Intestinal obstruction is a common surgical condition with a high mortality rate when not managed properly. There are many reasons for this situation: many intestinal obstruction surgeries are performed in emergency situations, where patients do not undergo adequate preoperative preparation and are often combined with water-electrolyte and acid-base disorders, malnutrition or anemia; some chronic diseases (such as diabetes or cardiovascular disease) are not adequately controlled and adjusted; most patients have a history of previous surgery and have a complicated abdominal situation; among patients without a history of abdominal surgery, adolescents are mostly caused by congenital disorders such as digestive tract malformations, which are uncommon and pose difficulties for proper diagnosis and management; the increasing incidence of mesenteric vascular disease in middle-aged and elderly patients, together with factors such as the increasing proportion of combined chronic diseases, have significantly increased the morbidity and mortality of complications. From the condition of the intestine itself, due to the inability to perform intestinal preparation, there is often a large amount of intestinal contents in the intestinal cavity, which easily causes abdominal contamination and anastomotic difficulties; due to the edema, congestion or ischemia of the intestinal canal and the large difference between the distal and proximal diameters of the obstruction, both manual anastomosis and the use of anastomosis are more difficult to operate than elective surgery, and are prone to anastomotic leakage and poor healing. From the physician’s point of view, emergency surgery is mostly performed by young physicians with insufficient experience in handling, and the limited time to observe and understand the condition makes it difficult to guarantee the treatment effect. Therefore, it is very important to improve the understanding of intestinal obstruction and to make adequate preoperative preparation to improve the treatment effect and reduce complications. Indications for surgery The most important thing that patients with intestinal obstruction need to clarify is not only the presence or absence of intestinal obstruction, but also the degree of obstruction. Doctors are most worried that if they do not operate urgently, they may miss the timing of surgery and bring danger to the patient; but if they operate urgently, will they operate the patient who should not be operated and regret when they open the abdominal cavity. To solve this problem, it is necessary to have a full understanding of the condition. First of all, the characteristics of intestinal obstruction should be clarified: paroxysmal or persistent colic is the most important feature of mechanical intestinal obstruction and intestinal blood supply disorder, if combined with fever, increased blood count, high intestinal tone or vomiting, it indicates serious condition; if accompanied by coffee-like anal excretion more indicates that there is intestinal blood flow disorder, which needs emergency surgical treatment; chronic abdominal distension but not accompanied by colic, weak or disappeared intestinal tone, or patients whose condition is free often do not require emergency surgical treatment. For those with a history of previous surgery, the characteristics of previous surgical modalities and postoperative symptoms and abdominal signs are decisive for the diagnosis of intestinal obstruction and the choice of treatment, and must be clarified before surgery. For the above reasons, the attending physician must personally ask the medical history and examine the patient, even if the same complaint, the same symptoms and signs, different doctors with different qualifications have different understanding of the condition due to their different experience, thinking styles and knowledge, and it will be more helpful if several doctors can have a brief discussion to clarify the diagnosis and formulate a reasonable diagnosis and treatment plan. If it is the first episode of adhesive intestinal obstruction, it means that the intestinal canal did not have the problem of poor passage in the past, and this episode may be combined with food blockage factors on top of the gradual narrowing of the intestinal lumen. Of course, if the obstruction gradually worsens and there is a large difference between the diameter of the proximal and distal intestinal canal of the obstruction, it is difficult to restore patency on its own and surgery is needed as soon as possible. If there is recurrent intestinal obstruction in the past, it means that the problem of intestinal stenosis persists, and non-surgical treatment often cannot solve the problem completely and surgery is needed. You should not refuse surgery because “the more you operate, the more adhesions”, because “adhesions” and “obstruction” are two concepts. The purpose of surgery is not to treat adhesions, but to treat obstruction. Early postoperative intestinal obstruction is sometimes more difficult to manage. Early postoperative inflammatory bowel obstruction is caused by the combination of edema, thickening and adhesions of the intestinal wall. Because of the dense adhesions and obvious congestion and edema of the intestinal tube, it is extremely difficult to separate them by surgery, and it is easy to cause extensive breakage of the intestinal tube and postoperative complications of intestinal fistula, so surgery is not recommended. With non-surgical treatment such as total parenteral nutrition, growth inhibitors and glucocorticoids, most patients can recover [2]. However, the early intestinal obstruction after abdominal surgery is not all inflammatory intestinal obstruction, and individual patients may