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Karimov Shavkat Ibragimovich, PhD, MD, Professor of department of faculty and hospital surgery of Tashkent medical academy, Uzbekistan
Baymakov Sayfiddin Risbaevich, PhD, docent of department of faculty and hospital surgery E-mail: [email protected],
Asrarov Askarkhon Asrarovich, PhD, MD, professor of department of faculty and hospital surgery
E-mail: [email protected]
Prevention of intestinal failure syndrome in patients with acute intestinal obstruction
Abstract: There were analyzed the results of investigation and treatment of119 patients with acute intestinal obstruction. Timely and adequate enteral treatment measures were an important stage of complex treatment of patients with intestinal obstruction (especially complicated with peritonitis) and, preventing the development of functional intestinal insufficiency, favored treatment outcomes. The studies allowed the rate of postoperative complications to be reduced from 33.9 % to 12.7 %, lethal outcome from 7.1 % to 3.2 %.
Keywords: acute intestinal obstruction, intestinal insufficiency syndrome, enteral measures, enterosorption, multiple organ failure.
The initial symptoms of intestinal failure syndrome (IFS) in acute intestinal obstruction (AIO), especially mechanical etiology, reflecting primarily pronounced inhibition of motor activity of the intestine may be the result of a reflex earlier-onset disease process. Surgical intervention against this background that becomes another factor contributing to the inhibition of intestinal motility.
Simultaneous local action and reflex factors leads to acute intestinal function failure [7; 9; 11]. Stretching increases the secretion of intestinal loops and extravasation liquid in the lumen of the gut, that the disorder causes a suction further hyperextension of the loop and a reflex inhibition of motility. These changes lead to an increase in intra-abdominal pressure, reduction of the diaphragm excursion and result in respiratory failure, causing a buildup of tissue hypoxia and weighing condition of patients [12; 13].
Consequently, the initial intestinal dysmotility contribute to the development of the IFS, which is the initial link ofsevere pathological
processes causing growing dramatically with the development of metabolic changes in this background of multiple organ failure (MOF) and leading to the death of the patient [12; 16]. Therefore, after the elimination of the causes ofAIO, especially when complication peritonitis, the complex treatment should include prevention of IFS and endogenous intoxication syndrome (EIS), starting with a powerful detoxification therapy, drainage of the abdominal cavity, intubation bowel nasointestinal probes and ending intra-abdominal (lavage or dialysis), and also performing in the early postoperative enteral treatment measures: bowel decompression (BD), intestinal lavage (IL), enterosorption, etc. [2; 3; 6; 15; 16]. Different using methods are often not effective without the implementation of the stimulation of the intestine [5; 8].
In this context, the aim of this study was to improve the results of treatment ofpatients with AIO by developing and improving enteral treatment measures: BD, IL and enterosorption.
Material and methods Medical Academy for the period 2008-2014. Age of the patients
We analyzed the results of treatment of 119 patients with acute ranged from 16 to 80 years. The share of man was 74 (62.2 %), mechanical intestinal obstruction, non-tumor origin, who was and women — 45 (37.8 %) patients. Types of AIO are presented hospitalized to the clinic of Surgical Department of the Tashkent in table 1.
