Patients who have undergone abdominal surgery and those who are likely to undergo abdominal surgery are concerned about one issue: intestinal adhesions after abdominal surgery. Why do intestinal adhesions occur? How to prevent intestinal adhesions? What should be done if there are intestinal adhesions? This issue has been a problem that medical practitioners have been studying and trying to solve.
Why do intestinal adhesions occur?
For the majority of readers, I am afraid that they have not had the opportunity to see the true face of intestinal adhesions. Therefore, to understand the problem of intestinal adhesions, it is better to start with the analogy of skin scarring, which is experienced and visible by everyone. When skin infections, such as boils and sores, eventually leave a little scar and heal, hence the name “sore scar”, indicating that sores and scars are inseparable. When the skin is cut and broken, or when a large wound is stitched up by a doctor, even if no bacterial infection occurs, a linear scar will remain after an inflammatory reaction and fiber proliferation. In fact scarring is a way for the tissue to repair and heal the injury. From this point of view, scarring is a blessing, not a curse. And it will gradually soften over time, or even become less visible. However, if the skin damage is large and severe, such as a severe burn with infection, it can be a blessing rather than a curse. If a large scar grows on the face, or crosses a joint, or causes two fingers (toes) to adhere together and affects aesthetics, normal life and limb function, then it is a curse.
There is no skin on the inner surface of the abdominal wall and on the surface of internal organs such as the stomach and intestines, but there is a plasma membrane composed of less differentiated mesothelial cells, which is equivalent to the “skin” of the abdominal cavity. The plasma membrane is very thin and tender, and is particularly vulnerable to damage compared to the skin, but it is also fast to repair. In addition to its lubricating and absorptive role, its exudative, defensive and repair functions are intrinsic to the formation of adhesions. When the peritoneum is biologically, physically or chemically damaged to varying degrees, an acute inflammatory response occurs, with a large amount of exudate containing fibrinogen, which in turn forms a fibrous network that concentrates on the surface of the irritated tissue and adheres to the surrounding tissue; fibroblasts and the resulting collagen bundles then connect the wound to the surrounding tissue to form adhesions. Adhesions can be seen as a normal response to the peritoneum’s own physiological and repair functions. However, under normal conditions peritoneal mesothelial cell exudate releases fibrinogen in addition to fibrinolysis, which dissolves and absorbs the fibrin network and reduces the formation of adhesions. The key factor leading to the imbalance between the above two is the degree of local injury and inflammatory response. As long as the abdomen is open, adhesions are inevitable, although it is true that some patients who have had abdominal surgery can barely find traces of peritoneal adhesions when they are operated on again for other reasons. However, according to statistics, about 60% to 90% of patients have adhesions after abdominal surgery. If this is the case, why is it that not every post-abdominal patient is diagnosed with intestinal adhesions? In fact, it is one thing to have intestinal adhesions and another thing to diagnose them. Just as with scars on the skin, not everyone with scars on the skin needs to be seen and treated. Similarly, most post-operative intestinal adhesions do not cause special discomfort, and only a small number of them have different degrees of symptoms, that is, only when intestinal adhesions cause discomfort such as abdominal pain, bloating, vomiting and other symptoms, the doctor will diagnose “intestinal adhesions”.
Second, how to prevent intestinal adhesions
Knowing the causes and mechanisms of intestinal adhesions, it is understood that intestinal adhesions are inevitable after abdominal surgery. Any injury in the abdominal cavity (trauma, infection, bleeding, ischemia, stimulation of its contents after gastrointestinal perforation) is bound to lead to the repair of the plasma membrane, that is, the possibility of intestinal adhesions forming in the abdominal cavity. Of course, the laparotomy performed to eliminate the disease present in the abdominal cavity is also an injury that causes intestinal adhesions. What we can do is to minimize the extent of intestinal adhesions and reduce the occurrence of physician-diagnosed intestinal adhesions. The following measures are commonly used.
