CC BY
17
II. ХИРУРГИЯ
мрнти 76.29.29 ADHESIVE DISEASE
(REVIEW)
ABOUT THE АUTHORS
I.R. Fakhradiev - PhD-doctoral, National Medical University named after S.D. Asfendiyarov ildariko@mail.ru
D.T. Zhymataev - PhD-doctoral, O.S. Asfendiyarov
A.N. Baymakhanov - Ph.D. prof. AO National Medical University named after S.D. Asfendiyarov
I.A. Almabayev- MD. prof. AO National Medical University named after S.D. Asfendiyarov
A.D. Raimkhanov - assistant of the National Medical University named after S.D. Asfendiyarov
Keywords
Adhesive disease, laparoscopy, antiadhesion barriers, bioelectric stimulation.
Fakhradiev I.R., Zhumataev D.T., Baymakhanov A.N., Almabayev I.A., Raimkhanov A.D.
National Medical University named after S.D. Asfendiyarov, Almaty, Kazakhstan
Abstract
Adhesive disease of the abdominal cavity is one of the most common complications after abdominal and small pelvic surgery. This complication, in turn, leads to infertility, chronic pain in the abdomen and intestinal obstruction. Laparoscopy has become a "Golden Standard" for surgery of surgical abdominal organs. Laparoscopic surgery has a number of advantages over open surgery, including rapid recovery, reduction of hospitalization days, post-operative pain reduction, as well as cosmetic priorities. Further improvement of this branch of technology, the development of modern techniques and the development of special laparoscopic skills - expanded the spectrum of operations on the abdomen, such as the construction of intra-corporal stitches and anastomosis. Postoperative adhesions are directly related to abbot subsection of the abomasum, and are the major cause of intestinal obstruction. At present, anti-drowning barriers are widely propagated in the prevention of adhesions. Studies show that adherence to adhesion does not adversely affect intestinal anastomosis. However, anastomoses are not recorded correctly in the abdomen, regardless of the presence of anti-deposition barriers. The review provides information on the pathophysiology and prevention of abdominal strokes.
Жабыспа ауруы (Эдеби шолу)
АВТОРЛАР ТУРАЛЫ
И.Р. Фахрадиев - Р110-докторант, С.Ж. Асфендияров атындаFы Казак, Улттык медицина университет!. ildariko@mail.ru
Д.Т. Жуматаев - Р110-докторант, С.Ж. Асфендияров атындаFы Казак Улттык медицина университет!.
А.Н. Баймаханов - к.м.н. проф. С.Ж. Асфендияров атындаFы Казак Улттык медицина университет!.
Ы.А. Алмабаев - д.м.н. проф. С.Ж. Асфендияров атындаFы Казак Улттык медицина университет!.
А.Д. Раимханов - ассистент С.Ж. Асфендияров атындаFы Казак Улттык медицина университет!.
Туйш сездер
перитонеальдi жасбыспалар, лапароскопия, ауру ce3iMi, антиадгезионды барьерлер, биоэлектрлiк стимуляция.
Фахрадиев И.Р., Жуматаев Д.Т., Баймаханов А.Н., Алмабаев Ы.А., Раимханов А.Д.