Table 1. - Patients with AIO
Types of intestinal obstruction Control group Main group
Mixed 29 (51.8 %) 41 (65.1 %)
Adhesive 27 (48.2 %) 23 (36.5 %)
Intussusception 2 (3.6 %) -
Strangulation 20 (35.7 %) 15 (23.8 %)
Volvulus 17 (30.4 %) 10 (15.9 %)
Formation of nodes 3 (5.3 %) 5 (7.9 %)
Obturation 7 (12.5 %) 7 (11.1 %)
Foreign body 2 (3.6 %) 2 (3.2 %)
Bile stones 2 (3.6 %) 4 (6.3 %)
Besoars 3 (5.3 %) 1 (1.6 %)
Total: 56 (100.0 %) 63 (100.0 %)
Types of surgeries
Adhesiolysis 27 (48.2 %) 38 (60.3 %)
Resection of intestine with resto-ration of intestinal passage 15 (26.8 %) 15 (23.8 %)
Unvolvulus 8 (14.3 %) 4 (6.4 %)
Enterotomy, remove of foreign body 4(7.1 %) 6 (9.5 %)
Desinvagination 2 (3.6 %) -
The structure of postoperative complications
Failure of suture 2 (3.6 %) -
Continuing peritonitis 2 (3.6 %) -
Eventration 1 (1.8 %) -
Small intestine hole 1 (1.8 %) 1 (1.6 %)
Early adhesive obstruction 2 (3.6 %) -
Pneumonia 1 (1.8 %) 2 (3.2 %)
Acute myocardial infarction 3 (5.4 %) 2 (3.2 %)
Surgical site infection 5 (8.9 %) 3 (4.8 %)
Complication due to long stay of catheter in the vein 2 (3.6 %) -
Total: 19 (33.9 %) 8 (12.7 %)
According to the table 1, the most common cause ofAIO was mixed out intestinal obstruction (70 patients), and the highest share occupied adhesive (50). Patients received after a day or more from onset of disease were 57 %. A direct correlation elapsed between the time from the onset of the disease, the severity of the patients and the pathological changes in the abdominal cavity.
The control group consisted of 56 patients, most of whom arrived to the clinic at the stage prior to this study, or for technical reasons it was not possible to produce transnasal intubation of the small intestine during surgery (massive adhesions in the abdominal cavity, is extremely serious condition of the patient), or for spontaneous removal of sick nasointestinal probes. A nasogastric tube was placed immediately after surgery for all of these patients in order to evacuate the contents of the gastrointestinal tract.
63 patients of the main group of traditional therapeutic measures after the removal of the source of AIO during the operation, have been supplemented: transoral intubation of the small intestine dual-channel plastic probe and performing intraoperative BD. After that, the probe was removed and made transnasal intubation of the small intestine thinner silicon probe the original design, to perform in the early postoperative enteral measures: BD, IL and enterosorption.
In the early postoperative period nasointestinal probe was used for enteral planned measures: BD, IL and enterosorption. The effectiveness of the gastrointestinal tract decompression was evaluated
using the following signs: improving the overall condition of the patient, the absence of abdominal distention and pain, the appearance of intestinal peristalsis, reduce of indicator of intoxication, as well as the improvement of peripheral and central hemodynamics, restoration of basic clinical and biochemical parameters of blood.
IL carried out to improve the passage of the small intestine and the additional-term correction of fluid and electrolyte balance salt solution. According to its electrolyte composition solution was similar to the intestinal chyme. IL started immediately after surgery (the first day), introducing the infusion of 1500 ml. of saline in 4 series (per day) through a small lumen of the probe, with an exposure of 30 minutes followed by aspiration.
In the future, as the improvement of methods of treatment, patients in the terminal stage of the toxic and diffuse purulent peritonitis with a view to further detoxification carried enterosorption. In contrast with the commonly held IL at enterosorption of the saline was added enterosorbent (enterosgele) at the rate of 4 g/kg of patient weight, and the method of its implementation is not particularly distinguished.
This procedure was conducted 3-4 times per day, series, and stopped at least the appearance of water and electrolyte absorption that is an indication for the implementation of the test sample.
The degree of endogenous intoxication was evaluated on the content medium mass molecules in serum, as well as index of leukocyte of intoxication (Kalf-Kalif index). Status of motor activity
of the gastrointestinal tract in the immediate postoperative period was controlled by the X-ray and indicators for the peripheral po-lielectroenterography G. D. Sobakin on the unit EGS-4m with integrated special filter.
Results of the research
The most characteristic symptom of AIO in patients from both groups had pain: 62 (52.1 %) — severe and constant, in 35 (29.4 %) — paroxysmal in 22 (18.5 %) — a sharp, constant. Pronounced tachycardia was observed in 100 (84 %) patients, fever — in 19 (16 %), delayed stool and gas — in 86 (72.3 %). Most intestinal peristalsis has been strengthened and had a spastic character (46.2 % of cases), sometimes completely absent (24.4 %), although sometimes mentioned at the beginning of its gain, and later disappearance (30.3 %), bowel sounds. On plain film "bowl" of Kloyber were detected in 83 (69.7 %) patients, and single swollen bowel loops — in 36 (30.3 %).
