老年癌性结直肠梗阻诊治体会--附58例临床分析

目的　探讨老年癌性结、直肠梗阻的诊治方法。方法　分析５８ 例老年癌性完全性结、直肠梗阻的临床表现,腹部Ｘ线检查、Ｂ超、ＣＴ、钡灌肠和腹腔穿刺等检查, 以及血清肌酸磷酸激酶和血清乳酸脱氢酶的测定, 对老年癌性结、直肠梗阻可能出现的绞窄性肠梗阻作出早期诊断,全面评估老年患者各脏器功能后,早期手术治疗。结果　本组５８ 例患者中有５５ 例行手术治疗。从入院至手术时间３ 小时至５ 天。术中诊断１３ 例为绞窄性肠梗阻,其中５ 例术前做出诊断,符合率３８％ 。５５ 例手术患者术后发生并发症３４ 例,死亡５ 例,病死率９ ％ ,其中绞窄性肠梗阻死亡３ 例。结论　对于老年癌性结、直肠梗阻, 能够早期并准确地认识到绞窄性肠梗阻的发生,对治疗和预后具有重要意义。     

腹部手术后早期炎性肠梗阻的处理

目的腹部手术后早期发生的肠梗阻原因较复杂,处理亦较困难,尤其是炎性肠梗阻,既有麻痹性因素,亦有机械性因素,使外科医师的医疗决策难以取舍,如是否需要手术、手术的时机、以及手术可能造成的并发症等均值得探讨。我科自1987年至1996年12月共收治了重型术后炎性肠梗阻48例,40例(83.3%)经非手术治疗痊愈;7例(14.6%)于症状消退后择期手术治疗并存症后治愈,1例2.1%死亡,临床非手术治疗时间为9～58天,平均27.6±10天,取得较满意的结果,为这种类型的肠梗阻治疗提供了一些经验。     

腹部手术后早期炎性肠梗阻的治疗

目的 探讨术后早期炎性肠梗阻的特点及治疗原则。方法 回顾性分析近期经治的术后早期炎性肠梗阻 9例。结果 1例患者经手术治疗,分离粘连时引起多发性肠破裂、肠瘘,后经保守治疗治愈; 8例患者均经胃肠减压、抗炎、应用生长抑素等保守治疗治愈,平均治愈时间为 21. 5 d,无 1例肠坏死。结论 术后早期炎性肠梗阻的特点： (1)发生于腹部手术后早期,虽有机械性因素,但大多都是腹腔内炎症所致广泛粘连引起; (2)症状以腹胀为主,腹痛相对轻,部分患者有少量肛门排气排便,体征虽典型,但较少发生绞窄; (3)保守治疗大都有效,治疗上最好先予以生长抑素为主的保守治疗,应严密观察,如出现肠坏死、腹膜炎征象时则再及时中转手术。     

Small bowel obstruction: computer-assisted prediction of strangulation at presentation

A multivariate computer analysis has been performed on the presenting data of patients with simple small bowel obstruction that settled with conservative treatment (n = 120) and of patients with viable strangulation small bowel obstruction (n = 38) and non-viable strangulation small bowel obstruction (n = 39) found at operation. Initially only 66 per cent of patients with viable strangulation and 46 per cent of those with non-viable strangulation had been treated by immediate surgery after resuscitation. The remainder had been treated conservatively for a median of 3.8 and 2.2 days respectively before undergoing surgery. The computer predicted on the basis of presenting symptoms and signs that 82 per cent of patients with viable strangulation and 97 per cent of those with non-viable strangulation had or would develop strangulation and should have undergone immediate surgery. We advocate that the computer can assist in the management of patients with small bowel obstruction.     

Early operation or conservative management of patients with small bowel obstruction?