С.Ж. Асфендияров атында?ы Казак, Улттык, медицина университету Алматы, Казахстан
Ацдатпа
1ш куысынын жабыспа ауруы - ш пен кш жамбас куысына жасалтан операциялардан кейн ен жи кездесет аскынулардьщ б'р болып табылады. Бул аскыну ез кезепнде бедеулкке, ¡штеп созылмалы ауру сез'шШе жэне шек етiмсiздiriне алып келе^.Лапароскопия бYriнri таща ш куысы мYшеперiнiн хирургиялык ауруларына операция жасауда «Алтын стандартка» айналды. Лапароскопиялык хирургия «ашык» хирургиямен салыстырганда бiрнеше басымдыкка ие, онын '¡ш'тде тез сауыгу, госпитали-язация кYндерiнiц кыскаруы, операциядан кейШп ауру сезiмiнiн азаюы, сонымен катар косметикалык басымдылыктар. Хирургияныц осы саласынын технология жагынан одан эр '! жет.1лу^ заманауи эдютердщ жасалуы жэне арнайы лапароскопиялык дагдылардын икр^у! - ш куысына жасалатын операциялардын спектрiн одан эр/' кенейт, мысалы интракорпорапьдi лпстер мен аностомоздар салу жэне т.б. Операциядан кейШп жабыспалар iшастардын абберантты жазылуымен ткелей байланысты жэне шек етiмсiздiriне алып келелн непзп себеп болып табылады. кдз.рп уакытта жабыспалардын ал-дын алуда антиадгезионды барьерлер ке^нен насихатталуда. Зерттеу нэтижеперi керсетШ отыргандай, адгезия туз'ту'1н тежеу iшек анастомоздарынын жазылуына кер'1 эсерiн тиriзбейдi. Ал анастомоздардын дурыс жазылмауы ш куысында антиадтзионды барьерлердiн болуына карамастан жабыспалардын тузлуне алып келед '1. Усынылып отырган шолуда ш куысы мYшелерi жабыспаларынын патофизиоло-гиясы жэне алдын алу туралы тындеректер кел^рл^.
Спаечная болезнь (Обзор литературы)
ОБ АВТОРАХ
Фахрадиев И.Р., Жуматаев Д.Т., Баймаханов А.Н., Алмабаев Ы.А., Раимханов А.Д.
АО Национальный медицинский университет им.С.Д. Асфендиярова, Алматы, Казахстан
Аннотация
Спаечная болезнь брюшной полости является одним из наиболее распространенных осложнений после операций на брюшной полости и малом тазу. Это осложнение, в свою очередь, приводит к бесплодию, хроническим болям в животе и кишечной непроходимости. Лапароскопия стала «золотым стандартом» для хирургии органов брюшной полости. Лапароскопическая хирургия имеет ряд преимуществ перед открытой операцией, включая быстрое выздоровление, сокращение дней госпитализации, уменьшение послеоперационной боли, а также косметические приоритеты. Дальнейшее совершенствование этой отрасли техники, разработка современных методик и развитие специальных лапароскопических навыков - расширили спектр операций на животе, таких как построение внутрикорпоративных швов и анастомозов. Послеоперационные спайки являются основной причиной кишечной непроходимости. В настоящее время противоспаечные барьеры широко распространены в профилактике спаек. Исследования показывают, что приверженность адгезии не оказывает неблагоприятного влияния на кишечный анастомоз. В обзоре представлена информация о патофизиологии и профилактике спаечного процесса брюшной полости на современном этапе.
И.Р. Фахрадиев - РЬО-докторант, АО Национальный медицинский университет им. С.Д. Асфендиярова ildariko@mail.ru
Д.Т. Ж^матаев - Р110-докторант, АО Национальный медицинский университет им. С.Д. Асфендиярова
А.Н. Баймаханов - к.м.н. проф. АО Национальный медицинский университет им. С.Д. Асфендиярова
Ы.А. Алмабаев - д.м.н. проф. АО Национальный медицинский университет им. С.Д. Асфендиярова
А.Д. Раимханов - ассистент АО Национальный медицинский университет им. С.Д. Асфендиярова
Ключевые слова
Спаечная болезнь, лапароскопия, противоспаечные барьеры, биоэлектрическая стимуляция.
Introduction
The abdominal cavity is the collagen «bubbles» formed as a result of the fibrin deposition between the serum of the inner organs and the parasitic intestine. Peritoneal adhesions is one of the most common complications encountered after abdominal surgery and is a serious problem for clinicians and competitors. The appearance of adhesions occurs in 55-100% after surgery, according to literature (1).
