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Baymakov Sayfiddin Risbaevich, PhD., of the faculty and hospital surgery.
Tashkent Medical Academy, E-mail: [email protected] Adilkhodjaev Askar Anvarovish, Tashkent Medical Academy, MD of the Faculty and Hospital Surgery E-mail: [email protected] Yunusov Seydamet Shevket-oglu, postgraduate student, the faculty of Surgery Tashkent Medical Academy, E-mail: [email protected] Elmuratov Iskandar Urazovich, postgraduate student, the faculty of Surgery.
Tashkent Medical Academy
THE ROLE AND PLACE OF ENTERAL MANAGMENT IN THE COMPLEX OF TREATMENT OF ACUTE INTESTINAL OBSTRUCTION NON-TOMOROUS ETIOLOGY
Abstract: We analyzed the results of treatment of 176 patients aged 20 to 78 based on the basis of 2nd and 3rd clinics of the Tashkent Medical Academy for the period 2010-2017, on the occasion of acute intestinal obstruction of non-tumor genesis. The most common was the adhesive intestinal obstruction, that was 57.9% in cases. All patients had intra- and postoperative decompression of the intestine. The standard treatment complex was amended with intestinal lavage, enterosorbtion using sorbent - zerotox and early enteral nutrition. The level of decrease of enteral intoxication was assessed by improving the general condition of the patient, determining the level of leukocyte index of intoxication, medium-weight molecules, urea and according to electroenterography, after which was started enteral feeding with a balanced nutrient mixture. Against the background of the complex treatment, spent bed-days amounted to 9 ± 1, postoperative complications 7.4%, without mortality.
Keywords: acute intestinal obstruction, enteral intoxication, syndrome of intestinal insufficiency, enterosorbtion, enteral feeding.
Acute intestinal obstruction (OIO) is one of the most complex problems in emergency surgery of the abdominal cavity [1, 3, 4]. The number ofpatients suffering from violations ofintestinal permeability of non-tumorous genesis increases yearly, especially among the elderly and senile. Against the background of the decline in manifested forms of the disease (curvature, nodulation, invagination, etc.), the incidence of adhesive obstruction significantly increased, which entails an increase in the late treatment of patients in medical institutions, increases the number
of diagnostic errors at all stages of providing care to this category of patients [2 , 8, 12].
Syndrome of intestinal insufficiency (SII) is an integral part of the pathogenesis of AIO [1, 5, 14]. SII is a complex symptoms, accompanied by a violation of all bowel functions, resulting in the latter becoming the main source of intoxication and development of multiple organ failure [7, 10, 15]. SII is the main cause of endogenous intoxication and is still one of the most difficult problems in terms of diagnosis and treatment [4, 6, 9].
Paresis of the intestine arises from the dysfunction of the autonomic nervous system, with an increase in the flow ofimpulses to the muscular shell of the intestinal wall along the sympathetic nerves and the suppression of parasympathetic innervation, which is caused by stimulation of the introns of internal organs and damage to the central nervous system due to intoxication [2, 8, 11]. According to a number of authors, intestinal and intra-abdominal pressure increase is observed, which causes metabolic disorders, absorption of intestinal contents, and translocation of bacterial flora, leading to intestinal insufficiency, which is the main cause of death ofpatients [5, 13].
Treatment ofAIO should include the elimination of the source of obstruction and measures to eliminate its aftermath [1, 9].
The purpose of our study was to improve methods of correcting SII in acute intestinal obstruction of non-tumor genesis by carrying out a complex of enteric measures.
Materials and methods
We conducted an analysis of the examination and treatment of 176 patients with acute mechanical intestinal obstruction of the non-tomorous genesis in the surgical department of the II and III clinics of the Tashkent Medical Academy in the period 2010-2017 at the age of 20 to 78 years. All patients were divided into 2 groups. The control group was 81 (46.1%) patients, and the main group was 95 (53.9%). Among them, there were 109 men (61.9%), and women 67 (38.1%).
Among all the examined patients, the most common cause of AIO was adhesive obstruction, which was observed in 102 (57.9%) cases. All patients with adhesive intestinal obstruction were 5 and 6, respectively, Clin-ico-morphological classification of peritoneal fibrosis according to P.N. Napalkov (1977). It should also be noted that the adhesive process in 91 cases was the cause of small intestinal obstruction and only 11 cases of colonic obstruction. In 6 (3.4%) patients, intussusception of the small intestine into a thick intestinal cavity was the cause of AIO, and thin-intestinal invagination in 2 (1.2%) patients. Strangulation intestinal obstruction was diagnosed in 49 (27.8%) patients (39 patients with gut rot, 10 with abdominal hernias). Obturation intestinal obstruction was in 17 (9.7%) patients (foreign bodies - 4 patients, gallstones and bezoars - 13 cases). In both groups, in the control group 13 (16%), and in the main 9 (9.5%) patients, peritonitis was performed by perito-
neal dialysis according by method of Academician Sh.I. Karimov (1991).
In the control group, postoperative management of patients included antibiotic therapy, correction of ho-meostatic dysfunction, parenteral nutrition, and decompression of the gastrointestinal tract with a nasogastric tube (due to the impossibility of establishing a nasoen-teral probe for technical reasons and a self -productive removal of the probe after the operation, a nasogastric tube was installed).
