At present, there is no unanimously recognized effective method for preventing intestinal obstruction by intestinal adhesions. Clinical experience has confirmed that there are several options available, one of which is to reduce the extent and degree of intestinal adhesions, and the other is to acknowledge that adhesions will inevitably occur, but allow them to form orderly, non-acute adhesions, thereby avoiding the occurrence of intestinal adhesions.
To reduce the scope and degree of intestinal adhesions and prevent intestinal obstruction
1. Abdominal flushing.
The use of saline for a large number of repeated abdominal flushing is the only effective method to date to reduce the scope and degree of abdominal adhesions. The amount of flushing can be as little as 60 mL/kg or as much as 300 mL/kg. through flushing, the residual foreign body, broken necrotic tissue, bacteria and bacterial products, pus and fibrous plaque (block) in the abdominal cavity are obviously reduced, and the fibrous tissue proliferation formed by these substances stimulating the peritoneum is reduced. Through observation of patients undergoing secondary surgery, we found that abdominal irrigation was effective in reducing the degree and extent of abdominal adhesions. The previous surgery flushing volume, again after the dissection into the abdomen will find that the intestinal canal is only “as thin as a cicada wing”, soft as silk layer of snow-white fibrous membrane.
2, drug prevention.
Through a large number of observations of patients after multiple surgeries, we found that, so far, have not found a drug that can effectively reduce abdominal adhesions. Some domestic literature claims that there are drugs that can reduce abdominal adhesions, and there are animal experiments to confirm. However, there is a lack of multicenter bulk prospective, randomized, double-blind clinical trial studies, which are mostly single-center empirical presentations. In practice, there are real difficulties in conducting clinical trials. First, there is a lack of quantitative description of abdominal adhesions, second, most patients do not have the opportunity for reoperation to observe abdominal adhesions, third, long-term follow-up is required, and fourth, the occurrence of intestinal obstruction with intestinal adhesions is multifactorial, such as the way of eating can lead to the occurrence of intestinal obstruction, let alone the type of food eaten. In patients with intestinal fistulas after intestinal adhesions and intestinal obstruction, we found that some anti-adhesion drugs were added during the previous surgery, which instead made the adhesions more severe in some patients than in similar surgeries, with scarred adhesions all over the abdominal cavity and unusual difficulties in separating the adhesions.
Some empirical means of preventing postoperative intestinal adhesions and intestinal obstruction
1.General principles
To reduce unnecessary separation, for intestinal obstruction caused by intestinal fistula, adhesive cords and local adhesions, it is clear before surgery that the intestinal canal is open at the distal and proximal ends of the lesion, and after removing the fistula to reconstruct the digestive tract and loosening the cords and local adhesions, extensive separation is not necessary. Otherwise, it will cause more extensive intestinal adhesions and also lay the groundwork for the next occurrence of adhesive intestinal obstruction.
The debridement of necrotic tissue is appropriate. Otherwise, the trauma left by the debridement will be the basis for the formation of adhesions. The blood exuded from the wound surface after debridement is also the material that causes adhesion formation. However, the necrotic and broken tissues that are free in the abdominal cavity should be eliminated as much as possible. The best way to remove it is to use saline for peritoneal irrigation.
As much as possible, ligation and suturing should be completed with absorbable sutures, and reconstruction of the digestive tract should be completed with anastomoses and sutures. Avoid the formation of filament granulomas and adhesions from the extensive use of silk sutures. During the intraoperative operation, treat the tissue gently and avoid repeated rubbing and squeezing. Avoid blocking the blood supply of the intestinal canal for a long time to reduce the time of intestinal ischemia and reduce the inflammatory edema of the intestinal wall.
2.Avoid unnecessary jejunostomy and ileostomy
Standard jejunostomy requires purse-string embedding, tunnel embedding and abdominal wall hanging. If improper hanging with the abdominal wall, it can lead to mechanical obstruction by hanging the jejunum at an acute angle. Strictly speaking, this is also a kind of adhesive intestinal obstruction, that is, the artificial suture causes adhesions between the abdominal wall and the jejunostomy, which can cause obstruction if slightly improper. The jejunostomy is generally chosen at about 15cm below the jejunostomy flexor ligament, which can avoid the hanging of the jejunostomy into the corner.
