Management of acute colonic obstruction

Abstract

T HE purpose of this article is to discuss the various methods of surgica1 treatment in coIonic obstruction. This article is not submitted as an attempt to produce any controversy as to the type of treatment which shouId be employed. It is not an attempt to be dogmatic as to the type of reIief in colonic obstruction. It is, rather, a study of our results and our faiIures. It is an attempt to point out which, in my hands, is the most successful method to use as a primary procedure to relieve the obstruction and a definitive procedure which wiI1 offer the best chance for permanent cure in the various types of coIonic obstruction. Too often either the physioIogy of the coIon is not understood or it has been forgotten. FrequentIy the attempt is made to dea1 with the Ieft side of the coIon in the same manner as with the right side. To put it another way, one may perform a one-stage operation on the right side of the coIon even in the face of improper bowe1 preparation, whereas on the Ieft side of the coIon one is inviting serious consequences and even disaster when a one-stage operation is attempted without preIiminary preparation. History. One hundred fifty years ago the descending colon was drained extraperitoneally through an incision in the Ieft Ioin, and the cecum through a simiIar opening in the right loin. The openings, however, were uncontroIIabIe and it was aImost impossibIe to take adequate care of the feca1 discharge. NeIaton’ is credited with the operation of enterostomy in acute intestinal obstruction. This operation was rareIy performed before that time. IntestinaI resections simpIy were not done. The artificial anus became so fixed in the minds of the profession and the laity that in spite of very marked success in Iater years, the repugnance of the artificial anus stiI1 remains in the minds of the Iaity. Bright,z distinguished physician of Guys HospitaI, described some very interesting cases of intestinal obstruction. Wilks,3 Guys Hospital, London, described bands of adhesions from the cecum, incIuding the appendix, crossing over the iIeum. He also described the smaI1 pouches sometimes seen in the colon, which often exist in great numbers and are not larger than a grape, filled with fecal matter. Blake4 gave an account of a man whose boweIs were obstructed for eighteen weeks. BIake kept this patient alive with ISO needle punctures of the coIon through the abdomina1 waI1, relieving the distended bowel. Hartwell and Hoguets found that the lives of dogs with high intestina1 obstruction couId be proIonged with subcutaneous administration of saIine solution. This experiment was aIso substantiated by Foster and HausIer.6 Saline soIution failed to afford the same protection to animals with ileal obstructions. This failure was due to the mechanica effects of distention upon the bowe1 wall. Anatomy and Physiology. The rationale of a physioIogic approach to coIonic surgery has Iong been understood by nearIy a11 surgeons. The contents of the cecum and ascending colon are very fluid, becoming Iess so as the hepatic Aexure and the middle of the transverse colon are approached. The bacteria1 count is very much Iess on the right side of the colon. The Ieft side of the transverse coIon contains much less ffuid than the preceding part of the colon. The solid content of the coIon increases in the descending coIon. Along with the increase in the soIid content there is a marked increase in the coIon bacteria1 count of the Ieft side. The type of growth in the right side of the coIon is a flat Iesion which frequentIy occurs on the lateral side of the cecum or ascending colon. Obstruction seldom occurs in this particuIar position. It is usuaIIy in the region of the hepatic flexure that obstruction does occur.