泛影葡胺造影剂对非绞窄性小肠梗阻患者手术时机判断及对术后疗效观察

论著 栏目

（内蒙古科技大学包头医学院第二附属医院消化微创中心，内蒙古    包头    014030）

资助项目：包头市科技计划项目（2019Z3011--03）

*通信作者：韩唯杰，E-mail：13608786@qq.com

摘要： 目的    研究泛影葡胺造影剂对非绞窄性小肠梗阻患者行腹腔镜手术时机的判断作用及对术后疗效和血清肠脂肪酸结合蛋白（IFABP）、二胺氧化酶（DAO）水平的影响。方法    选取2019年1月至2021年4月于内蒙古科技大学包头医学院第二附属医院消化微创中心诊断为肠梗阻的120例患者作为研究对象，按照随机数字表分为观察组与对照组，每组60例。对照组给予胃肠减压、抗感染等基础治疗，观察组在对照组基础上行泛影葡胺造影剂下的腹腔镜手术，对照组在保守治疗48 h无效后行腹腔镜治疗。比较两组治疗指标、非手术治疗疗效评价指标、血清IFABP及DAO水平、术后并发症发生情况。结果    观察组非手术治疗成功率高于对照组，排气时间及住院时间均短于对照组，差异有统计学意义（P＜0.05）。观察组胃肠减容量少于对照组，首次肛门排便时间、症状缓解时间均短于对照组，差异有统计学意义（P＜0.05）。治疗后，两组血清IFABP水平均低于治疗前，DAO水平均高于于治疗前，且观察组血清IFABP、DAO水平均低于对照组，差异有统计学意义（P＜0.05）。随访6个月，两组电解质紊乱、切口感染、再发肠梗阻、腹膜炎发生率比较差异无统计学意义。结论    泛影葡胺造影剂对非绞窄性小肠梗阻患者行腹腔镜手术时机的判断准确，可提高患者非手术率，缩短术后排便时间、住院时间，降低IFABP、DAO水平，显著改善患者肠黏膜缺血状态。

关键词： 泛影葡胺造影；肠梗阻；腹腔镜；肠脂肪酸结合蛋白；二胺氧化酶

Evaluation of operation time and observation of postoperative efficacy of meglumine diazotum contrast agent in patients with non-strangulated small intestinal obstruction

MA Yongqiang, WANG Qiuhong, ZHENG Shusheng, DUAN Shuquan, WANG Hailong, ZHANG Dongsheng, LI Xiaolong, HAN Weijie^*

(Digestive minimally invasive center, the Second Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology Baotou, Baotou, Inner Mongolia, 014030, China)

Abstract: Objective  To study the effect of meglumine diatrizoate contrast agent on the operation time of laparoscopic surgery in patients with non-strangulated small intestinal obstruction and its effect on postoperative efficacy and serum intestinal fatty acid binding protein (IFABP) and diamine oxidase (DAO) levels. Methods   120 patients diagnosed with intestinal obstruction in the Digestive Minimally Invasive Center of the Second Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology from January 2019 to April 2021were selected as the research subjects, they were divided into the observation group and the control group according to the random number table, with 60 cases in each group. The control group was given basic treatment such as gastrointestinal decompression and anti-infection, the observation group was given laparoscopic surgery under meglumine diatrizoate contrast agent on the basis of the control group. The control group was given laparoscopic treatment after 48 h of ineffective conservative treatment, the treatment indexes, evaluation indexes of non-surgical treatment efficacy, serum IFABP and DAO levels, and postoperative complications were compared between the two groups. Results  The success rate of non-operative treatment in the observation group was higher than that in the control group, the exhaust time and hospitalization time were shorter than that in the control group, the differences were statistically significant (P < 0.05). The gastrointestinal volume reduction in the observation group was less than that in the control group, and the time of first anal defecation and symptom relief were shorter than that in the control group, the differences were statistically significant (P < 0.05). After treatment, the levels of serum IFABP of the two groups were lower than those before treatment, the levels of DAO were higher than those before treatment, and the levels of serum IFABP and DAO in the observation group were lower than those in the control group, the differences were statistically significant (P＜0.05). After 6 months of follow-up, there was no significant difference in the incidence of electrolyte disturbance, incision infection, recurrent intestinal obstruction and peritonitis between the two groups. Conclusion  Meglumine diatrizoate contrast agent can accurately judge the timing of laparoscopic surgery in patients with non-strangulated small bowel obstruction, which can improve the non-surgical rate of patients, shorten the postoperative defecation time and hospitalization time, reduce the levels of IFABP and DAO, and significantly improve the intestinal mucosal ischemia state of patients.

