Intestinal Obstruction Caused by AdhesionsA Review of 388 Cases*

JoHN F. PERRY, JR., M.D., GRAFTON A. SMITH, M.D., AND EARL G. YONEHIRO, M.D.,Minneapolis, Minn.

ADHESIONS HAVE PROBABLY replaced ex-ternal hernia as the most common cause ofintestinal obstruction. Souttar (1925)13 andVick (1932),15 for example, when reviewingthe combined statistics from British Hospi-tals, found external hernia responsible for46 and 47.9 per cent of obstructions, respec-tively, while adhesions accounted for only11.1 and 7.3 per cent. In this country, in 1932,McIver"1 found external hernia the most fre-quent cause of bowel obstructions (44 percent), and adhesions the basis of occlusionless frequently (30 per cent). However, re-cent reports list adhesions as the prime causeof intestinal obstruction, and our experiencehad confirmed this. Probably responsible forthis change is the ever increasing number ofabdominal operations that are being done,and possibly the fact that more externalhernias are repaired while still in a relativelyearly stage.

In a survey of intestinal obstruction at theUniversity of Minnesota Hospitals for theperiod between January 1, 1942, and Sep-tember 1, 1953, 388 of the total of 1252 cases,or 31 per cent of obstructions, were foundto be caused by postoperative adhesions, orby adhesions of an inflammatory or congeni-tal nature. External hernia was responsiblefor only 10.2 per cent.Our purpose in this paper is to present a

review of our experience in management ofthese obstructions caused by adhesions, andto discuss this problem briefly. All cases ofadhesive obstruction are included, whetherintestinal obstruction was the illness thatnecessitated hospital admission or whether

it developed secondarily in the course ofanother disease.The diagnosis was confirmed by operation

or autopsy in 274 cases (70.6 per cent). In114 cases (29.4 per cent), treated by con-servative decompression, it was the clinicalimpression at the time plus a current reviewof available records and roentgenogramsthat established the diagnosis.

Etiology. Obstructions were caused byadhesions of three types: postoperative ad-hesions, inflammatory adhesions (withoutantecedent surgery), and congenital bands.Most frequent were occlusions due to post-operative adhesions; 79.4 per cent of thecases were of this type. Operations on thelarge bowel, appendectomies, and opera-tions for intestinal obstruction were the mostcommon preceding surgical procedures. In-flammatory adhesions were responsible for17.8 per cent of obstructions. Here, appendi-citis and diverticulitis were the most oftenencountered inflammatory diseases, as theyinitiated the adhesive process in 42 and 14.5per cent of these cases, respectively. Lesscommon causes, in the order of importance,were pelvic inflammatory disease, regionalenteritis, cholecystitis, and ulcerative colitis.Congenital bands accounted for only 2.8 percent of all adhesive obstructions.

Intraperitoneal abscesses were associatedlesions in these obstructions, and deservemention. Such abscesses accompanied orinitiated the adhesive process that causedobstruction in 17.8 per cent of all cases. Aswould be expected, intraperitoneal infectionof this character was present most commonlyin those patients with adhesive obstructionscaused by inflammatory diseases. Forty

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INTESTINAL OBSTRUCTION CAUSED BY ADHESIONS

seven and eight tenths per cent of these hadabscesses. Thirteen per cent of postoperativeobstructions were likewise associated withabscesses in the peritoneal cavity. Thus, in-traperitoneal infection was a significant con-sideration in the formation of adhesions thatled to obstruction.

Strangulation obstruction was a secondconcern, occurring in 11.8 per cent of allcases. It was common among those obstruc-tions caused by congenital bands, 45.9 percent were strangulation obstructions. It oc-curred less often in postoperative obstruc-tions (12 per cent), and strangulation was

rare when obstruction was caused by inflam-matory adhesions (2.9 per cent).

