Хирургические болезни. Практикум = Surgical diseases. Practice book. Учебное пособие

reach the ileocecal angle during the same time. Subsequent radiological investigations are performed in 6–8 hours. The retention of the stomach contents in 6 hours and of the small intestine contents in 12 hours indicates a mechanical form of AIO. To increase the informative value and shorten the study period up to 90 minutes, the probe enterography is performed through the previously inserted nasogastroduodenal probe (after the aspiration of the contents);

•if the colonic type of obstruction is suspected, an emergency irrigoscopy with double contrast is performed.

Treatment. Combination treatment of AIO includes:

•permanent gastric aspiration through an inserted nasogastric prode;

•elimination of sympathetic hypertension of the central nervous system for the normalization of parasympatheticsympathetic interaction.

It is achieved by:

•conducting a bilateral novocain paranephral blockade (according to the method of A.V. Vishnevsky);

•prolonged epidural anesthesia;

•drug block of the sympatic-adrenal system;

•stimulation of intestinal motility by:

intravenous administration of a 10% solution of sodium chloride;

intramuscular injection of anticholinesterase drugs (neostigmin, oxosyl, ubretid or proserin);

prokinetics (cerucal and spasmolytic agents of myotropic action);

•correction of hemorheological properties of blood and improvement of microcirculation of the intestinal wall;

•restoration of protein metabolism and correction of water-electrolyte disturbances;

•siphon enema administration.

In those cases when the presented complex is not effective and is not accompanied by a solution of the dynamic AIO, the mechanical nature of the intestinal passage disorders is suggested, and this complex is considered as the preoperative preparation.

Specific features of surgical treatment of AIO are:

•performing the operation only under endotracheal anesthesia using muscle relaxants;

•the optimal type of access is the median laparotomy, which allows a thorough examination of the abdominal cavity organs;

•elimination of the detected AIO cause is carried out by dissection of adheasions; disinvagination; detortion (reversal); obstructive resection of the intestine with the tumor, etc. In those cases when this is not possible, bypasses are formed or proximal colostomy is used;

•resection of the nonviable intestinal area is performed by backing down 30–40 cm for the adducting part and 20–25 cm for the abducting part (from the visible boundaries of circulatory disturbances). The restoration of

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the continuity of the small intestine, with a difference in the diameters of the adducting and abducting parts, is carried out by forming an anastomosis “side to side”, and in the presence of diffuse peritonitis is carried out by forming the jejuno-ileostomy or termo-lateral Y-shaped anastomosis with proximal protective ileostomy;

•bowel decompression by nasogastric intestinal intubation, after the completion of the main stage (in stages II–III of AIO) and after performing the resection of the intestine with the formation of anastomoses; and also with the target framework for the prevention of recurrencies of commissural IO. Preference during decompression of the intestine is given to nasogastric intestinal intubation with silicone (PVC) probes, and if it is impossible to perform – to intubation through the caecostoma (according to the method of Zhitnyuk), gastrostoma (according to Dederer) or through formed jejuno-ileostomas. In decompression of the colon (including children) preference is given to the closed technique – transanal retrograde intubation;

•in the presence of indications and technical capabilities videolaparoscopic (Hasson’s technique) or laparoscopically assisted operations from the mini-access are used.

Emergency interventions in case of obturative colonic obstruction are performed within 2–4 hours after making the diagnosis and preoperative preparation (in cases of diffuse peritonitis) due to tumor perforation or diastatic rupture of the proximal bowel site.

Urgent interventions are performed within 6–12 hours after making the diagnosis of AIO in the absence of conservative treatment effects.

Delayed interventions are carried out 10–14 days after the elimination of the phenomena of colonic obstruction, after an additional examination of the patient and correction of existing disorders and comorbidity.

Surgical treatment in colonic (tumor) obstruction should take into account the volume and extent of the tumor process; degree of AIO expression; existing complications; severity of the condition and age of the patient.

In case of cancer which is detected in more than 90% of cases and representing adenocarcinoma of different degrees of differentiation, general principles of cancer treatment should be used:

•radicality (due to adequate volume of performed resection and removal of areas of regional metastasis, zonality and sheath-like principles;

•ablasticity, consisting in intraoperative prevention of dissemination of tumor cells, antiblasticity due to intraoperative destruction of tumor cells with the help of physical or chemical techniques.

In patients who are in extremely severe condition minimal interventions are performed – the decompression of the colon above the obturation by various types of colostomies. The similar tactics can be used in stage IV of the tumor process with the presence of distant metastases or involvement of adjacent organs in the extensive tumor process.

