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Ibragimov Jasurbek Khabibjanovitch, Andizhan state medical institute, doctoral student, Department of Pediatric Surgery E-mail: [email protected] Akilov Khabibulla Ataullaevitch, MD., PhD., Ds., professor Tashkent Institute of Advanced Medical Studies, Rector of the Tashkent Institute of Advanced Medical Studies
E-mail: [email protected] Toshboev Sherzod Olimovich, PhD., associate professor of Andijon State Medical Institute, E-mail: [email protected]
FREQUENCY OF OCCURRENCE OF ADHESIVE INTESTINAL IMPASSABILITY IN THE STRUCTURE OF PEDIATRIC EMERGENCY SURGICAL CARE
Abstract: According to the World Health Organization and the International Society for the Study of Adhesions (International Adhesion Society), postoperative adhesions in the abdominal cavity are the most common complication (55-70%) of abdominal surgical interventions. In more than 50% of children, acute intestinal adhesive obstruction is resolved by conservative treatment. In this work, the analysis of frequency of occurrence of adhesive intestinal obstruction (AIO) in children in three medical centers of the Republic of Uzbekistan, selected according to the principle of a multilevel system of organization of medical care.
Keyword: emergency surgical care, frequency, adhesive intestinal obstruction, children.
Background. According to the World Health Organiza- dren in three medical centers of the Republic of Uzbekistan,
selected according to the principle of a multilevel system of organization of medical care.
Material and methods. Statistical indices for 2012-2016 have been analyzed for the number of hospitalized children with various surgical pathologies, with the determination of the share ofAIO in the Republican Scientific Center for Emergency Medical Care (RSCEMC), the Andijan branch of RS-CEMC (AFRNCEMC) and the Andijan regional children's multidisciplinary medical center (ARCMMD). Primarily, the structure of pathology was analyzed in children hospitalized in these medical centers with the definition of the proportion of intestinal obstruction and, accordingly, the adhesive form of this disease. According to clinical reports, 33582 cases of hospitalization of children with various surgical pathologies were analyzed from these centers. Of these, 19.019 children had abdominal pathology, the rest - another surgical structure of the disease. In total, the prevalence of797 cases of acute intestinal obstruction (AIO) was studied, of which 491 children were hospitalized with AIO.
Static studies were conducted on the basis of standard clinical recommendations. At the first stage of the statistical analysis, the main statistical characteristics of the studied parameters were determined (mean, median, quartiles, variance, standard deviation, standard error).
tion and the International Society for the Study ofAdhesions, the postoperative adhesion process in the abdominal cavity is the most common complication (55-70%) of abdominal surgical interventions [3; 6]. Currently, the frequency of acute adhesive intestinal obstruction ranges from 50.0% to 93.3% of all other acute intestinal obstruction types of non-tumorous genesis [4]. To date, it is known that the inflammatory process is the main reason for the formation of adhesions [1; 2]. Despite numerous experimental works and clinical studies, effective preventive measures have not been developed to date. In more than 50% of children, acute intestinal adhesive obstruction is resolved by conservative treatment [5]. At the same time, the number of unsatisfactory outcomes of conservative and operative treatment remains very high. The analysis of the literature testifies that at the present time, the therapeutic and diagnostic tactics in the case of adhesive intestinal obstruction in children are one of the topical and completely unsolved problems of modern children's abdominal surgery [7; 8]. A high percentage of unsatisfactory outcomes, lack of choice of the optimal method of treatment, taking into account the age of the patient and the stage of the disease, prompt further research in this area.
Objective. Conduct an analysis of the frequency of occurrence of adhesive intestinal obstruction (AIO) in chil-
Quantitative data are presented as the arithmetic mean (M) ± standard deviation (SD) for the normal distribution and as the median (Md) and quartile (Q) or (SD) for other distributions. The reliability of differences was determined from the paired and unpaired Student t-test and the criterion of non-parametric statistics - the criterion of homogeneity x2. The correctness of the sampling was carried out by the criteria: X2 (chi - square or the so-called Pearson's agreement criterion). The reliability of the differences was determined from the pair and unpaired t-criterion of the Student. Differences were considered statistically significant at p < 0.05.
