Objective We searched the best available evidence to provide a basis for the medical or palliative surgical treatment of a patient suffering from terminal colon cancer, complicated by intestinal obstruction (malignant intestinal obstruction), so as to improve the patient’s quality of life and alleviate her clinical symptoms. Methods We formed the clinical question according to the PICO principle. We searched for systematic reviews and randomized controlled trials in The Cochrane Library (Issue 1, 2007), MEDLINE (PubMed, January 1950 to March 2007) and ACP Journal Club (January 1991 to March 2007), and evaluated the evidence retrieveds.?Results We found that both scopolamine and octreotide could alleviate nausea, vomiting and abdominal pain, but that octreotide was superior to scopolamine in reducing the secretion of gastric acid. Metoclopramide was effective in relieving fatigue, vomiting and intestinal obstruction associated with advanced cancer. A nasogastric tube may be used to drain the secretions before the administration of medical treatment, but long-term use tubes may make patients intolerable and induced side effects, such as necrosis of nasal mucous membrane and infection. At present, empirical palliative surgery was used for the management of malignant intestinal obstruction. This varied in different regions, and so the patients’ clinical condition should be taken into consideration. Being informed of the advantages and disadvantages of different treatment regimens, the patient and her family made the final decision.Conclusion The current evidence suggests that medical treatment can improve quality of life and alleviate clinical symptoms for a patient suffering from terminal colon cancer complicated with intestinal obstruction. However, the effect of palliative surgical treatment remains to be proved, and the decision about the appropriate treatment needs to consider the patients’ condition and the doctors’ clinical experiences.
摘要:目的：回顾性分析比较左半结肠癌急性梗阻一期手术与同期左半结肠癌根治术患者的手术临床资料,探讨左半结肠癌急性梗阻一期手术的可行性。方法： 回顾性将我中心2004年1月至2007年3月收治的59例左半结肠癌急性梗阻一期手术病例分为A组,将同期226例左半结肠癌根治术病例分为B组,比较两组之间清除淋巴结数、术后进食时间、吻合口漏发生率、肺部感染率、切口感染率、住院时间、复发和转移率。结果： 在上述观察指标中,在A组分别为（133±18）枚,（36±09）d,1/59（169%）,4/59（678%）,2/59（339%）,(124±09)d,6/59（1017%）；B组分别为128±15,32±08,1/226（044%）,8/226（354%）,6/226（265%）,117±15,23/226（1062%）；经统计学处理,两组间没有显著性差异。结论：术中合理应用结肠灌洗,良好的手术技巧,术后积极辅助治疗,左半结肠癌急性梗阻一期手术是安全可行的,可避免二次手术带给患者的痛苦,术后并发症也无明显增加。Abstract: Objective: Retrospective analysis and comparison of acute obstruction of left colon cancer onestage surgery and the same period a radical mastectomy in patients with left colon cancer surgery clinical data,To study the possibility of acute obstruction of left colon cancer onestage surgery. Methods:A retrospective of my center from January 2004 to March 2007 were treated 59 cases of acute obstruction of left colon cancer onestage surgery patients were divided into A group, will be left over the same period 226 cases of radical resection of colon cancer patients were divided into group B, compare the number of lymph nodes removed between the two groups, after the consumption of time, the incidence of anastomotic leakage, pulmonary infection, incision infection, length of stay, recurrence and metastasis rate. Results: Observed in the above indicators, in the A group were 133±18,36±09,1/59 (169%),4/59 (678%), 2/59 (339%),124±09,6/59 (1017%); B group were 128±15,32±08,1/226 (044%), 8/226 (354%), 6/226 (265%), 117±15,23/226 (1062%); Statistical analysis between the two groups there was no significant difference. Conclusion: Rational application of intraoperative colonic irrigation, good surgical technique, postoperative adjuvant treatment of active, acute obstruction of left colon cancer onestage surgery is a safe and feasible, it may avoid the second operation to bring the patient’s pain, postoperative complications and no increased significantly.
Objective To explore the pathogenesis of the level of gene and therapeutic target genes associated with intestinal obstruction by analyzing the differential expression gene. Methods The gene expression data that came from public database gene expression omnibus （GEO） which provided adhesion formation’ gene expression data on 1， 3， 7，and 14 days after operation （n=8） and normal intestinal tissues’ gene expression data （n=2） of mouse were collected. The gene function and differential expression of genes were analyzed by using gene ontology （GO） and significance analysis of microarray （SAM）. Results There were a lot of response stimulated up-regulation of gene expression when occurrence of adhesion， and the products of these genes were distributed on cell membrane. The analysis results of gene expression at different time point after operation showed that expression up-regulated of Hmgcs 2 gene occurred on 3-14 days ofter operation and expression up-regulated of Stxbp 5 gene occurred on 14 days ofter operation. Conclusions The adhesion formation may be closely associated with the genes of response to stimulus and the gene product in membrane. The Hmgcs 2 and Stxbp 5 genes may be closely associated with the occurrence of other diseases which induced by adhesion formation.This provides a basis for the discovery of potential therapeutic targets.
