RU2739129C1 - Method for surgical management of perforated tuberculosis ulcers of the small intestine complicated by peritonitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to abdominal surgery. Small intestine segment is resected with perforated tuberculosis ulcers within the limits of healthy tissues at distance of 10 cm in the proximal and distal direction or a right-sided hemicolectomy is performed. Stump of the small intestine is closed with the help of linear stapling apparatuses by two rows of fastening sutures with a height of staples of 3.8 mm and the mesentery is treated with staplers with the staple height of 2.5 mm. Small intestine is intubated to its proximal stump by a naso-intestinal Miller-Abbot probe with active aspiration. Abdominal sanation is performed, 2-4 program sanation relaparotomy is carried out until relief of peritonitis. During program re-laparotomy in the absence of peritonitis phenomena, antiperistaltic delayed intestinal anastomosis is applied "side-to-side" by means of stapling apparatuses, by means of coagulation of a hole in the intestine, below 8 mm-sized staples, the intestines are aligned by the anti-mesenteric edge and the sutures are brought into the aperture. Stapling-cutting apparatus is sutured with intestinal walls. On the formed single stump 5 strands of holders are applied, grasping orifices of an intestine, through which branches are introduced, and a single stump is stitched with a sewing-cutting apparatus, without additional reinforcement by sutures of the anastomosis. Naso-intrinsic probe is inserted behind anastomosis by 20 cm, the abdominal cavity is closed tightly, and after 48-72 hours the probe is removed.

EFFECT: method allows arresting and preventing the development of pyoinflammatory complications, to reduce the length of stay of the patients in the clinic, improving the results of treatment in the early postoperative period, reducing lethality.

1 cl, 3 ex

Description

The invention relates to medicine, namely to abdominal surgery and can be used in the radical treatment of perforated tuberculous ulcers of the small intestine.

The manifestations of abdominal tuberculosis (AT) are well described in the works of researchers of the 19th and early 20th centuries, when operational manuals on this topic were not uncommon. Over the past 30 years, references to tuberculous lesions of the abdominal organs in textbooks and manuals on surgery have either practically disappeared, or they are given more than a modest place. Currently, the results of diagnosis and timely surgical treatment of patients with AT remain impermissibly unsatisfactory [Manchuryan D.A. Intestinal tuberculosis. - Moscow: Medgiz, 1948; Barinov V.S. Abdominal tuberculosis // Extrapulmonary tuberculosis. A guide for doctors / ed. A.V. Vasilyeva. - SPb .: IKF "Foliant", 2000].

In recent years, an increase in the number of cases of AT has been noted in the Russian Federation, the frequency of which ranges from 3 to 16% among other extrapulmonary localizations of tuberculosis. AT growth tendency more than 2 times for 2006-2018 associated primarily with an increase in the number of people with HIV infection. The most formidable and most frequent complication of AT is perforation of specific tuberculous intestinal ulcers, which, according to various authors, reaches 45-67% of all AT complications, with a mortality rate of up to 80%. Difficulties in the treatment of patients in this category are due to late detection of AT proceeding with severe intoxication, pulmonary heart failure, immunodeficiency and nutritional status deficiency. This leads to the rapid progression of peritonitis and the development of multiple organ failure in the patient. [Poddubnaya LV, Zyryanova TV, Petrenko TI, Kononenko VG, Kolpakova TA, Zhukova EM. Tuberculosis of the abdominal organs in patients with pulmonary tuberculosis // Experimental and Clinical Gastroenterology. - 2018. - No. 5. - S. 38-43 .; Sinitsyn MB, Belilovsky EM, Sokolina IA, Reshetnikov MN, Tityukhina MB, Baturin OV. Extrapulmonary localization of tuberculosis in patients with HIV infection // Tuberculosis and lung disease. - 2017. - No. 11. - S. 19-25 .; Reshetnikov MN, Skopin MS, Sinitsyn MB, Plotkin DV, Zuban ON. The choice of surgical tactics for perforated tuberculous intestinal ulcers in patients with HIV infection // Tuberculosis and lung diseases. - 2017. - No. 9. - S. 19-24 .; Belov SA, Grigoryuk AA, Pimenov N.A. The choice of the method of surgical care for patients with HIV infection and perforated intestinal ulcers of tuberculous etiology. Annals of Surgery. - 2018. - No. 6. - S. 354-357].

