Rapid Long Tube lntubation of the Jejunum by a New Endoscopic Device F. W. Johnson, MD, Minneapolis, Minnesota R. L. Goodale, MD, PhD, Minneapolis, Minnesota A. S. Leonard, MD, PhD, Minneapolis, Minnesota R. L. Varco, MD, PhD, Minneapolis, Minnesota
The present day regimen for treatment of intestinal obstruction includes fluid and electrolyte administration, decompression of the bowel if possible, antibiotics, and early operation. According to Leonard and Edlich [I], mortality rates vary from 9 to 45 per cent depending on the cause of obstruction and the presence of concommitant disease. Abdominal sepsis remains the greatest factor in morbidity and mortality. Causes of sepsis include spontaneous perforation from undue delay of operation and contamination of the peritoneal cavity during trochar enterotomy or enterostomy procedures. Delayed surgical intervention can be disastrous; precise surgical judgment and properly timed surgical intervention have no substitute. However, preoperative decompression of the obstructed loops can serve as an important adjunct in the therapy of acute intestinal obstruction. Major advantages of long tube intestinal decompression include: (1) decreasing the intraluminal pressure of distended bowel with consequent restoration of capillary blood flow and reduction of intramural edema; (2) removal of highly toxic, bacteria-laden intestinal fluid in an aseptic manner; (3) facilitating exposure of the obstructing lesion at operation; and (4) facilitating the closure of the
From the Department of Surgery, University of Minnesota Health Sciences Center. Reprint requests should be addressed to Robert L. Goodale. MD. Box 379, Mayo Memorial Building, University of Minnesota. Minneapolis, Minnesota 55455. Presented at the Sixteenth Annual Meeting of the Society for Surgery of the Alimentary Tract, San Antonio, Texas, May 20-21. 1975.
Volume 131, January 1976
wound by decompressing the dilated loops. In addition, the long intestinal tube may act as a splint postoperatively to allow the bowel loops to adhere in gentle curves, thereby preventing future adhesive obstructions. Despite these advantages of aseptic preoperative intubation of the small intestine, widespread acceptance is lacking. This is due to the difficulty and inconvenience of passing the long tube into the small bowel. Edlich et al [2] reported that 48 per cent of attempts result in failure to pass conventional tubes through the pylorus. We have overcome’ the difficulty and inconvenience of passage by utilizing the recent advances of flexible fiberoptic technics. Our method of long tube intubation is very simple. The tube is connected directly to the duodenoscope and is therefore passed through the pylorus and into the duodenum under fiberoptic guidance. In our first efforts, a loop was attached to the distal end of a long intestinal tube and grasped with biopsy forceps that had been passed through the scope. This assembly was then passed through the stomach and into the duodenum where the tube was detached from the endoscope and prodded into the jejunum. We now have developed a simple tube attachment that is more practical. The entire procedure, which takes less than 15 minutes, is reliable and relatively easy when performed by a skilled and well trained endoscopist. It is the purpose of this paper to give a preliminary report on the technic, which has now been carried out in five patients. A brief summary of each patient follows.
91
Johnson et al
Case Reports Case I. EH (11729698), a sixty-five year old female, was referred from an outside hospital for mechanical small bowel obstruction complicated by recent pulmonary embolism. Due to the patient’s precarious pulmonary condition, surgical delay was mandatory. The patient was fully heparinized and a long intestinal tube was passed endoscopically on the second day of admission. Contrast study, performed through the tube, revealed a high grade simple obstruction secondary to external compression. The patient was successfully decompressed and, on the tenth hospital day when her pulmonary status was stable, underwent definitive surgical therapy consisting of extensive enterolysis and clipping of her inferior vena cava. In this patient the tube allowed for a definitive diagnostic study as well as a temporizing mode of therapy while the patient’s critical pulmonary compromise improved. Case II. EW (1021628), a fifty-five year old white male, was admitted to University of Minnesota Hospitals with abdominal distension of 24 hours’ duration, obatipation, dehydration, and metabolic acidosis. Shortly after his admission, aseptic decompression was carried out by a long intestinal tube passed endoscopically. Twenty-four hours later, after fluid and electrolyte correction had been accomplished, the patient was brought to the operating room at which time an appendiceal abcess was found and drained. The patient’s postoperative recovery was benign. In this case the long tube again allowed time for correction of the patient’s metabolic status before definitive surgical intervention. Case III. IW (1214632), a thirty-one year old white female, was admitted for abdominal pain that led to surgical exploration for a ruptured appendix with an appendiceal abscess. Postoperatively the patient developed a marked paralytic ileus secondary to peritonitis. The long intestinal tube was passed with use of our technic on the second postoperative day and it successfully decompressed the bowel for ten days. Despite decompression, bowel function did not return and reexploration was carried out. More intraperitoneal abscesses were found and drained and the patient made an unremarkable recovery. Aseptic decompression in this case allowed for stabilization and hyperalimentation before the patient was subjected to a second laparotomy.
