Consequences of surgery for intestinal obstruction

What kind of obstruction happens?

Based on the mechanism of occurrence, there are two main types of obstruction:

• Dynamic;
• Mechanical.

Dynamic obstruction is the result of a violation of the normal contraction of the intestinal wall. It can be caused by either a strong spasm or a complete relaxation of the muscles of the intestinal wall. This type of obstruction must be treated conservatively; surgical intervention, on the contrary, can aggravate peristalsis disorders.

Mechanical obstruction is already a real obstacle to the path of food masses in the intestines. It happens:

1. Obstructive;
2. Strangulation;
3. Mixed.

Mechanical obstruction very rarely goes away on its own or with conservative measures. It is this type of obstruction that is an absolute indication for surgery. The causes of mechanical obstruction in the intestine can be:

• Tumors;
• Gallstones;
• Strangulated hernia;
• Parasites;
• Foreign bodies;
• Nodulation;
• Adhesive disease;
• Torsion of the intestinal loop;
• Intussusception (pressing one intestine into another).

The first symptoms and signs of intestinal cancer: treatment features, surgery, survival prognosis

Subjective symptoms are nausea, vomiting, cramping abdominal pain, stool retention, increased peristaltic noise.

Objective symptoms:

• bloating, dehydration, splashing noise, increased or decreased peristaltic sounds;
• obstruction at the level of the gastric outlet - profuse vomiting (“gushing”);
• obstruction at the level of the colon - fecal vomiting.

Intestinal cancer is a malignant neoplasm that develops from the mucous tissue of the intestinal walls. According to available statistics, the disease is most often detected in people of the older age group (after 40 years), while it is detected with the same frequency in men and women.

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A, B - polyps that degenerate into malignant tumors. B - area of ​​the intestine affected by cancer.

Tactics for suspected intestinal obstruction

It is quite easy to suspect intestinal obstruction based on the clinical picture. The main symptoms are pain, vomiting, bloating, and lack of stool. The same symptoms can be observed in other disasters in the abdominal cavity, but in any case, this is an acute condition requiring emergency hospitalization.

If such symptoms are present, the patient is urgently sent to the surgical department. The length of hospitalization determines the prognosis. The later the patient was admitted to the hospital, the higher the mortality rate.

To confirm the diagnosis, an abdominal x-ray is prescribed; emergency irrigoscopy (intestinal x-ray with contrast) or colonoscopy can be performed. Sometimes in difficult cases, diagnostic laparoscopy is performed.

All necessary tests are carried out urgently. The most important indicators here are the level of hemoglobin, hematocrit, leukocytes, ESR, in the serum - the level of protein, sodium, potassium, creatinine, amylase. The blood type and Rh factor are determined.

Several groups of patients with intestinal obstruction can be distinguished, to which different management tactics are applied:

1. Patients admitted in the first 24 hours from the onset of symptoms with dynamic obstruction or suspected obstruction, but without symptoms of peritonitis. Conservative therapy and intensive monitoring are prescribed. Conservative measures can eliminate the symptoms of dynamic and some types of mechanical obstruction. If the condition does not improve within 2 hours, the patient undergoes surgery.
2. Patients with suspected strangulation obstruction, with symptoms of inflammation of the peritoneum, in a compensated state, are taken immediately for surgery.
3. Patients in serious condition, admitted after 24 hours, in a state of hypovolemic shock, severe electrolyte disturbances, undergo intensive preoperative preparation (sometimes this requires more than 3-4 hours) and subsequent emergency surgery.

Diagnostics

Intestinal obstruction does not manifest itself as a sharp deterioration in condition. This is often preceded by intestinal dysfunction in the form of constipation, bloating and rumbling in the abdomen. Symptoms gradually increase, accompanied by nausea, vomiting and pain.

The pain is spastic in nature. The higher the obstruction (blockage), the faster vomiting will begin. If the colon is affected, only nausea and later vomiting are possible. It initially consists of gastric contents, but later acquires a yellow-green tint with a fecal odor.

Also, bloating and rumbling are disturbing. As the intoxication syndrome increases, the pressure decreases and the pulse quickens.

Instrumental techniques include barium radiography, abdominal ultrasound, colonoscopy and laparoscopy. Using tomography, the extent of the cancer process is assessed and the extent of surgical intervention is determined.

Principles of conservative therapy

Conservative therapy is also a method of preoperative preparation (if surgery is still required).

