腹腔镜在小肠不全梗阻手术中的应用

目的探讨腹腔镜治疗小肠不全梗阻的可行性及临床效果。方法回顾性分析2011年1月~2016年1月85例肠梗阻资料。5例因腹腔束带粘连导致梗阻,腹腔镜下切断束带解除梗阻;75例因小肠与小肠、腹壁、盆腔粘连、成角导致梗阻,腹腔镜下分离粘连、成角解除梗阻;3例探查发现阑尾炎导致梗阻,行阑尾切除术;2例因肠腔异物导致梗阻,腹腔镜下取出异物。腹胀明显者术前留置肠梗阻导管减轻腹胀。结果除2例局部粘连广泛、致密做小切口辅助手术切除部分肠管行端端吻合外,均在腹腔镜下完成,无并发症发生。术后随访3~60个月,平均35个月,未见梗阻症状复发。结论腹腔镜治疗小肠梗阻是可行的,具有切口小、创伤轻、恢复快、术后住院时间短等微创特点,避免开腹手术造成的创伤。     

多层螺旋CT对少见小肠梗阻的诊断价值

目的 评价多层螺旋CT(MSCT) 对罕少见病因肠梗阻诊断的价值。 方法 回顾性分析18例经手术证实的少见病因肠梗阻的MSCT表现。 结果 18例患者均有程度不等的肠梗阻。术前病因诊断正确率达72.22%,其中,先天性小肠壁神经节细胞减少1例,小肠阴性异物3例,小肠粪石2例,腹茧症1例,腹内疝2例,闭孔疝4例,小肠扭转5例。2例肠扭转并缺血坏死,3例并穿孔。结论 MSCT能用于少见小肠梗阻的诊断及判断严重程度, 还能明确肠梗阻的罕少见病因及有无并发症。     

CT在粘连性小肠梗阻诊断中的应用

粘连性小肠梗阻（ASBO）诊治中，对肠绞窄、肠扭转等并发症很难做出早期、及时、准确的诊断，依靠临床症状、体征、腹平片或其他检查做出诊断，往往为时已晚，因此许多作者主张早期手术，以降低病死率。近年，随着CT诊断技术不断提高，对小肠梗阻的部位、原因能做出诊断并能发现早期肠绞窄和肠粘连所致肠扭转。本文通过对我院粘连性小肠梗阻病例的分析，探讨CT在粘连性小肠梗阻诊断中的作用。     

粘连性肠梗阻的多层螺旋CT诊断及其临床应用价值

目的:探讨多层螺旋CT对粘连性肠梗阻的诊断作用。方法:对35例手术证实为粘连性肠梗阻患者的术前全腹多层螺旋CT征象进行回顾性分析，并以手术、病理结果为标准，评价CT诊断的准确性。结果:35例患者CT均确定了梗阻的存在。31例单发梗阻CT均准确确定了梗阻部位，4例多发梗阻者CT确定了11处梗阻中的9处。26例非癌性粘连中23例在CT上均有相应的CT征象支持粘连性肠梗阻的诊断;9例癌性粘连中5例CT发现癌性粘连的直接征象，2例提示癌灶复发或淋巴结转移。根据CT征象判断绞窄性肠梗阻的敏感性93.3％，特异性87.5％，准确性为91.4％。结论:多层螺旋CT可较为全面地评价粘连性肠梗阻，对于指导临床诊疗有较大帮助。     

胆石性小肠梗阻四例临床分析

从2004年11月至2005年3月，我科急诊接连收治胆石性小肠梗阻4例，男女各2例，年龄48～85岁，平均65岁。均为脐周阵发性腹痛伴恶心、呕吐，停止排气、排便，起病急，病程3～45d，平均20d，既往均无腹部手术史，术前确诊2例，B超3例发现胆囊结石，腹部平片示小肠积气、积液和扩张的肠襻，其中3例行CT检查，发现小肠完全性异物梗阻（图1），1例CT发现右。肾3cm大小实性占位。4例均在急诊全麻下行小肠异物切开取出术，术中探查右上腹腔均示胆囊被大网膜包裹，粘连严重，结石梗阻部位均为距回盲部约30cm处。     