When abdominal disease requires surgery, surgery should be performed promptly
One of the goals of surgery is to eliminate the primary disease that produced the abdominal injury factor. For example, in the case of gastric perforation, a perforation repair is performed and the gastric fluid flowing into the abdominal cavity is removed. In the case of appendicitis, appendectomy is performed to eliminate the source of pus. The second purpose of surgery is to eliminate the primary pathology in the abdominal cavity, which reduces or even terminates the series of factors that lead to inflammation – commonly known as “inflammation” – and reduces the degree of postoperative intestinal adhesions. Therefore, when there is a perforated viscus, rupture, peritonitis and other conditions requiring surgical treatment, looking ahead and hesitating to undergo surgery, so that the factors of injury persist in the abdominal cavity, serious life threatening, or less difficult to operate, aggravating the degree of postoperative intestinal adhesions and expanding the scope of adhesions. If septic or perforated appendicitis is compared with simple appendicitis, the degree and extent of postoperative intestinal adhesions will increase exponentially. It is important to understand that the more severe the injury and the longer it lasts, the more severe and extensive the adhesions will be.
Preventing and reducing intestinal adhesions is of course the responsibility of the physician
As mentioned above, when a patient has an abdominal surgical condition that requires surgery, the physician should explain in detail to gain the patient’s awareness and understanding, and make a prompt decision. It is also important to be gentle, meticulous, and precise during surgery to reduce the exposure of the viscera, exposure time, and mechanical stimulation, and to minimize damage to the abdominal wall and visceral plasma membrane. Before closing the abdomen, the bowel is returned to its normal position and the greater omentum is laid flat under the abdominal wall incision. Thoroughly remove foreign body, accumulated blood and purulent exudate from the abdominal cavity. Appropriate application of antibacterial drugs as needed to prevent and control intra-abdominal infections, etc. These are currently the most basic and important measures to prevent and reduce postoperative intestinal adhesions, and they are also the basic principles followed by surgeons.
Promote early recovery of gastrointestinal motility function after surgery
Patients who have stayed in the abdominal surgery ward or relatives who have accompanied them may have an impression that the doctor often asks three questions when seeing the patient after abdominal surgery: Is the wound painful? Is there a fever? Has the wound been deflated? And use the stethoscope to listen to the abdomen for bowel sounds. The purpose of this third sentence is to find out whether the bowel movement has returned to normal. Depending on the anesthesia and surgery, bowel movements should generally return gradually after 24 to 48 hours postoperatively if there is no severe abdominal inflammation or other specific conditions present. Since peritoneal or intestinal adhesions are an inevitable process of repair and healing, the doctor and patient can only try to prevent and minimize their occurrence, especially not the occurrence of “intestinal adhesions” that are diagnosed by the surgeon when symptoms appear. One very important method is to promote the early recovery of gastrointestinal motility after surgery, the purpose of which is to make the intestine automatically arranged in a normal position in the abdominal cavity before the formation of adhesions as far as possible. The methods to make the intestine resume peristalsis as soon as possible are.
1.The patient should get up and move around as early as possible with the permission of the doctor, if the condition permits.
2, according to the doctor’s request, when the time to drink, when the time to eat, and must pay attention to the quantity and quality requirements and gradual progress according to medical advice. Should not eat and drink when to eat and drink, or even eat and drink indiscriminately; should eat and drink when not eat and drink are not conducive to the recovery of the gastrointestinal tract motility function.
3, if necessary, doctors can also apply some drugs and methods to promote intestinal motility according to the situation.
Over the centuries, medical personnel have made many efforts and studies on the prevention of intestinal adhesions, mainly in the following areas.
Intraoperative isolation of the plasma membrane surface of the intestinal canal Such as intraperitoneal injection of dextran, which is used to cover the plasma membrane damaged surface of the intestinal canal, dilute and reduce local fibrin concentration and protect local fibrinolytic enzymeogen activator. Intraperitoneal injection of lecithin, human fat, α-chymotrypsin, and hyaluronic acid coating of the peritoneum and intestinal surface have also been used to prevent intestinal adhesions.
Drugs are used to prevent intestinal adhesions, such as intraperitoneal injection of trypsin, hyaluronidase, streptokinase, urokinase, and recombinant tissue fibrinogen activator. Isotonic saline lavage of the peritoneal cavity to remove fibrin has also been used.
