~ Wod rlJ~~wnal

World J. Surg. 9, 868-875, 1985

of S~wgery

9 1985by the Soci›233 Internationale de Chirurgie

Recurrent Adhesive Small Bowel Obstruction Peter F. Jones, M.Chir., FoR.C.S. Ed., and Alexander Munro, Ch.M., F.R.C.S. Ed. Department of Surgery, Woodend General Hospital and Royal Aberdeen Children's ttospital, University of Aberdeen; and Raigmore Hospital, Inverness, United Kingdom

Adhesive obstruction of the small bowel complicates about 5% of laparotomies; of these, 5-10% have recurrent attacks. The etiology of adhesions is incompletely understood and attempts to prevent their formation are of unproven value. Patients with recurrent acute obstruction that threatens strangulation, or that faiis to subside, require laparotomy. If numerous adhesions have to be divided, it is worth considering a procedure to encourage fresh adhesions to form in a favorable pattern. Suture plication of the bowel by Noble's technique has a high incidence of complications and recurrent obstruction, and transmesenteric plication cannot be used in the presence of sepsis. Splinting of the entire smali bowel by intraoperative passage of a long tube, which is ieft indwelling for 2-3 weeks, appears to be effective and safe. We have used this method in 140 patients without associated complications; of these, 17 had recurrent intestinal obstruction after 1-5 previous laparotomies for adhesions. A meticulous adhesiolysis followed by transluminal splinting through a jejunostomy has been followed by freedom from recurrence during 103 patientyears of follow-up.

In Western countries the most frequent cause of acute small bowel obstruction (SBO) is adhesions, and the majority of these are the legacy of a previous laparotomy [1, 2]. Although these obstructions appear to be common, they only occur in 4-5% of ail patients undergoing laparotomy [3] (although after a few operations such as total colectomy the incidence may be as high as 10% [4], or even 20% [5]). For most of these patients this is a single event, and many obstructive episodes settle with a few days of alimentary tract rest and intra-

Reprint requests: Peter F. Jones, M.Ch., F.R.C.S. Ed., Department of Surgery, Woodend General Hospital, Aberdeen AB9 2YS, United Kingdom.

venous fluids. For others, laparotomy and adhesiolysis is necessary, especially whenever strangulation is suspected. Only a minority of these patients---between 5% [I] and 14% [3]--suffers a second episode of adhesive SBO, and fewer still have further attacks. However, these recurring attacks cause much distress to the patients and can pose great technical problems for the surgeon. The etiology of adhesion formation is not well understood. Fibrinous adhesions form after laparotomy in most patients, and they play a useful role in the healing of intestinal anastomoses and walling off areas of infection in the peritoneal cavity. Whether they become fibrous and therefore permanent depends on many factors, including the presence of ischemia. Ellis [6] cautions against closing peritoneal defects under tension and argues that it is probably better to leave surfaces raw rather than produce ischemia with consequent adhesion formation. Excessive adhesion formation may also develop as a result of contamination of the peritoneal cavity at the time of laparotomy with gauze, lint, cotton wool, and glove powder. Although talc bas now been largely dispensed with as a glove powder, the starch that has replaced it bas also been shown to bring about granuloma formation (Fig. 1) and may occasionally produce very dense adhesions within the peritoneal cavity. Effective methods of washing starch from gloves have been described [7], but the introduction of starch-free gloves should eliminate one unusual cause of dense adhesion formation. Adhesions between loops of bowel may also occur in patients who have had practolol therapy, which produces a cocoon of fibrous tissue around the intestine known as sclerosing peritonitis [8]. Since practolol has been withdrawn, this unusual

P.F. Jones and A. Munro: Small Bowel Obstruction

869

Fig. 1. Starch granuloma, stained with hematoxylin and eosin and viewed under (A) normal light and (B) polarized light. Typical Maltese cross seen in field under polarized light.

