短期临床成果使用肠梗阻导管的小说更深插管技术（DIT）急性肠梗阻的患者后，

Abstract

Background。The ileus tube has been widely used for the treatment of acute small bowel obstruction. However, it is difficult to get the tube sufficiently adjacent to the obstruction site due to various reasons.方法。We developed a novel intubation technique, named Deeper Intubation Technique (DIT), by using the Zebra Urological Guidewire and digital gastrointestinal fluoroscopy, where we deepened the catheter intubation, and further compared the effects of DIT with the Traditional Intubation Technique (TIT) on the short-term clinical outcomes of 183 patients.Results。The average intubation depth of DIT apparently exceeds that of TIT ( vs. ， ）。与患者的TIT组相比，患者的DIT组中获得了较低的疼痛评分（ ），更短的恢复时间肛门排气排便（ vs. ， ），higher recovery rate in anal exhaust defecation (24 h, 16.8% vs. 5.7%, ;48 h, 46.3% vs. 27.3%, ），better symptomatic remission rate and imaging relief rate ( ），和增加的排水体积（ vs. ， ）。Importantly, the emergency surgery rate in the DIT group was lower than that in the TIT group (3.2% vs. 13.6%, ）。In addition, the DIT procedure was effective for patients with adhesive obstruction but not for cancerous and stercoral bowel obstruction.Conclusion。Compared to TIT, DIT produced better short-term clinical outcomes, indicating that DIT is a safe and feasible technique for the treatment of adhesive intestinal obstruction.

1。介绍

Intestinal obstruction is one of the most common reasons of all emergency department visits for acute abdominal pain [1]。Among all the conventional methods to treat the simple intestinal obstruction such as gastrointestinal decompression, fasting, pain control, intravenous fluid replacement, correction of electrolyte imbalances, and anti-infection, gastrointestinal decompression appears to be the most important [2]。Originally, the nasogastric tube (Levin tube) decompression was widely used. In 1953, a Japanese scholar officially presented a novel treatment strategy for intestinal obstruction named the ileus tube. The effect of this treatment was gradually confirmed and used [3-7]。With guidance of X-ray or electronic gastrointestinal endoscopy, the tube is usually placed in the jejunum with its tip through the pylorus, duodenum, and the ligament of Treitz. However, due to deficiencies of conventional ileus tube intubation such as high friction between tubes and guide wires, consistently shifting position, and the resistance of the intestine inner fold, it is difficult to get the tube sufficiently adjacent to the obstruction site by merely incubating the duodenum or the ligament of Treitz, with the intubation depth not more than 150 cm.

在本研究中，我们提出了一种新方法，插管，其允许管放置到通过所述数字胃肠透视和斑马泌尿导丝，其被命名为更深的插管技术（DIT）阻塞的近端。为了评估DIT的安全性和可行性，我们回顾性比较与DIT和同一时期的传统插管技术（TIT）治疗的患者短期的临床结果。

2。材料和方法

2。1。Patients

这项回顾性研究调查183医院ized patients with acute intestinal obstruction from January 2014 to December 2017 in the Central Hospital of Zibo. The criteria for case selection were listed as follows: (1) hospitalized patients had acute intestinal obstruction symptoms like nausea and vomiting, abdominal pain, abdominal distension, and exhaust defecation ceasing; (2) patients diagnosed with intestinal obstruction by abdominal X-ray plain films and abdominal CT examination; (3) patients suitable for conservative treatment with no severe abdominal pain or persistent abdominal pain, bloody vomiting or bloody stool, asymmetric abdominal distension, respiratory instability and even shock, peritoneal irritation, and other strangulated intestinal obstruction symptoms; (4) patients had no contraindications of tube intubation, such as the history of ENT surgery, and esophageal disease; and (5) detailed medical records and follow-up information were available.

在DIT组，95例（男48例，女47例），年龄45-96岁（63.7mmol年平均岁）与更深的插管技术人，其中59例有腹部手术史治疗。虽然TIT组中，88例患者采用传统工艺，47名男性和年龄在26-88岁（平均61.6年岁），女性41治疗，其中57间有历史腹部手术。

所有实验方案经淄博，中国的中心医院伦理委员会批准。所有受试者均签署知情同意书。

2.2。方法

2.2。1。Instrument Preparation

两组采用CLINY肠梗阻导管套件（创建军医，日本东京）（图1）。The ileus tube is 300 cm in length, whose commonly used specifications are 16 Fr and 18 Fr with three channels and two balloons. The facade of the tube has a weighted tip that is composed of six successive steel balls (no penetration of X-ray), which was used to facilitate the tube through the pylorus and guide the tube forward. Distilled water could be injected into the anterior balloon to advance the tube as well as using the rear balloon in high selective intestinal radiography. At the end of the tube, there are an anterior balloon valve, air hole, and rear balloon valve.