Objective To establish interstitial cells of Cajal （ICC） loss models caused by incomplete small intestinal obstruction in rats with modified method and verify it. Methods Modified method was used to establish the models， making the ring around the small intestine but not through it. Morphological changes were observed by general signs， pathological changes were tested by HE staining and transmission electron microscope （TEM）， and changes of ICC number were tested by immunohistochemistry staining. Results Success rate of this method was 56% （28/50）， weight loss happened compared with before operation in ileus group （P＜0.01）. Hyperemia and swelling were observed in ileus group， and gastric retention was obvious. Results of HE staining and TEM showed that there was obvious inflammatory change， and ICC reduced was observed by immunohistochemistry. Conclusion ICC loss models caused by incomplete small intestinal obstruction meet the basic performance， and can be used for further research.
ObjectiveTo investigate the clinical values of serum histidine decarboxylase (HDC), D-lactate, and alpha-glutathione S-transferase (α-GST) for diagnosing intestinal mucosal injury of patients with intestinal obstruction. MethodsThe expression levels of serum HDC, D-lactate, and α-GST in 28 patients with strangulated intestinal obstruction, 19 patients with simple intestinal obstruction, 17 patients with acute simple appendicitis, and 20 healthy volunteers were determined by enzyme linked immunosorbent assay (ELISA) before the treatment, and then the area under receiver operating characteristic curve (AUC) of these diagnostic indices were compared. In addition, the occurrence rates of systemic inflammatory response syndrome (SIRS) and infectious complications (abdominal cavity infection and pulmonary infection) were closely observed. The relevances of SIRS and infectious complications and the expression levels of these three diagnostic indices were analyzed. ResultsThe expression levels of serum HDC, D-lactate, and α-GST of the patients with strangulated intestinal obstruction were the highest among all the patients (Plt;0.01), and the expression levels of these three indices in the patients with simple intestinal obstruction were higher than those of the patients with acute simple appendicitis (Plt;0.05). The AUC of HDC (0.913) was larger than that of D-lactate (0.872) and α-GST (0.836) (P=0.000, P=0.000, respectively). When the cut off value of HDC was 31.00 μg/L, the sensitivity, specificity, false negative rate, and false positive rate of HDC were 74.5%, 94.6%, 25.5%, and 5.4%, respectively, which were all better than those of D-lactate and αGST. The occurrence rates of SIRS and abdominal cavity infection of the patients with strangulated intestinal obstruction were significantly higher than those of patients with simple intestinal obstruction (P=0.046) and acute simple appendicitis (P=0.027); while there was not significantly different of pulmonary infection among all the patients (P=0.728). The expression level of serum HDC in patients with strangulated intestinal obstruction suffered from SIRS (P=0.000) or abdominal cavity infection (P=0.002) was significantly higher than that of not-suffered from SIRS or uninfected patients. Meanwhile, the expression levels of serum D-lactate and α-GST in the patients with strangulated intestinal obstruction suffered from SIRS were higher than those of notsuffered from SIRS patients (P=0.032, P=0.021, respectively). The expression levels of HDC, D-lactate, and α-GST were significantly correlated with SIRS and abdominal cavity infection (Plt;0.05), among which the level of HDC and the incidence of SIRS had the highest correlation (r=0.608, P=0.001). ConclusionHDC may be a more effective index for diagnosing intestinal mucosal injury of patients with intestinal obstruction.
Objective To discuss the safety of fast track surgery for patients with obstructive colorectal cancer. Methods Between February 2008 and February 2009, 157 cases of obstructive colorectal cancer were analyzed retrospectively, 59 in fast track (FT) group and 98 in traditional group. Postoperative early rehabilitations and complications were studied and compared. Results The first time of passing flatus, oral intake and postoperative hospital stay in FT group were significantly earlier or less than those in traditional group （Plt;0.05）, while there were no significant differences in time of first ambulation, time with use of nasogastric tubes, urinary catheter, and drains between the 2 groups （Pgt;0.05）. There was also no statistically significant difference in postoperative complications rate between the 2 groups （Pgt;0.05）. Conclusion Fast track surgery for patients with obstructive colorectal cancer is safe and can accelerate recovery with decreasing length of hospital stay and improving life quality of the patients.
