Further Experience with the Childs-Phillips Plication Operation Jack D. McCarthy,
MD, FACS, Albuquerque,
New Mexico
Plication operations are designed to decrease the likelihood of subsequent obstruction of the small intestine. Until 1960 the only plication operation was that of Nobel [I], its inventor and principal proponent. Then Childs and Phillips [2] described a new technic for holding segments of intestine by suturing together the mesenteries of all the segments. Ferguson, Reihmer, and Gaspar [3], reporting some of their own cases, used the term “transmesenteric plication,” which because of its imagery is the best term for the procedure, if the label Childs-Phillips is considered awkward. In Figure 1, taken from the report of Childs and Phillips, it is seen that three long sutures, each doubled back upon itself and then tied, traverse the mesentery of each intestinal segment so that a pattern of intestinal segments similar to the appearance of sausages in a box is created. Scharf and I [4] simplified the suture placement by using only three passes of the transmesenteric needle (made from a Steinmann pin) and then tying each suture to its neighbor. We further suggested using a heavy monofilament suture (nylon in 1965, polypropylene now) and passing that suture a few centimeters from the bowel wall rather than adjacent to it. Figures 2, 3, and 4 illustrate the simplified procedure. This report reviews experience since 1965 and includes information upon which the operation continues to be recommended. From the Department Of Surgery, Lovelace-Bataan Medical Center, Albuquerque, New Mexico. Reprint requests should be addressed to Jack D. McCarthy, MD, Department of Surgery, Lovelace-Bataan Medical Center, Albuquerque, New Mexico 87108.
Volume 130, July 1975
Material and Methods Between 1960 and 1974 thirty-seven patients have undergone plication of the small intestine using the simplified technic; twenty-five new patients are reported on in addition to the twelve previously described [4]. Furthermore, other surgeons have performed the procedure in five additional patients in our institution. Thus, the patient population consists of forty-two patients, twentyfive females and seventeen males. There are two indications for plication. The first is recurrent small bowel obstruction. If recurrent obstruction is defined as at least one previous episode of small bowel obstruction, eighteen of the patients cared for personally and one in the group of five cared for by other surgeons are so categorized, comprising a group total of nineteen. The second indication for plication is the possibility of future intestinal obstruction. This group includes patients in whom intestinal obstruction would be catastrophic and in whom the jeopardy seems great. These patients commonly display long segments of serosal damage or large areas of loss of parietal peritoneum. Nineteen patients who underwent the simplified operation and four patients operated on by other surgeons according to the original technic of Childs and Phillips are placed in this category, comprising a group total of twenty-three. Results
The thirty-one patients who survived the postoperative period have, with one exception, been free of crampy abdominal pain, and none has experienced intestinal obstruction. Follow-up periods for these patients vary from 3 months to more than 13 years; the average is 5.9 years.
15
McCarthy
Jv
Mesentery
Figure 1. Diagram of the Child+Phillips plication operation [2]. (With permission of J. B. Lippincott Co.)
Because the use of plication as a prophylactic measure is controversial, it is convenient to analyze these thirty-one patients in two groups, those having had plication to prevent future intestinal obstruction, the “prophylactic group,” and those having had plication to correct intestinal obstruc-
tion, the “therapeutic group.” (Table I.) The patients in the therapeutic group, as stated previously, had had at least one previous episode of intestinal obstruction. Nineteen patients in the therapeutic group underwent operation for relief of at least the second episode of intestinal obstruction. Of these patients, two died postoperatively and one died several months later from asthma, debility, and an enterocutaneou$ fistula. One of the postoperative deaths was due to peritonitis and the other was due to recurrent small intestinal obstruction. In the latter patient an unusually long mesentery had allowed the small bowel to pack into an empty capacious pelvis. Only one patient in this group had residual crampy abdominal pain; in fact, he was the only such patient in either group. In one other patient in the group of five who underwent operation by the original technic of Childs and Phillips, fistulas developed along the course of the heavy silk transmesenteric sutures; the surgeon resected the fistulas and converted the plication to the Nobel operation. The prophylactic group consists of twenty-three patients operated on for a variety of serious intraperitoneal problems resulting in destruction of large areas of peritoneal surface. Seven of ten pa-
Figure 2. Simplified technic [2] for the Childs-Phillips p&cation. Segments of small intestine are arranged in pattern and held with a series of Babcock clamps. Figure 3. The center and right lateral needles are in place. The left needle is partway through its course to the far side of the mesentery of the last segment. The more cephalad segments are usually longer. Figure 4. The center suture is tied to each lateral suture at each end of the mesenteric pattern. Tension is just sufficient to maintain the pattern without compromise of the vasculature. The needle passes several centimeters from the bowel wall.
