Decompression is essential in the management of small bowel obstruction

Abstract

I n properly selected patients with small bowel obstruction due to adhesions, long tube decompression has been successful in relieving the obstruction in 80%. In 1925 it was standard practice at the University of Minnesota in patients with small bowel obstruction to perform laparotomy, introduce a long tube into the proximal small bowel, and decompress the bowel down to the point of obstruction.‘-’ Decompression alone relieved the obstruction in 80%. In 1938 Abbott and Johnston4*5 used the Miller-Abbott tube to decompress the distended bowel nonoperatively, and they too had 80% success. In 1985 Wolfson et al6 reported on 127 patients with adhesive small bowel obstruction with 64% success with long tube decompression in relieving the obstruction. In 1995 Fleshner et al’ in a prospective randomized study comparing long and short tubes found 75% success with long tube decompression and 51% with the short tube. They found the success of nonoperative therapy was influenced by long tube location as only 6 of 24 patients (25%) in whom the tube passed into the small bowel required operation. In the author’s prospective series 1983 to 1988 using the immediate endoscopic placement of the Miller-Abbott (Davol Corp., Cranston, Rhode Island), the Dennis (Sherwood Medical, St. Louis, Missouri), or the Anderson tube (Anderson Products, Oyster Bay, New York) into the small bowel, 12 of 17, or 70%, were cured. From 1989 to 1996 using our own tube (Cook Inc., Bloomington, Indiana) designed for endoscopic or fluoroscopic placement into the small bowel, successful decompression has been achieved in 15 of 17, or 88%. When an adhesion produces a 50% narrowing of the intestine, there is no delay in the slow passage of normal bowel contents. When, however, with an excess of air and fluid that segment just proximal to the point of obstruction becomes overloaded with the weight of a liter of fluid, the bowel is drawn down, kinking the lumen, so the 50% becomes a 95% obstruction. That loop of bowel, like a distended bladder, is helpless until it is decompressed. With decompression the bowel returns to normal size, motility is restored, and the 95% obstruction returns to a 50% obstruction with normal flow. If, however, the long tube decompresses the bowel but its progress is arrested at a point of tight or unyielding constriction, then barium or diatrizoate can be injected down the tube to identify the site and the degree of the obstruction prior to operation.