Bowel Obstruction and the Nathan L.
Brightwell, MD;
Arthur S.
(Arch Surg 112:505-511, 1977)
obstruction remains an unsolved problem that haunts many who have undergone any type of abdominal surgeons believe it is essen¬ tially impossible to prevent at least some degree of adhe¬ sion formation after such an operation. Noble,' in 1937, was the first to use intestinal adhesions to his advantage. The Noble plication consists of suturing the small bowel in loops with serosal stitches so that adhesions can eventually fix the bowel in gentle curves. There are, unfortunately, several disadvantages to the Noble plication: it is very time consuming, there is a high incidence of enteroenteric fistula formation with perforation and peritonitis, there is a long period of postoperative ileus, and patients under¬ going the procedure almost always complain of chronic abdominal pain. Childs and Phillips- introduced the transmesenteric plication in 1960, in which the small bowel is arranged in a plicated pattern and secured with transmesenteric mattress sutures passed on long needles. This method is faster than the Noble plication, but its efficacy and safety are questionable because of the fragile mesentery and the obvious inherent danger of injury of the mesenteric vessels. The intraluminal tube or long intestinal tube "stent" method of plicating the small bowel in gentle curves was first proposed by White' in 1956. Baker4 introduced the jejunostomy tube in 1959, and advocated the introduction of this long tube through either a purse-string or a Witzel
Intestinal operation. patients Many
Thereafter
Accepted
followed
a
Tube Stent
McFee, MD, PhD; J. Bradley Aust, MD, PhD
\s=b\ Fifty-eight cases of intestinal obstruction requiring operative intervention were reviewed. Enterolysis alone as the treatment for bowel obstruction as a result of adhesions appears to be as good or better than the long tube stent. Patients treated with enterolysis alone had a shorter period of postoperative ileus, a shorter hospital confinement following operation, and fewer recurrent obstructions. These patients also had a longer interval between episodes of reobstruction than did those treated with an intraluminal long tube stent.
jejunostomy.'"
Long
series
of
other
plication
for publication Dec 13, 1976. From the Bexar County Hospital (Dr Brightwell) and the Department of Surgery, University of Texas Health Science Center (Drs McFee and Aust), San Antonio, Tex. Read before the 84th annual meeting of the Western Surgical Association, Coronado, Calif, Nov 17, 1976. Reprint requests to Department of Surgery, University of Texas Health Science Center, 7703 Floyd Curl Dr, San Antonio, TX 78284 (Dr McFee).
procedures (Fig 1) such as the gastrostomy stent plication
with and without a tube exit cecostomy. These latter types of stent plications require an enterotomy or gastrotomy, which increases the risk of infection, especially when the gut has been obstructed.78 Postoperative infections, however, are not significantly increased if the long intes¬ tinal tube is passed via the mouth or the nose, and an enterotomy is avoided. All methods of the long intralu¬ minal tube stent have a common concept of controlling adhesions, which inevitably form, and using these adhe¬ sions to fix the bowel in gentle curves rather than allowing the bowel to develop acute angulations. There have been very few reports of the long tube used as an intestinal stent since White1 suggested this method in an address to the Western Surgical Association in 1955 (reported in 1956). The authors listed in Table 1 report a number of cases where the long tube intraluminal stent is used, the number of recurrent obstructions, and the years of follow up. However, we are unable to find any reports in the literature at this time that compare the results of enterolysis alone with the results of the long tube stent and the incidence of recurrent small bowel obstruction. SUBJECTS AND METHODS
Fifty-eight cases of small bowel obstruction at Bexar County Hospital in San Antonio were reviewed in a retrospective study of operations performed between October 1968 and December 1971. The period of follow-up ended Dec 31, 1975. This series represents
36 males and 22 females. Early obstruction, that is, an obstruction occurring within 30 days after an abdominal operation, developed in 17 patients; late obstruction developed in 41 patients. The 30 patients who were treated by enterolysis alone accounted for 51.7% of the total number of cases; the long tube was used as an intestinal stent in 28 patients (48.2%). The choice of treatment was at the discretion of the operating surgeon. There were four patients in our series who had never undergone an operation; the age range of the entire group was from 1 month to 88 years. Interestingly, the youngest patient, 1 month old, was one of those who never had a previous operation. This patient, as a neonate, had a documented case of primary peritonitis that was successfully treated. He did well until a bowel obstruction developed from adhesions. The infant in whom obstruction developed at 1 month of age was included in the early obstruction group. The other three patients, not operated on, experienced late obstruction from pelvic inflammatory disease. Appendectomy was the most common operation in our series, leading to 30% of the subsequent obstructions (Table 2); many, but not all, of these patients had a ruptured appendix with peritonitis at the time of appendectomy. Exploratory laparotomy for pene¬ trating abdominal trauma resulted in 24% of the subsequent obstructions; gynecological procedures caused 18%. Four patients
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Jejunostomy Tube Plication
Noble
Plication
Child-Phillips
2 Transmesenteric Plication
Nasogastrointestinal Stent Plication
Plication 4 Gastrostomy With Tube Exit Cecostomy
Gastrostomy Tube Plication
I
¡
1.—Most common types of plication procedures are shown, all intended to allow small bowel to form adhesions in rather than acute angulations (adapted from Grosfeld et al" and Leonard et al10).
Fig
Table 1.—Results of the
Source, yr White,3 1956 Baker & Ritter,5 1963 Baker,6 1968 Markee & Uhlig,7 1971 Grosfeld et al,s 1975 Present
study
Tube Used Stent
Long
No. of Cases 14 44
52 49 22 58
as an
No. of Recurrent Obstructions 1
0 4 0 13
Follow-up, yr 1-6 1-6 2-15 2-3 1-7
series of 58 cases of small bowel obstruction had undergone previous cholecystectomy. A previous patch closure for a perforated duodenal ulcer was performed in one patient, a resec¬ tion of a gastric carcinoma in another, and a third had undergone a previous abdominoperineal resection for carcinoma of the
in
Table 2.—Previous Abdominal Operations Small Bowel Obstructions*
Intestinal
our
a
rectum. In one half of our patients, bowel obstruction developed within four months of their abdominal operation, but in one patient obstruction occurred 25 years after a cholecystectomy. Follow-up studies were obtained up to seven years postoperatively with the patients treated by stent, and up to 6V2 years with the patients treated with enterolysis alone. The duration of postoperative ileus was compared in the two sets of ]fetients. The end of ileus was considered to be the first postoperative day that the patient could tolerate oral fluids. As
Type of Operation Appendectomy Exploratory laparotomy Penetrating trauma Blunt trauma Other
gentle
Leading
curves
to
No. (%) 20 (30)
16(24.2) 4 (6) 7(10.6) 12 (18.1)
Gynecological procedures 4 (6) Cholecystectomy 1 (1.5) Closure of perforated ulcer Resection of gastric carcinoma 1 (1.5) 1 (1.5) Abdominoperineal resection !,Some patients underwent multiple procedures prior to obstruction, and each of these is listed. Accordingly, the number of procedures exceeds the number of patients.
