中西医结合微创治疗急性肠梗阻方案的临床研究
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摘要
目的：建立中西医结合与腹腔镜手术联合微创治疗急性肠梗阻的方案，并探讨此方案的治疗效果。方法：自1997年10月至2003年3月，187例急性肠梗阻病人分三阶段进行中西医结合微创治疗。急性期中西医结合非手术治疗解除梗阻，梗阻未解除者行急症腹腔镜探查及手术。梗阻解除者在缓解期行腹腔镜手术，去除引起肠梗阻的病因。恢复期中药治疗减少术后粘连性肠梗阻的发生。结果：急性期17例入院后立即手术，170例采用中西医结合非手术治疗，成功148例，22例中转手术。急症腹腔镜探查共39例，腹腔镜手术成功17例，中转开腹手术22例(由于肠绞窄7例、结肠肿瘤10例、肠管损伤5例)。缓解期具备手术适应证107例，38例拒绝手术，接受择期腹腔镜手术69例，成功63例，中转开腹手术6例(由于小肠肿瘤1例、肠管损伤3例、肠管粘连成团无法分离2例)。腹腔镜粘连松解术成功63例，在恢复期中药治疗33例，对照组30例。中药组和对照组各有1例发生术后粘连性肠梗阻。全组病例死亡4例。结论：中西医结合非手术治疗可有效地解除急性梗阻。腹腔镜手术可有效地去除引起梗阻的病因，治愈疾病，并具有微创的特点，可减少术后粘连性肠梗阻的发生。中西医结合与腹腔镜手术联合治疗可以有效地提高腹腔镜手术的成功率并达到根治疾病的目的。中西医结合微创治疗急性肠梗阻方案是安全、有效的。
Objective: To creat a new regime, in which laparoscopic surgery is integrated into the combination of TCM and western medicine, in treatment of acute intestinal obstruction, as well as to explore the effect of the new program. Methods: From October 1997 to March 2003, 187 patients suffering from acute intestinal obstruction were treated in three stage. In the acute phase, the cases were initially conservative managed with combination of TCM and western medicine to resolve the obstruction. If the obstruction could not be released , the conversion to emergency laparoscopic operation was necessary. In the remission phase elective laparoscopic treatment was attempt to resolve the causes of the obstruction. Herb medicine was used in recovery phase,to prevent recurrent of adhesive small bowel obstruction. Results: In the acute phase, 17 cases underwent emergency surgery, and 170 were initially conservative treated with combination of TCM and western medicine. Conservative management was effective in 148 patients.
22 cases failed to convert to emergency operation. Emergency laparoscopic diagnostic operation was performed in 39 cases. The therapeutic operation was completed laparoscopically in 17 cases, while conversion to laparotomy proved necessary in 22 cases. The reason of conversion included: 7 intestinal infarction, 10 colon cancer, 5 intestinal perforation. After resolution of the obstruction, 107 patients should be managed with elective laparoscopic treatment in remission stage. 38 of them denied the operation. 69
cases were approached laparoscopically. 63 were completed laparoscopically, and 6 patients, including: 1 ileal tumor, 3 intestinal perforation, 2 convoluted mass of adherent bowel, were converted to open surgery. The outcome of laparoscopic adhesiolysis was successful in 63 patients. All of them were randomly divided into two groups (the herd's group 33 cases and the control group 30 cases) in recovery phase. In each of the groups, there was 1 patient that recurred adhesive small bowel obstruction. In all the 187 cases, 4 patients died. Conclusion: The method of conservative management with combination of TCM and western medicine is effective in releasing the obstruction in acute stage. The causes of the intestinal obstruction can be successful resolved with laparoscopic treatment, thus to cure the disease. The laparoscopic surgery is one kind of minimally invasion operation, which create fewer intra-abdominal adhesion that leads to adhesive small bowel obstruction. The integration of the two approaches is a
safe and effective treatment for acute intestinal obstruction.
Objective: To creat a new regime, in which laparoscopic surgery is integrated into the combination of TCM and western medicine, in treatment of acute intestinal obstruction, as well as to explore the effect of the new program. Methods: From October 1997 to March 2003, 187 patients suffering from acute intestinal obstruction were treated in three stage. In the acute phase, the cases were initially conservative managed with combination of TCM and western medicine to resolve the obstruction. If the obstruction could not be released , the conversion to emergency laparoscopic operation was necessary. In the remission phase elective laparoscopic treatment was attempt to resolve the causes of the obstruction. Herb medicine was used in recovery phase,to prevent recurrent of adhesive small bowel obstruction. Results: In the acute phase, 17 cases underwent emergency surgery, and 170 were initially conservative treated with combination of TCM and western medicine. Conservative management was effective in 148 patients.
