Strangulated Loop Research Articles

554 An Unusual Case of a “Hernia Within a Hernia” Resulting in Small Bowel Obstruction and Strangulation

Abstract 59-year-old female presented with symptoms of small bowel obstruction. She had a history of previous open right hemi-colectomy. She also had a previous complex strangulated ventral hernia which had required laparotomy and repair. Following this the patient had recurrence of the ventral hernia. Examination demonstrated a non-tender irreducible recurrent ventral hernia in a patient with a high BMI (> 40). CT reported a midline hernia containing dilated small bowel loops. Additionally, there was a separate narrower hernia arising from the original larger hernia containing a strangulated loop of small bowel. Emergency laparotomy was performed. At operation there was a large hernia containing a smaller secondary hernial defect. Within this secondary defect, there was a loop of jejunum with a constriction band. which was released. There was no vascular compromise to the bowel and no need for resection. The hernial sac was excised and the abdominal wall repaired. Post-operative recovery was uneventful. Discussion The patient had a known, recurrent wide necked ventral hernia. However, this was the first presentation of the new, smaller hernia. This case is unusual in that it demonstrates a multi-locular “hernia within a hernia”. Although multi-locular hernias have been previously described, there is a paucity of literature on these. Conclusions This “hernia within a hernia” is an uncommon surgical finding for which there is limited literature. Clearly without urgent surgical intervention there would be an increase in morbidity and mortality.

Value of the ultrasound research in the diagnostic of acute strangulated small bowel obstruction

Purpose. To identify and evaluate the effectiveness of sonographic signs of intestinal ischemia in patients with strangulated small bowel obstruction.Materials and methods. For the period 2017–2019, 115 patients with SIO were treated at the N.V. Sklifosovsky Federal Research Institute of Emergency Medicine. There were 64 women (55.6%) and 51 men (44.4%). The mean age was 62 ± 15 years. In all patients, the diagnosis was verified intraoperatively. All patients underwent ultrasound examination of the abdominal cavity in B-mode with the assessment of blood flow of the intestinal wall in the mode of CDI. Patients were divided on the basis of intraoperative data into 2 groups. The first group: 63 (54.8%) patients with signs of ischemia of the strangulated loop of the intestine. The second group consisted of 21 (18.1%) patients in whom intestinal necrosis was detected. The comparison group included 31 (26.7%) patients with adhesive small bowel obstruction without intestinal strangulation.Results. The most informative signs of ischemia of the strangulated intestine of the loop are infiltrative changes of its mesentery. In the second and third groups 9 (14.3%) and 12 (57.1%) participants, respectively, showed severity of intestinal ischemia, compared with 1 participant (3.2%) in the first group. The next informative criterion is the thickening of more than 0.4 cm and edema of the intestinal wall. In the second and third groups 30 (47.6%) and 14 (66.6%), in the comparison group 4 (12.9%), akinesis of the strangulated loop and paresis of the entire small intestine also directly correlated with intestinal ischemia. The absence of differentiation of intestinal wall layers occurs in (23.8%), the absence of blood flow in the intestinal wall in the CDI mode (19%), gas inclusions in the intestinal wall (4.3%).Conclusion. The assessment of sonographic symptoms allows to diagnose the presence of ischemic changes in the intestinal wall and perform surgery before the development of necrosis in the early period. In cases of late admission of the patient to the hospital, with the onset of intestinal necrosis and the associated erased clinical picture, ultrasound allows to establish indications for surgery before the development of peritonitis.

Features of surgical treatment of strangulated postoperative abdominal large and giant hernias

