internal hernia after excision
Introduction
Introduction to internal hemorrhoids after resection After the resection of the stomach, the residual stomach and the jejunum are anastomosed. The gap left behind the anastomosis is called the posterior anastomosis. The edge lacks elasticity, similar to an ankle ring. If the intestine sac protrudes into the anastomotic space, it is difficult to recover naturally. Formed postoperative gastrectomy (postgastrectomic internalalnia). Postoperative gastrectomy complicated with internal hemorrhoids is less common, more common in Billroth II type gastric resection, gastrojejunostomy, can occur in the early or late postoperative period, the invagination site is formed by post-colon gastrojejunostomy The back gap is most common. basic knowledge The proportion of illness: the incidence rate is about 0.003%-0.005% Susceptible people: no specific population Mode of infection: non-infectious Complications: acute pancreatitis
Cause
Causes of internal hemorrhoids after resection
Postoperative anatomic abnormalities (40%):
After gastrectomy, internal hemorrhoids occur after Billroth II surgery. The abnormal anatomical relationship between gastrojejunostomy and anastomosis is the potential basis for internal hemorrhoids. Another factor in the formation of internal hemorrhoids after gastric resection and post-colon residual gastrojejunostomy It is the transverse mesenteric hiatus and the weak fixation of the stomach wall, causing the suture to fall off, the needle spacing is too wide or forgetting to fix and fix, and the small intestine fistula can be invaded by the fissure between the gastric and transverse mesenteric membranes.
Input too long (35%):
The input is too long to increase the posterior gap, which increases the chance of input sputum and output stenosis intrusion, which is another important factor in the occurrence of internal hemorrhoids.
Postoperative adhesions, improper diet, body position changes (35%):
In some cases, different degrees of intestinal adhesion may occur after surgery, as well as changes in the quality and quantity of the diet after surgery, which may cause hyperactivity of the intestines, intestinal dysfunction, especially when the sudden change of body position increases the posterior space, and the increase of abdominal pressure. The force of pulling up the mesentery and so on, all have different effects on the occurrence of sputum.
Pathogenesis
Pathophysiology
Gastrojejunostomy not only creates abnormal anatomical gaps and fissures, but also anatomically reconstructs the digestive tract. The comprehensive literature has not reported cases of internal hemorrhoids after Billroth I surgery, which is close to normal anatomy and physiology. The status is not unrelated. Billroth I surgery is performed above the transverse colon. The postoperative pathophysiological changes are small. Although there is a fissure after the anastomosis, there is a certain tension after the gastroduodenal anastomosis. The barrier of the barrier, the small posterior gap and the faster adhesion and closure are positive for avoiding the occurrence of internal hemorrhoids. After the gastrectomy, almost all of the internal hemorrhoids occur in the Billroth II type surgery. In addition to the gap, the physiological disturbance of the digestive tract caused by the disorder of anatomical relationship is an important reason. (1) The direction of peristalsis changes: the stomach is retracted to the left upper abdomen, the position of the gastric jejunostomy is higher, and it is suspended in the left upper abdomen, most of the small intestine Located on the right abdomen, and the output is just on the right anterior side of the posterior space. The change of the anatomical position of the intestine and the change of the direction of peristalsis are the output from right to left into the posterior gap. Created the first machine, if the output is bent down into an angle or peristaltic at the anastomosis, it is more likely to cause the intestine to smash the posterior gap, (2) the power direction is disordered: from the mechanical point of view, if the output of the fistula The position is higher than the position of the input sacral intestine. When the two have a certain inclination angle, the gastrojejunostomy and the input jejunum and the mesentery together form a funnel-shaped depression. When the proximal jejunum is anastomosed to the large curved side, the mechanical action direction It is to the lower left, and the mechanical action direction of the proximal end to the small curve is to the lower right. When the peristalsis is restored, the output fistula can form the internal hemorrhoid through the upper right to the lower left or from the upper left to the lower right through the anastomotic space. The data also showed that 75% of the output sputum and almost all of the input sputum were from right to left. (3) The jejunum was compressed, and the effusion was aggravated: the jejunum and the jejunal intestine below the Treitz ligament were lifted and remnant When the small side is anastomosed, the intestine is turned from the left side to the right side, and the mesentery is turned from the right side to the left side, and the two sides are parallel to each other. The input jejunum is inevitably crossed by the mesentery. long After compression based film which, coupled with the pressing omentum and transverse colon, bowel fluid product gas is expanded or increased weight, increased weight of the input loop herniated readily occur within the gap hernia.