From a clinical point of view, these peritoneal adhesions are the cause of up to 30% of mechanical intestinal obstruction (2). Currently, peritoneal adhesions make 1% of all hospitalization. Fibrin excretion, activation of the fibrinolytic system, increased cytokine stimulation and increased proliferation of fibroblasts are of fundamental importance in the formation of adhesions. Therefore, any pharmacological and technological recommendations aimed at controlling or controlling the formation of peritoneal adhesions should take into account modern pathogenesis and pathophysiology of adhesion formation (3).
It is well-known that the most effective way to prevent abdominal cramping is to focus on the advanced surgical technique, which is to minimize the injury of the teeth by means of minimally invasive methods, to provide timely hemostasis, to remove the most comfortable threads and prosthesis, tissue infections and tissue removal. Some surgeons
are currently experimenting with the ingestion of various medicines (fibrinolithic, anticoagulants, antibiotics, anti-inflammatory drugs, lipid compounds, silicone, dextran, carboxymethylcellulose, hyaluronic acid, etc.). And some experts highly appreciate the effectiveness of barriers to various endogenous (large fat, peritoneal transplantants, fetal membranes, etc.) and exogenous (gelatin, oxidized cellulose, photopolymer gels, membranes and absorbent materials).
Postoperative adhesions
Postoperative adhesions are directly related to several adaptive factors. The first is a member of the operation. For example, after the operation of the uterus and the small intestine, the appearance of adhesion is 60-100%, and the adjuvants after the ovaries, the duodenum and pancreatic surgery are approximately 25% (2). The main reason for these differences is that the serum layer of intraperitoneal members and the presence of intestinal integrals in different sizes. The integral is Sa2 + - the dependent molecule - the only factor that leads to cell adhesion to extracellular matrix. The physiological dimension of entegrins is found to be higher in the serous layer of the small intestine than other internal organs. That is, tissue damage of these organisms will surely lead to the development of the adhesions (24). However, in the postoperative adhesion, there is a need to further investigate the cause of
this factor. The type of operation has its own effects in the formation of fibrosis (24). For example, the most extensive operations are performed primarily in emergency surgery, and the likelihood of large-scale adhesions after these operations is very high. The development of laparoscopy has reduced not only the technical innovation in surgery but also to the development of adhesions by up to 50% compared to open surgery (25,31). The materials used during the operation also contribute to this process. For example, the use of monofilaments can significantly reduce the likelihood of adhesion. In inflammation, however, there is a high probability of occurrence of inflammation in the area near large stranded diameters (32,33). Comparative studies have also been conducted between the absorbing and absorbing threads, but the information in different literature is contradictory. Therefore, based on the above information, it is desirable to use a monofilament threaded thread to reduce the likelihood of adhesion formation. Titanium-coated clamps are biologically inert, that is, aggressive effect on tissues (34), which in turn reduces the development of adhesion. Another important problem in preventing adhesions is to work with internal organs with high accuracy. (35) Prevention of accidental viscer-alisation. Drainage tubes after the operation of the cavity also cause inflammatory response from the body as a foreign body and should be used only in the most appropriate it must be strictly restricted in time (no more than 48 hours). At the same time, the requirements (flexible, soft, calibrated thin, silicon) must be consistent with the requirements (35). Hemostases during the operation should be timely and thorough. These facts have the most important place in the development of adhesive. Unfortunately, even if the above requirements are met, there is no guarantee that the adhesion will not occur because the adaptive factors that lead to adhesion in each patient are different. For example, the balance between fibrinogenesis and fibrinolysis in the body (36-38).