Keywords: Meglumine diatrizoate contrast agent; Intestinal obstruction; Laparoscopy; Intestinal fatty acid binding protein; diamine oxidase

肠梗阻是普外科常见的急腹症^[1]。目前肠梗阻治疗保守治疗以胃肠减压、控制感染、纠正水电解质及酸碱平衡紊乱等为基本治疗方式，但对手术时机的判断目前尚未有达成共识的辅助检查方法。非绞窄性肠梗阻治疗时机的选择对患者预后十分重要。76%的泛影葡胺为高渗液，可降低肠壁水肿，同时，可协助临床医生明确梗阻部位、性状。基于此，本研究通过对肠梗阻患者泛影葡胺造影剂对非绞窄性小肠梗阻患者行腹腔镜手术时机的判断作用及对术后疗效和血清肠脂肪酸结合蛋白（intestinal fatty acid binding protein，IFABP）、二胺氧化酶（diamine oxidase，DAO）水平的影响，以期为临床治疗提供科学依据，现报道如下。

1  资料与方法

1.1    临床资料    选取2019年1月至2021年4月于内蒙古科技大学包头医学院第二附属医院诊断为肠梗阻患者120例作为研究对象，按照随机机数字表分为观察组与对照组，每组60例。两组临床资料比较差异无统计学意义，具有可比性，见表1。本研究经内蒙古科技大学包头医学院医学伦理委员会审核批准（审批号：2019年伦理审第LW-010）。

表1    两组临床资料比较

Table 1  Comparison of clinical data between the two groups

纳入标准：①均符合肠梗阻诊断标准^[2]；②患者入院时均摄立位或左侧卧位腹部平片，均可见小肠有阶梯状液平；③患者及家属签署知情同意书。排除标准：①存在手术禁忌证患者；②绞窄性肠梗阻或肠坏死、肠梗阻导致弥漫性腹膜炎患者；③肠梗阻并发腹腔感染腹外病变引起的肠梗阻患者；④肠道炎症性病变及脓肿。

1.2    方法    两组入院后均先采取保守治疗，包括胃肠减压、抗感染、补液等。观察组在保守治疗基础上进行泛影葡胺造影剂下的腹腔镜手术。胃肠减压30～60 min后经鼻胃管注入或口服小肠造影剂：复方泛影葡胺（西安汉丰药业，规格：15.2 g/2 0ml）40 ml夹闭胃管4 h后打开胃管，于6、12、24、48 h摄腹部平片，评价泛影葡胺造影剂疗效，48 h后腹部平片提示泛影葡胺造影剂到达盲肠，提示保守治疗有效，继续保守治疗；如未能到达盲肠或肠梗阻症状不缓解或持续加重，则考虑行腹腔镜手术治疗。观察期间密切观察患者腹部体征即生命体征变化，如考虑绞窄性肠梗阻发生，积极采用手术治疗。

对照组在保守治疗48 h无效后行腹腔镜治疗。于腹腔镜直视下，依次探查患者十二指肠、小肠、结肠，根据术中具体情况再决定行肠粘连松解、肠切除肠吻合等术式。

1.3    观察指标    ①治疗指标：包括非手术治疗成功率、排气时间、住院时间。②保守治疗疗效评价指标：包括胃肠减压量、首次肛门排便时间及症状缓解时间。③血清IFABP、DAO：治疗前后，空腹采血4 ml，以离心半径8 cm，3 000 r/min离心20 min，分离血清。采用酶联免疫法检测IFABP、DAO。④术后并发症：随访6个月，记录患者电解质紊乱、腹膜炎、再发肠梗阻、切口感染发生情况。

1.4    统计学方法    采用SPSS 26.00统计学软件进行数据分析，正态分布计量资料以“x±s”表示，采用t检验，计数资料以[n（%）]表示，采用χ²检验，以P＜0.05为差异有统计学意义。

2  结果

2.1    两组治疗指标比较    观察组非手术治疗成功率高于对照组，排气时间及住院时间均短于对照组，差异有统计学意义（P＜0.05），见表2。

表2    两组治疗指标比较

Table 2  Comparison of therapeutic indexes between the two groups

2.2    两组非手术治疗疗效评价指标比较    观察组胃肠减容量少于对照组，首次肛门排便时间、症状缓解时间均短于对照组，差异有统计学意义（P＜0.05），见表3。

