RU2344842C1 - Method for enteral tube feeding after operations on account of gastroduodenal hemorrhage in patients having "pathologig blood reservoir" in gastrointestinal tract - Google Patents

Abstract

FIELD: medicine; intensive care.

SUBSTANCE: for enteral tube feeding in gastroduodenal hemorrhage operations cases, microsonde is introduced to patient. Before nutrients administration, 1.5 to 2.0 liters of solution containing 1 dose of "Fortrans" preparation to 1 liter boiled water is introduced; infusion rate being 40 to 60 drops during 6 to 8 hours.

EFFECT: reduced early recovery period of motor-evacuation function, increased nutritive maintenance efficiency, postoperative complications and lethality prevention due to early clearing of bowels from hemolysed blood.

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Description

The invention relates to medicine, surgery, intensive care and can be used as a probe enteral nutrition after surgery for gastroduodenal bleeding in patients with a “pathological reservoir of blood” in the gastrointestinal tract.

Closest to the proposed is the method of probe enteral nutrition in the postoperative period, proposed by G.K. Zherlov et al. [one]. The authors conducted a probe for enteral nutrition through the lower nasal passage, stomach and duodenum into the initial section of the jejunum below the Treitz ligament by 25-30 cm. The probe enteral nutrition was started the next day after surgery (the second day after the operation) with a drip of 800-1000 ml of mineral water. From the third day of the postoperative period, the authors introduced nutrient mixtures. The scope of the known method is limited, since this method cannot be used in patients in the postoperative period with a "pathological reservoir of blood" in the intestinal tract. The presence of spilled blood in the gastrointestinal tract in patients with successful gastroduodenal bleeding dramatically aggravates the course of the postoperative period.

In the conditions of postoperative disturbed intestinal passage, inhibition of the activity of cavity and parietal digestion, activation of microbial enzymatic cleavage, the spilled blood quickly decomposes and undergoes decay. Enterohepatic and enterohemic circulation of blood breakdown products leads to the development of endotoxemia, aggravation of tissue metabolism, the occurrence of multiple organ dysfunction and failure. Disorders of intestinal cell metabolism, increasing endogenous intoxication exacerbate postoperative disorders of the motor and secretory-resorptive function of the intestine, which, together with impaired barrier function and suppression of local immunity, cause the progression of postoperative paralytic obstruction. The lack of early restoration of the motor-evacuation function of the gastrointestinal tract in the postoperative period is the main cause of relapse of gastroduodenal bleeding, especially in patients after palliative interventions (suturing, tamponade of bleeding ulcers).

Providing enteral enteral nutrition with the above method in patients in the postoperative period with a “pathological reservoir of blood” in the intestinal tract will be ineffective against the background of suppression of motor and secretory-resorptive function of the intestine. Nutrient mixtures introduced into the gastric tract will enhance the fermentation and rotting of hemolyzed blood. The elimination of decaying blood from the gastrointestinal tract with the help of enemas and laxatives is almost impossible until the patient exits anesthesia and stabilizes.

A new technical task is to expand the scope of the method, reducing the time for early restoration of motor-evacuation functions, increasing the effectiveness of nutritional support, preventing postoperative complications and mortality.

To solve the problem in the proposed method of probe enteral nutrition after surgery for gastroduodenal bleeding in patients with a "pathological reservoir of blood" in the intestinal tract, which consists in installing a microprobe and introducing nutrients, 1.5-2.0 liters are introduced through a microprobe before introducing nutrients a solution containing 1 dose of Fortrans, dissolved in 1 liter of boiled water at a speed of 40-60 drops per minute for 6-8 hours.

New in the invention is that after the operation is completed, 1.5-2.0 liters of Fortrans solution (the contents of 1 sachet dissolved in 1 liter of boiled water) is introduced into the microprobe before enteral nutrition with nutrients at a speed of 40-60 drops per minute within 6-8 hours.

The method is as follows. After the completion of the main stage of the operation, aimed at the final stop of gastroduodenal bleeding, a microprobe is installed for enteral nutrition through the lower nasal passage into the initial sections of the jejunum below the Trent ligament by 25-30 cm beyond the area of the bleeding source or the area of the last anastomosis. Sutured abdominal cavity. Prepare 1.5-2 liters of Fortrans solution from the calculation: the contents of 1 dose (1 sachet) of Fortrans are dissolved in 1 liter of boiled water. During the first 6-8 hours after the intervention, an Fortrans aqueous solution is administered through a microprobe at a rate of 40-60 drops per minute, and then probe enteral nutrition with nutrients is started.