ObjectiveTo explore the feasibility and safety of the artificial pneumoperitoneum and gastrointestinal contrast CT imaging, and imaging diagnostic value on abdominal wall adhesion to intestine after operation. MethodsThirtynine patients with adhesive intestinal obstruction after operation relieved by conservative therapy were included from January 2008 to November 2009. After the artificial pneumoperitoneum established by injection of gas into abdominal cavity and gastrointestinal comparison by oral administration low concentration of meglucamine diatrizoate, CT scan imaging was performed and the radiographic results were compared with surgical findings. ResultsFour patients refused surgery and discharged, so enterolysis was performed in the remaining patients. The surgical findings were consistent with radiographic results. It was showed by laparoscopic operation that intestinal obstruction caused by the fibrous adhesions and the intestine did not adhere to the abdominal wall in eight patients with fibrous adhesion diagnosed by CT. Of eighteen patients with the abdominal wall septally adhered to the intestinal, the surgical findings showed the intestine and the abdominal wall formed “M”type adhesions and omentum adhesions in sixteen patients underwent open operation, and clear fat space was showed in eight patients and close adhesion was found in another eight patients between the intestine and abdominal wall. Of thirteen patients with the abdominal wall tentiformly adhered to the intestinal, the surgical findings showed the intestine and the abdominal wall formed continuous and tentiform adhesions and omentum adhesions to the intestine in eleven patients. After the followup of 6-18 months (mean 9 months), incomplete intestinal obstruction occurred in one patient and was relieved by conservative treatment. One patient with discontinuous discomfort in abdomen after operation did not receive any treatment. The other patients were cured. ConclusionThe artificial pneumoperitoneum and gastrointestinal contrast CT imaging can accurately show the location, area, and structure composition of the postoperative abdominal wall adhesion to intestine, which is safety, simple, and bly repeatable, and a better imaging method for the diagnosing of abdominal wall adhesion to intestine after operation.
Objective To investigate the effects and significance of nerve growth factor (NGF) and its high affinity receptor of tyrosine kinase A (TrkA) expressions on proliferative connective tissue of bile duct in rats after bile duct ligation (BDL). Methods Forty-six female Sprague-Dawley rats were randomly divided into two groups: control group ( n =6) and BDL group ( n =40). The model of obstructive jaundice in rat was made by bile duct ligation, then duodenohepatic ligament was taken and treated with anti-NGF and anti-TrkA receptor antibody. Expressions of NGF and TrkA receptor in connective tissue of bile duct were investigated by immunohistochemistry, blood specimens were collected from left ventricle to detect serum total bilirubin (TB) and alanine aminotransferase (ALT). Results After BDL, TB level obviously elevated in the third day, and continued until the fourteenth day, then descended. By day 21 and 28, it returned to normal level. Compared with normal bile duct, due to bile stasis, an increased thickness of the bile duct wall was observed by microscope which correlated with the proliferation and differentiation of connective tissue cell. NGF and TrkA were expressed by the cell membrane and the cytoplasm of connective tissue cell and inflammatory infiltration cell after BDL. The trend between their expressions and bilirubin levels was similar. Conclusion NGF and its receptor TrkA regulate the proliferate and differentiation of connective cell in bile duct. They may play a key role in the formation of bile duct scar, which seems to be hardly reversed by relief of bile stasis in a short time.
Objective To analyze the effect of meglumine diatrizoate on diagnosing and treating adhesiveness small intestinal obstruction. Methods The clinic data of 484 cases of adhesiveness small intestinal obstruction were analyzed retrospectively. Those patients were treated with radiography with 76% of meglumine diatrizoate by orally or injected. Results After taking meglumine diatrizoate, 362 patients were cured, and the other 122 cases were diagnosed clearly and treated with surgery. Conclusions Meglumine diatrizoate can be used to diagnose adhesiveness small intestinal obstruction and confirm where the obstruction is. It can be the routine treatment for adhesiveness small intestinal obstruction and can be used repeatedly. It also can provide evidence to surgical treatment and guide to make the surgical project.
Objective To investigate the effect of implanting uncovered self-expandable metal stent for treatment of distal malignant biliary obstruction through endoscope. Methods The effect of therapy about implanting uncovered self-expandable metal stents to 16 patients who had unsectable malignant tumors companing with obstructive jaundice through endoscope was reviewed. Results Fifteen of the studied patients were implanted uncovered self-expandable metal stents successfully (94%), for their internal drainage were patent. At the seventh and fourteenth day after implantation, liver function and B-ultrasound were rechecked. Compared to the data before operation, total bilirubin, direct bilirubin and transaminase declined respectively (P＜0.01). And the diameter of the total biliary duct became shorter (P＜0.01). Six of them returned to the normal level in three weeks. Early adverse events (in seven days) included mild acute pancreatitis (one case) and acute cholangitis (one case). Mean survival and patency of drainage were 186.93 days (54 to 426 days) and 156 days (51 to 426 days) respectively. All of them, 3 cases occured obstruction of stents (20%). Conclusion Implantation of uncovered selfexpandable metal stent through endoscope is an ideal therapy for distal malignant biliary obstruction.