In the domestic medical literature, when treating patients with acute intestinal obstruction and peritonitis, drainage of the small intestine is recommended. The most popular was the method of transnasal drainage of the small intestine according to Vangenshtin with an Abbott-Miller probe [V.P. Zemlyanoy, B.V. Sigua, A.V. Vovk, A.A. Kurkov, V.A. Ignatenko Abbott-Miller probe. to put or not? https://dr-sigua.ru/wp-content/uploads/2017/08/Zond-Abbot-Miller.-Set-or-no.docx.pdf].

The Abbott-Miller probe for nasointestinal intubation (SRI) was proposed by the American gastroenterologists W.O. Abbott and T.G. Miller in 1934 and was originally intended for sampling of gastrointestinal contents for research purposes [Sakakibara T., Harada A., Yaguchi T. et al. The indicator for surgery in adhesive small bowel obstruction patient managed with long tube // Hepatogastroenterology. 2007. Vol. 54, no. 75. P. 787-790]. Almost immediately, it began to be used by surgeons for decompression of the small intestine with its obstruction, and at the same time its high efficiency was noted [Harris F.I. A new rapid method of intubation with the Miller-Abbott tube // JAMA. 1944. Vol. 125, no.11. P. 784-785].

Decompression of the intestine provides a decrease in intra-abdominal and intra-intestinal pressure, an increase in transabdominal perfusion pressure, as a result of which the blood supply to the organs of the abdominal cavity and intestines, in particular, improves. The walls of the intestine fall off, its muscle layer contracts, which creates the best conditions for the restoration of peristalsis and the imposition of anastomosis, if necessary.

From the existing state of the art, there is a method of total decompression intubation of the small intestine with a probe of the Abbott-Miller type with diffuse fibrinous-purulent peritonitis [Arsyutov V.P., Volkov A.N., Arsyutov O. V., Mizurov N.A., Stolyarov S. AND. "Total decompression intubation of the small intestine in the complex treatment of diffuse fibrinous-purulent peritonitis" // In the collection: Modern cardiology and issues of interdisciplinary interaction Proceedings of the Republican scientific and practical conference. Edited by E.I. Busalaeva. - 2018. - S. - 130-134].

Probing was carried out antegrade endonasally up to the Bauhinian valve and retrograde up to the trait ligament through the appendicostomy in 29 patients, through the cecostomy in 42 patients, and in 28 patients through the ileostomy. In 22 cases, total decompression intubation of the small intestine was performed during relaparotomies for various postoperative complications: unresolved peritonitis - 8 cases, intestinal suture failure - 11 cases, and interintestinal abscesses - 3 cases. 16 patients underwent relaparotomy on days 3-5 of the postoperative period, 2 patients on days 6-9 and three patients on days 10-14. In 3 cases, relaparotomy was performed at a later date. Through a probe every 3 hours, the intestinal cavity was washed with furacilin, a weak solution of potassium permanganate in an amount of 300 ml using a Janet syringe.

With this technique, the main method of intubation of the small intestine is the passage of the Abbott-Miller probe retrograde and through various intestinal stomas, as well as the performance of sanitization relaparotomies at various times. With regard to perforated tuberculous ulcers of the small intestine, this technique is not suitable, because does not lead to radical cure - removal of foci of tuberculous inflammation in the intestine. Prolonged standing of the probe in the intestinal lumen leads to disruption of the passage of intestinal contents, the presence of various types of intestinal stomas leads to water and electrolyte losses, exhaustion of patients and their possible death.