A new method of probe enteral nutrition in the postoperative period in patients with a "pathological reservoir of blood" in the gastrointestinal tract for the first time allowed, without waiting for the restoration of motor-evacuation function of the intestine, to begin the safe administration of enteral mixtures immediately after surgery.

Initial administration of Fortrans solution quickly prevents intestinal paresis due to surgical trauma and the presence of decaying blood in the gastrointestinal tract due to restoration of the tone of intestinal loops, elimination of fluid levels and stimulation of normal motor activity. This effect is due to the high molecular weight of the Fortrans solution, which prevents the absorption of water and contributes to the accelerated evacuation of intestinal contents.

The rate of administration of Fortrans solution of 40-60 drops per minute is optimal, since in this case the solution manages to evacuate and does not cause intestinal overstretching. At the same time, in a minimum time of 6-8 hours, a volume of 1.5-2 liters of solution is introduced, which is necessary for effective cleaning of the intestinal tract and preparing it for nutritional support.

Early restoration of motor-evacuation function and effective removal of pathological contents of the intestine, together with opportunistic cavity microflora, allows nutrients to be administered through a naso-intestinal probe after 6-8 hours.

To illustrate the effectiveness of the developed method, we present clinical observations.

Clinical example 1

At 22 hours on February 27, 2007, an ambulance crew of patient A. 52 years old with a clinic of ongoing gastrointestinal bleeding, hemorrhagic shock of the first degree was delivered to the clinic of military surgery of the Tomsk Military Medical Institute. From the anamnesis of the disease: bleeding began about 2 hours ago with vomiting of fresh blood and clots, melena, fainting. According to the available medical records, in December 2006 the patient underwent surgery: the formation of cholecystoenteroanastomosis due to pseudotumor pancreatitis, pancreatic head cysts, obstructive jaundice.

The patient is placed in the intensive care unit. The condition is serious. The skin and mucous membranes are pale. Tongue dry, coated with plaque. Vesicular breathing. Heart sounds are muffled, tachycardia 102 beats. per minute. Blood pressure 90/50 mm Hg The abdomen is swollen, soft in all departments. Intestinal motility is inhibited. A digital examination of the rectum determines a black liquid feces with a cherry tint.

Blood test (02/27/07): Hb 60 g / l; erythritol. 2.3 · 10 ¹² / l; Ht 18%; lake. 8.1 · 10 ⁹ / l.

Fibroesophagogastroduodenoscopy (02.27.07 at 23 hours). We pass the esophagus, the mucosa of the distal esophagus with erosion, the cardia gapes, the reflux of fresh blood from the stomach is determined. The contents of the stomach are blood clots in a significant amount. Fresh blood leaks from the proximal stomach. At a detailed examination, the source of bleeding is a portion of the mucosa in the upper third of the body of the stomach along the front wall closer to the subcardia. Injection hemostasis with adrenaline. Antrum mucosa with superficial erosion. The gatekeeper is yawning. In the duodenum, altered blood.

Catheterization of the subclavian vein was performed (central venous pressure is negative). Intensive therapy has begun: infusion-transfusion, hemostatic and antiulcer therapy. The gastric tube could not be established due to the curvature of the nasal septum of the III degree and a pronounced vomiting reflex. After 6 hours, blood tests were repeated and fibroesophagogastroduodenoscopy was performed.

Blood test (1.03.07 g): Hb 62 g / l; erythritol. 2.3 · 10 ¹² / l; Ht 22%; lake. 11.2 · 10 ⁹ / l; stab neutrophils 1%; segmented neutrophils 72%; lymphocytes 25%; monocytes 2%; platelets 180 · 10 ⁹ / l; ESR 72 mm per hour; blood coagulation time 4'30 ''; bleeding duration 1'30 ''.

Fibroesophagogastroduodenoscopy (01.03.07, 6 hours). At the control examination, the reflux of fresh blood of the stomach into the distal esophagus is determined. In the stomach, fresh blood comes from the proximal sections closer to the subcardia; it is not possible to determine the source of bleeding in more detail. The gastric mucosa is swollen, severe mucosal anemia makes it difficult to examine. The gatekeeper is going through. Clearance of the duodenum gapes. In the area of the large duodenal nipple, a tumor of a polypoid shape, soft consistency, bright red up to 2 cm in diameter is determined, with a biopsy increased fragmentation, increased bleeding.