OBJECTIVE: To evaluate the outcome after initial non-operative treatment in patients with small bowel obstruction (SBO). DESIGN: Prospective study. SETTING: University hospital, Norway. PATIENTS: One hundred and fifty-four patients with 166 episodes of SBO admitted during the period (1994-1995). Patients younger than 10 years as well as patients with large bowel obstruction, paralytic ileus, incarcerated hernia or SBO caused by cancer were excluded from the study. INTERVENTIONS: Patients with signs of strangulation were operated on early. The rest were given a trial of conservative treatment. MAIN OUTCOME MEASURES: Need of operative treatment. Incidence of bowel strangulation, complications and death. RESULTS: There were 166 cases of SBO. Twenty patients were operated on early among whom bowel was strangulated in 9. Among the 146 patients initially treated conservatively 93 (64%) settled without operation, 9 (6%) had strangulated bowel and 3 (2%) died. Of the 91 patients with partial obstruction but no sign of strangulation, 72 (79%) resolved on conservative treatment. CONCLUSIONS: Patients with partial obstruction with no sign of strangulation should initially be treated conservatively. When complete obstruction is present, it may settle on conservative management, but the use of supplementary diagnostic tools might be desirable to find the patients who will need early operative treatment.     

腹部手术后早期小肠内疝的诊治

目的 研究术后早期小肠内疝的临床特点. 方法回顾性研究1994-2006年38例腹部手术后早期小肠梗阻(early postoperative small bowel obstruction,EPSBO)患者的临床资料.结果 手术治疗术后早期小肠梗阻(发生于术后30 d内)的38例中各种原因所致小肠内疝占9例(23.7%).男6例,女3例,平均年龄53.6岁(32～72岁).术后出现症状的平均时间为7.8 d(2～17 d),平均行保守治疗时间为3.4 d(1～8 d).术后早期内疝的主要临床表现为:完全性机械性梗阻表现,症状重,进展快,可早期出现肠绞窄.影像学检查可能发现特征性内疝表现,以增强CT检查最佳.本组术中见6例患者已发生肠绞窄,其中4例患者发生肠坏死.本组共行肠切除术5例.术后平均住院时间为15.8 d(8～42 d).1例患者术后发生切口感染,无围术期死亡患者.结论 小肠内疝可发生于术后早期,易于发生绞窄坏死,应积极外科手术治疗,可获得理想的效果.     

Complications and death after surgical treatment of small bowel obstruction: A 35-year institutional experience

OBJECTIVE: To study factors influencing complications and death after operations for small bowel obstruction (SBO) using multifactorial statistical methods. SUMMARY BACKGROUND DATA: Death after surgery for SBO is believed to be influenced by factors such as old age, comorbidities, bowel gangrene, and delay in treatment. No studies have been reported in which adverse factors related to death and complications have been systematically investigated with modern statistical methods. METHODS: The authors studied retrospectively 877 patients who underwent 1,007 operations for SBO from 1961 to 1995. Patients with paralytic ileus, intussusception, and abdominal cancer were excluded. Odds ratios for death, complications, postoperative hospital stay, and strangulation were calculated by means of logistic regression analyses. RESULTS: Death and complication rates decreased during the study period. Old age, comorbidity, nonviable strangulation, and a treatment delay of more than 24 hours were significantly associated with an increased death rate. The rate of nonviable strangulation increased markedly with patient age. Major factors increasing the complication rate were old age, comorbidity, a treatment delay of more than 24 hours, and the need for repeat surgery. CONCLUSION: Death and complication rates after SBO decreased from 1961 to 1995. Major factors influencing the rates were age, comorbidity, nonviable strangulation, and treatment delay. Nonviable strangulation was more common in old patients.     

Rare case of incarcerated obturator hernia: Case report and review of literature

IntroductionObturator hernia is a rare condition accounting for less than 1% of all intra abdominal hernias. Clinical diagnosis is considered a challenge for most surgeons. It usually appears as an intestinal obstruction. Confirmation of diagnosis is carried out by means of imaging or during surgery.Case reportAn 85-year-old female patient, with symptoms of intestinal obstruction of 24 h duration was admitted to the emergency room of Unimed Hospital – Belo Horizonte. Abdominal computed tomography (CT) demonstrated a herniation of the small bowel through the right obturator canal with an intestinal distension proximally. At laparotomy, the presence of a right obturator hernia with an ileal strangulation was confirmed. Segmental enterectomy with primary anastomosis and herniorrhaphy for the closure of the obturator foramen were performed.DiscussionObturator hernias typically affect women, elderly, emaciated and multiparous. Symptoms are non-specific and associated with an intestinal obstruction. Howship-Romberg sign, considered pathognomonic, is generally absent. Abdominal CT scan can aid in pre-operative diagnosis and the treatment is surgical.ConclusionEarly diagnosis and surgical treatment are imperative in obturator hernias due to the high morbidity and mortality that occur in cases where the intervention is delayed.     

