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11FACTORS THAT AFFECT THE FAILURE OF INTESTINAL SUTURES. WAYS TO ELIMINATE
THEM.
Moroz P.,
PhD, Assistant of the Department of Surgery № 1 Bukovynian State Medical University Kurchyk R.,
Student Higher State Educational Establishment of Ukraine Bukovinian State Medical University Kotelban A.,
PhD, Associate Professor of the Department of Pediatric Dentistry
Bukovynian State Medical University Kharabara O.
Chernivtsi Regional Clinical Hospital PhD, Head of Department of Surgery
Abstract
Failure of intestinal anastomoses remains an urgent and complex problem of abdominal surgery. It's caused by a number of post-surgery complications (peritonitis, abdominal abscesses, intestinal fistulas, etc.), as well as by related to them further surgical interventions, which is accompanied by an increase in the duration and cost of treatment of patients, as well as high mortality rates. According to statistics, failure of anastomoses occurs in 3.434.6% of cases, which leads to post-surgery peritonitis in 24.2-44.3%, and the mortality from the latter reaches 50-65%. This problem has not only medical but also socio-economic significance.
Keywords: abdominal surgery, failure of intestinal anastomoses, intestinal sutures, laparotomy, fibrin sealant, antimicrobial endoprotector, epidermized cryophilized xenodermoimplants.
The most important factors in the mechanism of development of intestinal suture failure are: disorders of microcirculation in the area of the anastomosis, reduction of regeneration processes, microbial permeability of mechanically sealed sutures. Intestinal wound healing is adversely affected by uremia, mechanical jaundice, diabetes, zinc deficiency, malnutrition, long-term use of corticosteroids, serum albumin below 3 g / l, intestinal obstruction, chronic obstructive pulmonary disease, postoperative hemotransfusion, hemotransfu-sion more intoxication, disturbance of intestinal microcirculation, late reperfusion of the ischemic intestine, administration of interleukin-2, 5-fluorouracil and other antineoplastic agents, intraoperative irradiation, average radiation doses before and after surgery.
In 2010, D.A. Telem et al., Identified 5 risk factors for failure of intestinal anastomoses: albumin levels before surgery below 35 g / l; the duration of the operation is more than 200 minutes; intraoperative blood loss of more than 200 ml; the need for intraoperative blood transfusion; involvement in the inflammatory process of the resection bowel during its histopathological examination. [2]
Common risk factors for anastomotic failure include: condition and pathomorphological processes occurring in anastomosed organs; adverse factors in which these sutures are applied or that occur in the postoperative period; technical features of suturing. It was found that immediately after suturing, more reliable he-mostasis is provided by Reverden-Multanovsky sutures, continuous-nodal through, continuous-nodal se-rous-submucosal. The lowest parameters of hemostasis are characteristic of the through intranodal suture of Mateshuk.
Intestinal sutures need to be strengthened to increase the reliability of intestinal communication, especially in patients with combined pathology in which regenerative processes are reduced. This is done in such a way that the edge of the large omentum is brought to
the line of intestinal sutures, the line of sutures is covered with it so that the omentum protrudes by 2-2.5 cm and it is sewn with separate sutures. The method is carried out in such a way that the edge of the large omen-tum is brought to the line of intestinal sutures, the line of sutures is covered with it so that the omentum protrudes by 2-2.5 cm and it is sewn with separate sutures. A thin omentum is inserted into the thickness of the omentum between its leaves. One end is brought to the line of sutures, and the other is brought to the anterior abdominal wall. At the site of insertion of the catheter into the thickness of the omentum, it is fixed with a separate ligature. And in the postoperative period, antibiotics, antiseptics or regeneration stimulants are injected through the catheter. The catheter is removed 5-7 days after surgery. [3]
The use of fibrin glue for the formation of suture-adhesive anastomoses promotes the formation of a delicate scar that does not deform the anastomosis, provides rapid structural recovery of the intestinal mucosa. The absence of cellular infiltration around the adhesive masses eliminates the complicated course of the inflammatory reaction. A slight binding process was observed in 14.28%. Failure of anastomoses is not observed. [4]