There is a known method of resection of the small intestine with the imposition of an anastomosis (RF Patent No. 2670694 dated 10.24.2018), including step-by-step reconstruction, removal of the intestine into the wound, stitching together the leading and withdrawing loops of the small intestine with two rows of interrupted sutures, forming a double-barreled stoma without opening the intestinal lumen, performing an anastomosis, characterized in that at the first stage, when a necrotically altered part of the intestine is detected, it is resected without opening the lumen, the leading and abducting stumps of the small intestine are sutured tightly, the leading loop of the small intestine is intubated using a nasogastrointestinal probe, the leading and abducting stumps are placed parallel to each other , between them impose two rows of nodal gray-serous interintestinal sutures for 65 mm, impose a double-barreled stoma without opening the lumen of the intestine, leading and abducting small intestine stumps are brought out and fixed to the skin with the help of nodular serous-skin sutures, the operation is completed by suturing the abdominal cavity and tightly; the second stage, with the viability of the stumps for 2-3 days from the local access, remove the sutures from the intestinal stump and serous-skin sutures, using a linear stapler impose an interintestinal fistula 65-75 mm, the end hole is sutured with a double-row suture manually or using a linear stapler with immersion anastomosis into the abdominal cavity, the wound of the anterior abdominal wall is sutured tightly.

The disadvantages of this method is that it is used in the absence of perforation of the intestinal wall, therefore, in the absence of peritonitis, while the sanation of the abdominal cavity is not carried out.

The closest to the claimed technical solution is the work of Plotkin D.V., Reshetnikov M.N., Gafarov U.O., Belentseva O.V., Stepanov E.A., Sinitsyn M.V. "Abdominal tuberculosis: return to surgery." (Bulletin of Avicenna. // 2019. - No. 1. - S.- 101-109), describing a technique when in some cases of treatment of abdominal tuberculosis, preference was given to suturing a perforated ulcer, and in others - resection of the affected area of the small intestine or right-sided hemicolectomy with the imposition of a primary or delayed interintestinal anastomosis. 12 (70.6%) patients with symptoms of continuing sluggish peritonitis required debridement relaparotomies after suturing of perforated ulcers, the remaining 72 (80.9%) patients with perforation of tuberculous intestinal ulcers underwent resection of the affected intestine or right-sided hemicolectomy with resection of the distal intestine. The primary anastomosis during operations, as a rule, was not applied, the stumps of the adducting and efferent intestine were sutured, and the adducting intestine was decompression. Sanitation relaparotomies were performed with an interval of 24-48 hours, and after regression of the phenomena of peritonitis, a side-to-side interintestinal anastomosis was applied. Each of the patients underwent 1 to 5 relaparotomies.

We have adopted this method as a prototype.

The disadvantages of this technical solution are:

1. There is no precise indication of the method of suturing the stumps of the small intestine and mesentery.

2. A high incidence of failure in suturing tuberculous ulcers, which can be regarded as a result of suturing in conditions of tuberculous inflammation of the intestinal wall.

The indicated disadvantages of the prototype are eliminated in the claimed technical solution.

The problem to be solved by the claimed invention is to develop more effective approaches to the surgical treatment of perforated tuberculous ulcers of the small intestine.

This problem is solved by the fact that in the method of surgical treatment of perforated tuberculosis ulcers of the small intestine, complicated by peritonitis, a section of the small intestine with perforated tuberculosis ulcers is resected within healthy tissues, 10 cm apart in the proximal and distal directions, or a right-sided hemicolectomy is performed, the stump of the small intestine is sutured of linear staplers with two rows of staples with a staple height of 3.8 mm and the mesentery is treated with staplers with a staple height of 2.5 mm, the small intestine is intubated to its proximal stump with a Miller-Abbott nasointestinal probe with active aspiration, the abdominal cavity is sanitized, 2-4 programmed sanitation relaparotomy before stopping the phenomena of peritonitis; in case of intraoperative detection of pre-perforation of tuberculous ulcers, resection of the small intestine is performed; during programmed relaparotomy, in the absence of peritonitis phenomena, an antiperistaltic delayed interintestinal anastomosis "side to side" is applied using staplers, making holes in the intestine by means of coagulation, below 8 mm staples, the intestines are compared along the antimesenteric edge and branches of the stapling device are inserted into the opening , stitch the intestinal walls with a stapling-cutting apparatus, put 5 threads of holders on the formed single stump, capturing the holes of the intestine through which the branches were inserted, and stitching a single stump with a stapling-cutting apparatus, without additional reinforcement with anastomosis sutures, the nasointestinal probe is carried out for an anastomosis, 20 cm the abdominal cavity is sutured tightly, after 48-72 hours the probe is removed.