Results of the study and their discussion. For the period from 2012 to 2016, 33.582 children were hospitalized, of which 25.504(75.9%) were with abdominal pathology. Op-
erative treatment was subjected to 16963(66.5%) ofthe child, 8541(33.5%) people were conservatively treated. Postoperative mortality in the group of abdominal pathology was 0.38% (64 of 16963), the overall mortality rate was 0.38% (96 of 25504 children). In turn, the overall mortality rate among all pediatric pathologies was 0.50% (169 of33.582 children). The proportion of intestinal obstruction in the general structure was 2.4% (797). Of these, 410 (51.4%) children were operated, 387 (48,6%) were conservatively treated, postoperative mortality was 3.17% (13 of 410), and the overall mortality was 1.63% (13 of797). 281 children (57.2% out of 491) were operated with AIO, 210 (42.8%) children were conservatively treated, mortality rates were 3,20% (9 of 281) and 1.83% (9 of 491) respectively (table 1).
Table 1. - Consolidated distribution of patients according to the type of emergency surgical pathology, type of treatment and the proportion of intestinal obstruction in the total structure of hospitalized children for 2012-2016
Pathology Total Operated Conser-vative Died after surgery Died total
abs. % abs. % abs. % abs. % abs. %
Abdominal pathology 25504 75.9 16963 66.5 8541 33.5 64 0.38 96 0.38
Pathology of the kid-neys and urinary tract 3698 11.0 2783 75.3 915 24.7 2 0.07 12 0.32
Pathology of the chest 806 2.4 434 53.8 372 46.2 8 1.84 24 2.98
Other 3574 10.6 1237 34.6 2337 65.4 8 0.65 37 1.04
Total 33582 100 21417 63.8 12165 36.2 82 0.38 169 0.50
Intestinal obstruction 797 2.4 410 51.4 387 48.6 13 3.17 13 1.63
Adhesive disease 491 1.5 281 57.2 210 42.8 9 3.20 9 1.83
10%
8%
6%
4%
2%
0%
■ RSCEMC ARSCEMC ■ ARCMMD »Total
5,6%
4,4% 2,4%
1,9% 1,7% 2,5% 2,4% 3,1%
In the general structure
Among abdominal pathologies
Figure 1. Prevalence of intestinal obstruction in the structure of emergency surgical pathology in children
In (figure 1) the comparative indices of the proportion of In RSCEMC, this indicator in the overall structure of
intestinal obstruction in three children's departments of vari- the entire children's pathology was 1.9%, in ARSEMC - 4.4% ous medical institutions are reflected. and ARCMMD - 1.7%, in the structure of abdominal dis-
eases - 2.5%, 5.6% and 2.4%% respectively. When analyzing ARCMMD this index was virtually identical - 73% and 71%, the share of the adhesive form in the general structure of the whereas in the ARCEMC the AIO was determined only in intestinal obstruction, it was noted that in the RSCEMC and 44.7% (P < 0.001) (Fig.2).
Figure 2. Distribution of the structure of intestinal obstruction, depending on the etiology
Thus, in the general structure of pediatric surgical pathology, the proportion of intestinal obstruction is 2.4% (797 out of 33.582), and among abdominal diseases - 3.1% (797 out of 25.504). In turn, the share of adhesive form of intestinal obstruction accounts for 61.6% (491 of797) cases,
in the remaining 38.4%, another etiology of the disease was determined. Indicators for the share of adhesive form in the structure of the entire intestinal obstruction significantly differed in the regional branch of the emergency center, with the predominance of other etiological factors.
