RU2303401C2 - Method for evaluating peritonitis severity degree in scores in perforated gastroduodenal peptic ulcercases - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves evaluating the following clinical course signs with scores. Time passed since disease onset, nature and amount of exudate into he abdominal cavity, available abdominal sepsis are evaluated as the clinical course signs by scoring. Each sign receives score value. Each hour of time passed since disease onset receives +1 score; peritonitis generalization degree is assessed with +1 score per each 100 ml of exudate; peritonitis evaluation with exudate nature is made with +0 in gastric content and serous exudate cases, +5 scores in serofibrinous exudate cases, +10 scores in pyofibrinous exudate cases; peritonitis evaluation with clinical manifestation severity is carried out by giving +0 scores in cases with no abdominal sepsis phenomena, +10 scores are given in cases with abdominal sepsis phenomena being available. Score sum being equal to or less than 11, mini-laparotomic access operation is considered to be advisable.

EFFECT: high objectivity level in evaluating inflammatory peritoneum changes severity degree, in determining contraindications to surgical treatment with mini-laparotomic access.

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Description

The invention relates to medicine, namely to minimally invasive surgery, and is used to determine indications and contraindications for surgical treatment of perforated gastroduodenal ulcers from minilaparotomic access, without using video laparoscopy, in the face of limited visual examination and revision of the abdominal organs.

Surgical treatment of perforated gastroduodenal ulcers can be carried out through traditional upper median laparotomy. This access allows you to perform surgical admission and sanitation of the abdominal cavity with this severe complication of peptic ulcer. However, the upper median laparotomy is rather traumatic, its length is 15-18 cm. An operational wound of such sizes causes pain in the postoperative period, and sometimes it causes formidable complications (suppuration, eventation, hernia formation).

Minimally invasive methods of surgical treatment of perforated gastroduodenal ulcers include laparoscopic and laparoscopic-assisted operations. With a laparoscopic version of the surgical treatment of perforated ulcers, all stages of the operation are performed with special endoscopic instruments under the control of a video monitor. Laparoscopically-assisted operations are performed in two stages, when laparoscopy is performed for the diagnosis and rehabilitation of the abdominal cavity, and minilaparotomic access is performed to perform surgical procedures. One way or another, all known minimally invasive methods of surgical treatment of perforated gastroduodenal ulcers are associated with laparoscopy and therefore have common disadvantages. The main ones include the need for expensive equipment and the difficulty in mastering the technique of surgical intervention. The negative effects of prolonged carboxypneuroperitoneum are known. It is significant that video laparoscopic operations are not accessible to a wide network of medical institutions - and this is, first of all, district and city hospitals, where the bulk of emergency surgery is concentrated.

We have proposed a minimally invasive method for surgical treatment of perforated gastroduodenal ulcers from minilaparotomic access without the use of video laparoscopy. The founder of operations from minilaparotomic access in our country is Professor MD Prudkov M.I. In 1999, by the joint efforts of the team of authors under the guidance of Professor Prudkov M.I. A universal set of tools for traditional and minimally invasive operations of the Mini-Assistant series was developed, passed clinical testing, and put into serial production. The Mini-Assistant kit allows you to confidently perform operations on the gallbladder and extrahepatic bile ducts, resection of the stomach in various modifications, operations on the aorta and its branches, operations on the kidneys and ureters, almost the entire range of gynecological operations, operations for pancreatic necrosis and surgery in cell spaces, as well as appendectomy, operations of Troyanov-Trendexiburg, Ivanisevich and others. The accumulated experience showed that developed by Professor Prudkov MI the technique of operations from mini-access and the Mini-Assistant series instruments are easily mastered by practical surgeons in any surgical hospital, reduces the treatment and rehabilitation time of patients by about half, is accompanied by fewer failures and complications compared to more complex methods and gives tangible savings in financial resources, labor personnel and supplies. The tool is easily processed, tolerates almost any sterilization and can be used in the field (Prudkov M.I., Fominykh I.V., 1998; Prudkov M.I., 2002).

