternative to resolve the situation. The procedure was carried out without complications and with an immediate effect. The patient has been free of the symptomatology of intestinal obstruction in the long term having the option of intermittent intestinal decompression as needed.

Chronic intestinal pseudo-obstruction (CIPO) is a severe form of gastrointestinal dysmotility (often due to derangement of the innervation/smooth muscle/interstitial cells of Cajal) with recurrent episodes of intestinal subocclusion mimicking a mechanical obstruction. Because of its complexity and heterogeneity, CIPO is often misdiagnosed or remains unrecognized until advanced stages. Management is a critical aspect in CIPO patient care. So far, most prokinetic drugs have not proven efficacy in restoring intestinal propulsion, thus nutritional support, fluid/electrolyte replacement, and antibiotics are the mainstay of treatment. In this issue of the journal, Ohkubo et al showed promising data indicating that percutaneous endoscopic gastro-jejunostomy (PEG-J) can be proposed as a measure for intestinal decompression, thereby improving CIPO-associated abdominal symptoms, including pain. In addition to a concise update of clinical and diagnostic features, the present minireview tackles management options, with a major emphasis on PEG-J, for CIPO patients.

Three adult cases of intussusception associated with malignant tumors of the small intestine are reported. All of them had no history of previous laparotomy, and were diagnosed as intestinal obstruction on admission. The diangosis of intussusception was made by elective examinations following the bowel decompression therapy. The enterography of the oral side of the obstructive lesion showed a tapering shape of the intestinal lumen, which is a characteristic and specific finding of intussusception, and named as “pencil tip appearance”. Mesenteric arteriography was useful in making the diagnosis of intussusception, but it failed to demonstrate location or qualitative picture of the tumors. Most adult intussusceptions are associated with some causative organic diseases. It is often difficult to make definite diagnosis preoperatively that leads to emergency operation in considerable cases. From these experiences, it was clarified that the preoperative intestinal decompression therapy was effective and elective surgery was able to be performed. When we entertain a large probability of malignant primary lesion in adult intussusception, the significance that preoperative evaluation of the pathology can be achieved for an intestinal obstruction should be emphasized for better and more proper operative strategy.

Two nationwide questionnaire surveys of intestinal obstruction in Japan were undertaken, covering two two-year periods, from January, 1975 to December, 1976 and from January, 1985 to December, 1986, respectively. The findings of a comparative review of these two surveys indicated that although the overall mortality of intestinal obstruction had not changed between 1975/76 and 1985/86, being 6.8 per cent and 6.5 per cent, respectively, simple adhesive obstruction had decreased from 3.2 per cent in 1975/76 to 2.0 per cent in 1985/86. The main cause of adhesion was laparotomy and in cases of both simple adhesive obstruction and strangulation adhesive obstruction, the rate of adhesion secondary to laparotomy of the upper gastrointestinal tract and colon and rectum had increased between 1975/76 and 1985/76. Obstructions caused by neoplasms had increased from 8.2 per cent in 1975/76 to 10.0 per cent in 1985/86, while those caused by adhesions had increased further still, from 42.5 per cent in 1975/76 to 60.8 per cent in 1985/86. Among the latter group, non-operatively treated cases had increased, which may be accounted for by the fact that facilities which adopt non-operative treatment using intestinal decompression as the first choice for simple adhesive obstruction cases have increased. In both surveys, the mortality of cases receiving nonoperative treatment was lower than that of operative cases.

This study aimed to determine the incidence of adhesive small bowel obstruction (SBO) after primary colorectal cancer surgery and the outcomes of conservative management using gastrointestinal tubes in such cases. Between October 2000 and December 2005, 2,586 primary colorectal cancer patients underwent consecutive operations and were followed up completely for a median of 38 months. During the follow-up periods, 119 patients with 130 consecutive cases of adhesive SBO underwent conservative management using nasogastric tubes and long intestinal tubes. The overall adhesive SBO rate was 5.0% in 38 months of follow-up, and the observed incidence rate was 0.0013 per patient-month. Of the 130 cases, 104 cases (80%) were successfully treated by conservative management, and the symptoms of SBO were resolved by the sixth day (range 1 to 22). Twenty-six cases (20%) underwent surgery because of lack of clinical improvement (17) or signs of strangulation (9). The high success rate indicates that initial conservative management with intestinal decompression using gastrointestinal tubes is recommended for patients with adhesive SBO after primary colorectal cancer surgery.

