The etiology and prevention of feeding intolerance paralytic ileus – revisiting an old concept

Gastro-intestinal (G-I) motility is impaired ("paralytic ileus") after abdominal surgery. Premature feeding attempts delay recovery by inducing "feeding intolerance," especially abdominal distention that compromises respiration. Controlled studies (e.g., from Sloan-Kettering Memorial Hospital) have lead to recommendations that patients not be fed soon after major abdominal surgery to avoid this complication

Studies on Canine Pancreatic Secretion

THE RESPONSE TO HISTAMINE. The pancreatic response to histamine and to control injections of secretin have been studied in 8 dogs. To exclude any fallacy due to activation of the endogenous secretin mechanism by gastric acid, 3 of the dogs had total gastrectomies carried out, and 5 dogs had gastrostomies through which the stomach could be kept empty. Histamine is a potent stimulator of pancreatic secretion in the absence of the endogenous secretin mechanism. The volume, bicarbonate concentration, and total bicarbonate output in response to histamine are on the average about 70% of the response to secretin in the doses used, and on occasion may even be greater than it. The concentrations of chloride and nitrogen in response to histamine are about 2-J times the corresponding concentrations in response to secretin, but the total outputs are approximately equal. The profiles of the responses to histamine and secretin are very similar as regards latent period, duration of response, and the timing of the peak of the response. 'Histamine is a true pancreatic secretagogue. Its action cannot be explained by activation of the endogenous secretin mechanism by gastric HCl, by direct secretin release, or by lowering of the threshold to secretin. It is not due to the concomitant secretion of bile, to vasodilatation, to lowering of the blood pressure, or to an increase in blood, flow through the pancreas. THE EFFECT OF ATROPINE. The effect of atropine on the response to histamine has been studied on 3 dogs with total gastrectomies and 4 dogs with gastrostomies. Atropine inhibits the volume and bicarbonate output in response to histamine and tnis inhibition may be complete when one hour is allowed to elapse between the injection of atropine and the subsequent injection of histamine. When an interval of only half an hour is allowed, inhibition does not invariably occur. The effect of atropine on the pancreatic response to secretin has been studied in one dog. Atropine produces a small but important reduction in the volume response to secretin. Atropine produces a significant increase in the bicarbonate concentration, but little change in the total bicarsbonate output in response to secretin. Both the concentration and total output of nitrogen are significantly decreased by atropine. The concentration and total output of chloride were not significantly affected by atropine. Vagotomy reduced the inhibitory effect of atropine on the concentration and total output of nitrogen to a significant degree, and reduced the increase in the bicarbonate concentration. Atropine appears to act directly on the secretory cell as well as blocking the secretory fibres of the vagus. (Abstract shortened by ProQuest.)

Postvagotomy dysphagia

No Abstract

Volume 29, index

The mission of CJS is to contribute to the effective continuing medical education of Canadian surgical specialists, using innovative techniques when feasible, and to provide surgeons with an effective vehicle for the dissemination of observations in the areas of clinical and basic science research. Visit the journal website at http://canjsurg.ca/ for more.https://ir.lib.uwo.ca/cjs/1214/thumbnail.jp

The use and abuse of gastrointestinal suction in the treatment of intestinal obstruction

An attempt has been made to investigate the rational behind the use of suction in cases Of intestinal obstruction. It would appear that the effect of distension with, or without a compromisation of the blood supply, is the initial condition. The effect of this distension leads to devitalisation and circulatory embarrassment, resulting in conditions which are conducive for the proliferation of bacteria and the production of the clinical picture of toxaemia. The effect on the colon is additionally complicated by the presence of the eaecum which has a distinct tendency t® perforate under pressure and lead to peritonitis.The importance of differentiating strangulated from non-strangulated obstruction is stressed and the negative finding of no clear points on which t© base this distinction is noted. On© view to be taken is that of Barker (1963) who describes operating on all cases of obstruction past a certain time limit; whereas Waldron and Hampton (I961) report an overall mortality of 1436, Baker in 126 cases of early obstruction had mortality and in 49 late cases 10.6% mortality - an average of 5.2%. He argues that complete surgical decompression has the advantages of 1) the site of obstruction is visualised and freed 2) respiratory embarrassment is relieved 3) the wound is more easily closed 4) there is less trauma to the viscera and 5) the opportunity of recurrent obstruction is reduced.With the safety factor increased by modern surgical techniques, anaesthetics an powerful antibiotics some indications for suction, or the extensive use of suction had been eliminated.The greatest difference of opinion would appear to revolve around the choice of the proper moment for operative correction. All agree that strangulated obstruction and obstruction of the colon are indications for surgery, but the role of suction in simple obstruction is in doubt. Some, like Barker, consider the diagnosis of obstruction whatever the type, to be an indication for surgery. Others, advocate operative techniques after a trial by suction although ©Iran Wangansteen admits that surgery is the mainstay of treatment in this conditionDeaths occurring in any series are important to analyse. Miller (1929) reported a mortality rate of 65% at the Charity Hospital in Hew Orleans. Tendler and Cartwright reported mortality rates of 51% from 1923/1932 , then 26% from 1933/46 and 8% from 1947/1953. Turner reported 100 consecutive cases from each of three decades and found a mortality of 27% in 1929, 21% in 1939 and 4% in 1949. Missed strangulated obstruction always led to death for although suction will remove the toxic products from a strangulated segment of gut, it will not do so in a closed loop situation. Even in the simple strangulated case, suction only acts to delay the inevitable operation. The question of time is also of importance as regards the production of complications from the mechanical effects of the suction tub®. It should be noted however, that there is one report of a patient with an indwelling nasogastric tube for 47 days without complication. This is exceptional and many complications arise in the first 48 hours of use.Post-operatively the picture is even more confused but with observations of the stomach after vagotomy the position is being resolved. Some consider that suction is absolutely necessary after operation involving vagotomy, believing that the stomach is flaccid and distends to a considerable size. It is true that a reduction in the contractile force dees occur, but intragastric pressure and aural tone is increased. Numerous reports have been read about the advantages of tubeless post-operative management and the remarkable degree of success it enjoys.As a development of heart pacing methods, Bilgutay et al (1962) describes a method ©f intestinal pacing to restore motility in ileus. He reports that these patients so treated have a lower incidence of complications and a shorter hospitalisation. The gut regaining its motility in 6/20 hours as compared with patients treated by suction in which the gut returns to normal in some 55 hours or more. This is extremely interesting, especially as Smith's (1965) work makes a plea for the treatment of paralytic ileus to be directed at the inhibition produced by trauma, rather than direct muscle stimulation