胆石性肠梗阻4例报告

回顾性分析了4例胆石性肠梗阻病人发病的过程及其诊治情况。4例均于术中确诊，并于梗阻近段切开小肠取出结石，横向关闭小肠切口，术后无并发症，痊愈出院。笔者认为胆石性肠梗阻不易早期诊断；其自身有发病的固有规律，即具有胆囊炎胆石症特点，转变成机械性肠梗阻的临床表现。胆石性肠梗阻有其特征性表现：突发性腹痛、呕吐与症状减轻或完全消失的交替性变化的表现。掌握这些规律和特点再结合影像学检查，有助于早期诊断和治疗。     

直肠癌术后放疗致粘连性肠梗阻12例诊治体会

目的　总结直肠癌术后放疗致粘连性肠梗阻的特点 ,诊断与鉴别诊断及治疗方式。方法　回顾性分析了近五年收治的直肠癌术后经60 Co及直线加速器放疗所致粘连性肠梗阻 12例 (其中 5例为直肠癌根治Miles术后 ,7例为低位直肠前切除后 )。结果　 12例患者均有机械性肠梗阻的典型临床表现 ,发病距放疗结束时间 7～ 32周 (平均 2 0 .5周 ) ;梗阻发生至手术时间 13～ 12 6小时 (平均 2 8小时 )。术中均表现为肠管的多段、广泛的紧密粘连 ,呈薄疤痕样“愈合” ,严重者与腹壁、盆腔周围粘连愈着呈冰冻状态。12例均行手术治疗。术式为小肠侧侧捷径吻合术。结论　直肠癌术后放疗所致粘连性肠梗阻多发生在放疗结束后半年内 ,表现为典型的机械性肠梗阻。诊断明确应立即手术治疗。术式宜行肠管的侧侧捷径吻合术     

胆囊-肠瘘致十二指肠降部胆石性完全梗阻一例

正胆石性肠梗阻是慢性结石性胆囊炎的罕见并发症,通常系巨大胆石通过胆肠间内瘘管进入肠道,嵌顿于肠管而引起肠道机械性梗阻所致。临床上常见的梗阻部位是末端回肠和回盲瓣,其次是近端空肠和回肠,胃和十二指肠则十分少见;而胆石滑脱阻塞十二指肠致肠腔完全性梗阻者更是少有。本文结合相关文献复习并讨论1例胆囊-十二指肠瘘致十二指肠完全性梗阻的诊断与治疗,现报道如下。     

嵌顿性闭孔疝8例临床诊治分析

我院1981年至2002年收治闭孔疝8例，仅3例术前得到确诊，手术死亡3例，值得引起临床重视，现报告如下。临床资料本组８例病人中男3例，女5例。除1例年龄为33岁外，其余7例为63～84岁，平均72岁。主要临床表现为腹痛、腹胀、呕吐，拟诊断为肠梗阻或不完全性肠梗阻入院。病史中述膝部疼痛３例，考虑为闭孔疝；2例既往有7～8年反复发作的、休息后可自行缓解的腹痛史；X线腹部平片均提示小肠梗阻或不全性肠梗阻，仅1例怀疑为闭孔疝所致；行CT检查1例提示闭孔疝。手术距发病时间1～14d，平均4.2d，术前均诊断为机械性肠梗阻，其中5例考虑为闭孔…     

MSCT多平面重建技术在腹内疝诊断及分型中的临床价值

目的探讨MSCT多平面重建(MPR)技术在腹内疝诊断及分型中的临床应用价值。方法回顾性分析2010年8月至2014年12月,扬州市第一人民医院经手术或随访证实的27例腹内疝患者的横轴面CT及MPR表现,观察肠管异位分布及其占位效应,肠梗阻及其肠壁、系膜缺血征象,梗阻肠袢与邻近肠管、系膜的关系等。结果肠黏连束带疝13例,右侧十二指肠旁疝3例,盆腔内疝3例,盲肠周围疝3例,乙状结肠周围疝2例,小肠系膜疝1例,左结肠系膜裂孔疝1例,吻合口后方疝1例。疝内容物均为小肠及其系膜,疝入小肠袢呈肿块状、囊袋状、簇状。闭袢性小肠梗阻18例,小肠壁水肿增厚9例,其中小肠坏死5例,小肠穿孔1例;近端小肠梗阻15例;肠系膜静脉增粗、聚集,向疝口部位集中形成"缆绳征"17例。15例CT随访检查中7例闭袢性小肠梗阻或近端小肠梗阻加重,4例减轻,4例无明显变化。结论 MSCT多平面重建技术能较准确地诊断腹内疝,为手术治疗提供了可靠依据,可作为腹内疝诊断及分型的首选影像检查手段。     