Intestinal antimicrobial endoprotector is a conical product that has stiffening rings that are perpendicular to its axis, which gives the tread the necessary elasticity and resilience. The gel body of the endoprotector is a matrix for antibacterial drugs, as well as glycerin, which is a plasticizer and creates a composition as close as possible to the intestinal wall. [4]
After resection of the hollow organ of the digestive tract, the formation of the anastomosis is performed with a single-row matching suture using threads modified with carbon nanotubes and antiseptic - poly-hexaguanidine chloride. [5] Experimental studies have shown that the use of polypropylene filaments modified
with carbon nanotubes and antiseptic - polyhexaguani-dine chloride, for the formation of the intestinal tract can reduce infection of the peritoneal cavity and anastomosis zone and provides high biological, physical tightness of the intestinal tract. Of particular interest are deepidermized cryolyophilized xenodermoimplants from pig skin, which contain active biological substances, in particular growth factors, that can positively affect the regeneration process in damaged tissues. [6]
A part of the intestine is removed into the laparotomy wound, it is crossed, making a linear incision through all its layers. Intestinal integrity was restored, forming an end-to-end anastomosis. The intestinal wound was sutured with a single-row nodal inverting suture, nodules on the outside (atraumatic needle, monofilament suture material 6/0). The intestinal suture line is strengthened with a strip of sterile DCC pre-im-mersed in a sterile solution of 0.9% sodium chloride (5 min.), Which closes the intestinal anastomosis line and the adjacent part of the intestine (0.5 cm from the anastomosis line); fixed to the surface of the intestine at the corners and middle of the serous serous nodal sutures with atraumatic suture material 6/0. The laparotomy wound was sutured tightly and treated with 5% iodine solution [6].
Thus, to prevent the failure of intestinal anastomoses, the following sequence of measures should be followed:
In the preoperative period:
1. Improving the rheological properties of blood and tissue perfusion.
2. Correction of anemia and hypoproteinemia.
3. Antibiotic prophylaxis
4. Preoperative cleansing of the colon.
In the postoperative period:
1. Gentle diet to create a state of physiological rest for intestinal anastomosis.
2. Antibacterial therapy.
3. Improving the rheological properties of blood and tissue perfusion.
4. Elimination of anemia and hypoproteinemia.
The problem of failure of the sutures of the intestinal wall is one of the important problems in the surgery of the gastrointestinal tract. Most postoperative peritonitis, abdominal abscesses, laryngeal fistulas, as well as complications and lethal consequences associated with relaparotomies are primarily due to the failure of the sutures. Reducing cases of intestinal suture and anastomosis failure is the goal of all abdominal surgeons.
References
1. Polianskyi I., Moskalyuk V., Maksymyuk V., Moroz P., Voytiv Y. New patterns of development and course of acute peritonitis and its treatment. Archives of the Balkan Medical Union. Conference papers. 2013;48:28-29.
2. Telem D.A., Chin E.H., Nguyen S.Q., Divino
C.M. Risk factors for anastomotic leak following colorectal surgery. The Archives of Surgery. 2010. Vol. 145, N.4. P. 371-376
3. Polianskyi I., Voytiv Y., Moroz V., Moskalyuk V. Algorithm of intraoperative prevention of intestinal sutures and anastomoses. Clinical Anatomy and Operative Surgery. 2011; T10 N 4 74-76.
4. Znaievskyi M. I. Experimental-clinical substantiation of the use of fibrin glue and temporary intestinal endoprotectors in intestinal surgery. Qualifying scientific work on the manuscript. Kyiv, 2018; 44:115
5. Viltsanyuk O., Lutkovskiy R., Khutoryanckiy M. Explanation of the use of polypropylene fibers modified by carbon nanotubes and antiseptics for prevention of intestinal anastomosis failure. Kharkiv Surgical School. 2010 N 6 (44) 44-46
6. Suchodolya A.I., Nazarchuk S.A., Dmitriev
D.V. Substantion of xenodermoimplants use for the prophylaxis of intestinesuture and anastomosis fail-urein critically ill oncological patients. Pain, Anesthesia and Intensive Care 2015; N 3 44-47
