1急性肠梗阻的病因学和病死率：705 例回顾分析【摘要】 总结急性肠梗阻的病因学类型和总体病死率，探索手术治疗前合理的保守治疗时间。方法：回顾性分析了华西医院 1995 年至 2002 年的住院病人病历，分类统计各类病因，并分析病死率与手术前保守治疗间期的相关性。结果：共纳入 705 例急性肠梗阻病例，其中 71.1%病变部位在小肠，82.6%为单纯性肠梗阻。最常见病因为粘连（62.0%） ，肿瘤次之（23.7%） 。56.7%的病例接受外科治疗。总体病死率为 1.6%，其中保守治疗组为 1.3%，外科治疗组为 1.7%。肠坏死发生率随保守治疗间期延长而增高，当绞窄发生超过 24 h 即可能死亡。结论：与西方相似，在中国同样有病因向粘连性转移的流行病学趋势。基于四川大学华西医院经验，近半数的单纯性肠梗阻病例可经保守治疗缓解。保守治疗延长且无缓解趋势的单纯性肠梗阻，或绞窄发生第一个 24 h 内的病例应接受外科治疗。【关键词】 肠梗阻 病因学 预后 病死率Acute intestinal obstruction is one of the most common surgical emergencies, which involves a partial or complete blockage of the bowel that induces mechanical impairment or 2complete arrest of the passage of contents through the intestine. The etiology of acute intestinal obstruction is various and complicated. In different countries or areas, the etiology of acute intestinal obstruction is diverse to some extent. While the most frequent etiological factor is postoperative adhesions in developed countries, and strangulated hernias are more common in developing countries1. Moreover, at different times, the etiology has also changed. Decades ago, the hernia was reported as the first cause of the acute intestinal obstruction2 , but recent reports demonstrated that intraperitoneal adhesion became the most possible cause of this disease2,3 . In China, there seemed to be the similar etiological transition trend4.It is common sense that most of the patients with acute intestinal obstruction require surgical intervention due to the mechanical nature of the disease. However, conservative therapy is still considered as a selective approach to the management of selected patients, such as incomplete adhesive obstruction. After effective intervention of gastrointestinal decompression, fasting, prophylactic or therapeutic antibiotics, and nutrition support, part of the 3patients with acute intestinal obstruction might achieve palliation and avoid operation. However, conservative therapy may increase the rate of strangulation, the risk of intestinal necrosis and the mortality.The present retrospective review aims to figure out the etiological factors and overall outcomes, and to explore the rational length of time for conservative therapy before conversion of operation.1 Clinical data and methods1.1 Patients The medical records of all the patients with obstruction admitted to West China Hospital through the computed patients registration system from January 1995 to December 2002 were retrospectively reviewed. The search strategy was searching “intestinal obstruction” in the diagnosis field, and anyone who was diagnosed with intestinal obstruction was considered for inclusion, which required further identification individually.All the hospital medical records of this series were 4reviewed, including data from patients on gender, age, etiological factors, lesion position, treatment (conservative or surgical), time interval between conservative therapy and operation and clinical outcomes (cure, relapse or death).The patients were diagnosed by the definite symptoms, signs, and imaging (abdominal Xray or computed tomography). Paralytic ileus was not considered for inclusion in the study. For all the patients, the conservative therapy was the initial treatment combined with fluid and electrolyte resuscitation, prophylactic or therapeutic antibiotics, gastrointestinal decompression, fasting and nutritional support. The indications for laparotomy was considered as conversion to complete obstruction, especially when strangulation recurred, or nonoperative management was more than 4872 hours without palliation or improvement. Surgical procedures included simple reposition for intussusceptions, volvulus, incarcerated hernias, or adhesiolysis for adhesive obstruction if there was no strangulation, otherwise enterectomy and anastomosis should be considered. Besides, enterectomy or colectomy could be applied to selective patients with small or large 5intestinal tumors, and if it was in an inappropriate condition, enterostomy or colostomy was inevitable. If intestinal perforation recurred, the decision on enterectomy or enterostomy was dependent on local and peritoneal condition, and peritoneal lavage and drainage was necessary. Some selected pediatric patients with intussusceptions could be administered the air enema for reposition by skilled pediatric surgeons. Postoperative management was consecutive to the preoperative conservative therapy. And the intensive care unit was considered for severe diseases with organ function disorder.1.2 Statistical analysis The continuous data were described as median and range, and category data were reported as events frequency and percentile. Statistics analysis approaches contained Pearson Chisquare test, Fishers exact test and Pearson linear correlation. Twosided P values less than 0.05 was regarded as statistically significant difference. The SPSS 13.0 software was used for statistics.1.3 Ethics Since the present study was retrospective