Location. The small bowel is considerablymore susceptible to obstruction by adhesionsthan is the colon, as is evident from the dis-tribution of cases. The majority, 88.4 per

cent, were small bowel obstructions. Only8.0 per cent were colic occlusions, and 3.6per cent of cases were of the mixed variety,with obstruction simultaneously of bothcolon and small bowel.The type of adhesions causing obstruction

also influenced the location of the obstruc-tion. Thus, large bowel and mixed obstruc-tions were common in the groups due to in-flammatory adhesions (30.5 per cent) or

congenital bands (22.3 per cent) but were

uncommon (6.8 per cent) in the group ofobstructions caused by postoperative adhe-sions.Age Distribution. The average age of pa-

tients was 45.9 years, and 68.6 per cent were60 years of age or younger. That patients inextremes of life were not exempt is evident,for 14 patients were less than one year old,and eight were over 80 years old.

Mortality Rates. There were 37 deaths, or

an overall case fatality rate of 9.5 per cent.Twelve patients who died had developedobstruction as a complication of anotherillness for which the patient had been hospi-talized. In each the bout of obstruction wassurvived, but the patient succumbed to his

TABLE I. Types of Adhesions Causing Obstructions.Adhesions with

Abscess or

Localized AdhesionsObstructing Total Simple Inflammatory withMechanism Cases Adhesions Perforation Strangulation

Postoperativeadhesions.... 308 231 40 37

Inflammatoryadhesions.... 69 34 33 2

Congenitalbands ...... 11 6 0 5

Total......... 388 271 73 44

original disease. Three additional patientswere moribund on arrival and they diedwithin six hours after admission. This leaves22 deaths for which intestinal obstructionor the treatment thereof was responsible. Ifjust these 22 deaths are considered, then themortality rate falls to 5.9 per cent.As would be expected, the occurrence of

abscesses in the peritoneal cavity in the pres-ence of intestinal obstruction increased therisk for the patient. Whereas simple obstruc-tion was treated 263 times with a mortalityrate of 3.8 per cent, among 69 patients withobstruction complicated by intraperito-neal abscesses, 7.3 per cent of the groupsuccumbed.

Strangulation obstruction was attendedby a mortality rate of 17.1 per cent in 41cases. Gangrene adversely influenced sur-vival even more as 36.8 per cent of the 19patients with non-viable bowel succumbed.In fact, all the deaths in the group withstrangulation obstruction were among thosepatients with gangrene.Very young and very old patients tolerate

obstruction poorly, as had been shown byothers.4' 6 In this group of cases, two of the12 patients under one year of age died (16.7per cent), and 14 of the 22 deaths due to ob-struction occurred in the group of 109 pa-tients 61 to 80 years of age, a mortality rateof 12.8 per cent. Eight patients over age 80were treated without fataliy, but the groupis too small to permit any conclusions.

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TABLE II. Death Due to Adhesive Obstructionby Age.

Number of MortalityAge Group Cases Deaths Percent

0- I yr ............. 12 2 16.7%1-20yr ............. 52 2 3.8%

21-40 yr ............. 73 2 2.7%41-60 yr ............. 119 2 1.7%61-80 yr ............. 109 14 12.8%Over80 ............. 8 0 0

Total ............... 373* 22 5.9%* Three patients moribund on arrival and 12 patients dying

of diseases other than obstruction are excluded.

Distension of the intestine and the train ofevents which is initiated thereby has beenshown experimentally to be an importantcause of death in simple intestinal obstruc-tion. Reduced venous pressure and reducedvenous outflow in the mesenteric veins fol-low distension, and finally, sustained intra-luminal pressures lead to loss of viabilityin areas of the intestine and an increasedpermeability of the bowel wall. This perme-ation of the bowel wall with impaired via-bility and subsequent peritoneal contamina-tion is the chief lethal issue in simpleobstruction.16' 17To evaluate this effect in patients, simple

postoperative adhesive obstructions of thesmall bowel were considered separately, andthe complicated obstructions excluded.Therefore, obstructions resulting from pri-mary inflammatory processes or congenitalbands, and all postoperative adhesive ob-structions with strangulation or intra-ab-dominal infection, were removed from con-sideration. The remaining simple smallbowel obstructions were divided into threegroups, based on the degree of intestinaldistension that had existed at the time ofobstruction. Roentgenographic and surgicalfindings were utilized to classify obstruc-tion into severe, moderate and slight degreesof intestinal distension. In 89 cases the de-gree of intestinal distension was classified assevere. Moderate and slight distension waspresent in 84 and 36 cases, respectively. That

TABLE III. Deaths and Duration of ObstructionPrior to Institution of Treatment.