In the literature available to us, we did not find information about the isolated use of minilaparotomic access (i.e., without the use of video laparoscopy) in the treatment of perforated gastroduodenal ulcers. All stages of our proposed surgical intervention for perforated gastroduodenal ulcer are performed from one local extremely small incision (3-4 cm) located in the middle third of the distance between the xiphoid process and the navel, using the Mini-Assistant surgical kit in the specification for gastric resection developed by professor M.I. Prudkov and manufactured by NPO Liga-7 CJSC in series (certificate of conformity No. ROSS RU.IMO2.BO8528). General surgical and endoscopic instruments were also used, in particular a forceps, an endoscopic clamp with a diameter of 10 mm, a length of 320 mm and a plunger trocar with a diameter of 10 mm. These tools are necessary for the rehabilitation and drainage of the abdominal cavity when suturing a perforated ulcer from the minilaparotomic access.

The location of the mini-access (along the midline in the middle third of the distance between the xiphoid process and the navel), for operations in the gastroduodenal zone, is justified in the dissertation of Bessonova S.L. (2003), carried out on the basis of the Department of Surgical Diseases FPK and PPS GOU VPO TyumGMA under the supervision of a professor MD A.M. Mashkina. The adequacy of rehabilitation from this minilaparotomic access was proved by us in a study on 63 corpses of people, the necessary tools and methods of rehabilitation were also determined for this. A strictly defined amount of liquid (water) was injected into the abdominal cavity of human corpses, which was removed in several ways, evaluating the effectiveness of each of them, counting the used napkins and fixing the time spent on the study.

To characterize the completeness of abdominal sanitation, we proposed to use the ratio of the mass of the removed fluid (MJ) to the mass of the injected fluid (MJ). This ratio, expressed as a percentage, we called the coefficient of completeness of fluid evacuation (Kpezh);

Kp.E.zh = Mu.zh. : M.W. × 100%

Mu.zh - mass of fluid removed from the abdominal cavity.

Mw.j is the mass of fluid introduced into the abdominal cavity.

The study of the completeness of fluid removal from the abdominal cavity was performed in 3 groups, 21 cases in each:

Group 1 - drainage of the abdominal cavity with gauze napkins from a standard upper middle laparotomy.

Group 2 - drainage of the abdominal cavity with gauze napkins from the upper midline minilaparotomy.

Group 3 - drainage of the abdominal cavity with gauze napkins and electric suction from the upper midline minilaparotomy.

Given the sequence of drainage of the abdominal cavity (first with an electric suction and then with wipes), the coefficient of liquid removal from the abdominal cavity only with an electric suction from the upper midline minilaparotomy was separately studied.

Drainage of the abdominal cavity was carried out in each case until the tissue removed from the abdominal cavity was dry, and when examining the accessible parts of the abdominal cavity no accumulations of liquid were detected. A napkin count was made and the time spent on the study was recorded. After this, a wide opening of the abdominal cavity was carried out, all its departments were examined in order to detect fluid leakage. A thorough audit of the abdominal organs was performed.

As a result of the experiment, it was proved that the coefficients of completeness of fluid evacuation from the abdominal cavity by general surgical methods, from the mini-laparotomy incision (average C.e.f. = 80 ± 8.7%), do not have significant differences with those during drainage from standard upper middle laparotomy (average K.ep.zh = 75.9 ± 9.3%) (t = 0.3). The quality of draining the abdominal cavity, the time spent on this and the number of used napkins compares favorably with other methods of combined use of an electric suction pump and gauze napkins. It is this method of abdominal sanitation that we have chosen as the main one in the surgical treatment of perforated ulcers from the mini-access. The significance of differences in the studied parameters was taken at a value of t≥2 (Student's confidence criterion).