condition should no longer be a problem. In the majority of patients, however, no specific cause of adhesion formation is known; and there seems to be no way of predicting individuals who have a tendency to form dense adhesions. Attempts have been ruade, based on animal experiments, to introduce methods of preventing adhesion formation in humans, and these have been reviewed by Ellis [6]. The use of streptokinase to remove fibrin from the peritoneal cavity has been tried in various animais and has been recommended for patients, but it has not yet become a popular method. Corticosteroids have also been advocated, although to date there is no convincing evidence that they alter the tendency to re-obstruction; the disadvantages of postoperative administration outweigh any benefit. Dextrans have been shown to reduce adhesion formation at the rime of initial surgery, but they were unable to prevent adhesion formation following division of adhesions at a second operation. Some recent work by Goldberg et al. [9] showed that the wetting properties of PVP (polyvinylpyrrolidone), if applied locally, may reduce serosal damage consequent on handling of the intestine. So far none of these methods has been considered sufficiently safe or effective t o b e adopted and, until prevention of adhesion formation

becomes practicable, adhesive SBO will continue to be seen. About one-third of obstructive episodes are seen in the year after the antecedent laparotomy, but the remainder occur over a long rime span extending up to 20 years [10]. Thus, the threat of adhesive SBO is a continuing one. Clinical Features

Patients with recurrent adhesive SBO broadly present in one of two ways: (a) about one-third have symptoms and signs of acute SBO with a scar or scars of 2 or more previous laparotomies. The combination of severe colicky abdominal pain, tenderness, plain abdominal x-rays showing total obstruction of small bowel only, and a high white cell count must raise suspicions of a strangulating obstruction, which generally can only be resolved by laparotomy [11, 12]; (b) a majority has less severe symptoms and signs which often respond well to nasogastric suction and intravenous fluids. There is little evidence that passage of a long Cantor tube into the upper small bowel is helpful, and it may cause delay in deciding on necessary surgery [12]. If the patient fails to improve with conservative measures, laparotomy is reluctantly but necessarily undertaken and may reveal a complex series

870

of adhesions and sometimes a tightly knotted segment of bowel which is difficult to disentangle. There is a tendency to solve this problem by shortcircuiting this segment with a side-to-side enteroenterostomy. The patient is often left with a tumid abdomen, which never completely deflates and is prone to painful distension with any dietary indiscretion. These patients have a serious disability, and itis appropriate to plan a major effort to correct it once and for ail. If the nutrition of the patient has been seriously impaired by longstanding depletion, a period of parenteral feeding may be necessary before attempting this major operation.

Operative Procedure The broad aires of the procedure are to free every loop of bowel, to take down any enteroanastomosis, to restore the continuity of the small bowel, and to prevent a recurrence of adhesive SBO.

Division of Adhesions The operation should be undertaken by an experienced surgeon. It is important to avoid opening into the small bowel, since this increases the risk of septic complications. Generally it is best to reopen a previous vertical incision rather than create a new one. The greatest care is needed to avoid adherent bowel when the peritoneal level is reached. We prefer to extend the incision above or below the old scar, so that the peritoneum can be opened at a point that would be free of adhesions. Once this is done, it is usually much easier to dissect the small bowel off the deep surface of the wound using either a sharp scalpel or blunt-nosed scissors. It is helpful to empty dilated loops of upper small bowel by gently milking the contents retrogradely into the stomach, from which the anesthetist can aspirate the contents through a wide-bore nasogastric tube. When the patient is being operated on within weeks of previous surgery, it is often possible to separate adhesions by gently squeezing them between finger and thumb. In later or repeated explorations, almost the whole of the small bowel may be matted together, and then it is most important to allow rime for the difficult dissection. A start is made at the point that looks most promising and then, when an impasse seems to have been reached, it is wise to move to another area; the difl9 area will be returned to, by another approach, and should prove to be more tractable. Despite great care, the intestine may occasionally be opened inadvertently, and these holes should be immedi-

Worid J. Surg. Vol. 9, No. 6, November 1985

ately repaired with interrupted sutures of braided nylon. If this steady, determined approach is adopted, the most daunting abdomen can be unravelled, and we have rarely found it necessary to abandon the effort to dissect out the whole small bowel. ff there is an area in the small bowel that is narrowed either at a previous anastomosis or at the site of dense adhesion formation, this is best resected rather than bypassed. Our practice is to perform an end-to-end anastomosis using a single layer of interrupted braided nylon sutures, we employ an open method and take care not to spill any small bowel contents, which are likely to be infected. A useful alternative method is the closed technique using Wangensteen's clamps. Any previous enteroanastomosis should be taken down, so that the continuity of the smaU bowel is restored.

