Zmushko Mikhail NikolaevichSurgeon, category 2, intern 1 ho TMO Kalinkovichi, Belarus.
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Acute intestinal obstruction (AOC) is a syndrome characterized by a violation of the passage of intestinal contents in the direction from the stomach to the rectum. Intestinal obstruction complicates the course of various diseases. Acute intestinal obstruction (OCH) is a syndromic category that combines the complicated course of diseases of various etiologies and pathological processes that form the morphological substrate of OCH.
Predisposing factors of acute intestinal obstruction:
1. Congenital factors:
Features of anatomy (lengthening of sections of the intestine (megacolon, dolichosigma)). Developmental abnormalities (incomplete bowing, agangliosis (Hirschsprung disease)).
2. Acquired factors:
Adhesions in the abdominal cavity. Neoplasms of the intestine and abdominal cavity. Foreign body intestine. Helminthiasis Cholelithiasis. Hernia of the abdominal wall. Unbalanced irregular nutrition.
Producing factors of acute intestinal obstruction:
Sharp increase in intra-abdominal pressure.
Excessive physical exertion.
Abundant food load.
OKN is 3.8% of all urgent diseases of the abdominal cavity. At the age of over 60 years, 53% is caused by colon cancer. The frequency of occurrence of OKN by obstacle level:
The frequency of occurrence of OKN on etiology:
- with acute small bowel obstruction: - adhesive in 63%
- 28% strangulation
- obstructive non-tumor genesis in 7%
- in acute colonic obstruction: - tumor obstruction in 93%
- torsion of the colon in 4%
Classification of acute intestinal obstruction:
A. By morphofunctional nature:
1. Dynamic obstruction: a) spastic, b) paralytic.
2. Mechanical obstruction: a) strangulation (bloat, nodulation, restraint, b) obturative (intraintestinal form, extraintestinal form), c) mixed (invagination, adhesive obstruction).
B. By obstacle level:
1. Enteric obstruction: a) High. b) Low.
In the clinical course of an OKN, there are three phases. (OS Kochnev 1984):
Phase "ileus shout." An acute violation of the intestinal passage occurs, i.e. stage local manifestations - has a duration of 2-12 hours (up to 14 hours). In this period, the predominant symptom is pain and local symptoms of the abdomen.
The phase of intoxication (intermediate, stage of apparent well-being), violation of intraparietal intestinal hemocirculation occurs - lasts from 12 to 36 hours. During this period, the pain loses its cramping character, becomes constant and less intense. The stomach is swollen, often asymmetrical. The peristalsis of the intestine weakens, the sound phenomena are less pronounced, the “noise of a falling drop” is heard. Full stool and gas retention. Signs of dehydration appear.
Phase of peritonitis (late, terminal stage) - occurs 36 hours after the onset of the disease. For this period, sharp functional disorders of hemodynamics are characteristic. The abdomen is significantly swollen, peristalsis is not heard. Peritonitis develops.
The phases of the flow of OKN are conditional in nature and each form of OKN has its own differences (with strangulation KN, phases 1 and 2 begin almost simultaneously.
Classification of acute endotoxemia in CN:
Zero stage. Endogenous toxic substances (ETS) are transferred from the pathological focus to the interstitium and transport media. Clinically at this stage, endotoxicosis is not manifested.
Stage of accumulation of products of primary affect. The current of blood and lymph ETS spreads in the internal environment. At this stage, it is possible to detect an increase in the concentration of ETS in biological fluids.
Stage of decompensation of regulatory systems and auto-aggression. This stage is characterized by tension and subsequent depletion of the function of histohematogenous barriers, the onset of excessive activation of the hemostatic system, the kallikrein-kinin system, and the processes of lipid peroxidation.
The stage of perversion of metabolism and homeostatic insolvency. This stage becomes the basis for the development of the syndrome of multiple organ failure (or the syndrome of multiplying organ failure).
The stage of disintegration of the organism as a whole. This is the terminal phase of destruction of interconnections and death of the organism.
Causes of dynamic acute intestinal obstruction:
1. Neurogenic factors:
A. Central mechanisms: Traumatic brain injury. Ischemic stroke. Uremia. Ketoacidosis Hysterical ileus. Dynamic obstruction with mental trauma. Spinal injuries.
B. Reflex mechanisms: Peritonitis. Acute pancreatitis. Abdominal injuries and operations. Injuries to the chest, large bones, combined injuries. Pleurisy. Acute myocardial infarction. Tumors, injuries and wounds of the retroperitoneal space. Nephrolithiasis and renal colic. Worm infestation. Rough food (paralytic food obstruction), phytobezoars, fecal stones.
2. Humoral and metabolic factors: Endotoxicosis of various origins, including acute surgical diseases. Hypokalemia, as a result of indomitable vomiting of various origins. Hypoproteinemia due to acute surgical disease, wound loss, nephrotic syndrome, etc.
3. Exogenous intoxication: Poisoning by salts of heavy metals. Food intoxication. Intestinal infections (typhoid fever).
4. Dyscirculatory disorders:
A. At the level of the great vessels: Thrombosis and embolism of the mesenteric vessels. Vasculitis of the mesenteric vessels. Arterial hypertension.
B. At the level of microcirculation: Acute inflammatory diseases of the abdominal organs.
The square of symptoms in CN.
· Abdominal pain. The pains are paroxysmal, cramping in nature. Patients have cold sweat, pale skin (with strangulation). Patients with horror expect the following attacks. The pains can subside: for example, there was a torsion, and then the intestine was straightened, which led to the disappearance of pain, but the disappearance of pain is a very insidious sign, because with strangulated CN, there is necrosis of the intestine, which leads to the death of nerve endings, therefore, the pain disappears.
· Vomiting. Multiple, first with the contents of the stomach, then with the contents of 12 p. (note that vomiting of bile comes from 12 k.s.), then vomiting appears with an unpleasant odor. Tongue with CN is dry.
· Abdominal distension, abdominal asymmetry
· Stool and gas retention is a formidable symptom that speaks of CN.
Intestinal noise can be heard, even at a distance, enhanced peristalsis is visible. You can feel the bloated bowel loop - a symptom of Valya. It is necessary to investigate patients per rectum: the rectal ampulla is empty — a symptom of Grekov or a symptom of an Obukhov hospital.
Survey fluoroscopy of the abdominal organs: this is a non-contrast study - the appearance of Kloyber's bowls.
OKN has a number of signs that are also observed in other diseases, which necessitates a differential diagnosis between OKN and diseases with similar clinical signs.
