Intestinal adhesion

　　From the etiology of intestinal adhesion, the formation of adhesions is caused by factors other than congenital causes, mainly injury or inflammation.

　　(1) Injury:(A) During surgery, if the intestinal tract is exposed for too long, air pollution, rough movements, large incisions, severe serosal damage, incomplete hemostasis, postoperative hemorrhage and effusion, incomplete abdominal lavage, or retained foreign bodies in the abdomen, all these can cause intestinal adhesion; (b) abdominal trauma, where the abdomen is suddenly subjected to external impact, although the affected area is not ruptured or perforated, there is still some degree of injury, with local tissue congestion and edema, or bloodstained effusion flowing into the abdomen, causing edema and adhesion of surrounding tissues; (c) chemical drugs, such as the drug leakage from birth control sterilization surgery into the abdomen can cause severe adhesions.

　　(2) Inflammation:(A) Intra-abdominal inflammation leads to inflammatory edema, with exudates or pus overflowing into the abdomen to cause adhesions; (b) tuberculous peritonitis can cause intestinal adhesion, which can be divided into dry and wet types. The characteristics of the dry type are that in addition to the presence of tuberculous nodules on the peritoneum, there are also fibrinous exudates, which, after organization, cause widespread adhesion of abdominal organs, omentum, and mesentery; (c) intestinal tuberculosis can cause intestinal adhesion, where on the serosal surface of the intestine, there are fibrinous exudates and numerous grayish-white tuberculous nodules. This is often due to ulcers causing occlusion of intestinal wall blood vessels, while the intestinal wall is often thickened and adherent to adjacent intestines or omentum due to fibrous tissue proliferation.

　　(3) Other causes include invasive growth of tumors that destroy surrounding tissues to form adhesions or intestinal adhesions of unknown etiology.Clinically, patients with intestinal adhesion often occur after surgery, especially after appendicitis or pelvic surgery, with the highest chance of concurrent intestinal adhesion. The severity of intestinal adhesion is related to the sensitivity of each individual's peritoneal or intestinal serosal injury response.

　　In addition to its clinical manifestations, intestinal adhesion can also cause other diseases. This disease is most prone to concurrent intestinal obstruction, and in severe cases, it can even induce intestinal necrosis, which should attract great attention from clinical doctors and patients. Once the disease occurs, immediate medical treatment should be sought.

　　In clinical diseases of intestinal adhesion, patients with intestinal adhesion often occur after accumulated surgery, especially after appendicitis or pelvic surgery, with the highest chance of concurrent intestinal adhesion. The severity of intestinal adhesion is related to the sensitivity of each individual's peritoneal or intestinal serosal injury response. The clinical status of patients with intestinal adhesion may vary due to the degree and location of adhesion, with mild cases showing no discomfort or occasionally mild abdominal pain and distension after eating, while severe cases may often be accompanied by abdominal pain, distension, poor peristalsis, belching, constipation, gas-filled lumps moving in the abdomen, and even incomplete obstruction.

　　Intestinal adhesion can be asymptomatic for a long time, or it can manifest as chronic abdominal pain, or cause mechanical obstruction. Due to the lack of objective minimally invasive examination methods, for a long time, people's understanding of the occurrence, development, and evolution of postoperative intestinal adhesion has been very limited. The adhesion of intestinal loops is generally not prone to strangulation, and the success rate of conservative treatment is high in both traditional Chinese and Western medicine. However, it is difficult to relieve adhesion by surgery, and it is easy to cause secondary injuries such as intestinal tract rupture, and the chance of recurrence is high. The localized adhesion of the abdominal wall is relatively high in the probability of torsion and strangulation compared to visceral adhesion. These intestines are often adhered to the abdominal wall through omental fat tissue, and dense adhesion is rare. Whether it is laparoscopic surgery or open surgery, the treatment is relatively simple. The technical method of pneumoperitoneal CT examination can directly show the location, type, and extent of adhesion between the intestinal tract and the abdominal wall, filling the blank in the直观 imaging of abdominal adhesion, and raising the clinical diagnosis of intestinal adhesion from conjecture to confirmation. It has great value for the selection of clinical surgical cases and prediction of the difficulty of surgery. Due to its objectivity, repeatability, and operability of measurement methods, its efficacy is equivalent to that of laparoscopy, and it is an ideal choice for the clinical endpoint evaluation of the effectiveness of preventing postoperative abdominal and pelvic adhesion.