Lactate levels in the detection of preoperative bowel strangulation

The aim of this retrospective study was to examine whether various laboratory parameters could predict viability of strangulation in patients with bowel obstruction. Forty patients diagnosed with bowel strangulation were included. We performed operations for all patients within 72 hours of the start of symptoms. Blood samples were obtained from all patients immediately before operation. Arterial blood was examined for pH and lactate levels using a blood gas analyzer. We also evaluated white blood cell count and serum levels of creatine phosphokinase, lactic dehydrogenase, amylase, and C-reactive protein. At surgery, 18 patients had viable strangulation and did not undergo resection, whereas 22 had nonviable strangulation and underwent resection of the necrotic bowel. None of the patients died. Bowel strangulation was caused most commonly by adhesions. In terms of diagnostic efficiency, lactate level was the only laboratory parameter significantly associated with viability (P < 0.01, Mann-Whitney test). Other laboratory data did not show statistically significant associations. These results suggest that arterial blood lactate level (2.0 mmol/L or greater) is a useful predictor of nonviable bowel strangulation.     

Preoperative recognition of intestinal strangulation obstruction. Prospective evaluation of diagnostic capability

Early recognition of intestinal strangulation in patients with small bowel obstruction is essential to allow safe nonoperative management of selected patients. We prospectively evaluated preoperative diagnostic parameters as well as the preoperative judgement of the senior attending surgeon for the determination of the presence or absence of intestinal strangulation in 51 consecutive patients who were about to undergo laparotomy for complete mechanical small bowel obstruction. Strangulation was present in 21 (42 percent) of the 51 patients. No preoperative clinical parameter, including the presence of continuous abdominal pain, fever, peritoneal signs, leukocytosis, or acidosis, or a combination thereof proved to be sensitive, specific, and predictive for strangulation. Moreover, the senior surgeon's experienced clinical judgement detected strangulation in only 10 of 21 patients with strangulation preoperatively (sensitivity, 48 percent). Indeed, only 1 of these 10 patients had an early, reversible lesion, whereas 9 had advanced, irreversible infarction. Only 25 of 36 preoperative assessments of simple obstruction proved correct (predictive value of an assessment of no strangulation, 69 percent). Overall, the preoperative assessment was correct in only 35 of the 51 patients (efficiency, 70 percent). These data show that in patients with complete mechanical small bowel obstruction, the preoperative diagnosis of strangulation cannot be made or excluded reliably by any known clinical parameter, combination of parameters, or by experienced clinical judgement. Nonoperative management of complete intestinal obstruction is therefore undertaken at a calculated risk (31 +/- 51 percent in the present series) of delaying definitive treatment of intestinal ischemia.     

急性粘连性肠梗阻手术时机的探讨

目的探讨急性粘连性肠梗阻手术时机的选择。方法回顾性分析我院1998年1月～2003年12月经手术治疗的88例急性粘连性肠梗阻的临床资料。其中，因入院时即诊断肠绞窄而行急诊手术5例；先保守观察后手术治疗83例：腹部体征加重，辅助检查提示向绞窄性肠梗阻发展45例；造影剂24h内未能到达结肠12例；保守治疗4～5d无好转15例；肠梗阻反复发作11例。手术方式包括粘连松解术80例，坏死肠管切除吻合术4例，肠短路吻合术3例，小肠内固定术l例。结果术后发生肠外瘘1例，经保守治疗45d后痊愈；切口感染10例，经1T期缝合后治愈。结论急性粘连性肠梗阻在保守治疗过程中应及时发现早期肠绞窄的线索，果断决定手术治疗，手术时机宜早勿迟，手术指征宜宽勿严。     

Fluid-filled intestinal obstruction.

Three cases of intestinal obstruction are described in which the diagnosis was delayed because of the absence of gas in the bowel. The obstructed bowel was entirely fluid-filled and so abdominal distension was not marked, peristaltic sounds were not accentuated and the abdominal X-rays did not show air-fluid levels.     