16
The American Journal of Surgery
Child.+Phillips
tients who had acute peritonitis died, and another died of what was then considered to be a pulmonary embolus. Three of the fifteen survivors also had peritonitis, although generally to a lesser degree than that in those who died. All survivors were free of crampy abdominal pain. Three patients later had recurrent intestinal cancer with symptoms of obstruction, two of whom died. Five other patients have also died, four from cancer and one postoperatively after operation to relieve radiation stricture of the rectum. The following two case reports illustrate the clinical course in patients in the therapeutic and . prophylactic groups: Case I (Therapeutic plication). A six year old boy was hospitalized with a second episode of intestinal obstruction. The first episode had occurred one month earlier as a consequence of adhesions that resulted from an appendectomy performed some weeks previously. Partial ileectomy had been performed to correct the first obstruction and, in turn, became complicated by dehiscence of the incision and water intoxication. After transfer to our hospital (the service of D. A. McKinnon, Jr, MD) the patient recovered but returned with a new episode of small intestinal obstruction. Partial small bowel volvulus was found and relieved by traversing many adhesions between loops of small bowel and the old midline incision. The transmesenteric plication operation was performed in November 1961. The patient is now asymptomatic except for mild pyrosis, which was investigated by roentgenography of the small bowel (Figure 5), showing a well maintained pattern thirteen years later. The patient’s growth and development have been completely normal. Case II (Prophylactic plication). A four year old boy was transferred to the Bataan Hospital in October 1969, at which time he was found to be skinny and exhausted with peritonitis. Supportive therapy was carried out for fifteen hours in preparation for appendectomy and drainage of an abscess. Initially, he responded well but required transabdominal drainage of a pelvic abscess four days later. Twelve days later, transperitoneal drainage of a left subphrenic abscess was followed by development of an ileocutaneous fistula. Intravenous hyperalimentation was begun and the patient responded well metabolically except that a cul de sac abscess formed, which was drained transrectally. After one month of intravenous hyperalimentation the patient underwent operation to restore gastrointestinal continuity and to relieve refractory ileus. Lysis of widespread, extraordinarily dense adhesions, resection of a segment of small bowel with a fistula, and the Childs-Phillips plication operation were performed. Oral maintenance began five days later. Three years later the patient was completely asymptomatic and had gained 15 kg, equivalent to his older brother’s growth pattern.
Volume
130,July
1975
TABLE
I
Indication
Present study Previous studyt Other+ Total
for Operation:
Plication
Numbers
Operation
of Patients
Therapeutic*
Prophylactic*
Total
10 8 1 19
15 4 4 23
25 12 5 42
[4]
* Defined in the text. 1_Cases of other surgeons
at Bataan
_
Hospital.
Comments
After lysis of extensive adhesions, which is assumed necessary, the surgeon faces four choices. First, the surgeon can do nothing additional and return the small bowel to the peritoneal cavity with the hope that reobstruction or future obstruction will not occur. It is impossible to give an accurate estimate of the probability of obstruction in such circumstances except to state that it obviously is not frequent. Krause’s data [5] suggest an approximate 5 per cent incidence of intestinal obstruction after operation for appendicitis with local or general peritonitis. The surgeon’s second choice is to use the Baker tube as a stent lying in the lumen of the small
Figure 5. Small bowel roentgenogram in an erjlhteen year old male, indicating that the Child+Phllllps plicatlon pattern is well maintained twelve years after operation.
