【作者】 王震宇；

【导师】 秦鸣放；

【作者基本信息】 天津医科大学 ， 中西医结合临床， 2009， 博士

【摘要】 目的建立联合应用中西医结合非手术治疗、腹腔镜微创手术和中药的三阶段治疗急性粘连性肠梗阻的方案,评估该方案的可行性、有效性和与其他治疗方案比较的优势,探讨影响粘连性肠梗阻治疗和治疗后复发的危险因素,为临床治疗方法的选择提供依据。方法“三阶段中西医结合微创治疗急性粘连性肠梗阻方案”指在急性期,行中西医结合非手术治疗,解除梗阻;在缓解期,行腹腔镜手术去除粘连,根除发病原因;在疗效巩固期,应用中药促进肠功能的恢复,减少粘连的形成,防止复发。将2003年1月～2008年3月收治的225例粘连性肠梗阻病人随机分为联合治疗组、中西医结合非手术组、西医非手术组、开腹手术组、急诊腹腔镜手术组,共5组,每组45例。各组按照设定的治疗方案进行治疗,治疗后随访1年以上。在急性期对比分析中西医结合非手术和西医非手术治疗结果。在缓解期对比分析择期腹腔镜手术和择期开腹手术、择期腹腔镜手术和急诊腹腔镜手术的结果。对比各组粘连性肠梗阻的复发情况。将病因为手术后粘连的术后粘连性肠梗阻病人197例的发病情况、治疗方法和结果进行影响因素分析。分析非手术治疗中转手术、腹腔镜手术中转开腹手术和术中并发症、重度腹腔内粘连以及粘连性肠梗阻复发的影响因素。结果在急性期,采用中西医结合非手术治疗,联合治疗组成功率93.3% (42/45)、中西医结合非手术组成功率91.1% (41/45)、开腹手术组成功率93.3% (42/45),显著优于西医非手术组76.3% (33/45)。联合治疗组肠梗阻缓解时间平均为19.21小时、中西医结合非手术组18.27小时、开腹手术组19.95小时,较西医非手术组28.76小时显著缩短。在缓解期,联合治疗组术中并发症9.5% (4/42),开腹手术组7.1% (3/45),两者没有显著性差异。联合治疗组手术时间平均65.41分钟、术后并发症5.1% (2/39)、术后排气时间平均46.49小时、术后住院天数平均4.18天,均显著优于开腹手术组的73.50分钟、21.4%、88.83小时和8.19天。联合治疗组与急诊腹腔镜组比较,中转开腹手术率分别为7.1% (3/42)和37.7%(17/45),术中并发症9.5% (4/42)和33.3% (15/45),平均手术时间65.41分钟和112.43分钟,术后并发症5.1% (2/39)和25% (7/28),排气时间46.49小时和54.68小时,术后住院天数4.18天和4.61天,联合治疗组均显著优于急诊腹腔镜组。随访复发率,联合治疗组5.1% (2/39),与中西医结合非手术组29.3%(12/41)、开腹手术组21.4% (9/42)、西医非手术组33.3% (11/33)有显著性差异,与急诊腹腔镜组14.3% (4/28)没有显著性差异。复发时间,联合治疗组28.5个月,较中西医结合非手术9个月、开腹手术组12个月、西医非手术组9个月显著延长,与急诊腹腔镜27个月,没有显著性差异。术后粘连性肠梗阻非手术治疗中转手术的危险因素是年龄在60岁以下、以往有急诊手术史。中西医结合非手术治疗是保护性因素,与西医非手术治疗相比,可显著减少中转手术的发生。多次发作肠梗阻是腹腔镜中转开腹手术的危险因素。择期手术是避免腹腔镜中转开腹手术和术中并发症的保护性因素,与急诊手术相比可显著减少二者的发生。重度粘连的形成与手术次数有关,多次腹部手术史是形成重度粘连的危险因素。多次发作和多次手术是复发的危险因素。治疗方法中开腹手术和非手术治疗是复发的危险因素,而腹腔镜手术则可能是避免术后复发的因素。结论1.“三阶段中西医结合微创治疗急性粘连性肠梗阻方案”,在急性期采用中西医结合非手术治疗,解除梗阻,避免急诊手术,在缓解期行择期腹腔镜手术,根除病因,防止复发。综合应用、充分发挥各种治疗方法的优势,相互弥补不足,可取得较单一治疗方法更优越的疗效。2.在急性期,中西医结合非手术治疗效果明显优于西医非手术治疗,是避免非手术治疗中转手术的保护性因素。在缓解期,择期腹腔镜粘连松解术比择期开腹手术有明显的微创优势。择期腹腔镜手术较急诊腹腔镜手术更安全、有效,是避免腹腔镜手术中转开腹手术和减少术中并发症的保护性因素。腹腔镜手术能降低粘连性肠梗阻的复发。更多还原