Fig 2, the average length of ileus with enterolysis alone only 4.6 days, with a median time of 4.0 days. On the other hand, the average duration of ileus in patients treated by stent was 7.9 days. The number of postoperative hospital days in the two series was almost twice as long in patients treated with a long tube stent. Figure 3 shows that the average length of hospitalization in patients treated by stent was 15.7 days, with a median time of 15 days, while the enterolysis group averaged only 8.8 days of
shown in was
postoperative convalescent time. The long-term benefits of the
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two methods of treatment of
12 11 10
Days
9
Median
8 (
Average
Ileus with stent
6
7.9
Ileus with
4
4.6
(
7 ·
enterolysis alone
-¬ nr
" 10
Duration of Ileus
Fig 2.—Durations of postoperative ileus with tolerated oral fluids.
long
30
20
tube stent and with
(days)
enterolysis
Fig 3.—Numbers of hospital days from operation to discharge after relief of small patients with enterolysis alone.
alone. End of ileus
was
bowel obstruction in
first
postoperative day patient
patients with long tube stent vs
10
Hospital Days 6
Median
Average
15
15.7
8
8.8
-
O •
Long tube stent Enterolysis alone
"¬
-r
30
10
Hospital Days
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15
58
Total cases
14
-
13
Recurrent obstruction
-
-
13 ·
12
Treatment Recurrent obstructions Percent Average months before recurrent obstruction
·
11 10
1
c
55
7
6 5 4
3 2
D Dennis tube
%
Leonard tube Cantor tube
1
1
VZ-
Enterolysis 12
-r-
-r
T"
3
4
5
alone -7-
6
7
8
9
10
11
12
Stent
Enterolysis
28
30
9 32
13
13
33
4
3
!J
-//- -l-1-r4 2 3
-^-
Time Before Recurrent Obstruction
Fig 4.—Recurrent small bowel obstruction in stent relation to protection from recurrent obstruction.
patients
vs
Months
Years
patients with enterolysis alone.
Duration of stent
("Stent Days")
has little
Fig 5.—Left, Density of adhesions found at operation in 58 patients with small bowel obstruction. Right, Density of adhesions found initial operation for 13 patients with recurrent obstruction (stent patients vs patients with enterolysis alone) are compared. 201 18
16-1 14-
Density
of adhesions
1-Single
band
O Long tube stent Enterolysis alone
2-Few or mild
o
12'
3-Numerous or
4-Severe
o
or
multiple
dense
10
O
4
3
6
O
2
4
O O
2-
-1-12
3
Density of Adhesions
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1
O -1-12
3
Density of Adhesions
at
small bowel obstruction were also examined (Fig 4). Of the 58 cases of intestinal obstruction, a recurrent or a second obstruction developed in 13. Twenty-eight of the 58 patients were treated with a stent; nine (32%) of these patients experienced reobstruction. Thirty of the 58 patients were treated by enterolysis alone; reobstruction occurred in four (13%) of these patients. The average time before reobstruction occurred in the stent group was 13 months; the average time in the enterolysis group was 33 months. Figure 4 shows that an early obstruction developed in one patient in each of the two groups. This figure also indicates the type of intraluminal tube stent used in each case, as well as the number of days the stent was left in place. The density of adhesions in each case was evaluated and graded according to the description of the adhesions in the operative reports (Fig 5). The adhesions were graded on a scale of 1 to 4. A single adhesive band was designated as a grade 1 adhesion; "mild or a few" adhesions, grade 2; "numerous or multiple" adhesions, grade 3; and "severe or dense" adhesions, grade 4. Figure 5 shows, on the left side, the density of adhesions in the 58 cases of intestinal obstruction, and shows data for the patients treated with enterolysis only as well as those treated with a long intestinal stent. There were approximately equal numbers of patients with all grades of adhesions treated by enterolysis alone as there were patients treated by stent. The right side of Fig 5 illustrates the number of recurrent obstructions and the density of the adhesions, as well as the type of treatment these patients received, ie, enterolysis or stent. The only patient with a grade 1 adhesion who experienced reobstruction was initially treated by stent; no patients with grade 1 adhesions initially treated by enterolysis alone experienced reobstruction. Similarly, three patients with grade 4 adhesions who were initially treated by stent experienced reobstruction, but none of the patients with grade 4 adhesions, previously treated by enterolysis alone, experienced reobstruction.
