CC BY
30
PREVENTION AND TREATMENT OF INTRAABDOMINAL HYPERTENSION IN PATIENTS WITH PERITONITIS Achilov M.T.1, Shonazarov I.Sh.2, Ahmedov G.K.3, Jabbarov Z.I.4, Tukhtaev J.K.5, Saydullaev Z.Yа.6 Email: [email protected]
1Achilov Mirzakarim Temirovich - Candidate of Medical Sciences, Associate Professor; 2Shonazarov Iskandar Shonazarovich - Candidate of Medical Sciences, Assistant, DEPARTMENT OF SURGERY, ENDOSCOPY AND ANESTHESIOLOGY-REANIMATOLOGY, FACULTY OF POSTGRADUATE EDUCATION; 3Ahmedov Gayrat Keldibaevich - Assistant, DEPARTMENT OF SURGICAL DISEASES, PEDIATRIC FACULTY, SAMARKAND STATE MEDICAL INSTITUTE; 4Jabbarov Zokir Ismailovich - Resident Doctor, II SURGICAL DEPARTMENT, SAMARKAND BRANCH REPUBLICAN SCIENTIFIC CENTER FOR EMERGENCY MEDICAL AID; 5Tukhtaev Jamshed Kodirkul ugli - Assistant, DEPARTMENT OF SURGICAL DISEASES OF THE PEDIATRIC FACULTY; 6Saydullayev Zayniddin Yashibayevich - Assistant, DEPARTMENT OF GENERAL SURGERY, SAMARKAND STATE MEDICAL INSTITUTE, SAMARKAND, REPUBLIC OF UZBEKISTAN
Abstract: the article deals with the treatment of patients with acute generalized peritonitis (AGP), which is one of the most important problems ofmodern abdominal surgery. At the time of admission in critical condition and in need of resuscitation, a significant increase in intraabdominal pressure is detected in more than 50% of cases, clinical signs of abdominal compartment syndrome are detected in about 4% of cases. Prevention of increased IAP in patients with peritonitis should be based not on the fact of finding an increase in intravesical pressure after surgery, but on clinical and intraoperative data. The combination of intubation of the gastrointestinal tract with laparostomy is an effective way to prevent an increase in IAP. Keywords: abdominal compartment syndrome( ACS), elevated intra-abdominal pressure syndrome (IAP), acute advanced peritonitis (ORP), laparostomy.
ПРОФИЛАКТИКА И ЛЕЧЕНИЕ ИНТРААБДОМИНАЛЬНОЙ
ГИПЕРТЕНЗИИ У БОЛЬНЫХ ПЕРИТОНИТОМ Ачилов М.Т.1, Шоназаров И.Ш.2, Ахмедов Г.К.3, Жаббаров З.И.4, Тухтаев Ж.К.5, Сайдуллаев З.Я.6
1Ачилов Мирзакарим Темирович - кандидат медицинских наук, доцент; 2Шоназаров Искандар Шоназарович - кандидат медицинских наук, ассистент, кафедра хирургии, эндоскопии и анестезиологии-реаниматологии, факультет последипломного образования; 3Ахмедов Гайрат Келдибаевич - ассистент, кафедра хирургических болезней, педиатрический факультет, Самаркандский государственный медицинский институт; 4Жаббаров Зокир Исмаилович - врач-ординатор, II хирургическое отделение, Самаркандский филиал Республиканский научный центр экстренной медицинской помощи; 5Тухтаев Жамшед Кодиркул угли - ассистент, кафедра хирургических болезней, педиатрический факультет; 6Сайдуллаев Зайниддин Яхшибаевич - ассистент, кафедра общей хирургии, Самаркандский государственный медицинский институт, г. Самарканд, Республика Узбекистан
Аннотация: в статье рассматривается лечение пациентов с острым генерализованным перитонитом (ОГП), который является одной из важнейших проблем современной абдоминальной хирургии. На момент поступления в критическом состоянии и при необходимости реанимации значительное повышение внутрибрюшного давления выявляется более чем в 50% случаев, клинические признаки синдрома брюшной полости выявляются примерно в 4% случаев. Профилактика повышенного ВБД у пациентов с перитонитом должна основываться не на факте обнаружения повышения внутрипузырного давления после операции, а на клинических и интраоперационных данных. Сочетание интубации желудочно-кишечного тракта с лапаростомией - эффективный способ предотвращения увеличения ВБД. Ключевые слова: синдром абдоминального компартмента, синдром повышенного внутрибрюшного давления, острый распространенный перитонит, лапаростомия.
