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II. ХИРУРГИЯ
МРНТИ 76.29.47
ACCOMPANYING DYSFUNCTION OF THE
ABOUT THE АUTHORS
Sarsenbayeva Gulzhan Iskandirovna -
Ph.D., pediatric cardiac surgeon. Deputy Director for Science, Scientific Center for Pediatrics Pediatric Surgery, Ministry of Health of the Republic of Kazakhstan. 87772337581, E-mail: gulzhan75@mail
Julia Burdukova, resident of Cardiology, KazNMU named after S. Asfendiyarov for 3 years
GASTROINTESTINAL TRACT IN CHILDREN AFTER CARDIOSURGICAL SURGERY
Sarsenbaeva G.I., Burdukova Yu.N., Supieva A.K., Niyazbekova L.A.
Scientific Center of Pediatrics and Pediatric Surgery, Almaty, Kazakhstan.
Keywords
congenital heart defects, children, cardiac surgery, intestinal dysfunction, necrotizing enterocolitis, extracardiac diseases
Abstract
The article presents the clinical and instrumental features of dysfunction of the gastrointestinal tract in patients with congenital heart defects after surgery under artificial blood circulation. It was noted that in 63.3% of cases, children showed signs of dynamic intestinal obstruction; 36.7% of newborns show signs of necrotizing enterocolitis of various degrees. The features of the bacteriological landscape, clinical manifestations and X-ray picture are presented depending on the type of intestinal function disorder. The role of hypoxia, hypoperfusion during the artificial blood circulation, the functioning of the open arterial duct in "blue" patients in the formation of risks of necrotizing enterocolitis is shown.
АВТОРЛАР ТУРАЛЫ
Сэрсенбаева Гулжан Ескенд'рчызы
- m.f.k., бала кардиохирургы, Педиатрия жэне балалар хирургиясы Fылыми орталы^ы директорыньщ FbrnbiM женшдеп орынбасары, 87772337581, E-mail: gulzhan75@mail
Бурдукова Юлия Николаевна -
С.Асфендияров атындаFы КазУМУ-дщ кардиология бойынша 3-шi оку жылындаFы резидентi
Туйш сездер
туа бткен журек акдуы, балалар, кардиохирургия, шек дисфунк-циясы, вл'1еттенц '1руш'1 энтероколит, экстракардиалдык ауру
Кардиохирургиялык отадан кейш балалардагы асказанчшек жолдарыньщ косарласкан бузылыстары
Сэрсенбаева Г.И., Бурдукова Ю.Н., Супиева А.К., Ниязбекова Л.А.
Педиатрия жэне балалар хирургиясы ?ылыми орталы^ы, Алматы к,., К,азак,стан
Ацдатпа
Макалада жасанды кан айналымы жагдайында туа бткен журек акдуы бар наукастардыц отадан кей1нп асказанчшек жолы дисфункциясыныц клиникалык-аспаптык ерекшел1ктер1 усынылды. 63,3% жардайда бала-ларда ¡шект1ц динамикалы тарылуыньщ белглерi, 36,7% нэрестеде некрозды энтероколиту эртурл1 децгейдеп белг'шерi байкалды. 1шек кызмет бузылысыныц турлер1не байланысты бактериологиялык пейзаж, клиникалык блну жэне рентгенологиялык кер1нЫц ерекшел1ктер1 усынылды. Жасанды кан айналымы кезнде гипоксияныц, гипоперфузияныц рел1 жэне некрозды энтероколиттц даму тэуекелдер1н1ц калыптасуында «кегерген» пациенттердеп ашык артериалдык езект1ц жумыс iстеу1 керсетшд1.
ОБ АВТОРАХ
Сарсенбаева Гульжан Искенди-ровна - к.м.н. детский кардиохирург. заместитель директора по науке Научного центра педиатрии детской хирургии МЗ РК. 87772337581, E-mail: gulzhan75@mail
Бурдукова Юлия Николаевна
- резидент 3 года по кардиологии КазНМУ имени С.Асфендиярова
Сопутствующая дисфункция желудочно-кишечного тракта у детей после кардиохирургических операций
Сарсенбаева Г.И., Бурдукова Ю.Н., Супиева А.К., Ниязбекова Л.А.