show mechanical intestinal obstruction such as abdominal colic after partial recovery of intestinal function, and if it cannot be relieved by active non-operative treatment, surgery should be performed promptly, and the postoperative intestinal obstruction should not be included in non-operative treatment. Of course, many factors need to be considered in the management of early postoperative intestinal obstruction, such as the most recent surgery, the difficulty of reoperation, the degree of disturbance and damage to the abdomen, the patient’s tolerance, the surgical approach, the support and understanding of the patient and his family, the influence on the reputation of the last surgeon, etc. Therefore, this type of intestinal obstruction is prone to deviations in the management and needs to be treated most seriously. Non-surgical treatment measures in the perioperative period If it is decided to perform non-surgical treatment for intestinal obstruction, each treatment measure must be put into place and must not be formal: gastrointestinal decompression is not simply a drainage tube built into the patient’s stomach, which cannot achieve the purpose of intestinal decompression; the tip of the decompression tube must be put into the proximal end of the obstruction so that the intestinal canal remains empty and the obstruction can be easily relieved. To reduce intestinal distension caused by intestinal contents, in addition to fasting and gastrointestinal decompression, adequate amounts of growth inhibitors should be used to minimize the secretion and loss of digestive juices. Intestinal wall edema is also one of the important causes of intestinal obstruction. Increasing plasma colloid osmotic pressure by diuresis, plasma or albumin infusion can help to relieve intestinal wall edema, expand intestinal tube internal diameter and improve intestinal mucosal oxygen supply; eliminating ascites can help to improve intestinal dynamics. Nutritional support increases plasma colloid osmotic pressure by improving nutritional status and can provide the body with the required nutrients, which is a necessary option for patients with intestinal obstruction. Many patients suffer from chronic constipation before surgery, but this factor is often overlooked by patients and health care providers. During the recovery of intestinal function after surgery, a large amount of water from intestinal contents is absorbed, coupled with intestinal dysmotility, dry stools block the intestine, and symptoms of intestinal obstruction easily appear. If this factor of preoperative constipation is ignored, it is easy to misjudge the condition and even take surgical treatment incorrectly when dealing with postoperative intestinal obstruction. However, as long as this medical history is understood and measures such as enema, laxative, and promotion of intestinal peristalsis are used, intestinal obstruction can mostly be relieved on its own. The diagnostic value and significance of abdominal plain film need not be elaborated, and CT is of great value in the diagnosis of intestinal obstruction: tumor, fecal stone and other occupying lesions can be revealed by CT, diffuse intestinal dilatation indicates power obstruction, partial intestinal dilatation and partial intestinal collapse indicate obstruction in a certain part of intestine, suggesting mechanical intestinal obstruction. CT can also detect abnormal signs such as ascites, thickening of the intestinal wall, and adhesions between the intestinal walls, which are important for identifying the cause of obstruction and selecting treatment modalities. For example, CT of early postoperative inflammatory bowel obstruction shows thickening of the intestinal canal wall, disappearance of the boundary of the intestinal wall, and shrinking or even disappearance of the intestinal lumen; intestinal torsion can be seen as a bundle of twisted mesenteric roots, and concentric vascular shadows can be seen on enhanced scans; intestinal obstruction caused by abdominal cocooning can be seen as intestinal canal confined within the peritoneum, resembling a mass. Oral iodine contrast has clinical value in evaluating the degree of intestinal patency and shortening the length of hospital stay in patients treated non-operatively [3]. The so-called coffee-like excrement and bloody ascites are signs of intestinal strangulation, and these signs should never be interpreted as indications for surgical exploration, and we should not wait passively because of the absence of the above symptoms until they appear. Such behavior is a serious dereliction of duty. It is well known that intestinal adhesions are easily caused after abdominal surgery, and in general, the more complicated the surgery the heavier the adhesions, which start immediately after surgery, worsen in about 2 weeks, are most significant within 3 months, and after 3 months, the adhesions begin to gradually loosen. Therefore, the interval between two abdominal surgeries should preferably be more than 3 months, or within 2 weeks. Of course, if a patient develops mechanical intestinal obstruction after surgery, which cannot be relieved by non-surgical treatment, surgery should be performed at any time, but the surgical procedure should be chosen carefully and should not be too complicated. In addition to assessing the possibility of separating the adherent intestines, which should take into account factors such as the complexity of the last surgical operation and contamination of the abdominal cavity, a physical examination of the abdomen is also helpful; if the abdomen is tough, it indicates severe abdominal adhesions; if the abdomen is soft, the adherent intestines can be easily separated. The degree of intestinal adhesions and the possibility