On the Viability of the Intestine in Intestinal Obstruction

Abstract

ONE of the greatest difficulties encountered in the surgery of intestinal obstruction is the management of gut of doubtful viability. Should it be returned? Should, it be resected? On occasions such gut has been returned to the peritoneal cavity in the belief that the circulation would take care of itself. If not, the involved segment could be subsequently removed should alarming symptoms develop. If it is left in situ the circulation may return and result in recovery or the segment may become gangrenous with or without rupture and result fatally. Often gut which is apparently not viable has been accidentally or deliberately returned to the abdomen and in some instances the patient recovered.CASE REPORTS CASE I.-SN 9, Male, age sixty-four. Type of obstruction-strangulated right femoral hernia. Pathology found at operation and operative treatment-hernial sac contained several c.c. of serosanguineous fluid and 20 cm. of black gut with strangulated omentum. Omentum resected. Lustre and color returned to segment after application of hot pads sufficiently to warrant its replacement (Plate ib). Post-operative coursepatient died four days after operation with signs of paralytic ileus. Wound inspectiongangrenous segment of gut found. Remarks-viability of the gut questionable, resection considered. Circulation apparently returned but subsequently became impaired resulting in gangrene of the segment. CASE II.-SN 126, male, age twenty-six. Type of obstruction-intussusception. Pathology found at operation and operative treatment-free serosangu:neous fluid in the peritoneal cavity, 6o cm. of ileum telescoped into cwcum and ascending colon. Reduction of intussusception was not difficult. About 10-I5 cm. of reduced ileum (intussuscipiens) appeared dark in color. After applying hot pads the color and luster returned sufficiently to warrant its replacement (Plate Ic). Post-operative course-paralytic ileus and pneumonia developed. The patient succumbed on the eleventh day. Autopsy-pneumonii and a gangrenous segment of ileum 10-I5 cm. in length. Remarks-viability of the gut questionable, resection considered. The pneumonia was the obvious cause of death. The question arises however, if the patient would have survived as the circulation after having apparently returned became permanently impaired.

The effect of distention on blood flow through the intestine.

“…There is universal agreement that pressure within the lumen of obstructed small intestine rises above normal (1, 2, 3, 4), and it has been suggested repeatedly that the increased pressure so impairs the circulation of blood through the intestine as to cause ischemic damage (5,6,7,8,9).…”