There are various causes of intestinal obstruction after abdominal surgery, and adhesive intestinal obstruction is a common cause, accounting for 20% to 40%. Adhesive intestinal obstruction is a common complication after abdominal surgery, which is an inflammatory reaction caused by trauma, infection and foreign body stimulation, mostly fibrous adhesions, usually occurring in the small intestine, and causing colonic obstruction is rare. This may be related to the long small intestinal tube, many tortuous twists and turns, large mobility, easy twisting of the small intestinal mesentery, and small intestinal lumen of the small intestine.
The common types are.
1, part of the intestinal tube and abdominal wall adhesions fixed, so that the intestinal tube is twisted at an acute angle;
2.Adhesive band compressing or winding the intestinal tube to form obstruction, or forming internal hernia;
3, the intestinal tube itself adhesions into a group, local intestinal stenosis or torsion, especially the extensive intestinal adhesions are heavy.
Therefore, the surgical treatment of adhesive intestinal obstruction is easy to fall into the vicious circle of “obstruction-operation-re-obstruction-operation”, which not only leads to long treatment time and high cost, but also leads to malnutrition, deterioration of general condition and postoperative complications such as intestinal fistula, short bowel and abdominal infection in serious cases.
One case in our group had an extra-intestinal fistula due to multiple operations. How to choose the timing of surgery for adhesive intestinal obstruction? Premature surgery will make some patients who can be cured by non-surgery experience another surgery risk; too late surgery, surgery only when the physical condition is extremely deteriorated or even intestinal strangulation occurs, the surgical efficacy decreases sharply and complications increase significantly.
Combining the relevant literature and clinical experience, we believe that the following points should be followed.
1.When intestinal obstruction has strangulation or strangulation may occur, surgery should be performed as soon as possible, and the observation time should not exceed 4~6h in general, especially for elderly patients with intestinal obstruction and pediatric intestinal obstruction.
2, non-surgical treatment is ineffective, the symptoms are not reduced but the condition is aggravated, or frequent, severe abdominal pain is difficult to relieve, even if there is no strangulation, surgery should be timely.
3, intestinal obstruction for a long time does not relieve (long duration of the disease) or recurrence of patients can be relieved by non-surgical treatment, but the recurrence rate is high, but also advocate surgery. To reduce the systemic impact of intestinal obstruction and local intestinal damage.
4, previous surgery for adhesiolysis and re-occurrence, the symptoms are not relieved by conservative treatment or have a tendency to aggravate, should be timely surgical treatment.
5, abdominal abscess triggered by adhesion intestinal obstruction.
The clinician must take a detailed history, dynamically observe the clinical symptoms, changes in signs and their evolution, and at the same time combine with the corresponding auxiliary examinations such as abdominal plain film, gastrointestinal imaging with water-soluble contrast agent if necessary, B ultrasound or CT, etc. Strictly grasp the indications for surgery, timely use of surgical treatment, and appropriate selection of surgical methods according to the situation during surgery. There are various forms of adhesions in intestinal obstruction, and the surgical method should not be confined to the format. The surgical method should be determined according to the specific situation of adhesions: if the adhesions in pieces make the intestinal canal adhere at an acute angle or cause intestinal stenosis, the intestinal canal should be carefully separated sharply and the blunt separation should be avoided.
Adhesions that cause obstruction by compression of the bundle should be removed or loosened, otherwise they should not be treated. If the intestinal canal is difficult to be separated or the blood flow is impaired, a small part of the adhesions can be removed. If the intestinal adhesions are too severe to be peeled off or the obstruction cannot be removed, or if the condition does not allow the implementation of a wide range of complicated operations, a shortcut operation should be performed, which should be used with caution. Except for the lesion, the open intestine should be kept as short as possible to avoid blind collaterals syndrome. If the adhesions are extensive, or if the adhesions are tight and the plasma muscle layer is heavily damaged after separation, and the chance of re-adhesion after surgery is inevitable, intestinal alignment is feasible.