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Chapter 14

WIDESPREAD PERITONITIS

Peritonitis (ICD 10: K65) is an acute nonspecific inflammation of the peritoneum caused by various causes, spreading to neighboring tissues and accompanied by impairment of the vital functions of the most important organs and systems of the body.

Currently, the term “intra-abdominal infection” is more commonly used to refer to widespread peritonitis and local abdominal abscesses (D. Wittmann, 1991). The introduction of the term is due to the need to combine the identical pathological processes in the abdominal cavity with the consideration of unified etiopathogenesis, but significant differences in clinical, diagnostic and therapeutic approaches. In the vast majority of cases, widespread peritonitis in the toxic and terminal stages is considered from the point of abdominal sepsis, which is facilitated by their general patterns.

Mortality with widespread peritonitis reaches 10–45%, with postoperative peritonitis and accompanying septic shock it is more than 70–80%.

Classification. Widespread peritonitis is classified according to:

•the phases of development (K.S. Simonyan, 1971):

reactive (the first 12–24 hours). It is characterized by a hyperergic reaction of the organism manifested by the maximum manifestation of local symptoms (pain, muscular defense, motor excitation, tachycardia, reflex vomiting);

toxic (lasts 24–72 hours);

terminal (> 72 hours) or progressive multiple organ failure (MOF) manifested by decompensated syndromic disorders;

•severity of intoxication (V.K. Gostishchev, 1992) – stages or degrees of endogenous intoxication:

Stage I (the first 6–8 hours) or painful. It is characterized by pain syndrome, fever, leukocytosis; endotoxicosis of the first degree;

Stage II (8–24 hours) or false convalescence is manifested by a decrease in the intensity of the pain syndrome, tachycardia, the development of an increasing intestinal paresis (endotoxicosis of the 2nd degree). Abdominal sepsis is absent;

Stage III (24–48 hours) or endotoxic shock and development of MOF (endotoxicosis of the 3rd degree). It is characterized by an increase in SEF – syndrome of enteric failure, respectively;

Stage IV (48–96 hours) is characterized by progressive MOF having both the phases of compensated and decompensated MOF (72– 96 hours);

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•the area involved (V.S. Sayat, V.D. Fedorov, 1974) (based on the involvement of the peritoneal area conventionally subdivided into 9 anatomical regions):

local:

−nondelimited;

−delimited (represented by various types of inflammatory infiltrates or abscesses of the abdominal cavity);

widespread, including 3 types:

−diffuse, i.e. inflammation of the peritoneum, involves from 2 to 4 anatomical areas (or up to 2 regions of the abdominal cavity);

−generalized, i.e. inflammation of the peritoneum involves more than 2 layers of the abdominal cavity;

−total, i.e. the involvement of the peritoneum of all anatomical regions;

•the nature of the exudate (V.K. Gostishchev et al., 1992): serous; fi- brinous; suppurative (or their combined forms: serous-fibrinous, fibrinouspurulent). The following types of peritonitis are distinguished separately: bilious, fecal (colonic contents), urinary; aseptic (containing blood, urine, chyleous fluid, which are conditionally sterile within 6–8 hours) and fermentative (mostly pancreatogenic);

•pathogenesis (causes of disease, D. Wittmann, 1990):

primary peritonitis resulting from:

−penetration of pathogens from any extraperitoneal focus by hematogenous, lymphogenic or contact way (for example, through the fallopian tubes from the vagina into the abdominal cavity);

−diplococcal inflammation or systemic collagenosis in children, as well as the manifestation of specific forms (ascites-peritonitis, carcinomatous peritonitis, parasitic perinotinis, tuberculous peritonitis);

secondary, which is a complication of inflammatory-destructive processes of the abdominal organs, traumatic perforations of hollow organs. This form accounts for up to 90% of all cases of peritonitis. On the basis of etiological signs (causes of occurrence) secondary peritonitis is further subdivided into inoculative, perforated, necrotic, abscessogenic and artificial forms;

tertiary (synonyms: indolent, persistent, cryptogenic (or of unknown cause) ). The disease develops in the early postoperative period 48 hours after the operation and is associated with a significant suppression of anti-infective body protection mechanisms and characterized (A. Nathens et al., 1998) by the following features:

−progression of the associated nosocomial microflora that appeared after the sanation and removal of the primary focus or the “primary” microflora;

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−development due to inadequate sanitation of the abdominal cavity or associated bacterial intestinal translocation of pathogens;

−the emergence of new sources of infection in the course of treatment (mostly, because of the suture failure, with “holding”);

−intestinal stitches; due to accompanying bacterial intestinal translocation or infection of the preperitoneal tissue; due to appearance of acute postoperative intestinal ulcers);

−chronization of the inflammatory process and “blurred” clinical manifestations associated with a pronounced decrease in immunoreactivity.