UDC 617.55-001-31.
Abdominal compartment syndrome (ACS) is understood as an increase in intraabdominal pressure, which leads to circulatory pathology, ischemia of organs and tissues with a violation of their functions and the development of multiple organ failure. The term "abdominal compartment syndrome" was proposed by Fiestsam in 1989 when he observed elevated intra-abdominal pressure syndrome (IAPD), which developed in 4 patients after laparotomy.
The causes leading to the occurrence of IAP are: the presence of blood and fluid in the abdominal cavity; intestinal paresis and edema of internal organs during inflammatory processes; resuscitation measures using massive infusions and transfusions; tissue overstrain when closing an abdominal wound; early postoperative intestinal obstruction; severe forms of hemodilution. IBD leads to dysfunction of the abdominal organs due to a decrease in their perfusion, which contributes to the occurrence of cardiovascular and respiratory failure, damage to the kidneys, central nervous system, etc., leading to an increase in the number of postoperative complications and mortality. In ACS, an increase in IAP causes a violation of microcirculation in the abdominal organs. Deep disorders of microcirculation (sludge syndrome) and increased permeability of the vascular wall play an important role in the pathogenesis [1, 4, 6].
According to a number of authors, of all patients admitted to the surgical hospital, about 15-20% of patients are admitted with acute abdominal surgical diseases and signs of local or diffuse peritonitis. Among surgical pathologies, most often the development of peritonitis leads to perforation of the hollow organ: stomach and duodenum about 28%, complicated appendicitis-more than 25%, lesions of the colon-20-22%, small intestine-about 15%. In elderly patients, the risk of developing common peritonitis and sepsis from gangrenous complicated appendicitis, perforation of the diverticula of the colon, increases several times more than younger patients [2, 5, 8, 10].
The simultaneous development of severe complications such as sepsis, septic shock and multiple organ failure increases the mortality rate to 70% or more. Analysis of mortality in peritonitis shows that in the stage of bacterial-toxic shock and multiple organ failure, it reaches 80-90 % [3, 7, 11].
Patients develop a very complex and interrelated complex of pathological syndromes in the form of respiratory and cardiovascular insufficiency, functional disorders of the kidneys and liver, disorders of metabolic homeostasis, up to metabolic encephalopathy, which require complex intensive therapy. It should be multicomponent, including infusion and antibacterial therapy, active detoxification methods, adequate nutritional support, correction of acid-base and water-electrolyte balance, maintenance of adequate gas exchange and functions of vital organs (heart, lungs, brain, kidneys, liver) [9, 12, 13].
The aim of the study is to evaluate and improve the results in patients with peritonitis by using surgical methods aimed at preventing ACS in complex treatment.
Material and methods. In the surgical departments of the Samarkand branch of the Republican Scientific Center of Emergency Medical Care, Samarkand, 112 patients were operated on for common peritonitis from 2016 to 2020. Men were 67, women-45; the age of patients varied from 17 to 68 years (average age -41.1 ± 1.65 years). Etiological factors of common peritonitis were: perforative ulcer-22, acute cholecystitis-14, acute appendicitis-39 pancreatic necrosis-17, damage to the duodenum-3, small and colon-6, complicated colon cancer-7, perforation of the colon-4.
Patients with peritonitis, depending on the method of completion of the operation, were divided into 3 groups: 1 and 2-control groups and 3-main group. The 1st control group included 37 (33%) patients in whom the prevention of ACS was not carried out (the abdominal cavity was sutured tightly after eliminating the causes of diseases).
The 2nd control group included 35 (31.3%) patients in whom the prevention of ACS was carried out by intubation of the gastrointestinal tract (GIT) by one of the methods. For this purpose, the most commonly used nasogastrointestinal intubation of the gastrointestinal tract, intubation of the gastrointestinal tract through the enterostome by Meidl.
The 3rd (main) group included 40 (35.7%) patients in whom the prevention of ACS was carried out by intubation of the gastrointestinal tract, using the above methods in combination with the formation of a laparostomy, or by using non-prolonged methods of closing the abdominal cavity. When forming laparostomy were used two approaches. When the large omentum was preserved, the laparostoma was formed by suturing it to the aponeurosis along the entire perimeter of the laparotomy wound. In the absence of a large omentum, the laparostomy was formed using a synthetic implant, which was sutured to the edges of the aponeurosis. This option of closing the abdominal wall in most patients in the future required the removal of the implant, since the latter was located on the loops of the intestine.