17
McCarthy
TABLE II
Reports by Other Surgeons of Experience Author
Country
Thomas, Edmark, and Jones [S] Boulvin [9] Calvet et al [10] Ferguson, Reihmer, and Gaspar [3] Moreaux et al [77] Hollender, Otenni, and Klein [II] Maillet and Micol et Baulieux [73] Papadimitriou et al 1741 Total
USA Iran France USA France France France Greece
* Defined in the text. t Three from prophylactic
with the Child+Phillips
Prophylactic*
. . 53
group and four from therapeutic
bowel from the site of a jejunostomy to the cecum, arranging the intestines in a plication-like pattern and then returning them to the abdominal cavity [6]. Baker [6] has termed such a procedure a “stitchless plication” and he points out that those surfaces most damaged are the most active in agglutinating. Adhesions form rapidly, so that ten to fourteen days later when the tube is removed, there is minimal risk of new, possibly deleterious adhesion formation. Although the plication pattern was often lost, only one of fifty patients demonstrated reobstruction. Three other patients may have had a brief, spontaneously resolving episode of intestinal obstruction. Internal herniation of mobile loops beneath a bridge of fixed small intestine remains a possible hazard. The surgeon’s third choice is the Nobel plication. Many reports testify to its efficacy, although there are criticisms based on fistula formation, subsequent obstruction, and frequency of crampy abdominal pain [7]. Another objection to the Nobel plication is the length of time necessary to perform the operation. Because one to two hours of additional operating time when both the patient and surgeon are exhausted are usually inadvisable, the alternative is either incomplete plication or its abandonment altogether. In either case further trouble may be expected. The fourth and most desirable choice is the Childs-Phillips plication operation, especially with the simplified technic. The intestines are permanently fixed in the new pattern, the plication itself usually requires only fifteen minutes, fistula formation is rare, and postoperative obstruction has been noted only once in this series and not at all in other series. (Table II.) Also, crampy abdominal pain was absent in all but one of the survivors. The use of the Childs-Phillips plication operation or any operation to prevent future intestinal obstruction requires that the operation be safe, ex-
18
Plication Operation
Therapeutic*
Total
Reobstruction
4 0
4 9
12 12 16 39 4 ... 87
45+ 12 26 48 4 17 175
0 0 0 1 0 9 0 0 10
Deaths 0 0 7t 0 0 0 0 0 7
group.
peditious, effective, and free of later deleterious sequelae. The safety of the operation as judged by the results in the patients reported on herein may be suspect; that is, eight of twenty-three patients who underwent plication in addition to the original operation died in the postoperative period. All but one of these had acute peritonitis. However, one of the criteria for plication, that postoperative obstruction would have been catastrophic, indicates that these patients were critically ill prior to plication. In retrospect, some of the operations would not be performed if the patients presented today, and also some of the patients could have been saved by more recent advances in the treatment of peritonitis. Nevertheless, it is prudent in current practice not to add the plication operation when generalized peritonitis is present. If the patient does not have generalized peritonitis, the operation is safe. Only one of the patients free of peritonitis died (from pulmonary embolus), which corresponds with the experience of others. (Table II.) Information already cited confirms that the operation is expeditious and effective. The favorable growth and development of two children indicate that deleterious long-term sequelae are unlikely. Consequently, for prophylactic purposes the operation may be recommended.
Summary
The Childs-Phillips plication operation was performed in forty-two patients, as treatment for recurrent small bowel obstruction in nineteen and as prophylaxis against future intestinal obstruction in twenty-three. Intestinal obstruction occurred later in only one patient. Eight of ten patients with acute peritonitis died in the postoperative period. Consequently, the operation is not recommended in the presence of generalized acute peritonitis.
The American Journal 01 Surgery
Child+Phillips Plication Operation
Only one patient of the thirty-one surviving has experienced crampy abdominal pain. Prudent use of the operation is recommended for both therapeutic and prophylactic purposes.