Small Bowel Obstruction Secondary to Bezoar Impaction: A Diagnostic Dilemma

Background Gastrointestinal bezoar (GIB) is uncommon and is reported to occur in 4% of all admissions for small-bowel obstruction (SBO). Because of a lack of diagnostic features, it is often associated with a delay in treatment, with increased morbidity. In this article, we report our experience with managing bezoar-induced SBO and the role of early computed tomography (CT) imaging in establishing the diagnosis. Methods We retrospectively reviewed all cases of bezoar-induced SBO treated in our unit between 1999 and 2005. Results There were 43 patients, of whom 2 had a recurrence, giving a total of 45 episodes. The frequency of bezoar in our patients presenting with SBO was 4.3%. All patients were of Asian origin: 41 Chinese, 1 Indian, and 1 Malay. Twenty-eight (65%) patients had previous abdominal surgery of which 26 were gastric surgery. Thirty-eight (88%) patients were edentulous. Forty-one (91%) underwent serial abdominal radiography, whereas only 4 patients (9%) had either CT imaging or contrast study alone. Only 11 (24%) cases had a correct diagnosis of bezoar impaction made preoperatively by CT imaging. The diagnostic accuracy of CT imaging in our series was 65%, with six cases of misdiagnosis. Overall, CT led to a change in management of 76% (13 in 17). The median time to surgery from admission was 2 (0–10) days. There were 2 cases of ischemic bowel that necessitated bowel resection. The median length of hospital stay was 11 (5–100) days. Ten patients (22%) had postoperative complications, and there was one death. Conclusion Bezoar-induced SBO is uncommon and remains a diagnostic and management challenge. It should be suspected in patients with an increased risk of formation of GIB, such as previous gastric surgery, poor dentition, and a suggestive history of increased fibre intake. We advocate that CT imaging be performed early in these at-risk patients and in patients presenting with SBO with or without a history of abdominal surgery in order to reduce unnecessary delays before appropriate surgical intervention.     

A rare cause of small bowel obstruction due to bezoar in a virgin abdomen

IntroductionBezoar is an unusual cause of small bowel obstruction accounting for 0.4–4% of all mechanical bowel obstruction. The common site of obstruction is terminal ileum.Case reportA 28-year-old male with no past surgical history, known to have severe mental retardation presented with anorexia. CT scan demonstrated dilated small bowel loops and intraluminal ileal mass with mottled appearance. At exploratory laparotomy, a bezoar was found impacted in the terminal ileum 5–6 inches away from the ileocecal valve and was removed through an enterotomy.DiscussionBezoars are concretions of fibers or foreign bodies in the alimentary tract. Small bowel obstruction is one of common clinical symptoms. The typical finding of well-defined intraluminal mass with mottled gas pattern in CT scan is suggestive of an intestinal bezoar. The treatment option of bezoar is surgery including manual fragmentation of bezoar and pushing it toward cecum, enterotomy or segmental bowel resection. Thorough exploration of abdominal cavity should be done to exclude the presence of concomitant bezoars. Recurrence is common unless underlying predisposing condition is corrected.ConclusionsBezoar-induced small bowel obstruction remains an uncommon diagnosis. It should be suspected in patients with an increased risk of bezoar formation, such as in the presence of previous gastric surgery, a history suggestive of increased fiber intake, or patient with psychiatric disorders. CT scan is helpful for preoperative diagnosis.     

Readmission for small-bowel obstruction in the early postoperative period: etiology and outcome.