(291 Cases)

Deaths

MortaityDuration Cases Number Percent

12 hours or less ......... 24 0 0.0%12-24 hours ............. 44 2 4.5%24-48 hours ............. 40 3 7.5%48 hours to oneweek. .. 98 9 9.2%Over oneweek.......... 85 8 9.4%

Total .. . . 291 22 7.5%

distension and its effects in the absence ofother complications was a lethal factor inobstruction was confirmed, as seven deathsoccurred among the patients with severeintestinal distension (7.9 per cent), whereasthe mortality rates were 1.2 per cent (onedeath) in those with moderate distension,and 2.8 per cent (one death) when disten-sion was slight.The duration of obstruction prior to treat-

ment influences survival.8' 12 In this series,in 291 cases the duration of symptoms priorto treatment was known. Of 24 cases treatedwithin 12 hours after onset of the obstruc-tion, none died. When the disease had ex-isted for 48 hours or longer untreated, deathoccurred in 9.3 per cent of cases.

Treatment. Cases were divided into threecategories to assess the merits of early opera-tion versus intestinal intubation. The firstgroup included those patients treated onlyby inlying gastric tube or long intestinaltube; the second was comprised of thosetreated for a period greater than 24 hours byintestinal intubation or inlying gastric tube,who then had an operation; the third con-sisted of those patients who had an operationwithin 24 hours of admission. As can be seen

fromTableIV, the best results were achievedin the group who were treated without op-

eration. Here, only 1.7 per cent of patientsdied. In the group treated by early operation(surgery witiin 24 hours of admission) 9.2

per cent succumbed, and a 7.2 per cent mor-

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INTESTINAL OBSTRUCTION CAUSED BY ADHESIONS

tality rate was encountered in the group op-erated upon after 24 or more hours of suctiontreatment. It is noteworthy that in this lastgroup the mortality rate was higher whendecompression was not achieved, and dis-tension remained uncorrected for periodsgreater than 24 hours (six deaths in 44 cases,13.6 per cent).

Strangulation obstructions were recog-nized before death in all except one patient.Twenty-two patients were correctly diag-nosed and operated upon without delay.Five of these died (22.7 per cent). Eighteenwere operated upon after a period of delaywith one death, and in one patient, conserva-tively treated, strangulation obstruction wasdiscovered at autopsy. Thus, delayed recog-nition of 19 strangulation obstructions re-sulted in death of 10.4 per cent patients.Among these 41 strangulation obstruc-

tions, gangrene had developed in 19 in-stances. Thirteen patients were recognizedto have strangulation obstructions and wereoperated upon without delay, with fivedeaths (38.4 per cent). Five patients wereoperated upon after a period of delay withone death, and one patient, mentionedabove, died during conservative treatmentand was found to have gangrene at autopsy.Thus, in this group of six patients with gan-grene, treated by suction, two died (33.3per cent).

Causes of Death. In the 22 cases wheredeath was due to obstruction or at least re-lated to its treatment, the following causeswere found: (a) Eleven patients succumbedto what is best described as the effects ofobstruction. Six of these deaths were the di-rect result of uncontrolled distension. An-other two patients had well defined peri-tonitis at the time of operation and deathresulted from this. The remaining three pa-

tients had gangrenous bowel at post-mortemexamination. One of these was never oper-

ated upon, and in the other two, the viabilityof the bowel was misjudged at operation.(b) Seven patients (31.8 per cent) suc-cumbed to complications which were di-

rectly related to the operative treatment ofobstruction. Six of these deaths were due toanastomotic breakdown or spillage at opera-tion, which resulted in peritonitis. The otherdeath was attributable to anesthesia. (c)Four patients (18.2 per cent) died of com-plications not so clearly related to the typeof treatment. Postoperative intussusceptionoccurred in one patient, and was not recog-nized. Aspiration pneumonia caused onedeath, and a third patient succumbed toa cerebro-vascular-accident. Finally, onedeath resulted from accidental air embolism.