2. Pathological typing
According to the invagination site, there are 3 types of sputum after gastrectomy: (1) Input sputum sputum: that is, jejunal input into the posterior anastomosis space (Fig. 4), mostly occurs in the anterior colon jejunum anastomosis, or jejunum If the input is too long and the left ligament of the ligament is away from the midline, the jejunum is still inserted into the stenosis and the stomach is slightly curved. (2) The output is the : the jejunum output is inserted into the anastomosis and the fissure can be from right to left. Intrusion, you can also invade from left to right, starting with the output of the anastomosis near the jejunum, followed by the rest of the small intestine, and even some of the greater cecum, the ascending colon can also be combined The incidence of clinical output of sputum sputum is higher than that of the input sputum, and the ratio is about 3:1. (3) Transverse mesenteric hiatal hernia: postoperative colonic gastrojejunostomy, the fixed small intestine is not fixed. Or the suture needle is too wide, or the mesenteric orifice is not repaired to form a pupil, so that the jejunal input and output sputum are involved, this type is less common than the input sputum and the output sputum.
Prevention
Prevention of internal hemorrhoids after resection
The occurrence of internal hemorrhoids after partial gastrectomy is closely related to the surgical procedure and surgical operation of gastric resection. The following targeted measures can be taken to reduce the occurrence of internal hemorrhoids:
1. Select Billroth I style anastomosis
After the major gastrectomy, Billroth I gastroduodenal anastomosis, the gastrointestinal tract is basically close to normal anatomy, physiological state, less complications, so far has not seen in the majority of gastric resection, Billroth I gastroduodenal Report of anastomotic surgery with internal hemorrhoids, due to a certain tension after gastroduodenal anastomosis, the posterior space is closed, postoperative pathophysiological changes are small, and the transverse mesenteric membrane is blocked, after the gastrectomy The occurrence of sputum has a preventive effect. Therefore, under the premise of not affecting the therapeutic effect, the Billroth I type anastomosis should be used for benign lesions of the stomach and gastric antrum.
2. Eliminate or reduce the back gap
The posterior anastomosis is the potential basis for the occurrence of internal hemorrhoids. In the case of Billroth II type gastric resection and gastric jejunal anastomosis, it is still controversial whether it is necessary to close the posterior space. Some people think that the Billroth II type gastric resection and the gastric jejunostomy have closed the gap. It takes less time, is simple to operate, eliminates the existence of back clearance, and is an extremely effective measure to avoid the occurrence of internal hemorrhoids. Most scholars believe that the edge of the posterior gap is irregular and the suture is not suitable for passing through the intestinal wall. There are certain difficulties in repairing, and improper closure is often counterproductive. Improper sutures can even form crypts or distortions, and even lead to jejunal input sputum, output sputum or transverse colon obstruction. It is not necessary to suture the jejunum into the cavity between the iliac crest and the transverse colon. Listen to it naturally forming a blocking seal.
During the operation, corresponding measures can be taken, such as shortening the input sputum, etc., which can reduce the posterior gap, which is beneficial to reduce the chance of sputum occurrence. When performing the operation on the internal hemorrhoids, the gap should be routinely sewed after the reset to prevent the internal hemorrhage from happening again. .
3. Shorten the length of the input port
A large number of reports have confirmed that the occurrence of internal hemorrhoids is closely related to the long input of the sputum. Therefore, whether it is the jejunal anastomosis before or after the colon, shortening its length as much as possible, and making the posterior gap smaller, will greatly reduce the incidence of internal hemorrhoids. Billroth II type gastric resection, gastric jejunostomy, the length of the indwelling stenosis into the jejunum must be different from person to person, under the premise of ensuring no tension in the anastomosis, no compression symptoms, the shorter the better, the length of the input: after the colon Gastrointestinal anastomosis, generally 6 ~ 8cm; colonic jejunal anastomosis in the colon is 8 ~ 10cm is appropriate (not more than 12cm), too long is prone to internal hemorrhoids, too short will cause the input sputum syndrome, some scholars advocate the use of colon after try The reason for the anastomosis is that the length of the input fistula can be shortened, especially for patients with a long transverse mesenteric membrane.
Peyt's (1984) study of the local anatomical features of the duodenum and jejunal initiation confirmed that there are variations in the duodenum and duodenal jejunum, and the position of the duodenum depends on the Treitz ligament. The length of the Treitz ligament, the fourth segment of the free duodenum, can change various anatomical variations, and can make the proximal end of the jejunum consistent with the residual stomach, thus shortening the length of the input fistula and avoiding the input syndrome And the occurrence of guilt.