Conclusion: continued bleeding (Forest Ic), the probable source of bleeding is the proximal stomach along the anterior wall closer to the subcardia.

On an emergency basis, according to absolute indications, the patient underwent an operation of upper midline laparotomy, gastrotomy, suturing of an ulcer of the subcardial part of the stomach, installing nasagastric and nasintestinal probes, drainage of the abdominal cavity.

Operation protocol. After processing the surgical field under general anesthesia, a median laparotomy was performed with a navel bypass on the left. In the upper floor of the abdominal cavity, a moderate adhesion process. During the audit, the stomach, loops of the small and large intestines are dilated, filled with blood (Fig. 1, A: total filling of the gastrointestinal tract with spilled blood and paralytic expansion of blood-filled loops of the small intestine and transverse colon). The first loop of the jejunum is anastomosed to the bottom of the gallbladder, end-to-side, with an intestinal anastomosis. The gallbladder is not strained, the anastomoses are wealthy, passable. Palpation through the stomach and duodenum determines an enlarged, non-moving pancreas 17 × 12 × 7 cm. The small omentum is obliterated. The infiltrative process from the lesser omentum extends to the posterior wall of the stomach, esophagus and duodenum. The tumor of the large duodenal nipple through the wall of the duodenum is not determined. An endoscopist is invited to the operating room to establish the source of bleeding. An endoscopic examination of the esophagus determines the reflux of fresh blood from the stomach. In the stomach, fresh blood in large volumes, there is a constant flow of fresh blood from the proximal stomach along the front wall closer to the subcardia (a possible source of bleeding). It is not possible to determine the source of bleeding in detail. In the region of the anterior wall of the upper third of the body of the stomach, two rows of filament-holders are applied in the longitudinal direction. Between the latter, the stomach wall is dissected to the submucosal layer. Flashing and ligation of submucosal vessels with single interrupted sutures was performed. Gastrotomy A giant clot in the form of an impression was removed from the cavity of the stomach (Fig. 1, B: evacuation of a giant "cast-like" blood clot through the gastrotomy opening in the upper third of the stomach body along the front wall). During the audit in the subcardial region of the stomach along the anterior wall of the stomach, an acute ellipsoid ulcer is 8 × 3 mm deep to the submucosal layer with fresh blood constantly coming from the bottom of the ulcer. The ulcer is stitched with two eight-shaped sutures - the bleeding is stopped. When examining the body and the output section of the stomach, no other sources of bleeding were found. Made suturing of the gastrotomy opening with double-row sutures. A nasogastrointestinal microprobe was introduced through the lower nasal passage for enteral nutrition into the jejunum 25 cm below the zone of biliodigestive anastomosis. Installed decompression probe into the stomach - detachable transparent. Drainage of the subhepatic space and small pelvis with selicon drainages. Layered suturing of the abdominal cavity.

The patient is given the final diagnosis. Main disease: Acute ulcer of the subcardial stomach, complicated by profuse bleeding, severe posthemorrhagic anemia. Hemorrhagic shock of the II degree. Concomitant disease: Pseudotumor pancreatitis. Pancreatic head cyst. Tumor of the large duodenal nipple. The distal block of the common bile duct. Condition after cholecystoenteroanastomosis with Brownian anastomosis due to obstructive jaundice of 12/27/06

After the operation, the patient was placed in the intensive care unit of the Department of Anesthesiology and Intensive Care for mechanical ventilation, infusion, transfusion, hemostatic, antiulcer therapy, probe enteral nutrition according to the proposed method

When carrying out fluoroscopy of the abdominal organs during the first hour after the operation, signs of intestinal paresis in the form of pneumatosis and fluid levels are determined. 40 ml of contrast medium (barium sulfate) was introduced into the jejunum through a nasointestinal probe. Peristalsis of the contrasting loop of the jejunum is not traced, it determines unstable fluid levels (Fig. 2, A: enterography in the postoperative period (1 hour after surgery), signs of paresis of the constricted loop of the jejunum in the form of gas and an unstable fluid level)).