Background Small bowel obstruction (SBO) after abdominal surgery is usually treated successfully with intestinal decompression using a long nasointestinal tube (LT), but some cases fail to respond. Methods Clinical background and laboratory data on admission were evaluated retrospectively for 53 patients with adhesive SBO to determine predictive factors for failure of LT decompression, and the appropriate timing of laparotomy was investigated. Results Complete SBO (no evidence of air within the large bowel) and increased serum creatine phosphokinase (≥130 IU/L) were independent predictive factors for LT decompression failure. Laparotomy was indicated in 14 patients (9 and 5 with complete and partial SBO, respectively), whereas successful LT decompression occurred in 39 patients (9 and 30, respectively). Resolution of SBO took significantly longer for complete SBO (6.3 days) than for partial SBO (2.6 days). Conclusions Patients with complete SBO or high serum creatine phosphokinase (CPK) may not respond to LT decompression. Laparotomy is appropriate after non-response for 7 and 3 days for complete and partial SBO, respectively.

We inserted a long intestinal tube via the percutaneous transgastric route in three patients with an inoperable malignant bowel obstruction. The percutaneous endoscopic gastrostomy technique facilitated this method. The main purpose of our procedure is to achieve direct intestinal de-compression without nasal intubation, which is not always possible by venting gastrostomy alone. Palliative intestinal decompression proved to be effective in all patients. This alternative therapeutic strategy for managing bowel obstruction in terminal cancer patients is herein presented.

Metallic stents are currently an established component of the endoluminal treatment of stenoses within the blood vessels, bile ducts, esophagus, trachea, and bronchi. With the development of newer stent designs and delivery systems and the general momentum toward minimally invasive therapies, metallic stent placement has expanded into the nonsurgical therapy for gastroduodenal and colorectal obstructions. The use of metallic stents within the stomach, duodenum, or colon is intended not to be curative but to provide nonsurgical palliation for the symptoms of gastric or colonic obstruction. This palliation may be intended for the life of the patient in the case of unresectable disease or as a temporizing procedure prior to a definitive surgical procedure. In the latter clinical scenario, the benefits of a minimally invasive intestinal decompression procedure include (a) quick and noninvasive relief of the intestinal obstruction in an acutely ill patient that obviates a more extensive procedure; (b) allowance of time to improve a patient's overall medical condition and thus to allow a patient to better tolerate the definitive surgical procedure; and (c) reduction of the complexity of the definitive procedure by eliminating the need for staged procedures and allowing the definitive procedure to be performed at one setting.

Die paralytische Darmdistension stellt die Ursache oder einen bedeutsamen Teilfaktor des Krankheitsbildes des postoperativen Fruhileus dar. Ihre Beseitigung leitet die entscheidende Wende im Krankheitsverlauf ein. Die lange Darmsonde ermoglicht als „intraluminares Stoma„ die notwendige Darmentlastung. Das Verfahren ist dank endoskopischer Hilfsmittel technisch ausgereift und bei geringem Eigenrisiko hocheffektiv. Die konservative Darmsondierung tragt zur Verminderung von Zweiteingriffen bei; ihr Hauptvorteil liegt in der Vermeidung der operativen Eroffnung des Ileusdarmes mit all ihren inharenten Gefahren.