22 cases failed to convert to emergency operation. Emergency laparoscopic diagnostic operation was performed in 39 cases. The therapeutic operation was completed laparoscopically in 17 cases, while conversion to laparotomy proved necessary in 22 cases. The reason of conversion included: 7 intestinal infarction, 10 colon cancer, 5 intestinal perforation. After resolution of the obstruction, 107 patients should be managed with elective laparoscopic treatment in remission stage. 38 of them denied the operation. 69
cases were approached laparoscopically. 63 were completed laparoscopically, and 6 patients, including: 1 ileal tumor, 3 intestinal perforation, 2 convoluted mass of adherent bowel, were converted to open surgery. The outcome of laparoscopic adhesiolysis was successful in 63 patients. All of them were randomly divided into two groups (the herd's group 33 cases and the control group 30 cases) in recovery phase. In each of the groups, there was 1 patient that recurred adhesive small bowel obstruction. In all the 187 cases, 4 patients died. Conclusion: The method of conservative management with combination of TCM and western medicine is effective in releasing the obstruction in acute stage. The causes of the intestinal obstruction can be successful resolved with laparoscopic treatment, thus to cure the disease. The laparoscopic surgery is one kind of minimally invasion operation, which create fewer intra-abdominal adhesion that leads to adhesive small bowel obstruction. The integration of the two approaches is a
safe and effective treatment for acute intestinal obstruction.
引文
1．郑显理，石水生主编．中国急腹症治疗学．第1版．天津：天津科学技术出版社，1996．
2．吴阶平，裘法祖主编．黄家驷外科学．第6版．北京：人民卫生出版社，1999．1067-1081
3．吴咸中，黄耀权主编．腹部外科实践．第二版．天津：中国医药科技出版社，1993．
4．何清宇 周振理 王光霞等．中西医结合治疗急性肠梗阻．第七届全国中西医结合普通外科临床与基础研究学术会议论文汇编，2001：62-64
5．吴咸中主编．中西医结合急腹症方药诠释．第一版．天津天津科学技术出版社，2001．
6．周业江，熊玉霞．中西医结合治疗粘连性肠梗阻临床观察．中国中医急症 2001．12．15；10(6)：333-334
7. Bogusevicius A. Analysis of the outcome of the treatment of small bowel obstruction and factors which determine the outcome (10-year experience at the Kaunas Medical University Clinic). Medicina (Kaunas) 2002;38(3):289-95
8．黎介寿．改善粘连性小肠梗阻手术的质量．中国实用外科杂志，2000，8；20(8)：450-452
9．王元和，阮灿平．肠梗阻手术时机的选择．中国实用外科杂志，2000，8；20(8)：458-459
10. Sato Y, Ido K, Kumagai M, et al. Laparoscopic adhesiolysis for recurrent small bowel obstruction: long-term follow-up. Gastrointest Endosc 2001 Oct;54(4):476-9.
11. Schwab DP, Blackhurst DW, Stieca RP. Operative acute small bowel obstruction: admitting service impacts outcome. Am Surg 2001 Nov;67(11): 1034-8; discussion 1038-40
12. Malangoni MA, Times ML, Kozik D, et al. Admitting service influences the outcomes of patients with small bowel obstruction. Surgery 2001 Oct;130(4):706-11; discussion 711-3
13. Agresta-F, Piazza-A, Michelet-T, et al. Small bowel obstruction. Laparoscopic approach. Surg-Endosc,2000Feb; 14(2): 154-6
14．孙小林，宗大伟，许红兵．腹腔镜技术在急性肠梗阻治疗中的应用．中华消化内镜杂志 1999，10；16(5)：268-270
15. Levard H, Boudet M J, Msika S, et al. Laparoscopic treatment of acute small
bowel obstruction: a multicentrcrctrospective study. ANZ J Surg 2001 Nov;71 (11):641-6