Acute appendicitis. Common symptoms are abdominal pain, delayed stool, vomiting. But pain in appendicitis begins gradually and does not reach such strength as in case of obstruction. When appendicitis pain localized, and with obstruction have a cramping character, more intense. Enhanced peristalsis and sound phenomena that are heard in the abdominal cavity, are characteristic of intestinal obstruction, but not appendicitis. In acute appendicitis, there are no radiographic signs characteristic of obstruction.
Perforated gastric ulcer and duodenal ulcer. The common symptoms are sudden onset, severe abdominal pain, delayed stool. However, in case of a perforated ulcer, the patient assumes a forced position, and in case of intestinal obstruction, the patient is restless, often changing position. Vomiting is not typical for perforated ulcers, but is often observed with intestinal obstruction. In case of perforated ulcer, the abdominal wall is tense, painful, does not participate in the act of breathing, while in OC, the abdomen is swollen, soft, slightly painful. When perforated ulcer from the very beginning of the disease there is no peristalsis, not heard "splashing noise". Radiographically, when perforated ulcer is determined free gas in the abdominal cavity, and when OKN - Kloyber bowls, arcades, symptom of pinnacles.
Acute cholecystitis. Pain in acute cholecystitis are permanent, localized in the right hypochondrium, radiating to the right scapula. With OKN, pain is cramping, non-localized. Hyperthermia is characteristic of acute cholecystitis, which is not the case with intestinal obstruction. Reinforced peristalsis, sonic phenomena, radiological signs of obstruction are absent in acute cholecystitis.
Acute pancreatitis. Common symptoms are a sudden onset of severe pain, a severe general condition, frequent vomiting, bloating and delayed stool. But with pancreatitis, the pains are localized in the upper abdomen, are shingles, and not cramping. There is a positive symptom of Mayo-Robson. Signs of enhanced peristalsis, characteristic of mechanical intestinal obstruction, with acute pancreatitis are absent. Diastasuria is characteristic of acute pancreatitis. Radiographically, pancreatitis is characterized by high standing of the left dome of the diaphragm, and in case of obstruction, the Kloyber bowl, arcade, transverse striation.
With intestinal infarction, as well as with acute intestinal obstruction, severe sudden abdominal pain, vomiting, severe general condition, and soft stomach are noted. However, the pains during intestinal infarction are constant, the peristalsis is completely absent, the abdominal distention is small, there is no asymmetry of the abdomen, with auscultation the “dead silence” is determined. With mechanical intestinal obstruction, violent peristalsis prevails, a large gamut of sound phenomena is heard, bloating more significant, often asymmetrical. The presence of an embologic disease, atrial fibrillation, high leukocytosis is pathognomonic (20-30 x10 9 / l) for intestinal infarction.
Renal colic and occlusion have similar symptoms - pronounced pain in the abdomen, bloating, delayed stools and gas, restless behavior of the patient. But pain in renal colic radiates to the lumbar region, genitals, there are dysuric phenomena with characteristic changes in the urine, a positive symptom of Pasternack. On the review radiograph in the kidney or ureter may be visible shadows of stones.
With pneumonia, abdominal pain and swelling may appear, which gives reason to think about intestinal obstruction. However, pneumonia is characterized by high fever, rapid breathing, blush on the cheeks, and a physical examination reveals crepitating rales, pleural friction noise, bronchial respiration, and lung sound dullness. An X-ray examination reveals a pneumonic focus.
With myocardial infarction, there may be sharp pains in the upper abdomen, bloating, sometimes vomiting, weakness, lowering of blood pressure, tachycardia, that is, signs resembling strangulated intestinal obstruction. However, in myocardial infarction, there is no asymmetry of the abdomen, increased peristalsis, symptoms of Val, Sklyarov, Schiemann, Spasokukotsky-Wilms, and there are no radiological signs of intestinal obstruction. Electrocardiographic study helps to clarify the diagnosis of myocardial infarction.
The scope of examination for acute intestinal obstruction:
Mandatory by cito: Urinalysis, complete blood count, blood glucose, blood type and rhesus affiliation, per rectum (reduced sphincter tone and empty ampoule, fecal stones are possible (as a cause of obstruction) and mucus with blood during invagination, tumor obturation , mesenteric window), ECG, radiography of the abdominal organs in an upright position.
According to indications: total protein, bilirubin, urea, creatinine, ions, ultrasound, radiography of the chest, barium passage through the intestines (performed to exclude CN), rectoromanoscopy, irrigology, colonoscopy, therapist consultation.
Diagnostic algorithm for OKN:
BUT. Collecting history.
B. Objective examination of the patient:
1. General inspection: Neuropsychological status. Ps and blood pressure (bradycardia - often strangulation). Examination of the skin and mucous membranes. Etc.
2. Objective examination of the abdomen:
a) Ad oculus: Abdominal distension, possible asymmetry, participation in breathing.
b) Inspection of the hernial rings.
c) Superficial palpation of the abdomen: identification of local or widespread protective tension of the muscles of the anterior abdominal wall.
d) Percussion: detecting tympanitis and blunting.
e) Primary abdominal auscultation: assessment of unprovoked motor activity of the intestine: metallic hue or gurgling, in the late stage - falling drop noise, impaired motility, listening to heart sounds.
e) Deep palpation: to determine the pathological formation of the abdominal cavity, to palpate the internal organs, to determine the local pain.
g) Repeated auscultation: to assess the appearance or strengthening of intestinal noise, to identify Sklyarov's symptom (splashing noise).
h) Identify the presence or absence of symptoms inherent in OKNs (see below).
AT. Instrumental studies:
X-ray examinations (see below).
Rrs. Colonoscopy (diagnostic and therapeutic).
Laparoscopy (diagnostic and therapeutic).
Computer diagnostics (CT, MRI, programs).
G. Laboratory research.
X-ray examination is the main special method of diagnostics OKN. At the same time the following signs come to light:
Kloiber's bowl - a horizontal level of liquid with a dome-shaped enlightenment above it, which has the form of an upside-down bowl. In case of strangulation obstruction, they can appear already after 1 hour, and in obstructive obstruction, in 3-5 hours from the moment of the disease. The number of bowls is different, sometimes they can layered one upon another in the form of a stepped staircase.
Intestinal arcades. They are obtained when the small intestine is swollen with gases, with horizontal fluid levels visible in the lower arches of the arcades.
