Chapter 2337: The Twisting Intestines
After introducing the equipment, and by reference to interventional surgery, there are two steps that must be completed under fluoroscopy before treating the child with this procedure.
First, determine whether the tube has been correctly positioned inside the body, whether it is properly secured, and whether the volume of the fixing balloon is too large or too small.
With practiced hands, Doctor Yang moved the control lever to fluoroscope the child’s anal area. A small bright mass appeared on the machine screen, indicating that the balloon was fully filling and sealing the anus.
The tube wasn’t leaking or displaced, so they could start insufflation. At this point the insufflation was not yet for treatment; as in an interventional surgery protocol, they had to first verify that the preoperative diagnosis was correct before proceeding.
For diagnostic testing, the gas volume did not need to be large; it only had to run at the lowest safe pressure, generally 8 kPa. Doctor Yang and the others had preset this value while calibrating the machine in the control room; now they only needed to remotely start the insufflation program.
The gas whooshed into the child’s intestinal tract, not to blow the bowel up to rupture.
Doctor Yang used the control lever to carry out continuous fluoroscopy of each segment. On the screen, they could see the distribution map of the bright gas bolus gradually advancing and diffusing within the child’s intestines.
As long as fluoroscopy was available, one could say every step was proceeding in an orderly manner under the doctor’s control. The issue now was whether this procedure could smoothly achieve its goal.
For the preliminary diagnostic step, the first objective was to drive the gas to the lesion site at the ileocecal region. Before that, as the gas advanced in the bowel it had to pass through a long segment of intestine. The human intestine is not a straight, smooth tube; it twists and turns like eighteen bends. "Eighteen bends" is an exaggeration, but there is no denying that even under normal conditions some bends in the gut are difficult for gas or liquid to pass. Among these physiological flexures, the most notable are the splenic flexure and the hepatic flexure.
The splenic flexure is in the left upper abdomen, the corner where the transverse colon turns into the descending colon, and because it is near the spleen it is called the colonic splenic flexure.
As for how difficult that turn is, it’s said that even during colonoscopy this is the spot that gives endoscopists the biggest headache when trying to get the scope through smoothly.
The body’s own excrement, stool, will occasionally get stuck there as well. Clinically, some patients experience pain under the left costal margin after meals or with food intake, and may be evaluated for a long time for gastritis or suspected pancreatitis without improvement, when in fact the problem lies at the splenic flexure. Excessive angulation and adhesions at the colonic splenic flexure can develop into a benign stricture, blocking gas and stool and causing discomfort; this is called splenic flexure syndrome.
Back to the current child: on the machine screen the gas could be seen entering from the anal canal into the rectum, then the sigmoid colon, passing through the descending colon and having to retrogradely negotiate the extremely difficult turn of the colonic splenic flexure to reach the transverse colon.
A grave look gradually appeared on Doctor Yang’s face. With the gas volume still low, this was just enough to conveniently test how much pressure the bowel could tolerate at this bend, in order to avoid a bowel rupture here when the gas volume was increased later.
As the gas passed the child’s splenic flexure, the local gas distribution was relatively sparse, indicating that the resistance encountered was unusually high. Was it due to the upstream intussusception causing intestinal obstruction? Or was this child’s local anatomy inherently more sharply angulated? The doctor could not say for the moment. What this flagged for the doctor was that, if they needed to increase the gas volume later, the margin for maneuver would be very limited.
The next major difficulty after the splenic flexure was the hepatic flexure.
The hepatic flexure is the corner where the ascending colon joins the transverse colon, with a physiological bend of up to 90 degrees; because it lies under the liver it is called the colonic hepatic flexure. Beyond the hepatic flexure is the ascending colon followed immediately by the cecum, which is very close to the ileocecal region where the intussusception has occurred.
Doctor Yang picked up the intercom to speak with the doctor in the control room: "Doctor Duan, I’m afraid this isn’t looking too good."