Digital gastrointestinal fluoroscopy (TU-51, Hitachi) and a Zebra guide wire (Nanjing Micro-Tech Co., Ltd., 4500 mm,Φ0。03五inches) were adopted to complete the DIT.

传统的技术认可的DSA操作仪（阿蒂斯Zeego，西门子Healthineers）和导丝与CLINY肠梗阻管套件与3.5米和4.5米长度相匹配，Φ0。04五inches.

2.2.2。插管方法

(1) Deeper Intubation Technique。该患者被局部麻醉，并且将管通过鼻子放置在胃中。然后，将患者的位置被变换，并通过胃肠透视观察到的管。We place the tip of the tube near the stomach, pylorus, and duodenal suspensory ligament, with 60 cm, 85 cm, and 110 cm marked. (For patients with digestive tract reconstruction, it is necessary to decide the intermittent length according to the reconstruction.) When the tube was blocked or coiled, it would demand to rotate the tube, change the patient’s posture, adjust the guide wire, and continue to push the tube. As the tube reached the jejunum, we observed the tube position every 15 cm pressed, where the Zebra guide wire guides the tube while draining intestinal contents at the same time, placing the tube close to the obstruction site. In the intubation process, we need to constantly change the patient’s position and facilitate the tube intubated downwards. If the tube went downwards with difficulties, appropriate air volume could be injected into the intestine via the tube to change the position of small bowels and then repeat the manipulation. It was also useful to pump water-soluble iodine contrast medium, which can be applied to observe the direction of bowel movement, stimulate the peristalsis, reduce bowel wall edema, and increase the secretion of digestive juices, so that we can push the tube downwards easily [8-10]。After the operation completion, 15 ml of sterile water would be injected into the anterior balloon connecting the end bore with a little negative pressure drainage (980-2450 Pa or 10-25 cm water column). We fixed the exposed tube on the cheek beside the nose and reviewed the abdominal plain film every 24 hours. Based on the patient’s clinical symptoms, bowel dilatation, and tube position, we can decide to push the tube to further adjust the size of the anterior balloon or perform the abdominal radiography.

(2) Traditional Intubation Technique。这是要求DSA透视和导丝匹配与CLINY肠梗阻管套件。管将通过后局部麻醉鼻子接近患者的胃。下透视，在管的前沿到达胃的大曲率而病人保持在左前斜位置。然后，患者应转动到左侧卧位，以保持所述管朝幽门的头部，和导丝将第一插通在管将得到引导到由导丝辅助十二指肠幽门。一旦管达到通过特赖茨氏韧带的空肠，管和导丝之间的摩擦可能会放大。摩擦将导致管的失控，并且变得难以得出导丝回来。插管完成后下面的步骤是一样的DIT。

所有的病人有如此保守的应用t methods as fasting, intravenous nutrition, anti-infection, maintenance of water, electrolyte and acid-base balance, etc. When patients presented with symptoms of severe abdominal pain, worsened distension, tachycardia, hematemesis, hematochezia, peritoneal irritation, isolated swelling bowel loops, and even shock, timely surgical treatment would be needed.

2.3。测量结果

患者的疼痛评分和排便情况应进行监测，并与患者每24小时前，插管后录疼痛得分数字评定量表（NRS）。腹部的位置的平膜或CT将每24小时在三天插管后进行审查，和将被记录的气液电平的数目和肠管扩张的程度，而胃肠减压管的每日引流将被记录。

平均插管深度，排水的量，疼痛评分，腹痛缓解率，恢复时间为肛门排气排便记录。处理效率被定义为临床或放射学的改善，缓解的腹部症状，排水体积减小，并且空气 - 流体水平的消失[11，12]。

2。4。Statistical Analysis

SPSS 20.0用于统计分析。两组间比较采用学生进行 -test for continuous variables and the chi-square test or Fisher’s exact test for categorical variables. All statistical tests were two-sided, and值小于0.05被认为是显著。

3.结果

3。1。Clinical Characteristics of Patients

所有患者均出现急性肠梗阻症状，如腹痛，腹胀，恶心，呕吐，大便失败和天然气通，也没有症状，提示绞窄性肠梗阻，这证明了保守治疗的要求。有平均年龄和性别比例没有显著差异，两组间（ ）。根据病史，体格检查和影像学检查，患者被分为四类，包括恶性肿瘤（癌）阻塞，粘连，和粪便阻塞。如表1，the baseline clinical characteristics of the patients between the two groups were of no statistic difference.

