Indications for Enterostomy

Abstract

Enterostomy as a therapeutic measure in intestinal obstructive lesions and in the distention of peritonitis has been quite generally accepted by the majority of surgeons. There has not, however, been a universal agreement concerning its indications or complete accord in the interpretation of its results. The general impression is gained that the operation is frequently done as a last resort when little or no result may be logically expected. It must also be recognized that many patients, apparently treated successfully by enterostomy, might recover without drainage of the bowel if properly treated by modern supportive methods.The logical use of enterostomy as a drainage operation involves some understanding of the pathologic changes and perverted function present in diseases associated with distention of the bowel. It has been quite conclusively shown that a bowel which retains its normal muscle tone and peristaltic activity does not absorb substances it should not absorb. If, however, blood supply to the bowel wall is damaged, the toxic content may reach the blood stream and produce symptoms.1 After the bowel is paralyzed from overdistention, drainage of more than a short segment cannot be antici¬ pated. If peristalsis is still active, drainage of the con¬ tent of the small bowel may be expected, provided the enterostomy tube is functioning. Enterostomy is indi¬ cated to remove from the bowel its content of gas and liquid, not primarily to prevent absorption of toxic material but to prevent overdistention and paralysis.Statistical studies have generally not shown that enterostomy decreases the mortality of intestinal obstruction and peritonitis.2 Such statistics are of doubtful value, since they do not sufficiently consider that many enterostomies have been done as last resort operations when hope of adequate bowel drainage could not reasonably be entertained. It would seem that rather too much has been expected of enterostomy and not sufficient attention given to its indications and limi¬ tations.The indications for intestinal drainage have grown less in recent years, since the chemical changes and disturbed physiology of the body, incident to obstructive lesions of the stomach and small intestine, are better understood. By maintaining the chemical and water balance, the tone of the intestine is in some degree improved. The use of morphine in adequate doses also increases the tone and rhythmic activity of the intestine. By these methods, overdistention is better controlled than formerly, thereby decreasing the indications for enterostomy.High jejunostomy has received more than its share of commendation as a means of relieving distention of the upper part of the small bowel. It is very doubtful whether as much can be accomplished with a high jejunostomy as with an indwelling duodenal or stomach