The symptom of feathering (cross-striation in the form of a stretched spring) occurs with high intestinal obstruction and is associated with stretching of the jejunum, which has high circular folds of the mucous membrane. Contrast study of the gastrointestinal tract is used for difficulties in the diagnosis of intestinal obstruction. The patient is allowed to drink 50 ml of barium suspension and conduct a dynamic study of the passage of barium. Delaying it for 4-6 hours or more gives reason to suspect a violation of the motor function of the intestine.
X-ray diagnosis of acute intestinal obstruction. After 6 h from the onset of the disease there are radiographic signs of intestinal obstruction. Pneumatosis of the small intestine is the initial symptom, normally gas is found only in the colon. Subsequently, fluid levels ("Kloyber bowls") are determined in the intestines.Fluid levels localized only in the left hypochondrium indicate a high obstruction. It is necessary to distinguish between thin and colonic levels. At enteric levels, the vertical dimensions prevail over the horizontal ones, the semilunar folds of the mucous membrane are visible, in the large intestine the horizontal dimensions of the level prevail over the vertical ones, the haustration is determined. Radiocontrast studies with giving barium through the mouth with intestinal obstruction are not appropriate, it contributes to the complete obstruction of the narrowed gut segment. Acceptance of water-soluble contrast agents in case of obstruction is promoted by sequestration of the fluid (all X-ray contrast agents are osmotically active), their use is possible only if they are administered through a nasointestinal aspiration probe after the study. An effective means of diagnosing colonic obstruction and in most cases its cause is irrigoscopy. Colonoscopy for colonic obstruction is undesirable because it leads to the flow of air into the adductor loop of the intestine and may contribute to the development of its perforation.
High and narrow bowls in the colon, low and wide - in a thin, not changing position - with a dynamic window, changing - with a mechanical one. Contrast study It is carried out in doubtful cases, with subacute course. Lag passage of barium to the cecum for more than 6 hours against the background of means of stimulating peristalsis - evidence of obstruction (normally barium enters the CEC in 4-6 hours without stimulation).
Indications to conduct studies with the reception of contrast in case of intestinal obstruction are:
- To confirm the exclusion of intestinal obstruction.
- in doubtful cases, in case of suspected intestinal obstruction with the aim of differential diagnosis and with complex treatment.
- adhesive OKN in patients who have repeatedly undergone surgical interventions, when arresting the latter.
- any form of small bowel obstruction (with the exception of strangulation), when, as a result of active conservative measures in the early stages of the process, it is possible to achieve a visible improvement. In this case, it becomes necessary to objectively confirm the legitimacy of conservative tactics. The reason for the termination of the Rg-gram series is to fix the flow of contrast into the large intestine.
- diagnosis of early postoperative obstruction in patients undergoing gastric resection. The absence of pyloric pulp causes unobstructed flow of contrast into the small intestine. In this case, the detection of the phenomenon of stop-contrast in the discharge loop serves as an indication for early relaparotomy.
Do not forget when the contrast agent does not enter the colon or is retained in the stomach, and the surgeon who focuses on controlling the movement of the contrast mass creates an illusion of active diagnostic activity that justifies therapeutic idleness in his own eyes. In this regard, recognizing in doubtful cases the known diagnostic value of X-ray contrast studies, it is necessary to clearly define the conditions that allow their use. These conditions can be summarized as follows:
1. Radiocontrast study for the diagnosis of OCD is permissible to use only with full conviction (based on clinical data and results of a survey radiography of the abdominal cavity) in the absence of a strangulation form of obstruction, constituting a threat of rapid loss of viability of the strangulated bowel.
2. Dynamic observation of the advancement of the contrasting mass must be combined with clinical observation, during which changes in local physical data and changes in the general condition of the patient are recorded. In case of aggravation of local signs of obstruction or the appearance of signs of endotoxicosis, the question of urgent surgical aid should be discussed independently of the radiological data characterizing the promotion of contrast through the intestines.
3. If the decision is made on the dynamic observation of the patient with the control of the passage through the intestines of the contrasting mass, such observation should be combined with therapeutic measures aimed at eliminating the dynamic component of obstruction. These interventions consist mainly in the use of anticholinergic, anticholinesterase and ganglioblokiruyuschih funds, as well as conducting (perirenal, sacrospinal) or epidural blockade.
The possibilities of the X-ray contrast study for the diagnosis of PCN are significantly enhanced when using the technique enterography. The study is performed using a sufficiently rigid probe, which, after emptying the stomach, is carried out for pyloric pulp into the duodenum. Through the probe, the contents of the proximal jejunum are removed as completely as possible, and then under a pressure of 200–250 mm of water. Art. 500-2000 ml of 20% barium suspension prepared in isotonic sodium chloride solution is injected into it. Within 20-90 minutes spend dynamic x-ray observation. If in the process of research in the small intestine fluid and gas again accumulate, the contents are removed through a probe, after which the contrast suspension is re-injected.
The method has several advantages. First, decompression of the proximal intestine, provided for by the method, not only improves the conditions of the study, but is also an important therapeutic measure in case of OC, since it helps to restore the blood supply to the intestinal wall. Secondly, the contrasting mass introduced below the pyloric sphincter makes it possible to move much faster to the level of a mechanical obstacle (if it exists) even in the conditions of incipient paresis. In the absence of a mechanical obstacle, the time of passage of barium into the large intestine in the rate of 40-60 minutes.
Tactics of treatment of acute intestinal obstruction.
Currently, an active tactic for the treatment of acute intestinal obstruction has been adopted.
All patients with a diagnosis of OC are operated after preoperative preparation (which should last no more than 3 hours), and if a strangulation CU is set, then the patient is served after a minimal volume of examination immediately to the operating room, where the preoperative preparation is performed by the anesthesiologist together with the surgeon (during more than 2 hours from the moment of receipt).
Emergency (i.e., completed within 2 hours of receipt), the operation is shown with OKN in the following cases:
1. When obstruction with signs of peritonitis,
2. In case of obstruction with clinical signs of intoxication and dehydration (that is, during the second phase of the course of an OCH),
3. In cases when, on the basis of the clinical picture, one gets the impression that there is a strangulation form of OKN.
All patients with suspected OKN should immediately begin with a complex of diagnostic and treatment measures within 3 hours (if a strangulated KN is suspected no more than 2 hours), and if OKN is confirmed or not excluded during this time, surgical treatment is indicated by an obsalyutno. A complex of diagnostic and treatment activities will be preoperative preparation. Barium is given to all patients for whom the OKN is excluded in order to control the passage through the intestines.