of separation can also be understood by abdominal CT. The choice of surgical approach The choice of incision has the following considerations: the closest to the lesion to make an incision to facilitate surgical operation, such as gastrointestinal tumors or other initial surgery often based on this principle to choose the incision, but for those who operate again or repeatedly, especially those who have adhesions below the incision, if directly along the original incision into the abdomen, although the closest to the lesion, but also incidentally can remove the original incision scar, but often just into the abdominal cavity, the intestinal tube that is The intestinal canal is often broken in many places, and even the intestinal canal has been cut without knowing whether to enter the abdominal cavity. According to foreign statistics, about 30% of patients operated for adhesional intestinal obstruction will suffer from subincisional intestinal injury if they enter the abdomen through the original incision. For this kind of surgery, the most serious part of adhesions should be avoided, and the most common method is to extend the original incision, and it is easier to enter the abdominal cavity from the extended part, and then gradually separate to the part with heavier adhesions, which can reduce the chance of intestinal tube injury. If another incision is made from other parts, the blood supply between the two incisions should be considered, the author has met a patient, only 2 weeks apart, the two operations were taken abdominal incision and rectus abdominis incision, the incision are long, the result of the two incisions between the abdominal wall layer necrosis, resulting in abdominal wall defects. The intestinal obstruction caused by radiation enteritis is more special, because external irradiation will injure the abdominal wall, and the depth of the abdominal wall irradiation site is often where the obstruction is located, if the incision is made at the abdominal wall radiation injury, postoperative incision healing is very difficult, therefore, the incision of this type of surgery should avoid the radiation injury, for pelvic surgery, often take the middle and lower abdominal transverse incision or curved incision. From the perspective of preventing postoperative intestinal obstruction, the chance of adhesions with the intestinal canal below the incision after transverse incision (25%) is also significantly less than that of longitudinal incision (70%). The distal and proximal intestinal tube diameters of the obstruction are often found to be far apart during intestinal obstruction, at which time an end-to-side anastomosis or a lateral anastomosis should be used, and an end-to-end anastomosis should not be used to avoid postoperative intussusception or obstruction, or even anastomotic fistula. Distal anastomotic obstruction is a common cause of unrelieved postoperative obstruction and intestinal fistula, so the whole gastrointestinal tract must be fully explored before intestinal anastomosis to exclude the possibility of multiple obstructions. Many surgeons are used to adopt the method of lateral anastomosis to open the obstructed intestinal segment when it is difficult to remove the diseased intestinal segment or the adhesions cannot be separated, although the short-term effect may be satisfactory, but in the long term, it has many complications and is prone to blind collaterals syndrome. The use of. The author has seen a patient who had 7 lateral anastomoses in one operation and still had intestinal obstruction after the operation. In fact, in this case, even if the intestinal canal was restored, due to excessive short-circuiting, short bowel syndrome and blind collaterals syndrome would occur, which is really more than worth the loss. For those who cannot be separated from the adhesions, if the adhesions are not large in scope, they can be resected; if the adhesions are large in scope, they should not be forcibly separated, and distal and proximal intestinal stomas can be made to relieve the obstruction, and the small intestine can be intubated or externally stomaed, and enteral nutrition is given after the operation, and digestive fluid is collected and transfused back. After a period of time, the adhesions and obstruction at the distal end of the stoma will mostly be relieved by themselves, at which time the stoma can be returned. In some patients, after the obstruction is restored, the intestinal integrity can be restored by removing the stoma tube directly, and it is not even necessary to surgically remove the stoma. Forced separation of adhesions often leads to unmanageable consequences: enterocutaneous fistula, postoperative reobstruction, extensive intestinal plasma membrane bleeding, extensive bowel resection, and short bowel syndrome, among others. For abdominal cocooning or extensive severe intestinal adhesions, if the operator is not sure enough to complete the operation, it is not advisable to force the operation and should end it early with only the simplest treatment to relieve the symptoms and facilitate the subsequent operation. Otherwise, the more operations are performed, the more difficult the next surgery will be and the greater the risk to the patient. After partial stripping of adhesions, as the obstruction is not completely lifted, postoperative intestinal edema and paralysis, the symptoms of intestinal obstruction are very likely to worsen, and sometimes another intestinal obstruction surgery has to be performed when the time is not yet ripe, which brings great difficulties to the surgical operation. Intestinal obstruction caused by Crohn’s disease of the small intestine is often combined with internal fistula and abscess between intestinal