16. Iannclli A, Fabiani P, Dahman M, et al. Small bowel volvulus resulting from a congenital band treated laparoscopically. Surg Endosc 2002 Mar;16(3):538
17. Guillem P, Cordonnier C, Bounoua F, et al. Small bowel incarceration in a broad ligament defect. Surg Endosc 2003 Jan;17(1):161-2
18. Duepree HJ, Senagorc AJ, Dclancy CP, et al. Advantages of laparoscopic resection for ileocecal Crohn's disease. Dis Colon Rectum 2002 May;45(5):605-10
19. Park KT, Kim SH, Song TJ, et al. Laparoscopic-assistcd resection of ileal lipoma causing ilco-ilco-colic intussusception. J Korean Med Sci 2001 Feb;16(1):119-22
20. Lezochc E, Feliciotti F, Paganini AM, et al. Laparoscopic vs open hemicolectomy for colon cancer. Surg Endosc 2002 Apr;16(4):596-602
21. Soto DJ, Evan SJ, Kavic MS. Laparoscopic management of gallstone ileus. JSLS 2001 Jul-Sep;5(3):279-85
22. Fujimoto A, Osuga Y, Tsutsumi O, et al. Successful laparoscopic treatment of ileo-cecal endometriosis producing bowel obstruction. J Obstct Gynaecol Res 2001 Aug;27(4):221-3
23．朱维铭，李宁．术后早期炎性肠梗阻的诊治．中国实用外科杂志，2000，8；20(8)：456-458
24．王元和，阮灿平．肠梗阻手术时机的选择．中国实用外科杂志，2000，8；20(8)：458-459
25．天津市南开医院中西医结合重点病种诊疗规范．天津市南开医院．2002，9；48-49
26．陈训如，Peter Mack主编．腹腔镜外科理论与实践．第一版．云南：云南科技出版社，1995．
27．朱江帆主编．普通外科内镜手术学．第一版．山东：山东科技出版社，2001．
28．邹声泉主编．实用腔镜外科学．第一版．北京：人民卫生出版社，2002．
29．吴咸中，崔乃强，何清宇等．通里攻下法在腹部外科疾病中的应用与基础研究．
30. Malangoni MA, Times ML, Kozik D, et al. Admitting service influences the outcomes of patients with small bowelobstruction. Surgery 2001 Oct; 130(4):706-11; discussion 711-3
31. Schwab DP, Blackhurst DW, Sticca RP. Operative acute small bowel obstruction: admitting service impacts outcome. Am Surg 2001 Nov;67(11): 1034-8; discussion 1038-40
32. Kriger AG, Andreitsev IL, Gorskii VA, et al. Diagnosis and treatment of acute adhesive small intestine obstruction. Khirurgiia (Mosk). 2001;(7):25-9
33. Strickland P, Lourie D J, Suddleson EA, et al. Is laparoscopy safe and effective for treatment of acute small-bowel obstruction? Surg Endosc 1999 Jul; 13(7):695-8
34. Navez B, Arimont JM, Guiot P. Laparoscopie approach in acute small bowel obstruction. A review of 68 patients. Surg Endosc 1999 Jun; 13(6):595-9
35. Chosidow D, Johanet H, Montariol T, et al. Laparoscopy for acute small-bowel obstruction secondary to adhesions. J Laparoendosc Adv Surg Tech A 2000 Jun;10(3):155-9
36. Benoist S, De Watteville JC, Gayral F. Role of celioscopy in acute obstruction of the small intestine. Surg Laparosc Endosc 1996 Apr;6(2): 155-9
37. Sato Y, Ido K, Kumagai M, et al. Laparoscopic adhesiolysis for recurrent small bowel obstruction: long-term follow-up. Gastrointest Endosc 2001 Oct;54(4):476-9
38．David C．Sabiston，Jr．主编．王德炳主译．克氏外科学．第15版．北京：人民卫生出版社，2000．772-779
39．吴咸中，田在善．主编．证与治则的现代研究．第1版．天津：天津科技翻译出版公司，1999．
40．江跃华．双管灌注大承气汤治疗粘连性肠梗阻35例．江西中医学院学报．2000；12(4)：149
41．刘清哲，刘牧林，方先业．中西医结合小肠减压治疗不全性肠梗阻．蚌埠医学院学报．2003；25(2)：13
42．管强．复方大承气汤治急性肠梗阻243例分析．江西中医药．1998；29(6)：11-12
43. Lin E, Wear K, Tiszenkel HI. Planned reduction of incarcerated groin hernias with hernia sac laparoscopy. Surg Endosc, 2002 Jun;16(6):936-8
44. Moore RG, Partin AW, Adams JB, et al. Adhesion formation after transperitoneal nephrectomy: laparoscopic v open approach. J Endourol 1995;9:277-80