Modern stroke prevention strategies
The need for postoperative adhesions is very high for human beings. For example, in the United States annually about 440,000 abdominal adhesive stroke operations are performed, and it is associated with a significant risk to the health of the patient. Annually, this pathology costs $ 1.2 billion (1,2,24). The preconditions for the formation of adhesion depends on a particular patient. In fact, nutrition, diabetes, and infectious diseases can change the function of leukocytes and fibroblasts, which increases the likelihood of adhesion development several times. In the study of ways to prevent the development of the brain, several methods and
pharmacological drugs have been commonly used. The most important of them are:
- further improvement of miniinvasive surgical methods;
- reduction of abdominal cavity trauma during surgery;
- application of additives in the prevention of adhesions;
Postoperative adhesions develop only when the two stomachs of the abdomen are damaged or in the abdomen when they have blood vessels, inflammatory exudates (serum, purulent exudates, fibrin). Careful manipulations during operation, thorough hemostasis and sanation considerably reduce the appearance of adhesion. At the same time, the thighs at the opening of the abdomen should not be excessively large. Adjuvant therapy - preventing adhesion from entering the inflammatory region by injecting drug. Currently available pharmacological drugs can be classified as non-inflammatory agents that are not immediate. These preparations slow down the activity of cyclooxygenases by modifying the normal metabolism of arachidon acids and reduce the synthesis of prostaglandins and throm-boxane. They in turn reduce the vascular permeability and aggregation of platelets, increase the activity of macrophages and prevent the formation of adhesion (39).
Glucocorticoids and antihistamine preparations Glucocorticosteroids reduce the vascular permeability by reducing the systemic inflammatory response of the body and increases the separation of cytokines and hemotaxial factors. These medications have yielded few results in the prevention of adhesions (40). Corticosteroids, such as dexa-methasone, hydrocortisone and prednisolone, were tested and tested separately, along with antihista-mines, such as promethazine (41). Antihistamines, combined with glucocorticoids, inhibit the proliferation of fibroblasts, which in turn prevents the growth of the adhesions. However, these drugs have side effects, such as immunosuppression or retardation of wound healing, so they are used with caution nowadays (42).
Progesterone
There are several sources in the literature on the reduction of pneumothoroholdosterone acido-sis. But when introducing acetate into the muscle or peritoneal to people, the frequency of occurrence of adhesions has increased immediately (43).
Anticoagulants
After the operation, the abdominal cavity is susceptible to isotonic crystalloide with heparin sulphate, and there is a significant slowdown in the growth of the adhesion, which is due to fibrin
coagulation inhibition. However, heparin, in turn, has a negative impact on the profuse bleeding and the postoperative wound healing. Treatment with a small dose of heparin (2500/5000 unit / l) did not produce any positive effect on the adhesion (44).
Fibrinolytics
Fibrinolytic agents may cause severe complications, such as bleeding, but it has been known that adhesion is inhibited when recombinant species are used locally in animals (45). For example, the use of recombinant tissue plasminogen activator (rtPA) in the prevention of plasminogen is a promising approach. The effectiveness of rtPA is shown in several scientific studies, such as the reduction of the activity of recombinant tissue activator of plasmino-gen - can play the role of pathogenic factor in the development of adhesion. In experimental animals, this activity was reduced by the use of thermal or mechanical injuries and ischemic effects. This, in turn, has resulted in the development of adhesions. The introduction of rabbits in the rabbits revealed a tendency of adhesion development. The main purpose of this research was to determine the safety and efficacy of these drugs for the organism when applied to rtPA. Animal clinical trials and studies have shown that this pathway can not be a complete barrier to the safety and efficacy of the route and the postperative adhesion development (46).
Antibiotics
It is known that antibiotics with broad spectrum effects are used to prevent postoperative infections and adhesions. However, antibiotics included in the right abdominal cavity are contraindicated in the development of adhesion - have been proven in studies and are therefore not recommended to be used as prevention agents (47).