OBJECTIVES: To determine the frequency of readmission for early postoperative small-bowel obstruction (SBO), to highlight factors that may predispose to this condition, to define the risks of strangulation and to compare the immediate and long-term risks and benefits of operative versus nonoperative treatment. DESIGN: A chart review. SETTING: The Sir Mortimer B. Davis-Jewish General Hospital, a university-affiliated teaching hospital in Montreal. PATIENTS: Out of a total of 1001 cases of SBO in 552 patients, 30 patients were readmitted within 50 days of a previous laparotomy with the diagnosis of SBO. INTERVENTION: Selective nonoperative management and exploratory laparotomy. MAIN OUTCOME MEASURES: The value of nonoperative management and need for operation. RESULTS: Adhesions were the cause of the obstruction in most cases (24); other causes were Crohn's disease (2), hernia (1), malignant neoplasm (1) and a combination of adhesions and malignant disease (2). Thirteen (43%) of the procedures preceding the obstruction were primary small-bowel operations. There was only 1 episode of strangulated bowel. Of the patients readmitted for SBO, 7 (23%) were treated operatively with a long-term recurrence rate of 57% compared with 63% for those treated nonoperatively for the SBO. The median time to recurrence was 0.1 years (range from 0.02-6 yr) for those whose SBO was managed operatively, compared with 0.7 years (range from 0.08-5 yr) for those managed nonoperatively for the SBO. The median length of stay for patients managed operatively for SBO was 12 days (range from 9-17 d) compared with 6 days (range from 2-33 d) for those managed nonoperatively. CONCLUSIONS: Readmission for SBO within 50 days of a previous laparotomy represents a small percentage of all cases of SBO. They frequently follow small-bowel operations. Cases of strangulation are no more common than in general cases of SBO. Patients treated nonoperatively for SBO did not experience less favourable outcomes with respect to resolution of symptoms, length of stay, risk of recurrence and reoperation. Thus, operative intervention is not necessary in an otherwise stable patient.     

Bezoar: An unusual cause of intestinal obstruction

Aim-Background

This article presents three cases of bezoar-induced small bowel obstruction (SBO). An uncommon entity, gastrointestinal bezoar (GIB) is reported to occur in 4% of all admissions for small bowel obstruction (SBO), with a prevalence in patients with a history of gastric surgery. Accurate preoperative diagnosis is notoriously difficult, and conventional management often necessitates laparotomy. Most bezoars are concretions of poorly digested food, which are usually formed in the stomach initially. Owing to their lack of diagnostic features, bezoars are often associated with delayed treatment and increased morbidity.

Case presentations

Herein, we describe three cases of SBO admitted to our department within the last 6 months. These patients initially presented with diffuse abdominal pain and abdominal distention. After undergoing the necessary laboratory and imaging investigation and failing to respond to conservative treatment, all three patients proceeded to surgery which revealed bezoar-induced SBO in all three cases. Two of the patients had a history of gastric surgery while the third had a bowel stenosis due to an adhesion band.

Conclusion

It is difficult to reach a preoperative diagnosis of bezoar-induced SBO based on clinical features. A GIB should be considered preoperatively as a cause of obstruction in patients with previous gastric surgery and digestive tract abnormalities such as adhesion bands. As yet, it remains a diagnostic and management challenge that usually demands early surgical intervention.     

Amphojeloma: antacid impaction in a critically ill patient

Patients in the intensive care unit seldom have mechanical small-bowel obstruction, and obstruction due to medication bezoars is even less common. A 65-year-old woman, in the intensive care unit because of septic shock and acute renal failure, had a small-bowel obstruction due to Amphojel concretions. Obstruction from such a cause may be prevented by including non-constipating antacids, stool softeners or sorbitol. Aggressive use of H2-antagonists to prevent gastrointestinal bleeding in septic patients will reduce the need for orally administered antacids. When obstruction occurs due to antacid concretions, it may be relieved by passing a long intestinal tube, by giving enemas for colonic obstruction or by operation.     

Surgical management of early small bowel obstruction after laparoscopic Roux-en-Y gastric bypass

BackgroundLimited data are available regarding early postoperative small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass (LRYGB). The aim of the present study was to review our experience with early SBO after LRYGB. The setting was a tertiary referral bariatric center.MethodsWe reviewed a prospectively maintained database to assess the diagnosis, management, and outcomes of patients who underwent surgery for SBO within 30 days of LRYGB.ResultsFrom April 2004 to December 2011, 2126 patients underwent LRYGB. Of these patients, 11 (.5%) required surgical management for early SBO. Of the 11 patients, 9 were women and 2 were men. with a mean age of 53 years (range 35–70) and mean body mass index of 45 kg/m² (range 38–65). The average interval from LRYGB to the presentation of SBO was 5.0 days (range 2–15). All early SBOs were diagnosed by computed tomography with oral contrast. The causes of early SBO included kinking at the jejunojejunostomy in 4, an intraluminal blood clot near the jejunojejunostomy in 2, angulation of the Roux limb in 1, mesenteric hematoma in 1, intra-abdominal hematoma in 1, obstruction of common channel in 1, and pelvic adhesions from previous surgery in 1. Diagnostic laparoscopy was attempted in all patients. Four patients required conversion to open surgery. Postoperative complications developed in 5 patients; no patient died. Laparoscopic management of early SBO resulted in fewer complications than the open approach.ConclusionEarly SBO after LRYGB is uncommon; however, a prompt diagnosis and surgical intervention are important to prevent additional morbidity. The ability to complete the reoperation laparoscopically varies with the etiology and location of the obstruction.     