COMMENTS

Postsurgical adhesions accounted for 79per cent of all adhesive obstructions here.It is likewise the experience of others, thatsurgery is the most common cause of ad-hesions that lead to obstruction. Becker(1952)2 found that 90 per cent of adhesiveobstruction in his material followed abdom-inal surgery, and Bollinger and Fowler(1953)3 reported that 41 per cent of allsmall bowel obstructions in their series wasdue to postoperative adhesions.Although the prevention of adhesions fol-

lowing operations has not been achieved,certain valid contributions have been madein this direction. Deaver7 long ago stressedthe importance of avoiding trauma to theperitoneum, and he recommended that care-ful operative technic, strict asepsis and mini-mal handling and exposure of the viscera bepracticed. Antopoll first described the gran-ulomatous lesions that might occur follow-ing the introduction of talc into the perito-neal cavity. Dennis" recently re-emphasizedthe r6le of glove powder in adhesion forma-tion, and suggested that hydrolyzed starchwhich has replaced talc for this purpose maynot be free of this complication. He advisedthe use of wet pads to wipe all traces of pow-der from the surgeons' gloves. In addition,he recommended that unnecessary traumato the abdominal viscera be avoided, andthat careful hemostasis be practiced. The

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TABLE IV. Treatment of Intestinal Obstruction Due to Adhesions.

Cases Excluding DeathsDeaths from Causes Due to

All Deaths other than Obstruction Obstruction*Allcases Number Percent Number Percent

Decompression with Tube, without operation 120 6 5.0 116 2 1.7Gastric suction .59 6 10.2 55 2 3.6Long Intestinal Tube .61 0 0 61 0 0

Preliminary Trial of Suction followed bySurgery .188 20 10.6 181 13 7.2

Gastric Suction .71 4 5.6 70 3 4.3Long Intestinal Tube .117 16 13.7 111 10 9.0

Successful Decompression .69 6 8.7 67 4 6.0Failure of Decompression .48 tO 20.8 44 6 13.6

Immediate Surgery after Intubation. 80 11 13.7 76 7 9.2Gastric Suction ............. 63 8 t2.7 59 4 6.8Long Tube. ..... .. 17 .3 17.7 17 .3 17.7

388 37 9.5 373 22 5.9

* Three patients moribund on arrival are excluded.

introduction of agents into the peritonealcavity for the prevention of postsurgical ad-hesions has not been successful.16' 17Although the magnitude of the insult in

part explains the greater risk attending ob-struction in infants, specific aspects of theproblem can be incriminated as contributoryto a greater death rate in these young pa-tients. Delayed diagnosis is attended withfluid and electrolyte derangements, and as-piration pneumonia from vomiting may bewell established. Technical difficulties atoperation, and problems of anesthesia aregreater. Responsibility for care is often di-vided between surgeon and medical staff.The dividends in terms of survival when theoperating surgeon has charge of preopera-tive and postoperative care has recentlybeen emphasized by Gross. Both Browne4and Gross10 expressed the opinion that bet-ter results will be achieved consistentlywhen those with special interest and train-ing have the responsibility for managementof infants with intestinal obstruction.Our results are in keeping with the trend

of higher mortality rates in the aged. Fromhis experience, Cutler6 concluded that theobstruction itself rather than the patient'sage and co-existing ailments had been re-

sponsible for the larger number of deathsencountered in older patients. Cole,5 how-ever, expressed the opinion that complicat-ing diseases do add a greater risk in the agedthan in the young patient. He likewise foundthat although an elderly patient free of con-current disease and complications will tol-erate a major operation almost as well as ayoung adult, the former will tolerate emer-gency operations poorly. Here, the manage-ment of the intestinal obstruction in olderpatients follows the plan subsequently de-scribed, but some details of preoperativeand postoperative management deservecomment. The necessity of replacing theblood volume to adequate levels is of primeimportance.5 Preoperative and daily postop-erative weighing of patients, coupled withcarefully recorded intake and output data,will serve to prevent overhydration or inade-quate fluid replacement. As infections aretolerated poorly by the older patient, aspira-tion pneumonia is to be avoided. Continuousgastroduodenal suction is utilized until nor-mal intestinal function is resumed. If a longintestinal tube is placed into the small bowel,a second shorter tube is passed into the stom-ach and both are maintained on continuoussuction, and thereby gastric regurgitation is