References 1. Nobel TB: Plication of the small intestine as prophylaxis against adhesions. Am J Surg 35: 41, 1937. 2. Childs WA, Phillips RB: Experience with intestinal plication and a proposed modification. Ann Surg 1952: 258. 1969. 3. Ferguson AT, Reihmer VA, Gaspar MR: Transmesenteric plication for small intestinal obstruction. Am J Surg 114: 203. 1967. 4. McCarthy JD, Scharf TJ: A simple intestinal plication. Surg GynecolObstet 121: 1340, 1965. 5. Krause U: Nobel plication for intestinal obstruction due to adhesions. Acta Chir Stand 118: 446, 1960. 6. Baker JW: Stitchless plication for recurring obstruction of the small bowel. Am J Surg 111: 555, 1966.
Vdume 130, July 1975
7. Ragins l-l, Freeman L, Coomaraswamy R, Lu S: Clinical and experimental comparison of the Nobel and the Childs-Phillips plications of the small bowel. Am J Surg 111: 555, 1966. 8. Thomas GI, Edmark KW, Jones TW: The Childs’ plication operation for recurrent intestinal obstruction. West J Surg 72: 243, 7964. 9. Boulvin R: La plicature mesenterique du grele on operation de Chills et Phillips. Ann Chir 18: 1334, 1964. 10. Calvet JP. Fellus PH, Setbon L, Answotth JW, Hirtz HR: Emploi de la plicature rnesenterique (procede de Childs-Phillips simplifie a titre prophylactique). A&m Acad Chir (Paris) 92: 200, 1966. 11. Moreaux J, Testart J. Bismuth H, Hepp J: La picature-fixation due m&sent&e selon Childs et Phillips. Ann Chir 22: 1239, 1968. 12. Hollender LF, Otteni F, Klein A: La plicature mesenterique selon Childs et Phillips, ensefgnements tires de 48 interventions. Lyon Chir 67: 24, 197 1. 13. Maillet P. Micol et Baulieux J: A propos des plicatures intestinales on mesenteriques. Lyon Chir 68: 265. 1972. 14. Papadimitriou J, Marselol A, Kyriakou K, Tour&s C: Childs versus Nobel plication. Chir GastroenterolG: 29, 1972.
19
MD, FACS, Albuquerque,
New Mexico
Plication operations are designed to decrease the likelihood of subsequent obstruction of the small intestine. Until 1960 the only plication operation was that of Nobel [I], its inventor and principal proponent. Then Childs and Phillips [2] described a new technic for holding segments of intestine by suturing together the mesenteries of all the segments. Ferguson, Reihmer, and Gaspar [3], reporting some of their own cases, used the term “transmesenteric plication,” which because of its imagery is the best term for the procedure, if the label Childs-Phillips is considered awkward. In Figure 1, taken from the report of Childs and Phillips, it is seen that three long sutures, each doubled back upon itself and then tied, traverse the mesentery of each intestinal segment so that a pattern of intestinal segments similar to the appearance of sausages in a box is created. Scharf and I [4] simplified the suture placement by using only three passes of the transmesenteric needle (made from a Steinmann pin) and then tying each suture to its neighbor. We further suggested using a heavy monofilament suture (nylon in 1965, polypropylene now) and passing that suture a few centimeters from the bowel wall rather than adjacent to it. Figures 2, 3, and 4 illustrate the simplified procedure. This report reviews experience since 1965 and includes information upon which the operation continues to be recommended. From the Department Of Surgery, Lovelace-Bataan Medical Center, Albuquerque, New Mexico. Reprint requests should be addressed to Jack D. McCarthy, MD, Department of Surgery, Lovelace-Bataan Medical Center, Albuquerque, New Mexico 87108.
