外科学进展课件：肠梗阻

BowelObstruction6545Articlesforbowelobstruction

CommoncausesofsmallbowelobstructionLesionsExtrinsictotheIntestinalWallAdhesions(usuallypostoperative)

Hernia

External(e.g.,inguinal,femoral,umbilical,orventralhernias)

Internal(e.g.,congenitaldefectssuchasparaduodenal,foramenofWinslow,anddiaphragmaticherniasorpostoperativesecondarytomesentericdefects)

Neoplastic(20%)

Carcinomatosis

Extraintestinalneoplasms

Metastaticlesions(peritonealimplants) intra-abdominalprimarytumorsuchasovarian, pancreatic,gastric,orcolonic

Distantsites,suchasbreast,lung,andmelanomaIntra-abdominalabscess

LesionsExtrinsictotheIntestinalWallAdhesions(usuallypostoperative)

Hernia

External(e.g.,inguinal,femoral,umbilical,orventralhernias)

Internal(e.g.,congenitaldefectssuchasparaduodenal,foramenofWinslow,anddiaphragmaticherniasorpostoperativesecondarytomesentericdefects)

Neoplastic(20%)

Carcinomatosis

Extraintestinalneoplasms

Metastaticlesions(peritonealimplants) intra-abdominalprimarytumorsuchasovarian, pancreatic,gastric,orcolonic

Distantsites,suchasbreast,lung,andmelanomaIntra-abdominalabscess

Post-operativeadhesionsafterdigestivesurgery:theirincidenceandprevention:reviewoftheliterature

JViscSurg.2012Apr;149(2):104-14

Peritonealadhesionsarereportedasthecauseof32%ofacuteintestinalobstructionand65-75%ofallsmallbowelobstructions.Itisestimatedthatperitonealadhesionsdevelopafter93-100%ofupperabdominallaparotomiesandafter67-93%oflowerabdominallaparotomies.Nevertheless,only15-18%oftheseadhesionsrequiresurgicalre-intervention.PreventionofadhesionsGentlehandlingoftheboweltoreduceserosaltraumaAvoidanceofunnecessarydissection;Exclusionofforeignmaterial(absorbablesuturematerial,theavoidanceofexcessiveuseofgauzesponges,andtheremovalofstarchfromgloves)AdequateirrigationandremovalofinfectiousandischemicdebrisPreservationanduseoftheomentumaroundthesiteofsurgeryorinthedenudedpelvis.Currentstrategiesandfutureperspectivesforintraperitonealadhesionprevention

JGastrointestSurg

2012Jun;16(6):1256-74Theformationofpostoperativeadhesionsresultsfromacascadeofeventsandisregulatedbyvariouscellularandhumoralfactors.Therefore,optimizationorfunctionalizationofbarriermaterialsbydevelopmentsinteractingwiththiscascadeonastructuralorpharmacologicallevelcouldgiveaninnovativeinputforfuturestrategiesinperitonealadhesionprevention.PharmacologicagentsCorticosteroids，anti-inflammatoryagents,cytotoxicdrugs,antihistamines，

anticoagulantsIntraperitonealinstillation：proteinases,Hyaluronidase,fibrinolyticagents，bioresorbablemembraneLesionsExtrinsictotheIntestinalWallAdhesions(usuallypostoperative)

Hernia

External(e.g.,inguinal,femoral,umbilical,orventralhernias)

Internal(e.g.,congenitaldefectssuchasparaduodenal,foramenofWinslow,anddiaphragmaticherniasorpostoperativesecondarytomesentericdefects)

Neoplastic(20%)

Carcinomatosis

Extraintestinalneoplasms

Metastaticlesions(peritonealimplants) intra-abdominalprimarytumorsuchasovarian, pancreatic,gastric,orcolonic

Distantsites,suchasbreast,lung,andmelanomaIntra-abdominalabscess

LesionsExtrinsictotheIntestinalWallAdhesions(usuallypostoperative)

Hernia

External(e.g.,inguinal,femoral,umbilical,orventralhernias)