术后早期肠梗阻的诊断和治疗

目的探讨腹部手术后早期肠梗阻的病因、临床特点和治疗方法。方法回顾性分析24例腹部手术后早期肠梗阻病例的临床资料。结果 24例中20例经禁食、抗炎、解痉、肠外营养、胃肠减压等保守治疗痊愈,缓解时间平均7d;4例再次手术,1例为内疝,2例为肠管壁疝,1例为束带形成。结论术后早期肠梗阻的特点:①多于术后3～30d开始出现梗阻症状。②以炎性肠梗阻多见,腹胀为主,腹痛较轻,较少发生绞窄。为腹腔炎症引起黏连所致,大多经保守治疗有效。③少数病例为机械性因素造成梗阻,多需手术解除梗阻。对绞窄性梗阻应及早手术。再次手术宜从简,以解决梗阻为目的。     

Therapeutic value of gastrografin in adhesive small bowel obstruction after unsuccessful conservative treatment: a prospective randomized trial

OBJECTIVE: To assess the therapeutic value of Gastrografin in the management of adhesive small bowel obstruction after unsuccessful conservative treatment. SUMMARY BACKGROUND DATA: Gastrografin is a hyperosmolar water-soluble contrast medium. Besides its predictive value for the need for surgery, there is probably a therapeutic role of this contrast medium in adhesive small bowel obstruction. METHODS: Patients with clinical evidence of adhesive small bowel obstruction were given trial conservative treatment unless there was suspicion of strangulation. Those who responded in the initial 48 hours had conservative treatment continued. Patients showing no clinical and radiologic improvement in the initial 48 hours were randomized to undergo either Gastrografin meal and follow-through study or surgery. Contrast that appeared in the large bowel within 24 hours was regarded as a partial obstruction, and conservative treatment was continued. Patients in whom contrast failed to reach the large bowel within 24 hours were considered to have complete obstruction, and laparotomy was performed. For patients who had conservative treatment for more than 48 hours with or without Gastrografin, surgery was performed when there was no continuing improvement. RESULTS: One hundred twenty-four patients with a total of 139 episodes of adhesive obstruction were included. Three patients underwent surgery soon after admission for suspected bowel strangulation. Strangulating obstruction was confirmed in two patients. One hundred one obstructive episodes showed improvement in the initial 48 hours and conservative treatment was continued. Only one patient required surgical treatment subsequently after conservative treatment for 6 days. Thirty-five patients showed no improvement within 48 hours. Nineteen patients were randomized to undergo Gastrografin meal and follow-through study and 16 patients to surgery. Gastrografin study revealed partial obstruction in 14 patients. Obstruction resolved subsequently in all of them after a mean of 41 hours. The other five patients underwent laparotomy because the contrast study showed complete obstruction. The use of Gastrografin significantly reduced the need for surgery by 74%. There was no complication that could be attributed to the use of Gastrografin. No strangulation of bowel occurred in either group. CONCLUSIONS: The use of Gastrografin in adhesive small bowel obstruction is safe and reduces the need for surgery when conservative treatment fails.     

Laparoscopic diagnosis and treatment of acute small bowel obstruction resulting from a congenital band

Acute small bowel obstruction is a common problem, especially for those patients with previous abdominal surgery that can cause postoperative adhesions. Acute, non-postoperative small bowel obstruction is less common and has various etiologies. We report a case of acute small bowel obstruction without previous abdominal surgery. The patient underwent laparoscopic exploration, and a congenital band was found to cause direct compression of the ileum and entrapment of a segment of bowel loop. There was evidence of bowel strangulation. The color and peristalsis of the entrapped bowel loop recovered gradually after division of the band, and segmental bowel resection was avoided. He has remained asymptomatic since the procedure. We suggest early and aggressive surgical intervention for patients with acute, non-postoperative small bowel obstruction to avoid possible complications of bowel strangulation and gangrene. A laparoscopic approach may be a safe, feasible, and favorable option for correct diagnosis and appropriate treatment in this situation.     

Adhesive small bowel obstruction in children: the place and predictors of success for conservative treatment