Background. Strangulation of postoperative abdominal hernias (PAH) of large and giant size occurs in 6.2-25.1 % of cases. Elderly and senile patients predominate among patients with strangulation. The clinical course of strangulated PAH depends on the size of the hernial protrusion and its location, the nature and duration of strangulation, and the severity of comorbidities. In PAH of large and giant sizes with a multi-chamber bag, strangulation can occur in one of the chambers, which makes it difficult to diagnose. Mortality from PAH strangulation in the elderly and senile patients is 25-30 %.
 Objective. To describe the features of surgical treatment of PAH strangulation.
 Materials and methods. Analysis of literature sources on this issue.
 Results and discussion. Strangulations can be elastic, parietal, fecal and retrograde. Elastic strangulation occurs when there is an acute increase in intra-abdominal pressure, during which the hernia gate is excessively stretched, and when the intra-abdominal pressure is reduced, the organs in the hernia sac are compressed. In retrograde compression, the intestinal loop in the abdominal cavity is strangulated and necrotized. Under conditions of parietal compression, the intestinal wall opposite the mesentery is strangulated. Fecal strangulation occurs as a result of compression of the efferent loop by the overfilled afferent loop. Acute pain that occurs in the area of the postoperative scar during exercise allows to suspect PAH strangulation. For the purpose of differential diagnosis, radiography and ultrasound examination of the abdominal cavity are performed. The main principle of treatment of strangulated PAH is to carry out an urgent surgery. Short-term preoperative preparation for 2 hours is mandatory. Preoperative preparation includes detoxification (saline solutions, Reosorbilact, “Yuria-Pharm”), correction of fluid and electrolyte metabolism and disorders of the cardiovascular and pulmonary systems, prevention of thromboembolic complications. The viability of the strangulated loop is determined by its color, the condition of the mesentery, and the reaction to irritation with warm saline. If the small intestine is not viable, it is resected with removal of the afferent loop at the distance of 30-40 cm from the necrosis zone and the efferent loop at the distance of 20 cm from the necrosis zone, followed by creation of a side-to-side or end-to-end anastomosis. If the large intestine is not viable, it is resected within the above limits with the formation of colostoma. At the stages of herniotomy, hernioplasty and before drainage and suturing antiseptic washing is performed with a help of Dekasan (“Yuria-Pharm”); 800-1200 ml are used depending on the area of the wound surface. When there is a phlegmon of the hernia sac, one should perform laparotomy outside the inflammatory process, resect the necrotized organ, and then remove the hernia sac with its contents. After washing with antiseptics solutions (Dekasan) and drainage of the abdominal cavity, it is covered with the own tissues. Alloplasty is contraindicated in such cases.
 Conclusions. 1. Strangulations of PAH of big and giant sizes require urgent surgery after short preoperative preparation. 2. Surgical treatment of such strangulations should be performed with separation of the anatomical components of the abdominal wall in combination with alloplasty. 3. In case of strangulation of PAH and extremely severe condition of the patient, operation is aimed at the elimination of strangulation without defect closure.

Right paraduodenal hernia, rare cause of gangrene bowel: case report with review of literature

A right paraduodenal hernia includes small bowel trapped within a peritoneal sac between the right and transverse colon, positioned right of midline, with the hernia sac opening to the left at the ligament of treitz, with either the superior mesenteric or ileo-colic artery at the anterior aspect of the sac. Patients with PDH often present with signs and symptoms of obstruction and/or bowel gangrene. We report a case of a 50 year old male presenting with small bowel ischaemia due to right paraduodenal hernia. Patient presented with chief complaints of colicky abdominal pain since two days and abdominal distension, and altered sensorium since one day. Abdominal ultrasonography showed dilated small bowel loops, and CT scan of abdomen was suggestive of clustering of small bowel loops with proximal dilatation. Exploratory laparotomy revealed a right PDH with a strangulated loop of 160 cm of small bowel within. The peritoneum at the ligament of Treitz was lax. The DJ flexure showed gangrenous changes along the anti-mesenteric edge. Resection and anastomosis of small bowel was done along with wedge resection of the DJ flexure, followed by feeding jejunostomy. The sac was opened up wide and plicated over itself to prevent recurrences. Perioperative course was uneventful, and patient discharged on post op day 10. Jejunostomy tube was removed after one week. Patient is being followed up at OPD level with close surveillance to prevent nutritional deficiency due to short gut syndrome. A vigilant mind is of utmost importance to suspect and diagnose paraduodenal hernia to limit morbidity and mortality.

Кишечная стенка при острой ишемии: данные прижизненной оптической когерентной томографии и гистологического анализа