Volume 130, July 1975
Material and Methods Between 1960 and 1974 thirty-seven patients have undergone plication of the small intestine using the simplified technic; twenty-five new patients are reported on in addition to the twelve previously described [4]. Furthermore, other surgeons have performed the procedure in five additional patients in our institution. Thus, the patient population consists of forty-two patients, twentyfive females and seventeen males. There are two indications for plication. The first is recurrent small bowel obstruction. If recurrent obstruction is defined as at least one previous episode of small bowel obstruction, eighteen of the patients cared for personally and one in the group of five cared for by other surgeons are so categorized, comprising a group total of nineteen. The second indication for plication is the possibility of future intestinal obstruction. This group includes patients in whom intestinal obstruction would be catastrophic and in whom the jeopardy seems great. These patients commonly display long segments of serosal damage or large areas of loss of parietal peritoneum. Nineteen patients who underwent the simplified operation and four patients operated on by other surgeons according to the original technic of Childs and Phillips are placed in this category, comprising a group total of twenty-three. Results
The thirty-one patients who survived the postoperative period have, with one exception, been free of crampy abdominal pain, and none has experienced intestinal obstruction. Follow-up periods for these patients vary from 3 months to more than 13 years; the average is 5.9 years.
15
McCarthy
Jv
Mesentery
Figure 1. Diagram of the Child+Phillips plication operation [2]. (With permission of J. B. Lippincott Co.)
Because the use of plication as a prophylactic measure is controversial, it is convenient to analyze these thirty-one patients in two groups, those having had plication to prevent future intestinal obstruction, the “prophylactic group,” and those having had plication to correct intestinal obstruc-
tion, the “therapeutic group.” (Table I.) The patients in the therapeutic group, as stated previously, had had at least one previous episode of intestinal obstruction. Nineteen patients in the therapeutic group underwent operation for relief of at least the second episode of intestinal obstruction. Of these patients, two died postoperatively and one died several months later from asthma, debility, and an enterocutaneou$ fistula. One of the postoperative deaths was due to peritonitis and the other was due to recurrent small intestinal obstruction. In the latter patient an unusually long mesentery had allowed the small bowel to pack into an empty capacious pelvis. Only one patient in this group had residual crampy abdominal pain; in fact, he was the only such patient in either group. In one other patient in the group of five who underwent operation by the original technic of Childs and Phillips, fistulas developed along the course of the heavy silk transmesenteric sutures; the surgeon resected the fistulas and converted the plication to the Nobel operation. The prophylactic group consists of twenty-three patients operated on for a variety of serious intraperitoneal problems resulting in destruction of large areas of peritoneal surface. Seven of ten pa-
Figure 2. Simplified technic [2] for the Childs-Phillips p&cation. Segments of small intestine are arranged in pattern and held with a series of Babcock clamps. Figure 3. The center and right lateral needles are in place. The left needle is partway through its course to the far side of the mesentery of the last segment. The more cephalad segments are usually longer. Figure 4. The center suture is tied to each lateral suture at each end of the mesenteric pattern. Tension is just sufficient to maintain the pattern without compromise of the vasculature. The needle passes several centimeters from the bowel wall.
16
The American Journal of Surgery
Child.+Phillips
tients who had acute peritonitis died, and another died of what was then considered to be a pulmonary embolus. Three of the fifteen survivors also had peritonitis, although generally to a lesser degree than that in those who died. All survivors were free of crampy abdominal pain. Three patients later had recurrent intestinal cancer with symptoms of obstruction, two of whom died. Five other patients have also died, four from cancer and one postoperatively after operation to relieve radiation stricture of the rectum. The following two case reports illustrate the clinical course in patients in the therapeutic and . prophylactic groups: Case I (Therapeutic plication). A six year old boy was hospitalized with a second episode of intestinal obstruction. The first episode had occurred one month earlier as a consequence of adhesions that resulted from an appendectomy performed some weeks previously. Partial ileectomy had been performed to correct the first obstruction and, in turn, became complicated by dehiscence of the incision and water intoxication. After transfer to our hospital (the service of D. A. McKinnon, Jr, MD) the patient recovered but returned with a new episode of small intestinal obstruction. Partial small bowel volvulus was found and relieved by traversing many adhesions between loops of small bowel and the old midline incision. The transmesenteric plication operation was performed in November 1961. The patient is now asymptomatic except for mild pyrosis, which was investigated by roentgenography of the small bowel (Figure 5), showing a well maintained pattern thirteen years later. The patient’s growth and development have been completely normal. Case II (Prophylactic plication). A four year old boy was transferred to the Bataan Hospital in October 1969, at which time he was found to be skinny and exhausted with peritonitis. Supportive therapy was carried out for fifteen hours in preparation for appendectomy and drainage of an abscess. Initially, he responded well but required transabdominal drainage of a pelvic abscess four days later. Twelve days later, transperitoneal drainage of a left subphrenic abscess was followed by development of an ileocutaneous fistula. Intravenous hyperalimentation was begun and the patient responded well metabolically except that a cul de sac abscess formed, which was drained transrectally. After one month of intravenous hyperalimentation the patient underwent operation to restore gastrointestinal continuity and to relieve refractory ileus. Lysis of widespread, extraordinarily dense adhesions, resection of a segment of small bowel with a fistula, and the Childs-Phillips plication operation were performed. Oral maintenance began five days later. Three years later the patient was completely asymptomatic and had gained 15 kg, equivalent to his older brother’s growth pattern.