Barber
Currently known antihistamines are mainly divided into two groups: macromolecular liquid barriers and mechanical barriers. As for the fluid, the absorption of isotonic solutions and electrolytes in the abdomen is rapidly absorbed, for example, 500 ml of sodium chloride solution absorbed within 24 hours. Considering that the resorption of mesothe-lial membranes should take about 5-8 days, crystalloid solutions should be well absorbed until the fibrin deposition and adhesion develop. However, studies by foreign scientists have shown that 80% of patients who have taken crystalloid solutions as prophylaxis in the abdomen appear to have clingy (24, 32, 33). Moreover, after the laparotomy, fluid left in the abdomen promotes the development of infection. In experimental animals, including the isotonic solution in the abdominal cavity from 1 to
10 l, their fever increased to 20-60%. Given that the abdominal cavity moves to ph acid, it is important to select an irrigation solution (37). For example, Ringer's lactate solution is safe, inexpensive, it is a buffer fluid rather than a simple and physiological solution. It has been established that the introduction of the solution into the abdominal cavity leads to the development of adhesion growth (48). The mechanism of action is still unknown, yet no scientist has proven it. However, there are several assumptions that, in particular, Ringer lactate solution retains the physiological condition of the cavities, and this fluid absorbs the abdomen from fibrin-ous exudates, thereby reducing the activity of the fibroblasts. However, it has been established that the solution is quickly absorbed by the stomach and can not be a barrier to the formation of adhesive. Further information is available from the use of dekstran 70 solution for the prevention of adhesions. When the structures in the abdominal cavity were hydrophlosed with this solution, the hemoglobin layers separated from each other without any injuries (49). The dextran in the abdominal cavity reduces the local concentration of fibrin, retains the plasminogen's local activator, and impedes the expression of polymorph and nuclear neutrophils, which are adhesion molecules. The dextran is slowly absorbed in the abdomen, while it absorbs extracellular fluid in the abdomen (42-44). However, in deeper studies of this fluid, the frequency of adhesion growth has not been significantly reduced. Also dangerous side effects such as ascites, weight gain, accumulation of natural fluids (pleura, pericardium, etc.), gastrointestinal ulcers, DWS syndrome, and anaphylactic shock have been identified. The high molecular weight dextran (dextran 3270) However, negative results were found in the research. Hyaluronic acid is known as glycosami-noglycan, which is the main ingredient of cellular matrix, including connective tissue, skin, cartilage and synovial fluid. It is acidic bioavailability that has no toxic effect on the body and is easily digested by natural ways and is a negative charge in acidic environment, such as carboxymethylcellulose.
Hyaluronic Acid protects against serum, and protects it against various damages. However, these acids are mainly used in the clinic with phosphate buffer physiological solutions to prevent adhesions after fatigue damage. In pharminite, these additives are known as Sepracoat® trade names. The Sepracoat® is used at the beginning of the operation to prevent abdominal damage before opening the abdomen. Animal studies have shown that this substance has significantly reduced the rate of growth of the adhesions by reducing some of the intestinal damage. Randomized trials on patients also showed positive results, ie the rate of adhesion was
significantly reduced in patients with abdominal CT surgery (50). Carboxymethylcellulose is a cellulose derivative that has a negative charge under normal pH and has a rapid digestion. The systemic clearance is lower than that of hyaluronic acid, but is rapidly exposed to metabolism. Its main mechanism of action is not to stick to the damaged area and the whole region of the intestine, thereby avoiding pareto-visceral adhesions.
An important issue in the prevention of adhesions now is the limitation of the damaged area of visceral plaque on the end of the operation. It can be carried out by means of the motorway swing or synthetic barriers. As practice shows, it is known that microsurgical applications of the affected areas can be prevented through adhesions. The advantage of synthetic barriers over autotransplant is that it does not require additional surgical intervention such as autotransplant detachment from healthy ticks and does not require additional seams.
At present, many natural and synthetic barriers are used to reduce the formation of adhesion in the subunit substitution zone. Natural barriers include butter, fatty oil, amnion film, and even chorionic fibers (51).
