LETTERS TO THE EDITOR
Vol. 212 * No. I
mediate vicinity of the anastomosis. Finally, when we applied the same stringent definition of continence to polyposis patients, the incidence of night-time spotting after ileorectostomy, where the entire rectal mucosa was retained, did not differ very much from that seen after IPAA (Ambroze, Dozois, and Pemberton, unpublished data). Similarly Newton and Baker8 have reported some degree ofincontinence after ileorectostomy in 22% of their polyposis patients. One would not anticipate such results if anal dilatation and/or removal of the transition zone were solely responsible for night-time incontinence. We must continue to look for ways to improve the functional results of IPAA, but ideally this should be accomplished without compromising our opportunity to cure the offending colorectal disease. References 1. Nicholls RJ, Shepherd NA, Hulten L, et al. Pouchitis workshop. Int J Colorect Dis 1989; 4:205-229. 2. Stryker SJ, Carney JA, Dozois RR. Multiple adenomatous polyps arising in a continent reservoir ileostomy. Int J Colorect Dis 1987; 2:43-45. 3. lida M, Itoh H, Matsui T, et al. Ileal adenomas in postcolectomy patients with familial adenomatosis coli (Gardner's syndrome). Dis Colon Rectum 1989; 32:1034-1038. 4. Pemberton JH, Kelly KA, Beart RW Jr, et al. Ileal pouch-anal anastomosis: long-term results. Ann Surg 1987; 206:504-513. 5. Keighley MRB, Winslet MC, Yoshika K, et al. Discrimination is not impaired by excision of the anal transition zone after restorative proctocolectomy. Br J Surg 1987; 74:1118-1121. 6. King DW, Lubowski DZ, Cook TA. Anal canal mucosa in restorative proctocolectomy for ulcerative colitis. Br J Surg 1989; 76:970972. 7. Emblem R, Bergan A, Larsen S. Straight ileoanal anastomosis with preserved anal mucosa for ulcerative colitis and familial polyposis. Scan J Gastroenterol 1988; 23:913-919. 8. Newton CR, Baker WNW. Comparison of bowel function after ileorectal anastomosis for ulcerative colitis and colonic polyposis. Gut 1975; 16:785-791.
ROGER R. Dozois, M.D.
Rochester, Minnesota December 27, 1989 Dear Editor: In an attempt to formulate treatment guidelines for early postoperative small bowel obstruction, Pickleman and Lee' do not advocate the routine performance of upper GI x-rays. This may be so for the contrast radiographic method they use, i.e., the barium follow-through examination. No mention is made, however, of the diagnostically more useful enteroclysis (small bowel enema) method. I wish to bring to the attention of the authors a recent publication from the departments of Radiology and Surgery in Oxford, emphasising specifically the contribution of enteroclysis to the diagnosis of early postoperative intestinal
obstruction.2 Enteroclysis is an easy examination to perform and gives consistently good results.3 The main advantage of enteroclysis is the demonstration of all small bowel loops in a state of luminal distention.4 The most consistent sign of obstruction on enteroclysis is a constant segment of narrowing, with an acute transition in caliber between the distended proximal loops and the collapsed distal intestine. Adhesive obstruction can be shown with a high degree of reliability and an overall prospective accuracy of about 90%.5
121
It is much faster to perform enteroclysis than the barium follow-through examination, and enteroclysis avoids the logistical difficulties involved in performing intermittent protracted serial radiography on an ill patient. However, in some patients with marked obstruction, it may be necessary to take delayed radiographs because of the slow transit ofbarium in the dilated fluidfilled loops. In these patients concentrated barium may be used and the enteroclysis tube may be left in situ after the examination to aid intestinal decompression. Small bowel obstruction in the early postoperative period demands a rapid and accurate diagnostic method. Unfortunately enteroclysis continues to receive little attention in the surgical literature. The high reliability of a positive or negative result of enteroclysis emphasises its importance in the evaluation of obstruction. In difficult cases during the early postoperative period, knowledge of the level, degree and probable cause of obstruction, as shown by enteroclysis, allows confident conservative management or early reoperation. References 1. Pickleman J, Lee RM. The management of patients with suspected early postoperative small bowel obstruction. Ann Surg 1989; 210: 216-219. 2. Dehn CB, Nolan DJ. Enteroclysis in the diagnosis of intestinal obstruction in the early postoperative period. Gastrointest Radiol 1989; 14:15-2 1. 3. Nolan DJ, Cadman PJ. The small bowel enema made easy. Clin Radiol 1987; 38:295-301. 4. Maglinte DDT, Lappas JC, Kelvin FM, et al. Small bowel radiography: how, when, and why? Radiology 1987; 163:297-305. 5. Caroline DF, Herlinger H, Laufer I, et al. Small bowel enema in the diagnosis of adhesive obstructions. AJR 1984; 142:1133-1139.