collaterals, and a large number of small intestines are adhered to form a mass, so if surgery is performed during this period, a large number of small intestines will inevitably be removed, and if intestinal anastomosis is performed, anastomotic fistula or abdominal cavity residual infection will easily occur. In such patients, fasting, parenteral nutrition, glucocorticoids or TNF monoclonal antibodies can be administered first, and abscess drainage can be performed first for combined abdominal or intercollateral abscesses, so that the scope of inflammation can be significantly reduced, and the obstruction symptoms can often be relieved, and even if the obstruction is not relieved, the scope of intestinal resection will be significantly reduced. Another difficulty in intestinal obstruction surgery is the determination of the extent of blood supply, especially in dealing with extensive intestinal ischemia/sludge or mesenteric vascular disease, surgeons are often very conflicted: if they want to have a satisfactory anastomosis, the anastomosis must be established at a site with absolutely reliable blood supply, and the intestine with uncertain blood supply must be resected, which often results in too much resected intestine and easily leads to short bowel syndrome; if they want to preserve more intestine, the intestine without complete If one wants to preserve more intestinal tubes, intestinal tubes that are not completely necrotic should not be resected, so that the anastomotic blood supply is uncertain and anastomotic fistula or stenosis can easily occur after surgery. In fact, it is not necessary to perform intestinal anastomosis immediately after intestinal resection, and all problems can be solved if an external stoma is placed at the severed end of the intestinal tube: the intestinal tube without definite necrosis but with uncertain blood supply can be placed externally, and postoperative dynamic observation can decide whether to resect or preserve according to the change of blood supply, and then perform intestinal anastomosis at a later date after the viability of the intestinal tube is determined. This ensures the blood supply to the intestinal anastomosis and is consistent with the concept of damage control surgery in critically ill patients. For chronic intestinal ischemia, intraoperative fiberoptic enteroscopy can be performed: the intestinal mucosa is extremely poor in tolerating ischemia and hypoxia, and even though the blood supply to the plasma muscle layer of the intestine is normal, the intestinal mucosa may be ischemic and necrotic or even detached, which can be seen at a glance by intraoperative enteroscopy and provide a basis for the extent of intestinal resection. In conclusion, if the scope of intestinal resection is small, the part with suspicious blood supply should be removed to make the anastomotic blood supply reliable. However, if extensive bowel resection is done and there is a possibility of short bowel syndrome after surgery, the part with suspicious blood supply should be preserved to avoid more cuts. In order to avoid anastomotic fistula, an enterostomy should be done, and then stoma rejection should be performed at an elective stage. The treatment of intestinal obstruction caused by advanced tumor is mainly aimed at relieving the obstruction, which is a reduction surgery, and an enterostomy can be done. The scope of surgery should not be too large, and it is not advisable to excessively pursue the removal of tumor to avoid excessive trauma and surgical complications, which is counterproductive. Prevention of re-obstruction Re-obstruction is more common after intestinal obstruction, and various attempts have been made to avoid this problem, but no satisfactory effect has been received so far. At present, it is believed that adhesions are an indispensable part of tissue healing, but under normal circumstances, the body will release the adhesions by itself through the process of fibrinolysis within a short time after the formation of adhesions. If the peritoneum is damaged by excessive stretching, cutting, contusion, ischemia, drying and hematoma due to trauma or surgical operation, the fibrinolytic process is stalled, and even fibrin deposition and mechanization occur, resulting in dense adhesions. There have been various anti-adhesion methods, including the use of heparin, glucocorticoids, NSAID, and sodium hyaluronate, all of which are ineffective and even have side effects. The most effective measures to prevent adhesions and obstruction are currently considered to be to reduce the adverse stimulation of the peritoneum caused by surgical operations and abdominal foreign bodies, to pay attention to the protection of the intestinal canal and peritoneum, to operate carefully to reduce bleeding and the resulting ligation and electrocoagulation, to flush the peritoneal cavity adequately before closing the abdomen, to remove all foreign bodies, including autologous inactivated tissue and blood clots, and to eliminate the rough surface of the plasma membrane whenever possible. In cases of extensive damage to the plasma membrane surface of the intestine, internal alignment should be used to prevent reinfarction, and the placement of anti-adhesive agents is not advocated. Conclusion The surgical treatment of intestinal obstruction must be given high priority. The ideal treatment effect can be received only if the condition is carefully understood before the operation, and the appropriate operation time, the appropriate personnel and the appropriate operation style are selected. If the operation cannot be completed satisfactorily, do not act recklessly, so as not to end the operation when it cannot be carried out, and “keep it simple” to facilitate future treatment.