　　Although there is no very effective prevention for intestinal adhesion, according to experience, there are general principles and special situations:

　　1. General principles: Minimize unnecessary separation. For intestinal fistula, adhesion bands, and local adhesions causing intestinal obstruction, it is necessary to clarify the patency of the intestinal tract at the proximal and distal ends before surgery. After resection and reconstruction of the digestive tract, release of adhesion bands and local adhesions, there is no need for extensive separation. Otherwise, it will cause more extensive intestinal adhesions and lay the groundwork for the occurrence of adhesive ileus in the future. Debridement of necrotic tissue should be done appropriately. Otherwise, the wound surface left by debridement will be the basis for adhesion formation. The blood exuding from the wound surface after debridement is also a material causing adhesion formation. However, necrotic and fragmented tissue floating in the abdominal cavity should be eliminated as much as possible. The best way to clear is to use normal saline for abdominal lavage. Try to use absorbable sutures for ligation and suture, and use anastomotic and缝合 devices for reconstruction of the digestive tract. Avoid the use of silk thread in large quantities to form granulomas and adhesions. During operation, gently handle the tissue and avoid repeated rubbing and squeezing. Avoid long-term occlusion of the blood supply to the intestinal tract, reduce the time of intestinal ischemia, and alleviate the inflammation and edema of the intestinal wall.

　　2. Avoid unnecessary ileal and jejunum fistulae. Standard ileal fistula requirements include purse-string suture, tunnel suture, and abdominal wall suspension. Improper suspension of the ileum can lead to a sharp angle formation causing mechanical obstruction. In a strict sense, this is also a type of adhesive ileus, where artificial suture causes adhesion between the abdominal wall and ileal fistula, and slight improper handling can cause obstruction. The ileal fistula is generally chosen at about 15cm below the Treitz ligament of the ileum, which can avoid the ileal fistula from being suspended at an angle.

　　3. Try not to do shunt surgery Shunt surgery, also known as short-circuit surgery, is one of the traditional methods for treating adhesive intestinal obstruction. It is a temporary measure when the adhesion and obstruction site cannot be separated. Long-term clinical observation has found that postoperative intestinal obstruction will still recur. Since a small circulation is formed locally, when the obstruction site is reopened, it will反而加剧腹胀, and it is more likely to cause intestinal obstruction. It has been found that in patients who have undergone shunt surgery and need to be operated on again, the shunted intestines, due to the lack of effective intraluminal nutrition, are often atrophic, the intestinal wall is thin, and the original unused intestinal loop is easily damaged during surgery separation, and it is difficult to repair after damage. The unused intestinal loop has no normal intestinal fluid passing through it, lacks factors to inhibit bacterial proliferation, and bacteria in the intestinal lumen will overproliferate. In addition, due to the atrophy of the intestinal mucosa, it is very easy to cause bacterial or toxin translocation in the intestines, leading to chills and fever. Therefore, for intractable adhesive intestinal obstruction, especially those dominated by inflammatory factors, performing a shunt operation is not better than not performing any operation. In fact, most adhesive intestinal obstructions can be relieved. Of course, as a palliative treatment method, shunt surgery across cancerous obstruction can still be performed.

　　4. Avoid using artificial patches that cause adhesion in the abdominal cavity In recent years, with the use of various artificial patches, intestinal adhesions and intestinal obstructions caused by improper use of patches have occurred from time to time. In severe cases, intestinal fistula may also occur. There are three methods for repairing abdominal defects with patches: covering, filling (inlay), and lining (underlay). The lining method is most prone to adhesion, as the patch directly contacts the abdominal cavity, which is very easy to cause intestinal adhesion.