The records of 230 adhesive small bowel obstruction (ASBO) episodes in 181 patients have been reviewed to observe the place of conservative treatment and to establish criteria to predict the success of conservative trial. Immediate operation has been reserved for 81 episodes that have presented with fever and leucocytosis and/or localized abdominal tenderness, or complete obstruction. The remaining 149 episodes have initially undergone conservative trial. Although 110 episodes (73.8%) have been cured with conservative trial, 39 (26.2%) subsequently necessitated surgical intervention. No adverse occurrences have been observed during or after delayed operations. There was no strangulated bowel nor mortality both in delayed operation and conservatively treated groups. Recurrence has occurred with rate of 18.75% and 36.47% after surgery and conservative treatment, respectively, being significantly different (P less than .01), but the treatment method of the previous episode has been without influence on the method used in the recurrent obstruction (P less than .05). Among the assumed predictive criteria, age at recent laparotomy (P less than .02), time elapsed between recent laparotomy and obstructive episode (P less than .01), the primary condition necessitating laparotomy (P less than .01), the incision of previous laparotomy (P less than .05), and duration of conservative trial (P less than .01) correlated significantly with the success of conservative trial. The number of previous laparotomies and obstructive episodes (P less than .05) have not showed correlation. By the conservative approach used in selected patients with ASBO, 40% overall have been spared operation, without any adverse occurrences. Using the proposed criteria, the success rate of conservative treatment can be predicted.     

放射性肠炎并发急性肠梗阻的临床特点及治疗

目的:探讨放射性肠炎并发急性肠梗阻的临床特点和治疗方法.方法:对2006年10月-2011年3月收治的25例放射性肠炎并发急性肠梗阻病例的临床资料进行回顾性分析.结果:患者入院后均实施肠梗阻导管肠道减压及积极营养支持等非手术治疗,急症病情得到缓解后,经导管行选择性泛影葡胺小肠造影,显示梗阻部位的病理变化.全组24例接受了手术治疗,术中显示放射性损伤以盆腔和回肠为著,器官之间和肠袢之间界限不清,甚至相互融合形似冰冻状;13例行病变肠袢切除肠吻合术,10例行回肠-结肠短路吻合术,1例行右半结肠切除术,21例同时行小肠内置管排列术;1例行非手术治疗后梗阻解除.除1例肠切除患者术后因腹腔和肺部感染死亡外,全组96.0％ (24/25)获得治愈.23例随访6～24个月,远期有效率为95.7％( 22/23).结论:放射性肠炎并发急性肠梗阻采用恰当的非手术治疗可将急症手术转变为限期或择期手术,病变肠袢切除或肠短路吻合术联合小肠内置管排列术是较好的手术方式.     

Small-bowel intestinal obstruction caused by an unusual internal hernia

We report a rare case of transomental small-bowel herniation in a 91-year-old lady who presented with central abdominal pain and mild distension. Urgent abdominal computed tomography (CT) showed a segment of dilated ileum with features suggestive of strangulation. Emergency exploration revealed a segment of congested small-bowel loop herniated through a defect over the greater omentum. Reduction of the bowel loops and division of the omental defect was performed without the need for bowel resection. The patient made an uneventful recovery. We discuss the value of CT scan and highlight the importance of recognizing this rare cause of small-bowel obstruction.     

Adhesive small bowel adhesions obstruction: Evolutions in diagnosis,management and prevention

Intra-abdominal adhesions following abdominal surgery represent a major unsolved problem. They are the first cause of small bowel obstruction. Diagnosis is based on clinical evaluation, water-soluble contrast followthrough and computed tomography scan. For patients presenting no signs of strangulation, peritonitis or severe intestinal impairment there is good evidence to support non-operative management. Open surgery is the preferred method for the surgical treatment of adhesive small bowel obstruction, in case of suspected strangulation or after failed conservative management, but laparoscopy is gaining widespread acceptance especially in selected group of patients. "Good" surgical technique and anti-adhesive barriers are the main current concepts of adhesion prevention. We discuss current knowledge in modern diagnosis and evolving strategies for management and prevention that are leading to stratified care for patients.     

Aortic dissection with ischemia of the abdominal organs

Abdominal organ ischemia associated with aortic dissection is a serious problem, although its incidence is not so high. In particular, the prognosis of bowel ischemia is extremely poor, especially, in cases with the diagnosis delayed and with extensive bowel ischemia. Consequently, 1st it should be suspected, in cases with abdominal pain or distension associated with acute or chronic aortic dissection. Then, its pathology should be assessed quickly with enhanced computed tomography (CT) or ultrasound examination to clarify the mechanism of critical organ ischemia including dynamic obstruction or static obstruction of the visceral arteries. According to the mechanism of abdominal organ ischemia, the best treatment of catheter interventions such as catheter fenestration, endovascular aortic repair, and branch-stenting, or of conventional open surgery such as surgical abdominal aortic fenestration, graft replacement, and branch-bypass should be appropriately chosen without delay.