For patients with hypertrophic omental hyperplasia, it is best to remove the anterior colonic gastrojejunostomy to shorten the length of the input fistula and reduce the posterior gap.
4. Choose the right way to fit
Since the majority of the duodenal jejunum is located on the left side of the spine, the jejunal input of the anterior jejunum to the small curved anastomosis can cause the anatomical relationship between the input of the enteral intestine and its mesangial anterior and posterior symmetry, and requires a long input sputum, thus easily leading to Postoperative internal hemorrhoids should be taken as far as possible after the colon is introduced into the small curved anastomosis or the large bow anastomosis before the colon to shorten the length of the jejunal input fistula and avoid cross-change of the intestine and the mesentery.
5. Postoperative diet, physical labor recovery should be appropriate
The quality and quantity of the diet are closely related to gastrointestinal dysfunction. Especially after a certain adhesion in the abdominal cavity after abdominal operation, severe physical activity or overeating after eating is more likely to cause gastrointestinal motility dysfunction, and induce internal hemorrhoids. Avoid it, a small amount of meals after stomach surgery, should be light, easy to digest food, avoid strenuous activities after meals.
6. Membrane opening repair should be reliable
The transverse mesenteric membrane is open at the root, repaired and fixed, and should not be too high to avoid the occurrence of transverse mesenteric rupture.
Complication
Postoperative internal hemorrhoids complications Complications acute pancreatitis
Duodenal stump rupture
The internal hemorrhoids occur in the short-term after surgery, because the duodenal stump has not yet healed firmly, and the input sputum obstruction caused by the internal hemorrhoids can cause duodenal bile, pancreatic juice accumulation, and retention of dilatation. The pressure is increased and ruptured.
2. Acute pancreatitis
A small number of patients may have acute pancreatitis due to internal hemorrhoids due to:
(1) Input sputum sputum causes input sputum obstruction, followed by duodenal bile, pancreatic juice accumulation, internal pressure increased, causing duodenal juice to flow back into the pancreatic duct, induced acute pancreatitis.
(2) The output can also be pressed into the jejunum to cause the input sputum obstruction, and then induce acute pancreatitis, the patient's blood, urine amylase is significantly increased.
Symptom
Postoperative resection of internal hemorrhoids symptoms Common symptoms Peritonitis pain, abdominal pain, metabolic acidosis, nausea, abdominal distension, venous reflux disorder, persistent pain, peritoneal irritation, mobile dullness
After internal gastrectomy, internal hemorrhoids occur mostly in the early postoperative period. The shortest is 2 days after surgery. About half of them occur within 1 month after surgery, and 1/4 occur within 2 to 12 months after surgery. The remainder occurred 1 year after surgery.
1. Acute intestinal obstruction
The main symptoms are acute high-level complete small bowel obstruction, most of which are acute and the clinical process is dangerous. If the diagnosis and treatment are not timely, the mortality rate can be as high as 40%. Once the internal hemorrhoids occur after the gastrectomy, there are often a large number of small intestines. In the posterior space, because of the proximal jejunum intrusion, the patient's abdominal distension is not obvious, vomiting is more frequent, but the clinical symptoms and signs of the internal hemorrhoids and the output fistula are different.
(1) Input : more manifested as persistent pain in the upper abdomen, less vomiting, and vomit does not contain bile, bloating is not obvious, the upper abdomen often touches the tender mass, the bowel sounds are not Breaking into, rarely smelling the sound of water.
(2) Output : manifested as paroxysmal upper abdomen or upper abdomen left cramps, most patients with low back pain, vomiting, vomit contains bile, abdominal distension is relatively obvious, can smell the intestines The sound of snoring or gas over water, no abdominal mass, X-ray examination of the stomach tube into the iodine can be seen in the residual stomach of the contrast agent emptying delay and / or output sputum obstruction, the oblique position visible output is located behind the input In addition, the input sputum of the patient who is discharged from the iliac crest can also be obstructed by compression at the ankle ring, thus having both the symptoms and signs of jejunal input fistula and output fistula obstruction.
2. Diffuse peritonitis, toxic shock performance
As the disease progresses, intestinal tube dilatation, intestinal wall circulation disorder, and even strangulation, if it can not be resolved in time, intestinal wall circulation disorder is aggravated, small intestinal bowel necrosis occurs, diffuse peritonitis appears, due to small bowel necrosis, diffuse Peritonitis, a large amount of toxin absorption, patients can quickly develop toxic shock, some patients have mucus and blood, physical examination: significant abdominal distension, bowel sounds weakened or disappeared, obvious peritoneal irritation, percussive mobile dullness positive, abdominal puncture and hemorrhagic fluid, The whole body showed elevated body temperature, fine pulse rate, small pulse pressure difference, less urine, and no obvious improvement in anti-shock treatment symptoms.