Case IV. DK (1201267), a forty-five year old diabetic white male, was admitted to the hospital for severe rejection two months after receiving a renal transplant. His main complaint was fever and back pain. The patient was initially treated for both rejection and sepsis and eventually underwent transplant nephrectomy. Shortly after transplant nephrectomy the patient became obtunded and then comatose. At this point feeding tube gastrostomy was considered but contraindicated
92
due to sepsis, obundation, intermittent hypotension, and a bleeding duodenal ulcer with duodenal ileus. The long intestinal tube was passed into the duodenum endoscopically beyond the area of ileus and used as a feed-
ing conduit. The patient slowly improved and was discharged one month after transplant nephrectomy. In this patient duodenal intubation allowed restoration of nutrition and avoidance of gastrostomy. Case V. CS (1163770), a sixty-seven year old white male, was admitted for a ruptured abdominal aneurysm. Emergency aneurysmectomy with prosthetic graft replacement was accomplished. The patient’s postoperative course was complicated by (1) renal failure necessitating hemodiolysis, (2) cardiac dysrhythmias, (3) sepsis, (4) respiratory failure, and (5) progressive small bowel distention. The rapid abdominal distention necessitated operative consideration, but the patient’s condition would not permit a surgical procedure. Aseptic decompression was successfully carried out. The patient, however, eventually died from a myocardial infarction. Although death was the final outcome in this patient, aseptic decompression avoided a major operative procedure. We believe that aseptic decompression via the long intestinal tube can be significantly worthwhile in the treatment of ileus or mechanical small bowel obstruction and that its lack of acceptance is due to the difficulty in passage of the tube through the pylorus. The new technic described, when performed by a dedicated and fully trained endoscopist, is not only rapid and reliable but is relatively safe and therefore should encourage the wider acceptance of aseptic long tube decompression. Tube decompression, however, should never be allowed to replace good surgical judgment and timing but instead should, be regarded as an adjunct to definitive surgical therapy for obstruction. Summary Despite the advantages of aseptic nonoperative intubation of the small intestine for decompression of obstructed loops, 48 per cent of the attempts lead to failure to pass the tube through the pylorus. The difficulty and inconvenience of passage beyond the stomach have been overcome by the development of a special tube attachment adapted to a fiberoptic duodenoscope (Olympus Model GIF-K). Under direct endoscopic vision the tube can be carried into the second and third portion of the duodenum, released from the scope, and then further prodded into the jejunum. The entire procedure takes less than 15 minutes. Rapid intubation has now been easily carried out in five patients. Three patients had mechanical bowel ob-
The American Journal of Surgery
lntubationof Jejunum struction. Rapid and effective decompression allowed adequate time for stabilization of concomitant serious problems such as (1) marked cardiopulmonary dysfunction secondary to a near fatal pulmonary embolus, (2) severe peritonitis post appendectomy, and (3) acidosis and dehydration. Surgical correction of the obstructing lesions was safely deferred for up to one week until the concomitant problems improved. The fourth patient, who was a renal transplant recipient, had chronic gastric ileus secondary to duodenal ulcer. Rapid passage of the long tube into the jejunum allowed restoration of nutrition and avoidance of gastrostomy. The fifth patient, with an ileus secondary to an infected abdominal aortic graft, underwent successful decompression but died of sepsis. He represents the only mortality. We propose that jejunal intubation using our technic is not only rapid but relatively easy and should encourage the wider acceptance of aseptic long tube intestinal decompression. References 1. Leonard AS, Edlii RF: Clinical experience with intestinal obstruction in tha University of Minnesota Hospitals. Univ Minn A&d Bull40: 241, 1966. 2. Edlich RF, Gadgaudas E, Leonard AS, Wangensteen OH: New long Intestinal tube for rapld nonoperative intubation: a prelimlnary report. Arch Sutg 95: 443.1967.