Научный центр педиатрии и детской хирургии, Алматы, Казахстан
Ключевые слова
врожденные пороки сердца, дети, кардиохирургия, кишечная дисфункция, некротизиру-ющий энтероколит, экстракар-диальные заболевания
Аннотация
В статье представлены клинико-инструментальные особенности дисфункции желудочно-кишечного тракта у пациентов с врожденными пороками сердца после операции в условиях искусственного кровообращения. Отмечено, что в 63,3% случаях у детей встречались признаки динамической кишечной непроходимости; у 36,7% новорожденных признаки некротизирующего энтероколита различной степени. Представлены особенности бактериологического пейзажа, клинических проявлений и рентгенологической картины в зависимости от типа нарушения кишечной функции. Показана роль гипоксии, гипоперфузии во время искусственного кровообращения, функционирования открытого артериального протока у «синих» пациентов в формировании рисков развития не-кротизирующего энтероколита.
ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 4-2018
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Actuality
Necrotizing enterocolitis (NEC) remains the most difficult and least studied problem in pediatrics [1, 2, 5, 6]. In child's cardiac surgery low perfusion pressure during artificial circulation (AC), small cardiac output in the postoperative period, aggravated by sympathetic vasoconstriction due to a stressful response to the operation, and the introduction of exogenous catecholamines generate reduced perfusion of the internal organs of the abdominal cavity. According to literature data, NEC refers to severe, relatively rare complications, arising after surgical interventions on the heart [3, 4]. NEC, arising in the postoperative period, is often not recognized in a timely manner, the child accordingly does not receive the necessary treatment, which can lead to a fatal outcome.
Material and methods
There were analyzed medical histories of 30 children, hospitalized in the Scientific Center for Pediatrics and Pediatric Surgery with congenital heart diseases (CHD) and vascular malformations for the period 2014-2017.
All children underwent standard research methods: echocardiography, chest X-ray, clinical and laboratory studies, bloodtests on fetal infections, on procalcitonin, immunogram, angiocardiography, CT and MRT on indications, bacteriological examinations of smears and sputum, abdominal radiography in standard positions.
Results and discussion
Among the patients studied, the age structure included 18 infants, children under 6 months old -10 children, over 1 year - 2 children. All patients underwent interdisciplinary therapy with a neurologist, pulmonologist and neonatal surgeon, specialists in radiation diagnostics, infectious diseases and nephrologists.
Analysis of clinical manifestations in children in the pre-operative and postoperative periods showed that in 19 cases (63.3%) were signs of dynamic intestinal obstruction. This group of children comprised: 7 newborns (36.8%) and 12 post-neonatal patients. All patients were after heart surgery (2 patients after pulmonary artery narrowing and 10 operated under artificial circulation). In this group of patients, clinical symptoms were observed in the first 24 hours after the operation as a moderate uniform bloating, a scant "light" stagnant gastric discharge, and there was heard listless peristalsis of the intestine. There was noted only moderate gas filling of the intestinal loops in these patients on the series of survey radiographic images of the abdominal cavity organs. Conditionally pathogenic microflora is isolated in 36.8% of cases in bacteriological monitoring in this group of patients before the operation and after (smears from the pharynx,
blood and bucket sowing).
There were conducted conservative therapy of paretic postoperative intestinal obstruction and intensive therapy of somatic status in this group of patients. The measures were effective, which allowed the symptoms of intestinal pathology to be quenched in patients without complications.
The most complex and severe group of patients after heart and vascular surgery were children with congenital heart diseases (CHD) who developed signs of necrotizing enterocolitis (NEC) - 11 patients (36.6%). 10 children were newborns, 1 patient older than 5 years (after Fontaine's surgery with severe multi-organ failure, who was on dialysis).
