Al-Rashedy Mohammed, Issa M Eyad, Ballester Pedro, Ammori Basil J
Manchester Royal Infirmary, Manchester, United Kingdom.
J Laparoendosc Adv Surg Tech A. 2005 Apr;15(2):153-9. doi: 10.1089/lap.2005.15.153.
Surgical relief of gastric outlet obstruction (GOO) or small bowel obstruction in patients who had undergone major resection or palliative bypass surgery for malignancy is conventionally achieved at a laparotomy. The potential role of minimally invasive surgery in the management of these complications has not been previously explored.
Between 2003 and 2004, 4 consecutive patients, age range 37 to 72 years, where admitted with gastric outlet or proximal small bowel obstruction following previous open surgery for suspected intra-abdominal malignancy, under the care of one surgeon. The respective past histories of these patients were recurrent GOO and concomitant distal biliary obstruction following a previous open gastric bypass elsewhere for metastatic pancreatic head cancer; persistent adhesive small bowel obstruction following radical gastrectomy for gastric cancer; GOO secondary to intra-abdominal recurrence 6 months after hepatobiliary resection for hilar cholangiocarcinoma; and GOO following previous pancreatico-duodenectomy for suspected pancreatic head cancer. Their respective surgical management consisted of a laparoscopic re-do gastric bypass and concomitant cholecystojejunostomy; adhesiolysis and revision of the Roux-en-Y enteric anastomosis; a Devine exclusion gastroenterostomy; and resection and refashioning of the gastroenterostomy.
There were no conversions to open surgery and no postoperative complications. The median operating time was 240 minutes (range, 145 to 300 minutes). Oral free fluid intake was resumed on postoperative day (POD) 1, while diet was resumed between POD 2 and 4. The median postoperative hospital stay was 15.5 days (range, 14 to 25 days).
Previous laparotomy and major resection or palliation of malignancy do not preclude the application of the laparoscopic approach for the management of upper gastrointestinal obstruction. Laparoscopic adhesiolysis and revision of enteroenteric and gastroenteric anastomoses are feasible management options in the hands of those experienced with complex laparoscopic surgery.
对于因恶性肿瘤接受过大部切除或姑息性旁路手术的患者，胃出口梗阻（GOO）或小肠梗阻的手术缓解传统上是通过开腹手术实现的。此前尚未探讨过微创手术在这些并发症管理中的潜在作用。
2003年至2004年间，连续4例年龄在37至72岁之间的患者，因先前因疑似腹内恶性肿瘤接受开放手术后出现胃出口或近端小肠梗阻而入院，由一名外科医生负责治疗。这些患者各自的既往病史分别为：曾在其他地方因转移性胰头癌接受开放胃旁路手术后复发性GOO并伴有远端胆管梗阻；因胃癌行根治性胃切除术后持续性粘连性小肠梗阻；肝门胆管癌行肝胆切除术后6个月因腹内复发导致的GOO；以及先前因疑似胰头癌行胰十二指肠切除术后出现的GOO。他们各自的手术治疗包括腹腔镜再次胃旁路手术及同期胆囊空肠吻合术；粘连松解及Roux-en-Y肠吻合口修复；Devine式胃造口术；以及胃造口术的切除与重建。
均未转为开腹手术，也未出现术后并发症。中位手术时间为240分钟（范围为145至300分钟）。术后第1天恢复口服自由液体摄入，术后第2至4天恢复饮食。中位术后住院时间为15.5天（范围为14至25天）。
先前的开腹手术及恶性肿瘤的大部切除或姑息治疗并不排除应用腹腔镜方法治疗上消化道梗阻。对于有复杂腹腔镜手术经验的医生来说，腹腔镜粘连松解及肠肠和胃肠吻合口修复是可行的治疗选择。
