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0DIAGNOSIS AND TREATMENT FOR ADHESION DISEASE IN
CHILDREN
Sattarov Zh.B.
Tashkent Pediatric Medical Institute https://doi.org/10.5281/zenodo.13685163
Abstract. The algorithm of diagnostics and the treatment of adhesive disease is developed on experience of treatment of 231 children. Algorithm basis have compounded sonography of abdomen, antiadhesive therapy and laparoscopic adhesiolysis. The timing and methods of conservative treatment of the disease, as well as indications for surgical intervention, were determined. The use of the developed set of conservative measures made it possible to achieve a positive result in 133 patients (57.6%). 98patients were operated on with good outcomes.
Keywords: an adhesive disease, antiadhesive therapy, laparoscopic adhesiolysis, children.
Actuality. It is important to inform that Adhesive disease (AD) is the pathogenetic basis for the formation of adhesions in the abdominal cavity and is clinically characterized by a violation of the evacuation function of the gastrointestinal tract and recurrent abdominal pain syndrome [1]. The main complaints of patients with this disease are abdominal pain, vomiting, and in the later stages - upset stomach and gas retention. From the patient's history, information about surgical intervention in the abdominal cavity is determined [7]. The adhesive process in the abdominal cavity is a protective reaction of the body aimed at limiting the pathological process in the abdominal cavity, and allows you to combat severe infectious or traumatic damage to the abdominal organs. At the same time, the adhesive process in the abdominal cavity is one of the main causes of CD and its complication - adhesive intestinal obstruction (IBD). Low efficiency of traditional methods of CD treatment, high recurrence rate and high mortality after repeated surgical interventions (1.4-12%) prompted us to look for new approaches to solving this problem [3,5,11]. CD is characterized by a complex of symptoms, among which abdominal pain syndrome dominates [6,8,12]. The intensity and frequency of pain attacks are variable, and in severe cases even a minor violation of the diet or simple physical activity cause severe pain, nausea and vomiting. Against this background, asthenovegetative disorders develop, the quality of life of patients with severe CD is significantly reduced, their social adaptation is impaired [3,7,10]. The most dangerous form of CD - adhesive intestinal obstruction often requires repeated surgical intervention, which inevitably leads to the formation of new adhesions. According to the literature, the share of childhood diseases in practice among other types of intestinal obstruction is 30-40%. 60% of all relaparotomies in children are caused by intestinal obstruction. In 7-10% of cases, the adhesive process becomes progressive and causes clinical manifestation of recurrent BC [2,4,7,9,11].
One of the main ways to improve the results of CD treatment is early diagnosis of the disease. At the same time, the information content of traditional methods of X-ray examination (general radiography, abdominal X-ray) in adhesive disease is low and amounts to 50-60% [23,7,11,12,13]. In recent years, the use of ultrasound for the diagnosis of CD has become increasingly widespread [10,12,13]. The absence of radiation exposure, painlessness, relatively quick examination and non-invasiveness of the method allow its repeated use, including for the purpose of dynamic echographic control. An alternative to the traditional open surgical method of
treatment is currently a minimally invasive intervention - laparoscopic adhesiolysis [2,3,14]. Minimal tissue damage during laparoscopic surgery creates fewer conditions for the development of adhesions and associated complications in the abdominal cavity [6,7,13]. The risk of developing puncture complications (injury to large vessels and hollow organs) can be successfully avoided by using a safe, effective method of direct puncture of the abdominal cavity with a blunt trocar [3,19]. Laparoscopy allows one to assess the localization of the adhesion process in the abdominal cavity, the degree of its severity, and the condition of the intestinal loops involved in the adhesive conglomerate.
Definitely, the impact on the adhesive process in the abdominal cavity was achieved by using a special treatment tactic developed in the clinic taking into account modern principles of the pathogenesis of postoperative adhesions [5,9,18].
The solution to the interrelated problems of ultrasound diagnostics, anti-adhesion therapy with drugs and minimization of surgical trauma by minimally invasive interventions was carried out using the proposed algorithm for the diagnosis and treatment of CD in children [3,5,7,12,20].
The purpose of the research is the diagnosis and treatment of patients with abdominal adhesions.
Materials and methods of research. The research work is based on the results of examination and treatment of 231 patients who suffered adhesive complications in the abdominal cavity after surgery, who were treated in the clinic in 2018-2023. The age of patients ranged from 3 months to 18 years. 174 (75.3%) patients were hospitalized once, 36 (15.6%) patients - twice, 21 (9.1%) patients - from 3 to 11 times. The analyzed group of patients with adhesive disease was represented by the following manifestations:
• recurrent abdominal pain accompanied by vomiting during physical exertion or after overcoming paresis in children who have undergone abdominal surgery;
• clinical signs of complete or partial adhesive intestinal obstruction eliminated by conservative treatment;
• sonographic signs of the presence and spread of abdominal adhesions in children who have undergone abdominal surgery.
Ultrasound examination technique. Taking into account the clinical signs of the disease (localization of pain, presence of postoperative scars), poly positional scanning (a series of longitudinal and transverse scans of the abdomen) is performed on the suspected area of the abdominal cavity in mode 0, in which a longitudinal section of the intestinal tube is displayed on the screen and the viscero-visceral and viscero-parietal junctions are determined. In elder children, this examination is recommended to be performed while holding the breath.
For describing the adhesive process in the abdominal cavity, two signs were taken into account: the presence of a conglomerate in the intestinal loops and the Fixed Intestinal Loop Sign (FILS), which indicates the fixation of intestinal loops to the parietal or visceral peritoneum.