Although some progress has been made in the prevention of abdominal adhesions through the unremitting efforts of medical personnel at home and abroad, and it can be said that there are many ways, it is not realistic to completely prevent the occurrence of intestinal adhesions at present, and some methods have side effects. Therefore, even if the above methods have been used clinically, they have not become common and routinely applied. It can be said that it is like a “scabies head prescription” before there are no effective anti-fungal drugs. There is no panacea to completely stop the occurrence of intestinal adhesions, the key is to cooperate closely with both doctors and patients and follow the aforementioned principles.
C. Adhesive intestinal obstruction
This is the most serious problem caused by intestinal adhesions, the good thing is that most of the intestinal adhesions do not lead to intestinal obstruction, some data show that the occurrence of adhesive intestinal obstruction after abdominal surgery is only 3% to 4%, that is, most adhesions do not cause trouble. The occurrence of adhesive intestinal obstruction often has certain causative factors, the common ones are: gastrointestinal peristaltic dysfunction caused by improper diet or gastrointestinal inflammation; overeating so that a large amount of food suddenly enters the proximal intestinal tube compressed or pulled by adhesions; or strenuous physical activity or sudden change of position after meals, so that the proximal food-filled intestinal tube of adhesions twists due to gravity, etc. (Figure 1). Intestinal obstruction can be partial obstruction, that is, the intestinal tube is partially blocked, or complete obstruction can occur, and more serious intestinal necrosis can occur due to compression by the adhesions or twisting of the intestinal tube. Therefore, patients suffering from intestinal adhesions should pay attention to avoid the above-mentioned triggers.
Fourth, the diagnosis of intestinal adhesions how to do
The majority of patients after abdominal surgery can often have varying degrees of intestinal adhesions, because the adhesions do not affect their function, and over time, the adhesions will gradually reduce, so most people are not diagnosed with intestinal adhesions, and do not need to deal with. When intestinal adhesions cause abdominal pain, bloating and vomiting, the diagnosis is “intestinal adhesions”. The treatment of intestinal adhesions should be decided according to the cause, location, and degree of symptoms.
1, does not occur intestinal passage obstacle, in principle, do not need surgery. If only general abdominal pain, abdominal distension or vomiting, generally after fasting, or simultaneous gastrointestinal decompression, or only with general treatment such as antispasmodic drugs, most can be relieved.
2.When adhesive intestinal obstruction occurs, if there is no intestinal necrosis as judged by the doctor’s examination, conservative treatment such as fasting, gastrointestinal decompression, intravenous fluids to give nutritional support is generally used first, and most, especially partial intestinal obstruction can often be relieved.
3.If intestinal obstruction is ineffective after the above conservative treatment, or signs of intestinal necrosis appear during the treatment, or intestinal necrosis is suspected at the beginning of intestinal obstruction, then it should be decisive and surgery should be performed to lift intestinal obstruction.
4.When multiple surgeries cannot completely solve the extensive and serious intestinal adhesions, internal or external fixation of intestinal tubes is feasible, which means that the extensively adhered intestinal tubes will be lined up in a regular manner from top to bottom. One of the methods is to fix the intestinal canal with ligamentous sutures, which is called external fixation. The second method is to place a tube with appropriate elasticity inside the intestinal canal and remove it after a certain period of time, which is called internal fixation.
The purpose is to make the intestinal tubes adhere to each other and fix them in a suitable position, so as to avoid the intestinal tubes folding into acute angles and affecting the passage of intestinal contents, and also to prevent the recurrence of intestinal obstruction. Two points need to be emphasized here: first, the occurrence of abdominal pain, abdominal distension, vomiting after abdominal surgery
When abdominal pain, abdominal distension, vomiting and other discomforts occur after abdominal surgery, they may not always be intestinal adhesions. Secondly, post-operative intestinal adhesions often occur in most patients, but the degree varies, and patients who have undergone abdominal surgery should not be at risk because most of them do not cause adverse consequences. The common goal of both doctors and patients is to prevent symptomatic intestinal adhesions from occurring. To achieve this goal, a concerted effort by both physicians and patients is required.