Serous fibrinous effusion was registered in 21 patients, the serous — in 18 patients, purulent — at 16. Diffuse peritonitis ascertained in 2 patients in the control group and in 6 patients from the main group, who was received 72 hours after onset of the disease.
Standard complex of treatment used in 3 stages. Correction of fluid and electrolyte balance, acid-base balance, disorders of hemodynamic and respiratory functions of vital organs, taking into account co-morbidities were performed in the preoperative period, as well as measures aimed at eliminating AIO conservatively, which lasted about two hours.
Surgical intervention to remove the cause of intestinal obstruction was performed after failure of conservative treatment in these terms.
Basically surgery was to eliminate the source of intestinal obstruction. In 30 (30.3 %) patients the operation ended with bowel resection with restoration of intestinal passage — installed of entero-entero anastomosis "side to side".
A nasogastric tube was installed for patients in the control group for the gastrointestinal tract decompression. Exudates evacuation, irrigation of the abdominal cavity with antiseptic solutions, novocainisation root of the mesentery of the small intestine and abdominal drainage were carried out in the presence of acute diffuse peritonitis. Abdominal drain was conducted by the method developed in our clinic (by Karimov Sh. I. et al.) for peritoneal dialysis in the postoperative period.
Intensive infusion and antibiotic therapy with the inclusion of parenteral nutrition, gastrointestinal decompression with nasogastric tube were conducted postoperatively. The majority of patients in the control group continued intestinal paresis hampered passive outflow of the contents of the digestive tract, and attempts to active aspiration of single lumen gastric probe proved unsuccessful due to the suction effect of the gastric mucosa, which prevented adequate decompression of the gastrointestinal tract. All this played an important role in the development of specific and non-specific complications in 22.7 % of patients.
Preoperative management of main and control group's patients was not significantly different. In contrast to the implemented remedial measures in the control group, 63 patients of the main group of traditional healing activities undertaken during the operation, it has been supplemented: technical support for enteral planned activities both during surgery and in the early postoperative period.
Overall the majority of the main group's patients remained severe due to severe intoxication in the early postoperative period. Drug-induced intestinal stimulation was started on the day after surgery. Nasointestinal probe was connected to active aspiration in the active mode, BD, IL and enterosorption in the early postoperative period. Following the success of the BD series enterosorption
injected into the small intestine 20 % enterosgele solution, which after 30 minutes of exposure was removed by active aspiration.
The amount of liquid aspirated during intraoperative BD ranged from 900 to 2700 ml. (mean 1255.0 ± 25.5 mL). A direct correlation was observed between the separated liquid amount from the intestine and the severity of peritonitis.
A similar pattern was also observed at postoperative BD and in the early postoperative period. Thus, in the 1st postoperative day in patients without signs of diffuse peritonitis the amount of separated liquid from nasointestinal probe was 650.0 ± 28.0 ml., 2nd — 240.0 ± 11.0 ml. As a rule, on the 2nd day after the operation they have seen improvement in general condition, reduced toxicity and the emergence of intestinal peristalsis. The separated liquid from nasointestinal probe became more transparent along with a reduction in its amount, lost stagnant shade, which served as an indication for removal of the probe by the end of 2 days after surgery and transfer to a mild oral nutrition.
The discharge from nasointestinal probe remained high (on the 1st day — 1250.0 ± 46.0 ml., on the 2nd — 870.0 ± 37.0 ml, on the 3rd — 820.0 ± 25.5 ml.) in patients with diffuse peritonitis despite intra-operative lavage and BD. Improvement in general condition of patients observed and the discharge from nasointestinal probe decreased to 340.0 ± 27.0 ml., resistant intestinal peristalsis was detected with a favorable course of the disease by the end of 4 days was. These signs were the indications for removal nasoin-testinal probe.