The main group was divided into 2 subgroups. The first subgroup included 58 patients who underwent a naso-intestinal probe intraoperatively. The complex of treatment was supplemented with decompression of the intestine (DI), bowel lavage (BL), enterosorption. The second subgroup consisted of 37 patients who also had a nasoenteric probe and performed DI, BL, enterosorption and supplemented with enteric probe feeding (EPF).
To conduct BL with enterosorption in the first subgroup of group 2 from the first day of the postoperative period, 1500 ml of saline solution in a complex with enterosorbent (zerotox (domestic production)) was injected into the intestine. This manipulation was performed by patients 3-4 times a day. In the second subgroup, BL was performed with enterosorbent (zerotox) and supplemented with EPF with a balanced nutrient mixture - Perative. EPF was performed in stages, intravenous drip introduced nutrient mixture, after restoration of bowel function.
The effectiveness of the measures performed was assessed depending on the patient's general condition, according to the laboratory test (leukocyte intoxication index (LII) was determined by the Calph-Caliph method (1941), the concentration of medium weight molecules (MWM) toxins according to the method of N.I. Gabrielian and (1986), urea concentration), the appearance of peristaltic waves (determined with the help of electroenceology by EGS-4m apparatus (according to D. Sobakin (1995)).
Results of the study: In patients of the control group, the study of the level of leukocyte intoxication index, medium-weight molecules and urea revealed the first degree of endotoxemia in 18 (22.2%), II degree 45 (55.6%) and grade III - in 18 (22.2% %) of patients. In patients with I degree, peristaltic waves appeared already on day 3, with grade II on days 4-5, and from III to only
6-7 days after the operation, peristaltic waves close to normal on day 5.
The results of the study show that when using the nasogastric tube there is no possibility of adequate decompression of the intestine (there is no possibility of aspiration of the contents of the intestine, passive outflow is difficult due to a persistent intestinal paresis, active aspiration is not possible due to suction of the gastric mucosa to the probe). All this aggravated the patient's condition due to the preservation of endotoxemia for a long time, the absence of intestinal peristalsis and the intestinal absorption function, which made it impossible to start feeding the patient. Continuing intoxication played an important role in the development of complications in 19 (23.4%), and lethality in 7 (8.6%) cases.
In the main group, conducted studies at an early postoperative period revealed high indices of LII, MWM and urea levels, as well as a persistent disturbance of the digestive and suction function of the intestine. With such indicators, the supply of nutrient components was not possible, and only measures aimed at reducing the level of intoxication and compensating for hypovolemia continued. The level of dehydration was determined by the breakdown on the hydrophilicity of the tissues by P.I. Shelestyuk (1978). In the first subgroup, patients with the first degree of endotoxemia were 14 (24.1%), with grade II 32 (55.2%) and grade III 12 (20.7%). And in the second subgroup I degree was noted in 9 (24.3%), II degree 20 (54.1%) and III degree 8 (21.6%) patients.
At 2-3 days, the stabilization of laboratory test results and the appearance ofperistaltic waves were noted. Parenteral nutrition was added to the carried out complex of enteral measures in the first subgroup, and in the second group, in addition to the parenteral nutrition of EZP. In the second subgroup of patients, compensatory measures were performed parenterally at the first stage, and subsequently parenterally-efferent. In this group of patients, the water-electrolyte balance was compensated for 3-4 days, and on the 4th-5th day the protein balance. The appearance of active peristaltic waves was noted
on average 2-3 days after the operation, and peristaltic waves approximated to the norm on the 4th day.
When comparing the obtained data of all groups of patients, it was revealed that in patients with 2 subgroups in the ratio of patients to the control group and 1 subgroup, an earlier decrease in intoxication was observed, which was followed by evidence of improvement in all clinical and biochemical indices, as well as recovery of digestive and absorption functions of the intestine. In this group of patients, the positive balance of all the investigated parameters was observed on the 5th-6th day in the postoperative period, which was facilitated, after normalization of the digestive and absorption functions of the intestine, by the addition of enteral administration of the balanced nutritional formula Perative, which included proteins, fats and carbohydrates.
Postoperative complications in the control group were 23.4% (19 cases), and lethality 8.6% (7 cases). In patients with 1 subgroup of the main group, complications were noted in 15.5% (9 cases), lethal outcome was 1.7% (1 case), and in 2 subgroup complications were observed in 13.5% (5 cases) and deaths did not have.
In the control group, the spent bed days averaged 17 ± 2, in the first subgroup of the main group 12 ± 1 and in the second subgroup 9 ± 1. Supplementation of complex treatment with enteric treatment measures contributes to a significant reduction in the number ofpostopera-tive complications (from 23.4% to 13.5%) and mortality (from 8.6% to 1.7%), reduction of bed-days to 1.6 times.
Conclusions
1. Conducting complex enteral measures in the early postoperative period (adequate bowel decompression, intestinal lavage, enterosorption and enteral feeding) in patients with initially high endotoxemia contributes to earlier stabilization of clinical and biochemical parameters, restoration of intestinal peristalsis and digestive and absorption function of the intestine .
2. Correct implementation of enteral measures significantly reduces postoperative complications, lethality
1.
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