Risk of Small Bowel Obstruction After the Ileal Pouch–Anal Anastomosis

OBJECTIVE: To determine the incidence of small bowel obstruction (SBO), to identify risk factors for its development, and to determine the most common sites of adhesions causing SBO in patients undergoing ileal pouch-anal anastomosis (IPAA). METHODS: All patients undergoing IPAA at Mount Sinai Hospital were included. Data were obtained from the institution's database, patient charts, and a mailed questionnaire. SBO was based on clinical, radiologic, and surgical findings. Early SBO was defined as a hospital stay greater than 10 or 14 days because of delayed bowel function, or need for reoperation or readmission for SBO within 30 days. All patients readmitted after 30 days with a discharge diagnosis of SBO were considered to have late SBO. RESULTS: Between 1981 and 1999, 1,178 patients underwent IPAA (664 men, 514 women; mean age 40.7 years). A total of 351 episodes of SBO were documented in 272 (23%) patients during a mean follow-up of 8.7 years (mean 1.29 episodes/patient). Fifty-four patients had more than one SBO. One hundred fifty-four (44%) of the SBOs occurred in the first 30 days; 197 (56%) were late SBOs. The cumulative risk of SBO was 8.7% at 30 days, 18.1% at 1 year, 26.7% at 5 years, and 31.4% at 10 years. The need for surgery for SBO was 0.8% at 30 days, 2.7% at 1 year, 6.7% at 5 years, and 7.5% at 10 years. In patients requiring laparotomy, the obstruction was most commonly due to pelvic adhesions (32%), followed by adhesions at the ileostomy closure site (21%). A multivariate analysis showed that when only late SBOs were considered, performance of a diverting ileostomy and pouch reconstruction both led to a significantly higher risk of SBO. CONCLUSIONS: The risk of SBO after IPAA is high, although most do not require surgical intervention. Thus, strategies that reduce the risk of adhesions are warranted in this group of patients to improve patient outcome and decrease healthcare costs.     

Pictorial Interlude: caught up in a 'whirl'

A patient with the 'whirl sign' on computed tomography (CT) is 25.3 times as likely as a patient without to have small-bowel obstruction (SBO) necessitating surgery. There is therefore an important role for the 'whirl sign' in assessment of patients with clinical and radiological signs of SBO.     

Effectiveness of intestinal tube splinting: a prospective observational study

BACKGROUND/AIMS: To assess the effectiveness of intestinal tube splinting. PATIENTS AND METHODS: The clinical, operative and outcome data of 186 patients undergoing 200 intestinal splinting procedures from 1973 until 1996 were accumulated in a prospective database. Endpoints were perioperative morbidity, mortality and the incidence of subsequent small bowel obstruction (SBO). The latest follow-up performed in 1998 updated the outcome of 197 procedures after 1-25 (median 7) years. RESULTS: In the early postoperative period, the overall incidence of complications was 9%, procedural complications 2%, and repeat surgery 3%. Three patients died during the index hospitalization. No patient suffered early SBO. Between 1 and 13 years after splinting, 6 complete SBOs (3%) necessitated reoperation and 5 incomplete SBOs (2.5%) were managed conservatively. After splinting for late SBO, freedom from complete SBO was 0.989 and of incomplete SBO 0.906, after splinting for early SBO 0.872 and 0.972, respectively, and for segmental peritonitic SBO freedom from complete SBO 0.8. No obstruction followed prophylactic splinting. CONCLUSIONS: Splinting was a reasonably safe procedure with comparatively low morbidity and mortality. The procedure prevented early SBO in all indicatory subgroups, reduced the rate of late recurrent SBO in patients treated for late adhesive SBO as compared with historical outcome data of simple enterolysis and prevented late SBO when performed prophylactically.