3。2。Short-Term Outcomes after DIT or TIT Treatment

如图2，the TIT treatment could reach the proximal jejunum. While for the DIT group, the intubation could obtain the ileum of the patients with a maximum depth up to 265 cm (Figure3）。

Table2provides the detailed short-term outcomes between the DIT and the TIT group. We could see that the intubation depth in the DIT group was significantly deeper than that in the TIT group ( vs. ， ）。

在NRS分数没有显著差异两组之间示出插管的肠梗阻管（前 vs. ， ），while the NRS score in the DIT group was significantly lower than that in the TIT group 24 ( vs. ， ）和48hours ( vs. ， ）after intubation.

对于排便，我们观察到，排气排便时间的DIT组显著缩短相比TIT组（ vs. 天， ）。24（16.8％对5.7％以内的排便速度， ）和48小时（46.3％对27.3％， ）后插管的DIT组中显着增加。以上的两组患者半回收的72小时内排气排便（61.1％对51.1％， ）。虽然孵化后第7天，多数病人在两个组恢复排便（90.5％对83％， ）。

With respect to remission of the disease, we observed the relief condition via two parameters, symptomatic remission and imaging relief. Time for symptomatic remission in the DIT group was 天，而 days in the TIT group ( ）。在24小时，48小时，和72小时的症状缓解率分别为25.5％，63.2％，和86.3％的DIT组中。虽然TIT组中，在24小时，48小时，和72小时的症状缓解率分别为9.1％，38.6％，和68.2％。腹部透视平片被插管后每日进行，患者的肠扩张和气体 - 液体水平的情况被记录下来。至于成像救济条件，用于成像缓解时间为 该DIT组天 days in the TIT group ( ）。在DIT组，在24小时，48小时，和72小时的摄像浮雕率分别为分别为21.1％，54.7％，和82.1％，而那些该TIT组中分别为8.0％，30.7％，和62.5％，。

所述DIT组的在插管后第一个24小时排水体积比TIT组显著更高（ vs. ， ）。虽然有两组之间的手术率无显著差别，DIT组显示手术较低的趋势相比，TIT组（12.6％对19.3％， ）。此外，紧急手术率显著的DIT组中降低相比，TIT组（3.2％对13.6％， ）。

3.3。总体疗效肠梗阻的不同类型

如表3，56例患者被诊断为粘连性肠梗阻，和50（89.3％）的他们DIT组插管后回收。虽然TIT组中，共有52名患者诊断为粘连性肠梗阻，和38（73.1％）患者表现充分固化（ ）。无显著差异，两组间显示，当涉及到粪便阻塞（ ）和cancerous obstruction ( ）。

4。讨论

对于急性肠梗阻，胃肠减压可以从近端梗阻排出肠内容物，减少十二指肠腔内的压力，并恢复十二指肠血液循环，这可以改善患者的症状，避免肠坏死，降低肠道细菌易位。研究表明，肠梗阻的解压缩效果比传统的鼻胃管显著更好[12-14]。据报道，传统的鼻胃管减压效率仅在于在30-40％[1五-17]，而肠梗阻管的效力升高至70-80％[12，18]。因此，一些学者提出，肠梗阻管，代替鼻胃管或手术，应该是急性肠梗阻的第一选择，不含绞阻塞或其他禁忌[后3，17，19]。然而，鼻胃管仍然是首选的治疗方法由于在临床实践中其简单的操作。

通常,肠梗阻的插管方法管的计谋ld be classified into X-ray-guided intubation and endoscopy-guided intubation. The traditional intubation method is inserting the tip of the tube through the ligament of Treitz and filling the front balloon so that the tube could move forward under the drive of intestinal peristalsis. Once the tip of the tube passes through the ligament of Treitz, operation will become difficult, which may result from several reasons. First of all, the guide wire matching the CLINY Ileus Tube suite has a diameter of 0.045 inches and a high degree of hardness. The friction between the guide wire and tube will be increased with the increase of intubation depth, resulting in considerable difficulties in controlling the tube and guide wire and even failing to pull out the guide wire [20]。其次，在操作过程中，患者的位置需要，以便于将管插管不断改变。肠梗阻患者的耐受性差，无法应付体位改变。第三，肠道褶皱可以作为转发管障碍。