1. Aspiration of the contents of the stomach and upper intestines through an installed probe.
2. Carrying out cleansing and siphon enemas. Sometimes this measure can help remove an obstacle (for example, wash away dense fecal debris).
3. Urgent colonoscopy. It is carried out for diagnostic purposes, but can also eliminate some types of obstruction (for example, intussusception, or partially expand the intestine during obstruction).
4. Replenishment of fluid and electrolyte losses. To do this, under the control of central venous pressure, diuresis, and plasma electrolytes, infusions of saline, saline solutions, protein hydrolysates, rheological solutions, and plasma are carried out. Typically, the volume of infused funds is up to 5 liters.
5. For increased peristalsis and pain, antispasmodics are prescribed; for intestinal paresis, agents that stimulate peristalsis are prescribed.
6. Antibacterial agents are also prescribed.

Operations for intestinal obstruction

If conservative measures do not eliminate the problem, surgery cannot be avoided. The main objectives of surgical intervention:

• Removing an obstacle.
• If possible, eliminate the disease that led to this complication.
• Maximum possible actions to prevent postoperative complications and relapse.

The main stages of the operation and the surgeon’s tactics

1. Anesthesia. Usually this is endotracheal anesthesia with muscle relaxants.

2.

Access is most often a wide median laparotomy.

3. Revision of the abdominal cavity. The exact level of the obstacle is located. Above this place, the intestinal loops are swollen, purple-bluish in color, while the efferent intestine is collapsed, the color is usually not changed. The entire intestine is examined, since sometimes obstruction can be detected at different levels simultaneously.

4. Decompression and cleansing of the adductor colon, if this could not be done before surgery. To do this, nasointestinal intubation is performed (through an esophageal tube), or intubation of the intestine itself through a small incision.

5. Directly eliminating the obstacle itself. Several types of interventions can be applied here:

• Enterotomy - the intestinal wall is opened, the obstruction is removed (for example, a ball of roundworms, a foreign body, gallstones) and sutured.
• If a hernia is strangulated, the strangulated intestinal loops are repositioned.
• In case of strangulation obstruction – dissection of adhesions, tying of knots, elimination of intussusception and volvulus.
• Resection of a section of intestine in the presence of a tumor or intestinal necrosis.
• Bypass anastomosis in cases where the obstruction cannot be removed in the usual way.
• A colostomy (permanent or temporary) is usually performed in cases of left hemicolectomy.

6. Assessment of intestinal viability and its resection.

This is a very crucial moment of the operation; the further prognosis depends on it. The viability of the intestine is assessed by its color, contractility and vascular pulsation. Any doubt about the normal condition of the intestine is a reason for its resection.

If there are signs of intestinal necrosis, this area is resected within healthy tissue. There is a rule to resect the intestine 40-60 cm above the border of non-viability and 10-15 cm below it.

During resection of the small intestine, an end-to-end anastomosis is formed. If there is obstruction in the area of ​​the cecum, ascending or right half of the transverse colon, a right hemicolectomy with ileotransverse anastomosis is performed.

When the tumor is located in the left half of the colon, a one-stage operation cannot be performed in most cases. In this case, a colostomy is performed with bowel resection, and subsequently a second operation is performed to remove the colostomy and create an anastomosis.

A one-stage radical operation is not performed in case of developed peritonitis. In this case, the surgeon’s task is to remove the obstruction, rinse and drain the abdominal cavity.

Sometimes surgical treatment is even divided into three stages: 1 - application of a unloading stoma, 2 - resection of the intestine with a tumor, 3 - creation of an anastomosis and elimination of the stoma.

7. Washing and removing effusion from the abdominal cavity.

8. Drainage of the abdominal cavity.

9. Suturing the wound.

Treatment

Both acute and chronic forms of the disease are in most cases treated surgically. Only at the very beginning of the disease, when the general condition of the patient is not yet disturbed, after examination, conservative measures are carefully applied - gastric lavage, cleansing enemas; in case of atony, peristalsis is stimulated with drugs (injections of proserin, neostigmine). If the treatment is ineffective within a few hours or the cause is a tumor, adhesions, anomalies, or mesenteric thrombosis, surgical treatment is performed.

Surgical treatment of intestinal adhesions

During the intervention, the cause of the disease is eliminated: adhesions are cut, tumors, stones, torsions, pinched loops are removed. Not in all cases it is possible to immediately eliminate the cause of ileus, for example, with cancer or with a serious condition of the patient. Or when a large section of the intestine is removed due to a tumor, inflammation, or necrosis. Then a unloading stoma is applied after intestinal surgery - an external fistula for emptying. It can be permanent or temporary. The latter is removed during a repeat operation after eliminating the cause and restoring patency.