Laparoscopy. One of the main conditions was the use of video laparoscopy. The first site of trocar insertion was determined based on ultrasound data, taking into account the location of postoperative scars on the anterior abdominal wall (contralateral). An endoscope with a trocar is inserted into the abdominal cavity, after which CO2 is introduced into the abdominal cavity 14 mm above (carboxyperitoneum), the visible parts of the abdominal cavity are examined and inspected. Laparoscopic adhesiolysis was performed using a standard endovideolaparoscopic complex. The set of necessary equipment includes atraumatic clamps, scissors, and bipolar or
ultrasonic coagulators. During laparoscopy, adhesions must be coagulated with an electro coagulator before the incision to prevent further bleeding. Adhesions were excised with laparoscopic scissors, and in preoperatively prepared patients, most adhesions were excised bluntly, without blood.
Anti-adhesion treatment method. Cuprenil was prescribed once a day (during the day -between meals), daily. Dosage: children under 2 years old - 1/4 tablet (65 mg); From 2 to 4 years old - 1/3 tablet (85 mg); From 4 to 8 years old - 1/2 tablet (125 mg); Over 8 years old - 1 tablet (250 mg). Physiotherapeutic procedures (electrophoresis with cholysin) were carried out daily. In this case, the child is lying on his back; the electrodes are located transversely. Two electrodes are used, their area (200-300-400 cm2) is selected depending on the patient's age. One electrode is placed on the anterior abdominal wall and connected to the positive pole, the other is placed on the lower back and connected to the negative pole. The medicinal substance cholysin is administered from the positive electrode. Current strength is 10 mA. Duration of the procedure: first session - 3-5 minutes, subsequent sessions - 6-8 minutes.
Results of the study and their discussion. The distribution of CD patients by types of treatment is presented in Table 1.
Table-1
Distribution of patients by types of treatment
Type of treatment Number of patients
Abs. %
Conservative treatment 133 57,6
Laparoscopic adhesiolysis 29 12,5
Laparotomy, adhesion separation 69 29,9
Total: 231 100
From the 231 patients with CD in our observation, laparoscopic adhesiolysis was planned in 29 (12.5%), conversion was required in 8 (27.6%), and conservative treatment was performed in the remaining 133 (57.6%) patients. All patients with abdominal pain syndrome that developed after abdominal surgeries underwent a general clinical examination, as well as ultrasound of the abdominal organs. In cases where echographic signs of the adhesive process were not detected, additional instrumental and laboratory studies were carried out to establish the cause of the pain syndrome (X-ray of the abdominal organs, gastrointestinal tract passage, irrigography, FGDS, urography, CT, etc.). When pathology was detected, patients were referred to appropriate specialists: gastroenterologist, nephrologist, etc. The treatment tactics for patients with adhesions detected during echographic examination depended on the severity of the pain syndrome and anamnesis. In case of mild and moderate pain, a full course of anti-adhesion therapy was prescribed followed by ultrasound. For patients with severe pain syndrome, as well as patients with an attack of adhesions during the last 3 months, a course of anti-adhesion treatment was carried out simultaneously with preparation for a planned operation.
Besides that, after the first course of anti-adhesion treatment, a repeat ultrasound examination of the abdominal organs was performed. If the disappearance of abdominal pain was accompanied by the disappearance of echographic signs of adhesions, the patients followed a diet for 3-5 years and underwent an ultrasound examination every 6 months.
Patients with positive dynamics of pain syndrome, the presence or absence of echographic signs of adhesions were prescribed a repeat course of anti-adhesion treatment after 1 month. Depending on the manifestation of clinical signs, repeated courses of treatment were carried out.
It should be mentioned that indications for laparoscopic adhesiolysis were cases when the course of anti-adhesion therapy was clinically ineffective. After laparoscopic intervention for adhesiolysis, patients were given courses of anti-relapse treatment for 7 days. Patients who developed adhesiolysis were prescribed 2-3 courses of anti-adhesion treatment for 10 days with an interval of 3 months, followed by ultrasound control. These children were subsequently observed on an outpatient basis with mandatory follow-up medical examinations and ultrasound examinations every 3 months during the first year and every 6 months during the following 3-5 years. The number of courses of conservative treatment was determined individually depending on the extent of surgical intervention, the level of clinical effectiveness and the dynamics of echographic signs.
In laparoscopic intervention, indications for open laparotomy using conversion and videoassisted methods were cases with severe adhesive process and high risk of damage to internal organs. At the same time, visual examination of the abdominal cavity allowed avoiding unnecessary extended laparotomies, which increase the trauma of the intervention. A study of the remote results of 1-2 courses of anti-adhesive therapy in 231 patients with CD showed that 133 (57.6%) patients were re-hospitalized due to persistent or recurrent pain, of which 98 (42.4%) had acute adhesive intestine. They were hospitalized with symptoms of convulsions and operated on in accordance with urgent instructions. Stabilization of the general condition, pain relief and normalization of nutrition were achieved in 24 patients with diffuse adhesive processes in the abdominal cavity, however, the risk of intestinal obstruction required constant dispensary observation of patients.
Conclusion. By summarizing it should be suggested that indications for surgical treatment of patients with CD are unsatisfactory clinical efficacy of conservative treatment and the presence of echo graphic and radiographic signs of intestinal obstruction, indicating adhesion of intestinal loops to the parietal or visceral peritoneum.
In patients with a pronounced positive clinical effect, when removing a conglomerate adhered to the parietal or visceral peritoneum, as well as with radiographic signs of intestinal obstruction, it is necessary to conduct several courses of conservative treatment until the pain syndrome completely disappears.
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