Under the control of fluoroscopy, a drip solution of Fortrans solution prepared from the calculation: the contents of 1 dose dissolved in 1 liter of boiled water was started through a nasointestinal probe. At the same time as the start of the administration of the Fortrans solution, the restoration of the tone of the loops of the jejunum with the disappearance of fluid levels and the appearance of a typical cirrus relief, as well as normal motor activity with the evacuation of contrast medium in the isoperistaltic direction was noted (Fig. 2, B: restoration of tone, relief and peristaltic activity of the jejunum when Fortrans solution is introduced into the microprobe). Over the next 8 hours, the patient was injected with 2.0 liters of Fortrans solution at a rate of 60 drops per minute, and probe enteral nutrition with nutrients was started.

Against the background of conducting enteral enteral nutrition, the patient 16 hours after surgery had stool with the release of altered blood in the form of a black fetid gruel. From this moment, intestinal gases began to flow away from the patient and intestinal motility was determined. In dynamics, normalization of the leukocyte formula in the general analysis of blood and body temperature of the patient was noted.

Blood test (2.03.07 g): Hb 70 g / l; erythritol. 2.3 · 10 ¹² / l; lake. 8.4 · 10 ⁹ / l; stab neutrophils 4%; segmented neutrophils 73%; lymphocytes 20%; monocytes 3%; platelets 200 · 10 ⁹ / l; ESR 57 mm per hour.

Blood test (03/05/07): Hb 75 g / l; erythritol. 2.5 · 10 ¹² / l; lake. 7.6 · 10 ⁹ / l; stab neutrophils 3%; segmented neutrophils 69%; lymphocytes 24%; monocytes 4%; platelets 210 · 10 ⁹ / l; ESR 55 mm per hour.

The postoperative period was favorable. From the 5th day the patient was eating, on the 12th day he was discharged in satisfactory condition under the supervision of a surgeon and an oncologist at the clinic.

Clinical example 2

Patient A., aged 34, was delivered to the clinic of military surgery of the Tomsk Military Medical Institute on March 22, 2007, with a clinic of ongoing gastrointestinal bleeding, moderate posthemorrhagic anemia. From the anamnesis of the disease: bleeding began about 6 hours ago with vomiting of fresh blood and clots, melena, fainting. According to the available medical documentation, there are no chronic diseases, no ulcerative history.

The state of moderate severity. The skin and mucous membranes are pale. Tongue dry, coated with plaque. Vesicular breathing. Heart sounds are muffled, tachycardia 98 beats. per minute. Blood pressure 100/60 mm Hg The abdomen on palpation is soft in all departments. Intestinal motility is heard. A digital examination of the rectum determines a black liquid feces with a cherry tint.

Blood test (03/22/07): Hb 100 g / l; erythritol. 2.8 · 10 ¹² / l; Ht 28%; lake. 6.2 · 10 ⁹ / l.

Fibroesophagogastroduodenoscopy (03/22/07 at 10 o’clock in the clinic). We pass the esophagus, the mucosa of the distal esophagus with erosion, the cardia gapes, the reflux of fresh blood from the stomach is determined. The contents of the stomach: fresh blood and "coffee grounds". Fresh blood leaks from the distal part of the stomach. Upon a detailed examination, the source of bleeding is a stomach ulcer in the middle third of the body of the stomach along the lesser curvature up to 3 cm in size. The antrum mucosa with the presence of superficial erosion. In the duodenum, an ulcer along the anterior wall in the epithelialization stage, cicatricial deformity of the duodenal bulb is determined.

Intensive therapy has begun: infusion-transfusion, hemostatic and antiulcer therapy. After 6 hours, blood tests were repeated and fibroesophagogastroduodenoscopy was performed.

Blood test (03/22/07): Hb 90 g / l; erythritol. 2.6 · 10 ¹² / l; Ht 26%; lake. 9.2 · 10 ⁹ / l.

Fibroesophagogastroduodenoscopy (03/22/07 after 6 hours). At the control examination, the reflux of fresh blood of the stomach into the distal esophagus is determined. In the stomach, fresh blood comes from a stomach ulcer. Peptic ulcer up to 2.5 cm with blood leakage, ulcer bottom necrotic masses, anemic mucosa. Conclusion: a large chronic ulcer of the middle third of the body of the stomach along the lesser curvature, continuing bleeding (Forest IV).

