胆石性肠梗阻的诊治(附11例临床分析)

目的探讨胆石性肠梗阻的临床特点和治疗方法. 方法我院1985年～2000年共收治胆石性肠梗阻11例,术前仅3例确诊.均经手术治疗,其中10例行肠管切开取石,1例因肠坏死切除坏死肠段.失访2例,余9例患者一期术后6～9月行胆囊切除和(或)内瘘修补术. 结果Ⅰ期手术后并发呼吸道感染2例,切口感染1例,随访结果显示Ⅱ期手术后9例患者均获治愈. 结论胆石性肠梗阻术前确诊率低,但及时的B超及X线检查有助于其早期诊断,分期手术治疗胆石性肠梗阻效果显著.     

Jejunal Gallstone Ileus: An Unusual Site of Gallstone Impaction

Introduction  Gallstone ileus is a life-threatening surgical emergency where characteristic imaging can be diagnostic. Jejunum is the one of the rare sites of gallstone impaction. Materials and Methods  We hereby emphasize the role of multidetector computed tomography (MDCT) by describing a case of jejunal gallstone ileus with cholecystoduodenal fistula in a 59-year-old lady who presented with symptoms and signs of proximal small bowel obstruction. Conclusion  MDCT of the abdomen established the diagnosis, and the patient managed surgically.     

Zum Stellenwert der Miller-Abbott-Sonde in der Behandlung des postoperativen Ileus

Zusammenfassung In einer vergleichenden Studie wird über die Behandlung des postoperativen Frühheus berichtet. Eine Gruppe von 51 Patienten war mit der endoskopisch gelegten Miller-Abbott-Sonde (MAS), ein zweites vergleichbares Kollektiv von 41 Patienten durch primär operative Maßnahmen behandelt worden. Die vorliegende Arbeit referiert über Indikationsstellung, Technik und Probleme der Sondenbehandlung; Erfolge und Niederlagen beider Gruppen werden verglichen und diskutiert. Aufgrund der Ergebnisse der konservativen Therapie erfolgt eine neuerliche Wertung dieses Verfahrens.

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Significance of the Miller-Abbott-tube in the treatment of postoperative ileus

Summary This comparative study reports about therapeutic procedures in postoperative ileus. A group of 51 patients was treated with the Miller-Abbott-tube, placed by endoscopy, another comparable group, covering 41 patients, was attended by primary relaparotomy. The present study describes indications, technique, and problems of the Miller-Abbott procedure; success and failure in both groups are compared and discussed. The results of the Miller-Abbott-group enable us to reestimate conservative treatment of postoperative ileus.

     

Muir-Torre Syndrome Presenting with Ileus: a Case Report

The Muir-Torre syndrome is characterized by cutaneous neoplasms and visceral malignancies. At least one sebaceous adenoma, epithelioma or carcinoma and at least one internal malignancy are required to make a reliable diagnosis. According to medical literature only two cases of Muir-Torre syndrome with jejunal carcinoma have been reported to date and there is no reported case with intestinal obstruction. Here, we report an unusual case of jejunal carcinoma presenting with ileus.     

Chewing Gum Reduces Postoperative Ileus after Open Appendectomy

Hypothesis: It is suggested that chewing gum may accelerate postoperative intestinal transit recovery. Chewing gum may therefore produce the same result after open appendectomy. Design and setting: Prospective, randomized study in a University teaching hospital.

Patients: 46 patients operated on by open appendectomy due to acute catarrhal appendicitis, appendicular abscess and appendicular generalized peritonitis.

Main outcome measures: Interest was in occurrence of first flatus, first bowel movement, hospital duration and complications.

Results: A total of 46 patients were randomly divided into two groups: a chewing gum group (n = 23) and a control group (n = 23). In the first group, patients chewed sugarless gum for 30 minutes thrice daily until resumption of intestinal transit. Patient demographics, intra-operative, and postoperative care were the same for both groups. Chewing gum was well tolerated by all the patients.

The first passage of flatus occurred on postoperative day 2.2 in the gum-chewing group and on day 3.0 in the control group (P < 0.0001). The first bowel movement occurred at postoperative day 2.3 in the chewing gum group and at postoperative day 3.3 in the control group (P < 0.0001). Five complications were noted overall. Hospital stay was shorter in the chewing gum group (4.9 days.) than in the control group (6.7 days), (P < 0.0001).

Conclusion: Chewing gum ameliorates recovery after open appendectomy by reducing postoperative ileus. It is a cheap and helpful treatment to be recommended in developing countries in Africa.     