Tools to cope more effectively with the bowel obstruction problem have been gradually evolving over the past four decades. It is possible to recognize most varieties of acute intestinal obstruction early enough to salvage the patient from the threat of a disorder that a few decades ago commanded a forbidding mortality. Great intestinal distention does not loom as difficult a problem today as it did four decades ago. The large residual mortality of intestinal obstruction today concerns primarily strangulating varieties. In fact, more than half the deaths from intestinal obstruction derive from the profession's failure to deal promptly with strangulated hernias and with internal strangulations before the bowel becomes nonviable. The current achievement with intussusception contrasts strikingly with our failure to deal competently with other strangulating varieties of intestinal obstruction. So similarly, the accomplishment with congenital intestinal atresia bespeaks the finesse of modern-day surgeons in coping with anastomoses of small tubular structures. The profession needs to take a more serious interest in intubation technics in dealing with intestinal distention, to which developments my colleagues, Doctors Arnold Leonard and Richard Edlich, have made significant contributions. The team approach to the problem of intestinal obstruction is essential. Every hospital with an interest in intestinal obstruction should have on its Bowel Obstruction Team an intestinal intubator with both interest and expertise. Leonard and Edlich and others who have achieved striking success with intestinal decompression by per oral intubation have a responsibility to train intubators and to transmit their expertise to others who can carry on. The problem in many respects is not unlike the history of utilization of gastroscopy for diagnosis. Only within the past decade have most American hospitals enjoyed ready access to competent gastroscopists, despite the fact that Mikulicz's first effort with gastroscopy traces back more than a century. It is important to preserve the skill and expertise that experienced intubators have acquired. Their lessons and experience will be lost unless transmitted to younger professional associates. Early diagnosis, prompt surgical management of all strangulated hernias, and per oral decompression of the distended small bowel prior to and/or at operation in all simple obstructions are fundamental criteria for success in any plan of treatment. When the obstruction is complete, after operative decompression, the obstructing mechanism must be removed surgically. For incomplete simple obstructions of the small intestine following adequate decompression, operation may not be necessary. Most instances of paralytic ileus, not septic in nature, respond favorably to conservative management. In colic obstructions, early decompression proximal to the obstruction is indicated. Effective intestinal decompression, preserving the sterility of the peritoneal cavity lies at the root of the matter. This recounting of a long experience in attempting to understand the bowel obstruction problem suggests that clinical observation, reinforced by experimental studies, is a useful tool in lending a forward thrust to improved accomplishment.

Post operative adhesional ileus is a critical problem in the patients receiving intra-abdominal surgery. Intestinal decompression using a long tube is useful, but many cases relapse and the resultant long periods of hospitalization restrict quality of life.Four patients with recurrent postoperative adhesional ileus and two patients with severe intestinal adhesions were treated by the total intestinal splinting method. The postoperative courses were excellent and resulted in a normal quality of life.

Gastrointestinal intubation has found increasing applications over the past several years. Although usually an uncomplicated procedure, passage of an intestinal tube may be impeded by ineffective peristalsis, obstructing lesions or surgical alteration of the normal anatomy. A variety of techniques are described for passing tubes into the stomach, duodenum and small bowel. These techniques are an out-growth of those initially developed for manipulating tubes through the vascular, biliary and genitourinary systems. The characteristics of the various decompression and alimentation tubes as well as the dangers of gastrointestinal intubation are also discussed.

Summary A review of 134 consecutive cases of intestinal obstruction in the newborn period seen over a fourteen-year period is presented and the various causes are discussed. Follow-up data on the survivals are recorded. The mortality rate was 44.8 per cent. It fell from 58.7 to 37.5 in comparable seven-year periods. The high mortality was due to delayed diagnosis, prematurity, co-existing anomalies, peritonitis, shock, dehydration, electrolyte imbalance, and nutritional disturbances. The value of adequate supportive measure, intestinal decompression, the use of antibiotics, better care of the premature infant, and the importance of an experienced anesthesiologist are stressed. A plea is made for the earlier recognition and treatment of intestinal obstruction in this age group. Greater benefits are to be derived from the closer cooperation of the general practitioner, the obstetrician, the pediatrician, and the surgeon.

