Chinese Medical Journal

70 1 THE CHINESE MEDICAL JOURNAL

used for the stoma. The proximal jejunal loop measured about 14 em from the ligament of Treitz. The postoperative course was uneventful and the patient was discharged sixteen days after the operation.

She was admitted for the second time on March 1, 1952, and for the third time on March 13, 1952. On both occasions she complained of upper abdominal distention and pain, and symptomatic treatment gave relief. The clinical diagnosis was partial intestinal obstruction due to postoperative adhesions. Z

She was admitted for the fourth time on April 21, 1952 (one hundred and forty-five days after her partial gastrectomy operation) for sudden onset of upper abdominal pain of twenty-four hours’ duration accompanied by marked nausea and vomiting. The vomitus was scanty and without bile. On examination, she was found to be thin and acutely ill, The upper abdomen was moderately distended, tender and spastic on palpation. In the first twenty-four hours after admission, symptomatic treatment was instituted but failed to give any relief. The abdominal pain soon became colicky and unbearable. Her general condition also deteriorated as evidenced by weakened pulse and much sweating. A mass was then felt over the left upper abdomen, and distention, tenderness and spasm spread over the entire abdomen. A clinical diagnosis of intestinal obstruction was made and an immediate exploratory operation was decided upon.

Under ether anesthesia, the abdomen was reopened through a left rectus incision. About 400 ec of reddish-brown fiuid were removed from the peritoneal cavity. Many adhesions were noted among the intestinal loops. A bluish cystic mass about the size of a fetal head with patches of necrosis was found in the left upper abdomen. In an attempt to identify the mass by minimal dissections, it was ruptured. About 800 ce of bilious and bloody fiuid were aspirated from the cystic mass. It then became apparent that the cystic mass was actually the proximal jejunal loop, which had herniated through an opening made up by the distal jejunal loop of the gastrojejunostomy in front and the transverse colon behind. The herniated loop was distended with bile and intestinal secretions, and its wall gangrenous (Fig. 1). Resection of the gangrenous loop of jejunum was carried out, and after closing the cut end of the jejunum near the gastrojejunostomy, an end-to-side jejunojejunostomy was done (Fig. 2) to re-establish the intestinal continuity. She stood the opera-

Fig. 1. Findings at second operation (Cases 1 and 2). Herniation of

the afferent jejunal loop behind the Fig, 2. After resection of the anastomosis with gangrene of the gangrenous jejunum, an end-to-side bowel. _ jejunojejunostomy was done.

tion well and was discharged on May 23, 1952, thirty-one days after the second operation. Two years later, upon follow up inquiry, the patient reported that she had gained 10 kg in body weight, ate with good appetite without any dietary