DlscussJon R. L. Goodale:We are now seeing a second generation of instruments, all spawned by fiberoptic endoscopes and all taking advantage of the marvelous opportunity that fiberoptics gives us to reach formerly inaccessible areas. Doctor Johnson and I hesitated to say that the technic of intestinal intubation was simple and easy. In the literature on long intestinal tubes, you will note that many have said their methods were easy. When surgeons are enthusiastic and skilled, technics become easy, whereas other surgeons do not have that skill and may fail to get good results. We also hesitate because a further development in intubation may come
Vokmm 131, Jsmwy 1076
alongthat is truly easy. Doctor Johnson, a surgical resident of some skill, found it took two months of endoscopy training before he was able to intubate the pylorus. At the end he was regularly intubating the duodenum. So, endoscopy itself was not easy at the start. Finally, a few cautions about intestinal intubations. I urge that we be very, very selective in application of this method. Do not use it when there is evidence of peritonitis or possibility of perforation or possible mesenteric infarction. Marshall Freedman (Denver, CO): (Slide) This is a postoperative gastric atony, after gastrectomy, in which the stomach did not function. The stoma was able to be forced open by the endoscope. An ordinary piece of Auto-Analyzer tubing was inserted into the jejunum so that the patient was able to be fed for the period until the gastric atony was relieved. A special device is not necessarily required, but a long piece of fine tubing will permit jejunostomy feeding through the nose for weeks, if necessary, until the patient’s ordinary source of nutrition is accomplished. Stig Bengmark (Lund, Sweden): I disagree on one point, namely that this is a procedure that was necessarily to be done by a special endoscopist. If we are going to make progress in surgery in the coming years, I do think that we have to utilize gastroscopes and colonoscopes more frequently and this is very often to be done at nights and on weekends when there are no endoscopista available. I think the time has come when all gastrointestinal surgeons should train in endoscopy and utilize the apparatus day and night. It is very often overemphasized that it is SO difficult to make these investigations, and some people dealing with endoscopy like to describe it as a sophisticated procedure only to be carried out by experts when, in fact, it is not. It is the best diagnostic tool for the gastrointestinal surgeon and we should take the instrument in hand. F. W. Johnson (closing): When I used the word “endoscopist,” I did mean surgeon as well as internist and I agree fully that the surgeon should play a major role. As a final comment, I would like to emphasize once again that tube decompression should never be allowed to replace good surgical judgment and timing but should be considered as an adjunct to proper surgical management in obstruction.
93
The present day regimen for treatment of intestinal obstruction includes fluid and electrolyte administration, decompression of the bowel if possible, antibiotics, and early operation. According to Leonard and Edlich [I], mortality rates vary from 9 to 45 per cent depending on the cause of obstruction and the presence of concommitant disease. Abdominal sepsis remains the greatest factor in morbidity and mortality. Causes of sepsis include spontaneous perforation from undue delay of operation and contamination of the peritoneal cavity during trochar enterotomy or enterostomy procedures. Delayed surgical intervention can be disastrous; precise surgical judgment and properly timed surgical intervention have no substitute. However, preoperative decompression of the obstructed loops can serve as an important adjunct in the therapy of acute intestinal obstruction. Major advantages of long tube intestinal decompression include: (1) decreasing the intraluminal pressure of distended bowel with consequent restoration of capillary blood flow and reduction of intramural edema; (2) removal of highly toxic, bacteria-laden intestinal fluid in an aseptic manner; (3) facilitating exposure of the obstructing lesion at operation; and (4) facilitating the closure of the
From the Department of Surgery, University of Minnesota Health Sciences Center. Reprint requests should be addressed to Robert L. Goodale. MD. Box 379, Mayo Memorial Building, University of Minnesota. Minneapolis, Minnesota 55455. Presented at the Sixteenth Annual Meeting of the Society for Surgery of the Alimentary Tract, San Antonio, Texas, May 20-21. 1975.