【Abstract】 ObjectiveTo establish a scheme,in which the integrated traditional Chinese and westemmedicine,laparoscopic surgery,as well as herbal medicine are carried out by threestages in the treatment of acute adhesive intestinal obstruction,and to evaluate thefeasibility,effectiveness and superiority of the scheme comparing with other schemes,and to determine the risk factors of non-operation,laparoscopic adhesiolysis,thepostoperative intraperitoneal adhesion formation,recurrence after treatmentsrespectively,so as to provide foundations to select the type of treatment.MethodsThe process of the scheme are,in the acute phase,the cases which were initiallyconservative managed with integrated traditional Chinese and western medicine toresolve the obstruction;in the remission phase,re-scheduled laparoscopicadhesiolysis was attempt to resolve the causes of the obstruction;in the phase ofconsolidating effectiveness,herb medicine was used to promote the return of bowelfunction,that will reduce the formation of postoperative adhesions to avoidrecurrence of intestinal obstruction.From January 2003 to March 2008,225 patients suffering from acute adhesiveintestinal obstruction were randomized into five groups:combined treatmentgroup(CTG),integrated traditional Chinese and western medicine non-operationgroup(CWnG),western medicine non-operation group(WnG),open surgerygroup(OSG)and emergency laparoscopic group(ELG),each group of 45 patients.Each group was treated according to the scheme respectively;each case wasfollowed-up more than one year.In the acute phase,the outcomes of conservativetreatment with integrated traditional Chinese and western medicine were comparedwith that of westem medicine non-operation treatment.In the remission phase,theoutcomes were compared between re-scheduled laparoscopic surgery andre-scheduled open surgery as well as re-scheduled and.emergency laparoscopicsurgery.The recurrence of each group was compared,too. There are 197 cases in which the cause of obstruction is postoperativeintraperitoneal adhesions.Data collected included their relative information,type ofmanagement,and outcomes of treatment and we determined the risk factors ofsurgical intervention of conservative management,conversion to laparotomy andintra-operation morbidity of laparoscopic surgery,severe degree intraperitonealadhesions,and recurrence after treatment.ResultsPatients in CTG,CWnG and OSG were conservative managed with integratedtraditional Chinese and western medicine in acute phase and the successful rate ofnon-operation was 93.3%(42/45),91.1%(41/45),93.3%(42/45)in each grouprespectively,statistically significantly higher than that of WnG (73.3%,33/45)inwhich patients were conservative managed with western medicine.The time ofresolving obstruction in CTG was 19.21 hours,CWnG 18.27 hours,OSG 19.95 hours,significantly shorter than that of WnG (28.76 hours).In the remission phase,the rateof intraoperative complications in CTG were 9.5% (4/42)is similar with OSG (7.1%,3/45).In CTG the operation time was 65.41 minutes,postoperative complicationswere 5.1% (2/39),time to first bowel movement was 46.49 hours,and the length ofpostoperative hospital stay was 4.18 days,significantly superior than that in OSG,73.50 minutes,21.4% (9/42),88.83 hours,8.19 days.CTG compared with ELG,thefrequency oflaparotomic conversion was 7.1% (3/42)vs.37.7% (17/45),the rate ofintraoperative complication was 9.5% (4/42)vs.33.3% (15/45),median operationtime was 65.41 vs.112.43 minutes,the rate of postoperative complications was 5.1%(2/39)vs.25% (7/28),the time to first bowel movement was 46.49 vs.54.68 hours,the length of postoperative hospital stay was 4.18 vs.4.61 days,the outcomes in CTGwere superior than those in ELG.Through a long-term follow-up,the recurrence ratein CTG was 5.1% (2/39),significantly lower than that in CWnG (29.3%,12/41),OSG (21.4%,9/42)and WnG (33.3%,11/33)respectively,and no significantlydifferences were found with ELG (14.3%,4/28).The time of interval between aftertreatment and recurrence in CTG was 28.5 months,significantly longer than that inCWnG (9 months),OSG (12 months),WnG (9 months),and similar with ELG (27 months).The risk factors of surgical intervention of conservative management are agelower than 60 years and previous emergency surgery.The conservative treatment ofthe integrated traditional Chinese and western medicine were the protection factors,compared with westem medicine non-operative management,significantly reducedthe conversion rate.More episodes of acute small bowel obstruction (ASBO)was therisk factors of conversion to laparotomy.The re-scheduled laparoscopic treatment wasthe protective factor of conversion to laparotomy and intraoperative complications,which could avoid those compared with emergency laparoscopic surgery.Severeintraperitoneal adhesions was relative with the number of previous operations,moreprevious abdominal operations was the risk factor of severe adhesions.More episodesof ASBO and more previous abdominal operations were the risk factors of recurrence.Open surgery and non-operative management were the risk factors of recurrence,while laparoscopic surgery maybe avoid recurrence.Conclusion1.In acute phase,the scheme of“combined treatment of integrated traditionalChinese and western medicine and minimally invasive surgery in acute adhesiveintestinal obstruction in three stages”adopts conservative management of integratedtraditional Chinese and westem medicine to resolve the obstruction and avoidemergency operation;in the remission phase,re-scheduled laparoscopic adhesiolysiswas attempt to resolve the causes of the obstruction and avoid recurrence.Combinedtreatment of integrated traditional Chinese and western medicine and minimallyinvasive surgery play to their strengths,and meet the shortfall,and weight over asingle treatment.2.In acute phase,the outcome of conservative treatment of integratedtraditional Chinese and western medicine is superior to that of western medicinenon-operation,and is the protective factor to avoid surgical conversion.In theremission phase,re-scheduled laparoscopic lysis、has the superior of minimallyinvasive.re-scheduled laparoscopic surgery is safer and more effective thanemergency laparoscopic surgery,and is the protective factor to avoid conversion to laparotomy and intraoperative complications.The laparoscopic surgery will reducethe recurrence of adhesive intestinal obstruction.更多还原