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Khadjibaev Abduhakim Muminovich, Professor, General Director of Republican Research Center of Emergency Medicine, Tashkent city, Uzbekistan
Khodjimukhamedova Nigora Abdukamalovna,
Senior researcher E-mail: [email protected]
Yangiev Ravshan Akhmedovich, Senior researcher
Diagnosis features of the damaged intestine in abdomen injuries and prevention of the postoperative complications
Abstract: Small and large intestine injuries are still the actual issues of abdominal surgery. They are considered as one of the most negative prognostic factor. So, the insufficiency of the sutures of intestinal anastomosis remains to be the typical complication of the resection of the large intestine. The methods of treating intestine traumas have been noticeably changed for he last 20 years: the primary closure without colostomy has been popular here in Uzbekistan and abroad though the discussion about the necessity of stoming are still lasted in the surgical editions.
Keywords: intestine injuries, abdominal surgery, anastomosis, postoperative complications, colostomy, suture failure.
Introduction
The trauma remains to be one of the leading causes of the mortality and disability of the population. The heavy multiple and associated injuries due to increase in cases of road accidents and industrial traumatism have become of dominating significance over the last years.
The treatment of the colon injuries appeared to be the most difficult. The colon injuries occupy the special place because of frequent complications in the postoperative period and high lethality that is connected with severity degree of the injury of the colon, as well as with multiple and associated damages in which prognostic factor of the colon is considered to be the most unfavourable.
At the isolated injuries of the large intestine the frequency of the lethal outcomes varied from 2 to 14 % [1; 4], at the injuries of the large intestine on the basis of the associated trauma from 39.5 to 51.8 % [3; 7; 8], and on the background of the multiple injuries accounts for 25.3-41.2 % [16].
The complicated development of the small and large intestines has been registered in 20.0-65.0 % cases [1]. The failure of the sutures of intestinal anastomoses remains to be typical complication of the large intestine and is found in 4-20 % of surgeries [5; 6; 9; 10]. The main cause of death in the postoperative period is intraperitoneal complications which may occur in a half of patients.
At present time there is no universal tactics in the choice of the method of treatment of the injuries of the small and large intestines, particularly on the background of the polytrauma, in relation to character and severity of the injury ofthe intestinal wall and its mesentery, time from the moment of injury, degree of contamination of the abdominal cavity, blood lost at the multiple injuries of the parenchymatous organs, severity of traumatic shock. In the literature there are occurred various, frequently contradictory data in relation to rationality of radical or palliative operation at this pathology. Prestigious technique and new modifications of the intestinal anastomosis sutures have not been the critical keys for successful surgeries on the intestine though they reduce the number of complications [1; 4; 5].
The knotty problem for positive solution is raised in spite of the multiple proposed clinical criteria, laboratory tests and instrumental methods for the evaluation ofthe intestine viability; the question about the state of reparative regeneration of the damaged area at the various time from the moment oftrauma has not been still resolved [2; 11; 17].
Materials and methods
During the period from 2003 to 2014 in the Republican Research Center ofEmergency Medical Aid there were treated 1 740 patients with abdomen injuries that accounted for 4.1 % from the total number of the operated patients. From them we analyzed treatment efficacy in 187 victims of traumas of the small and large intestines. Among the patients males were 106 (56.7 %) and females — 61 (43.3 %). More than 60 % of patients at the admission were at the state of alcohol effect. According to the character of the trauma the patients were divided by the following way: penetrating stab-incised traumas — 120 (63.98 %) closed abdominal trauma — 65 (35 %) and gunshot wounds in 2 (1.02 %) patients. With single injury of the hollow organs of the abdominal cavity there were 99 (52.9 %) suffering, with multiple — 14 (8.3 %) and with associated — 74 (39.6 %) patients. The injury of the hollow organs of the abdominal cavity associated with injuries of the thorax, fractures of the upper or lower extremities, fractures of the pelvic bones, brain trauma. Among all the admitted patients the thoracic-abdominal wounds with intestinal injuries were found in 78 (41.7 %). Among all patients admitted with this pathology at the state of shock accounted for 78 %.
Clinical-diagnostic measures were performed in parallel with antishock therapy. The numbers of diagnostic measures included: examinations of the other specialists, such as urologist, traumatologist neurosurgeon, and such methods as roentgenography, contrast roentgenologic investigations, ultrasound scanning, esophagogas-troduodenoscopy, computed tomography, diagnostic laparoscopy with study of exudate from the abdominal cavity for enzymatic contents. Performance of the type of examination was depended on the severity of the patient's state.