It is better to operate on the adhesive disease than to skip the adhesive window.
The complex of therapeutic and diagnostic activities and preoperative preparation include:
Impact on the autonomic nervous system - bilateral perirenal procaine blockade
Decompression of the gastrointestinal tract by aspirating the contents through a nasogastric tube and siphon enema.
Correction of water and electrolyte disorders, detoxification, antispasmodic therapy, treatment of enteral insufficiency.
Restoration of intestinal function contributes to the decompression of the gastrointestinal tract, since intestinal distention entails a violation of the capillary, and later venous and arterial circulation in the intestinal wall and the progressive deterioration of bowel function.
To compensate for water and electrolyte disturbances, Ringer-Locke solution is used, which contains not only sodium and chlorine ions, but also all the necessary cations. To compensate for the loss of potassium in the composition of the infusion media include solutions of potassium, along with solutions of glucose with insulin. If metabolic acidosis is present, sodium bicarbonate solution is prescribed. When OKN develops a deficit in the volume of circulating blood mainly due to the loss of the plasma part of the blood, it is therefore necessary to inject solutions of albumin, protein, plasma, amino acids. It should be remembered that the introduction of only crystalloid solutions in case of obstruction only contributes to the sequestration of the liquid, it is necessary to introduce plasma-substituting solutions, protein preparations in combination with crystalloids. To improve microcirculation, reopolyglukine with complamin and trental is prescribed. The criterion of an adequate volume of infusion fluids administered is the normalization of circulating blood volume, hematocrit, central venous pressure, and increased diuresis. Hourly diuresis should be at least 40 ml / h.
The discharge of copious amounts of gas and feces, the cessation of pain and the improvement of the patient's condition after conservative measures indicates the resolution (exclusion) of intestinal obstruction. If conservative treatment does not have an effect for 3 hours, then the patient must be operated on. The use of agents that excite peristalsis, in doubtful cases, reduce the time of diagnosis, and with a positive effect exclude OKN.
Protocols of surgical tactics for acute intestinal obstruction
1. An operation for an OKN is always performed under general anesthesia by a medical team.
2. At the stage of laparotomy, revision, identification of pathological substrate obstruction and determining the plan of operation, participation in the operation of the most experienced surgeon of the duty team, as a rule, the responsible duty surgeon, is obligatory.
3. In case of any localization of obstruction, access is median laparotomy, if necessary with excision of scars and careful dissection of adhesions when entering the abdominal cavity.
4. Operations about OKN provide for the consistent solution of the following tasks:
-establishment of the cause and level of obstruction,
- before manipulations with the intestines, it is necessary to conduct a novocainic blockade of the mesentery (if there is no cancer pathology),
- elimination of the morphological substrate OKN,
- determination of the viability of the intestine in the area of the obstacle and determination of indications for its resection,
- the establishment of the boundaries of resection of the modified intestine and its implementation,
- determination of indications for drainage of the intestinal tube and the choice of the method of drainage,
- sanitation and drainage of the abdominal cavity in the presence of peritonitis.
5. Detection of the obstruction zone immediately after laparotomy does not exempt from the need for a systematic revision of the state of the small intestine throughout its length, as well as the colon. Revision is preceded by mandatory infiltration of the mesentery root with a solution of a local anesthetic. In case of marked overflow of intestinal loops with contents, before revision the intestine is decompressed using a gastrojejunal probe.
6. Elimination of obstruction is a key and most complex component of the intervention. It is carried out in the least traumatic way with a clear definition of specific indications for the use of various methods: dissection of multiple adhesions, resection of the altered intestine, elimination of torsions, invaginations, nodules, or resection of these structures without preliminary manipulations on the altered intestine.
7. When determining indications for bowel resection, visual signs (color, wall edema, subserous hemorrhages, peristalsis, pulsation and blood filling of parietal vessels) are used, as well as the dynamics of these signs after the introduction of a warm local anesthetic solution into the mesentery of the intestine.
Gut viability It is evaluated clinically based on the following symptoms (the main ones are pulsation of the mesenteric arteries and the state of peristalsis):
Gut color (cyanotic, dark purple or black coloration of the intestinal wall indicates deep and, as a rule, irreversible ischemic changes in the intestine).
The state of the serous membrane of the intestine (in the normal peritoneum, covering the intestine thin and shiny, with necrosis of the intestine, it becomes swollen, dull, dull).
Peristalsis (the ischemic intestine does not contract, palpation and tapping do not initiate a peristaltic wave).
Pulsation of the arteries of the mesentery, distinct in norm, is absent in case of thrombosis of vessels, which develops during prolonged strangulation.
If there are doubts about the viability of the intestine over a large length of it, it is permissible to postpone the resolution of the issue of resection using a programmed relaparotomy after 12 hours or laparoscopy. The indication for bowel resection with an OC is usually its necrosis.
8. When deciding on the boundaries of resection, use should be made of the protocols established on the basis of clinical experience: deviate from the visible borders of the disturbance of the blood supply to the intestinal wall in the direction of the leading section by 35-40 cm, and in the direction of the discharge section of 20-25 cm. Exceptions are resection near ligament Treits or ileocecal angle, where it is possible to limit these requirements with favorable visual characteristics of the intestine in the area of the intended intersection. In this case, the following control indicators are necessarily used: bleeding from the vessels of the wall at its intersection and the state of the mucous membrane. It is also possible to use | transillumination or other objective methods of assessing the blood supply.
9. If indicated, drain the small intestine. Indications see below.
10. In case of colorectal tumor obstruction and the absence of signs of inoperability, one-stage or two-stage operations are performed depending on the stage of the tumor process and the severity of manifestations of colonic obstruction.
If the cause of the obstruction is a cancerous tumor, various tactical options can be taken.
A. When a tumor is blind, ascending colon, hepatic angle:
· Without signs of peritonitis, right-sided hemicolonectomy is indicated. · In case of peritonitis and severe condition of the patient - ileostomy, toilet and drainage of the abdominal cavity. · With an inoperable tumor and the absence of peritonitis - iletotransverstomy
B. When a tumor of the splenic angle and descending colon:
· Left-sided hemicolonectomy, colostomy are performed without signs of peritonitis. · With peritonitis and severe hemodynamic disturbances, transverzostomy is indicated. · If the tumor is inoperable - bypass anastomosis, with peritonitis - transverstomy. · With a sigmoid colon tumor - resection of a section of the intestine with a tumor with the imposition of a primary anastomosis or Hartmann's operation, or the imposition of double-barreled colostomy. The formation of double-barreled colostomy is justified when it is impossible to resect the intestine against the background of decompensated OKNS.
