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UDC 616.381-002-089
SURGICAL TECHNOLOGIES OF OPEN ABDOMINAL MANAGEMENT IN PATIENTS WITH POSTOPERATIVE PERITONITIS
Altai State Medical University, Barnaul A.N. Zharikov, V.G. Lubyansky, A.R. Aliyev
The analysis of surgical treatment of 32 patients with postoperative peritonitis, which arose as a result of multiple perforations of the small intestine and the inconsistency of enteroenteroanastomosis, was analyzed. The severity of the condition on the APACHE II scale was 17.3 ± 1.4 points, the severity of peritonitis according to the abdominal index (Savelyev V.S. et al., 2009) - 22.6 ± 0.2 points. All patients underwent the elimination of the source of peritonitis with restoration of the continuity of the gastrointestinal tract in the course of planned sanation of the abdominal cavity. The location of perforated polymer films for the formation of a temporary laparostoma under the edges of the anterior abdominal wall showed efficacy in 13 (72,2%) patients with predominance of phlegmon of the anterior abdominal wall and in 12 (85,7%) patients with fixation of its skin with compartmental syndrome. The completion of programmed relаparotomy, the imposition of delayed interintestinal anastomosis, and the closure of the laparostomal wound were performed with the improvement of the patient's condition (APACHE II <9,6 ± 1,8 points) and the arrest of peritonitis (abdominal index <12,3 ± 2,4 points). Mortality was 40,6%. Key words: postoperative peritonitis, open abdomen, programmed relaparotomy, laparostomy.
Recently, using tactics of terminal surgical treatment, laparostomy continues to be one of the effective methods of open peritonitis management [1, 2, 3, 4, 5]. It is becoming increasingly relevant and developing with the presence of intra-abdom-inal hypertension syndrome (abdominal compartment - syndrome) and its influence on the progression of multiple organ failure (6, 7). It is established that in the formation of laparostoma with the use of gauze napkins, wound depletion, superinfection, the progression of acute viscerite, the formation of external intestinal fistula and extensive ventral hernias quickly occur [8]. At present, new methods and materials are being widely introduced in the formation of laparostoma in patients with peritonitis, including bags of Bogota [9], sandwich technologies [10], vacuum aspiration drainage [11]. However, to date, the question of the optimal option for completing operations in programmed abdominal sanitation, a temporary or final method for closing a middle wound in patients with postoperative peritonitis remains open.
Materials and methods
The basis of the work constituted 32 patients with postoperative peritonitis (PP) admitted to the hospital surgery clinic from 2016 to 2017. The men were 23 (71.9%), women - 9 (28.1%). The mean age was 58.4 ± 1.4 years. Postoperative peritonitis occurred after operations for acute adhesive intestinal obstruction, abdominal injuries, infected pancreonecrosis and was the result of multiple (from 2 to 5) perforations of the small intestine wall and the inconsistency of interintestinal anastomoses. The number of operations at the previous stages before admission to the clinic was 2.1 ± 0.3. The severity of patients on the APACHE II scale reached 17.3 ± 1.4 points, the severity of peritonitis
(V.S. Savelyev's abdominal cavity index) was 22.6 ± 0.2 points. After removal of the source of peritonitis and restoration of the continuity of the gastrointestinal tract, programmed sanitations of the abdominal cavity were performed, the regimen of which was determined after the first relaparotomy with the formation of a temporary laparostom after each sanation. The main problems in the treatment of patients with postoperative peritonitis were the phlegmon of the anterior abdominal wall and the abdominal compartment syndrome. The use of gauze tampons for the formation of laparostomy caused a violation of the drainage function and the formation of dense splices of gauze with the underlying intestinal loops, and the use of drainage pipes or handicraft materials from plastic resulted in increased traumatization of the intestinal wall with the risk of perforation and the formation of unformed intestinal fistula (Figure 1).
Figure 1. Forming laparostoma from plastic with screws
In this connection, polyethylene films (bags for infusion solutions) with multiple apertures
for outflow of exudate were used to isolate the intestinal loops from the external environment, the tissues of the anterior abdominal wall, and also to create an adequate outflow of purulent exudate as a material for the formation of a temporary lap-arostoma in 15 patients (Figure 2a). The film was loosely located above the loops of the intestine, well delimiting them from the edges of the wound of the anterior abdominal wall, easily removed when performing a programmed sanitation of the abdominal cavity. In a number of cases,
the formation of a temporary laparostomy wound was terminated by the imposition of rare ligatures (Figures 2-3) only on the skin edges of the anterior abdominal wall without capturing the aponeu-rosis. In addition, other synthetic materials were used for the temporary formation of laparostomal wounds in 3 (9.4%) observations, and, in particular, polypropylene grid of large size (Figure 2b). These materials we placed under the edges of the wound of the anterior abdominal wall by its phlegmon.
Figure 2. The use of polyethylene and polymeric materials for the formation of laparostoma wounds in patients with PP:
a - a sterile package for infusion solutions; b - polypropylene grid
In addition, in 14 (43.8%) patients with postoperative peritonitis with high indices of intra-abdom-inal pressure (more than 14 mm Hg), there were used temporary perforated polymer endoprosthe-ses with their location on the anterior abdominal wall, which increased the volume of the abdominal
cavity. Circular fixation of the film by nodal seams to the skin or with a stapler prevented its dislocation and loss of intestinal loops (Figures 3a, b). This resulted in a decrease in the manifestations of abdominal compartment syndrome.