Prevention of Recurrence If the cause of recurrent SBO is localized at the site of one or two bands, these should be divided and nothing further should be done. If, however, the whole length of the small bowel is involved in adhesions, then we feel that, after complete adhesiolysis, very serious consideration should be given to a splinting procedure, which would reduce the chances of a recurrence of obstruction. There are two main ways of achieving such splinting: (a) division of adhesions with suture plication of the smail intestine, and (b) division of adhesions with intraluminal splinting. Noble [13] was the first to use a method of suture plication of the small intestine. From 1920 he tried to encourage "controlled" adhesions by suturing together adjacent loops of bowel that had serosal damage, so that they would lie with a smooth bend at each change of direction, thus discouraging the development of sharp kinks. Noble published his results in 1937, three years after Wichmann [14], but it seems likely that Noble was the true originator of the method. The problem with this method is that it has a high complication rate and a high risk of recurrence. Wilson [15] reported 7 deaths and 24 recurrent obstructions among 127 Noble procedures. Noble's plication is now rarely used by surgeons to prevent further episodes of small bowel obstruction, but a modification of the procedure has increased in popularity. This method, described by Childs and Phillips in 1960 [16], involves transmesenteric plication rather than placing sutures in the bowel wall. The advantages are that it can be performed much more quickly than Noble's plication and that sutures are not placed on the bowel wall; therefore, the risk of fistula formation (a problem with Noble's plication) should be less. This

P.F. Jones and A. Munro: Small Bowel Obstruction

form of plication has been associated with a high mortality rate in patients with generalized peritonitis [17] and is, therefore, contraindicated in any patient who has intestinal obstruction associated with intraperitoneal sepsis [17, 18]. Small bowel fistula formation has rarely been described with this technique and can be avoided by placing the transmesenteric sutures 3-4 cm away from the bowel wall. Delayed hemorrhage from the small bowel mesentery owing to erosion of a mesenteric vessel by the thread used to perform the plication bas been described. Hollender et al. [19] bave given a useful review of the technique and results of mesenteric plication; among 51 of their patients followed over 1-17 years, 43 had a good result. We favor division of adhesions with intraluminal splinting when faced with the patient who has small bowel obstruction due to dense adhesions. We decided to adopt this method in 1972 when confronted with a patient who had already undergone 5 laparotomies for adhesive small bowel obstruction, including a complete Noble's plication. The principle of the operation is to splint the small bowel with a long tube passed along the whole length of the small intestine. White [20] of Texas was the originator of this method. He passed a Miller-Abbot tube through the nose and threaded it via several enterotomies to the cecum. Baker [21] of Seattle modified the technique and intubated the small bowel using a long no. 16 Fr. balloon catheter introduced through a jejunostomy. Baker recommended leaving the tube in situ for approximately 10 days. Out own technique is in essence similar to the method described by Baker. We have designed a no. 18 Ff. balloon catheter 300 cm long that has 6 small side holes cut at 15-cm intervals above the balloon (available from Franklin Medical Ltd., High Wycombe; code no. 463018). The tube is inserted into the bowel through a jejunostomy 10-15 cm distal to the duodenojejunal fixture. A pursestring suture of catgut is used to prevent leakage of small bowel contents around the site of entry of the tube. If the length of tube inserted into the intestine exceeds the length of the segment of the tube with holes in it, further holes may be cut to allow the small bowel content to drain adequately. The balloon is a small one, so that when distended with 2-3 ml of water it makes a tight sphere which greatly eases the task of drawing the tip of the tube through the small bowel. (This process has an important function in displaying any unnoticed kinks and also reveals unsuspected mucosal tears which can be immediately repaired.) When the tip of the tube has reached the ileocecal valve, it is usually necessary to reduce the size of the balloon to allow it to pass through the valve. Once the balloon is situated in the cecum, it can be inflated with I0--15 ml water. A

871

Fig. 2. Adult 300-cm-long no. 18 Fr. intestinal tube. Note the 6 small side holes cut in the distal 100 cm to provide decompression.

little time must be taken to insert enough tubing to abolish pleating of the bowel on the tube. The length of tubing required varies greatly, but the whole 300 cm is rarely necessary (Fig. 2). A second pursestring catgut suture is then inserted around the first pursestring, and the ends are tied. The jejunum around the entry site of the tube is then sutured to the under surface of the abdominal wall, and a skin stitch is used to anchor the tube to the anterior abdominal wall (Fig. 3). The tube is left on gravity drainage. When intestinal function recovers and the patient is passing flatus, the tube may be occluded. It should be left in situ for 10-14 days. The no. 18 Fr. catheter can be used for ail ages of patients from 5-6 years upward. A no. 12 Fr. catheter, 180 cm long, has recently been designed for the neonate and smaller child. The site of insertion of the tube is controversial. The use of a gastrostomy has been advocated [22], but we do hOt think this method of insertion has any advantages over a jejunostomy except in children. In 37 patients who had intubation performed through a gastrostomy, Robbins et al. [23] had 8 patients with an unduly high output from the gastrostomy; and 2 patients had a persistent fistula after removal of the tube. Other researchers believe that the tube should be passed through the nose, into the stomach, through the duodenum, and then along the whole length of the small bowel. Nelson and Nyhus [24] have designed a double balloon tube to facilitate manipulation through the duodenal loop. However, McMillin et al. [25] reported airway complications in 43% of 21 patients who had the tube left in situ for more than 24 hours. Many of these complications could be directly attributed to the presence of a long intestinal tube inserted via