IAP measurement was performed using standard trans-bubble methods during surgery and several times in the postoperative period. IAP was evaluated according to the J. Burch classification.
Laparostomy was performed using non-adhesive plastic to cover the open loops of the intestine. Laparostomy was applied by the following method. A sterile plastic bag was placed over the loops of the intestine, if necessary, the edges of the wound through the skin and fascia were reduced by suturing, gauze napkins were applied over the film. The dressing was changed every 24 hours or more often as needed. After 24-36 hours, a planned sanitation of the abdominal cavity was carried out, during which the viability of the intestine in the area of surgical intervention and the degree of subsiding of the acute inflammatory process in the abdominal cavity (light exudate, single fibrin deposits, reduction of edema of the intestinal wall, shiny serous cover) were subjectively evaluated. Severe surgical diseases of the abdominal cavity, acute pancreatitis with the development of gland necrosis, peritonitis, complicated gastric ulcer and others are often complicated by acute intestinal obstruction with an increase in IAP of varying degrees.
Results and discussion. Of the patients with peritonitis included in the 1st control group, 16 (43.2%) patients were monitored for IAP dynamics during treatment. 12 of them had intra-abdominal hypertension of varying severity. An increase in IAP was noted both before and during the first day after surgery. With a positive dynamics of the course of the disease, it decreased by the third day. On the contrary, with negative dynamics of the course of the disease, intra-abdominal hypertension persisted, which served, along with clinical manifestations, as an indication for relaparotomy aimed at eliminating unresolved or newly developed complications. Taking into account the obtained data, the results of treatment of patients with peritonitis were considered from the point of view of using techniques aimed at preventing an increase in IAP. That in patients of group 3 in the stage of enteral and multiple organ failure, they significantly differed in a positive direction from the results of treatment of patients of the 1st and 2nd control groups, which differed in the methods of completing the operation. In the reactive stage, when there is no intestinal dilatation, the
tactics of preventive intubation due to its traumatic nature can lead to an increase in the number of postoperative complications.
Evaluation of the results of treatment in patients of the main group showed that during the formation of laparostomy during 1 operation, 7 patients died, 5 died during 1 relaparotomy, and 1 died during 2 relaparotomy.
Consequently, earlier formation of laparostoma contributed to improved results in patients with advanced forms of peritonitis. Among the factors influencing the outcome of the intervention, there is a link between the need to eliminate the cause of acute surgical disease in the abdominal cavity and the methods of completing the operation, which should be aimed at preventing the development of ACS. Thus, in peritonitis in patients of group 1, where patients with the reactive stage prevailed, in the case of using methods of prevention of ACS, the mortality rate was 21 %. In the 2nd control group, where patients with the 2nd and 3rd stages of peritonitis prevailed, and the prevention of ACS was carried out only by intubation of the gastrointestinal tract, the mortality rate reached 40 %. In the 3rd (main) group, where the composition of patients was close to the composition of the 2nd group, the full range of measures for the prevention of ACS allowed to reduce the mortality rate to 24.5 %.
In this regard, intubation of the gastrointestinal tract itself does not facilitate suturing of the abdominal cavity at the final stage of the operation, and therefore in an isolated form can not be a way to prevent an increase in IAP after surgery. The combination of intubation of the gastrointestinal tract with laparostomy allows you to get the desired effect on the prevention of increased IAP after surgery. Moreover, indications for laparostomy should be of a preventive nature, based on intraoperative data, and not based on confirmation by figures of IAP measured after surgery.
Thus, an increase in intra-abdominal pressure is a component of pathogenesis in patients with peritonitis. Prevention of increased IAP in patients with peritonitis should be based not on the fact of finding an increase in intravesical pressure after surgery, but on clinical and intraoperative data. The combination of intubation of the gastrointestinal tract with laparostomy is an effective way to prevent an increase in IAP.
CONCLUSIONS: 1. Common peritonitis is a frequent complication in emergency surgery, accompanied by an increase in IAP, which dramatically worsens the postoperative course and increases the risk of multiple organ failure and death.
2. The use in the postoperative period of such methods as nasointestinal intubation, peridural analgesia, as well as antibacterial drugs in accordance with the sensitivity of the microflora in patients with advanced peritonitis allowed to reduce postoperative mortality from 26.9 to 6.7%. At the same time, the stay of patients in the hospital was reduced by 4.5 days.