One of the most important complications incidental to the use of the single lumen intestinal decompression tube is the permeation of intestinal gases into the lumen of the balloon of such tubes. Various methods have been proposed to prevent this complication. None of the methods heretofore proposed provided a simple but absolutely effective prevention. The use of a stylet inserted through the most distal hole and then the application of a tight tie over the tube at this point followed with the removal of the stylet provided a good safety valve vent. However, a certain nicety in judgment as to exactly how tight this tie should be tied resulted in two types of error, namely, if tied too loosely, the mercury would escape; if tied too tightly, no safety vent would be formed. As a result of m vitro and in viro experiments a further simplification of an already simplified tube was made possible. In this newer tube the end of a simple tube was completely sealed off. The balloon is then applied to the end of the tube. This creates a simplified radiopaque tube without any metal parts and tipped by a simple neoprene rubber balloon. (Cantor tube, Fig. 6.) The required amount of mercury is then injected into the balloon through a 21 gauge needle after which all the air is aspirated. Thus in one procedure the mercury is injected, a hole is made in the balloon to act as a safety vent and the air remaining within the balloon is aspirated. Because the end of the tube is sealed, no mercury can leak out with proper handling. The perforation of the wall of the balloon by the 21 gauge needle has been shown in vitro and in vivo to prevent overdistention of such balloons by any gas. A smaller caliber needle than a 21 gauge would not make a perforation large enough, whereas a larger caliber needle than a 21 gauge would make a hole so large that mercury would leak out. The 21 gauge needle was found experimentally to be the ideal size for this purpose since the hole it makes is large enough to permit a rapid loss of gas within the balloon and yet the vent is small enough to prevent mercury from leaking if the perforation is not stretched during the insertion of the balloon into the nose.

Intubation of the entire obstructed small bowel at surgery has been accomplished in forty-four of forty-seven patients with the use of a coiled spring tube as an oral enterostomy. Refinements in this apparatus have contributed to the ease of passage and safe use of this device. We believe this tube may come to serve a useful purpose in the operative management of intestinal obstruction.

Summary 1 The history of appendicitis mortality prior to 1933 is briefly reviewed. 2 Mortality statistics for appendicitis in Australia from 1933 to 1957 are presented, both for the population as a whole, and for the various age groups. A remarkable reduction in mortality rates is in evidence. 3 Possible reasons for the improving prognosis are advanced. These possibilities ar.e examined in the light of two series of appendicitis cases from the Royal Adelaide Hospital (Series A from 1936-8, Series B from 1956-7). Antibiotics, intestinal decompression and intravenous infusions appear to have been the main factors contributing to the improved prognosis. This improvement has occurred principally in the group of perforative-appendicitis. 4 The graver prognosis of appendicitis in the aged is shown; and factors responsible for this are summarized. This older group remains a challenge for further improvement. 5 Post-operative complications in the Royal Adelaide Hospital Series are reviewed.

Since it has been demonstrated that mercury in a balloon tipped tube will carry the tube down the gastrointestinal tract, there is no longer the need for a double lumen tube. We have presented twenty-two cases of severe intestinal distention which were treated by a single lumen intestinal tube and in which the results were far better than our expectations. In all cases, the tube was carried far down the ileum or into the colon by the mercury. The caliber of the lumen in the tube used is considerably larger than in the currently used tubes and the number of holes were increased to sixteen. These sixteen holes are spread over an area of twenty-four inches. The size of the holes are also much larger than in any of the currently used tubes and the shape of the holes, we believe, contributes immeasurably to the excellent results obtained as plugging with particulate matter did not occur. Only one word of caution must be uttered at this time; that is, after the last hole has been inserted into the nose, do not insert more than six inches of tube until the balloon has passed through the pylorus and into the duodenum . It takes one to two hours for the balloon to pass into the duodenum, then the tube is advanced six inches every two hours. If too much tube is inserted into the stomach before the balloon has passed into the duodenum, coiling of the tube will occur with the resultant danger of knot formation.

The widespread acceptance by surgeons of the long intestinal decompression tube for the treatment of all types of intestinal distention has led to accumulation of a rather voluminous literature, chiefly in the surgical journals. One could easily acquire the impression that intestinal intubation belongs solely to the department of surgery. The role of the radiologist has generally been that of a mere technician rather than a consultant in the procedure. Decisions as to how the tubes should be passed as well as when they should be removed appear to have been regarded as purely surgical problems. With the increasing use of these tubes, however, it has become apparent that the radiologist can be of inestimable aid to the surgeon, not only in assuring a higher percentage of successful intubations but also in furnishing exact information, based upon accurate radiological observations, as to when the tubes should be removed. This latter information may be of vital importance, since premature removal may result i...