TARIK F. MASSOUD, M.B.
Oxford, England January 15, 1990 Dear Editor: Dr. Massoud brings to our attention the underused method of small bowel enteroclysis, which, he rightly notes, has received scant attention in the surgical literature dealing with small bowel obstruction. I suspect that this is not an example of surgical Neanderthal logic but rather that we surgeons have come to grips with the inconsistencies of the clinical signs and the laboratory tests in patients with small bowel obstruction, and have learned the hard way that early operation is the safest course of action in many patients. What I wished to stress in my article was that early postoperative bowel obstruction may represent an entity distinct from the usual adhesive small bowel obstruction occurring remotely
after celiotomy. In our series none of the 101 patients had ischemic bowel, and I would therefore disagree with the emphasis placed on Dr. Massoud's statement that 'Small bowel obstruction in the early postoperative period demands a rapid and accurate diagnostic method.' Patients who become distended and vomit after operation will have either ileus or small bowel obstruction. In my opinion the treatment is similar, mainly nasogastric suction for a sufficient period of time to allow resolution of either process, with reoperation reserved for those patients who do not improve in 10 or 14 days or for the rare patient who manifests evidence of ischemic bowel. JACK PICKLEMAN, M.D. Maywood, Illinois
Vol. 212 * No. I
mediate vicinity of the anastomosis. Finally, when we applied the same stringent definition of continence to polyposis patients, the incidence of night-time spotting after ileorectostomy, where the entire rectal mucosa was retained, did not differ very much from that seen after IPAA (Ambroze, Dozois, and Pemberton, unpublished data). Similarly Newton and Baker8 have reported some degree ofincontinence after ileorectostomy in 22% of their polyposis patients. One would not anticipate such results if anal dilatation and/or removal of the transition zone were solely responsible for night-time incontinence. We must continue to look for ways to improve the functional results of IPAA, but ideally this should be accomplished without compromising our opportunity to cure the offending colorectal disease. References 1. Nicholls RJ, Shepherd NA, Hulten L, et al. Pouchitis workshop. Int J Colorect Dis 1989; 4:205-229. 2. Stryker SJ, Carney JA, Dozois RR. Multiple adenomatous polyps arising in a continent reservoir ileostomy. Int J Colorect Dis 1987; 2:43-45. 3. lida M, Itoh H, Matsui T, et al. Ileal adenomas in postcolectomy patients with familial adenomatosis coli (Gardner's syndrome). Dis Colon Rectum 1989; 32:1034-1038. 4. Pemberton JH, Kelly KA, Beart RW Jr, et al. Ileal pouch-anal anastomosis: long-term results. Ann Surg 1987; 206:504-513. 5. Keighley MRB, Winslet MC, Yoshika K, et al. Discrimination is not impaired by excision of the anal transition zone after restorative proctocolectomy. Br J Surg 1987; 74:1118-1121. 6. King DW, Lubowski DZ, Cook TA. Anal canal mucosa in restorative proctocolectomy for ulcerative colitis. Br J Surg 1989; 76:970972. 7. Emblem R, Bergan A, Larsen S. Straight ileoanal anastomosis with preserved anal mucosa for ulcerative colitis and familial polyposis. Scan J Gastroenterol 1988; 23:913-919. 8. Newton CR, Baker WNW. Comparison of bowel function after ileorectal anastomosis for ulcerative colitis and colonic polyposis. Gut 1975; 16:785-791.