The method of fluid evacuation only by electric suction from mini-laparotomic access (average K.ep.zh = 65.7 ± 10.4%) was designated as ineffective, since it has significant differences with drainage of the abdominal cavity from standard laparotomy (t = 2.5), and the least effective this method with small volumes of fluid in the abdominal cavity (up to 200 ml).

The size of the minilaparotomic wound (3-4 cm), located in the middle third of the distance between the xiphoid process and the navel, does not allow the operating surgeon to examine all parts of the abdominal cavity, but he can assess the nature, amount of effusion and the severity of clinical manifestations with perforated gastroduodenal ulcer.

For an objective assessment of the severity of peritonitis in the conditions of "limited" (by the size of the surgical wound) revision of the abdominal cavity and determination of contraindications to the application of the proposed method, a scoring system for assessing the severity of peritonitis is developed.

The task to which the invention is directed is to create a system that together allows to objectively assess the severity of inflammatory changes in the peritoneum with perforated gastroduodenal ulcers and determine contraindications for surgical treatment from minilaparotomic access (3-4 cm), with limited visual examination and revisions of the abdominal cavity. In addition, a combined objective assessment of the severity of peritonitis with perforated ulcer can be used to determine the representativeness of the compared groups of patients.

Given that the severity of peritonitis is characterized by its prevalence, the nature of effusion in the abdominal cavity and the severity of clinical manifestations, the solution to the problem is achieved by scoring each of the above characteristics, as well as the time elapsed since perforation.

A system for assessing the severity of peritonitis in patients with perforated gastroduodenal ulcer Criteria for evaluation Points 1. Estimated time elapsed since perforation - Every hour + 1 point. 2. Assessment of the prevalence of peritonitis - Every 100 ml of effusion + 1 point. 3. Assessment of peritonitis by the nature of effusion in the abdominal cavity - Gastric contents, serous effusion
- Serous fibrinous effusion
- Purulent-fibrinous effusion 0 points.
+ 5 points.
+ 10 points. 4. Assessment of peritonitis by the severity of clinical manifestations - Peritonitis without the phenomena of abdominal sepsis
- Peritonitis with the phenomena of abdominal sepsis 0 points.
+ 10 points.

Given the definitions of pathological conditions associated with sepsis adopted at a conciliation conference in 1991 (Chicago), the clinical criteria for diagnosing abdominal sepsis are considered to be more than two signs of CERV (systemic reaction to inflammation syndrome) with an existing “focus of infection”, in this case peritonitis.

The severity of peritonitis is proposed to be determined by summing up the scores obtained by evaluating each criterion.

For example: Patient N was admitted to the surgical hospital after 3 hours from the moment of ulcer perforation - 3 points; without the phenomena of abdominal sepsis - 0 points; for surgery in a patient in the abdominal cavity 200 ml - 2 points; serous effusion - 0 points: 3 + 0 + 2 + 0 = 5 points.

In developing the proposed method for the surgical treatment of perforated gastroduodenal ulcers, we were guided by the need to screen out patients with severe peritonitis, that is, widespread, purulent-fibrinous, with symptoms of abdominal sepsis (10 points according to our proposed methodology for assessing the severity of peritonitis). Summarizing the experience of many researchers (Afendulov S.A., Krasnolutsky N.A., Zhuravlev G.Yu., 2003; Yeryukhin I.A., 2003; Pantsirev Yu.M., Mikhalev A.I., Fedorov E.D. , 2003), we can confidently say that there is no high bacterial contamination and highly virulent types of microorganisms in the first 6 hours from the time of perforation of the gastroduodenal ulcer, which causes a “non-aggressive” course of peritonitis and the possibility of using minimally invasive treatment methods in these periods. Therefore, the indications for the use of minilaparotomic access were limited to 6 hours from the time of perforation. In a retrospective analysis of case histories of 300 patients operated on for perforated gastroduodenal ulcers, it turned out that within 6 hours 79.7 ± 3.7% were operated on, the same number of patients scored no more than 11 points according to our proposed methodology for assessing the severity of peritonitis with perforated gastroduodenal ulcer. Therefore, we consider 11 points to be the maximum possible amount allowing surgical treatment of perforated gastroduodenal ulcers from minilaparotomic access. It is the 11-point barrier that will allow a fairly large portion of patients with perforated ulcer (70-80%) to operate from the mini-access and exclude the possibility of surgery in patients with severe peritonitis. We divided the contraindications for surgical treatment of perforated ulcers from minilaparotomic access into absolute and relative.