It is apparent from an examination of the table of permeability that silicone rubber is highly permeable to oxygen and carbon dioxide. Carbon dioxide is a very troublesome gas within the obstructed bowel because of its ability to diffuse into balloons of intestinal decompression tubes [7]. In bowel obstruction, it may be found in concentrations of 4 to 18 per cent whereas its concentration in the atmosphere is only 0.03 per cent. The extremely high degree of permeability of silicone rubber to carbon dioxide makes it possible for this gas to diffuse rapidly through the wall of the silicone rubber intestinal decompression tube into its lumen and from there to be suctioned out. As a result, the entire length of the silicone rubber intestinal decompression tube acts as a decompression unit. Because of this, a new concept in obtaining intestinal decompression for intestinal gases must now be considered.

Although it has long been known that the small bowel pleats itself along the long intestinal decompression tube as it passes downward, no previous studies have been under-taken to demonstrate differences that occur by the use of different lengths of tube. The importance of such observations is that the optimum length of tube to be passed is that length which best decompresses the bowel and least interferes with the normal physiology of the gastrointestinal tract. This latter consideration is of the utmost importance if the tube is to remain within the bowel for any length of time. Studying this problem by comparison between roentgen studies preoperatively and the finding at operation demonstrates that the shorter the length of tube down the bowel, the tighter the plication of the bowel about this tube. As a result of this there is the greatest impairment of peristaltic activity and the greatest decrease in absorptive area. The tighter the plication of the bowel upon the tube, the more prone is intussusception to occur. A 6 foot long tube down the gastrointestinal tract appears to be far better than a 4 foot length of tube because the plication is much looser and peristaltic activity unimpaired to a great extent. The 10 foot long tube results in the least interference with the normal physiology of the bowel. Peristaltic activity is unimpaired and the maximum area of mucosa is available for absorption and secretion. Intussusception is least likely to occur with this length of tube. There is little point in pushing more than 6 feet of tube down the gastrointestinal tract if the bowel will not accommodate itself to this length of tube of its own accord. To do so merely results in looping of the tube within the bowel and knot formation. Emphasis is placed upon the point that the intestinal tube must not be fastened to the face of the patient. By leaving the tube free the swallowing acts of the patient, ambulation and the return of peristaltic activity usually result in the tube being slowly pulled down the gastrointestinal tract without being pushed by the surgeon. Such conditions are ideal because the bowel will only pull down sufficient tubing to which it can accommodate itself. A dependence upon the normal physiologic mechanism by which foreign bodies pass along the gastrointestinal tract results in the least interference with this mechanism. Looseness of plication of the bowel upon such tubes is the rule. In those cases in which the tube is fastened to the face and the intestinal musculature pulls upon the tube head against the resistance of it being fastened above plication is tight as a rule. The degree of plication depends upon the length of tube down the bowel. The shorter the length of tube the tighter the plication.

The effect of submersion of balloons of intestinal decompression tubes inflated with different gases in water was studied and compared with similar studies in which the inflated balloons were exposed to air. The experiment indicated that there was very little or no difference in the speed of diffusion of the gases from within the balloons exposed to air or submerged in water. In reproducing in vivo conditions the inflated balloons were inserted within the intestinal tract of an hour-old autopsy specimen. The inflated balloon caused the bowel wall to be stretched tightly over it. We noted that the speed of diffusion of the gases out of the balloons was the same whether the bowel was empty or filled with intestinal secretions. There appeared to be very little difference between the speed of diffusion of gases out of the balloons within the bowel or those submerged in liquid or exposed to air. This experimental study clearly shows that if an intestinal decompression tube balloon becomes inflated as a result of carbon dioxide or hydrogen sulfide, the passage of a second intestinal tube to decompress the circumjacent bowel would rapidly result in the diffusion of the hydrogen sulfide or the carbon dioxide from within the balloon into the bowel. The speed of diffusion of the hydrogen sulfide is so fast that it is extremely doubtful whether this gas enters into the problem at all. The only possible influence this gas might have is suggested by our observations that balloons filled with hydrogen sulfide rapidly lost this gas in less than four hours. If then these balloons were permitted to lie exposed to the air, they took up some of the air. This diffusion of air into balloons formerly filled with hydrogen sulfide might constitute a real problem in intubation, or the presence of an air-filled Miller-Abbott balloon which could not be evacuated as a result of a knot in the tube might be quite serious for the patient. The reason for this is obvious from our observations that the air-filled balloons showed very little or no change in twenty-four hours. Some balloons filled with air were observed for four days and were then noted to show very little if any loss of air. When we recall that approximately 80 per cent of the air consists of nitrogen, a gas which is extremely slowly diffusible through a rubber membrane, it becomes obvious why this should be so. Once air has accumulated within the intestinal tube balloons many days of bowel decompression are required before any appreciable loss of air occurs from the balloon. The best treatment for this unusual accident is to prevent it by the use of a No. 18 French lumen tube and a safety valve vent as described in an earlier publication.1