COMMENT
The data presented show that patients who undergo operation for small bowel obstruction and have a long tube intestinal stent placed at operation have a period of postoperative ileus lasting almost twice as long as do patients who undergo operation with enterolysis alone. Hospital confinement is similarly nearly twice as long with stent patients as with those who do not receive intralu¬
minal support. The best comparison between the two methods, however, is the prevention of recurrent obstruction. Thirteen recur¬ rent obstructions developed in the original 58 patients. Nine of the reobstructions were in stented patients, and four were in patients treated by enterolysis. In the enterol¬ ysis group, one patient had an early obstruction, and the other three experienced reobstruction at two, four, and five years, respectively. The data in Fig 4 further illustrate that the Dennis" tube gives the poorest results in preventing recurrent obstruction, while the Leonard tube1" in this series had a slightly better performance. Since a Cantor tube was used in only one stent patient in this study, we are unable to make any conclusion regarding its effective¬ ness. The Baker tube4 was not used in any of the patients in this review. Interestingly, there seems to be no relation between the number of days the intraluminal tube stent is left in place and the average number of months before recurrent obstruction develops. For example, a patient
illustrated in Fig 4 had a Leonard tube intraluminal stent in place for 11 days, but reobstruction occurred in only three months; another patient had a Leonard tube stent for only six days and did well for two years before a second small bowel obstruction occurred. Adhesions, varying from a single band to very dense, were treated in approximately equal numbers by the two methods, ie, stenting and enterolysis. Patients treated with enterolysis alone fared better. In one patient with a grade 1 adhesion (a single band) in whom a stent was placed, a reobstruction developed, no patients in this group undergoing enterolysis alone experienced reobstruction. Logically, excessive handling of the bowel with threading onto the stent at operation likely caused even more adhe¬ sions to form, and may well explain why reobstruction occurred in this patient. There were six patients with severe or very dense adhesions treated with an intralu¬ minal stent, and five similar patients with severe adhe¬ sions treated by enterolysis alone. Three (50%) of the stent patients with severe adhesions experienced reobstruction, but none of the similar group treated with enterolysis did. The same explanation probably holds: threading an intra¬ luminal stent through and around multiple adhesions likely results in tearing or denuding the serosal covering from the bowel and causing even more adhesions to develop. There are many complications and disadvantages of the long tube in the upper nasopharynx and upper gastrointes¬ tinal system. The most common sequela of prolonged gastrointestinal suction is electrolyte and pH imbalance; however, this problem is generally anticipated and rela¬ tively easily treated. Less common complications of nasogastrointestinal tubes are abscesses of the nasal septum, sinusitis, otitis media, ulcérations of the larynx, and occa¬ sional stenosis. Reported but very rarely seen complica¬ tions include rupture of esophageal varices; perforation of the esophagus, stomach, or small bowel; knotting of the tube in the stomach or the intestines; intussusception with the balloon as the leading point; and inability to withdraw the balloon-tipped tube. Perhaps a very common but unnoticed complication is aspiration pneumonitis, which has impressive clinical significance. References 1. Noble TB Jr: Plication of small intestine as prophylaxis against adhesions. Am J Surg 35:41-44, 1937. 2. Childs WA, Phillips RB: Experience with intestinal plication and proposed modification. Ann Surg 152:258-265, 1960. 3. White RR: Prevention of recurrent small bowel obstruction due to adhesions. Ann Surg 143:714-719, 1956. 4. Baker JW: A long jejunostomy tube for decompressing intestinal obstruction. Surg Gynecol Obstet 109:518, 1959. 5. Baker JW, Ritter KJ: Complete surgical decompression for late obstruction of the small intestine, with reference to a method. Ann Surg 157:759-769, 1963. 6. Baker JW: Stitchless plication for recurring obstruction of the small bowel. Am J Surg 116:316-324, 1968. 7. Markee RK, Uhlig BE: Baker tube jejunostomy: Management of small bowel obstruction. Minn Med 54:981-984, 1971. 8. Grosfeld JL, Cooney DR, Csicsko JF: Gastrointestinal tube stent plication in infants and children. Arch Surg 110:594-599, 1975. 9. Dennis C: The gastrointestinal sump tube. Surgery 66:309-312, 1969. 10. Leonard AS, Nicoloff D, Griffin WO, et al: Intestinal decompression: Use of a long tube with a coiled spring for relief of distention without enterotomy or enterostomy. Surgery 49:440-449, 1961.
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Discussion William F. Pollock, MD, Santa Monica, Calif: The original thought that Dr Noble had, and that was repeated by Childs, Gaspar, White, and Baker, was that adhesions were formed no matter what you do, and therefore, they wished to control them. One point I would like to ask the authors about: in the patients who were reoperated on, did or did not the sutureless plication plicate the bowel? At reoperation for patients who have previously had a long tube stent placed, was or was not the bowel, in fact, folded
on
itself in the same way that it would be if the Noble or the
Childs-Phillips plication were undertaken? The end point of the ileus described by the authors was the ability to tolerate oral fluids; this might be supplemented with some information as to when peristalsis was audible and when flatus was passed. In essence, they conclude that sutureless long tube stents are not efficient in preventing recurring trouble, and with that conclusion I am in hearty agreement.
Erich W. Pollar, MD, Davis, Calif: An analysis of the results of Dr Brightwell in patients undergoing long tube stenting and in those undergoing plain enterolysis showed a highly statistically significant difference between the two groups (P < .01). Con¬ versely, we thought that a significant difference in the incidence of postoperative obstruction in the two groups was not demon¬ strated by the authors ( 1' 1.95; > .05). We did not believe that these results could be compared with those of Noble small bowel plication. According to data presented by the authors today; the 58 patients had undergone a total of 66 previous operations (an average of 1.1 opeations per patient). Thus, these were not the type of patients in whom anybody would have done a Noble plication. The Noble plication was devised for patients with several previous celiotomies for recurrent small bowel obstructions due to intestinal adhesions. In some instances, patients had undergone as many as 14 previous operations, as did one patient in our own series. Noble plication has been somewhat discredited in more recent years, because several authors have reported considerable morbidity following plication. In my series of 16 patients with five or more prior obstructive episodes who subsequently underwent a Noble plication, only one genuine recurrent small bowel obstruction developed during a follow-up period of five years. In most patients, following plication, the small bowel loops became tridimensionally anchored to adjacent loops and to the anterior abdominal wall due to adhesions. Consequently, radiological pictures showed air in the small bowel even in the absence of actual obstruction. Radiological pictures such as the above in patients complaining of ill-defined symptoms occasionally led to an erroneous diagnosis of intestinal obstruction, and even to useless celiotomies. As we pointed out more than ten years ago, radiological studies of the upper gastrointestinal tract with hydrosoluble contrast media were extremely useful to lead to the correct diagnosis and to avoid unnecessary operations. A review of the literature and our own experience showed that when a true intestinal obstruction developed in patients with Noble plication, it was always related to a technical failure in the performance of the operation or to the performance of an incom¬ plete intestinal plication. This above is not intended to allege that Noble plication is a perfect operation. It has severe shortcom¬ =
ings.