In order for the delayed absolute indications patient operation performed verhnesredinnaya laparotomy, resection of _^half stomach Billroth-1 to form a pulp-valve in gastroduodenoanastomoza installation nazagastralnogo and nazaintestinalnogo probes abdominal drainage.

Operation protocol. After processing the surgical field under general anesthesia, a median laparotomy was performed with a navel bypass on the left. During the audit, the loops of the small intestine are filled with blood. In the stomach, an ulcer defect with an infiltration of the gastric wall up to 3-4 cm is palpated along the lesser curvature in the middle third. The duodenum is deformed, signs of compensated stenosis are determined. Given the patient’s age, stable condition, localization of the ulcer in the stomach and its size, increase in the size of the gastric ulcer in the dynamics, ongoing bleeding, the patient underwent resection ^of _1/2 stomach by Billroth-1 with the formation of the pulp valve in the region of gastroduodenoanastomosis. A nasogastrointestinal microprobe was introduced through the lower nasal passage for enteral nutrition into the jejunum 25 cm below the Trent ligament. Installed decompression probe into the stomach - detachable transparent. Drainage of the subhepatic space and small pelvis with selicon drainages. Layered suturing of the abdominal cavity.

Macropreparations: _^half of the stomach, blood in the lumen and "coffee grounds", ulcerative defect on the lesser curvature up to 2.5 cm in diameter, the bottom - necrotic masses thrombosed vessels.

The patient was diagnosed definitively: Type II gastric ulcer (according to Jornson): a large chronic ulcer of the middle third of the stomach body due to lesser curvature, complicated by bleeding. Chronic ulcer of the duodenum along the front wall in the epithelialization stage. Cicatricial deformity of the duodenal bulb. Posthemorrhagic anemia of moderate severity.

After the operation, the patient was placed in the intensive care unit of the anesthesiology and intensive care unit for artificial lung ventilation, infusion, transfusion, hemostatic, antiulcer therapy, probe enteral nutrition according to the proposed method.

Through a nasointestinal probe, drip administration of the Fortrans solution prepared from the calculation was started: the contents of 1 dose dissolved in 1 liter of boiled water. Over the next 6 hours, the patient was administered 1.5 liters of Fortrans solution at a rate of 40 drops per minute and probe enteral nutrition with nutrients was started.

Against the background of conducting enteral enteral nutrition, the patient had stool in the form of melena 22 hours after surgery. From this moment, intestinal gases began to flow away from the patient and intestinal motility was determined. In dynamics, as in the first clinical example, normalization of the leukocyte formula in the general analysis of the blood and body temperature of the patient was noted.

Blood test (03/24/07): Hb 90 g / l; erythritol. 2.0 · 10 ¹² / l; lake. 8.0 · 10 ⁹ / l; stab neutrophils 6%; segmented neutrophils 68%; lymphocytes 23%; monocytes 6%; platelets 180 · 10 ⁹ / l; ESR 34 mm per hour.

The postoperative period was favorable. From the 5th day the patient was eating, on the 12th day she was discharged in satisfactory condition for rehabilitation sanatorium-resort treatment.

Thus, the proposed method of enteral enteral nutrition after surgery for gastroduodenal bleeding in patients with a "pathological reservoir of blood" in the gastrointestinal tract allows us to simultaneously solve several key tasks that determine the frequency of postoperative complications and mortality:

- early cleansing of the intestines from hemolyzed blood;

- the elimination of endotoxemia due to the circulation of blood decay products in the gastrointestinal tract;

- early restoration of motor-evacuation function by stimulating the tone and propulsive activity of intestinal loops, eliminating fluid levels;

- increasing the effectiveness of nutritional support by removing the pathological contents of the intestine along with conditionally pathogenic cavity microflora.

Literature

1. Zherlov G.K. Sawmill and pylorus-preserving stomach resections. / G.K. Zherlov, A.I. Baranov, N.V. Gibadulin. M .: MZ Press, 2000 .-- 224 p.

Claims (1)

The method of enteral tube feeding in patients after surgery for gastroduodenal bleeding, which consists in installing a microprobe and introducing nutrients, characterized in that through the microprobe before the introduction of nutrients, 1.5-2.0 l of a solution containing 1 dose of Fortrans drug dissolved in 1 liter of boiled water, at a speed of 40-60 drops per minute for 6-8 hours

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