872

Worid J. Surg. Vol. 9, No. 6, November 1985

and of persistent leakage from the jejunostomy after tube withdrawal, but other reports on the use of intubation [21, 27-29] have reported few complications, most of a minor nature. Our own experience has shown that intubation through ajejunostomy is a safe procedure [30]. Our total experience in 140 patients, 126 of whom had intubation through a jejunostomy, has not revealed any case of obstruction of the jejunal loop or of a fistula. Removal of the tube has generaUy been easy, although in 5 cases withdrawal was staged over an hour or two because of discomfort. Five of our patients died, 3 owing to cardiorespiratory disease and 2 owing to uncontrolled peritonitis; no death or major complication was associated with use of the tube. Discussion

Fig. 3. Possible placements used in operative intubation. On the left, the tube is introduced via a jejunostomy or gastrostomy and passed to the cecum; the balloon is then inflated to prevent retraction. Two modes of retrograde insertion after total colectomy are illustrated on the right. the nose. In addition to respiratory complications, it is unpleasant for the patient to have to tolerate a tube inserted through one nostril for I0 days. We, therefore, feel that this route of insertion has little to recommend it, and we continue to practice insertion through a jejunostomy. If a patient who has an ileostomy requires small bowel intubation, retrograde insertion via the ileostomy seems to be a convenient method which avoids the use of separate enterotomy (Fig. 3). Once the tube is in place, the balloon should be deflated and the tube sutured to the skin around the ileostomy, to prevent its becoming dislodged. Similarly, if the patient has had a total colectomy with ileorectal anastomosis, intubation may be performed retrogradely through the anal canal. There appear to be relatively few complications of intraoperative intubation. Chilimindris and Stonesifer [26] state that they experienced a number of cases of obstruction at the site of the jejunostomy

The accepted treatment for adhesive SBO that requires surgical correction is division of the adhesions that are causing the obstructing constriction or kink. There is general agreement that this is the correct treatment for isolated bands or adhesions, especially when they are the cause of the first episode of obstruction. It is more difficult to decide on the best treatment for the unfortunate minority who surfer from recurrent adhesive obstruction. Although most surgeons will have treated a small number of these patients, there are few reports on the frequency of this troublesome sequence. Krook [3] followed 309 patients who had already had one laparotomy for division of obstructing adhesions. He found that 14% of the patients later required a second laparotomy for adhesive SBO and that 15% of this group suffered a third obstruction and adhesiolysis. The recurrence rate after this third operation was as high as 30%, although the groups arfected were by then small. The experience of this thorough survey led Krook to write: "the results of these repeated operations must be regarded as anything but encouraging; every fresh intervention gives a result inferior to the preceding one." Many reports of patients with adhesive SBO confirm that simple division of bands and adhesions does not protect against recurrent adhesive obstruction. Weigelt et al. [31] found that among 118 patients with widespread adhesions, 41 had a history of one or more previous adhesive obstructions. Janik and associates [11] treated 131 children, of whom 31 had previously required a laparotomy for adhesive obstruction; 15 of them had already had 45 such operations. In our own series of 17 patients there had been 43 obstructive episodes. Conservative management was used in 17, and adhesiolysis was required on 27 occasions before ail 17 were

P.F. Jones and A. Munro: SmaU Bowcl Obstruction

873

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71

73

75

77

79

81

83

85

Fig. 4. Diagram representing the progress of 17 patients with recurrent adhesive small bowel obstruction, before and after intestinal intubation.

Year

Table 1. Recurrent adhesive obstruction in 17 patients requiring more than one laparotomy for small bowel obstruction (SBO).