Raleigh White III, MD, Temple, Tex: About 26 years ago I first utilized this method of long tube splinting of the small bowel after release of massive adhesions in patients with intestinal obstruc¬ tion. Most of the patients had already undergone previous multiple operations with simple lysis of adhesions, and the adhesions with obstruction had recurred. I subsequently reported my early expe¬ rience at a meeting of this Association in Colorado Springs, Colo,
in 1954, in discussion of a paper by Gordon Smith of Los Angeles. Of the original group of 32 patients followed up for periods of to 11 years, there was one patient with documented recurring obstruc¬ tion who had to undergo subsequent surgery. I want to make the point that these are seriously ill patients. They have massive adhesions. They usually have undergone multiple operations and principally failure with simple lysis. You all know this type of patient, who has multiple abdominal scars and often is a narcotic addict. I do note that in the authors' series of the 58 patients, 30 had either a single adhesion or minimal or few adhesions, grade I or grade II. I certainly agree that in this type of patient we would not recommend long tube splinting. The manipulation of the bowel and the morbidity and the discomfort of the patient with the long tube splint for 10 or 12 days is really not justified for simple, single, or few adhesions. What we are really talking about is massive adhesions, and I note that of the 11 patients the authors reported in the category of massive adhesions, six of them were splinted, and of that six, three experienced recurrence with a 50% failure rate. I really can't explain this. I don't blame the authors for being disenchanted with splinting if they had a 50i? failure rate in the complicated cases, which are the ones we are really talking about. From communications with surgeons across the country through these years and the many reports in the literature in which modifications of the splinting technique have been suggested, together with Joel Baker's reported experience, (the Baker tube is a real advance) it would appear to me that it still has a place. One last point. I would remind you that long tube splinting may be of value prophylactically to prevent intestinal obstruction in the high-risk patient who has had massive denuding of peritoneal surfaces, as in pelvic exenteration. Gene Bricker often related to me his opinion that long tube splinting is an important modality in preventing postoperative obstruction following this type of surgery. Allen M. Boyden, MD, Portland, Ore: I became interested in the Noble plication many years ago, and in various discussions, have reported our cases. I became disenchanted with the procedure and disappointed by the complications that resulted, including late obstructions. I was impressed by Joel Baker's report a number of years ago, and since that time have utilized the long tube that bears his name. The statistics reported by Drs Brightwell, McFee, and Aust concern me, for certainly many of the patients included in their study would not have undergone intubation at the Portland Clinic. I do not use any kind of splinting in simple obstruction, in nonoperative obstruction, or when few or single adhesions are present, but reserve its use for patients with massive adhesions, using it either prophylactically or following the release of obstruc¬
tion. We prefer the Baker tube, and I recommend it to you. It is stiffer than the others, so that one can expect the intubated bowel to lie in gentle loops that will not obstruct with the tube in place, and hopefully will remain adherent similarly in the future. One can predict varying degrees of postoperative ileus when the bowel is denuded to this extent and handled as much as is necessary in passing the tube. This complication one must accept in order to avoid mechanical obstruction in the postoperative period. Such a complication is tragic and can be avoided when intubation is properly used. I believe the answer, Dr Brightwell, may be that you and your associates should be using the stiffer tube and using it only when extensive adhesive disease is pres¬ ent.
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Jack D. McCarthy, MD, Albuquerque, NM: As is evident from the discussion so far, we really don't have a significant control group that we can rely on when looking at these matters. We really don't know if the maneuvers that we are doing are successful. Some years ago before this audience, I described my own satisfaction with the Childs-Phillips plication, and I continue to experience the same satisfaction. The number of patients now involved is approximately 50, and in that entire group there has been but one reobstruction. I notice the authors report a recurrence rate of nine in 28 to one group and four of 30 in the other group. This would seem to imply that the frequency of intestinal obstruction after the operations as described is astoundingly great, I think greater than what any of us would automatically think. When faced with these problems and the surgeon has done an enterolysis, he really has several options open to him. The first option is to do nothing, as these authors have described, and drop the serosely damaged small bowel back into place. The second option is to put down a long tube. The Baker tube is widely used, I believe. I think perhaps it's more commonly used through an enterotomy brought through the abdominal wall, which, compared with the nasal route, obviates some of the complications listed. A third option after denuding the small bowel in its enterolysis is to do the Noble plication. The Noble plication is probably not a very popular operation for several reasons. One, as pointed out, is that it is tremendously time consuming. The frequency of cramp¬ ing abdominal pain and intestinal fistula seem to be inordinately high with it. A fourth option is the so-called transmesentery plication, that of Childs and Phillips. In my own hands it has been extraordinarily safe and, perhaps even more important than that, astoundingly effective. So, on a prophylactic basis, after taking down a great many adhesions, I will often do the Childs-Phillips plication. Admittedly, it is not to be used in everybody, and even though safe and effective, it is a maneuver that has to be selected with care. Frederic W. Taylor, MD, Indianapolis: I come from Noble country, and from Noble's hospital. We became disenchanted with this procedure because in a number of his patients, and ours, too, who were reoperated on either for obstruction, gallbladder, or other causes, the plication had completely disappeared. In these cases nature had taken its own course in healing. The plication was no longer there. Dr McFee: It is always extremely unsettling to one when his own patients and figures tend to refute firmly preconceived notions. Those of us who have had the privilege of training—and a number of us in San Antonio did-at the University of Minnesota really believe that the alimentary tract was established to be intubated either from above or below; we do so frequently. To find
that it may not be the best procedure is unsettling indeed. With regard to specific questions, I can provide some answers. Dr Pollock, we did not find a definite plication effect on those patients who underwent reoperation. A signal for removing the tube was the return of peristalsis, as evidenced by audible bowel sounds. Having removed the tube, we waited 24 hours before the patients were allowed to tolerate any diet. Frequently, however, in this series, we fed patients around the tube after peristalsis had returned, because we wished to leave it in an arbitrary number of
days, usually
15.
am grateful for the fact that you did the statistical analysis on our study. We did not do so simply because we thought the samples were far too small for such manipulation. Addition¬ ally, we did not do any Noble plications and have not done any in our hospital to my knowledge. Drs White and Boyden, we agree completely that a tube plication is an operation that should be reserved for the person who is seriously ill and who has undergone much obstructive difficulty. Drs Smith and McCarthy, we are grateful for the comments that have amplified our review so much. This study obviously suffers from a number of deficiencies that I think are quite evident. Primarily, it is a retrospective study. We did not have prospective control of the patients who were entered. The selection of treatment, as Dr Brightwell pointed out, largely came down to the preferences of the individual staff man at that time, and, as is true in every other hospital, staff preferences are occasionally forceful and over-ride a great number of other considerations. Nevertheless, when examined, the patient popula¬ tion in each group is, I think, a fair, equal distribution that could not have been improved had we randomized for all obstructions the patients coming sequentially over the same period of time. The period for operative procedures extended from the opening of the hospital in October of 1968 to Dec 31, 1971. The follow-up period ended on Dec 31, 1975. Although the patients have been followed up for from one to seven years, the average follow-up period for each individual patient is two years. Some of our patients have simply disappeared from San Antonio or from the purview of the Bexar County Hospital district, and are never heard from again. In general, intubations were through the mouth or the nose. Very few have been done through a gastrostomy, and, up until 1971, almost none through an enterostomy route. We would conclude, with our discussants, that obviously we have overtreated the patients with a single band. Similarly, many of the patients who had peritoneal syncytia have probably been undertreated. We are concerned with this latter kind of patient, and we would emphasize that a 50% recurrence rate in this group of patients after intubation is one of the principal points of the studythat we wish to bring to the attention of the group.