Intestinal alignment is a last resort treatment when adhesional intestinal obstruction occurs repeatedly and no effective treatment is available, and it should not be widely used. It should be performed only in cases of recurrent intestinal adhesion obstruction that still occurs after two surgeries. In a few cases, after extensive intestinal detachment, the intestinal wall is rough and the intestinal plasma layer is heavily broken, predicting the inevitable occurrence of intestinal adhesion obstruction, postoperative intestinal alignment can be performed. However, because of its main shortcomings of increasing the operation area, prolonging the operation time, and the need to repeatedly squeeze the intestinal tube to cause intestinal tube congestion and edema, local alignment should be used, that is, only the part of the intestinal tube with rough walls should be arranged.
Regardless of the method, it should be simple, safe and reliable, not only to separate the adhesions and lift the obstruction, but also to protect the continuity of the normal intestinal tube and preventatively reduce the recurrence rate of obstruction. Surgery is a method of treatment, but it also provides conditions for the formation of intestinal adhesions. Theoretically any surgery can lead to intestinal adhesions, and adhesions are part of the tissue healing mechanism. However, too much or inappropriate extent and location of adhesions will affect normal physiological functions.
Therefore, it is important to pay attention to the prevention of adhesions at the same time of surgery: one is to reduce adhesions, and the other is to guide controlled adhesions between the intestine and the bowel without obstruction. Some data show that the causes of intestinal adhesions are mainly surgical factors accounting for 80% and other inflammatory adhesions accounting for 10% to 20%. However, surgery itself does not play a decisive role in the occurrence of adhesions, but is related to the neglect of minor intraoperative aspects and individual physical differences. This shows the importance of artificial and unnecessary factors of surgical injury in the prevention of adhesions.
The following aspects should be noted.
1, intraoperative care of tissues, pay attention to the protection of the intestinal canal, avoid excessive blunt separation of adhesions, reduce the time of exposure of the intestinal canal in the air and the exposed area, protect the intestinal canal with warm saline gauze pads if necessary, which helps to protect the plasma membrane surface of the intestinal canal and does not show water loss. Prevent intraoperative peritoneal tears, defects and ligation of large tissues. Do not block the vessels or clamp the intestinal canal for a long time.
2, intraoperative efforts to make the trauma peritoneal, absorbable sutures externally suture the peritoneum of the incision. Suture stitches should be small and minimize foreign body residue z such as threads are too long.
3, carefully remove the pus and necrotic tissue attached to the organs and peritoneum, intra-abdominal hemostasis should be complete, reduce the use of electric knife to prevent current to plasma membrane injury.
4, early postoperative bed activity, early recovery of gastrointestinal motility.
5, for long operation time, wide range of surgical operations, bleeding and exudate, heavy contamination of the abdominal cavity, a large amount of warm saline or dilute iodine to flush the abdominal cavity at the end of the operation, postoperative fasting time can be extended, alert to the possibility of intestinal adhesion.
6, avoid unnecessary drainage tube placement, or choose the appropriate abdominal drainage, and remove it as early as possible.
7, postoperative attention to correct the water-electrolyte and acid-base balance disorders, to prevent low potassium, low magnesium.
8.Improve the nutritional status of the patient and perform parenteral nutrition support.
9.Rational use of antibiotics to prevent or control infection, and correct management of abdominal infection complications.
10.In order to prevent adhesive intestinal obstruction, use medical sodium hyaluronate gel or anti-adhesive medical film before abdominal surgery. As an anti-adhesion barrier, it can prevent postoperative tissue adhesions and excessive proliferation of fibrous tissue to a certain extent and reduce the incidence of adhesions.
11.People with history of abdominal surgery should develop good habits in daily life.
Avoid full meals, excessive drinking and greasy food, avoid eating unclean or allergic food, and do not give indigestible food, such as persimmon and glutinous rice. Avoid strenuous exercise or sudden change of body position. For constipation, deal with it in time.
12, the current development of laparoscopic surgical methods can also reduce the occurrence of intestinal adhesions.