11. Elimination of strangulating intestinal obstruction. When nodulating, twisting - eliminate the knot, inversion, with necrosis - resection of the intestine, with peritonitis - intestinal stoma. 12. With invagination, deinvagination is performed, Hagen-Thorne meso-sigmoplication, with necrosis, resection, with peritonitis, with an ulcer.If invagination is due to Meckel's diverticulum, resection of the intestine along with the diverticulum and invaginate. 13. In case of adhesive intestinal obstruction, intersection of adhesions and elimination of double-barrels is shown. In order to prevent adhesive disease, the abdominal cavity is washed with fibrinolytic solutions. 14. All operations on the colon are completed with the deviation of the external sphincter of the anus. 15. The presence of diffuse peritonitis requires additional sanation and drainage of the abdominal cavity in accordance with the principles of treatment of acute peritonitis.
Great importance in combating intoxication is attached to the removal of toxic intestinal contents, which accumulates in the adductor region and intestinal loops. Emptying of the leading sections of the intestine provides decompression of the intestine, intraoperative elimination of toxic substances from its lumen (detoxification effect) and improves the conditions of manipulation - resection, suturing of the intestine, imposition of anastomoses. It is shown in cases wherethe gut is significantly stretched by fluid and gas. It is preferable to evacuate the contents of the afferent loop before opening its lumen. The best option for such decompression is nasointestinal drainage of the small intestine according to Wangenshtin. A long probe through the nose into the small intestine drains it all the way. After removal of intestinal contents, the probe can be left for prolonged decompression. In the absence of a long probe, the intestinal contents can be removed through a probe inserted into the stomach or large intestine, or it can be expressed in the intestine to be resected. Sometimes it is impossible to decompress the intestine without opening its lumen. In these cases, the enterotomy opening is superimposed and the contents of the intestine are evacuated using an electric suction device. With this manipulation, it is necessary to carefully distinguish the enterotomy opening from the abdominal cavity in order to prevent its infection.
The main tasks of extended decompression are:
- Removal of toxic contents from the intestinal lumen,
- Conducting intraintestinal detoxification therapy,
-The effect on the intestinal mucosa to restore its barrier and functional viability, early enteral nutrition of the patient.
Indications for intubation of the small intestine (IA Eryukhin, VP Petrov):
Paretic condition of the small intestine.
Resection of the intestine or closure of a hole in its wall in conditions of paresis or diffuse peritonitis.
Relaparotomy for early adhesive or paralytic intestinal obstruction.
Repeated surgery for adhesive intestinal obstruction. (Pakhomova GV 1987)
When imposing primary colonic anastomoses with OKN. (Sun Kochurin 1974, LA Ender 1988, VN Nikolsky 1992)
Spilled peritonitis in 2 or 3 tbsp.
Existence of an extensive retroperitoneal hematoma or phlegmon of the retroperitoneal space in combination with peritonitis.
General rules for drainage of the small intestine:
-Drainage is carried out with stable hemodynamic parameters. Before it is carried out, it is necessary to deepen anesthesia and inject 100-150 ml 0.25% novocaine into the mesentery root of the small intestine.
- Necessarily tends to intubate the entire small intestine, it is advisable to advance the probe due to pressure along its axis, rather than by manually pulling through the lumen of the intestine, to reduce the morbidity of manipulation before the end of intubation should not empty the small intestine from liquid contents and gases.
- After the drainage is completed, the small intestine is laid in the abdominal cavity in the form of 5-8 horizontal loops, and is covered with a large omentum from above; the loops of the intestine should not be fixed to each other with sutures, since the intestinal placement on the enterostomy tube in the order specified prevents them from being vicious location
- To prevent the formation of bedsores in the intestinal wall, the abdominal cavity is drained with a minimum number of drains, which should not be in contact with the intubated intestine if possible.
Exists5main types of drainage of the small intestine.
Transnasal drainage of the small intestine throughout. This method is often called the name Wangenshtin (Wangensteen) or T.Miller and W.Abbot, although there is evidence that the pioneers of transnasal intestinal intubation with an Abbott-Miller probe (1934) during surgery were G.A.Smith(1956) and J.C.Thurner (1958). This method of decompression is most preferable due to minimal invasiveness. The probe is carried out in the small intestine during the operation and is used simultaneously for both intraoperative and prolonged decompression of the small intestine. The disadvantage of the method is a violation of nasal breathing, which can lead to deterioration in patients with chronic lung diseases or provoke the development of pneumonia.
Method proposed J.M.Ferris and G.K.Smith in 1956 and described in detail in the domestic literatureYu.M. Dederer (1962), intubation of the small intestine through the gastrostomy tube is deprived of this disadvantage and is indicated in patients in whom it is impossible to pass the probe through the nose for some reason or a violation of nasal breathing due to the probe increases the risk of postoperative pulmonary complications.
Drainage of the small intestine through the enterostomy, for example, the method I.D. Zhitnyukwhich was widely used in emergency surgery before the advent of industrialized nasogastric intubation probes. It involves retrograde drainage of the small intestine through the suspension ileostomy. (There is a method of antegrade drainage through its J.W.Baker (1959), separate drainage of the proximal and distal small intestine through the suspended enterostomy White (1949) and their numerous modifications). These methods appear to be the least preferred due to possible complications of the enterostomy, the danger of the formation of an enteric fistula at the site of the enterostomy, etc.
Retrograde drainage of the small intestine through microcecoma (G.Sheide, 1965) can be used when antegrade intubation is impossible. Perhaps the only drawback of the method is the difficulty of conducting the probe through the Bauhinia flap and the impaired function of the ileo-cecal valve. Cecostomy after removal of the probe, as a rule, heals on its own. A variant of the previous method is the proposed I.S.Mgaloblishvili (1959) method of drainage of the small intestine through appendicostomy.
Transrectal drainage of the small intestine is used almost exclusively in pediatric surgery, although the successful use of this method in adults is described.
Numerous combined methods of drainage of the small intestine, including elements and closed (not associated with the opening of the lumen of the stomach or intestine) and open methods, are proposed.
With decompression detoxification, the probe is set in the intestinal lumen for 3-6 days, the indication for probe removal is the restoration of peristalsis and the absence of stagnant discharge along the probe (if this happened on the first day, then the probe can be removed on the first day). With the frame target, the probe is installed for 6-8 days (no more than 14 days).