Dr
Pollak, I
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Brightwell, MD;
Arthur S.
(Arch Surg 112:505-511, 1977)
obstruction remains an unsolved problem that haunts many who have undergone any type of abdominal surgeons believe it is essen¬ tially impossible to prevent at least some degree of adhe¬ sion formation after such an operation. Noble,' in 1937, was the first to use intestinal adhesions to his advantage. The Noble plication consists of suturing the small bowel in loops with serosal stitches so that adhesions can eventually fix the bowel in gentle curves. There are, unfortunately, several disadvantages to the Noble plication: it is very time consuming, there is a high incidence of enteroenteric fistula formation with perforation and peritonitis, there is a long period of postoperative ileus, and patients under¬ going the procedure almost always complain of chronic abdominal pain. Childs and Phillips- introduced the transmesenteric plication in 1960, in which the small bowel is arranged in a plicated pattern and secured with transmesenteric mattress sutures passed on long needles. This method is faster than the Noble plication, but its efficacy and safety are questionable because of the fragile mesentery and the obvious inherent danger of injury of the mesenteric vessels. The intraluminal tube or long intestinal tube "stent" method of plicating the small bowel in gentle curves was first proposed by White' in 1956. Baker4 introduced the jejunostomy tube in 1959, and advocated the introduction of this long tube through either a purse-string or a Witzel
Intestinal operation. patients Many
Thereafter
Accepted
followed
a
Tube Stent
McFee, MD, PhD; J. Bradley Aust, MD, PhD
\s=b\ Fifty-eight cases of intestinal obstruction requiring operative intervention were reviewed. Enterolysis alone as the treatment for bowel obstruction as a result of adhesions appears to be as good or better than the long tube stent. Patients treated with enterolysis alone had a shorter period of postoperative ileus, a shorter hospital confinement following operation, and fewer recurrent obstructions. These patients also had a longer interval between episodes of reobstruction than did those treated with an intraluminal long tube stent.
jejunostomy.'"
Long
series
of
other
plication
for publication Dec 13, 1976. From the Bexar County Hospital (Dr Brightwell) and the Department of Surgery, University of Texas Health Science Center (Drs McFee and Aust), San Antonio, Tex. Read before the 84th annual meeting of the Western Surgical Association, Coronado, Calif, Nov 17, 1976. Reprint requests to Department of Surgery, University of Texas Health Science Center, 7703 Floyd Curl Dr, San Antonio, TX 78284 (Dr McFee).
procedures (Fig 1) such as the gastrostomy stent plication
with and without a tube exit cecostomy. These latter types of stent plications require an enterotomy or gastrotomy, which increases the risk of infection, especially when the gut has been obstructed.78 Postoperative infections, however, are not significantly increased if the long intes¬ tinal tube is passed via the mouth or the nose, and an enterotomy is avoided. All methods of the long intralu¬ minal tube stent have a common concept of controlling adhesions, which inevitably form, and using these adhe¬ sions to fix the bowel in gentle curves rather than allowing the bowel to develop acute angulations. There have been very few reports of the long tube used as an intestinal stent since White1 suggested this method in an address to the Western Surgical Association in 1955 (reported in 1956). The authors listed in Table 1 report a number of cases where the long tube intraluminal stent is used, the number of recurrent obstructions, and the years of follow up. However, we are unable to find any reports in the literature at this time that compare the results of enterolysis alone with the results of the long tube stent and the incidence of recurrent small bowel obstruction. SUBJECTS AND METHODS
Fifty-eight cases of small bowel obstruction at Bexar County Hospital in San Antonio were reviewed in a retrospective study of operations performed between October 1968 and December 1971. The period of follow-up ended Dec 31, 1975. This series represents
36 males and 22 females. Early obstruction, that is, an obstruction occurring within 30 days after an abdominal operation, developed in 17 patients; late obstruction developed in 41 patients. The 30 patients who were treated by enterolysis alone accounted for 51.7% of the total number of cases; the long tube was used as an intestinal stent in 28 patients (48.2%). The choice of treatment was at the discretion of the operating surgeon. There were four patients in our series who had never undergone an operation; the age range of the entire group was from 1 month to 88 years. Interestingly, the youngest patient, 1 month old, was one of those who never had a previous operation. This patient, as a neonate, had a documented case of primary peritonitis that was successfully treated. He did well until a bowel obstruction developed from adhesions. The infant in whom obstruction developed at 1 month of age was included in the early obstruction group. The other three patients, not operated on, experienced late obstruction from pelvic inflammatory disease. Appendectomy was the most common operation in our series, leading to 30% of the subsequent obstructions (Table 2); many, but not all, of these patients had a ruptured appendix with peritonitis at the time of appendectomy. Exploratory laparotomy for pene¬ trating abdominal trauma resulted in 24% of the subsequent obstructions; gynecological procedures caused 18%. Four patients
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Jejunostomy Tube Plication
Noble
Plication
Child-Phillips
2 Transmesenteric Plication
Nasogastrointestinal Stent Plication
Plication 4 Gastrostomy With Tube Exit Cecostomy
Gastrostomy Tube Plication
I
¡
1.—Most common types of plication procedures are shown, all intended to allow small bowel to form adhesions in rather than acute angulations (adapted from Grosfeld et al" and Leonard et al10).
Fig
Table 1.—Results of the
Source, yr White,3 1956 Baker & Ritter,5 1963 Baker,6 1968 Markee & Uhlig,7 1971 Grosfeld et al,s 1975 Present
study
Tube Used Stent
Long
No. of Cases 14 44
52 49 22 58
as an
No. of Recurrent Obstructions 1
0 4 0 13
Follow-up, yr 1-6 1-6 2-15 2-3 1-7
series of 58 cases of small bowel obstruction had undergone previous cholecystectomy. A previous patch closure for a perforated duodenal ulcer was performed in one patient, a resec¬ tion of a gastric carcinoma in another, and a third had undergone a previous abdominoperineal resection for carcinoma of the
in
Table 2.—Previous Abdominal Operations Small Bowel Obstructions*
Intestinal
our
a
rectum. In one half of our patients, bowel obstruction developed within four months of their abdominal operation, but in one patient obstruction occurred 25 years after a cholecystectomy. Follow-up studies were obtained up to seven years postoperatively with the patients treated by stent, and up to 6V2 years with the patients treated with enterolysis alone. The duration of postoperative ileus was compared in the two sets of ]fetients. The end of ileus was considered to be the first postoperative day that the patient could tolerate oral fluids. As
Type of Operation Appendectomy Exploratory laparotomy Penetrating trauma Blunt trauma Other
gentle
Leading
curves
to
No. (%) 20 (30)
16(24.2) 4 (6) 7(10.6) 12 (18.1)
Gynecological procedures 4 (6) Cholecystectomy 1 (1.5) Closure of perforated ulcer Resection of gastric carcinoma 1 (1.5) 1 (1.5) Abdominoperineal resection !,Some patients underwent multiple procedures prior to obstruction, and each of these is listed. Accordingly, the number of procedures exceeds the number of patients.