Absolute contraindications:
1. The amount is more than 11 points, when assessing the severity of peritonitis according to our methodology.
2. Suspicion of tumor perforation.
3. Atypical perforation, perforation of the subcardial and cardiac sections of the stomach. Relative contraindications:
1. Patient weight more than 80 kg.
2. Previous surgery on the organs of the abdominal cavity.
3. Repeated perforation of the ulcer.
4. Dates over 6 hours from the moment of perforation.

In the absence of contraindications, we consider it possible to use this method in all patients with a perforated ulcer of the pyloroduodenal zone. Inspection of the abdominal cavity through a minilaparotomic approach (according to the principle of open laparoscopy), in combination with the proposed scoring system for assessing the severity of peritonitis, allows the operating surgeon to collectively and objectively assess the severity and prevalence of peritonitis with perforated gastroduodenal ulcer. The absence of high bacterial contamination and highly virulent types of microorganisms that cause a "non-aggressive" course of peritonitis in the first 6 hours of the disease allows surgical intervention and adequate sanitation of the abdominal cavity from minilaparotomic access using a general surgical technique for draining the abdominal cavity with suction and gauze wipes.

Over the course of three years (2002-2004), we performed more than 70 suturing of perforated ulcers and sanitation of the abdominal cavity according to the proposed method, using a point system for assessing the severity of peritonitis with perforated gastroduodenal ulcer. In addition, four primary distal resections of 2/3 of the stomach were performed with perforated ulcer of the gastroduodenal zone from the minilaparotomic access. No complications associated with surgery were observed. The average severity of peritonitis in points was 6.2 ± 0.3. The average length of the mini-approach when suturing a perforated ulcer was 30.8 ± 0.6 mm, which is 5.6 times less than the average length of a traditional laparotomy. Reducing the size of the surgical wound leads to a decrease in the level of pain in the postoperative period, and consequently, a decrease in the use of painkillers. Patients operated on from mini-access are activated earlier, are earlier discharged from the hospital and begin to work. A significant decrease in the level of postoperative complications associated with the surgical wound in patients operated on from a small incision than from traditional laparotomy was also noted, and the cosmetic effect is also important.

In the literature available to us, we did not find a description of scoring systems for assessing the severity of peritonitis in patients with perforated gastroduodenal ulcers, which would be used to determine indications and contraindications for the use of minimally invasive operations in this category of patients.

Claims (1)

A method for determining indications for surgery from minilaparotomic access for perforated gastroduodenal ulcers, which consists in evaluating the following clinical signs of the course of the disease in points: the time elapsed since the onset of the disease, the nature and amount of effusion in the abdominal cavity, the presence or absence of abdominal sepsis, assigning each of the signs has a point score: assessment of the time elapsed from the moment of perforation - every hour - “+1” point; assessment of the prevalence of peritonitis - every 100 ml of effusion - "+1" point; assessment of peritonitis by the nature of the abdominal effusion: gastric contents, serous effusion - "+0" points, serous-fibrinous effusion - "+5" points, purulent-fibrinous effusion - "+10" points; assessment of peritonitis according to the severity of clinical manifestations: peritonitis without the phenomena of abdominal sepsis - “+0” points, peritonitis with the phenomena of abdominal sepsis - “+10” points, and with the sum of the points not exceeding 11, the operation performed from minilaparotomic access is considered shown.