Early postoperative inflammatory small bowel obstruction (EPISBO) refers to edema and exudation of the intestinal wall caused by surgical trauma and aseptic inflammation in the abdominal cavity within 1-2 weeks after abdominal surgery, forming The concept is different from conventional mechanical or strangulated intestinal obstruction, which is caused by extensive separation of adhesions during abdominal surgery, prolonged intestinal tube exposure or postoperative aseptic inflammation of the abdominal cavity. The clinical manifestation is characterized by the resumption of defecation after surgery, or even resumption of postoperative feeding but followed by abdominal pain, abdominal distension and anal cessation of defecation or recurrent vomiting symptoms.
In the early postoperative period, the possibility of developing strangulated intestinal obstruction is generally low due to extensive adhesions and edema in the abdominal intestinal canal. Inadequate knowledge of this characteristic intestinal obstruction may aggravate the damage to the abdominal intestinal canal if intestinal adhesions are rashly reopened for release, and may even lead to serious postoperative complications such as extra-intestinal fistula. Reviewing the treatment results of 15 patients treated in our department, the results of conservative treatment were satisfactory.
Conventional conservative treatment measures for intestinal obstruction, in addition to anti-infection, fasting and water fasting and gastrointestinal decompression can effectively gastrointestinal decompression, which is conducive to reducing intestinal pressure, restoring intestinal blood circulation and promoting the regression of intestinal inflammatory edema, and is also applicable to EPISBO patients. Parenteral nutrition support therapy is an important treatment tool. We adopt the method of “All in one (AIO)” parenteral nutrition solution in the configuration of “3-liter bag”, which is 25-30 Kcal per kg of body weight per day. The ratio of sugar to fat is 5:5 or 6:4, while amino acids, vitamins, electrolytes and trace elements are supplemented to provide nutritional support to improve the edema and exudation of the intestinal wall and maintain the energy needs of the patient under fasting. In addition, albumin should be infused appropriately to increase colloid osmotic pressure and diuretics to reduce intestinal edema, so that the intestinal function can be restored as soon as possible. Growth inhibitor octreotide (Sunning) can significantly inhibit the release of gastrointestinal hormones and the secretion of digestive juices, reduce the secretion of intestinal inflammatory exudate and digestive juices, reduce intestinal pressure and abdominal pressure, and strengthen intestinal blood supply, which is also beneficial to the recovery of intestinal function. Oxytetracycline 0.1mg-0.3mg is usually given in saline 59ml-57ml in a total of 60ml by continuous infusion via micro-venous pump for 24 hours. Adrenocorticotropic hormone has the effect of anti-inflammatory to prevent postoperative intestinal adhesions, and its early use can relieve inter-intestinal adhesions and promote the edema of intestinal wall. Of course, adrenocorticotropic hormone may also bring toxic side risks such as acute peptic ulcers, so a treatment strategy of small doses of short course dexamethasone, 5mg-10mg/d, should be used, and the dose should be gradually reduced to discontinued after about 5 days.
During the treatment process, the condition should be closely observed, especially the changes in abdominal signs, abdominal swelling subsides and becomes soft, the amount of gastrointestinal decompression and drainage fluid decreases and becomes clear, and bowel sounds return, and the anus resumes venting and defecation, which are signs of gradual recovery of intestinal motility. At this time, the dosage of growth inhibitor and adrenocorticotropic hormone can be gradually withdrawn, and if the intestinal function is restored for more than 3 consecutive days, the gastrointestinal decompression tube can be removed more safely and enteral nutrition can be restored from liquid diet. The process of resuming feeding should not be rushed, and the duration of the fluid diet prepared by enteral nutrition powder can be appropriately extended to gradually transition to a normal diet, our experience is the “4-3-3” model (i.e. 4 days of fluid diet, 3 days of semi-liquid diet, 3 days of normal diet), which can fully allow the intestine to gradually adapt to the state of fasting to feeding.
If conservative treatment is still ineffective for about 2 weeks, in order to prevent prolonged intestinal wall edema and ischemia or strangulated intestinal obstruction such as intussusception, re-operation can be considered.