RU2239397C1 - Method for treating adhesion disease of abdominal cavity - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: one should remove intestinal adhesive obstruction during acute period due to dissecting deforming adhesions and fixing intestinal tube in physiological position, moreover, fixation should be carried out after preliminary cryogenic treatment of lateral walls of intestinal loops at the sites of scar-adhesive process at exposure being 15 sec. The method suggested enables to develop organotypical scar accretions not inhibiting early restoration of intestinal peristaltics and its further growth.

EFFECT: higher curative effect.

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Description

The invention relates to medicine, namely to pediatric surgery, and can be used to treat adhesive intestinal obstruction and adhesive disease of the abdominal cavity. In pediatric emergency surgery, one of the most common complications after surgery on the abdominal organs is adhesive intestinal obstruction. The frequency of adhesive intestinal obstruction (2.1-3.8% among all diseases of the abdominal organs), the number of relapses (12-15%), mortality (7.2-11.0%) continue to be high. Despite the many methods of prevention and treatment, the question of the treatment of adhesive disease of the abdominal cavity is still not fully resolved due to frequent relapses. A known method of treating adhesive disease of the abdominal cavity by eliminating obstruction due to dissection of adhesions followed by intestinal intubation in a different way (transnasal, transanal, through the gastrostomy and enterostomy) / Volkov BP, Moiseev A.Yu., Prokhorova TP Splinting of the small intestine as a way to prevent adhesive obstruction. Herald of Surgery, 1986, No. 5, pp. 70-73 /. The disadvantage of this method is the formation of inter-intestinal, interlobular adhesions in the non-physiological position of the intestine, intubated with an intestinal probe, as well as accompanied by the absence of physiological peristalsis, which subsequently leads to a relapse of adhesive intestinal obstruction after removal of the intubation probe.

Known methods for surgical treatment of adhesive disease, which include fixing the small intestine in a functionally advantageous position in which the newly formed adhesions do not violate the passage of the chyme (Noble operation) / Noble T.B., Am. J.nSurg., 1937, v. 35, p. 41 /. A disadvantage of the known methods are frequent complications in the form of prolonged intestinal paresis, the formation of intestinal abscesses, intestinal fistulas and relapses of adhesive obstruction against the background of the formation of gross, deforming intestinal wall scars. The closest to the achieved positive result is a method of treating recurrent adhesive intestinal obstruction, which consists in fixing the intestines with glue "Tsiakrin" / Schmidt G.G. - Intestinoplication "cyacrine" in case of recurrent adhesive intestinal obstruction. Surgery, 1973, No. 6, pp. 84-87 /. The disadvantage of this method is the recurrence of adhesive obstruction due to asymmetry between the growth of the intestines on the one hand and an obstacle to this polymerized adhesive base, on the other hand.

A positive result of the proposed method is to increase the effectiveness of treatment of recurrent adhesive intestinal obstruction due to fixation of the intestinal tube by cryointestinoplication, which further contributes to the formation of organotypic adhesions that do not impede the early restoration of intestinal motility and its further growth.

A positive result is achieved by the fact that before applying adaptive gray-serous sutures after mobilization of intestinal loops, their free side walls are subjected to cryotherapy of the serous membrane, which subsequently leads to the formation of organotypic cicatricial adhesions and does not interfere with further intestinal growth. To determine the reaction of the intestinal wall to cryotherapy, a series of experiments was carried out on 12 chinchilla rabbits. A local exposure with liquid nitrogen to the wall of the small intestine was carried out by the Repnikov-Shafranov apparatus. The applicator in all cases was 10 mm in diameter. The reaction of the intestinal wall was investigated after cryotherapy with different exposures: 5, 10, 15 and 25 seconds, immediately after manipulation, on the 4th and 7th day.

Macroscopically, areas of cryotherapy on the intestinal wall with an exposure of up to 10 seconds on days 4 and 7 are rather difficult to distinguish from a normal intestine. When exposed with an exposure of 15 seconds, there was a slight hyperemia of the serous membrane, moderate edema. With a longer exposure, the areas of cryotherapy are covered with fibrin and soldered loops of the small intestine. In a histological examination, the degree of change in the intestinal wall increases with increasing exposure. With an exposure of up to 10 seconds, only the serous and muscle membranes are included in the process, moderate plethora of vessels, focal edema of the mucosa are noted. With an increase in exposure to 25 seconds, the appearance of foci of necrosis in all layers of the intestinal wall, detachment of the mucosa, desquamation of the epithelium are visible. In the next series of experiments, after opening the abdominal cavity, loops of the small intestine, 8-10 cm long, were laid in horizontal rows for each intestinal pair in the middle third and three adaptive gray-serous sutures were applied along the edges, with preliminary cryoprocessing of the lateral walls of the intestinal tube. At the end of enteroplication, the abdominal cavity was sutured tightly. The postoperative period was uneventful. Animals were withdrawn from the experiment on days 7, 14, 21, 30 by overdose of thiopental sodium.