Volume
130,July
1975
TABLE
I
Indication
Present study Previous studyt Other+ Total
for Operation:
Plication
Numbers
Operation
of Patients
Therapeutic*
Prophylactic*
Total
10 8 1 19
15 4 4 23
25 12 5 42
[4]
* Defined in the text. 1_Cases of other surgeons
at Bataan
_
Hospital.
Comments
After lysis of extensive adhesions, which is assumed necessary, the surgeon faces four choices. First, the surgeon can do nothing additional and return the small bowel to the peritoneal cavity with the hope that reobstruction or future obstruction will not occur. It is impossible to give an accurate estimate of the probability of obstruction in such circumstances except to state that it obviously is not frequent. Krause’s data [5] suggest an approximate 5 per cent incidence of intestinal obstruction after operation for appendicitis with local or general peritonitis. The surgeon’s second choice is to use the Baker tube as a stent lying in the lumen of the small
Figure 5. Small bowel roentgenogram in an erjlhteen year old male, indicating that the Child+Phllllps plicatlon pattern is well maintained twelve years after operation.
17
McCarthy
TABLE II
Reports by Other Surgeons of Experience Author
Country
Thomas, Edmark, and Jones [S] Boulvin [9] Calvet et al [10] Ferguson, Reihmer, and Gaspar [3] Moreaux et al [77] Hollender, Otenni, and Klein [II] Maillet and Micol et Baulieux [73] Papadimitriou et al 1741 Total
USA Iran France USA France France France Greece
* Defined in the text. t Three from prophylactic
with the Child+Phillips
Prophylactic*
. . 53
group and four from therapeutic
bowel from the site of a jejunostomy to the cecum, arranging the intestines in a plication-like pattern and then returning them to the abdominal cavity [6]. Baker [6] has termed such a procedure a “stitchless plication” and he points out that those surfaces most damaged are the most active in agglutinating. Adhesions form rapidly, so that ten to fourteen days later when the tube is removed, there is minimal risk of new, possibly deleterious adhesion formation. Although the plication pattern was often lost, only one of fifty patients demonstrated reobstruction. Three other patients may have had a brief, spontaneously resolving episode of intestinal obstruction. Internal herniation of mobile loops beneath a bridge of fixed small intestine remains a possible hazard. The surgeon’s third choice is the Nobel plication. Many reports testify to its efficacy, although there are criticisms based on fistula formation, subsequent obstruction, and frequency of crampy abdominal pain [7]. Another objection to the Nobel plication is the length of time necessary to perform the operation. Because one to two hours of additional operating time when both the patient and surgeon are exhausted are usually inadvisable, the alternative is either incomplete plication or its abandonment altogether. In either case further trouble may be expected. The fourth and most desirable choice is the Childs-Phillips plication operation, especially with the simplified technic. The intestines are permanently fixed in the new pattern, the plication itself usually requires only fifteen minutes, fistula formation is rare, and postoperative obstruction has been noted only once in this series and not at all in other series. (Table II.) Also, crampy abdominal pain was absent in all but one of the survivors. The use of the Childs-Phillips plication operation or any operation to prevent future intestinal obstruction requires that the operation be safe, ex-
18
Plication Operation
Therapeutic*
Total
Reobstruction
4 0
4 9
12 12 16 39 4 ... 87
45+ 12 26 48 4 17 175
0 0 0 1 0 9 0 0 10
Deaths 0 0 7t 0 0 0 0 0 7
group.