The state of the patients progressively deteriorated, it is clinically manifested by persistent manifestations of the IFS and the EIS, the MOF of nasointestinal probe continued to act murky, stagnant secretions, intestinal peristalsis is not listened to, and advancing in 2 (3.6 %) patients, death by continuing sluggish peritonitis in cases of unfavorable course of the disease.
Our studies have shown that despite the elimination of the source of AIO and conducted comprehensive treatment of patients in the control group, the use of nasogastric intubation did not allow most patients to carry complete decompression of the gastrointestinal tract intraoperative and early postoperative period. The persistent postoperative intestinal paresis also hampered the passive outflow of the contents of probe despite drugs bowel stimulation and active aspiration did not give effect. Of course, all this affected the results of the treatment of this group of patients.
This was evidenced by persistent intestinal paresis, continuing in the early postoperative period in 19 (33.9 %) patients in the control group. Severe endogenous intoxication, electrolyte imbalance also played an important role in the development of postoperative complications (table 1), including such formidable as suture failure and ongoing peritonitis, bowel eventration and enteric fistulas. Mortality in the control group was 7.1 % (4 patients died).
The transoral intubation of the small intestine pursued during surgery with active aspiration of the gastrointestinal tract in this group of patients had quite obvious advantages. It let the vast majority of patients to carry complete decompression of the stomach and small intestine. The transnasal intubation of the small intestine with thinner dual-channel silicone probe during the operation and conduction of early postoperative active BD, IL and enterosorption contributed an additional correction of electrolyte metabolism and detoxification by enteral way in the vast majority of patients. We saw earlier recovery of not only the motor activity of the intestine, but also its other functions, even in the presence of common forms of peritonitis due to the implementation of enteral medical actions.
The effectiveness of enteral therapeutic measures in treatment of patients with AIO from the main group shows a significant reduction in the number of postoperative (primarily specific for this disease) complications and mortality.
So, postoperative complications were observed in 8 (12.7 %) patients in the study group. The mortality rate was — 3.2 % (2 patients died).
Conclusion
The complete set of traditional therapeutic interventions, with intra- and postoperative BD, IL and enterosorption is an important step in breaking the chain of pathogenetic IFS
patients AIO. It contributes not only to the prevention of the IFS, and reduction of endogenous intoxication, restoration of bowel function, as well as create conditions for the early activation of patients and reimbursement of energy costs and the need for plastic materials of the body naturally — enteral route. Timely and adequate conduct of enteral treatment measures: intra- and postoperative BD, IL, and enterosorption, represents an important stage of complex treatment of patients with AIO (especially when complicated with peritonitis) and prevention of IFS, reduces postoperative complications from 33.9 % to 12.7 % and mortality from 7.1 % to 3.2 %.
References:
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Bakhritdinova Fazilat Arifovna, Tashkent Medical Academy, Department of eye diseases, Doctor of medicine, Professor E-mail: [email protected]
Yusupov Azamat Farkhadovich, JV «SIHATKO'Z» LLC, Candidate of medical sciences, Chief medical officer E-mail: [email protected] Mukhanov Shavkat Abduvaliyevich, JV «<SIHATKO'Z» LLC, Ophthalmologist E-mail: [email protected]
Assessment of the quality of life of patients with age-related macular degeneration
Abstract: This article is dedicated to the study of the quality of life of patients with the help of an adapted questionnaire VFQ-25 in Uzbek language and assessment of complex treatment of early and late manifestations of age-related macular degeneration.
Keywords: age-related macular degeneration, anti-VEGF therapy, medotilin, quality of life, questionnaire VFQ- 25.
Relevance. Over the last years, there has been a significant growth of interest in the notion «quality of life» (QL) by the representatives of various spheres of medicine, including ophthalmologists, and an increase in the number of publications on this problem [1, 263; 2, 26-29]. A special importance is given to the study
of the QL of patients with age-related macular degeneration (AMD) in Europe and the USA. A steady growth of the number ofAMD patients in the world, slow progressive course of disease leading to partial sight and blindness in people over 55 years old certify about medical-social importance of this problem [2, 26-29; 3, 199-201].
