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Baymakov Sayfiddin Risbaevich, Ph D., of the Surgery and Military Field Surgery.
Tashkent State Dental Institute E-mail: bsayfiddin@yahoo.com Aslonov Zafarjon Ahrorovich, assistant, surgery and military field surgery Tashkent State Dental Institute E-mail: azafarjon@list.ru Boltaev Sherzod Shavkatovich, assistant, surgery and military field surgery Tashkent State Dental Institute E-mail: saidazam9377@gmail.com Yunusov Seydamet Shevket-oglu, assistant, surgery and military field surgery Tashkent State Dental Institute E-mail: u-s90@mail.ru
ESTIMATED OF EFFECTIVENESS OF USING OF ENTEROSORBTION IN COMPLEX TREATMENT OF ACUTE INTESTINAL OBSTRUCTION
Abstract: Diagnosis and treatment of acute intestinal obstruction is one of the most complex problems of urgent abdominal surgery. Progression of acute intestinal obstruction and peritonitis of various etiologies promotes to the development of the syndrome of intestinal insufficiency, which is a complex symptom complex with violation of all bowel function. The most effective variant of correction of the syndrome of intestinal failure is naso-intestinal decompression in combination with various methods of intestinal therapy.
Keywords: intestinal obstruction, intestinal insufficiency syndrome, enterosorption, zerotox.
Diagnosis and treatment of acute intestinal obstruction flammatory process in the abdominal cavity and in the case of
(AIO) is one of the most difficult problems of modern sur- AIO against the background of intestinal paresis [3; 5; 12]. SII
gery. Despite the achievements in this field of medicine and is a complex symptom complex, accompanied by a violation
a large arsenal of various methods of postoperative intensive of all functions of the intestine, resulting in the latter becomes
care, the results of treatment of patients with AIO can not be the main source of intoxication and development of multiple
considered satisfactory, since the mortality rate due to this organ failure (MOF) [4; 7; 8; 10].
pathology is 17-21% [1; 2; 3; 9; 10]. Considering the key role of the "intestinal" component
Progression of AIO and peritonitis of various etiologies of endotoxicosis in case of AIO, the interest of clinicians in
contributes to disruption of the gastrointestinal tract and met- various methods of removing toxic substances from the in-
abolic processes in it with the development of intestinal pare- testinal lumen and detoxification becomes clear. Obviously,
sis, the formation of toxic substances and overfilling with the a sufficient effect of surgical treatment of AIO and peritonitis
toxic liquid contents of its lumen. Toxic factors and increase in can not be achieved in most cases without complex correction
intraluminal pressure lead to disturbances of microcirculation of SII. The most effective variant of such correction is nasoin-
in the intestinal wall, have a detrimental effect on the nerve testinal decompression combined with various methods of
elements and musculature of the intestinal wall and together intestinal therapy [2; 5; 7].
with other numerous pathogenetic changes in homeostasis Along with the mechanical removal of toxic compounds
cause the translocation of microorganisms and endotoxins from the lumen of the small intestine, an important role is
from the lumen of the intestine to the systemic circulation played by enterosorption [1; 6; 7]. For this, drugs of sorption-
[4; 6; 7; 9]. This justifies the generally accepted opinion that detoxification action of various nature are used.
the development of the syndrome of intestinal insufficiency In recent years, information has appeared on the zero-
(SII) is one of the main mechanisms of the onset and progres- tox preparation of domestic production, obtained from the
sion of endogenous intoxication in the dynamics of the in- natural product - hydrolytic lignin husks of cottonseed, which
has a high adsorption capacity not only to toxic products of exogenous and endogenous origin, but also to pathogenic bacteria with subsequent destruction (Ismailova M. G., Yu-nuskhodjaeva Kh. G. 2014). Information on the use of this drug in surgical practice, we did not find [11].
The purpose of our study was to evaluate the effectiveness of the use of naso-intestinal decompression with entero-sorption in the complex treatment of patients with AIO.
Materials and research methods. The results of examination and treatment of 63 patients with non-tumor origin AIO, hospitalized in the surgical department of 2 and 3 clinics of the Tashkent Medical Academy in 2014-2017 are analyzed. Patients were aged 16 to 83 years, ofwhom over 60 years old - 10 (15.9%) patients. The most common cause of AIO was adhesive intestinal obstruction - in 36 (57.1%) patients, and strangulation intestinal obstruction was diagnosed in 18(28.6%) patients and obturation intestinal obstruction - in 7(11.1%).
The collection of the history of the disease made it possible to establish that up to 6 hours from the onset of the disease 5(7.9%) patients appealed, up to 12 hours - 6(9.5%), up to 24 hours - 9(14.3%), for 1-3 days - 29(46%), after three days - 14(22.3%). Thus, in most patients, the duration of the disease exceeded two days.