Moreover, intestinal intubation is widely used in the clinic to combat abdominal compartment syndrome (Yu.M. Dederer, 1962). In our work, for many years we have used naso-intestinal intubation (Figure 4). Intraoperative emptying of the intestine allowed not only to form a laparostoma better, but also to perform intestinal la-
vage, enterosorption and early enteral nutrition in the postoperative period. For intestinal intubation, both standard probes and probes of the original design were used. Complications with intestinal intubation were not noted. The length of the probe presence was 3.4 ± 0.8 days.
Results and discussion
The number of programmed abdominal san-ations in patients with postoperative peritonitis ranged from 2 to 4 and averaged 2.8 ± 0.8. The interval between sanation was 36-48 hours. The location of the perforated polymer coating in the abdominal wall position for the temporary formation of the laparostomy wound at the stages of abdominal sanation was shown to be effective in 13 (72.2%) patients with postoperative peritonitis
complicated by phlegmon of the anterior abdominal wall. The use of polymeric films with fixation of it to the skin of the anterior abdominal wall was effective in 12 (85.7%) patients with postoperative peritonitis with prevalence of intraperitoneal hypertension syndrome. Later, as the open management of patients with postoperative peritonitis was mastered, in three cases we used a laparostoma with vacuum aspiration drainage (Figure 5).
Figure 3. Postoperative peritonitis: a - formation of vacuum laparostoma, b - final view of vacuum laparostoma with
aspiration.
The duration of open management of the abdominal cavity by postoperative peritonitis was 16.7 ± 1.2 days. Criteria for the end of the pro-
grammed abdominal rehabilitation and the transition to the semi-closed method of abdominal cavity management were the arrest of multichannel
insufficiency (APACHE II), clinical and laboratory signs of a decrease in the systemic inflammatory response, a reduction in its severity on the basis of a scale score (abdominal cavity index V.S. Savel-
yiev), restoration of the passage through the intestine, normalization of indices of intra-abdominal pressure (Table 1).
Table 1
Criteria for temporary laparostoma and its final closure in patients with postoperative peritonitis
Indices Temporary laparostoma Final closure of the laparostoma P
X±m X±m
APACHE II (scores) 17,3±2,5 9,6±1,8 <0,05
Abdominal cavity index (scores) 21,6±3,7 12,3±2,4 <0,05
Intra-abdominal pressure (mm Hg) 20,6±3,6 12,1+1,9 <0,05
Note: p - significance of differences between temporal formation and final closure of laparostoma
The completion of the program of the terminal surgical treatment of postoperative peritonitis was mainly due to the reduction in the severity of the patient's condition on the APACHE II scale, less than 10 points, the severity of the peritonitis (abdominal index) of less than 12 points and the decrease in the level of intra-abdominal pressure less than 12 mm Hg. During this period, measures were developed to finally close the laparostomy wound. They were carried out earlier, without waiting for mature granulations in the wound and rigidity of the edges of the anterior abdominal wall. Along with the traditional approach in the final closure of laparostomous wounds (the application of secondary-delayed sutures with granulating wounds) in an effort to form the anterior abdominal wall frame in the laparostoma region, we used original solutions. As a result of the treatment, 19 (59.4%) patients with postoperative peritonitis recovered. However, despite the ongoing surgical treatment, 13 (40.6%) patients died. Death was due to the progression of abdominal sepsis, multiple organ failure.
Conclusions
1. The severity of the patient with postoperative peritonitis, the prevalence of the inflammatory process in the abdominal cavity, the presence of the phlegmon of the anterior abdominal wall, the abdominal compartment syndrome are indications to the open management of the abdominal cavity.
2. The formation of a temporary laparostomy is an obligatory element of the programmed sanitation stage in patients with postoperative peritonitis. As materials, modern perforated polymer films can be used with their location under the edges of the anterior abdominal wall by its phlegmon or by fixation to the skin in the presence of abdominal compartment syndrome, as well as the use of vacuum aspiration systems.
3. The termination of the programmed abdominal sanation and delayed inter-intestinal anastomosing is carried out by a decrease in the APACHE
II scores of less than 10 points, an abdominal index less than 12 points, an intra-abdominal pressure of less than 12 mm Hg and implies the early closure of the laparostomy wound by superimposing secondary seams.
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Contacts
Corresponding author: Zharikov Andrey Niko-layevich, Doctor of Medical Sciences, Professor of the Department of Faculty Surgery named after Professor I.I. Neimark, hospital surgery with the course of FVE of the Altai State Medical University, Barnaul.
656056, Barnaul, ul. Lyapidevskogo, 1. Tel.: (3852) 689574. Email: zhar67@mail.ru
Lubyansky Vladimir Grigorievich, Doctor of Medical Sciences, Professor, Professor of the Department of Faculty Surgery named after Professor I.I. Neimark, hospital surgery with course of FVE of the Altai State Medical University, Barnaul. 656056, Barnaul, ul. Lyapidevskogo, 1. Tel.: (3852) 689574. Email: lvg51@mail.ru
Aliyev Aleksandr Rushtievich, Candidate of Medical Sciences, Associate Professor of the Department of Faculty Surgery named after Professor I.I. Neimark, hospital surgery with course of FVE of the Altai State Medical University, Barnaul. 656056, Barnaul, ul. Lyapidevskogo 1. Tel.: (3852) 689674. Email: science@agmu.ru
