术后肠梗阻诊治再认识

Review of the diagnosis and treatment of postoperative bowel obstruction

手术后肠梗阻因好发于小肠,也称手术后小肠梗阻(PSBO),是腹部手术后常见急腹症。其诊治关键是准确把握病情走向,避免贻误手术时机造成肠坏死严重后果,但过于积极的手术干预可能会造成不必要的手术。PSBO诊断水平的提高得益于影像学技术的进步,增强CT对预测肠绞窄和急诊手术的准确率可达90%,判断病因的准确率也达85%~90%;小肠插管减压后经导管注入Gastrografin进行造影,不但能够促进PSBO缓解,提高非手术治疗成功率,还可以缩短住院时间,避免贻误手术时机。除术后早期炎性肠梗阻外,对于反复发作的PSBO,手术治疗能够去病因,避免复发。择期手术疗效优于急诊手术,对于反复发作的PSBO,应争取在最佳的时机进行手术治疗。对于简单的PSBO,可选择腹腔镜手术,但要避免伤及小肠,同时松解粘连要完全;复杂的PSBO首选开放手术,其效果满意。PSBO的预防依赖于仔细的手术操作,虽然腔镜手术后PSBO发病率是否低于开放手术尚缺乏可靠的数据,但保护肠管、避免异物残留,是预防PSBO的关键。

Postoperative intestinal obstruction,also known as postoperative small bowel obstruction(PSBO),is the most common acute abdomen after abdominal operations.The key to the treatment is accurate determination of therapeutic strategy.While avoiding unnecessary operation,delayed operation will cause intestinal obstruction and endanger the patients.PSBO diagnosis was improved owing to the progress of imaging techniques.Contrast enhanced CT can reach 90%in the diagnostic accuracy of intestinal strangulation,necessity of emergency operation and elucidation of etiology.Intestinal decompression via small intestinal decompression tube and subsequent gastrografin challenge can promote resolution of PSBO,increase the success rate of nonoperative management,avoid operation delay,and shorten the length of hospital stay.Operation is indicated for repeated episode of PSBO to eliminating the cause and avoiding recurrence.Elective operation is preferred over emergency.Laparoscopic operation is indicated for simple adhesions,but laparotomy is indicated for complex one.Meticulous operation,either laparoscopic or laparotomic,intestinal protection and eliminating foreign material and tissue debris are the keys to the prophylaxis of PSBO.