One hundred thirty-eight consecutive patients undergoing elective colonic resections were treated prospectively and randomly with either a long intestinal (Cantor) tube preoperatively, a nasogastric tube placed intraoperatively, or no gastrointestinal tube at all. Patients were evaluated for length of hospital stay, duration of postoperative ileus, adequacy of intraoperative intestinal decompression, gastric dilatation, and operative complications. No significant difference could be seen in the tubed or no-tube group.

In 1790 the British physician John Hunter first introduced gastric intubation as an artificial means of feeding a paralyzed patient (1). During the last century William Beaumont’s classic studies of gastric juice led to further utilization of such tubes in the analysis of digestive functions of the stomach (2). More recently, however, technical refinements have made gastrointestinal intubation a routine procedure in medical and surgical management of many abdominal disorders. The principal application of this technique is in intestinal decompression in patients with obstructive symptoms or paralytic ileus (3,4). Flexible tubes are also placed into the gastrointestinal tract for various other diagnostic or therapeutic purposes, including alimentation with liquefied food (5–7), hypotonic duodenography, enteroclysis, gastrointestinal secretory tests, and mucosal biopsy (8–13).

This report describes the value of repeated use of gastrografin enema in uncomplicated meconium ileus. Fourteen of 21 neonates had successful intestinal decompression (66.6%) — 5 after a single enema and 9 after repeated attempts (up to 7 times in 1 case).

1. Intestinal obstructhrn produced by the unintentional use of barium suspension in a case of partial bowel obstruction, was simply and effectively treated by intuhation with a single lumen tube of adequate caliber and holes of sufficiently large size. 2. Surgical intervention is not indicated to remove the barium. 3. Surgical intervention is definitely indicated after proper intestinal decompression in order to correct the obstructing process.

Introduction During the past half-century the management of intestinal obstruction has undergone significant improvement; however, strangulation continues to represent a serious complication. Silen and associates 8 recently reviewed 480 cases of intestinal obstruction and found an over-all mortality rate of 10.5%. When strangulation was present 21.4% died, whereas with simple obstruction the mortality rate was 7.3%. Thus, strangulation imposes a serious threat to the patient with intestinal obstruction, and medical measures, including intestinal decompression, fluid and electrolyte replacement, and antibiotic therapy, have not reduced the mortality rate appreciably. Extensive investigation into the nature of toxicity in strangulation obstruction has been in progress for years 1-3,6,7,9 and eventually may provide an answer to this perplexing problem. Another approach involves the earlier recognition of strangulation during a stage when surgical intervention might be expected to prevent progression to infarction. The present study demonstrates that isotopelabeled serum albumin concentrates in the fluid which

A method of transcecal long intestinal tube decompression of the small intestine is described. The procedure is simple and very useful for intestinal obstruction which does not respond to proximal decompression. It is also suitable in the management of recurrent intestinal obstruction, and may be helpful as an adjunctive procedure with a Noble plication.

THE problem of handling distended loops of bowel has plagued the medical profession for centuries, and it has only been in recent years that a satisfactory solution has been found. With the use of ...

1. Increasing the number of holes in intestinal decompression tubes increases their efficiency because such tubes do not depend upon a negative suction pressure at the end of the tube, but rather the intestinal contents are forced into the tube by an increase in the intra-luminal intestinal pressure.