Internal(e.g.,congenitaldefectssuchasparaduodenal,foramenofWinslow,anddiaphragmaticherniasorpostoperativesecondarytomesentericdefects)

Neoplastic(20%)

Carcinomatosis

Extraintestinalneoplasms

Metastaticlesions(peritonealimplants) Intra-abdominalprimarytumor,suchasovarian, pancreatic,gastric,orcolonic

Distantsites,suchasbreast,lung,andmelanomaIntra-abdominalabscess

LesionsIntrinsictothe

IntestinalWallCongenital:Malrotation,Duplications/cysts

Inflammatory:

Crohn’sdisease，Mcrohn

Infections:Tuberculosis,Actinomycosis,Diverticulitis

Neoplastic

Primarysmallboweltumors:exceedinglyrare.

Metastaticneoplasms

Traumatic:Hematoma,Ischemicstricture

Miscellaneous

Intussusception

Endometriosis

Radiationenteropathy/stricture

LesionsIntrinsictothe

IntestinalWallCongenital:Malrotation,Duplications/cysts

Inflammatory:

Neoplastic

Primarysmallboweltumors:exceedinglyrare.

Metastaticneoplasms

Traumatic:Hematoma,Ischemicstricture

Miscellaneous

Intussusception

Endometriosis

Radiationenteropathy/stricture

LesionsIntrinsictothe

IntestinalWallCo

Infl

Cr

Inf

Ne

Pri

Traumatic:Hematoma,Ischemicstricture

Miscellaneous

Intussusception

Endometriosis

Radiationenteropathy/stricture

合并多发伤69%，误诊率12~45%，死亡率32~70%LesionsIntrinsictothe

IntestinalWallCongenital:Malrotation,Duplications/cysts

Inflammatory:

Crohn’sdisease

Infections:Tuberculosis,Actinomycosis,Diverticulitis

Neoplastic

Primarysmallboweltumors:exceedinglyrare.

Metastaticneoplasms

Traumatic:Hematoma,Ischemicstricture

Miscellaneous

Intussusception

Endometriosis

Radiationenteropathy/stricture

Intraluminal/ObturatorObstructionGallstone

Enterolith

Bezoar

diospyroskakil.f.

persimmonIntraluminal/ObturatorObstructionGallstone

EnterolithBezoar

DiseasesofVas

SmallIntestine突发的剧烈腹部绞痛，严重程度与轻微的体征明显不相称；

胃肠道排空症状：恶心呕吐和腹泻…；

心血管疾病：心房纤颤、动脉瘤…。.Bergan三联征PathophysiologyIncreaseinperistalsis:diarrhea；Fatiguedintestine:dilates,lesscontractions.Increaseinperistalsis:diarrheaFatiguedintestine:dilates,lesscontractionsthehigherthelevelofobstruction,thelessthedistentionandthemorerapidtheonsetofvomitingproximalSBOcentralabdominaldistentionmaybemarked,andvomitingisusuallyalatefeature

distalSBOPathophysiologyStrangulatedSBOscanoccurwhenaloopofdistendedboweltwistsonitsmesentericpedicle.Thearterialocclusionleadstobowelischemiaandnecrosis.Ifleftuntreated,thisprogressestoperforation,peritonitis,anddeath.StrangulationSymptomsColickyabdominalpainNausea,vomitingAbdominaldistentionFailuretopassflatusandfeces(Constipation)

diarrheasecondarytoincreasedperistalsisSymptomsHigherintestinalobstruction:

morecommennauseaandvomiting

typicalcrampingabdominalpain(4-5minintervals);Distalobstruction: lessemesis,alatefeature; lessfrequentlypain centralabdominaldistention.PhysicalExaminationDistendedabdomenPeristalticwaves(visibleperistalsis)Hyperactivebowelsounds,borborygmi

inthelatestage,Hypoactivebowelsounds

Mildabdominaltenderness.PlainradiographsPlainRadiographRadiologicExaminationsPlainradiographs dilatedloopsof