表3    两组非手术治疗疗效评价指标比较（x±s）

Table 3  Comparison of curative effect evaluation of non-surgical treatment indexes between the two groups (x±s)

2.3    两组治疗前后血清IFABP、DAO水平比较    治疗前，两组血清IFABP、DAO水平比较差异无统计学意义；治疗后，两组血清IFABP水平均低于治疗前，DAO水平均高于于治疗前，且观察组IFABP、DAO水平均低于对照组，差异有统计学意义（P＜0.05）。见表4。

表4    两组治疗前后血清IFABP、DAO水平比较（x±s）

Table 4  Comparison of serum IFABP and DAO levels between two groups before and after treatment (x±s)

注：IFABP，肠脂肪酸结合蛋白；DAO，二胺氧化酶。与本组治疗前比较，^aP＜0.05

2.4    两组术后并发症发生情况比较    随访6个月，两组电解质紊乱、切口感染、再发肠梗阻、腹膜炎发生率比较差异无统计学意义，见表5。

表5    两组术后并发症发生情况比较[n（%）]

Table 5  Comparisons of postoperative complications between two groups [n(%)]

注：^*采用连续性校正x2检验

3  讨论

肠梗阻是临床较常见疾病，但目前临床参数在核实肠缺血方面缺乏准确性^[3]，因此，在对患者治疗过程中及时掌握病情，降低患者手术损伤，对提高患者生命质量具有积极意义^[4]。有研究表明，在密切观察患者病情变化的前提下，监测泛影葡胺在消化道的动态运行情况，48 h内患者的病情保持稳定^[5]。泛影葡胺造影通过扩张患者肠道，降低局部炎症反应和水肿，通过6、12、24、48 h的不间断观察，及早识别手术指征，准确判断手术时机。而传统腹腔镜手术，48 h保守治疗无明显改善，即刻对患者采取腹腔镜手术，患者普遍手术治疗率较高^[6]，患者病灶部位损伤较大，患者预后生命质量显著下降^[7]。

本研究结果显示，观察组非手术治疗成功率高于对照组，排气时间及住院时间均短于对照组，差异有统计学意义（P＜0.05）。泛影葡胺是水溶性造影剂，渗透压为2 150 mOsm/L，能减少小肠壁水肿，稀释肠内容物，促进肠道蠕动^[8-9]。同时，腹部平片可显影，提示病情变化，对手术治疗具有显著提示作用。本研究结果显示，观察组胃肠减容量、首次肛门排便时间、症状缓解时间均低于对照组，差异有统计学意义（P＜0.05）。

IFABP属于胞液蛋白，仅存在于肠道黏膜中^[10]，可特异性结合长链脂肪酸^[11]。本研究结果显示，治疗后，观察组血清IFABP、DAO水平均低于对照组，差异有统计学意义（P＜0.05），IFABP是早期诊断肠缺血的敏感指标^[12]，随着患者肠梗阻的缓解，其缺血状态显著改善，患者血清IFABP显著下降。血清DAO是反映肠道氧化应激状态的重要指标，可通过该指标判断肠梗阻肠道黏膜损伤程度^[13]，肠梗阻较重时，会导致患者肠道粘膜受损，血清DAO活性升高说明患者肠道粘膜受损，间接说明血清DAO与肠梗阻患者梗阻程度相关^[14]。血清DAO水平能预测肠上皮细胞的成熟度和完整性，随着患者血清DAO水平的降低，患者肠梗阻情况显著改善。有研究显示，随着患者血清IFABP水平降低，患者肠梗阻情况显著改善^[15]。动物试验证实，血清DAO水平与大鼠的肠梗阻情况呈现负相关^[16]，与本研究相互印证。本研究结果显示，两组电解质紊乱、切口感染、再发肠梗阻、腹膜炎发生率比较差异无统计学意义。提示在腹腔镜术前进行泛影葡胺造影，安全性较好。

综上所述，泛影葡胺造影剂对非绞窄性小肠梗阻患者行腹腔镜手术时机的判断准确，可提高患者非手术率，缩短术后排便时间、住院时间，降低IFABP、DAO水平，显著改善患者肠黏膜缺血状态。

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