术后肠梗阻的发生机制研究进展

目的总结术后肠梗阻的发生机制的研究进展,阐述术后肠梗阻的发生机制对临床诊断、治疗及预防的重要意义。方法分析总结近年来有关术后肠梗阻发生机制的文献报道。结果术后肠梗阻的发生与术后神经反射抑制、炎症反应、药物作用等多种因素有关,它是多种机制共同相互调节的结果。结论术后肠梗阻的胃肠道动力主要由神经反射、炎症反应及药物相互作用三种机制共同调节,三者在不同的时间段所起的作用不同,但又相互作用构成一个整体,其中炎症反应对术后肠梗阻的持续起着关键性作用。     

腹腔镜肠黏连松解联合应用生物蛋白胶治疗黏连性肠梗阻

目的探讨腹腔镜肠黏连松解联合应用生物蛋白胶治疗黏连性肠梗阻的可行性及其疗效。方法总结1998年5月至2003年10月间,28例黏连性小肠梗阻患者进行腹腔镜黏连松解术、并配合留置医用生物蛋白胶防止再黏连的临床资料。结果应用腹腔镜全组均成功实施黏连松解术解除肠梗阻,均于术中留置医用生物蛋白胶防止再黏连,未出现手术并发症和过敏现象;随访3～60个月,未发现肠梗阻症状复发。结论腹腔镜肠黏连松解术配合生物蛋白胶治疗黏连性肠梗阻安全实用,疗效满意,是处理黏连性肠梗阻的理想手段之一。     

Laparoscopic Enterolithotomy Is a Valid Option to Treat Gallstone Ileus

Gallstone ileus is a well-recognized clinical entity. It usually affects elderly female patients, and very often diagnosis can be delayed resulting in high morbidity and mortality. An abdominal x-ray and computed tomographic (CT) scan of the abdomen may show classical radiological features of small bowel obstruction, pneumobilia, and an ectopic gallstone. Laparotomy and enterlithotomy with or without definite biliary surgery is an established treatment. Since 1992, many cases of laparoscopic-assisted enterolithotomy have been reported. Only a few cases of a totally laparoscopic approach have been documented. We present the case of a 75-year-old lady who presented with features of intestinal obstruction. A plain x-ray of the abdomen and a CT scan confirmed the classical features of gallstone ileus. A totally laparoscopic enterolithotomy was performed using 6 ports. A 6-cm gallstone was retrieved through a longitudinal enterotomy. The transverse closure of the enterotomy was performed with intracorporeal suturing, resulting in an uneventful postoperative recovery. We suggest that a CT scan helps in the early diagnosis of the cause of intestinal obstruction, and totally laparoscopic enterolithomy with intracorporeal enterotomy repair is a valid, safe option.     

Der rezidivierende Gallensteinileus

Zusammenfassung Der G.I. ist eine ernste Spätkomplikation des Gallensteinleidens mit einer Sterblichkeit von 29,4% bei 864 Fällen in 78 Arbeiten der Jahre 1955 bis 1968. In etwa 5% ist mit einem Rezidiv durch im Darm zurück gelassene oder aus der G.Bl. nachwandernde Steine zu rechnen. Einschließlich der eigenen 2 fanden wir 70 Rezidive mit einer Mortalität von 21,4%. Das frühe Rezidiv im unmittelbaren postoperativen Verlauf ist mit hoher Sterblichkeit belastet (50%). Bei der Operation muß daher der gesamte Darm ober- und unterhalb der Einklemmung auf weitere Steine und Darmwandschäden abgesucht werden. Das häufigere späte Rezidiv nach Monaten oder sogar Jahren hat eine günstigere Prognose.Hohes Alter und die durch den Ileus hervorgerufenen allgemeinen Schäden erlauben in der Regel nur die Enterolithotomie. Bei weiteren großen Steinen in der G.Bl. kann bei günstigem Allgemeinzustand die Cholecystolithotomie oder die Cholecystektomie unmittelbar angeschlossen werden. Letztere erfordert immer den Nachweis steinfreier und durchgängiger Gallenwege.Nach überstehen des Ileus ist die diagnostische Klärung der Gallenwegserkrankung in jedem Fall durchzuführen; die Operation des Gallenleidens zu wählbarem Zeitpunkt wird operationsfähigen Kranken empfohlen zur Vermeidung des späteren Ileusrezidivs und anderer Komplikationen von seiten der Gallenwege.