The presence of the probe in the lumen of the intestine can lead to a number of complications. This is primarily bedsores and perforation of the intestinal wall, bleeding. When nasointestinal drainage may develop pulmonary complications (purulent tracheobronchitis, pneumonia). Possible suppuration of wounds in the area of the stoma. Sometimes nodal deformation of the probe in the lumen of the intestine makes its removal impossible and requires surgical intervention. On the part of the ENT organs (nosebleeds, necrosis of the wings of the nose, rhinitis, sinusitis, sinusitis, bedsores, laryngitis, laryngostenosis). In order to avoid complications that develop when the probe is removed, a soluble probe from synthetic protein is proposed, which is absorbed 4 days after surgery (D. Jung et al., 1988).
Decompression of the colon with colonic obstruction will be achieved colostomy overlay. In some cases, transrectal drainage of the colon by a large tube is possible.
Contraindications to nasoenteric drainage:
Organic disease of the upper GI tract.
Varicose veins of the esophagus.
Respiratory failure 2-3 tbsp., Severe cardiac pathology.
When to perform nasoenteric drainage is technically impossible or extremely traumatic for technical difficulties (adhesions of the upper abdominal cavity, impaired nasal passages and upper gastrointestinal tract, etc.).
Postoperative treatment of OCD includes the following mandatory directions.:
- Replacement of the BCC, correction of the electrolyte and protein composition of blood,
-Treatment of endotoxemia, including mandatory antibiotic therapy,
- Restoration of motor, secretory and absorption functions of the intestine, that is, the treatment of enteral insufficiency.
Norenberg-Charkviani A. E. "Acute intestinal obstruction", M., 1969,
Saveliev V.S. "Guide for emergency surgery of the abdominal cavity", M., 1986,
Skripnichenko D.F. “Emergency surgery of the abdominal cavity”, Kiev, “Health”, 1974,
Hegglin R. "Differential diagnosis of internal diseases", M., 1991.
Eryukhin, Petrov, Hanevich “Intestinal obstruction”
Abramov A.Yu., Larichev AB, Volkov A.V. et al. The place of intubation decompression in the surgical treatment of adhesive small bowel obstruction // Proc. report IX Vseros. congress of surgeons. - Volgograd, 2000.-P.137.
The results of treatment of acute intestinal obstruction // Proc. report IX Vseros. congress of surgeons. -Volgograd, 2000.-С.211.
Aliev SA, Ashrafov AA Surgical tactics in obstructive tumor obstruction of the colon in patients with increased operational risk / Vestn.surgery named after Grekov.-1997.-№1.-P.46-49.
Order of the Ministry of Health of the Russian Federation of April 17, 1998 N 125 "On the standards (protocols) of diagnosis and treatment of patients with diseases of the digestive system".
Practical guide for students of the IV course of the medical faculty and the faculty of sports medicine. Prof. V.M. Sedov, D.A. Smirnov, S.M.Pudyakov “Acute intestinal obstruction”.
Classification of acute intestinal obstruction
In the first half of the 19th century, two types of intestinal obstruction were identified - mechanical and dynamic. Subsequently, the mechanical intestinal obstruction Wal (Wahl) proposed to divide into strangulation and obstructive. The most simple and expedient at the present time can be considered a classification in which OKN is divided by morphofunctional nature:
- Dynamic (functional) obstruction (12%):
- Spastic, arising from diseases of the nervous system, hysteria, intestinal dyskinesia, helminthic invasion, etc.
- Paralytic (infectious diseases, thrombosis of mesenteric vessels, retroperitoneal hematoma, peritonitis, diseases and injuries of the spinal cord, etc.
- Mechanical bowel obstruction (88%):
- Strangulation (inversion, nodulation, internal restraint)
A. intraorganic (foreign bodies, fecal and gallstones, worm infestation, located in the intestinal lumen)
b. intramural (tumor, Crohn's disease, tuberculosis, cicatricial stricture affecting the intestinal wall)
at. extraorgan (cysts of the mesentery and ovary, tumors of the retroperitoneal space and organs of the small pelvis, which cause compression of the intestine from outside).
but. Adhesive obstruction
According to the level of obstruction:
- Enteric: a. high b. low
- Colonic - According to the dynamics of the development of the pathological process
(on the example of adhesive intestinal obstruction)
I stage. Acute violation of intestinal passage - the stage of "ileus cry" - the first 12 hours from the onset of the disease)
Stage II Acute violation of intraparietal intestinal hemocirculation
(phase of intoxication) - 12-36 hours.
Stage III. Peritonitis - more than 36 hours from the onset of the disease.
Significant differences are found in the literature on the determination of the severity of colonic obstruction. This circumstance gave rise to many classifications of the clinical course of the disease. The most commonly used in urgent coloproctology is the classification developed at the Research Institute of Coloproctology of the Russian Academy of Medical Sciences. According to the proposed classification, there are 3 degrees of manifestation of colonic obstruction:
I degree (compensated). Complaints of recurrent constipation, lasting 2-3 days, which can be eliminated with the help of diet and laxatives. The general condition of the patient is satisfactory, there is a periodic abdominal distention, symptoms of intoxication are absent. The results of colonoscopy and irrigography show that the tumor narrows the lumen of the intestine to 1.5 cm, there is a small accumulation of gases and intestinal contents in the colon.
II degree (subcompensated). Complaints of persistent constipation, the lack of an independent chair. Taking laxatives is ineffective and gives a temporary effect. Periodic abdominal distension, difficulty passing gas. The general condition is relatively satisfactory. Symptoms of intoxication are noticeable. The tumor narrows the lumen of the intestine up to 1 cm. When X-ray examination, the colon is enlarged, filled with intestinal contents. Individual fluid levels (Kloyber bowls) can be determined.
Grade III (decompensated). Complaints about the absence of a chair and the discharge of gas, increasing cramping abdominal pain and bloating, nausea, and sometimes vomiting. Severe signs of intoxication, violation of water and electrolyte balance and KOS, anemia, hypoproteinemia. When X-ray examination, the intestinal loops are enlarged, inflated with gas. Multiple fluid levels are determined. As a rule, the majority of patients admitted to the emergency hospital for obstructive colonic obstruction of tumor etiology have a decompensated degree of the disease, which ultimately determines the high incidence of postoperative complications and mortality.
