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APPROACHES TO INTESTINAL DECOMPRESSION DURING DIFFERENT APPENDICULAR PERITONITIS IN CHILDREN Abduvoyitov B.B.1, Khasanov A.B.2, Djalolov D.A.3, Yusupova Sh.Sh.4
1Abduvoyitov Bobur Bahodirovich - Student;
2Khasanov Aziz Batirovich - Student;
3Djalolov Davlatshokh Abduvokhidovich - Student;
4Yusupova Shakhlo Shavkatovna - Student, DEPARTMENT OF PEDIATRIC SURGERY MEDICAL SCHOOL
SAMARKAND STATE MEDICAL INSTITUTE, SAMARKAND, REPUBLIC OF UZBEKISTAN
Abstract: functional intestinal insufficiency due to diffuse purulent peritonitis is an actual problem in surgery. The results of the surgical treatment of 164 children hospitalized with diffuse appendicular peritonitis is perfomed. The results of the treatment of intestinal paresis with the method of intestinal decompression by appendico or cecoenterostomy are analyzed.
Keywords: decompression, peritonitis, paresis, cесoenterostomy, appendix ceco enterostomy.
Introduction. A common and most severe complication of acute appendicitis in children is diffuse appendicular peritonitis (DAP) [1, 4, 9, 19, 23]. Frequently in such cases DAP is complicated by functional failure in intestinal tract (paresis) [6, 10, 18, 20]. To resolve intestinal paresis, decompression of the gastrointestinal tract (GIT) is used, which is an essential component of surgical treatment of children with RAP, aimed at eliminating increased intra-intestinal and intra-abdominal pressure, ensuring continuous aspiration and sanitation of toxic intestinal contents, improving the microcirculation of the intestinal wall [3, 7, 17, 24]. Nasointestinal intubation of the small intestine and transrectal colon intubation are most commonly used for intestinal decompression [2, 5, 16, 22].
However, these methods, in our opinion, have several disadvantages. Thus, with nasointestinal intubation of the small intestine, there are well-known technical difficulties in conducting a nasointestinal probe in children due to the anatomical features of the
duodenum and the ligamentum of Trejac. In addition, when the probe is in the upper gastrointestinal tract for a long time, the stomach and esophagus are infected with intestinal microflora. Duodenogastric and gastroesophageal refluxes, hypersecretion of the stomach and an increase in stagnant contents with the development of erosive-ulcerative gastroduodenitis and esophagitis occur [8, 15, 21]. In addition, children are psychologically extremely difficult to tolerate the introduction and finding of nasogastric and nasoenteric tubes. With transrectal colon intubation, there are difficulties in carrying the probe from the rectum to the sigmoid colon, through the splenic and hepatic flexures of the colon, to the Bauhinia valve [9, 14].
At the same time, the intestinal tube is quickly blocked with feces and already for 2-3 days it ceases to perform the drainage function. Another feature of transrectal drainage is the difficulty of long-term fixation of the proximal end of the tube at the required level.
Objective. To evaluate the effectiveness of the developed methods of intestinal decompression in the treatment of diffuse appendicular peritonitis in children.
Materials and methods. In the 2nd clinic of the Samarkand State Medical Institute under our supervision there were 164 sick children with DAP, of which 96 (58.7%) examined with the RAP were children of school age. Children of early age (up to 3 years) -26 (15.6%) were rarely received. There were 101 boys (61.7%), girls - 37 (38.3%). Of the general somatic complications in children with RAP, we most often observed toxic pneumonia, encephalopathy and carditis.
To assess the severity of the condition, the following research methods were used: complete blood and urine analysis, leukocyte intoxication index (LII) Ya.Ya. Kalf-Kalif, blood toxicity index (PTK) using a parametric test according to F.Yu.Garib, complex ultrasound sonography and of necessity - X-ray examination.
Results and discussion. All patients with RAP were given preoperative preparation for 8-12 hours, aimed at maintaining adequate tissue perfusion, acid-base and electrolyte balance, oxygen transport and normal hemostasis parameters.
Our choice in favor of a cecoenterostomy (performed in two variants: the cecoenterostomy proper or the appendicotcocecoenterostomy) was due to the following considerations: the probe entering through the cecum does not result in deformation of the intestinal tube, the discharge of the cecostomy from the anterior abdominal wall is less dangerous than the enterostomy, the fistula is less aggressive and does not macerate the skin, and the fistula usually closes on its own. Decompression of the small intestine through an appendicostomy was performed using a special probe inserted into the small intestine through the stump of the appendix, the end of which is output to the anterior abdominal wall in the right iliac region through a mini-incision (1-1.5 cm long). At the same time, the dome of the cecum is temporarily fixed to the skin in the area of the appendicostomy. Our proposed method of decompression of the small intestine was used in 55 (20.8%) patients who underwent appendectomy with preservation of the base of the vermiform process (1-2 cm), sufficient to impose an appendicenterostomy. The technical conditions for performing an appendicostomy were the possibility of removing the main part of the small intestine to the wound, the absence of a common and dense infiltrative adhesion process between intestinal loops, which greatly complicates the decompression probe, the absence of a pronounced destructive process at the base of the appendix for at least 1 -2 cm.
In the absence of the above conditions for the imposition of an appenicustoma after ligature appendectomy, intestinal decompression was performed by means of a cecoenterostomy.
The method of spontaneously closing temporary cecostomy differs from the traditional one, firstly, by removing the stoma through an incision in the anterior abdominal wall (1.5-2 cm long), secondly by intubation method. the center produces a puncture of the wall, through which a special probe is carried into the lumen in the proximal direction. After the insertion of this probe through the bentine capsule and the baugin valve in the small
intestine, the first - internal purse string suture on the wall of the cecum is tightened and tightly tied on the probe, then slightly submerging it, the second is stitched - the external string purl to the probe on one node. The wall of the caecum is fixed to the anterior abdominal wall according to the method described below, and the threads of the purse-string sutures are brought out. After the signs of intestinal paresis are eliminated, the decompression tube is removed, and the threads of the external intestinal suture are tightened with the tips of two clamps and closed with a cecotoma.
The proposed method of cecostomy in children eliminates repeated surgical intervention, reduce the invasiveness of the operation and prevent the development of postoperative complications. Indications for the application of a cecostomy are similar to those for the application of an appendicostomy. In this case, preference is given to the latter, which allows not to injure the dome of the cecum. Cecotoma is used exclusively in cases when there is a destruction of the base of the vermiform process and the phenomenon of typhlitis.
The methods proposed by us for decompression of the small intestine in children with RAP contributed to an earlier restoration of intestinal motility and the appearance of the first independent stool (by 4 days), normalization of body temperature by 4-5 days, reduction of the duration of the stomach probe (up to 3 days) and early activation of the patients (2 -3 day).
Conclusion. One of the main elements of the surgical treatment of children with diffuse appendicular peritonitis, complicated by intestinal paresis, is its decompression by appendico or cecoenterostomy, which effectively restores intestinal motility, promotes a favorable postoperative course and eliminates repeated surgical intervention.
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