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Recurrent gallstone ileus

Summary Two recurrences among our 6 cases of gallstoneileus (g.i.) made us work on recurrent g.i. G.i. is a serious subsequent complication in cholelithiasis with a mortality of 29.4% among 864 cases, which are published in 78 papers from 1955 to 1968. A recurrence may be expected in 5% of the cases, caused by stones remaining in the gut or by stones descended from the gallbladder. We found 70 recurrences including our 2 cases with a mortality of 21.4%. Early recurrence in the immediate postoperative course means high mortality (50%). During the operation the intestinal tract has to be checked for other stones and wall damage above and below the site of obstruction. The more common late recurrence — after months or even years — has a better prognosis.Old age and general damage caused by the intestinal obstruction usually only allow simple enterotomy. In cases with further big stones in the gallbladder connected with a good condition of the patient cholecystolithotomy or cholecystectomy can be done immediately afterwards. Cholecystectomy always demands evidence of free passage and abscence of stones in the biliary tract.After recovery from the ileus diagnostic clarification of the diseased biliary tract ist necessary in any case; operable patients ought to have an operation on their gallbladder disease at an elective time in order to prevent later ileus recurrence and other complications from the biliary tract.

     

Bacterial Translocation as a Cause for Septic Complications in Obstructive Colonic Ileus

Abstract

Failure of intestinal barrier function and subsequent translocation of microorganisms and their degradation products play a decisive role in development of systemic septic complications for many systemic and intra-abdominal pathologies, for example, following obstructive colonic ileus (Od). This study was aimed at the evaluation of the intestinal barrier state in OCI. Sixty albino Wistar rats weighing 250 to 300 g (mean 265 g) were divided into four groups (15 animals in each). Acute colonic ileus (ACI) was modeled as follows except a control group (Group 1). Our objective was to examine changes in bacterial flora in the abdomen, mesenteric lymphatic nodes (MLN), liver, spleen, and lungs during the model of OCI after 72 hours following the beginning of experiment. The composition of parietal mucus in normal and in OCI 48 hours following the beginning of experiment examined. Interleukine (IL-VI) levels were determined in both portal and peripheral blood. The right-hand half of colon was ligated at the level of ileocaecal junction in animals of Group 2 (n = 15), whereas in animals of Group 3 (n = 15) it was ligated at the level of sigmoid colon. With the same purpose, a portion of the suspended caecal content was administered into lumen of the jejunum at a concentration of 10⁶ colony-forming units (CFU) in animals of Group 4 (n = 15). Experimentally — induced OCI causes significant bacterial translocation (BT) in rats. The process of colonization of the proximal small intestine with colonic flora takes place under the conditions of ileus. The conditions favorable for the development of BT are generated with colonization of 10⁶ CFU in volume. As a result, intestinal flora penetrates into the abdominal organs and lungs. Its highest concentrations are noted in the lymph nodes, lungs and liver. The modeling of the small intestine colonization with colonic flora (Group 4) demonstrates critical parameters of microbial semination.     

Ileus Management International (IMAGINE): protocol for a multicentre,observational study of ileus after colorectal surgery

Aim

The management of postoperative ileus following colorectal surgery remains controversial. It is the commonest complication after elective colorectal resection and is associated with an increased incidence of postoperative adverse events. The prevention and management of postoperative ileus remains unstandardized. This study aims to describe an international profile of gastrointestinal recovery after colorectal surgery and will assess the role of non‐steroidal anti‐inflammatory drugs, when used as postoperative analgesia, in expediting the return of gastrointestinal function.

Methods

A multicentre, student‐ and trainee‐led, prospective cohort study will be conducted across both Europe and Australasia. Adult patients undergoing elective colorectal resection during 2‐week data collection periods between January and April 2018 will be included. A site‐specific questionnaire will capture compliance to Enhanced Recovery after Surgery components at participating centres. The primary outcome is time to gastrointestinal recovery, measured using a composite outcome of bowel function and oral tolerance. The impact of non‐steroidal anti‐inflammatory drugs on gastrointestinal recovery will be evaluated along with safety data with respect to anastomotic leak, acute kidney injury and complications within 30 days of surgery.

Discussion

This protocol describes the methodology of an international, observational assessment of gastrointestinal recovery after colorectal surgery. It discusses key challenges and describes how the results will impact on future investigation. The study will be conducted across a large student‐ and trainee‐led collaborative network, with prospective quality assurance and data validation strategies.     