3. Water, electrolyte and acid-base balance disorders
Due to inability to eat and frequent vomiting, a large amount of gastrointestinal fluid and bile is lost; the obstructed intestinal tube is over-expanded, the venous return disorder caused by compression of the intestinal wall, the plasma leaking into the intestinal lumen and the abdominal cavity, and the intestinal narrowing causes a large amount of blood loss, etc., causing serious deficiency Water, reduced blood volume and metabolic acidosis.
Examine
Examination of internal hemorrhoids after resection
Blood test
(1) White blood cell count and classification: generally increase, the wider the range of inflammation, the more severe the infection, the more obvious the increase of white blood cell count.
(2) Hemoglobin and hematocrit: The body is severely dehydrated, the blood is concentrated, and the hemoglobin and hematocrit are slightly elevated.
2. Serum electrolytes (K, Na, Cl-) can reflect the balance of water, electrolyte and acid-base.
3. Blood gas analysis pH decreased, SB decreased, BE negative value, PCO2 showed a compensatory decline, considering the possibility of metabolic acidosis.
4. Serum amylase over 500U suggests acute pancreatitis, because serum amylase increases within 2 to 12 hours after onset, and returns to normal after 48 to 72 hours. At this time, the total amount of urinary amylase can be measured for 2 hours, and the urine amylase per hour exceeds At 300U, the diagnostic accuracy rate is higher.
5. Amylase / creatinine clearance value In acute pancreatitis, there are more renal amylase than creatinine, so the value of >5 is highly suggestive of acute pancreatitis. If it is a simple input sputum obstruction, serum amylase can be elevated, but amylase / creatinine clearance value does not increase, it is meaningful for differential diagnosis.
Auxiliary inspection
1. X-ray abdominal plain film
There is an enlarged intestinal fistula in the left upper abdomen, a liquid level in the small omentum, compression deformation of the residual stomach and other signs of mechanical obstruction.
2. X-ray gastrointestinal angiography
The iodine agent is injected through the gastric tube to show the output sputum obstruction, and the oblique smear shows that the output is located behind the input .
Diagnosis
Diagnostic diagnosis of internal hemorrhoids after resection
diagnosis
The incidence of this disease is low, the early symptoms are atypical, and the diagnosis is difficult. For those suspected to be complicated with postoperative internal hemorrhoids, the following conditions should be understood in detail: including and analyzing the clinical features, when Biumth II type gastric resection, surgery The patient should be considered for the following conditions.
1. Patients with a history of major gastrectomy should pay attention to the surgical procedure, the extent of gastric tissue resection, the length of the jejunum, and the method of anastomosing the stomach jejunum (before or after the colon, the proximal jejunum is small or curved). The position of the transverse mesenteric opening and the position fixed on the residual stomach.
2. Clinical manifestations of patients with a history of gastrojejunostomy (Billroth II surgery) with major gastrectomy, the following performance is highly suspected.
(1) Sudden onset, rapid progression, strangulated intestinal obstruction, diffuse peritonitis and toxic shock in the short term.
(2) persistent pain in the upper abdomen, paroxysmal aggravation, accompanied by pain in the back area or radiation to the left shoulder, nausea, vomiting more frequently (may contain bile), abdominal pain after vomiting still does not relieve, such as less vomiting, vomit Bile-containing can be considered as the possibility of inputting sputum; vomiting is high, vomiting is frequent, and vomit contains bile, which is considered as an output sputum.
(3) Signs: There are surgical scars in the abdomen, the abdominal distension of the patient is not obvious, the left upper abdomen is tender, the muscles are tense, and the mass can often be touched. The bowel sounds are not hyperthyroidism, and there is little sound of water and water; Obviously, the whole abdomen is extensively tender, and the bowel sounds are early hyperthyroidism. In severe cases, the pulse is fast, cold sweat, pale, low blood pressure and other strangulated intestinal obstruction.
Differential diagnosis
The disease should be distinguished from anastomotic obstruction or rupture, other causes of sputum obstruction and postoperative pancreatitis and other complications. A large number of clinical data confirmed that duodenal stump rupture, intestinal obstruction, internal hemorrhoids after gastric surgery Such complications can cause elevated serum amylase, which is easily misdiagnosed as postoperative acute pancreatitis. The relevant data are not uncommon. Therefore, when serum amylase is found to increase, the possibility of related diseases should be carefully considered to avoid delay in surgery.