Fig 2, the average length of ileus with enterolysis alone only 4.6 days, with a median time of 4.0 days. On the other hand, the average duration of ileus in patients treated by stent was 7.9 days. The number of postoperative hospital days in the two series was almost twice as long in patients treated with a long tube stent. Figure 3 shows that the average length of hospitalization in patients treated by stent was 15.7 days, with a median time of 15 days, while the enterolysis group averaged only 8.8 days of
shown in was
postoperative convalescent time. The long-term benefits of the
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two methods of treatment of
12 11 10
Days
9
Median
8 (
Average
Ileus with stent
6
7.9
Ileus with
4
4.6
(
7 ·
enterolysis alone
-¬ nr
" 10
Duration of Ileus
Fig 2.—Durations of postoperative ileus with tolerated oral fluids.
long
30
20
tube stent and with
(days)
enterolysis
Fig 3.—Numbers of hospital days from operation to discharge after relief of small patients with enterolysis alone.
alone. End of ileus
was
bowel obstruction in
first
postoperative day patient
patients with long tube stent vs
10
Hospital Days 6
Median
Average
15
15.7
8
8.8
-
O •
Long tube stent Enterolysis alone
"¬
-r
30
10
Hospital Days
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15
58
Total cases
14
-
13
Recurrent obstruction
-
-
13 ·
12
Treatment Recurrent obstructions Percent Average months before recurrent obstruction
·
11 10
1
c
55
7
6 5 4
3 2
D Dennis tube
%
Leonard tube Cantor tube
1
1
VZ-
Enterolysis 12
-r-
-r
T"
3
4
5
alone -7-
6
7
8
9
10
11
12
Stent
Enterolysis
28
30
9 32
13
13
33
4
3
!J
-//- -l-1-r4 2 3
-^-
Time Before Recurrent Obstruction
Fig 4.—Recurrent small bowel obstruction in stent relation to protection from recurrent obstruction.
patients
vs
Months
Years
patients with enterolysis alone.
Duration of stent
("Stent Days")
has little
Fig 5.—Left, Density of adhesions found at operation in 58 patients with small bowel obstruction. Right, Density of adhesions found initial operation for 13 patients with recurrent obstruction (stent patients vs patients with enterolysis alone) are compared. 201 18
16-1 14-
Density
of adhesions
1-Single
band
O Long tube stent Enterolysis alone
2-Few or mild
o
12'
3-Numerous or
4-Severe
o
or
multiple
dense
10
O
4
3
6
O
2
4
O O
2-
-1-12
3
Density of Adhesions
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1
O -1-12
3
Density of Adhesions
at
small bowel obstruction were also examined (Fig 4). Of the 58 cases of intestinal obstruction, a recurrent or a second obstruction developed in 13. Twenty-eight of the 58 patients were treated with a stent; nine (32%) of these patients experienced reobstruction. Thirty of the 58 patients were treated by enterolysis alone; reobstruction occurred in four (13%) of these patients. The average time before reobstruction occurred in the stent group was 13 months; the average time in the enterolysis group was 33 months. Figure 4 shows that an early obstruction developed in one patient in each of the two groups. This figure also indicates the type of intraluminal tube stent used in each case, as well as the number of days the stent was left in place. The density of adhesions in each case was evaluated and graded according to the description of the adhesions in the operative reports (Fig 5). The adhesions were graded on a scale of 1 to 4. A single adhesive band was designated as a grade 1 adhesion; "mild or a few" adhesions, grade 2; "numerous or multiple" adhesions, grade 3; and "severe or dense" adhesions, grade 4. Figure 5 shows, on the left side, the density of adhesions in the 58 cases of intestinal obstruction, and shows data for the patients treated with enterolysis only as well as those treated with a long intestinal stent. There were approximately equal numbers of patients with all grades of adhesions treated by enterolysis alone as there were patients treated by stent. The right side of Fig 5 illustrates the number of recurrent obstructions and the density of the adhesions, as well as the type of treatment these patients received, ie, enterolysis or stent. The only patient with a grade 1 adhesion who experienced reobstruction was initially treated by stent; no patients with grade 1 adhesions initially treated by enterolysis alone experienced reobstruction. Similarly, three patients with grade 4 adhesions who were initially treated by stent experienced reobstruction, but none of the patients with grade 4 adhesions, previously treated by enterolysis alone, experienced reobstruction.
