J.Jpn. Surg. Soc.. 55(7): 676-697, 1954
宿題報告
Ileus (From the standpoint of therapy)
|
Department of Surgery, Nippon Medical School Kiyoshi SAITO |
The total mortality was 23% and the operative mortality was 24%.
In the case of operative mechanical obstructions the mortality was 23%, previous to the war (1935 to 1940) it was 30% during the war (1941 to 1946) it was 32% and in the postwar period (1947 to 1953) it was 20%. The data showed that there was no remarkable influence of the war upon the kind of ileus.
Adhesive and postoperative ileus showed a tendency to increase every year but, on the contrary, their mortality appeared to be declining and the particularly in the later case, the frequency was 32% of all ileus cases presented in the last 4 years and the most recent of 3 years the mortality was below 10%.
What pathological changes occur after removal of ileus? This subject had not been thoroughly studied previously. Therefore, we sutdied it extensively and systematically from the standpoint of functional and organic changes in the various organs, such as the intestine, lung, liver, kidney, suprarenal body and central nervous system.
There were continued to have various changes occurred at least several days after its removal, that is the ileus continued to exist and often showed the condition advancing may be indefinite ileus symptoms. However, it required about 7 to 14 days to return to the normal.
We found that the histamine quantity in the lung and liver increased and this was closely associated with, not only the retention of intestinal contents, but also in the lower part of intestine rather than obstructed region itself.
Immediately after removal of ileus there will be a stagnation of body fluid in the intestinal wall. This condition is resulted the decreased blood flow through the liver, and at the same time there will be an increased anoxia. Occasionally a sudden decrease in the circulation of the entire body will occur. These facts show the importance of body fluid administration and oxygen supply to the liver before, during and after operation.
We also noticed that after 10 to 14 days an anemia occurred even after ileus had been completely relieved. This type of anemia is very similar to that which is produced when injections of ileus intestine, and especially duodenal wall extract are given. One of the chief factors in this type of anemia is an acute congestion of the liver and spleen. This anemia could easily be prevented by protection of the liver and supplying adequate nutrition.
We also found certain nerve cell changes as a result of a severe contraction of central nervous system blood vessels occurring during ileus. However, these changes can be made to subsided remarkably by applying a general anaesthesia. Yet. it will take at least 10 to 15 days to bring about a complete recovery after all the ileus symptoms are relieved.
It is recognized by many people that the method of decompression by suction is a most valuable and effective therapy, but this method of therapy is not utilized widely in Japan. However, the biggest weakness of this method is that the ileus tube is difficult to pass through the pylorus. But I have found that continuously applying suction of the gastric contents and especially swallowed gas would bring excellent and effective results regardless of the difficulty in passing the ileus tube.
In our clinic as soon as the diagnosis is made that the patient is suffering from ileus whether the case is simple or strangulated, we routinely apply the suction method , and this has proved to be a most adequate and rational emergency therapy. Furthermore, I have specailly designed an ileus tube for Japanese patients which has worked favorably. This has been applied in 31 of 51 cases passe the pylorus but lost one case which was very serious. Where gastric suction alone was used in 41 cases, 3 died and these were very serious and inoperative. Finally, whether suction should be continue to use or not, we must give a careful consideration and the detail ed studies of the patient's condition.
I feel that oxygen therapy is a necessary treatment for the anoxia of ileus and even after ilues was relieved. In this study I have emphasized on the arterializing of the portal vein and oxygen inhalation alone is not sufficient enough for the arterialization, therefore, I believe administration of fluid is necessary at the same time.
I have recommended the oxygenated blood transfusion last several years, because the oxygenated blood is not only supply the oxygen but it has an action which stronger stimulation to the tissues and the organs in anoxia condition. This intraportal injection of oxygenated blood has a remarkable effect on the liver function and it help for during he ileus operation.
Introducing oxygen to the intra-intestinal lumen is also my own interesting and original investigation. The technique is to introduce through a small puncture in the intestine was made during the operation and durimg closing the wound to inserta fine tube into the previously made puncture. In this way the oxygen can be administered even postoperatively.
I believe that chemotherapy is indispensable and most rational for treating the ileus case either by local or general administration of various antibiotics. With chemotherapy experimental animals show improvement of clinical symptoms and often survive due to the reduction of bacterial flora in the intestine. I have no doubt that intestinal bacteria play an important part in the symptomatology of ileus.
The fluid and electrolytes administration are also indispensable but I reached the final conclusion that the administration of Ringer's solution and 5% glucose solution in the amount of 25 cc. per kilogram of body weight is the most suitable treatment. Both the adreno-cortical hormones, LAC was the drug of choice but Cortisone and A.C.T.H were not effective.
(author's abstract)
To read the PDF file you will need Adobe Reader installed on your computer.