And synthetic materials include polyvinyl alcohol and film tantalum. In recent times, interest has been driven by mechanical barriers, which are left abruptly for the barrier to separate the parasites and internal organs at the end of the operation. Such bars are known in the pharmaceutical industry as Gelfilm @, Gelfoam @, Silastic @, Gore-Tex @, Interceed @, Seprafilm @, Gore-Tex @. Barriers like polytetrafluoroethylene are hypoallergenic, nontoxic, antithrombogenic, thereby reducing the migration of fibroblasts and reducing the adhesion process. But this method can be used only in pure, aseptic surgery (52).
Randomized studies have shown that polytetrafluoroethylene is particularly effective in preventing the postoperative myomectomy, as well as the adhesion of the lateral walls of the abdomen than Interceed. Application of polytetrafluoroethylene in laparoscopic expansions requires complicated action. In addition, this material should be sutured to the body and it should be surgically removed after a certain period of time as it does not absorb. Polythmathanol is a material that is resistant to the reaction of the organism, and this property leads to the morphological changes of the intestine nearest to it, and pseudo-capsules are formed soon afterwards. These materials are used as a pericardial plaque in cardiovascular surgery (54).
In the removal of polytetrafluoroethylene, viscera can not guarantee the appearance of defects in the stems, bleeding from teeth, incomplete he-mostasis. Therefore, clinicians are skeptical about
the effectiveness of these materials. Interlude ORC (oxidized regenerated cellulose) is currently one of the most effective methods for the prevention of adhesions, in particular barriers, which cause physical barriers to the damaged and healthy contaminants, thereby reducing the adhesion between them. In the affected area of the intestine it becomes gel within 8 hours after insertion (55). Clinical observations have shown that Interguste ORC can absorb bleeding in the bloodstream, resulting in the formation of fibroblasts along the bloodstream and leads to collagen formation.42 These changes are the prerequisites for adhesion, suggesting that the barrier may have a non-adherent appearance. In order to be effective, it is important to have a hematopoietic hemostasis and use a wide range of barrier. If the hemostasis is not complete, the barrier becomes dark or brown-black. In this case, the barrier will be removed and reconstructed thorough hemostasis. Seprafilm (carboxymethylcellulose) is a non-toxic and hypoallergenic organism, one of the most effective ways to prevent postoperative massive adhesions. In the course of the operation, the barrier is converted into hydrophilic gel within 24 hours after being placed in the veins and maintains a protective layer in that region for up to 7 days. The barrier components, however, are completely out of the body after 28 days. Interlace ORC is more likely to be used for bariers even if they are in the bloodstream. Decrease postoperative sealant reduces the adhesion to 50%, and the overall adhesion development rate to an average of 400% compared to the control group. According to the results of the research, the rate of postoperative paralysis and the high incidence of growth of the adhesion between the fat, gastric, small intestine, abdominal wall and bladder has been significantly reduced. In some sources, information on pulmonary arthroid thromboembolism and peritoneal abscesses is presented in patients using these barriers. However, the statistical significance of these data is very low, and the mechanism of development of these complications has not yet been studied (56). Minimally invasive surgery is important in preventing adhesions. For example, the use of laparoscopic surgery and miniinvasive therapy in the treatment of adhesions has proven its superiority in practice. In particular, laparoscopic separation of adhesions compared to laparotomy has reduced the incidence of stroke by 50%. Another important issue is the unhealthy adhesion of the abdomen to the patient, as the research of foreign scientists in recent years has shown that the main cause of discomfort is neo- genesis of sensitive nerve fibers in adhesions (57-60). Sensor peptides were also found in the adhesive structure after the operation in the thorax and the pelvic cavity (61-63).
Conclusion
Postoperative adhesion processes in the abdominal cavity are commonly referred to as complications after abdominal surgery and are known to reduce the efficacy and the quality of life of the patient. It is well known that such short-term and long-term complications, such as intestinal acute malformations, abdominal pain, and infertility, are the result of these adhesions. So far, the only and most reliable treatment method for the emerging adhesions is surgical adhesion. But at the same time, the likelihood of recurrence of adhesions is
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