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INTESTINAL OBSTRUCTION CAUSED BY ADHESIONS

prevented. Thrombophlebitis and phlebo-thrombosis are treated currently with anti-coagulant drugs.The reports of McKittrick12 and Dennis,8

as well as our results, indicate the necessityfor early diagnosis and institution of appro-priate treatment promptly in intestinal ob-struction. The utilization of routine abdomi-nal roentgenograms early in the course ofall unexplained abdominal conditions maybe helpful in this regard, as intestinal dis-tension may be detected thereby when clin-ical abdominal distension is absent. Diag-nosis and institution of treatment of obstruc-tion before the disease is over 24 hours oldoffers the best prognosis. If this advantageis to be gained, the diagnosis must usually bemade or suspected by the first physician inattendance.The type of treatment to be employed in

adhesive obstructions is a final considera-tion. Most of the recent efforts to further im-prove results in the treatment of intestinalobstruction have been directed toward earlyoperation. McKittrick in 1941,12 and more

recently Becker (1952),2 and Bollinger andFowler (1953),3 have recommended imme-diate surgical treatment in the majority ofcases.

Most proponents, of early operations basetheir recommendations principally on thethesis that strangulating obstructions cannotbe diagnosed in 100 per cent of cases, andthat delay in those that are misdiagnosedcarries a risk that outweighs the advantagesgained by conservative decompression. Wedo not agree. We feel that non-operative de-compression has a definite place in the man-agement of simple intestinal obstructions,and should not be abandoned. Those pa-

tients who can be successfully treated bythis modality are managed at a negligiblerisk. Moreover, a significant number of ad-hesive obstructions respond to intestinal de-compression. Almost one-third (114 cases,

30.5 per cent) of adhesive obstructions inthis group were relieved by non-operativemeans, and the mortality rate encountered

was low. Among those patients initiallytreated by suction who subsequently re-quired operation, the mortality has not beenhigher than for those managed by early oper-ation unless decompression had failed anddistension remained uncontrolled.

It is recognized that utilization of con-servative decompression for treatment of ob-struction assumes the risk of unrecognizedstrangulation obstruction. Strangulation ob-structions in the group treated by early oper-ation were in many instances advanced (13of 22 were gangrenous), and the risk wasaccordingly high (22.7 per cent died). Inthose patients who initially manifested nosigns of strangulation and were treated bytube, and in whom strangulation was subse-quently suspected and operation carried out,the diagnosis was usually made before ad-vanced vascular impairment had occurred(five of 18 were gangrenous), and the riskof treatment was consequently lower (onedeath). In only one instance (one of 41strangulation obstructions) was the diagno-sis not made until autopsy. Thus, in 19 pa-

tients with delayed recognition, the riskwas 10.5 per cent (two deaths). It is con-

cluded, therefore, that the advantages innonoperative relief of adhesive obstructionsachieved at a low death rate outweigh therisk of delayed recognition in strangulationin adhesive obstructions.

Control of intestinal distension is a pri-mary consideration in management of in-testinal obstruction. The lethal character ofthe sequence of events which distension ini-tiates makes decompression imperative;therefore, failure to relieve intestinal disten-sion by suction after 12 hours is an indicationfor operative intervention.Based on the above conclusions, the fol-

lowing plan for the management of adhesiveobstructions has been adopted in this clinic:

1. All patients with findings suggestive or

indicative of strangulation obstruction or

wherein coexisting abdominal conditionsare compelling factors for immediate sur-

gery are operated upon as soon as they can

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be prepared. With few exceptions patientswho have large bowel obstructions with dis-tension are operated upon without delay.Transverse colostomy is performed if theobstruction is not relieved by division ofadhesive bands. Primary resection and anas-tomosis in the face of large bowel distensionis not recommended.17