45. Bulletti C, Polli V, Negrini V, et al. Adhesion formation after laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 1996;3:533-6
46. Fischer CP, Doherty D. Laparoscopic approach to small bowel obstruction. Semin Laparosc Surg 2002 Mar;9(1):40-5
47．陈小伍，剧永乐，戎祯祥等．腹腔镜肠粘连松解术治疗粘连性肠梗阻 38例报告．中国实用外科杂志，2003；23(1)：60
48. Shayani V, Sicgert C, Favia P. The role of laparoscopic adhesiolysis in the treatment of patients with chronic abdominal pain or recurrent bowel obstruction. JSLS 2002 Apr-Jun;6(2):111-4
49．陈道达，张波，卢建华．腹腔粘连的术中预防．中国实用外科杂志，2000；20(8)：488-489
50．天津中西医结合急腹症研究所基础理论组．重要活血化瘀汤等对家兔实验性腹腔内粘连的预防作用．中西医结合急腹症通讯，1978；3：47
51．谢义明，邹学坤，朱大江．活血理气重要预防术后肠粘连的实验研究．中国中西医结合外科杂志，1998；4(5)269-271
52．赵振波，栾昌义，张纯田．加减复方大承气汤预防术后粘连性肠梗阻疗效观察．中西医结合杂志，1989；9(8)：496-497
2．吴阶平，裘法祖主编．黄家驷外科学．第6版．北京：人民卫生出版社，1999．1067-1081
3．吴咸中，黄耀权主编．腹部外科实践．第二版．天津：中国医药科技出版社，1993．
4．何清宇 周振理 王光霞等．中西医结合治疗急性肠梗阻．第七届全国中西医结合普通外科临床与基础研究学术会议论文汇编，2001：62-64
5．吴咸中主编．中西医结合急腹症方药诠释．第一版．天津天津科学技术出版社，2001．
6．周业江，熊玉霞．中西医结合治疗粘连性肠梗阻临床观察．中国中医急症 2001．12．15；10(6)：333-334
7. Bogusevicius A. Analysis of the outcome of the treatment of small bowel obstruction and factors which determine the outcome (10-year experience at the Kaunas Medical University Clinic). Medicina (Kaunas) 2002;38(3):289-95
8．黎介寿．改善粘连性小肠梗阻手术的质量．中国实用外科杂志，2000，8；20(8)：450-452
9．王元和，阮灿平．肠梗阻手术时机的选择．中国实用外科杂志，2000，8；20(8)：458-459
10. Sato Y, Ido K, Kumagai M, et al. Laparoscopic adhesiolysis for recurrent small bowel obstruction: long-term follow-up. Gastrointest Endosc 2001 Oct;54(4):476-9.
11. Schwab DP, Blackhurst DW, Stieca RP. Operative acute small bowel obstruction: admitting service impacts outcome. Am Surg 2001 Nov;67(11): 1034-8; discussion 1038-40
12. Malangoni MA, Times ML, Kozik D, et al. Admitting service influences the outcomes of patients with small bowel obstruction. Surgery 2001 Oct;130(4):706-11; discussion 711-3
13. Agresta-F, Piazza-A, Michelet-T, et al. Small bowel obstruction. Laparoscopic approach. Surg-Endosc,2000Feb; 14(2): 154-6
14．孙小林，宗大伟，许红兵．腹腔镜技术在急性肠梗阻治疗中的应用．中华消化内镜杂志 1999，10；16(5)：268-270
15. Levard H, Boudet M J, Msika S, et al. Laparoscopic treatment of acute small
bowel obstruction: a multicentrcrctrospective study. ANZ J Surg 2001 Nov;71 (11):641-6
16. Iannclli A, Fabiani P, Dahman M, et al. Small bowel volvulus resulting from a congenital band treated laparoscopically. Surg Endosc 2002 Mar;16(3):538
17. Guillem P, Cordonnier C, Bounoua F, et al. Small bowel incarceration in a broad ligament defect. Surg Endosc 2003 Jan;17(1):161-2
18. Duepree HJ, Senagorc AJ, Dclancy CP, et al. Advantages of laparoscopic resection for ileocecal Crohn's disease. Dis Colon Rectum 2002 May;45(5):605-10
19. Park KT, Kim SH, Song TJ, et al. Laparoscopic-assistcd resection of ileal lipoma causing ilco-ilco-colic intussusception. J Korean Med Sci 2001 Feb;16(1):119-22
20. Lezochc E, Feliciotti F, Paganini AM, et al. Laparoscopic vs open hemicolectomy for colon cancer. Surg Endosc 2002 Apr;16(4):596-602
21. Soto DJ, Evan SJ, Kavic MS. Laparoscopic management of gallstone ileus. JSLS 2001 Jul-Sep;5(3):279-85