peditious, effective, and free of later deleterious sequelae. The safety of the operation as judged by the results in the patients reported on herein may be suspect; that is, eight of twenty-three patients who underwent plication in addition to the original operation died in the postoperative period. All but one of these had acute peritonitis. However, one of the criteria for plication, that postoperative obstruction would have been catastrophic, indicates that these patients were critically ill prior to plication. In retrospect, some of the operations would not be performed if the patients presented today, and also some of the patients could have been saved by more recent advances in the treatment of peritonitis. Nevertheless, it is prudent in current practice not to add the plication operation when generalized peritonitis is present. If the patient does not have generalized peritonitis, the operation is safe. Only one of the patients free of peritonitis died (from pulmonary embolus), which corresponds with the experience of others. (Table II.) Information already cited confirms that the operation is expeditious and effective. The favorable growth and development of two children indicate that deleterious long-term sequelae are unlikely. Consequently, for prophylactic purposes the operation may be recommended.
Summary
The Childs-Phillips plication operation was performed in forty-two patients, as treatment for recurrent small bowel obstruction in nineteen and as prophylaxis against future intestinal obstruction in twenty-three. Intestinal obstruction occurred later in only one patient. Eight of ten patients with acute peritonitis died in the postoperative period. Consequently, the operation is not recommended in the presence of generalized acute peritonitis.
The American Journal 01 Surgery
Child+Phillips Plication Operation
Only one patient of the thirty-one surviving has experienced crampy abdominal pain. Prudent use of the operation is recommended for both therapeutic and prophylactic purposes.
References 1. Nobel TB: Plication of the small intestine as prophylaxis against adhesions. Am J Surg 35: 41, 1937. 2. Childs WA, Phillips RB: Experience with intestinal plication and a proposed modification. Ann Surg 1952: 258. 1969. 3. Ferguson AT, Reihmer VA, Gaspar MR: Transmesenteric plication for small intestinal obstruction. Am J Surg 114: 203. 1967. 4. McCarthy JD, Scharf TJ: A simple intestinal plication. Surg GynecolObstet 121: 1340, 1965. 5. Krause U: Nobel plication for intestinal obstruction due to adhesions. Acta Chir Stand 118: 446, 1960. 6. Baker JW: Stitchless plication for recurring obstruction of the small bowel. Am J Surg 111: 555, 1966.
Vdume 130, July 1975
7. Ragins l-l, Freeman L, Coomaraswamy R, Lu S: Clinical and experimental comparison of the Nobel and the Childs-Phillips plications of the small bowel. Am J Surg 111: 555, 1966. 8. Thomas GI, Edmark KW, Jones TW: The Childs’ plication operation for recurrent intestinal obstruction. West J Surg 72: 243, 7964. 9. Boulvin R: La plicature mesenterique du grele on operation de Chills et Phillips. Ann Chir 18: 1334, 1964. 10. Calvet JP. Fellus PH, Setbon L, Answotth JW, Hirtz HR: Emploi de la plicature rnesenterique (procede de Childs-Phillips simplifie a titre prophylactique). A&m Acad Chir (Paris) 92: 200, 1966. 11. Moreaux J, Testart J. Bismuth H, Hepp J: La picature-fixation due m&sent&e selon Childs et Phillips. Ann Chir 22: 1239, 1968. 12. Hollender LF, Otteni F, Klein A: La plicature mesenterique selon Childs et Phillips, ensefgnements tires de 48 interventions. Lyon Chir 67: 24, 197 1. 13. Maillet P. Micol et Baulieux J: A propos des plicatures intestinales on mesenteriques. Lyon Chir 68: 265. 1972. 14. Papadimitriou J, Marselol A, Kyriakou K, Tour&s C: Childs versus Nobel plication. Chir GastroenterolG: 29, 1972.
19