2. In remaining patients a trial of intesti-nal intubation is carried out. Conservativetreatment is interrupted at any time if signssuggesting strangulation develop. At the endof a 12 hour period abdominal roentgeno-grams are repeated and the patients status isre-evaluated. If no real progress has beenmade in the relief of distension, conservativetreatment is interrupted and operation car-ried out. Conservative decompression is con-tinued if no signs or symptoms of strangula-tion obstruction develop and improvementis progressive.

SUMMARY

Adhesions, accounting for 31 per cent ofall cases, were the most common cause ofintestinal obstruction at the University ofMinnesota hospitals during the 11 year eightmonth period ending September 1, 1953.The overall mortality rate in these ob-

structions was 9.5 per cent. Excluding thosepatients dying of other diseases and thosemoribund on arrival, the mortality rate was5.9 per cent.Age, duration of obstruction prior to

treatment, strangulation, intraperitonealsepsis and degree of intestinal distension in-fluenced survival.

Indications for operative and non-opera-tive treatment of obstructions due to adhe-sions are given: Simple obstructions areinitially treated by intestinal suction; stran-gulation obstructions by early operation.Suction treatment of simple obstructions isinterrupted if distension of the bowel is notrelieved in 12 hours, or if signs of stran-

gulation develop. Suction is continued ifdistension is relieved and improvement isprogressive.

BIBLIOGRAPHY1 Antopol, W.: Lycopodium Granuloma, Its Clin-

ical and Pathological Significance Togetherwith Note on Granuloma Produced by Talc.Arch. Path., 16: 326, 1933.

2 Becker, W. F.: Acute Adhesive Ileus; A Studyof 412 Cases with Particular Reference toAbuse of Decompression in Treatment. Surg.,Gynec. & Obst., 95: 472, 1952.

3 Bollinger, J. A., and E. F. Fowler: Results ofTreatment of Acute Small Bowel Obstruction.Arch. Surg., 66: 888, 1953.

4 Browne, D.: Neonatal Obstruction. Proc. RoyalSoc. Med., 44: 623, 1951.

5 Cole, W. H.: Operability in the Young and Aged.Ann. Surg., 138: 145, 1953.

e Cutler, C. W.: Acute Intestinal Obstruction inElderly Patients. Surg., Gynec. & Obst., 94:481, 1952.

7 Deaver, J. B.: Intraabdominal Adhesions. Surg.,Gynec. & Obst., 37: 506, 1923.

8 Dennis, C., and S. P. Browne: Treatment ofSmall Bowel Obstruction. Procedure Used atthe University of Minnesota Hospitals. Sur-gery, 13: 94, 1943.

9 Dennis, C.: Current Procedure in Managementof Obstruction of Small Intestine. J. A. M. A.,154: 463, 1954.

10 Gross, R.: The Surgery of Infancy and Child-hood. W. B. Saunders Co., Philadelphia, 1953.

McIver, M. A.: Acute Intestinal Obstruction:General Considerations. Arch. Surg., 25: 1098,1932.

12 McKittrick, L. S.: The Diagnosis and Manage-ment of Acute Obstruction of the Small In-testine. New England J. Med., 225: 642, 1941.

13 Souttar, H. S.: Acute Intestinal Obstruction. Proc.of Sections at Annual Meeting, Bath, 1925,Section of Surgery. Brit. M. J., 2: 993, 1925.

14 Smith, G. A., J. F. Perry and E. G. Yonehiro:Mechanical Intestinal Obstruction, a Studyof 1252 Cases. To be published.

15 Vick, R. M.: Statistics et Acute Intestinal Ob-struction. Brit. M. J., 1: 596, 1932.

16 Wangensteen, 0. H.: Intestinal Obstruction, 2ndEdition. Charles Thomas Co., Springfield,Illinois, 1942.

17 -: Intestinal Obstruction, Srd Edition.Charles Thomas Co., Springfield, Illinois,1955.

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