The group of patients with "pale" CHD were presented by 1 patient with a critical coarctation of the aorta 3 patients (with an aortic arch interruption, an interventricular septal defect with coarctation of the aorta) and 3 patients with an aortic arch interruption, an interventricular septal defect with coarctation of the aorta. "Blue" CHD were presented by 4 patients (with transposition of trunk - 2, total abnormal drainage - 1, pulmonary artery atreusia - 1). In 2 cases (25%) performed an operation without artificial circulation (with pulmonary artery atresia, superimposition of systemic - pulmonary anastamosis and resection of coarctation of the aorta), and in 75% of cases with prolonged artificial circulation (AC) (more than 60 minutes and hypothermia, in 3 cases with circulatory arrest). This group of patients had more severe postoperative period due to the development of severe postperfusion syndrome, heart failure, multiple organ disorders.
In this group of patients 7 (63.6%) diagnosed "uncomplicated" NEC 1 and 2 stages; in 4 cases (36.3%) - NEC with the development of peritonitis and intestinal perforation. In the most cases, there were children with CHD who underwent an open-heart surgery under artificial circulation and spent more than 7 days on ventilatory ventilation due to heart failure and multiple organ dysfunction, sepsis.
In patients diagnosed with uncomplicated NEC, clinical manifestations were: unevenly increased bloating of abdomen, lax intestinal peristalsis, moderate stagnant duodenal content from the nasogastric tube, lack of stools. In the resulting of X-ray examination non-uniform gas filling of the gastrointestinal tract was noted. In the X-ray contrast study there were manifestations of dynamic intestinal obstruction, the phenomenon of a "static" loop. The uneven, moderately pronounced dilatation of the intestinal loops, sluggish peristalsis or its absence were determined with ultrasound of the abdominal cavity. All patients were regularly examined by a neonatal surgeon. The conservative therapy of NEC was performed by adequate antibiotic therapy (including the sensitivity of the microflora), metronidazole, complete parenteral feeding with decompression of the gastrointestinal tract and low cardiac output, correction of hypoxemia, electro-
lyte balance, microcirculation, immunotherapy. In the result of treating the signs of NEC were gone. In a bacteriological study of sputum, a mixed culture planted in most cases: Strep. spp, Staph. spp, Enterobacter spp. In the hemocultures bloodtests Staph. Interme-dius was detected in 2 cases, in the remaining 5 cases the blood culture was clean. In the intensive care unit (ICU) on the ventilator were treated 4 patients with the predominant flora of Staph. spp, mainly coagulase-negative, multi-resistant staphylococci. There were 2 patients with Staph. spp in the ICU. By them followed representatives of the family of Eterobacteriaceae in 2 patients and fungi of the genus Candida spp in 1 case. In a bacteriological study a klebsiella seeding, multidrug-resistant to antibiotics from the enterobac-ter family was received.
Complications in the form of preperforation and intestinal perforation with peritonitis developed in 4 cases (13.3%) in patients with NEC 3 and 4 stages. According to our analysis, this severe group of patients included patients with "blue" CHD, severe arterial hyperoxemia, which discharged prior to surgery. All of newborns entered in the clinic with very serious condition due to severe hypoxemia, heart failure, without infusion of vasoprostan at the stage of primary health care (PHC). From the anamnesis these patients underwent intrapartum hypoxemia (according to APGAR 3-5-6 points, weighed obstetric anamnesis, intrauterine pneumonia). In the structure of CHD in these children 75% newborns had a simple form of transposition of the main vessels (TMV), 25% new-borns had a total anomalous drainage of the pulmonary veins without a defect in the interatrial septum. Considering the ductus-dependent CHD and severe arterial hypoxemia, after preoperative preparation, all the newborns were operated in the conditions of AC (more than 120 minutes) and deep hypothermia. According to the analysis, in the postoperative period a severe postperfusion syndrome was marked in all patients: cardiac weakness, respiratory insufficiency, neurological disorders. All of these patients were on prolonged mechanical ventilation for more than 2 weeks. In the first day of the postoperative period acute renal failure (ARF) was developed in all cases, with further transformation to a septic state. A sepsis proceeded according to the hyperergic type with pronounced leukocytosis, increase of procalci-tonin and CRP, intoxication in 3 cases, and in 1 case it proceeded to the hypoergic type with leukope-nia, without hyperthermia, and moderate increase of procalcitonin. All children had bloating, sluggish peristalsis, gastro-duodenal copious discharge from the nasogastric tube. Severe swelling of the soft tissues was marked in all patients after surgery on the background of acute renal failure and the syndrome of "capillary leakage", in connection with this, it was impossible to differentiate the swelling of the anterior abdominal wall, characteristic of peritonitis.
