Ellis H
Division of Anatomy and Cell Biology, Guy's Hospital, London, United Kingdom.
Eur J Surg Suppl. 1997(577):5-9.
Postoperative adhesions occur after almost every abdominal surgery and are the leading cause of intestinal obstruction, accounting for more than 40% of all cases and 60% to 70% of those involving the small bowel. This contrasts with earlier experience in the Western World and current practice in the Third World, where abdominal operations are infrequent, hernias remain untreated, and strangulated hernia is common. These are among the findings of prospective and retrospective studies on adhesions conducted at the Westminster Medical School, University of London, London, UK, and of other published studies on the clinical consequences of postoperative intra-abdominal adhesions and resultant intestinal obstruction. In an analysis of 210 patients who had undergone at least one previous abdominal operation, 92.9% had postsurgical adhesions. This is not surprising, given the extreme delicacy of the peritoneum and the fact that apposition of two injured surfaces nearly always results in adhesion formation. Problems resulting from postsurgical adhesions create a considerable workload. At Westminster Hospital over 24 years, intestinal obstruction accounted for 0.9% of all admissions, 3.3% of major laparotomies and 28.8% of cases of large or small bowel obstructions. A 1992 British survey reported an annual total of 12,000 to 14,400 cases of adhesive intestinal obstruction. In 1988 in the United States, admissions for adhesiolysis accounted for nearly 950,000 days of inpatient care. Risk factors, such as type of surgery and site of adhesions, as well as timing and recurrence rate of adhesive obstruction, remain unpredictable or poorly understood. The type of surgery most frequently leading to adhesive obstruction includes colonic, and especially rectal surgery, appendicectomy, and gynecological procedures. Laparoscopy does not seem to eliminate the risk of adhesions and adhesive obstruction. Adhesions involving the small intestine occur less frequently than those involving the omentum, but are more likely to become obstructive. Follow-up of over 2,000 laparotomies at the Westminster Hospital demonstrated that 1% of patients developed adhesive obstruction within one year of surgery, and half of these occurred within the first postoperative month. However, obstruction may occur at any time, and some 20% of cases appeared more than 10 years later. Recurrent obstruction following adhesiolysis is common, but actuarial tables still need to be constructed. Adhesive obstruction is clinically challenging, since there is no simple way to differentiate between adhesive and strangulated obstructions. Mortality rates escalate from 3% for simple obstructions to 30% when the bowel becomes necrotic or perforated.
几乎每例腹部手术后都会发生术后粘连，粘连是肠梗阻的主要原因，占所有肠梗阻病例的40%以上，在涉及小肠的肠梗阻病例中占60%至70%。这与西方世界早期的情况以及第三世界的当前做法形成对比，在第三世界，腹部手术很少，疝气得不到治疗，绞窄性疝很常见。这些是英国伦敦大学威斯敏斯特医学院进行的关于粘连的前瞻性和回顾性研究以及其他已发表的关于术后腹腔内粘连及其导致的肠梗阻临床后果的研究结果。在对210例曾至少接受过一次腹部手术的患者进行的分析中，92.9%的患者有术后粘连。考虑到腹膜极其脆弱，而且两个受损表面几乎总会形成粘连，这并不奇怪。术后粘连导致的问题带来了相当大的工作量。在威斯敏斯特医院的24年里，肠梗阻占所有住院病例的0.9%，占大手术的3.3%，占大小肠梗阻病例的28.8%。1992年英国的一项调查显示，每年粘连性肠梗阻病例总数为12000至14400例。1988年在美国，粘连松解术的住院天数占近95万天。手术类型、粘连部位等危险因素，以及粘连性梗阻的发生时间和复发率，仍然难以预测或了解甚少。最常导致粘连性梗阻的手术类型包括结肠手术，尤其是直肠手术、阑尾切除术和妇科手术。腹腔镜检查似乎并不能消除粘连和粘连性梗阻的风险。涉及小肠的粘连比涉及大网膜的粘连发生频率低，但更有可能导致梗阻。威斯敏斯特医院对2000多例剖腹手术的随访表明，1%的患者在术后一年内发生粘连性梗阻，其中一半发生在术后第一个月内。然而，梗阻可能在任何时候发生，约20%的病例在10多年后出现。粘连松解术后复发性梗阻很常见，但仍需要构建精算表。粘连性梗阻在临床上具有挑战性，因为没有简单的方法来区分粘连性梗阻和绞窄性梗阻。死亡率从单纯性梗阻的3%上升到肠坏死或穿孔时的30%。