Macroscopically inflammatory reaction and adhesions in the free abdominal cavity were not detected. Loops of the small intestine are located in a predetermined position and are fixed among themselves by scar adhesions that do not deform the intestinal wall. During a histological examination, the established fact was the presence of connective tissue in the spaces between the intestinal walls in the form of mature, well-vascularized fibrous adhesions that grow from the mesentery and do not deform the surface of the intestinal tube. The method is as follows: produce a mid-median laparotomy. With an audit of the intestines, adhesions leading to intestinal obstruction are dissected. Retreating 10-15 cm from the tracheal ligament, the loops of the small intestine are sequentially laid (Fig. 1) in horizontal rows of 15-20 cm long. Three adaptive gray-serous sutures are placed between adjacent intestinal loops in the middle third and along the edges, not reaching 5 -8 cm to the bent knee loop. In the terminal part of the small intestine, a portion of the intestine with a length of up to 15 cm is left free. First, cryoprocessing of the lateral free walls of the intestinal tube in the places of the former fusion with the Repnikov-Shafranov apparatus is performed for 15 seconds with an applicator with a diameter of 10 mm. The abdominal wall is sutured tightly. Postoperative management of the child includes infusion therapy and measures aimed at restoring intestinal motility. The operation is carried out in the acute period of adhesive disease.

The high efficiency of the method is ensured by the fact that the cicatricial fusion of the intestinal loops after their cryoprocessing with the application of adaptive gray-serous sutures is in the form of normotrophic, organotinous tissues, which in the future does not cause the formation of deforming cicatricial fusion and prevents the relapse of adhesions, but does not prevent synchronous intestinal growth in places of his plication.

Clinical example.

Patient K 16 years old, I.B. No. 937, was operated on in May 1995 for gangrenous-perforated appendicitis, diffuse purulent peritonitis, and then re-operated in June 1998 and January 2001 for adhesive small bowel obstruction. Adhesions were separated to restore intestinal patency. In the postoperative period, anti-adhesion therapy courses were conducted: electrophoresis with KJ, paraffin baths, every 6 months. In the period from February 2001 to July 2001, paroxysmal pains in the abdomen, sometimes bloating, were periodically noted.

She was admitted again to the clinic 4 hours after the onset of the disease. Conservative treatment was carried out (antispasmodics, sacrospinal blockade, high cleansing enemas, infusion therapy). Despite the ongoing therapy, the child's condition did not improve, a laparotomy was performed. After opening the abdominal cavity, an extensive adhesion process is established. Loops of the small intestine are soldered to the peritoneum. During the audit at the navel level, a conglomerate of intestinal loops welded together in the form of double-barrels and two cord-like adhesions at a distance of about 50 cm from the ileocecal angle was found. Given the extensive adhesion process in the abdominal cavity, it was decided to produce cryointestinoplication. From the tracheal ligament to the ileocecal angle, the intestines are laid in horizontal rows. Three adaptive gray-serous sutures were placed between adjacent intestinal loops, cryoprocessing of the lateral walls of the intestinal tube was preliminarily performed at the places of the former fusion using the Repnikov-Shafranov apparatus with an exposure of 15 sec and an applicator with a diameter of 10 mm. The postoperative period was uneventful, the gases began to depart by the end of the second day. Chair independently from the third day. Discharged 10 days after surgery.

One year after the operation, the condition is satisfactory, no complaints. An X-ray examination of the gastrointestinal tract with barium was performed and it was found that the loops of the small intestine have a horizontal direction, filling it took 4 hours. Thus, the application of the method allows to achieve organotypic fusion of the surfaces of the lateral walls of the intestine in the places of its former scar-adhesive process, thereby eliminating the relapse of adhesive scar deformity of the intestinal tube.

Claims (1)

A method of treating commissural disease of the abdominal cavity, which consists in eliminating intestinal commissural obstruction in the acute period due to dissection of deforming commissures and fixation of the intestinal tube in physiological position, characterized in that the fixation is carried out after preliminary cryogenic treatment of the side walls of intestinal loops at the sites of the scar-adhesion process, exposure of 15 s.