　　In the diagnosis of intestinal adhesions, in addition to relying on clinical manifestations, auxiliary examinations are also needed. Color Doppler ultrasound examination can make a clear diagnosis, showing irregular adhesion between intestinal loops, between intestines and peritoneum, and between intestines and abdominal organs, as well as the slowing of intestinal peristalsis.

　　Dietary health plays a very important role in the treatment of intestinal adhesions, which is closely related to our lives. Patients with intestinal adhesions should protect themselves in terms of diet, because their intestinal morphology and function have become abnormal. Although the location and degree of adhesion vary, the symptoms are more or less, and the severity of the disease varies, the physiological structure of the intestinal loop being fixed on the posterior abdominal wall by the mesentery has not changed. As long as the patient assumes a prone position after eating to protect themselves, the intestines with food and those without food can both maintain a downward clockwise state, which is conducive to the slow passage of food in the upper part of the intestinal loop through the narrow part and safely entering the lower part of the intestinal loop below the adhesion, so that both ends of the intestinal loop above and below the adhesion have food. In this way, the pressure inside the intestines is balanced, and the intestines with food will not shift, twist, or topple over, of course, avoiding the aggravation of the disease and the occurrence of intestinal obstruction. If abdominal adhesions do not affect the movement of the intestines, they are generally considered harmless.

　　Most adhesions do not pose a barrier to the patency of the empty intestine, but when the contents of the intestine increase and expand, adhesions are more likely to affect the patency of the intestine. It indicates that an increase in the contents of the intestinal lumen and the expansion of the intestine are the most common causes of intestinal obstruction in patients with postoperative intestinal adhesion. Therefore, patients with intestinal adhesion must pay attention to dietary control, eat less and more frequently, choose easily digestible low-fiber diet, do not overeat, do not eat indigestible food and gas-producing food, to avoid the occurrence of diarrhea (diarrhea can cause the small intestine to dilate and accumulate fluid). Once abdominal pain and distension occur after eating, reduce food intake or temporarily stop eating, and go to the hospital or clinic for intravenous fluid therapy to maintain the constant level of body electrolytes. In terms of diet, attention should be paid to: do not eat hard food, sticky food, and fibrous food; do not eat cold food, do not drink cold drinks; try to eat soft food and liquid food such as congee, steamed buns, cakes, milk, soy milk, etc. Also, eat less and more frequently, and avoid overeating. It is necessary to lie on the stomach for one hour after each meal. The benefits of this are: it is conducive to digestion and absorption, and can avoid improper eating or food being blocked in the narrow intestine at the site of adhesion, leading to the aggravation of the condition. Department of General Surgery, Xinhua Hospital, Hubei Province. Shenyang.

　　It is important to distinguish whether the adhesive intestinal obstruction is simple or strangulated, complete or incomplete in the treatment of adhesive intestinal obstruction. Because surgical treatment cannot eliminate adhesions, on the contrary, new adhesions are inevitably formed after surgery, so non-surgical treatment is generally preferred for simple intestinal obstruction and incomplete obstruction. Especially for patients with extensive adhesions, non-surgical treatment is usually chosen. Traditional Chinese medicine treatment can use Compound Dachengqi Decoction, and for those with mild symptoms and signs, raw vegetable oil or Qi-regulating and intestinal-relaxing decoction can be used. Acupuncture at Zusanli (ST36) can also be combined. If adhesive intestinal obstruction occurs early after surgery, it is usually simple intestinal obstruction, and these newly formed adhesions can be partially or completely absorbed in the future, and the effect of non-surgical treatment is often satisfactory. If adhesive intestinal obstruction does not improve or even worsens after non-surgical treatment, or if it is suspected to be a narrow intestinal obstruction, especially a闭袢性 obstruction, surgery must be performed early to prevent intestinal necrosis. Surgical treatment should also be considered for patients with recurrent and frequent adhesive intestinal obstruction.