Very often, obstruction develops as a result of adhesions after interventions on the abdominal and pelvic organs. They glue the intestinal loops together, limiting their movements and causing their fusion with other organs. How to treat intestinal adhesions after surgery or prevent their formation? For this purpose, the patient is prescribed to get up as early as possible after surgery, therapeutic exercises, proteolytic enzymes and physical therapy, if there are no contraindications to it.

After operation

The postoperative stage in such patients is a very important moment of treatment, no less significant than the operation itself.

After surgery, the patient is sent to the intensive care unit. Main events:

• 24/7 monitoring of vital signs.
• Suction of intestinal contents through an intestinal tube. It is carried out to prevent intestinal paresis and reduce intoxication. Aspiration is combined with intestinal lavage and the introduction of antibacterial agents into its lumen. It is carried out until active peristalsis appears (usually 3-4 days).
• Parenteral fluid administration under the control of central venous pressure and diuresis.
• Parenteral administration of saline solutions under the control of plasma electrolytes.
• Parenteral nutrition (solutions of glucose, amino acids, protein hydrolysates).
• Antibacterial therapy.
• To stimulate intestinal motility, a hypertonic solution of sodium chloride, anticholinesterase agents (proserin) are administered, cleansing enemas are performed, and physiotherapy in the form of electrical stimulation of the intestine may be prescribed. Perinephric blockade has a good effect.
• Elastic bandaging of the lower extremities for the prevention of thromboembolic complications.

After 3-4 days, liquid food and drink are allowed. The diet is gradually expanding - slimy porridges, vegetable and fruit purees, meat soufflé, and fermented milk products are allowed. A diet excluding coarse, spicy foods and foods that cause increased gas formation and fermentation should be followed for up to 2 months.

Postoperative period

The first days or weeks of the postoperative patient are in the hospital and receive all the appointments of the attending physician:

• diet therapy;
• intestinal stimulation;
• anti-inflammatory therapy;
• intravenous infusions to replenish fluids, minerals, and remove toxins;
• physical therapy to prevent the formation of adhesions (an exception is an abdominal tumor);
• therapeutic exercises.

After discharge from the department, the patient is observed on an outpatient basis and follows all the doctor’s recommendations and prescriptions. It is necessary to perform special physical exercises, but with limited load.

Advice: some operated patients try to spend more time in bed, believing that it is safer (the wound hurts less, the stitches will not come apart, and so on). This is a misconception, the consequence of which can again be obstruction due to the development of adhesions against the background of physical inactivity.

And finally, diet, adherence to which is very important. Nutrition after intestinal surgery depends on its nature and volume, and should be within the scope of the doctor’s individual recommendations. However, there are general nutritional rules that must be followed. This is the exclusion of spicy and rough foods, foods that cause fermentation and bloating (milk, legumes, carbonated drinks), extractive foods, rich broths. The amount of fats and carbohydrates is limited, and the intake of protein and vitamins should be sufficient.

Fermented milk products containing lactobacilli and bifidobacteria to restore intestinal microflora, fruit purees and juices, boiled mucous porridges and soups are recommended. You can expand your diet no earlier than 2-3 months, and only after consulting with a specialist.

The state of health after surgery for intestinal obstruction largely depends on the patient himself. You can avoid repeated surgery and prevent undesirable consequences by carefully following all the necessary medical recommendations.

Features of the operation for the most common types of obstruction

The most common type of small bowel obstruction is obstruction due to adhesive disease. For the colon, this is the blocking of the intestinal lumen by a tumor.

Adhesive intestinal obstruction

Adhesions are scar strands in the form of cords or films that occur after abdominal surgery. Adhesions can cause both obstructive obstruction (squeezing the intestinal lumen) and strangulation (squeezing the intestinal mesentery).

The essence of the operation is to dissect the scar cords and resection of the necrotic area of ​​the intestine. If possible, all adhesions are dissected, and not just those that caused complete obstruction.

The peculiarity of this type of obstruction is that adhesive obstruction is prone to relapse. By cutting adhesions, we create the preconditions for the formation of new adhesions. It turns out to be a vicious circle.

adhesive intestinal obstruction

In recent years, new techniques have been proposed for the prevention of relapses in adhesive obstruction. Briefly, their essence is this: place the loops of the small intestine in the abdominal cavity as correctly as possible, try to fix them in this way (sew the mesentery). But these methods do not guarantee the absence of relapses.