All patients were regularly examined by neo-
natal surgeons. Daily monitoring of radiation was carried out for exclusion of acute surgical pathology from the side of the abdomen. In 1 patient with total abnormal drainage with left ventricular hypo-plasia after surgery, the diagnosis of NEC was not exposed, perforation and peritonitis were a clinical finding in a pathomorphological study at autopsy. This patient after a surgery, on a background of left ventricular hypoplasia had a low cardiac output and took high-dose catecholamine therapy. In 3 cases after correction of TMV by surgeons, the risk of NEC emergence was exposed. All children had a series of dynamic panoramic X-rays - there were no data for acute pathology from the abdominal cavity. An uneven increased swelling of the intestinal loops was on the X-rays. There were not datas for the pneumo-peritoneum on the X-rays. Sonography also noted in all cases pronounced hyperpneumo-tization of the intestine, the presence of ascites between the intestinal loops. It was regarded as manifestations of anasarka in acute renal failure. A picture of limited peritonitis developed in 1 case. The laparocentesis with drainage of the abdominal cavity was performed for this patient in the first stage, however, in dynamics there was the progression of peritonitis, so a laparotomy was performed. The risk of NEC was exposed in 2 cases, during the installation of peritoneal drainage was obtained from the abdominal cavity - a calorie content and doctor diagnosed intestinal perforation. Meanwhile after carrying out of X-Ray of the abdominal cavity in the frontal and lateral positions in these patients, there were no signs of acute surgical pathology, in particular, intestinal perforation. Emergency laparotomy, with resection and removal of the intestinal stoma carried out for all children. Intraoperative with laparotomy, diffuse fecal peritonitis with intestinal perforation was exposed, it was confirmed histologically, bacteriological analyzes were taken. The most common reason of NEC are Kl. pneumonia, E. coli, clostridia, staphylococcus, streptococcus and fungi of the genus Candida according to foreign authors. It is important to note, that the surgeon examined patients in the intensive care unit, where the bacterial colonization of the child's intestines is extremely aggressive, already at the stage of peritonitis or perforation of the intestine, after a catastrophe in the abdominal cavity.
There was 1 case with presence of Klebsiella after bacteriological culture of abdominal contents in our observations. There was a conditional pathogenic flora in 2 cases. There was 1 patient with intrauterine pneumonia, he had already had bacteremia with seeding of staphylococcus. After surgery on the heart in conditions of AC this complicated the course of the postoperative period and development of septic complications, including peritonitis. All of these children received intensive therapy, including broad-spectrum antibiotics, immunomodulators, parenteral feeding,
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ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 4-2018
low cardiac output therapy, prolonged ventilation for more than 3 weeks. Despite the therapy in this group, the patients died. The cause of death was multiple organ failure and septic state. Manifestations of NEC and peritonitis were complications of the septic state.