ROGER R. Dozois, M.D.
Rochester, Minnesota December 27, 1989 Dear Editor: In an attempt to formulate treatment guidelines for early postoperative small bowel obstruction, Pickleman and Lee' do not advocate the routine performance of upper GI x-rays. This may be so for the contrast radiographic method they use, i.e., the barium follow-through examination. No mention is made, however, of the diagnostically more useful enteroclysis (small bowel enema) method. I wish to bring to the attention of the authors a recent publication from the departments of Radiology and Surgery in Oxford, emphasising specifically the contribution of enteroclysis to the diagnosis of early postoperative intestinal
obstruction.2 Enteroclysis is an easy examination to perform and gives consistently good results.3 The main advantage of enteroclysis is the demonstration of all small bowel loops in a state of luminal distention.4 The most consistent sign of obstruction on enteroclysis is a constant segment of narrowing, with an acute transition in caliber between the distended proximal loops and the collapsed distal intestine. Adhesive obstruction can be shown with a high degree of reliability and an overall prospective accuracy of about 90%.5
121
It is much faster to perform enteroclysis than the barium follow-through examination, and enteroclysis avoids the logistical difficulties involved in performing intermittent protracted serial radiography on an ill patient. However, in some patients with marked obstruction, it may be necessary to take delayed radiographs because of the slow transit ofbarium in the dilated fluidfilled loops. In these patients concentrated barium may be used and the enteroclysis tube may be left in situ after the examination to aid intestinal decompression. Small bowel obstruction in the early postoperative period demands a rapid and accurate diagnostic method. Unfortunately enteroclysis continues to receive little attention in the surgical literature. The high reliability of a positive or negative result of enteroclysis emphasises its importance in the evaluation of obstruction. In difficult cases during the early postoperative period, knowledge of the level, degree and probable cause of obstruction, as shown by enteroclysis, allows confident conservative management or early reoperation. References 1. Pickleman J, Lee RM. The management of patients with suspected early postoperative small bowel obstruction. Ann Surg 1989; 210: 216-219. 2. Dehn CB, Nolan DJ. Enteroclysis in the diagnosis of intestinal obstruction in the early postoperative period. Gastrointest Radiol 1989; 14:15-2 1. 3. Nolan DJ, Cadman PJ. The small bowel enema made easy. Clin Radiol 1987; 38:295-301. 4. Maglinte DDT, Lappas JC, Kelvin FM, et al. Small bowel radiography: how, when, and why? Radiology 1987; 163:297-305. 5. Caroline DF, Herlinger H, Laufer I, et al. Small bowel enema in the diagnosis of adhesive obstructions. AJR 1984; 142:1133-1139.
TARIK F. MASSOUD, M.B.
Oxford, England January 15, 1990 Dear Editor: Dr. Massoud brings to our attention the underused method of small bowel enteroclysis, which, he rightly notes, has received scant attention in the surgical literature dealing with small bowel obstruction. I suspect that this is not an example of surgical Neanderthal logic but rather that we surgeons have come to grips with the inconsistencies of the clinical signs and the laboratory tests in patients with small bowel obstruction, and have learned the hard way that early operation is the safest course of action in many patients. What I wished to stress in my article was that early postoperative bowel obstruction may represent an entity distinct from the usual adhesive small bowel obstruction occurring remotely
after celiotomy. In our series none of the 101 patients had ischemic bowel, and I would therefore disagree with the emphasis placed on Dr. Massoud's statement that 'Small bowel obstruction in the early postoperative period demands a rapid and accurate diagnostic method.' Patients who become distended and vomit after operation will have either ileus or small bowel obstruction. In my opinion the treatment is similar, mainly nasogastric suction for a sufficient period of time to allow resolution of either process, with reoperation reserved for those patients who do not improve in 10 or 14 days or for the rare patient who manifests evidence of ischemic bowel. JACK PICKLEMAN, M.D. Maywood, Illinois