复方积雪草灌肠剂治疗结直肠癌合并肠梗阻的临床疗效观察

目的观察复方积雪草灌肠剂治疗结直肠癌合并肠梗阻的临床疗效。方法将符合纳入标准的80例结直肠癌并发恶性肠梗阻患者随机分为两组,对照组予以禁食、胃肠减压等常规内科保守治疗,治疗组在对照组治疗的基础上予复方积雪草灌肠剂保留灌肠治疗,比较两组的疗效和症状缓解时间。结果复方积雪草灌肠剂治疗的患者有效率和腹痛腹胀、肛门排气排便时间、改善症状等方面均优于常规保守治疗组,且差异具有统计学意义(P<0.05),两组不良反应总体发生率相似,中药灌肠组腹泻发生率稍高于对照组。结论:复方积雪草灌肠剂治疗恶性肠梗阻疗效较好,且不良反应可控。     

复方大承气汤联合肠梗阻导管治疗恶性肠梗阻的临床研究

目的:研究复方大承气汤联合经鼻型肠梗阻导管对恶性肠梗阻(MBO)的治疗效果、损伤的肠黏膜屏障修复和免疫紊乱的影响.方法:选择2018年7月—2019年8月我院收治的MBO患者30例,随机数表法分成对照组和中药组,各15例,两组均给予常规治疗,对照组在此基础上急症放置经鼻型肠梗阻导管,24 h后开始口服温开水100 mL...     

结直肠癌术后早期炎性肠梗阻的相关危险因素

目的:探讨结直肠癌术后早期炎性肠梗阻的发生及预防策略.方法:回顾性分析120例结直肠癌术后早期炎性肠梗阻患者的临床资料,对其发生的相关危险素进行单素及多素分析.结果:早期炎性肠梗阻与年龄(P=0.023)、手术方式(P=0.008)、腹部手术史(P=0.002)、肠道准备情况(P<0.001)、术中防粘连剂使用(P=0.006)、手术时间(P=0.042)有关;开腹手术(P=0.024)、有腹部手术史(P=0.034)及术前未行肠道准备(P=0.006)是结直肠癌术后早期炎性肠梗阻发生的独立危险素.结论:开腹手术、有腹部手术史及术前未行肠道准备是结直肠癌术后早期炎性肠梗阻发病的独立危险素.     

自拟承气汤配合穴位贴敷治疗术后早期炎性肠梗阻

目的：探讨自拟承气汤配合穴位贴敷治疗术后早期炎性肠梗阻的效果。方法：收集术后早期炎性肠梗阻 68 例,随 机分为观察组和对照组各 34 例。两组均接受常规治疗,对照组同时给予自拟承气汤,观察组在对照组的基础上再予以穴位 贴敷治疗,均治疗 7 天。比较两组的胃液引流量、排气、排便时间、住院时间、临床症状改善情况、血清炎症因子：血清白细胞介素 -6（IL-6）、肿瘤坏死因子 -α（TNF-α）以及超敏 C 反应蛋白（hs-CRP）;丙二醛、二胺氧化酶水平等指标。结果： 与对照组相比,观察组治疗有效率较高,为 91.2%（P ＜ 0.05）;腹胀、腹痛、便秘以及呕吐等症状评分降低,如腹胀症状 观察组治疗后症状评分（2.10±0.27）,与对照组治疗后症状评分（3.82±0.41）相比有显著降低（P ＜ 0.05）;胃液引流 量降低,观察组（388.02±40.59）mL,低于对照组（520.39±57.39）mL（P ＜ 0.05）;排气、排便时间以及住院时间缩短, 如排气时间观察组（2.89±0.37）d 短于对照组（5.47±0.66）d（P ＜ 0.05）;血清 IL-6、TNF-α、hs-CRP 较对照组水平较低, 丙二醛、二胺氧化酶水平较低,如血清 IL-6 治疗后观察组为（33.10±3.54）ng/L,低于对照组（87.93±9.42）ng/L （P ＜ 0.05）。结论：自拟承气汤配合穴位贴敷治疗术后早期炎性肠梗阻,疗效显著,可改善炎症反应。     

Die Wertigkeit der Röntgenuntersuchungen in der Ileusdiagnostik

Zusammenfassung Von 1972–1982 wurden an 327 Patienten 350 Operationen unter der Indikationsstellung Heus durchgeführt. In 315 Fällen (90%) kamen präoperativ folgende Röntgenuntersuchungen zur Anwendung: 315 AbdomenNativaufnahmen (92,7% richtige Befunde), 21 orale Gastrografin-Passagen (95,2%), 52 Colon-Kontrasteinläufe (98,1%). Wurde die Ätiologie eines Ileus präoperativ durch Einsatz aller radiologischen Maßnahmen möglichst exakt abgeklärt, so lag die Letalität in dieser Patientengruppe mit 22% signifikant unter der Gesamtletalität von 33%.