The objective is to study the morphometric signs of small bowel ischemic damage basing on intravital optical coherence tomography data and further histological analysis Materials and methods. The study was carried out on male Wistar rats with the use of two models of acute intestinal ischemia: acute occlusive mesenteric ischemia by а. jejunales ligation (group “I”) and acute arteriovenous ischemia by a small bowel loop and frill strangulation together with а. et v. jejunales (group “II”). The state of intramural vessels in vivo was evaluated with the use of optical coherence angiography (OCA). After the macroscopic signs of non-viability appeared the bowel was resected and its stepwise histological analysis was carried out. Results. Ischemic damage development in group “I” was accompanied by decrease of bowel wall thickness by 34,8-42,4% (p=0,032) due to submucous layer destruction - based on histological analysis data and also by decrease of total length of functioning intramural vessels by 4,6% (p=0,004) - based on OCA data. According to the OCA data in group “II” the length of functioning vessels decreased by 89,6%in the strangulated bowel loop and by 6,1% in adducent and abducent sections (p=0,001). In the strangulated loop histological specimens sharply dilated thrombosed veins were seen in all layers of bowel wall, seromuscular layer oedema and diapedesis hemorrhages of mucous coat also took place as well as bowel wall thickening by 25,2% in comparison with the intact one. Conclusions. Сomplex analysis of in vivo optical coherence tomography results and further histological analysis of ischemic small bowel wall made it possible to determine the morphological manifestations which are specific for arterial and arteriovenous mesenteric blood flow disorder. In cases of mesenteric artery occlusion hypoperfusion and mucous coat ischemia are predominant among pathogenetic mechanisms of bowel wall alteration. In the strangulated bowel the main factor of destruction and necrosis is acute insufficiency of venous outflow.

Strangulating Closed-Loop Obstruction: Sonographic Signs.

To evaluate different sonographic signs of strangulating closed-loop obstruction retrospectively. Over a period of approximately 10 years all documents, US scans and video clips of patients with strangulating intestinal obstruction were reviewed. The following sonographic signs were evaluated: akinetic bowel loops; echo-free luminal content; hyperechoic congestion of the mesentery; free peritoneal fluid; bowel wall thickening; signs of ischemia on color Doppler or contrast-enhanced US. Moreover, we looked for signs of bowel obstruction proximal to the closed loop and for the width of the strangulated segment. The most often documented features of strangulating closed-loop obstruction were an akinetic bowel loop (94 %), a hyperechoic and thickened mesentery (82 %) and free peritoneal fluid (100 %). In 54 % of cases the luminal content was almost anechoic. In 76 % of patients bowel wall thickening and in 50 % signs of ischemia on color Doppler or contrast-enhanced US were documented. In 67 % small bowel dilatation proximal to the strangulated bowel segment was present. The width of the strangulated bowel loops was 2.86 cm on average. The akinetic bowel loops, hyperechoic thickening of the attached mesentery and free peritoneal fluid are typical for strangulating closed-loop obstruction. An anechoic luminal content is only visible in about half of the patients, but this eye-catcher can lead the investigator to the correct diagnosis. In about one third of patients no signs of bowel obstruction proximal to the strangulated loops are present. Dilatation of the strangulated loop may be absent or mild.

Late presentation of congenital diaphragmatic Hernia after a diagnostic laparoscopic surgery (a case report)

The authors report a rare case of 17-year-old lady with late presentation of congenital diaphragmatic hernia. She presented with vague abdominal pain and was thought to have urinary tract infection, ruptured ovarian cyst, and appendicitis by different medical teams in the first few days. She eventually underwent a diagnostic laparoscopy with no significant findings. In the early postoperative recovery period, she suffered from severe cardiorespiratory distress and a large intestinal left diaphragmatic hernia was diagnosed subsequently. At further operation a strangulated loop of large bowel herniating through a left antero-lateral congenital diaphragmatic hernia was discovered, which was reduced and repaired with a prolene mesh through thoracotomy. She made an excellent recovery and was discharged a few days after the operation. The authors postulate a mechanism of positive pressure from laparoscopic surgery causing herniation of large bowel through a pre-existing diaphragmatic defect. This case highlights the diagnostic challenge of this disease due to its diverse clinical presentation, the importance of prompt diagnosis and intervention.

Retroperitoneal hernia following radical cystectomy: case report

Retroperitoneal hernias are rare. When they occur, they most often occur in naturally occurring fossas, such as with paraduodenal hernias. Due to the anatomy of the ureterovesicular system, patients with prior urological operations may be more likely to develop retroperitoneal hernias. We report the case of a 76-year-old male who had undergone a radical cystectomy with ileal loop conduit for bladder cancer, who presented with recurrent episodes of nausea and vomiting. Upon exploratory laparotomy, he was found to have a retroperitoneal hernia. The patient underwent resection of the strangulated loop of small bowel, and recovered without complications. In our patient, ureteral dissection from his prior procedure had created a defect in the peritoneum posterior to the sigmoid mesocolon, which allowed for herniation and subsequent strangulation of a portion of small bowel. Retroperitoneal hernias may represent an under-diagnosed etiology of intestinal obstruction in post-operative urological patients. Knowledge of anatomy is crucial in patients with previous abdominal operations, and prior operative notes should be reviewed, including non general surgical operations such as urological and gynecological procedures. The surgeon must remain vigilant in such cases of small bowel obstruction, as delayed intervention may lead to bowel compromise.