smallintestine, multipleair-fluidlevels,

oftenlayerinastepwise

patternCTexaminationSensitiveforcompleteorhigh-gradeobstructionDeterminingthelocationandcauseofobstructionExtrinsiccauseofbowelobstruction(abdominaltumors,inflammatorydisease,orabscess)Usefulindeterminingbowelstrangulation.(irreversibleischemiaandnecrosis)CTexaminationDeterminingthelocationandcauseofobstructionCTexaminationDeterminingthelocationandcauseofobstructionBariumstudiesLow-grade,intermittentobstructionDiagnosisisclinicallyuncertainJejunojejunalintussusception肠梗阻诊疗指南水溶性造影剂被推荐用于胃肠造影2~4%含碘造影剂口服或胃肠减压管注入临床诊断困难or判断不全梗阻病人接受保守治疗的效果及预后若造影剂在24h内到达结肠:肠梗阻得到缓解，预后良好。LaboratoryexaminationsAssessthedegreeofdehydration

(8-10Lofwaterperdayenterthesmallintestine)Assesstheadequacyoffluid;resuscitationHematocritWhitebloodcellcount Leukocytosis:StrangulationSimpleObstructionPartialintestinalobstruction

simple,nonstrangulatedMechanicalblockageoftheflowofluminalcontentswithoutcompromisedviabilityoftheintestinalwallStrangulatingObstructionVascularsupplytoasegmentofintestineiscompromised,canleadtointestinalinfarctionIncreasedmorbidityandmortalityriskClassicsigns: Tachycardia,Fever,Leukocytosis,andaconstant,noncrampingabdominalPain.

noclinicalparametersorlaboratorymeasurementscanaccuratelydetectorexcludethepresenceofstrangulationClosed-loopobstructionTwistofthebowelArterialocclusionand

ischemiaifleftuntreatedMaypotentiallyleadtobowelperforationandperitonitis.NonoperativetreatmentFluidResuscitation:

Intravenousreplacementwithanisotonicsalinesolution,potassiumchlorideSerialelectrolytemeasurements,hematocritandwhitebloodcellcountUrineoutputmonitoredCentralvenousassessment,Swan-GanzcatheterAntibiotics:

ProphylacticalBroad-spectrumantibiotics,TubeDecompressionNasogastricsuctionLongintestinaltubes

(Cantor,Bakertubes)12-to24-hourPalliativeGastrointestinalStentingPalliativetreatmentwithself-expandingmetalstents(SEMS)isregardedasahighlyeffectiveproce-dureforreliefofsymptomscaused

bymalignantobstructionsofthegastrointestinal(GI)tractStentsweredeployedendoscopicallyunderfluoroscopicguidanceNonoperativeTreatmentOP-

complicationsStrangulationSurgery24hOperativeManagementIndication:CompletesmallbowelobstructionNonop:overlookinganunderlyingstrangulationobstruction,delaying

thetreatmentofstrangulationEvaluatebowelviabilityafterthereleaseofastrangulation:warm,saline-moistenedspongefor15to20minutes;“secondlook”laparotomy18to24hourslater.Regionswherethereispotentialforrecoverymaybeobservedfor24to36hoursandreassessedata“secondlook”operation.Themortalityratereportedforpatientsundergoingsurgeryforacuteintestinalischemiaisashighas85%,withaggressivediagnosisandintervention,maybereducedto25%OperativeManagementObstructionsecondarytoanadhesiveband:lysisofadhesionsOperativeManagementIncarceratedhernias: operativerepairsObstructionmalignanttumors: bypass,resection.ExternalplicationSutureofintestineoritsmesenteryinlarge,gentlycurvingloopsCopplictions:fistulas,grossleakage,peritonitislowoverallsuccessrateLaparoscopicmanagementMildabdominaldistentionallowingadequatevisualizationProximalobstructionPartialobstructionAnticipatedsingle-bandobstructionLaparoscopicmanagementLaparoscopicmanagementInhig