Figure 3. Distribution of the structure of intestinal obstruction, depending on etiology, type of treatment and lethality
No less interesting statistical analysis is the distribution of the frequency of AIO depending on the period of its de-
velopment, that is, as an early or late complication of surgical interventions on the abdominal organs. In our study, out of
797 cases of intestinal obstruction in children, 61.6% (491) fell on AIO and 38.4% (306 children) on another etiology of the disease. In turn, it was noted that in the management of these patients (conservative or surgical treatment), as well as the frequency of postoperative and general mortality, there was a significant difference in the AIO group with a predominance of the share of surgical treatment and, in fact, a half-fold increase in the risk of overall mortality (^-17.474, Df = 3, P < 0.001). Thus, 281 (57.2%) children were operated in this group, whereas in the other etiology of intestinal obstruction - 129 (42.2%), 210 (42.8%) and 177 (57.8%) were conservatively treated children. Postoperative mortality was
3.20% (9 of 281) and 3.10% (4 of 129), in turn the share of the overall mortality was 1.81% (9 of 491) versus 1.31%(4 of 306) (Figure 3).
The earliest form ofAIO was reported in 62 (12,6%) children, of which 28 (45.2%) were operated on, 34 (54.8%) were treated conservatively, postoperative mortality was 3.57% (1 case), and the general lethality - 1.61% (1). In turn, a late form of complication developed in 429 (87.4%) children, 253 (59%) were operated, 176 (41%) managed to resolve obstruction by conservative measures, postoperative mortality was 3.16% (8 cases), and the overall mortality rate was 1.86% (8) (Figure 4).
Figure 4. Distribution of early and late commissural intestinal obstruction, depending on the type of treatment and lethality
Studies have shown that AIO is one of the most difficult problems of pediatric surgery. Despite the seemingly low incidence of this complication, the results of her treatment can not be attributed to the resolved problem. First, this is due to the imperfection of diagnostic tactics, when in some cases it is the adhesive nature of the development of obstruction that can not be determined in time. This leads to belated surgical treatment and, accordingly, an increase in the frequency of postoperative complications and the risk of mortality. The other side is a long-term attempt to conduct conservative therapy, which is also unjustified in a number of cases and leads to a deterioration in the results of surgical treatment of AIO. Secondly, AIO can develop not only in the presence of phenomena of peritonitis, but also in any other surgical intervention on the organs of the abdominal cavity or other organs, the operations on which are carried out through abdominal access. The literature describes a number of risk factors for the development of this complication in surgery, ranging from
the blood group, the state of hemodynamics and the composition of blood components, concomitant pathology, up to the type of acetylation phenotype and other causes. In this case, AIO is often a recurrent disease, which in more than half the cases may require regular surgical treatment with the subsequent risk of developing a repeat episode of the disease. This significantly increases the state of children, worsens their quality of life. Third, the timely tactics of surgical treatment and the overall integrated approach to managing this group of patients, including intra- and postoperative preventive measures, also have an impact on the outcome of treatment. Later, surgical treatment, the prevalence of adhesions, the presence of peritonitis against the background of obstruction worsen the prognosis of the disease. That is why the statistical analysis performed showed a relatively high incidence of mortality in children with AIO compared with other groups of diseases.
Conclusions. In the structure of general children's emergency surgical pathology, the proportion of intestinal obstruc-
tion is 2.4% (797 of 33582 patients), among the group of abdominal diseases - 3.1% (797 of 25504 patients), of which 51.4% (410 of 797) underwent surgical treatment, with a postoperative mortality rate of 3.17% (13 patients out of 410 operated) and 1.63% (13 of797) in the total group of patients. In the structure of intestinal obstruction, 61.6% (491 out of
797 patients) accounted for the adhesive etiology, of which 57.2% (281 out of 491) underwent surgical treatment with a mortality rate of 3.20% (9 patients) and 1.83% (9 out of 491) in the total group of patients, while among other causes of obstruction, the mortality rate in the total group of patients was 1.31% (4 of 306) (j2-17.474, Df=3, P < 0.001).
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