3. Prevention of increased IAP in patients with peritonitis should be based not on the fact of an increase in intravesical pressure after surgery, but on clinical and intraoperative data. The combination of intubation of the gastrointestinal tract with laparostomy is an effective way to prevent an increase in IAP.
References / Список литературы
1. Aitken E.L., Gough V., Jones A., MacDonald A. Observational study of intra-abdominal pressure monitoring in acute pancreatitis. 2014. Volume 155. № 5. P. 910-918.
2. Babajanov A.S. Achilov M.T., Akhmedov G.K., Tukhtaev J.K., Saidullaev Z.Ya. Improvement of methods of hernioabdominoplasty with simultaneous surgical diseases // " Science and world " International Scientific Journal, Russia, Volgograd. № 4 (80), 2020. Vol. 2. Page 65-67.
3. Babajanov A.S., Ahmedov G.K., Obidov Sh.X. Ways of optimization of surgical treatment of postoperative ventral hernias in patients with obesity of the III and IV degree. // "Science and world" International Scientific Journal, Russia. Volgograd. № 7 (23), 2015. Pp. 137-139.
4. Beloborodov V.A., Beloborodov A.A., Berdnikov D.S. Abdominal compartment syndrome: diagnosis, clinical course, treatment and prevention. // Sibir. med. obozre, 2009; 4 (58): 111-114.
5. Boon B., Zureikat A., Hughes S.J., Moser A.J. et al. Abdominal compartment syndrome -an early lethal complication of acute pancreatitis // Am. Surg. 2013, Vol. 79. № 6. P. 601-607.
6. De Waele J.J., Kimball E., Malbrain M., Nesbitt I. et al. Decompressive laparotomy in abdominal compartment syndrome // Br. J. Surg., 2016. Vol. 103. P. 709-715.
7. Kurbaniyazov Z.B. Babajanov A.S. Sayinaev F.K., Ahmedov G.K. / Abdominoplasty in the treatment of ventral hernias. // "Problems of biology and medicine" 2012. № 4. Pp. 39-42.
8. Mustafakulov I.B., Karabaev Kh.K., Mizamov F.O., Elmurodov G.K., Umedov Kh.A. Severe combined bump injury. Journal of hepatogastroenterology research, 2020. Vol. 1. Issue 1. Pp. 63-68.
9. Mustafakulov I.B., Mizamov F.O., Elmurodov G.K., Umedov Kh.A. Journal of critical reviews ISSN- 2394-5125, Vol. 2214-2221. Issue 11, 2020/ Severe combined abdominal trauma.
10. Ovchinnikov V.A., Sokolov V.A. Abdominal compartment syndrome. // Lie. technol. vmed., 2013; (1): 122-129.
11. Zdzitovetsky D.A., Borisov R.N. Prevention and treatment of intra-abdominal hypertension in patients with widespread purulent peritonitis.// Med. and educated. in Siberia, 2012; (1): 37-39.
12. Shonazarov I. et al. DIAGNOSIS AND TREATMENT OF ADHESIVE SMALL BOWEL OBSTRUCTION WITH USING LAPAROSCOPIC METHOD // European Journal of Molecular & Clinical Medicine, 2020. T. 7. № 3. P. 3192-3198.
13. Shamsiev A. et al. The causes of postoperative intra-abdominal abscesses in children and ways of their prevention // Medical Sciences, 2020. P. 5.
14. Shonazarov I. et al. ANALYSIS OF THE RESULTS OF SURGICAL TACTICS AND TREATMENT IN PATIENTS WITH ACUTE NECROTIC PANCREATITIS // European Journal of Molecular & Clinical Medicine, 2020. T. 7. № 3. P. 3130-3135.
15.Abduvokhidovich D.D., Nuralievich S.R., Shavkatovna Y.S. Prediction of postoperative intrabrusive purulent complications with appendicular peritonitis in children // Voprosy nauki i obrazovaniya,, 2019. № 20 (67).
16. Bahodirovich A.B. et al. Immunological feature of the body in children with diffused appendicular peritonitis // Voprosy nauki i obrazovaniya, 2019. № 2 (45).
17. Djalolov D.A. et al. Features of microflora in the etiological structure of diffuse appendicular peritonitis // Voprosy nauki i obrazovaniya,2018. T. 8. № 2. P. 116.