In recent years, the so-called false colon obstruction syndrome, first described by N. Ogilvie in 1948, has been increasingly mentioned. This syndrome manifests itself most often as a clinic of acute dynamic obstruction of the intestine due to impaired sympathetic innervation. Often this condition is observed in the early postoperative period, which leads to repeated laparotomy. Most authors have noted diagnostic difficulties in establishing Ogilvy syndrome. A positive effect has bilateral perirephral novocainic blockade according to A.V. Vishnevsky.
When the clinical manifestations of the disease are accompanied by dull symptoms, we do not set the diagnosis “partial intestinal obstruction”, considering it to be unjustified in tactical terms. In this case, most often, it is about the incomplete closure of the lumen of the intestine by a growing tumor, adherence obstruction or recurrent torsion. Such a diagnosis confuses the surgeon and leads to late operations.
Symptoms of acute intestinal obstruction
The clinical picture of acute intestinal obstruction consists of 2 groups of symptoms. The first group is directly related to the changes occurring in the gastrointestinal tract and the abdominal cavity in case of OCs. The second group reflects the general reaction of the organism to the pathological process.
I group. The earliest and one of the most constant signs of the disease is pain syndrome. The occurrence of cramping pain is characteristic of acute obstruction of the intestinal lumen and is associated with its peristalsis. Sharp persistent pains often accompany acutely developed strangulation.If the OKN is not diagnosed in a timely manner, then for 2-3 days from the onset of the disease the motor activity of the intestine is inhibited, which is accompanied by a decrease in the intensity of pain and a change in its nature. At the same time, symptoms of endogenous intoxication begin to prevail, which is a poor prognostic sign. Pathognomonic symptom in case of heart failure is stool retention and non-passage of gas. However, with a high small bowel obstruction at the beginning of the disease, there may be discharge of gases and stools due to emptying of the distal parts of the intestine, which do not bring relief to the patient, which often disorients the doctor. One of the early clinical signs of an OV is vomiting. Its frequency depends on the level of obstruction in the intestine, the type and form of obstruction, and the duration of the disease. Initially, vomiting is reflex in nature, and subsequently occurs due to overflow of the proximal gastrointestinal tract. The higher intestinal obstruction, the more pronounced vomiting. In the initial stage of colonic obstruction, vomiting may be absent. With low small bowel obstruction, vomiting is observed with large gaps and an abundance of vomit, which acquire the character of intestinal contents with a fecal odor. In the later stages of an OV, vomiting results from not only stagnation, but also endotoxicosis. During this period, it is not possible to eliminate vomiting movements even by intestinal intubation.
One of the local signs of an OCH is bloating. "Oblique abdomen" (Bayer symptom), when the swelling leads to asymmetry of the abdomen and is located in the direction from the right hypochondrium through the navel to the left iliac region, is characteristic of a torsional sigmoid colon. Intestinal obstruction caused by obstruction of the lumen of the proximal jejunum, leads to bloating in the upper sections of the jejunum, while impaired patency in the ileum and large intestine leads to bloating of the entire abdomen. In order to diagnose the mechanical form of intestinal obstruction, a triad of clinical signs (Valya's symptom) was described: 1. Asymmetry of the abdomen, 2. Palpable swollen intestinal loop (elastic cylinder) with high tympanitis, 3. Peristalsis visible to the eye. To identify a possible strangulated hernia, accompanied by the clinic of acute intestinal obstruction, it is necessary to carefully examine and palpate the epigastric, umbilical and inguinal areas, as well as the existing postoperative scars on the anterior abdominal wall. When examining patients with an OCD, it is very important to remember a possible parietal (Richter's) infringement of the intestine, in which the “classical” clinical picture of complete intestinal obstruction, as well as the presence of a tumor-like formation characteristic of a strangulated hernia, is absent.
Palpation of the abdomen until the development of peritonitis remains soft and slightly painful. However, in the period of active peristalsis, accompanied by an attack of pain, there is tension in the muscles of the anterior abdominal wall. For turning the caecum pathognomonic is considered a symptom of Shiman-Dans, which is defined as a feeling of emptiness during palpation in the right iliac region due to bowel movement. In case of colonic obstruction, meteorism is determined in the right iliac region (Anschutz symptom). Of considerable diagnostic value is the symptom described by I.P. Sklyarov ("splashing noise") in 1922, detected with a slight shake of the anterior abdominal wall. Its presence indicates an overflow of fluid and gases leading the intestine, which occurs when mechanical intestinal obstruction. Reproduce this symptom should be before setting cleansing enema. Percussion of the anterior abdominal wall identifies areas of high tympanitis with a metallic tinge (Kivul symptom), as a result of developing pneumatosis of the small intestine. This is always a warning sign, since gas in the small intestine does not accumulate in normal conditions.
During auscultation of the anterior abdominal wall at the onset of the disease, intestinal noise of various heights and intensities is heard, the source of which is the inflated but not yet lost motor activity of the small intestine. The development of intestinal paresis and peritonitis marks the weakening of intestinal noise, which appear in the form of individual weak bursts, resembling the sound of a falling drop (a symptom of Spasokukotsky) or the sound of bursting bubbles (a symptom of Wilms). Soon these sounds cease to be defined. The state of "silent belly" indicates the development of severe intestinal paresis. Due to changes in the resonating properties of the contents of the abdominal cavity, against the background of an increased abdominal volume, heart tones (Bailey symptom) begin to be clearly heard. At this stage, the clinical picture of acute intestinal obstruction more and more combined with the symptoms of peritonitis.
Diagnosis of acute intestinal obstruction
In the diagnosis of acute intestinal obstruction, a carefully collected history, scrupulous identification of clinical symptoms of the disease, and critical analysis of radiological and laboratory data are of great importance.
Examination of a patient with an OV should be supplemented with a finger examination of the rectum, which allows determining the presence of fecal masses (“coprostasis”) in it, foreign bodies, a tumor or the head of invaginate. Pathognomonic signs of mechanical intestinal obstruction are balloon-shaped bulging of the empty ampulla of the rectum and a decrease in the tone of the sphincter of the anus ("anus gaping"), described by I.I. Grekov in 1927 as "a symptom of the Obukhov hospital".
II group. The nature of common disorders in an OCD is determined by endotoxicosis, dehydration, and metabolic disorders. There is thirst, dry mouth, tachycardia, decreased diuresis, blood clots, as determined by laboratory parameters.
A very important diagnostic stage is an x-ray examination of the abdominal cavity, which is divided into:
- Non-contrast method (survey radiography of the abdominal cavity). Additionally perform a survey radiography of the chest cavity.