Scintigraphic visualization of bacterial translocation in experimental strangulated intestinal obstruction

The purpose of this study was to obtain scintigraphic images depicting translocation of (99m)Tc-labelled Escherichia coli bacteria through the intestinal barrier and to quantify this process using methods of nuclear medicine. Thirty male Wistar rats (including 20 rats with modelled strangulated intestinal obstruction and 10 healthy rats) were used for bacterial scintigraphy. (99m)Tc-labelled E. coli bacteria ((99m)Tsmall es, Cyrillic-E. coli) with an activity of 7.4-11.1 MBq were administered into a section of the small intestine. Scintigraphic visualization of bacterial translocation into organs and tissues of laboratory animals was recorded in dynamic (240 min) and static (15 min) modes. The number of labelled bacteria, which migrated through the intestinal barrier, was quantified by calculating the translocation index (TI). Control indicated no translocation of (99m)Tsmall es, Cyrillic-E. coli administered into the intestine through the parietes of the small intestine's distal part in healthy animals. Animals with strangulated obstruction demonstrated different migration strength and routes of labelled bacteria from strangulated and superior to strangulation sections of the small intestine. (99m)Tsmall es, Cyrillic-E. coli migrated from the strangulated loop into the peritoneal cavity later causing systemic bacteraemia through peritoneal resorption. The section of the small intestine, which was superior to the strangulation, demonstrated migration of labelled bacteria first into the portal and then into the systemic circulation. The strangulated section of the small intestine was the main source of bacteria dissemination since the number of labelled bacteria, which migrated from this section significantly, exceeded that of the area superior to the strangulation section of the small intestine (p = 0.0003). Bacterial scintigraphy demonstrated the possibility of visualizing migration routes of labelled bacteria and quantifying their translocation through the intestinal barrier. This approach to study bacterial translocation may be successfully applied not only in strangulated intestinal obstruction, but also in other modelled pathological conditions.

Unusual case of small bowel strangulation due to Meckel’s diverticulum

Meckel's diverticulum of the small bowel is the commonest congenital abnormality of the gastrointestinal system. It is a recognised cause of small bowel obstruction; however, the mechanism behind such obstruction is variable. We present case report about an adult male who presented with small bowel obstruction, requiring a laparotomy. He was found to have a strangulated loop of small bowel with an encircling Meckel's diverticulum around the base of the mesentry. This was resected with a small bowel anastomosis.He made a good recovery and was discharged home. Our case illustrates a rarely seen complication of obstruction and strangulation caused by Meckel's diverticulum. Yet this is not frequent enough to justify routine excision and the debate as to whether to remove an incidental Meckel's shall continue.

Incarceration of Meckel’s diverticulum through a ventral incisional defect: a rare presentation of Littre’s hernia

Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract and is the result of the incomplete obliteration of the omphalomesenteric duct. Herniation of Meckel's diverticulum is called Littre's hernia and is a rare occurrence. Herein is described an extremely rare case of incarcerated and strangulated Meckel's diverticulum through an incisional ventral defect in a 59-year-old female patient, who presented with manifestations of acute surgical abdomen. At emergency laparotomy, a strangulated small-bowel loop containing a Meckel's diverticulum was found, which had migrated through the subcutaneous tissues to the right iliac fossa, where a painful mass was palpated on admission. Segmental resection of the ischemic ileum was performed and the abdomen was closed without the use of a prosthetic mesh. Histopathological findings were suggestive of a true diverticulum containing heterotopic gastric mucosa.

Diaphragmatic hernia with strangulated loop of bowel presenting after colonoscopy: case report

BackgroundThe incidence of diaphragmatic hernias caused or exacerbated by diagnostic colonoscopy is not well elucidated at this time, and is believed to be very rare.Case PresentationWe present the case of a 57 year old man with remote history of traumatic injury who first presented with vague left shoulder pain for two weeks, mild anemia, and tested positive for fecal occult blood. Four days post colonoscopy the patient was found to have a strangulated loop of bowel herniated through the diaphragm into the left hemithorax.ConclusionsIn patients with previous history of serious traumatic injury and particularly those with previous splenectomy, a thorough history and physical examination before routine colonoscopy is important. A high level of suspicion for post-operative complications should also be maintained when assessing such patients.