The results of the clinical examination showed that in all patients the main complaint was pain (100%). Abdominal distention was observed in 51 (81%) patients, gas retention in 42(66.7%), stool in 40(63.5%), nausea and vomiting in 48(76.2%), thirst and dryness in the mouth - in 36(57.1%), weakness and dizziness - in 33(52.4%), body temperature increase - in 5(7.9%). In the analysis of objective data, dryness and pallor of the skin were revealed in 16(25.4%), abdominal distension - in 51(81%), with asymmetry - in 37(58.7%).
All patients after the diagnosis was carried out a set of conservative medical measures aimed at eliminating the AIO. The unsuccessfulness of these measures for two hours served as a testimony to the performance of emergency surgery, the choice ofwhich depended on the operational finding and the cause of the AIO. When performing surgery, preference was given to the mid-median laparotomy, after which a revision of the abdominal cavity and the main stage of the operation in volume, depending on the nature of the pathology, were performed. The surgical intervention was terminated by intubation of the small intestine with a polyfunctional two-channel probe, which during the operation and from the first hours of the postoperative period was used for decompression, lavage and enterosorption. Antibiotic therapy was carried out with preparations of a wide spectrum of action, followed by correction, after clarifying the type of microflora.
It is important to note that in many cases, SII was accompanied by peritonitis, especially in cases of bowel necrosis:
diffuse peritonitis was detected in 24(38.1%) patients, diffuse in 4(6.3%). In 11(39.3%) patients, the effusion was serous, 13(46.4%) had serous-fibrinous effusion, and 4(14.3%) had purulent effusion. These patients required adequate treatment of acute peritonitis both during surgical intervention and in the early postoperative period.
Depending on the treatment measures used, patients were divided into 2 groups: 25 patients made up a control group without sorbent, 38 patients with enterosorbent were included in the main group.
Patients of the control group received treatment according to the traditional method adopted in the clinic with an active post-operative decompression of the intestine (DI) and intestinal lavage (IL) in the early naso-intestinal probe. In the early postoperative period, active DI and IL were performed. The latter was carried out by dropping 1500 ml of saline solution (identical in its electrolyte composition to the small intestine) through a small lumen of the naso-intestinal probe, with an exposure of 30 minutes and subsequent active aspiration.
Patients of the main group received a complex of therapeutic measures supplemented with enterosorption. As an en-terosorbent, a zerotox preparation based on hydrolytic lignin of cottonseed husks (manufactured by the A. Sultanov Uzbek Scientific Research Chemical and Pharmaceutical Institute, Tashkent) was used. To do this, a suspension was prepared based on 10.0 g zerotox powder per 1000 ml of a 0.9% sodium chloride solution. Enterosorption was started with a drip injection into the naso-intestinal tube. Single volume of sorbent was 500 ml. After the administration of the drug, the exposure was created for 30 minutes and active aspirating was carried out from the large lumen of the probe. In the future, every 8 hours (3 times per day) in the intensive care unit or the after-care ward conducted series of enterosorption. The rest of the time, the naso-intestinal probe was in the DC mode. Enterosorption was performed depending on the above parameters for 3-5 days. Prior to the operation and during postoperative follow-up, the volume of gastrointestinal contents of patients with AIO, obtained with the help of a naso-intestinal probe, was estimated.
The condition of the patients before and after the operation in the dynamics was evaluated by ultrasound, which, being the most accessible, cheap and highly informative research method for the diagnosis of AIO, along with the reduction in the time of examination of patients and providing the possibility of safe dynamic observation, reveals the presence of swollen loops and intestinal motility, free fluid in the lumen of the intestine and in the abdominal cavity. The sonography was performed on an ultrasonic instrument "Aloka SSD-500" using convection and sector sensors with a frequency of 3.5 and 4.0 MHz.
Diagnosis of endogenous intoxication (EI) was carried out using the calculation of leukocyte indices (leukocyte
index of intoxication (LII) according to the Kalf-Kalifa formula, pulse-leukocyte-temperature index of intoxication (PDTII) according to S. D. Khimich and L. H. Garkavi lymphocyte index) [6].
Studies of the species composition of the microflora of the exudate of the abdominal cavity and intestinal contents in patients with AIO were conducted at the Department of Microbiology of the Tashkent State Dental Institute. The material was taken during the operation, then after the operation at 1-, 3-, 5-, and 7th days with the observance of the rules of aseptic and antiseptic. Taken exudate and intestinal contents were delivered to the laboratory in the same volume with a thioglycolic medium (a universal medium for maintaining the viability of aerobes and anaerobes) for 2 hours, a number of serial dilutions were prepared from them in the laboratory. Quantitative assessment of the content of microorganisms in various media was performed using the Gould sector method for highly selective nutrient media. When working on a modified procedure, the result was taken into account with the latest dilution, in which bacterial growth was obtained. The number of microbes of each species was expressed in lg CFU/ml.