COMMENT
The data presented show that patients who undergo operation for small bowel obstruction and have a long tube intestinal stent placed at operation have a period of postoperative ileus lasting almost twice as long as do patients who undergo operation with enterolysis alone. Hospital confinement is similarly nearly twice as long with stent patients as with those who do not receive intralu¬
minal support. The best comparison between the two methods, however, is the prevention of recurrent obstruction. Thirteen recur¬ rent obstructions developed in the original 58 patients. Nine of the reobstructions were in stented patients, and four were in patients treated by enterolysis. In the enterol¬ ysis group, one patient had an early obstruction, and the other three experienced reobstruction at two, four, and five years, respectively. The data in Fig 4 further illustrate that the Dennis" tube gives the poorest results in preventing recurrent obstruction, while the Leonard tube1" in this series had a slightly better performance. Since a Cantor tube was used in only one stent patient in this study, we are unable to make any conclusion regarding its effective¬ ness. The Baker tube4 was not used in any of the patients in this review. Interestingly, there seems to be no relation between the number of days the intraluminal tube stent is left in place and the average number of months before recurrent obstruction develops. For example, a patient
illustrated in Fig 4 had a Leonard tube intraluminal stent in place for 11 days, but reobstruction occurred in only three months; another patient had a Leonard tube stent for only six days and did well for two years before a second small bowel obstruction occurred. Adhesions, varying from a single band to very dense, were treated in approximately equal numbers by the two methods, ie, stenting and enterolysis. Patients treated with enterolysis alone fared better. In one patient with a grade 1 adhesion (a single band) in whom a stent was placed, a reobstruction developed, no patients in this group undergoing enterolysis alone experienced reobstruction. Logically, excessive handling of the bowel with threading onto the stent at operation likely caused even more adhe¬ sions to form, and may well explain why reobstruction occurred in this patient. There were six patients with severe or very dense adhesions treated with an intralu¬ minal stent, and five similar patients with severe adhe¬ sions treated by enterolysis alone. Three (50%) of the stent patients with severe adhesions experienced reobstruction, but none of the similar group treated with enterolysis did. The same explanation probably holds: threading an intra¬ luminal stent through and around multiple adhesions likely results in tearing or denuding the serosal covering from the bowel and causing even more adhesions to develop. There are many complications and disadvantages of the long tube in the upper nasopharynx and upper gastrointes¬ tinal system. The most common sequela of prolonged gastrointestinal suction is electrolyte and pH imbalance; however, this problem is generally anticipated and rela¬ tively easily treated. Less common complications of nasogastrointestinal tubes are abscesses of the nasal septum, sinusitis, otitis media, ulcérations of the larynx, and occa¬ sional stenosis. Reported but very rarely seen complica¬ tions include rupture of esophageal varices; perforation of the esophagus, stomach, or small bowel; knotting of the tube in the stomach or the intestines; intussusception with the balloon as the leading point; and inability to withdraw the balloon-tipped tube. Perhaps a very common but unnoticed complication is aspiration pneumonitis, which has impressive clinical significance. References 1. Noble TB Jr: Plication of small intestine as prophylaxis against adhesions. Am J Surg 35:41-44, 1937. 2. Childs WA, Phillips RB: Experience with intestinal plication and proposed modification. Ann Surg 152:258-265, 1960. 3. White RR: Prevention of recurrent small bowel obstruction due to adhesions. Ann Surg 143:714-719, 1956. 4. Baker JW: A long jejunostomy tube for decompressing intestinal obstruction. Surg Gynecol Obstet 109:518, 1959. 5. Baker JW, Ritter KJ: Complete surgical decompression for late obstruction of the small intestine, with reference to a method. Ann Surg 157:759-769, 1963. 6. Baker JW: Stitchless plication for recurring obstruction of the small bowel. Am J Surg 116:316-324, 1968. 7. Markee RK, Uhlig BE: Baker tube jejunostomy: Management of small bowel obstruction. Minn Med 54:981-984, 1971. 8. Grosfeld JL, Cooney DR, Csicsko JF: Gastrointestinal tube stent plication in infants and children. Arch Surg 110:594-599, 1975. 9. Dennis C: The gastrointestinal sump tube. Surgery 66:309-312, 1969. 10. Leonard AS, Nicoloff D, Griffin WO, et al: Intestinal decompression: Use of a long tube with a coiled spring for relief of distention without enterotomy or enterostomy. Surgery 49:440-449, 1961.
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Discussion William F. Pollock, MD, Santa Monica, Calif: The original thought that Dr Noble had, and that was repeated by Childs, Gaspar, White, and Baker, was that adhesions were formed no matter what you do, and therefore, they wished to control them. One point I would like to ask the authors about: in the patients who were reoperated on, did or did not the sutureless plication plicate the bowel? At reoperation for patients who have previously had a long tube stent placed, was or was not the bowel, in fact, folded
on
itself in the same way that it would be if the Noble or the
Childs-Phillips plication were undertaken? The end point of the ileus described by the authors was the ability to tolerate oral fluids; this might be supplemented with some information as to when peristalsis was audible and when flatus was passed. In essence, they conclude that sutureless long tube stents are not efficient in preventing recurring trouble, and with that conclusion I am in hearty agreement.
Erich W. Pollar, MD, Davis, Calif: An analysis of the results of Dr Brightwell in patients undergoing long tube stenting and in those undergoing plain enterolysis showed a highly statistically significant difference between the two groups (P < .01). Con¬ versely, we thought that a significant difference in the incidence of postoperative obstruction in the two groups was not demon¬ strated by the authors ( 1' 1.95; > .05). We did not believe that these results could be compared with those of Noble small bowel plication. According to data presented by the authors today; the 58 patients had undergone a total of 66 previous operations (an average of 1.1 opeations per patient). Thus, these were not the type of patients in whom anybody would have done a Noble plication. The Noble plication was devised for patients with several previous celiotomies for recurrent small bowel obstructions due to intestinal adhesions. In some instances, patients had undergone as many as 14 previous operations, as did one patient in our own series. Noble plication has been somewhat discredited in more recent years, because several authors have reported considerable morbidity following plication. In my series of 16 patients with five or more prior obstructive episodes who subsequently underwent a Noble plication, only one genuine recurrent small bowel obstruction developed during a follow-up period of five years. In most patients, following plication, the small bowel loops became tridimensionally anchored to adjacent loops and to the anterior abdominal wall due to adhesions. Consequently, radiological pictures showed air in the small bowel even in the absence of actual obstruction. Radiological pictures such as the above in patients complaining of ill-defined symptoms occasionally led to an erroneous diagnosis of intestinal obstruction, and even to useless celiotomies. As we pointed out more than ten years ago, radiological studies of the upper gastrointestinal tract with hydrosoluble contrast media were extremely useful to lead to the correct diagnosis and to avoid unnecessary operations. A review of the literature and our own experience showed that when a true intestinal obstruction developed in patients with Noble plication, it was always related to a technical failure in the performance of the operation or to the performance of an incom¬ plete intestinal plication. This above is not intended to allege that Noble plication is a perfect operation. It has severe shortcom¬ =
ings.