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The value of X-ray examinations in the diagnosis of ileus

Summary From 1972–1982 350 operations were performed on 327 patients suffering from ileus. In 315 cases (90%) preoperatively the following X-ray examinations were performed. 315 plain abdominal X-rays (92.7% correct radiological findings), 21 oral gastrografin-passages (95.2%), 52 barium enemas (98.1%). If by all radiological means an exact preoperative diagnosis was possible, the lethality was significantly lower (22%) than in the overall group (33%).

Herrn Prof. Dr. Steiner zum 65. Geburtstag gewidmet     

经肛肠梗阻导管在左半结直肠肿瘤切除中的应用

目的：探讨腹腔镜联合经肛肠梗阻导管在左半结直肠肿瘤急性梗阻中的治疗价值。方法：将126例左半结直肠肿瘤急性梗阻病例随机分为2组,治疗组应用经肛肠梗阻导管行梗阻近段结肠减压、灌洗等治疗后,行腹腔镜手术并一期切除吻合;对照组按常规准备后手术治疗。结果：术后吻合口瘘发生率治疗组（1.6%）低于对照组（11.1%）,治疗组住院时间、总住院费用和术后第7 d血清白蛋白水平与对照组比较有显著性差异（P＜0.01）。结论：腹腔镜联合肠梗阻导管置入冲洗减压,在左半结直肠肿瘤急性梗阻中的应用安全、有效。     

Comparison Study of Patient Demographics,Risk Factors,and Lengths of Stay for Postoperative Ileus After Primary Total Knee Arthroplasty

BackgroundPostoperative ileus is a potential complication after orthopedic surgery, which has not been well studied after total knee arthroplasty (TKA). The aims of this study were to analyze rates of postoperative ileus; patient demographic profiles; in-hospital lengths of stay (LOS); and patient-related risk factors for postoperative ileus after primary TKA.MethodsA query was performed from January 1, 2005 to March 31, 2014 using the Medicare Standard Analytical Files. Patients who underwent primary TKA and developed postoperative ileus within 3 days after their index procedure were identified. Patients who did not develop ileus represented controls. Primary outcomes analyzed and compared included patient demographics, risk factors, and in-hospital LOS. A P value less than .05 was considered statistically significant.ResultsIleus patients were older, more likely to be male, and had higher Elixhauser-Comorbidity Index scores (8 vs 6; P < .0001) compared with controls. Male patients (odds ratio [OR], 2.12; P < .0001), patients with preoperative electrolyte/fluid imbalance (OR, 3.40; P < .001), patients older than 70 years (OR, 1.62-2.33; P < .015), and body mass indices greater than 30 kg/m² (OR, 1.79-2.00; P < .001) were at the greatest risk of developing ileus. In addition, ileus patients had significantly longer in-hospital LOS (5.42 vs 3.22 days; P < .001).ConclusionThe study demonstrated differences in patient demographics, patient-related risk factors, and an increased in-hospital LOS for ileus patients after primary TKA. The study is important as it can allow orthopedists to properly identify and optimize patients with certain risk factors to potentially mitigate this adverse event from occurring.     

Der Gallensteinileus —ein diagnostisches und indikatorisches Problem —Bericht über 35 Patienten

Zusammenfassung Die Analyse der Krankheitsverläufe und Untersuchungsbefunde von 35 Patienten, die von 1970–1984 in der Abteilung Allgemeinchirurgie der Chirurgischen Universitätsklinik Freiburg operiert wurden, zeigt, daß die klassischen Symptome dieser Erkrankung — zweizeitiges Ereignis, Dünndarmileus bei Aerobilie — nur in 20% der Fälle nachweisbar sind. Ein Dünndarmileus bei älteren, nicht voroperierten Patientinnen mit einem Krankheitsverlauf von 3 und mehr Tagen sollte auch bei wenig eindrucksvollem klinischen Befund an einen Gallensteinileus denken lassen. Die alleinige Durchführung der Enterolithotomie hat sich als Standardverfahren mit geringer postoperativer Letalität bewährt.

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Gallstone ileus — A problem of diagnosis and indication — Report of 35 cases

Summary The clinical data of 35 patients with gallstone ileus treated between 1970 and 1984 at the Department of Surgery of the University Hospital of Freiburg were retrospectively analysed with respect to duration of symptoms prior to surgery, preoperative diagnostic, operative procedure and outcome. No reliable test could be found that will lead the clinician to the correct diagnosis in most cases. The classical sign of gallstone ileus — small bowel obstruction combined with pneumobilia in the plain abdominal X-ray — was apparent only in 20%. So, a high index of suspicion, especially in old female patients with small bowel obstruction and prompt surgical intervention will decrease mortality. Enterotomy with removal of the stone without simultaneous cholecystectomy can be recommended as a safe procedure even in very old patients.