There were more than 80% of our patients underwent surgery under conditions of AC according to our data. According to the literature data, the danger of complications' development exists after each heart surgery, in both cases: after surgical interventions in conditions of artificial circulation and under hypothermia. [Meshalkin EN, 1973, 1985]. The highest frequency of complications observed in groups of complex, especially cyanotic or combined CHD. A sepsis, multiple organ dysfunction and cardiac insufficiency, exceeding the time of operation with AC provided the decisive role in the development of complications, toxic and ischemic genesis. Maybe, the provoking factors of complications' development, including from the gastrointestinal tract and ischemia of the intestine are the non-pulsating blood flow during AC, postoperative low cardiac output syndrome, using of direct and indirect anticoagulants. There were patients of the neonatal period, including those with intestinal perforation and peritonitis in 60% of cases with manifestations of NEC and dynamic intestinal obstruction. Specifically, this group is vulnerable, where provoking factors can cause severe complications. Necrotizing enterocolitis of newborns is polyethological disease. The main pathogenetic factors are hypoxia and ischemia in the perinatal period, inadequate nutrition of the newborn and colonization of the intestine by abnormal microorganisms. There were patients with severe manifestations of NEC in our observations, who were admitted to the clinic with a very serious condition, they had intrapartum hypoxemia and intrauterine pneumonia, which aggravated after surgery under conditions of AC and hypothermia. Maybe, the factor of intestinal ischemia in cases of "blue" CHD with the presence of a neonatal arterial duct (NAD) is diastolic steal syndrome of the mesenteric arteries. There are cases of NEC in premature infants with functioning of NAD in the literature, however, we have not found any studies of the influence of NAD in patients with "blue" CHD on blood pressure in the intestinal blood flow, which
References
1. Arapova, A.V. Ulcerative necrotizing enterocolitis in newborns / A.V. Arapova, E.B. Olkhova, V.E. Shchi-tinin // Pediatric surgery, - 2003. -№ 1.- P. 11-15.
2. Karavaeva, S.A. Diagnostics and features of the clinical course of necrotizing enterocolitis in children // Bulletin of Surgery. 2002. - T. 161.-№4. -P. 41-46.
3. Sokolova O.V. Stress damage of the gastrointestinal tract in the syndrome of polyorganic insufficiency / O.V. Sokolova // Bulletin of the National Medical-Surgical Center. N.I. Pirogov, -2012. - T. 7, No. 2.- P. 111-117.
4. Shevchenko J.L. Complications of the digestive system in the hospital period after cardiac surgery
requires further study. As for the influence of catecholamines on the body, it is known that they cause a spasm of the abdominal cavity vessels. In our cases, all patients received exogenous catecholamines: epinephrine, norepinephrine, dopamine. The cardiotonic support was high doses of catecholamines in the group with low cardiac output.
According to our observations, the typical clinical signs of perforation of the intestine and peritonitis disguise in "blue" patients, in "edematous" patients, who received long-term infusions of muscle relaxants and morphine in the early postoperative period. The clinical picture of acute surgical pathology in the abdominal cavity had its difficultly differentiated features, both clinical and diagnostic, as it was flatten out by the general severe condition of the patient after heart surgery in conditions of AC and the characteristics of the CHD.
Conclusions
Thus, according to our clinical observations, we made the following conclusions:
1. The presence of background pathology, severe anamnesis, intrapartum hypoxia, inadequate intensive therapy at the level of PHC in children, especially with "blue", ductus-dependent CHD, are the risk of complications after surgery in conditions of AC and hypothermia, including NEC.
2. A comprehensive radiological study (including X-ray, ultrasound, computed tomography) should performed in a group of patients at risk of developing NEC and intestinal perforation after heart surgery.
3. The presence of hyperpneumatization and fluid sequestration between the intestinal loops in the sonography of the abdominal cavity can be regarded as a predictor of the development of severe NEC and peritonitis.
4. The interpretation of the radiographic picture and clinic of acute surgical pathology in the abdominal cavity may be difficult in the group of severe patients, who are on prolonged ventilation, receive morphine infusion, muscle relaxants and have the signs of an anasarka.
/ J.L. Shevchenko, Yu.M. Stoyko, Yu.I. Gorokho-vatsky, A.L. Levchuk, V.P. Tyurin, L.V. Popov, O.V. Sokolova // Bulletin of the National Medical-Surgical Center. N.I. Pirogov. -2014.T. 9, No. 1. - P. 14-18.
5. Epelman M., Daneman A., Navarro O.M. et al. Necrotizing enterocolitis: review of state-of-the-art imajing findings with pathologic correlations // Radiographics. - 2007. - Vol. 27. - P. 285-305.
6. Brook I. Microbiology and management of neonatal necrotizing enterocolitis // Am. J. Perinatol. - 2008. - Vol. 25. - P. 111-118.