Volume 131, January 1976
wound by decompressing the dilated loops. In addition, the long intestinal tube may act as a splint postoperatively to allow the bowel loops to adhere in gentle curves, thereby preventing future adhesive obstructions. Despite these advantages of aseptic preoperative intubation of the small intestine, widespread acceptance is lacking. This is due to the difficulty and inconvenience of passing the long tube into the small bowel. Edlich et al [2] reported that 48 per cent of attempts result in failure to pass conventional tubes through the pylorus. We have overcome’ the difficulty and inconvenience of passage by utilizing the recent advances of flexible fiberoptic technics. Our method of long tube intubation is very simple. The tube is connected directly to the duodenoscope and is therefore passed through the pylorus and into the duodenum under fiberoptic guidance. In our first efforts, a loop was attached to the distal end of a long intestinal tube and grasped with biopsy forceps that had been passed through the scope. This assembly was then passed through the stomach and into the duodenum where the tube was detached from the endoscope and prodded into the jejunum. We now have developed a simple tube attachment that is more practical. The entire procedure, which takes less than 15 minutes, is reliable and relatively easy when performed by a skilled and well trained endoscopist. It is the purpose of this paper to give a preliminary report on the technic, which has now been carried out in five patients. A brief summary of each patient follows.
91
Johnson et al
Case Reports Case I. EH (11729698), a sixty-five year old female, was referred from an outside hospital for mechanical small bowel obstruction complicated by recent pulmonary embolism. Due to the patient’s precarious pulmonary condition, surgical delay was mandatory. The patient was fully heparinized and a long intestinal tube was passed endoscopically on the second day of admission. Contrast study, performed through the tube, revealed a high grade simple obstruction secondary to external compression. The patient was successfully decompressed and, on the tenth hospital day when her pulmonary status was stable, underwent definitive surgical therapy consisting of extensive enterolysis and clipping of her inferior vena cava. In this patient the tube allowed for a definitive diagnostic study as well as a temporizing mode of therapy while the patient’s critical pulmonary compromise improved. Case II. EW (1021628), a fifty-five year old white male, was admitted to University of Minnesota Hospitals with abdominal distension of 24 hours’ duration, obatipation, dehydration, and metabolic acidosis. Shortly after his admission, aseptic decompression was carried out by a long intestinal tube passed endoscopically. Twenty-four hours later, after fluid and electrolyte correction had been accomplished, the patient was brought to the operating room at which time an appendiceal abcess was found and drained. The patient’s postoperative recovery was benign. In this case the long tube again allowed time for correction of the patient’s metabolic status before definitive surgical intervention. Case III. IW (1214632), a thirty-one year old white female, was admitted for abdominal pain that led to surgical exploration for a ruptured appendix with an appendiceal abscess. Postoperatively the patient developed a marked paralytic ileus secondary to peritonitis. The long intestinal tube was passed with use of our technic on the second postoperative day and it successfully decompressed the bowel for ten days. Despite decompression, bowel function did not return and reexploration was carried out. More intraperitoneal abscesses were found and drained and the patient made an unremarkable recovery. Aseptic decompression in this case allowed for stabilization and hyperalimentation before the patient was subjected to a second laparotomy.
Case IV. DK (1201267), a forty-five year old diabetic white male, was admitted to the hospital for severe rejection two months after receiving a renal transplant. His main complaint was fever and back pain. The patient was initially treated for both rejection and sepsis and eventually underwent transplant nephrectomy. Shortly after transplant nephrectomy the patient became obtunded and then comatose. At this point feeding tube gastrostomy was considered but contraindicated
92
due to sepsis, obundation, intermittent hypotension, and a bleeding duodenal ulcer with duodenal ileus. The long intestinal tube was passed into the duodenum endoscopically beyond the area of ileus and used as a feed-
ing conduit. The patient slowly improved and was discharged one month after transplant nephrectomy. In this patient duodenal intubation allowed restoration of nutrition and avoidance of gastrostomy. Case V. CS (1163770), a sixty-seven year old white male, was admitted for a ruptured abdominal aneurysm. Emergency aneurysmectomy with prosthetic graft replacement was accomplished. The patient’s postoperative course was complicated by (1) renal failure necessitating hemodiolysis, (2) cardiac dysrhythmias, (3) sepsis, (4) respiratory failure, and (5) progressive small bowel distention. The rapid abdominal distention necessitated operative consideration, but the patient’s condition would not permit a surgical procedure. Aseptic decompression was successfully carried out. The patient, however, eventually died from a myocardial infarction. Although death was the final outcome in this patient, aseptic decompression avoided a major operative procedure. We believe that aseptic decompression via the long intestinal tube can be significantly worthwhile