3, try not to do shortcut surgery
Short-cut surgery, i.e. short-circuit surgery, is one of the traditional methods of treating adhesive intestinal obstruction. It is a stopgap measure when the intestinal adhesions and intestinal obstruction parts cannot be separated. Through long-term clinical observation, it is found that intestinal obstruction will still recur after surgery. Due to the formation of a small local circulation, when the obstruction site is reopened later, it will, on the contrary, increase the abdominal distension and make the intestinal obstruction more likely to occur. It is found that the short-circuited intestinal canal is atrophied and the intestinal wall is thin due to the absence of effective intracavitary nutrition, and the original open intestinal canal is easily broken during surgical separation, and it is not easy to repair after the breakage. In the absence of normal intestinal fluid, the intestinal cavity of the open intestinal canal lacks factors that inhibit bacterial proliferation, and the bacteria in the intestinal cavity will overproliferate. Therefore, it is better to perform a short-circuiting operation on the adhesional intestinal obstruction that cannot be separated, especially the intestinal obstruction dominated by inflammatory factors, than not to do any operation. In fact, most of the adherent intestinal obstruction can be relieved. Of course, as a palliative treatment, short-circuit surgery across the cancerous obstruction can still be performed.
4.Avoid the use of artificial patch that causes adhesions in the abdominal cavity
In recent years, with the use of various artificial patches, intestinal adhesions and intestinal obstruction due to improper use of patches have occurred from time to time, and serious cases may also lead to the occurrence of intestinal fistula. For abdominal defects, patch repair methods include onlay, inlay, and underlay. The most prone to adhesions is the inlay type, which is highly susceptible to intestinal adhesions because the patch is in direct contact with the abdominal cavity.
Patches that can clearly cause intestinal adhesions include polypropylene mesh and polyester fabric. These materials can abrade the intestinal wall and stimulate granulation, which can facilitate temporary abdominal closure and wound implantation in patients with open abdominal cavity, but not permanent reconstruction of the abdominal wall. Continuous abrasion and granulation will cause extensive intestinal adhesions under and around the mesh. Granulation can also grow within the mesh of the patch, making it extremely difficult to remove the mesh. Contracture and deformation of the mesh can cause intestinal obstruction. Prolonged abrasion can also cause intestinal rupture leading to the development of intestinal fistulas.
A proven patch that can reduce abdominal adhesions is polytetrafluoroethylene. However, its tensile strength is poor, so there are products that paste polypropylene mesh and PTFE together to give full play to the tensile capacity of polypropylene and the anti-adhesive capacity of PTFE, but the PTFE surface must be placed on the visceral surface of the abdominal cavity, otherwise, the effect is counterproductive.
A more desirable method of abdominal wall repair is to use a covered repair, with a layer of peritoneal tissue or hernia sac tissue in the inner layer and a polypropylene mesh repair outside. It would be better to add a layer of rectus abdominis tissue in front of the peritoneal tissue by the technique of sheath separation of rectus abdominis and then reinforced with polypropylene mesh.
5. Non-surgical methods to prevent intestinal adhesions and intestinal obstruction
Lifestyle changes are an important means to prevent the frequent occurrence of adhesive intestinal obstruction. This is a problem often ignored by both clinicians and patients. Surgery is not the only way to solve the disease. If patients do not change their lifestyle and “eat and drink a lot”, they will still have intestinal obstruction even after intestinal alignment surgery.
The correct way of eating is to consume small amounts of food several times, which is called “less food and more meals”. Avoid the instantaneous increase of intestinal contents, which may cause the adherent intestine to drop down into an angle. Patients with frequent adhesive intestinal obstruction should not eat food with crumbled food. First, try to eat less insoluble dietary fiber, such as leeks, bamboo shoots or dried bamboo shoots, which is known as crude fiber in folklore; second, eat less food containing tannic acid, such as persimmon, hawthorn with dates. Tannic acid in these foods will make the protein deformation and the formation of the group fast, into the intestinal cavity is not easy for the digestive juices and the mechanical movement of the small intestine crushed, in the intestinal tube adhesion hanging into the corner of the formation of obstruction.
There is no once-and-for-all method to solve adhesive intestinal obstruction. In addition to using various methods mentioned above to reduce the occurrence of adhesions, the best way is to summarize the pattern of occurrence of adhesional intestinal obstruction each time it occurs. It is more important to avoid eating the mode and food that cause adhesive bowel obstruction than to operate again. Intestinal alignment should be considered only in cases of frequent occurrence of adhesive bowel obstruction despite repeated attention to lifestyle. Lifestyle changes should still be attended to after intestinal alignment surgery. After the occurrence of adhesive intestinal obstruction, if there is a long asymptomatic “quiet period”, the intestinal wall will be less inflammatory edema, the adhesions will gradually evolve from scar adhesions to membranous adhesions, and the incidence of intestinal obstruction will also become smaller. In Chinese medicine, the so-called post-cesarean section is a major injury to the vital energy, and it takes years to accumulate vital energy, which in a way emphasizes the role of quiet recuperation and waiting for the adhesions to relax.