Raleigh White III, MD, Temple, Tex: About 26 years ago I first utilized this method of long tube splinting of the small bowel after release of massive adhesions in patients with intestinal obstruc¬ tion. Most of the patients had already undergone previous multiple operations with simple lysis of adhesions, and the adhesions with obstruction had recurred. I subsequently reported my early expe¬ rience at a meeting of this Association in Colorado Springs, Colo,
in 1954, in discussion of a paper by Gordon Smith of Los Angeles. Of the original group of 32 patients followed up for periods of to 11 years, there was one patient with documented recurring obstruc¬ tion who had to undergo subsequent surgery. I want to make the point that these are seriously ill patients. They have massive adhesions. They usually have undergone multiple operations and principally failure with simple lysis. You all know this type of patient, who has multiple abdominal scars and often is a narcotic addict. I do note that in the authors' series of the 58 patients, 30 had either a single adhesion or minimal or few adhesions, grade I or grade II. I certainly agree that in this type of patient we would not recommend long tube splinting. The manipulation of the bowel and the morbidity and the discomfort of the patient with the long tube splint for 10 or 12 days is really not justified for simple, single, or few adhesions. What we are really talking about is massive adhesions, and I note that of the 11 patients the authors reported in the category of massive adhesions, six of them were splinted, and of that six, three experienced recurrence with a 50% failure rate. I really can't explain this. I don't blame the authors for being disenchanted with splinting if they had a 50i? failure rate in the complicated cases, which are the ones we are really talking about. From communications with surgeons across the country through these years and the many reports in the literature in which modifications of the splinting technique have been suggested, together with Joel Baker's reported experience, (the Baker tube is a real advance) it would appear to me that it still has a place. One last point. I would remind you that long tube splinting may be of value prophylactically to prevent intestinal obstruction in the high-risk patient who has had massive denuding of peritoneal surfaces, as in pelvic exenteration. Gene Bricker often related to me his opinion that long tube splinting is an important modality in preventing postoperative obstruction following this type of surgery. Allen M. Boyden, MD, Portland, Ore: I became interested in the Noble plication many years ago, and in various discussions, have reported our cases. I became disenchanted with the procedure and disappointed by the complications that resulted, including late obstructions. I was impressed by Joel Baker's report a number of years ago, and since that time have utilized the long tube that bears his name. The statistics reported by Drs Brightwell, McFee, and Aust concern me, for certainly many of the patients included in their study would not have undergone intubation at the Portland Clinic. I do not use any kind of splinting in simple obstruction, in nonoperative obstruction, or when few or single adhesions are present, but reserve its use for patients with massive adhesions, using it either prophylactically or following the release of obstruc¬
tion. We prefer the Baker tube, and I recommend it to you. It is stiffer than the others, so that one can expect the intubated bowel to lie in gentle loops that will not obstruct with the tube in place, and hopefully will remain adherent similarly in the future. One can predict varying degrees of postoperative ileus when the bowel is denuded to this extent and handled as much as is necessary in passing the tube. This complication one must accept in order to avoid mechanical obstruction in the postoperative period. Such a complication is tragic and can be avoided when intubation is properly used. I believe the answer, Dr Brightwell, may be that you and your associates should be using the stiffer tube and using it only when extensive adhesive disease is pres¬ ent.
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Jack D. McCarthy, MD, Albuquerque, NM: As is evident from the discussion so far, we really don't have a significant control group that we can rely on when looking at these matters. We really don't know if the maneuvers that we are doing are successful. Some years ago before this audience, I described my own satisfaction with the Childs-Phillips plication, and I continue to experience the same satisfaction. The number of patients now involved is approximately 50, and in that entire group there has been but one reobstruction. I notice the authors report a recurrence rate of nine in 28 to one group and four of 30 in the other group. This would seem to imply that the frequency of intestinal obstruction after the operations as described is astoundingly great, I think greater than what any of us would automatically think. When faced with these problems and the surgeon has done an enterolysis, he really has several options open to him. The first option is to do nothing, as these authors have described, and drop the serosely damaged small bowel back into place. The second option is to put down a long tube. The Baker tube is widely used, I believe. I think perhaps it's more commonly used through an enterotomy brought through the abdominal wall, which, compared with the nasal route, obviates some of the complications listed. A third option after denuding the small bowel in its enterolysis is to do the Noble plication. The Noble plication is probably not a very popular operation for several reasons. One, as pointed out, is that it is tremendously time consuming. The frequency of cramp¬ ing abdominal pain and intestinal fistula seem to be inordinately high with it. A fourth option is the so-called transmesentery plication, that of Childs and Phillips. In my own hands it has been extraordinarily safe and, perhaps even more important than that, astoundingly effective. So, on a prophylactic basis, after taking down a great many adhesions, I will often do the Childs-Phillips plication. Admittedly, it is not to be used in everybody, and even though safe and effective, it is a maneuver that has to be selected with care. Frederic W. Taylor, MD, Indianapolis: I come from Noble country, and from Noble's hospital. We became disenchanted with this procedure because in a number of his patients, and ours, too, who were reoperated on either for obstruction, gallbladder, or other causes, the plication had completely disappeared. In these cases nature had taken its own course in healing. The plication was no longer there. Dr McFee: It is always extremely unsettling to one when his own patients and figures tend to refute firmly preconceived notions. Those of us who have had the privilege of training—and a number of us in San Antonio did-at the University of Minnesota really believe that the alimentary tract was established to be intubated either from above or below; we do so frequently. To find
that it may not be the best procedure is unsettling indeed. With regard to specific questions, I can provide some answers. Dr Pollock, we did not find a definite plication effect on those patients who underwent reoperation. A signal for removing the tube was the return of peristalsis, as evidenced by audible bowel sounds. Having removed the tube, we waited 24 hours before the patients were allowed to tolerate any diet. Frequently, however, in this series, we fed patients around the tube after peristalsis had returned, because we wished to leave it in an arbitrary number of
days, usually
15.
am grateful for the fact that you did the statistical analysis on our study. We did not do so simply because we thought the samples were far too small for such manipulation. Addition¬ ally, we did not do any Noble plications and have not done any in our hospital to my knowledge. Drs White and Boyden, we agree completely that a tube plication is an operation that should be reserved for the person who is seriously ill and who has undergone much obstructive difficulty. Drs Smith and McCarthy, we are grateful for the comments that have amplified our review so much. This study obviously suffers from a number of deficiencies that I think are quite evident. Primarily, it is a retrospective study. We did not have prospective control of the patients who were entered. The selection of treatment, as Dr Brightwell pointed out, largely came down to the preferences of the individual staff man at that time, and, as is true in every other hospital, staff preferences are occasionally forceful and over-ride a great number of other considerations. Nevertheless, when examined, the patient popula¬ tion in each group is, I think, a fair, equal distribution that could not have been improved had we randomized for all obstructions the patients coming sequentially over the same period of time. The period for operative procedures extended from the opening of the hospital in October of 1968 to Dec 31, 1971. The follow-up period ended on Dec 31, 1975. Although the patients have been followed up for from one to seven years, the average follow-up period for each individual patient is two years. Some of our patients have simply disappeared from San Antonio or from the purview of the Bexar County Hospital district, and are never heard from again. In general, intubations were through the mouth or the nose. Very few have been done through a gastrostomy, and, up until 1971, almost none through an enterostomy route. We would conclude, with our discussants, that obviously we have overtreated the patients with a single band. Similarly, many of the patients who had peritoneal syncytia have probably been undertreated. We are concerned with this latter kind of patient, and we would emphasize that a 50% recurrence rate in this group of patients after intubation is one of the principal points of the studythat we wish to bring to the attention of the group.
Dr
Pollak, I
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