in the treatment of ileus or mechanical small bowel obstruction and that its lack of acceptance is due to the difficulty in passage of the tube through the pylorus. The new technic described, when performed by a dedicated and fully trained endoscopist, is not only rapid and reliable but is relatively safe and therefore should encourage the wider acceptance of aseptic long tube decompression. Tube decompression, however, should never be allowed to replace good surgical judgment and timing but instead should, be regarded as an adjunct to definitive surgical therapy for obstruction. Summary Despite the advantages of aseptic nonoperative intubation of the small intestine for decompression of obstructed loops, 48 per cent of the attempts lead to failure to pass the tube through the pylorus. The difficulty and inconvenience of passage beyond the stomach have been overcome by the development of a special tube attachment adapted to a fiberoptic duodenoscope (Olympus Model GIF-K). Under direct endoscopic vision the tube can be carried into the second and third portion of the duodenum, released from the scope, and then further prodded into the jejunum. The entire procedure takes less than 15 minutes. Rapid intubation has now been easily carried out in five patients. Three patients had mechanical bowel ob-
The American Journal of Surgery
lntubationof Jejunum struction. Rapid and effective decompression allowed adequate time for stabilization of concomitant serious problems such as (1) marked cardiopulmonary dysfunction secondary to a near fatal pulmonary embolus, (2) severe peritonitis post appendectomy, and (3) acidosis and dehydration. Surgical correction of the obstructing lesions was safely deferred for up to one week until the concomitant problems improved. The fourth patient, who was a renal transplant recipient, had chronic gastric ileus secondary to duodenal ulcer. Rapid passage of the long tube into the jejunum allowed restoration of nutrition and avoidance of gastrostomy. The fifth patient, with an ileus secondary to an infected abdominal aortic graft, underwent successful decompression but died of sepsis. He represents the only mortality. We propose that jejunal intubation using our technic is not only rapid but relatively easy and should encourage the wider acceptance of aseptic long tube intestinal decompression. References 1. Leonard AS, Edlii RF: Clinical experience with intestinal obstruction in tha University of Minnesota Hospitals. Univ Minn A&d Bull40: 241, 1966. 2. Edlich RF, Gadgaudas E, Leonard AS, Wangensteen OH: New long Intestinal tube for rapld nonoperative intubation: a prelimlnary report. Arch Sutg 95: 443.1967.
DlscussJon R. L. Goodale:We are now seeing a second generation of instruments, all spawned by fiberoptic endoscopes and all taking advantage of the marvelous opportunity that fiberoptics gives us to reach formerly inaccessible areas. Doctor Johnson and I hesitated to say that the technic of intestinal intubation was simple and easy. In the literature on long intestinal tubes, you will note that many have said their methods were easy. When surgeons are enthusiastic and skilled, technics become easy, whereas other surgeons do not have that skill and may fail to get good results. We also hesitate because a further development in intubation may come
Vokmm 131, Jsmwy 1076
alongthat is truly easy. Doctor Johnson, a surgical resident of some skill, found it took two months of endoscopy training before he was able to intubate the pylorus. At the end he was regularly intubating the duodenum. So, endoscopy itself was not easy at the start. Finally, a few cautions about intestinal intubations. I urge that we be very, very selective in application of this method. Do not use it when there is evidence of peritonitis or possibility of perforation or possible mesenteric infarction. Marshall Freedman (Denver, CO): (Slide) This is a postoperative gastric atony, after gastrectomy, in which the stomach did not function. The stoma was able to be forced open by the endoscope. An ordinary piece of Auto-Analyzer tubing was inserted into the jejunum so that the patient was able to be fed for the period until the gastric atony was relieved. A special device is not necessarily required, but a long piece of fine tubing will permit jejunostomy feeding through the nose for weeks, if necessary, until the patient’s ordinary source of nutrition is accomplished. Stig Bengmark (Lund, Sweden): I disagree on one point, namely that this is a procedure that was necessarily to be done by a special endoscopist. If we are going to make progress in surgery in the coming years, I do think that we have to utilize gastroscopes and colonoscopes more frequently and this is very often to be done at nights and on weekends when there are no endoscopista available. I think the time has come when all gastrointestinal surgeons should train in endoscopy and utilize the apparatus day and night. It is very often overemphasized that it is SO difficult to make these investigations, and some people dealing with endoscopy like to describe it as a sophisticated procedure only to be carried out by experts when, in fact, it is not. It is the best diagnostic tool for the gastrointestinal surgeon and we should take the instrument in hand. F. W. Johnson (closing): When I used the word “endoscopist,” I did mean surgeon as well as internist and I agree fully that the surgeon should play a major role. As a final comment, I would like to emphasize once again that tube decompression should never be allowed to replace good surgical judgment and timing but should be considered as an adjunct to proper surgical management in obstruction.
93