In addition, laparoscopic removal of adhesive obstruction is gaining popularity. This operation has all the advantages of minimally invasive surgery: low trauma, quick activation, short rehabilitation period. However, surgeons are reluctant to perform laparoscopic operations for intestinal obstruction. As a rule, during such operations it is still often necessary to go into open access.

Intestinal obstruction due to tumor

The tumor nature of obstruction is a special part of surgery. Operations for this type of obstruction are among the most difficult. Often, patients with intestinal tumors are admitted to the hospital for the first time only when a picture of intestinal obstruction has developed; the diagnosis is made on the operating table. Such patients, as a rule, are weakened and anemic long before surgery.

During surgery, there are two tasks: eliminating the obstruction and removing the tumor. Very rarely this can be done at once. Radical surgery cannot be performed:

1. If it is technically impossible to remove the tumor.
2. Extremely serious condition.
3. With developed peritonitis.

In these cases, in order to eliminate the obstruction, they are limited to removing the intestinal stoma outside. After eliminating the symptoms of intoxication and preparing the patient, a radical operation is performed a few weeks later - resection of the section of intestine with the tumor and elimination of the colostomy (removal of the colostomy can be delayed and transferred to the third stage).

If the patient’s condition allows, the tumor is removed simultaneously with the elimination of intestinal obstruction. Removal is carried out in compliance with ablastics - that is, as extensively as possible, as a single block with regional lymph nodes. For tumors in the colon, a right or left hemicolectomy is usually performed.

right/left hemicolectomy

For tumors of the small intestine – subtotal resection of the small intestine. If the tumor is located in the sigmoid colon, a Hartmann operation is possible. For rectal cancer, extirpation or amputation of the rectum is performed.

If it is impossible to remove the tumor, palliative operations are performed - an unnatural anus or a bypass anastomosis is created to restore patency.

The occurrence of complications after the intervention

If the patient does not follow the doctor’s recommendations, then unpleasant consequences arise after surgery for intestinal obstruction. Therefore, you should be wary of the appearance of ruptures in the walls of the small intestine if resection was performed. This process can be multiple or single. After surgery, peritonitis may develop, when the peritoneal wall in the area of ​​the sutures becomes inflamed.

Sometimes tissue necrosis continues if a small area of ​​dead epithelium is not removed. If the diet is not followed, the sutures may rupture. When symptoms of complications occur, you need to seek help from your doctor.

Intestinal obstruction occurs in young people, adults and the elderly. The main treatment is the prescription of medications. When medications do not help the patient, an emergency or elective surgical procedure is performed. Depending on the type of intestinal obstruction, the operation can last several stages and days. In the postoperative period, the patient is prescribed complex therapy. Otherwise, unpleasant consequences arise.

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Price

The operation to eliminate intestinal obstruction is an emergency. It is carried out free of charge at any nearest surgical hospital.

A paid operation is also possible, but you need to know clinics that specialize in providing emergency care. The price depends on the volume of intervention. The minimum cost of such operations is 50 thousand rubles. Then everything depends on the length of stay in the hospital.

The cost of laparoscopic surgery for adhesive intestinal obstruction is from 40 thousand rubles.

Preparatory manipulations

Surgeries for intestinal obstruction can be planned or urgent. It all depends on the cause, diagnosis and general condition of the patient.

Before this, preparatory manipulations are carried out. If the procedure is planned, then preparation can be done at home and then continued in the hospital.

The preparatory stage for chronic and acute intestinal obstruction consists of the following steps:

1. Following a special diet. Vegetable and fruit crops, milk and bread are excluded from the menu. The emphasis is on drinking plenty of fluids.
2. Drugs with a laxative effect are prescribed. These products include Fortrans, magnesium-based solution, petroleum jelly, Duphalac.
3. Perform cleansing enemas every evening before bed.
4. Taking medications to reduce spasms. This group includes Drotaverine, No-Shpa, Spazmalgon.
5. Administration of the solution through a vein. This will help normalize the level of electrolytes, fluid volume in the body, water-salt and energy metabolism.
6. Visit specialist doctors to identify concomitant diseases.

Fluid adjustment depends on the age and weight of the patient, the condition of the cardiovascular system and kidneys.