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14«C@yL@qyiym-J®yrMaL»#19î71),2©2© / MEDICAL SCIENCES
MEDICAL SCIENCES
Berdiev Ergash Abdullaevich,
Candidate of Medical Sciences Deputy Director for Innovation and scientific activity of Termez branch Tashkent Medical Academy Zhumaev Mamoziyo Yusupovich, Candidate of Medical Sciences Davlatov Utkir Hamdamovich Candidate of Medical Sciences DOI: 10.24411/2520-6990-2020-12040 PREDICTION OF THE TENDENCY FOR THE ADHESIVE PROCESS IN CHILDREN AFTER
SURGICAL INTERVENTIONS
Abstract.
The authors studied the pathogenetic factors of the individual tendency of the adhesive process of each patient (27) individually. The results of the study showed that about 50% ofpatients have a tendency to adhesions. The indicators determining the tendency to adhesion formation are a sharp inhibition of fibrinolysis and an increase in the concentration of fibrinogen in operated children. Based on this, appropriate measures have been taken for the early prevention of adhesions.
Key words: adhesive intestinal obstruction, diagnosis, prevention, treatment.
Relevance: The treatment of adhesive intestinal obstruction (AIO) continues to be one of the important problems in surgery. The incidence of AIO after operations on the abdominal organs, according to the literature, ranges from 25% to 80%. One of the most common reasons leading to unsatisfactory treatment results for patients with adhesive intestinal obstruction is untimely diagnosis. In 30-40% of patients, surgery is performed more than 24 hours after the moment of illness, and postoperative mortality in this group of patients reaches 19-20%. In this aspect, attempts to improve the methods of diagnosis are quite justified, and also find new ways that could help in the shortest possible time to recognize adhesive intestinal obstruction. Thanks to scientific and technological progress in recent years, a whole group of new technologies for radiation diagnostics, such as ultrasound, MRI, CT, et.c. All this provides the need for a serious adjustment of the laws established over many years and reassessment of the current arsenal of instrumental research [2, 3, 5]. The issues of diagnosis, treatment tactics, rehabilitation and prevention of this formidable complication of abdominal surgery have again and again become the subject of study and discussion and still remain in the focus of attention of researchers and practitioners [1, 2, 4]. The problem concerns not only adult patients, but remains very acute in childhood surgery.
The relevance and unresolved issues of AIO in children are due to the high frequency of occurrence of pathology, a tendency to relapse (up to 7-10%), a high level of complications and mortality (up to 31.5-40%). According to available literature data, adhesions with obstruction most often develop in childhood after appendectomies (up to 37.5%), operations to eliminate obstructive obstruction (up to 22.9%), coloproctologi-cal operations (up to 10%) [2, 4, 5 , 7, 8]. Any surgical intervention on the abdominal organs is accompanied
by the development of an adhesion process of one degree or another. AIO is a polyetiologicaldisease, there are many reasons that initiate the process of adhesion formation. These include mechanical trauma to the intestine, an aggressive effect on the intestinal wall of certain exogenous chemicals, inflammatory diseases of the abdominal organs, intestinal paresis and some other factors. Consideration of the above factors underlies the pathogenetic approach to the treatment and prevention of adhesive disease [2, 3, 4, 6]. Adhesion often causes deformation of the intestinal tube with the development of obstruction of the digestive tract. Moreover, AIO is one of the most formidable complications of the postoperative period, since delayed diagnosis and untimely or incorrectly selected treatment can lead to intestinal necrosis due to the development of strangulation of the latter. Timely diagnosis and the right treatment tactics depending on the type of AIO are crucial in the outcome of the disease, and an integrated approach to the rehabilitation and prevention of pathology determines a positive prognosis and the absence of relapse.
It is known that each person is one in the anatomical aspect, but in physiology, psychology and physiology of the nervous system is clearly different from each other. This thought has been proven by practice. We have analyzed the medical history of patients for the period 2008-2019, operated on for acute surgical pathology of the abdominal cavity.
The analysis showed that out of 3,128 operated children with various pathologies, 263 (8.4%) patients were admitted with a picture of adhesive disease, 687 (22%) children came with periodic abdominal pain. These data indicate that not all patients have an adhesive process that is the same. Along with this, during a conversation with parents of 49 children, it was revealed that of them 27 (55.1%) underwent surgery in the abdominal cavity (appendectomy-12, perforation of a duodenal ulcer-7, strangulated hernia-5, and about the
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injury abdominal organs-3). But only 9 (33.3%) had adhesive disease and 3 of them were operated on for adhesive intestinal obstruction. The aim of the work was to study the individual tendency to adhesions, which performed surgical interventions in the abdominal cavity in children.
Materials and research methods.
It is known that one of the key points in the pathogenesis of the formation of postoperative adhesions is a violation in the tissue fibrinolysis system (1,2,3). We decided to study the state of fibrinolysis and fibrinogen concentration, before surgery, during surgery, and in the postoperative period for 5 days.
27 patients with acute destructive appendicitis (phlegmonous, gangrenous) were examined. Of these, 18 boys, 9 girls, aged 4 to 18 years. Patients were conditionally divided into two groups. The first group included 16 (59.2%) children who, prior to the operation, were informed that surgery was planned. And the second group included 11 (40.3%) who were not given information about the operation, it was said that an examination was planned.