Internal Herniation Through the Mesenteric Opening After Laparoscopy-assisted Right Colectomy: Report of a Case

We discuss a rare complication in a patient who underwent laparoscopic colectomy. A 69-year-old woman underwent laparoscopy-assisted right colectomy for cancer of the ascending colon. Two months after the operation, bowel obstruction developed. Decompression with a long intestinal tube failed to resolve the obstruction. Thus, surgery was performed. Abdominal exploration revealed a strangulated ileal loop caused by herniation through the mesenteric opening at the anastomotic site. The mesenterium had not been sutured during the previous operation. The anastomotic segment had twisted semicircularly and adhered to the retroperitoneum, so the mesenteric opening had narrowed.

Laparoscopic management of an internal double omental hernia: A rare cause of intestinal obstruction

Internal hernia is a very rare cause of intestinal obstruction (0.2-0.9% of cases), associated with 45% mortality. A review of the literature revealed just eight reported cases of double omental hernia since 1950 of which our patient is the first case successfully treated laparoscopically. We report on a 29-year-old man who presented with signs and symptoms of intestinal obstruction. The patient underwent emergent exploratory laparoscopy. This revealed herniation of a 20-cm jejunal loop through the gastrocolic ligament and reemergence through a defect in the gastrohepatic ligament. The strangulated loop was reduced with slight traction, and the defect was repaired. The patient was discharged from hospital in just 5 days' time, and after 6 months of follow-up, the general condition of the patient was normal. Laparoscopy is a good technique with minimal complications compared with laparotomy. As many cases are missed due to nonspecific signs and symptoms, an urgent laparoscopy or laparotomy is highly recommended in such a situation.

Fluid resuscitation improves intestinal blood flow and reduces the mucosal damage associated with strangulation obstruction in pigs

Background Strangulation obstruction of the small bowel is associated with local and systemic circulatory changes, local loss of fluid, and damage of the strangulated bowel segment. We wanted to examine to which extent these changes can be prevented by intravenous fluid administration. Materials and methods In anesthetized pigs, strangulation obstruction was induced by increasing the pressure in a baby pressure gasket placed around a loop of ileum until venous pressure in the loop reached 50 mm Hg. During the strangulation period (180 min), a group of eight animals (Fluid min group) received 10 ml · kg -1 · hour -1 Ringer acetate solution intravenously, whereas another eight animals (Fluid max group) received 55 ml · kg -1 · hour -1 Ringer acetate solution intravenously. Blood flow to the strangulated bowel was measured by transit time flowmetry and colored microspheres. After completed experiments, whole wall samples of the strangulated loop were selected for microscopy. Results In the Fluid min group, the heart rate increased, the arterial pressure decreased markedly, and the urine output decreased toward zero. In the Fluid max group, the heart rate and arterial pressure remained fairly constant and the urine output increased. Blood flow to the strangulated bowel decreased in both groups, but significantly more in the Fluid min group. The intestinal blood flow was highly dependent on the arterial blood pressure. The strangulated mucosa showed markedly more damage in the Fluid min group than the Fluid max group. The degree of mucosal damage correlated linearly with the mucosal blood flow. Conclusion The administration of large amounts of fluid to animals with strangulation obstruction normalized the arterial pressure and improved the intestinal blood flow thus minimizing damage to the intestinal mucosa.

Endotoxin and Cytokine Release in Strangulation Obstruction and in Partial Occlusion of the Mesenteric Artery in Pigs

Background: The study was performed to determine if endotoxin or the cytokines interleukin-1 (IL-1), interleukin-6 (IL-6) and tumor necrosis factor (TNF) are liberated from strangulated or partially ischemic small bowel. Methods: Strangulation obstruction was induced by elevating pressure in a gasket placed around a loop of ileum until venous pressure reached 50 mm Hg. Low arterial flow in a loop of ileum was produced by arterial clamping reducing blood flow by 70%. A proximal bowel loop was used for control. Arterial blood flow was measured by transit time flowmetry. Blood samples were collected before and after 30, 90 and 180 min of strangulation or clamping. Plasma levels of endotoxin and cytokines (TNF, IL-1 and IL-6) were measured by limulus amebocyte lysate test and bioassays, respectively. Results: Strangulation obstruction caused more extensive mucosal damage than arterial clamping. Strangulation was followed by markedly increased venous concentration and release of IL-6 in the strangulated loop. Partial arterial occlusion did not cause increased release of IL-6. Strangulation or partial clamping did not influence the concentration of endotoxin, IL-1 or TNF in intestinal venous blood. Conclusions: Strangulation obstruction causes increased release of IL-6 to intestinal venous blood. IL-6 levels did not increase after 70% reduction of arterial blood flow. The early IL-6 increase was not detected in systemic blood. Strangulation did not cause early changes in plasma levels of endotoxin, TNF or IL-1.