Results and discussion
In our clinic there has been developed clear tactics for management of the patients with traumas of small and large intestine of different severity for the last decade. This tactics is individual and depends on the character of injuries, degree of blood supplying disturbances of the damaged site of the intestine, health state of the patients. At the open injuries there was performed revision and primary surgical debridement of the wounds. The penetrating character of the wound without organ eventration or active blood hemorrhage was the indication firstly for the diagnostic laparoscopy, then if necessary, for conversion. We have performed
Section 5. Medical science
diagnostic laparoscopy in 125 patients with intestinal injuries, of them in 113 (90 %) cases there was conversion. Contraindications for laparoscopic treatment of the wounds of the abdominal cavity, in our opinion, are gunshot wounds of the abdominal cavity; multiple wounds; unstable hemodynamics, hemorrhagic shock; eventration of the intestinal loops. For this category of patients there was immediately performed laparotomy. The suffering patients under the state of shock at presence of active bleeding were carried out minimum of examinations and they were quickly transferred into the operation room. All suffering patients admitted without clinical picture of peritonitis and shock as well as with stable hemodynamics were performed diagnostic laparoscopy as the first step. At the late referral of the patient with symptoms of peritonitis, first of all, there was carried out short preoperative preparation. At the thoracic-abdominal wounds before operation in the obligatory order the pleural cavity was drained, as well as if it was required thoracoscopy was made.
The risk factors at intestinal injury included heavy shock, massive blood lost, associated trauma, fecal contamination of the abdominal cavity and peritonitis.
Table 1. - The character of injuries of the small and large intestine
Type of small and large intestine injures n %
Duodenum penetrating wounds 8 4.3
Duodenum rupture 2 1
Penetrating injuries of the small intestine 110 58.8
Multiple ruptures of the small intestine 5 2.7
Penetrating injuries of the large intestine 56 29.9
Injuries of the small and large intestine 26 13.9
Totally 187 100
Peritonitis was diagnosed in 95 (51 %) suffering patients. The stomach, liver, pancreatic gland, spleen were damaged associated more often with intestine injury. It is known that the most difficult group in relation to diagnosis appeared to be the patients with closed trauma of the abdomen. During diagnostic laparoscopy it does not always manage to perform complete revision of all the loops oflarge and small intestine, and frequently this procedure may require long time in severe associated injury. From 2008 in all the patients at diagnostic laparoscopy the exudate was removal from the abdominal cavity (even in the little quantity the presenting exudate in the abdominal cavity) and in the obligatory order underwent to express analysis (apparatus "Vitros 200") for determination of the amylase, ammonia and alkaline phosphatase. The parameters of the presence of amylase and ammonia may show damage of hollow organs, and, consequently, resolve the question about conversion and more careful revision. Ammonia concentration in the exudates from the abdomen in the patients without signs ofperforation of the hollow organ does not prevail 100 micromol of NH3/l, and amylase is practically absent. At injury of the small and large intestine the content of ammonia increases, as well as in the exudates there was found amylase more than 40 mg/ml/hour.
During choice of operative intervention such factors as sizes of the wound defects of intestine, signs of peritonitis, type of injury, severity of the state of suffering patient, haemodynamic stability were taken into attention. The injuries of the large intestine in relation to clinical course are more severe than the injuries of the small intestine. The more size of the large intestine defect then the more expressed: shock intensity, volume of blood lost, peritonitis expression. Besides, the size of the wound defects rendered significant effect on the outcomes of the treatment. As the clinical studies showed
during increase in wound sizes, consequently, the number of complications increased, including frequency of intra-abdominal infections and the level oflethality increased too. Development ofperitonitis to the moment of primary operative intervention had significant effect on the trauma outcome and was accompanied by higher frequency of complications. Taking this into account all patients in the intraoperative and early postoperative period were performed antibacterial therapy with preparations of the wide spectrum of effect, as minimum in two groups. Then antibacterial therapy was performed in dependence to sensitivity after bacteriological investigation. The significant moment during operation was assessment of adequacy of the vascularization of the damaged segment of the large intestine and other its parts. It was of particular importance in wounds and ruptures of the intestine mesenterial margin, mesenterial hematomas, gunshot wounds, because the main cause of the suture failure of the large intestine is missed evaluation during operation of the blood supplying adequacy of the sutured site. We consider that the technique of the anastomosis is of great importance. All anastomoses are applied by the manual method with double — row sutures. The interintestinal anastomoses were created by our developed technique with use of frame from metallic ring (Patent No FAP of 2007 useful model "Device for anastomosis application in the gastrointestinal tract") in 22 cases. This method allows to preserve mechanic strength and hermeticy of the intestinal anastomosis, because the area of anastomosis is under the state of stabilization, as well as increase in intestinal pressure does not result in tension and dehiscence in anastomosis line on the background of "compromise" abdominal cavity.