Clinical picture. The clinical features of widespread peritonitis depend on the stage of the process; age (the older the patient, the less pronounced are the tension of the muscles of the anterior abdominal wall and the pain syndrome); presence of concomitant pathology; the nature of the underlying disease or injury (acute onset with severe pain all over the abdomen due to perforation of the hollow organ, thrombosis of the mesenteric vessels or strangulated hernia, a gradual onset is more typical for the ongoing inflammatory-destructive process in the abdominal cavity); presence (absence) of abdominal sepsis.

Diagnosis. Diagnosis of widespread peritonitis is based on the clarification of complaints, the past history, clinical pattern with the determination of positive peritoneal symptoms, ultrasound findings, plain radiography of the abdominal cavity, and laboratory tests.

Treatment. Preoperative preparation (PoP) in case of widespread peritonitis is performed to all patients with the manifestations of abdominal sepsis or septic shock, children, elderly patients and patients of senile age, in case of MOF, severe concomitant pathology; with a score of more than 10–12 according to APACHE-II or SAPS-II scales.

The goal of PoP – stabilization of blood pressure and CVP (hypovolemia); correction of microcirculatory disorders; transformation of concomitant pathology into the subcompensated state.

Surgical intervention in advanced peritonitis should be performed as soon as possible after the diagnosis has been made (standard concept suggested by I.I. Grekov and approved at the XII Congress of Russian Surgeons in 1912) and short-term PO (within 2–4 hours).

The main stages of surgical intervention are:

1.Adequate surgical access (midline laporatomy with general anesthesia using artificial lung ventilation and muscle relaxants).

2.Exploration of the abdominal cavity organs with the removal (aspiration) of pathological exudates and subsequent bacteriological investigation of its susceptibility to antibiotics.

3.Radical elimination of the primary and / or secondary foci of peritonitis (if it is impossible to remove them, for example, in destructive pancre-

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atitis, or stump suture failure of the duodenum, delimitation of these foci from the free abdominal cavity should be performed using drains or by creating additional ways of contents outflow with the help of drainage, or a system of permanent vacuum aspiration of YAС-therapy (negative pressure wound therapy)), which creates a constant pressure drop in the abdominal cavity to 100–120 mm Hg.

In case of postoperative peritonitis caused by the failure of the intestinal sutures, it is possible to perform various operational assisting procedures, the range of which depends on the specific situation, from additional repair of the defect with extraperitonization (moving the given area from the abdominal cavity to the retroperitoneal tissue or subcutaneously) to the isolation of the leaking anastomoses with the formation of proximal colostomies.

4. Intraoperative sanation of the abdominal cavity, being one of the types of mechanical antiseptics and including the removal of microflora, fibrous overlays, and toxins from the abdominal cavity by its repeated cleansing (lavage consisting of 8–12 liters of physiological solution with the addition of antiseptics (chlorhexidine, sodium hypochlorite, ozonized solutions)) until the aspirated liquid becomes visually pure.

With the purpose of increasing the efficiency of sanation of the abdominal cavity intraoperatively, the methods of physical antiseptics are applied including:

•“pulsating” flush of antiseptics, their introduction in the form of oxy- gen-drug suspensions (V.P. Zemlyanaya et al., 2016);

•ultrasonic cavitation (for adequate evacuation of the discharge and separation of fibrinous-purulent overlays).

5. Elimination of the EFS phenomena, enteric failure syndrome, by decompression of the small intestine.

The most frequent method applied for this purpose is transnasogastrointestinal intubation using double-lumen probe, and more rarely, intubation of the intestine through the formed jejunostoma.

6. Drainage of the abdominal cavity. It is carried out by single or double lumen drainages (mostly made of tubular silicone or PVC), which are introduced through separate counteropenings and installed to the point of the eliminated source in the form of additional microirrigators, along both lateral canals, into the subhepatic space, small pelvis (less often into other inclined areas of the abdominal cavity).

The installed drainage facilitates postoperative sanation of the abdominal cavity, as well as aspiration (more often passive) of exudate.

7. Closing of the abdominal cavity. Closing of the abdominal cavity in layers is performed in cases of serous or delimited serous-purulent peritonitis, after radical elimination of the primary and other sources of intoxication.

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In cases when the condition of the patient with widespread peritonitis is critical (more than 13 points on the APACHE II scale or more than 14 points according to SAPS II); in case of doubtful reliability of the previously formed intestinal anastomosis; with an incompletely eliminated primary source of peritonitis associated with persisting necrosis of tissues, in case of tertiary peritonitis repeated (usually with 24–48-hour interval) programmed relaparotomy with abdominal sanation with antiseptic solutions, separation of fusions and removal of fibrinous overlays, as well as examination of the areas of formed intestinal anastomoses are performed.