Release of Endothelin-1 in Strangulation Obstruction of the Small Bowel in Pigs

Evidence has been provided that increased portal vein pressure results in increased release of endothelin-1 (ET-1). Strangulation obstruction is associated with increased venous pressure, and we wanted to determine if it is associated with increased local release of ET-1 and elevated concentration of ET-1 in systemic blood. Strangulation obstruction was induced by elevating pressure in a gasket placed around a loop of ileum until venous pressure reached 50 mm Hg. Ischemia in a bowel loop was induced by arterial clamping, reducing blood flow by 70%. Blood samples were collected before and after 30, 90, and 180 min of strangulation or ischemia. ET-1 was determined by radioimmunoassay following acidification and extraction on C18columns. In strangulated loop the blood flow decreased by 70%. ET-1 concentration remained around 5 pg/ml in arterial blood, increased fourfold in strangulated venous blood, and remained unchanged in venous blood from control bowel. The release of ET-1 from the strangulated loop to blood increased twofold. Ischemia resulted in reduced release of ET-1. It is concluded that strangulation obstruction causes increased release of ET-1 to venous blood in the strangulated loop, but not increased ET-1 concentration in systemic blood. The increased ET-1 release was probably due to increased venous pressure, not to low blood flow.

Studies on a factor in intestinal strangulation fluid from germfree and conventional rats inhibiting serum bactericidal activity on Escherichia coli.

Exudate collected from a strangulated loop of intestine in conventional and germfree rats has the property of inhibiting the opsonic and bactericidal activity of normal rat serum on Escherichia coli. Using release of radioactivity from 32P‐labelled E. coli as an indicator of bactericidal activity, the inhibitory property of strangulation fluid on serum bactericidal activity has been subjected to further studies. The inhibitory factor (FIB) resisted heat treatment for 30 min up to 100°C, and did not disappear following dialysis. Chromatography of strangulation fluid from germfree rats on Sephadex G‐100 indicated that FIB had a molecular weight higher than 100 000. Homogenates from intestinal mucosal cells contained FIB, while intestinal contents contained FIB of considerably stronger activity. The results indicated that high molecular substances of intestinal origin were responible for the FIB activity of rat strangulation fluid.

Studies on a toxicity-enhancing factor in fluid from experimentally strangulated intestinal loops in the rat

Summary The nature and origin of an ultrafiltrable toxicity-enhancing factor present in toxic intestinal strangulation fluid has been investigated. The factor increases the toxicity of suspensions of E. coli as tested by intraperitoneal injections in mice. The factor is probably of protein nature, as it can be removed from a fluid by sedimentation with trichloroacetic acid (TCA). It is not dialyzable but is destroyed by heating to 100° C. for 15 minutes. The factor cannot be a bacterial product, since it is present also in the sterile strangulation fluid from germfree animals, and since it does not appear in nontoxic strangulation fluid in which E. coli is cultured for 24 hours. The toxicity of saline suspensions of E. coli is not enhanced by the addition of plasma or by the addition of erythrocytes (or of hemolysate) to a hemoglobin concentration comparable to that found in most of the toxic strangulation fluids. It is concluded that the toxicity-enhancing factor (or factors) present in toxic strangulation fluid probably originates from disintegrating tissue in the strangulated loop of intestine.

A technique for the isolation and visualization of intestinal segments for study of closed loop strangulation

Summary The high mortality rate in patients with a short loop of obstructed and strangulated intestine is thought to be due to the action of poorly understood toxic substances which exude from the serosal surfaces of the dying intestine. Additional detailed pathologic-physiologic studies concerning this problem are necessary if progress is to be made in lowering the death rate. This report describes a new method that has been developed and used in experimental animals for isolating a strangulated closed loop of intestine in a plastic bag. This technique permits the continuous visualization and palpation of the exteriorized, isolated loop of intestine without fear of outside contamination, provides easy and accurate representative and serial sampling of the strangulation fluid, and adequately seals the strangulated loop from the peritoneal cavity. Dilution of the toxic fluid by the peritoneal secretions is prevented and complete control of the time and circumstance of liberation of the toxins from the isolated preparation is possible. The technique is being used effectively in a series of experiments to study the nature of the “strangulation” fluids, its physiologic and pathologic effects, and its bacterial flora.