No. of previous laparotomies for adhesive obstruction

Follow-up since last laparotomy plus intubationy

1 3

4 3

2

2

10

1

13 years 13, 8, and 4 years 9 years, and 6 months 13, 9, 8, 7, 6, 5,

No. of patients

1

1

years 1

7 episodes SBO, no

laparotomy

9 years

aNo hospital mortality, no recurrence of obstruction since intubation.

finally subjected to division of all adhesions and intubation (Fig. 4). These statistics strongly suggest that although laparotomy and division of adhesions is effective for many patients, it is of no lasting assistance to a number of patients who persistently reform adhesions. For them it is necessary to find a procedure that not only completely relieves the obstruction

but also minimizes the possibility of recurrence of obstruction. The desirable features of such an operation include speed and simplicity of performance, safety in the presence of peritonitis, and freedom from major complications. Maintenance of decompression of the small bowel after operation would be an additional bonus. Of the available procedures, Noble's plication fails to meet these requirements because of a relatively high incidence of fistula formation and recurrence of obstruction [15]. We have no experience of the Childs-Phillips operation, but Hollender et al. [19] have recently reported favorably on its use in 69 patients with recurrent adhesive SBO, with 43 of 51 patients followed securing a good result. However, their review of the literature showed a mortality rate of about 6%, a recurrence of obstruction in 3--4% and intestinal fistulae in 2-5%. McCarthy [17] recorded a prohibitive mortality (8 of 10 patients) when mesenteric plication was used in peritonitis. We believe that operative intubation offers a safer and more effective alternative. We have operated on 17 patients with recurrent small bowel obstruction due to adhesions during the past 13 years (Table 1). There were no postoperative deaths in this group of patients. The length of follow-up bas varied from under 1 year to 13 years, and during this

World J. Surg. Vol. 9, No. 6, November 1985

874

Table 2. Intraoperative small bowel intubation for recurrence of adhesive obstruction after one or more operations for

adhesions.

White [20] Ramsey-Stewart & Shun [32] Jones, Salter Stewart, & Brennan [29] Present series Baker [21]

Total no. patients

Recurrences after intubation

Follow-up

5 13 10 17 46a

1 0 0 0 0

0, 0, 2, 5, 5 years 1-3 years %2- 4 l/` years 103 patient-years 2-15 years

aThe majority of these patients had a recurrent obstruction, but exact figures are not given.

time there has been no definite evidence of recurrence of obstruction. Two patients required laparotomy 2 and 3 years, respectively, after small bowel intubation for recurrent abdominal pain, but no evidence of intestinal obstruction was found. Three of the 17 patients died from an unrelated cause several years after operation. There has been no recurrence of obstruction in 103 patient-years of follow-up (Fig. 4). There are only 3 other reports that clearly state the results of intubation for recurrent adhesive SBO (Table 2), and there are two others that report an unstated number of such patients. In all these studies, there bas so far been only 1 recurrence of obstruction. Inspection of Fig. 4 very strongly suggests that intubation played an important role in terminating a sequence of unsuccessful operations for adhesive SBO. The reason for this success appears t o b e that the stiffness of the tube holds the bowel in open curves while the raw serosal surfaces form first fibrinous and then organized adhesions, which prevent later kinking and volvulus. This seems to be the explanation for our having seen no further obstruction in 75 patients who were intubated after the separation of diffuse small bowel adhesions: 17 were in the recurrent group already described, 28 had severe generalized fibrous peritonitis, and 30 had a prophylactic intubation. These patients have been fully described elsewhere [30]. So far there bas been no prospective trial comparing simple adhesiolysis alone with the results of adding plication or intubation. The relatively small numbers of patients with recurrent adhesive SBO and the length of follow-up required would delay a result for a long time, even if a multicenter trial could be organized. Until then, we believe that the combined results presented show that intraoperative intubation is safe, without major complications even in the presence of peritonitis, that it can be performed readily and quickly, and that it can make a real contribution to the management of recurrent adhesive small intestinal obstruction.

R›233

L'occlusion de l'intestin grœ secondaire ” des adh› complique environ 5% des laparotomies et r› dans 5-10% des cas. L'› pr› des adh› n'est pas parfaitement connue et toutes les m› de pr› qui ont ›233 tent› n'ont pas fait leur preuve. Tous les malades qui pr› des attaques r›233233 et des menaces d'› intestinal doivent œ op›233 Si les adh› ” lever sont trš nombreuses il est n› d'avoir recours ” une m› th› tique qui favorise la reconstitution en bon ordre de nouvelles adh› L a plicature ordonn› des anses intestinales selon la technique de Noble est suivie de nombreuses complications et de r› la plicature transm›233 selon la technique de Child ne peut œ employ› en cas d'infection. C'est la raison pour laquelle il convient de substituer ” ces modes de plicature, celle qui fait appel ” un long tube intradigestif qui est laiss› en place 2-3 semaines. L a m› est d›233 de danger et efficace. Elle a ~t› employ› chez 140 malades sans aucune complication alors mœ que 17 d'entre eux pr› des occlusions ” r›233 tion, et avaient subi de 1 ” 5 laparotomies. Cette technique de lib› des adh› suivie de la plicature ordonn› des anses intestinales sur un tube introduit dans le grœ par la voie d'une petite j› a permis d'enregistrer l'absence de r› de l'occlusion chez 103 malades qui ont › attentivement suivis. Resumen