Venous blood was taken from all children after 2 hours to study the concentration of fibrinogen and blood fibrinolytic activity.
Study Results and Discussion
In patients belonging to the first group of 16 (59.2%), an increase in the concentration of fibrinogen was revealed in 9 (56.2%), which amounted to 412 ± 18.4 mg%, but 3 of them (10.3%) had fibrinogen increased from 468 to 488 mg%. In the remaining (18) patients, fibrinogen was in the range of 364-400 mg%. These indicators are also considered to be high compared with the norm (normal average 338 ± 26 mg%). In patients belonging to the second group of 24 (45.2%), only two showed an increase in fibrinogen concentration to 394 mg%. And the rest of the indicators were close to normal numbers. These data indicate that if the patient knows that the operation is planned, the body is preparing for this, which is a protective reaction. No wonder Oxner, (1930) spoke at one time; "If the abdominal cavity did not have the ability to form adhesions, surgery was hardly feasible."
During laparoscopic surgery, blood tests for fi-brinogen concentration and fibrinolytic activity were repeated. Moreover, in all patients, the increase in fi-brinogen concentration was different from 480 to 1240 mg% and averaged 844 ± 28 mg%. Along with this, a sharp inhibition of blood fibrinolytic activity was detected, which ranged from 96 to 158 mg% (at a rate of 310 ± 8.7 mg%), an average of 136 ± 7.6 mg%. These indicators testified to the fact that against the background of a sharp inhibition of blood fibrinolytic activity, optimal conditions are created for the conversion of fibrinogen to fibrin, and fibrin passes into collagen, which is the beginning of the adhesion process. In addition, we can say that the increase in fibrinogen concentration in some patients was 1.5-3 times. And fibri-nolytic activity also coincided with the concentration of fibrinogen. These data suggest that in those patients whose fibrinolysis inhibitors are within normal limits, the concentration of fibrinogen increased by 1.5-2
times and fibrinolytic activity was expressed, not inhibited. Only in those (17) patients who had deficiency of inhibitors, there was a sharp increase in the concentration of fibrinogen and inhibition of fibrinolytic blood activity.
The obtained research data showed that in those patients in whom the concentration of fibrinogen increases sharply and fibrinolysis is inhibited, they are prone to adhesions. Naturally, these patients require appropriate correction of fibrinolytic activity for early prevention of adhesions. For this purpose, at the end of the operation, a fibrinolytic mixture consisting of hep-arin 10,000 units + fibrinolysin 20,000 units + hydrocortisone 125 mg + gentamicin 80 mg + novocaine solution 0.25% -200 was injected into the abdominal cavity at the end of the operation. In those (17) patients, to whom the microirrigator was left in the abdominal cavity, the same mixture was taken after 6-8 hours.
6 hours after the infusion, venous blood was examined again. At the same time, there was a decrease in fibrinogen concentration compared to the initial data to 614 ± 14 mg% P <0.001 (initially 844 ± 28 mg%), an increase in blood fibrinolytic activity to 248 ± 8.4 mg% versus 136 ± 7.6 mg%. It is known that at a high concentration of fibrinogen, naturally fibrinolysis remains somewhat inhibited. Given the foregoing, continued intraperitoneal administration of the fibrinolytic mixture 2 times a day. At the end of the second and the beginning of the third day, a gradual decrease in the concentration of fibirinogen was noted, but the indices were different in all patients. Of the 53 patients, 38 (71.7%) showed a decrease in fibrinogen concentration on average 402 ± 12 mg%, and in 15 (28.3%), fibrino-gen remained high compared to normal, and amounted to 486 ± 16 mg%. Along with this, an increase in fibri-nolytic activity of 288 ± 18 mg% and 212 ± 14 mg%, respectively, is noted. Only in those patients who have a drainage tube (15), in the treatment complex, the introduction of the fibrinolytic mixture continued. On the 5th day after the operation, all patients were active, intestinal motility was well heard and intestinal passage was. Repeated analyzes showed a decrease in fibrinogen concentration on average 386 ± 16 mg% and an increase in fibrinolytic activity on average 302 ± 6.0 mg%. These indicators did not differ much from normal values. Thus, we can conclude that the concentration of fibrinogen and fibrinolytic blood activity are of key importance in the pathogenesis of adhesions. During surgical interventions, patients with a tendency to adhesion can be detected depending on the levels of fi-brinogen concentration and fibrinolytic activity of the blood. Prone to adhesions can be considered those patients who have a sharp increase in fibrinogen concentration of more than 1 million mg% and a decrease in fibrinolytic activity to 60-80 mg%. For early prevention from the moment of surgical intervention in the treatment complex, intra-abdominal administration of the fibrinolytic mixture through drainage is necessary under the control of the concentration of fibrinogen and the fibrinolytic activity of venous blood. With adequate correction of fibrinolysis within 5-6 days, a gradual normalization of these indicators is noted. Along with
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this, thanks to the early prevention of the adhesive process, a rapid restoration of intestinal motility is observed, which also prevents the adhesive process. The real prevention of adhesions is the prevention of adhesions from the beginning of the formation of fibrin and collagen, and after the appearance of connective tissue, the therapy is ineffective.
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