A simplified intestinal decompression sound ∗ ∗Manufactured by the Clay-Adams Company, Inc., New York, N. Y. is presented as an additional instrument for use in the treatment of intestinal obstruction. By its use it is hoped that the mortality rate of 15 per cent which is being generally reported can be reduced still further. This seems quite possible because now for the first time the surgeon has at his disposal a simple instrument permitting rapid intestinal decompression at the time of surgery. Needless delay necessitated by intestinal distention can now be avoided. In the use of this instrument a note of caution is in order. Since the obstructed bowel is generally edematous and often friable, the bowel should gently be threaded along the sound after the distended bowel has first been collapsed by suction. In no case should the sound be pushed forcibly along the gastrointestinal tract. To do so is to invite perforation of the thinned out edematous bowel wall. In addition, the proximal bowel being threaded onto the sound must always be done under direct vision to avoid pushing the sound against the bowel wall too strongly. The use of the decompression sound is not required in any case in which a survey film prior to surgery demonstrates that the long intestinal decompression tube head has passed beyond the ligament of Treitz. In cases of this type the intestinal decompression tube can be rapidly passed down the gastrointestinal tract decompressing it by the application of suction to the end of the tube. In those cases in which the long intestinal decompression tube head will be found to be in the stomach, however, the use of the simplified intestinal decompression sound and its proper management may constitute a life-saving procedure because the instrument safely permits rapid intestinal decompression with the abdomen open. By so doing the point of obstruction and its cause can be well exposed after the collapsed bowel has been packed away. Surgical correction of the obstruction then becomes a simple procedure.

• We describe a simple method for rapid intubation of the small intestine. The method was successful in 13 out of 14 attempts. A forward-viewing fiberscope, two endoscopic biopsy forceps, five rubber bands, and the tube to be positioned are required for the method. It should have broad application for the passage of tubes for small intestinal decompression, jejunal feeding, jejunal biopsy, and biliary and pancreatic drainage studies. (Arch Surg113:196-198, 1978)

IN RECENT years the widespread acceptance of metallic mercury within the head of tubes for intestinal decompression as a highly effective method of obtaining intestinal intubation has resulted in its use in practically all such tubes. It was found by using metallic mercury in the balloon of these tubes that the number of successful intubations increased and the duodenum was intubated more rapidly. The amount of mercury which various authors advocated to be used ranged from 3 to 10 cc. 1 As a result of the observations of my colleagues and me over the past three years, during which time 441 patients were intubated, we attempted to make certain observations and conclusions regarding the optimum amount of mercury that should be used in any type of case. In 1589 Galileo demonstrated that bodies of different weights fell with the same velocity. He proved this important point by the simple expedient

The commonest controversial problems of surgery are discussed in the text by 50 contributors from all over the country, who work in private, university, and Veterans Administration hospitals. Most of them are also "teaching" surgeons with university assignments, who write from both clinical experience and research investigation. In each area, one of the editors elucidates the problem, which is then discussed by two or more, and sometimes as many as four, specialists. Their investigation considers the complications of duodenal ulcer, various types of polyps of the colon, approaches to repair of hiatal hernia, early operation versus intestinal decompression and delayed surgery in small intestinal obstruction, whether to use an abdominal or perineal approach to correct a prolapse of the rectum, the extent to which antibiotics should be used when operating on the intestine, and whether or not to suture the common bile duct. These are only a few of the

METALLICmercury, generally regarded as inert, is known to stimulate the formation of granulomatous lesions. 1 We have recently treated a patient in whom intestinal obstruction was caused by mercury granulomas. It is clear from our experience and from a review of the literature that rupture of the mercury-filled balloon fixed to the end of a long intestinal tube may lead to serious complications. In this communication, we list practices which we now follow in such cases. Report of a Case A 68-year-old man was admitted to the hospital with symptoms and physical signs of intestinal obstruction. The diagnosis was confirmed by roentgenograms. Three years before, the patient had had sigmoid colectomy for chronic volvulus. Two months later, he had mechanical intestinal obstruction, which, during a 48-hour trial, failed to respond to intestinal decompression with a Miller-Abbott tube. Abdominal exploration was required for enterolysis. Two enterotomies had to be done to decompress