La obstrucci› por adherencias es una complicaci› que ocurre en alrededor del 5% de las laparotomfas, y de los pacientes que la desarrollan 5-10% sufren episodios recurrentes. L a etiolog~a de las adherencia no es totalmente conocida, y los intentos orientados a prevenir su formaci› han probado ser de utilidad no comprobada. Los pacientes con obstrucci› aguda que presagia estrangulaci› o que no cede con un manejo de

P.F. Jones and A. Munro: Smail Bowei Obstruction

unos dias de reposo intestinal y lfquidos parenterales, requieren laparotomfa. Cuando es necesario dividir numerosas adherencias, es t]til considerar la realizaci6n de un procedimiento que p r o m u e v a la formaci6n de adherencias frescas en un patr6n ordenado y favorable. L a plicaci6n mediante suturas segtin la t› de Noble se acompafia de una elevada tasa de complicaciones y de obstrucci6n recurrente, y la plicaci6n transmesent› est~i contraindicada en presencia de sepsis. L a fijaci6n de la totalidad del intestino delgado mediante la colocaci6n intraoperatoria de un tubo intestinal largo, el cual es dejado por 2-3 sernanas, parece ser un m › efectivo y seguro. H e m o s utilizado tal m› en 140 pacientes sin complicaciones; de › 17 presentaban obstrucci6n recurrente despu› de 1-5 laparotomfas previas p o r adherencias. L a meticulosa lisis de las adherencias seguida de la fijaci6n transluminal mediante tubo colocado a trav› de una y e y u n o s t o m f a a 10-15 cm del ~ingulo duodenoyeyunal ha resultado en ausencia de recurrencia en 103 pacientes-afio de seguimiento.

875

13. 14. 15. 16. 17. 18. 19.

20. 2 l. 22.

References

1. Thomas, D.: Acute small bowel obstruction. Aust. N.Z.J. Surg. 37:302, 1968 2. R~if, L.E.: Causes of abdominal adhesions in cases of intestinal obstruction. Acta Chir. Scand. 135:73, 1969 3. Krook, S.S.: Obstruction ofthe small intestine due to adhesions and bands. Acta Chir. Scand. 95[Suppl. 125]:1, 1947 4. Ritchie, J.K.: Ulcerative colitis treated by ileostomy and excisional surgery. Br. J. Surg. 59:345, 1972 5. Lockhart-Mummery, H.E.: Intestinal polyposis: The present position. Proc. R. Soc. Med. 60:38l, 1967 6. Ellis, H.: Adhesions: An introduction. In Adhesions: The Problems, H. Ellis, M. Lennox, editors. London, Westminster Hospital Medical School, 1983, pp. 1-5. 7. Fraser, I.: Simple and effective method of removing starch powder from surgical gloves. Br. Med. J. 284:1835, 1982 8. Brown, P., Baddeley, H., Read, A.E., Davies, J.D., McGarry, J.: Sclerosing peritonitis: An unusual reaction to a fl-adrenergic blocking drug (practolol). Lancet 2:1477, 1974 9. Goldberg, E.P., Sheets, J.W., Habal, M.B.: Peritoneal adhesions: Prevention with the use of hydrophilic polymer eoatings. Arch. Surg. 115:776, 1980 10. R~if, L.E.: Causes of abdominal adhesions in cases of intestinal obstruction. Acta Chir. Scand. 135:73, 1969 11. Janik, S.J., Ein, S.H., Filler, R.M., Shandling, B., Simpson, J.S., Stephens, C.A.: An assessment of the surgical treatment of adhesive small bowel obstruction in infants and children. J. Ped. Surg. 16:225, 1981 12. Bizer, L.S., Liebling, R.W., Delany, H.M., Gliedman, M.L.: Small bowel obstruction: The role of

23. 24. 25. 26. 27. 28. 29.

30,

31. 32.

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