- Contrast methods for studying the movement of barium suspension through the intestines after oral administration (Schwartz test and its modification), its introduction through the nasoduodenal probe and retrograde filling of the large intestine with contrast enema.
In the survey images of the abdominal cavity can be identified direct and indirect symptoms of acute intestinal obstruction. Direct symptoms include:
1. Accumulation of gas in the small intestine is a warning sign, since under normal conditions gas is observed only in the stomach and large intestine.
- The presence of the Kloiber bowls, named after the author who described this feature in 1919, is considered to be the classic xenological feature of mechanical intestinal obstruction. They represent the horizontal levels of fluid found in stretched intestinal loops, which are detected 2-4 hours after the onset of the disease. Attention is paid to the ratio of the height and width of gas bubbles above the liquid level and their localization in the abdominal cavity, which is important for the differential diagnosis of OKN types. However, it should be remembered that Kloyber's bowls can also form after cleansing enemas, as well as in weakened patients who are in bed for a long time. Horizontal levels are visible not only in the vertical position of the patient, but also in lateroposition.
- The symptom of transverse striation of the lumen of the intestine, referred to as a symptom of Case (1928), "stretched spring", "fish skeleton". This symptom is considered as a manifestation of edema of the corring (circular) folds of the mucous membrane of the small intestine. In the jejunum, this symptom is more pronounced than in the ileum, which is associated with the anatomical features of the mucosal relief of these intestinal sections .. The clearly visible folds of the small intestine are evidence of the satisfactory condition of its wall. Abrasion of the folds indicates a significant violation of intramural hemodynamics.
In cases where the diagnosis of OCD presents great difficulties, apply the second stage of x-ray examination using contrast methods.
Radiocontrast method. Indications for its use can be formulated as follows:
- Reasonable doubts about the presence of a patient with a mechanical form of a window.
- The initial stages of adhesive intestinal obstruction, when the patient's condition does not inspire fear and there is hope for its conservative resolution
- Dynamic observation of the advancement of contrast mass must be combined with a clinical study of the patient's condition and the conduct of conservative therapeutic measures aimed at resolving intestinal obstruction. In the case of aggravation of local signs of OKN and an increase in endotoxicosis, the study is terminated and the question of conducting an emergency surgical intervention is raised.
When conducting oral contrasting and interpreting the data obtained, it is necessary to take into account the timing of the movement of the contrast agent through the intestines. In a healthy person, a barium suspension, drunk per os, reaches the cecum after 3-3.5 hours, the right bend of the colon - after 5-6 hours, the left bend - after 10-12 hours, the rectum - after 17-24 hours. The use of oral radiopaque methods is not shown for colonic obstruction due to their low information content. In such cases, an emergency colonoscopy is performed.
An ultrasound scan of the abdominal organs complements the X-ray examination, especially in the early stages of an OCH. It allows you to repeatedly observe the nature of peristaltic movements of the intestine, without exposing the patient to radiation, to determine the presence and volume of effusion in the abdominal cavity, to examine patients in the early postoperative period. The most important features in the evaluation of the OCD stage are the diameter of the intestine, which can be in the range from 2.5 to 5.5 cm and its wall thickness is 3 to 5 mm. the presence of free fluid in the abdominal cavity. With the development of destructive changes in intestinal loops, the thickness of the wall can reach 7-10 mm, and its structure becomes non-uniform with the presence of inclusions in the form of thin echo-negative strips.
Laparoscopy. The development of endoscopic methods of investigation in emergency surgery allowed the use of laparoscopy in the diagnosis of PCD. A number of domestic and foreign authors indicate the possibilities of the method for the differential diagnosis of the mechanical and dynamic forms of acute intestinal obstruction, for dissecting individual adhesions. However, as our experience in using laparoscopy shows, it is in most cases not only incompletely informative, but also dangerous due to the possible occurrence of severe complications, to use it under conditions of pronounced intestinal paresis and adhesions in the abdominal cavity. Therefore, the main indications for the use of laparoscopy with an OC are objective difficulties in the differential diagnosis of acute surgical pathology.
Treatment of acute intestinal obstruction
Conservative therapy. Based on the concepts of the vascular genesis of disturbances in strangulation OKN and the speed of their development, the only way to treat it is emergency surgery with corrective therapy on the surgical table and in the postoperative period. In all other cases, treatment of OCH should begin with conservative measures, which in 52% -58% of cases have a positive effect, while in other patients they are a stage of preoperative preparation.
The basis of conservative therapy is the principle of "drip and suck" (drip and suck). Treatment begins with the introduction of a nasogastric probe for decompression and washing of the upper digestive tract, which reduces intracavitary pressure in the intestine and the absorption of toxic products. The pararenal novocainic blockade according to A.V. has not lost its therapeutic value. Vishnevsky. Setting enemas has independent value only when obstructive colonic obstruction. In other cases, they are one of the methods of stimulation of the intestines, so there is no reason to pin great hopes on their effectiveness. Conducting drug stimulation of the gastrointestinal tract is justified only when the motor activity of the intestine decreases, and also after the removal of an obstacle in the path of the intestinal passage. Otherwise, such stimulation can aggravate the course of the pathological process and lead to a rapid depletion of neuromuscular excitability against the background of increasing hypoxia and metabolic disorders.
An obligatory component of conservative treatment is infusion therapy, with the help of which BCC is restored, cardio hemodynamic is stabilized, protein and electrolyte disturbances are corrected, and detoxification is carried out. Its volume and composition depends on the severity of the patient's condition and averages 3.0-3.5 liters. In case of a serious condition of a patient, preoperative preparation should be carried out by a surgeon together with an anesthesiologist-resuscitator in the intensive care unit or intensive care unit.
Surgical treatment. Conservative therapy should be recognized as effective if in the next 3 hours after the patient entered the hospital after enemas, a large amount of gas escaped and there was abundant stools, abdominal pain and swelling decreased, vomiting stopped and the patient's general condition improved. In all other cases (with the exception of dynamic intestinal obstruction), the conducted conservative therapy should be considered ineffective and should be used for surgical treatment. In case of dynamic intestinal obstruction, the duration of conservative treatment should not exceed 5 days. The indications for surgical treatment in this case are the ineffectiveness of the conservative measures taken and the need for intestinal intubation with the purpose of its decompression.
Advances in the treatment of OC are directly dependent on adequate preoperative preparation, the correct choice of surgical tactics and the postoperative management of patients. Various types of mechanical acute intestinal obstruction require an individual approach to surgical treatment.