基于上述问题，我们改进了传统的技术如下，它被命名为DIT。首先，当管的尖端进入空肠，插管应当继续尽可能向前移动的前端。然后，为了减小导丝和管，更精细和更软的斑马导丝之间的摩擦与0.035英寸直径被选择。与斑马导丝的帮助下，这将是更容易控制管当插管深度增加。此外，作为用于肠梗阻管的插管的操作平台，数字胃肠透视是用于改变患者的姿势比DSA容易。另一个重要的优点是，医生可以使用数字胃肠透视间歇地操作，避免了DSA的连续的X射线辐射。When intubation encounters obstacles such as intestinal folds or swerve, an appropriate volume of air could be injected into the bowel via the catheter to change the stereo direction of the bowel, changing patients’ posture and guiding the weighted tip to conform to the track of the bowel at the same time. In addition, operators can inject the water-soluble iodine contrast medium into the bowl to observe the stereo track of the bowel and stimulate peristalsis [8-10]。说的过程中,管的顶端reach the obstruction more closely and decompress the intestine contents more sufficiently, which effectively reduces bowel dilatation and promotes the recovery of bowel function [14]。

The two groups were comparable as no significant difference was shown in age, sex ratio, previous laparotomies, and obstruction types, etc. In the DIT group, the mean intubation depth is up to 213.89 cm, obviously greater than that of the TIT group. Intestinal peristalsis is the major power promoting the tube forward in TIT. However, due to the application of analgesics, abdominal (intestinal) infection, and electrolyte disorders, patients usually present with weakened or even vanished intestinal peristalsis. This is one of the key reasons that decrease the effectiveness of the TIT procedure. By DIT, operators can easily intubate the tip of the tube to the distal end of the jejunum; even in the condition where the intestinal peristalsis is weakened, the satisfactory drainage could also be obtained. The ileus tube quickly drains the effusion and pneumatosis in the bowel and facilitates the recovery of intestinal blood supply. As bowel diameter decreases and intestinal peristalsis recovers, the tube will be pushed forward, leading to a positive feedback. So patients’ symptoms in the DIT group could be relieved faster.

The present study results have shown the advantages of DIT in intestinal decompression, with significantly increased drainage in 24 hours. Meanwhile, patients’ abdominal pain was relieved faster, and patients in the DIT group recovered faster, both symptomatically and radiologically. As time went on, the ileus tube would move towards the obstruction due to the gravity action of the tip of the tube and the intestinal peristalsis. As the tube moved forward, the tip of the tube in the TIT group could reach the same site with the DIT group finally. Therefore, the advantage of DIT in the early stage of acute intestinal obstruction is more evident. This may account for the lower emergency surgery rate in the DIT group. Reducing the emergency surgery rate is of vital importance for the treatment of intestinal obstruction. The surgeons could make a sufficient preoperative preparation improving patients’ general situation, which can reduce complications and mortality. In addition, the DIT procedure could improve patients’ symptoms rapidly and convert emergency surgery into nonemergency surgery. All the aforementioned effects of the DIT procedure led to better short-term outcomes for patients with intestinal obstruction.

DIT的不同类型肠梗阻的影响也进行了研究。对于粘连性肠梗阻，最常见的类型肠梗阻[11，21]，对于DIT过程的总效力高达89.3％。从肠梗阻的反复发作的痛苦有些患者通常有严重的肠粘连，并经历了腹部手术的好几倍。对于这些患者，手术是很具挑战性和风险性和并发症的发生率较高。此外，手术治疗可能加重肠粘连和诱发肠梗阻复发[22]。该DIT的过程可能会增加保守治疗的疗效和降低开工率，这可能帮助患者避免手术，减少经济负担。在临床实践中，管的顶端将达到阻塞部位更迅速地采用DIT的过程，并能比TIT程序较早进行溶石治疗。对于患者大便阻塞，所述产气剂（主要成分为柠檬酸和碳酸氢钠的）或液体石蜡将通过管，其可以促进stercolith的溶解和固化进行说明。有两个方法来治疗恶性梗阻的疗效无显著差异，功效是三种类型肠梗阻，这与以前的研究是一致的[中最差14]。

One of the important limitations of the present study is the lack of long-term survival. Further study investigating the prognosis of patients in the DIT group is warranted. Moreover, as the baseline parameters of patients of the two groups were similar (number of patients, age, sex, obstruction type, and history of abdominal surgery) and the number of patients is limited, case-matched analysis was not available in the present study. In addition, multicenter comparative prospective studies with increased number of cases are needed to verify the safety and effectiveness of DIT.

五。Conclusion

总之，这项研究提出了一种新的技术可能显著改善肠道梗阻患者的短期临床疗效，尤其是对患者的粘连性肠梗阻。该DIT可以作为患者肠梗阻一种安全，有效的方法。

Data Availability

用来支持这项研究的结果的原始数据请直接从相应的作者。

Conflicts of Interest

The authors declare that there are no conflicts of interest.

作者的贡献

牛俊设计的研究;Yanlu谭，蔡文姬毛，和沁园参与数据采集，分析和解释;Yanlu谭写文章;海滨陈有助于使表和数字;和君牛修订的文件。

致谢

This study was supported by research grants from the National Natural Sciences Foundation of China (No. 81572414).

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