Operative intervention in such cases for subsequent faster access or for the prevention of the development of abdominal compartment syndrome is carried out by means of:

•incomplete reapproximation of the edges of the wound by sewing in a reticulated synthetic explant (in the form of laparostoma);

•sewing zipper-type fasteners into the edges of the wound;

•approximation of the edges with the help of U-shaped stitches (through all layers of the abdominal wall) on synthetic pads or on fragments of drainage half-tubes;

•application of stationary approximation devices (ventrophils), between which gauze drains soaked with a water-soluble ointment are to be previously laid. Alternatively, fabric carbonaceous sorbents, spongy polyurethane or alginate products intensifying the process of prolonged peritoneal dialysis can be applied locally.

In the presence of the manifestations of purulent infiltration of the edges or the development of intestinal fistula, the postoperative wound is managed in a semi-open manner by using inert synthetic films (over the intestinal loops) with additional placement of gauze drains with water-sol- uble ointments thereon, the ointments being derivatives of polyethylene epoxides, alginates, hydrogels and hydrocolloids, or by using absorbable collagen plates (like “kolpara”, Germany). Besides, NPWT (YAС) – systems are applied for dosed vacuum depression.

Recently, a video-laparoscopic technique for the staged sanitization of the abdominal cavity has been used by introducing special devices for the “open” management (Hasson’s trocar), which facilitate the obturation of the wound of the abdominal wall at the point of the minilaparotomy entry into the abdominal cavity (laparolifting), as well as aspiration-course devices for sanitation of the “Brusan” type and others (RF).

Postoperative Intensive Care (PIC) of peritonitis should be performed in the intensive care unit and includes the main principles of management of severe abdominal sepsis:

1. Restoration of functional activity of the gastrointestinal tract: prolonged epidural anesthesia, which precludes afferent pain and sympathetic effects; percutaneous electrostimulation of the intestine (with the help of

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“Endoton” apparatus, etc.); intravenous administration of serotonin adipate (up to 20–40 mg / day);

2.Efficient use of antibacterial therapy (ABT). At the first stage it is carried out empirically taking into account the suggested microbiological pathogen and the determined focus of peritonitis. For initial treatment cephalosporins of class III–IV (ceftriaxon, cefeperazon, cefepim) in combination with aminoglycosides of class III (amikacin, netromycin) and metronidazole are mostly used. In case of the accompanying MOF (with the total severity score according to SAPS > 20), the treatment begins with the use of carbapenems (meropenem, imipenem, ertapenem, doripenem).

3.Activation of the reactions of natural immunoreactivity and immune response by means of the administration of the medications for passive immunotherapy (containing the ready-use factors of nonspecific and specific resistance) and active immunotherapy (contributing to the development of proper antibodies and cellular factors). This takes into account the fact that activation of a specific immune response in WP requires no less than 4–7 days, so medications for specific active immunotherapy at this time should not be used. Among the remedies of nonspecific passive immunotherapy, the most commonly used drugs are immunoglobulins (venoglobin, intraglobin, actagam, pentaglobin, sandoglobin, cytotec), and leukocyte concentrate. The immune disorders stabilized, or after 6–7 days, the treatment should include medications of recombinant interleukins (Roncoleukin or IL-2 “Cetus”); recombinant colony-stimu- lating factors (CSF) (leukomax, leukogen or filgrastim), activators of the T-cell component of immunity (thymosin, timopentin, vylon, beastim, imunofan); recombinant inducers of γ-interferon (poludan, kagocel, and ragosin).

4.Carrying out infusion-transfusion therapy according to the principle of normo-hypervolemic hemodilution followed by forced diuresis by creating an osmotic concentration gradient between the vascular and extravascular spaces (extracellular sector).

In case of decompensated metabolic acidosis, a trisbuffer (THAM) is used in the dose of 10–15 ml followed by drip infusion under the control of ABB.

In the presence of hypovolemia signs, the hemodilution program should include drugs that increase the colloid-osmotic pressure of the plasma: solutions of hydroxyethyl starch (refortan, stabisol, HAES-steril, volecam); gelatin drugs (hemogel, gelofusin, plasmogel, gelatin), blood substitutes for hemorheological and complex action (reamberin, cytofl a- vin, remaxol).

In case of accompanying septic shock continuous titration of hydrocortisone (300 mg IV (more rarely intraarterially)) in combination with vaso-

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