22. Fujimoto A, Osuga Y, Tsutsumi O, et al. Successful laparoscopic treatment of ileo-cecal endometriosis producing bowel obstruction. J Obstct Gynaecol Res 2001 Aug;27(4):221-3
23．朱维铭，李宁．术后早期炎性肠梗阻的诊治．中国实用外科杂志，2000，8；20(8)：456-458
24．王元和，阮灿平．肠梗阻手术时机的选择．中国实用外科杂志，2000，8；20(8)：458-459
25．天津市南开医院中西医结合重点病种诊疗规范．天津市南开医院．2002，9；48-49
26．陈训如，Peter Mack主编．腹腔镜外科理论与实践．第一版．云南：云南科技出版社，1995．
27．朱江帆主编．普通外科内镜手术学．第一版．山东：山东科技出版社，2001．
28．邹声泉主编．实用腔镜外科学．第一版．北京：人民卫生出版社，2002．
29．吴咸中，崔乃强，何清宇等．通里攻下法在腹部外科疾病中的应用与基础研究．
30. Malangoni MA, Times ML, Kozik D, et al. Admitting service influences the outcomes of patients with small bowelobstruction. Surgery 2001 Oct; 130(4):706-11; discussion 711-3
31. Schwab DP, Blackhurst DW, Sticca RP. Operative acute small bowel obstruction: admitting service impacts outcome. Am Surg 2001 Nov;67(11): 1034-8; discussion 1038-40
32. Kriger AG, Andreitsev IL, Gorskii VA, et al. Diagnosis and treatment of acute adhesive small intestine obstruction. Khirurgiia (Mosk). 2001;(7):25-9
33. Strickland P, Lourie D J, Suddleson EA, et al. Is laparoscopy safe and effective for treatment of acute small-bowel obstruction? Surg Endosc 1999 Jul; 13(7):695-8
34. Navez B, Arimont JM, Guiot P. Laparoscopie approach in acute small bowel obstruction. A review of 68 patients. Surg Endosc 1999 Jun; 13(6):595-9
35. Chosidow D, Johanet H, Montariol T, et al. Laparoscopy for acute small-bowel obstruction secondary to adhesions. J Laparoendosc Adv Surg Tech A 2000 Jun;10(3):155-9
36. Benoist S, De Watteville JC, Gayral F. Role of celioscopy in acute obstruction of the small intestine. Surg Laparosc Endosc 1996 Apr;6(2): 155-9
37. Sato Y, Ido K, Kumagai M, et al. Laparoscopic adhesiolysis for recurrent small bowel obstruction: long-term follow-up. Gastrointest Endosc 2001 Oct;54(4):476-9
38．David C．Sabiston，Jr．主编．王德炳主译．克氏外科学．第15版．北京：人民卫生出版社，2000．772-779
39．吴咸中，田在善．主编．证与治则的现代研究．第1版．天津：天津科技翻译出版公司，1999．
40．江跃华．双管灌注大承气汤治疗粘连性肠梗阻35例．江西中医学院学报．2000；12(4)：149
41．刘清哲，刘牧林，方先业．中西医结合小肠减压治疗不全性肠梗阻．蚌埠医学院学报．2003；25(2)：13
42．管强．复方大承气汤治急性肠梗阻243例分析．江西中医药．1998；29(6)：11-12
43. Lin E, Wear K, Tiszenkel HI. Planned reduction of incarcerated groin hernias with hernia sac laparoscopy. Surg Endosc, 2002 Jun;16(6):936-8
44. Moore RG, Partin AW, Adams JB, et al. Adhesion formation after transperitoneal nephrectomy: laparoscopic v open approach. J Endourol 1995;9:277-80
45. Bulletti C, Polli V, Negrini V, et al. Adhesion formation after laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 1996;3:533-6
46. Fischer CP, Doherty D. Laparoscopic approach to small bowel obstruction. Semin Laparosc Surg 2002 Mar;9(1):40-5
47．陈小伍，剧永乐，戎祯祥等．腹腔镜肠粘连松解术治疗粘连性肠梗阻 38例报告．中国实用外科杂志，2003；23(1)：60
48. Shayani V, Sicgert C, Favia P. The role of laparoscopic adhesiolysis in the treatment of patients with chronic abdominal pain or recurrent bowel obstruction. JSLS 2002 Apr-Jun;6(2):111-4
49．陈道达，张波，卢建华．腹腔粘连的术中预防．中国实用外科杂志，2000；20(8)：488-489
50．天津中西医结合急腹症研究所基础理论组．重要活血化瘀汤等对家兔实验性腹腔内粘连的预防作用．中西医结合急腹症通讯，1978；3：47
51．谢义明，邹学坤，朱大江．活血理气重要预防术后肠粘连的实验研究．中国中西医结合外科杂志，1998；4(5)269-271
52．赵振波，栾昌义，张纯田．加减复方大承气汤预防术后粘连性肠梗阻疗效观察．中西医结合杂志，1989；9(8)：496-497