Table 2. - The types of performed operative interventions on the small and large intestine
Types of operative interventions n
Suture of wound in the small intestine 56
Laparoscopic suture of wound in the small intestine 7
Suture of wound in the large intestine 24
Suture of wound in the small and large intestine 16
Resection of the small intestine with application of EEA 11
Resection of the large intestine with application of ICA 4
Resection of the small intestine with application of ileostomy 4
Resection of the large intestine with application of colostomy 3
Suture of wound in the duodenum 7
Wedge resection of the small intestine 15
Wedge resection of the large intestine 6
Suture of wound in combination with suture of the gastric wound 5
Totally 187
All the stab-incised wounds of the small and colon intestine were sutured by double-row sutures. The proximal colostomy was applied in rare cases. It would be especially interested to stop at the tactics in the damage only of the posterior wall of the ascending and descending colon. This occurred more frequently in the stab-incised wounds of the lumbar area. We observed 5 similar cases. To reveal such injury is very difficult. As a rule, during performance of the primary surgical debridement the direction of the wound to the end cannot be determined. At laparoscopy it may be seen only retroperitoneal hematoma of any severity degree at the area of lateral canal. To suggest injury may be only in rare cases of excretion of gases and feces. The vulnerography may be only one method of diagnosis, but only at the wide wound hole in the intestinal wall, as well as if the hole is not covered by fecal stones. The contrast substance is introduced into the wound and roentgenography is performed. At injury of the intestinal wall we see contrast in the
lumen of the intestine. However, the diagnostic error occurs most of frequently. During development of the clinical picture of the lumbar phlegmon the drainage of all suppurative leaks is performed, the wound is treated by open way and the formed fecal fistula is gradually closed by conservative method. The proximal colostomy with complete exclusion of the damaged site from passage was applied on the elderly weak patients with diabetes mellitus. In table 2 there are presented types of the performed operative interventions on the small and large intestine in isolated and associated injuries.
In the early postoperative period all patients were performed diagnostic monitoring to reveal intraperitoneal complications: USI-monitoring of the peritoneal cavity, exudates investigation from the peritoneal cavity for contents of ammonia, amylase on the 3-5 day for purpose of early diagnosis of the development of intestinal sutures failed. During increase in these characteristics we can suggest about occurrence of insufficiency, and accordingly choose the following management ofthe patients. The postoperative complications were fixed in 66 (35 %) patients. The failed intestinal sutures were observed in 12 patients, of them in 9 — insufficiency of the suture on the intestinal wall and in 3 — failure of intestinal anastomosis. Of them in 26 patients (including additionally patients with failure of the intestinal sutures, because they all had suppuration) there was found suppuration of the postoperative wound, in 7 patients — early commissural ileus (resolved by conservative method), in 6 cases — abscess of the peritoneal cavity, in 36 cases the postoperative pneumonia developed. The suture failure was the most critical group of complications: the intestinal suture failure — in 4 patients, anastomosis suture failure — in 3 patients. In the patients with suggestion of the intraperitoneal complication the diagnostic fibrolaparoscopy was performed through left laparoport. Taking into account mini-invasive methods of investigations (fibrolaparoscopy, clinical and
biochemical parameters of blood and exudates and others) the patients with early commissural ileus, abdominal cavity abscess as well as failure of sutures at early time were performed relaparotomy, sanitation and drainage of the peritoneal cavity. At the failure of intestinal anastomosis the resection of the part of intestine was performed with application of the repeated anastomosis or enterostomy. The general lethality accounted for 26.8 %. Of them the most part ofpatients dead on the first day due to severe associated injury, traumatic shock. The complications of the injuries of small and large intestine served as a cause of the lethal outcome in 6 (3.2 %) patients. The death induced by continuing peritonitis and polyorgan insufficiency. The analysis of the results of complications and lethal outcomes in the control group showed two types of tactic mistakes. In the majority of cases the volume of operative appliance was "risen", and this resulted in significant worsening of the severe health state of the patients. In the other cases the volume of operation was "lowered", that resulted, first of all, in increase in the number of suture insufficiency in the sutures of defects and development of peritonitis.
Thus, the primary suture or anastomosing may be performed practically at any wounds of the small and large intestine according to special rules and providing of the adequate blood supplying. The adequate sanitation of the abdominal cavity, intraoperative antibacterial therapy by preparations of the wide spectrum of effect and intestinal decompression should be obligatory component of the operative appliance at the intestinal injuries.
During intraoperative and early postoperative periods these patients have to be performed investigations of the exudates of the peritoneal cavity with purpose of possibility of early diagnosis of the suture failure or continuing inflammatory process in the peritoneal cavity. Besides, in the patients of risk group it is necessary to perform diagnostic fibrolaparoscopy on the 4-5 day after operation.
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