Results and its discussion. The use of enterosorption facilitated faster normalization of the condition, decreased intensity and disappearance of pain, changes in body temperature, restoration of intestinal motility, determined by clinical signs in the postoperative period.
The positive process was also revealed in ultrasound pictures in dynamics. The volume of gastric contents of patients with AIO before surgery was up to 1 L and decreased in the postoperative period up to 5 days. The use of zerotox accelerated this process for almost 2 days.
The results of the study also showed that the indices of the inflammatory process - leukocytosis and ESR were the highest at admission, i.e. at the height of the disease, and returned to normal only 7 days after the operation. In patients who received enterosorption, the norm was achieved 2 days earlier.
LII in the blood of patients on the day of surgery, showing a 3-fold increase in the leukocyte shift pattern, characterized the severity of the process, largely a marker of bacterial aggression. A day after the operation, except for the tendency to a certain increase, there were no special changes in this indicator. Subsequently, there was a gradual decrease in LII in the control group, approaching normal values only 5 days after the operation. While the use of enterosorbent statistically significantly reduced this period for 2 days.
On the day of the operation, patients with AIO with a marked picture of intestinal failure against a background of high levels of intoxication, a significant drop in the lymphocyte index of L. Kh. Kharqavi arose. This circumstance indicates the failure of the immune system in the anti-infective
control of the microbial flora, including inside the intestinal wall. However, this index begins to be restored 24 hours after the operation and if in the control group it reaches the lower limit of normal values only after 5 days from the operation day, the use of enterosorbent reduces this period by 2 days.
The intestinal microflora after the application of enterosorbent was significantly improved already on the 5th day after the operation. So against the background of an increase in the number of anaerobic bacteria, the content of aerobic bacteria is significantly reduced. On the 7th day, the amount of anaerobic and aerobic microorganisms approached the norm. Staphylococci, streptococci and protaeus were not detected.
Examination of the abdominal cavity in patients with AIO revealed significant violations of local protective factors, as expressed at the height of the AIO, as well as in the early periods after the operation. And the progression of intestinal dysbiosis was accompanied by more significant violations of local immunity. On the third day, when the indices of dysbiosis improve somewhat, in parallel, positive changes occur and local protection factors. In healthy people, the local factors of protection (lysozyme titer, phagocytosis index and sIgA level) in healthy subj ects in comparison with biological fluids (blood, saliva) of other parts of the body changed insignificantly. However, with the onset of the development of AIO, these indicators due to inflammation and translocation of the intestinal microflora significantly increase, which is evident from the exudate taken during the operation. At the same time, 24 hours after the operation, pronounced immunodeficiency occurs in all the exponents of the abdominal cavity in all indices of local factors of protection, which was caused by the stressful situation and the use of narcotic drugs.
Postoperative complications were observed in 7(28%) patients, mainly with a severe degree of endotoxemia. The reason, in our opinion, was a slow decline in the level of EI in these patients, despite the spent in the postoperative period of DI and IL. In the control group, 2 patients (8%) died due to multiorgan insufficiency.
In patients of the main group after the application of enterosorbent, on the 3rd day after the operation in the exudate of the abdominal cavity the local factors of protection were restored, approaching the control values.
Analysis of the results of treatment showed that due to a differentiated approach to the treatment of AIO in the main group, postoperative complications occurred only in 5(13.2%) patients 1(2.6%) died of myocardial infarction.
Thus, based on the studies conducted in patients with IPC, the development of dysbiosis in the contents of the intestine, as well as microbial contamination in the exudate of the abdominal cavity in the presence of peritonitis, indicating a bacterial translocation. In the exudate of the abdominal cav-
ity, the indicators of local factors of protection significantly increase in patients with AIO, which is associated with the development of the inflammatory process.
The detoxification effect of naso-intestinal intubation is more effective in a complex with enterotoxicosis by zerotox, which is confirmed by the dynamics of changes in EI parameters, early restoration of intestinal peristalsis, improvement of the general condition of the patient. Zerotox shortens the process of postoperative normalization of the general state, body temperature, restoration of intestinal motility, reduction
of pain intensity, leukocytosis and ESR, indices of intoxication (PLTII and FII) and intensity of immune response (L. H. Gar-kavi's lymphocyte index) for almost 2 days.
After the application of enterosorbent, the quantitative and qualitative composition of the intestinal microflora is significantly improved, an earlier cessation of exudation into the abdominal cavity is observed, as well as positive shifts of all local defense indicators already on the 3rd day after the operation, which significantly reduces the number of postoperative complications and lethality.
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