The technical result provided by the above set of features is the relief and reliable prevention of pyoinflammatory complications, with a 2-fold decrease in the number of postoperative complications in the surgically controlled treatment of peritonitis and perforated tuberculous ulcers of the small intestine. This is due to the radical removal of the small intestine area affected by tuberculous ulcers, refusal to apply the primary anastomosis in conditions of active peritonitis, visual control of the treatment of peritonitis with the possibility of timely detection and elimination of new perforations.

The high incidence of failure during suturing of tuberculous ulcers can be regarded as a result of suturing under conditions of tuberculous inflammation of the intestinal wall, where infiltrative processes associated with loss of intestinal elasticity and disruption of its regional blood supply are noticeably expressed.

Decompression of the intestine using active aspiration provides: a decrease in intra-abdominal and intra-intestinal pressure, elimination of the abdominal compartment syndrome, the possibility of suturing the wound of the anterior abdominal wall without tension, as well as an increase in transabdominal perfusion pressure, as a result of which the blood supply to the abdominal cavity and intestines is improved. When carrying out effective decompression of the intestine, mechanical evacuation of toxic contents from the intestinal lumen also occurs, due to which the contribution of the intestinal factor to the formation of endogenous intoxication is reduced and the damaging effect on the mucous membrane is prevented [Khadzhibaev A.M., Madiev R.Z., Khalilov A.S. Differential approach to the use of nasoenteric intubation in acute intestinal obstruction and peritonitis // Bulletin of emergency medicine. 2015. No. 2 S. 54-59].

The combination of decompression of the small intestine with active aspiration of intestinal contents through the Abbott-Miller probe contributes to a significant reduction in endogenous intoxication of the body and early restoration of the intestinal motor-evacuation function. The positive clinical effect of the method is due to the early evacuation of toxic intestinal contents and gases, which leads to the restoration of the microvasculature in the intestinal wall. The presence of the probe promotes the free outflow of the toxic contents of the intestine, its decompression, helps to maintain the correct position of the loops of the small intestine, given to them by the "splinting" tube, and is the method of choice for the prevention of early adhesive intestinal obstruction.

The advantage of antiperistaltic anastomosis in this case is that there is no need to create additional holes in the intestine when the branch of the stapler is inserted, followed by their suturing, as in the isoperistaltic method. Anastomosis is made through the intestinal stump, which is a protective method for the intestinal area compromised as a result of tuberculous lesion.

An indent of 10 cm during bowel resection in the distal and proximal directions ensures the prevention of intestinal necrosis while maintaining its blood supply, corresponding to the vascular arcades of the mesentery.

The use of staplers ensures uniform pressure of the staples on the intestinal wall and a more delicate connection of the intestinal sections compared to manual stitching. The use of staplers for the treatment of the mesentery allows to achieve reliable hemostasis in conditions of altered tissues and does not lead to its deformation, in contrast to the traditional method when using clamps and ligatures with suturing and ligating the vessels.

In patients with perforated tuberculous ulcers of the small intestine, resection of a section of the intestine with perforated tuberculous ulcers, nasointestinal intubation and programmed sanitation relaparotomies of the abdominal cavity, as well as the imposition of a delayed anastomosis (after the symptoms of peritonitis have subsided), is the most optimal method of surgical treatment anti-tuberculosis therapy can reduce the percentage of postoperative complications and reduce mortality.

Passing the Miller-Abbott probe beyond the anastomosis helps to reduce the load on the staple line to prevent its failure. Detailed description of the method and examples of its clinical implementation

The method is carried out as follows.

The operation is performed under endotracheal anesthesia. A median laparotomy is performed. After the evacuation of the exudate, the abdominal cavity is revised, the source of peritonitis is found - perforated tuberculous ulcers. Depending on the localization of perforated tuberculous ulcers, resection of the small intestine is performed when ulcers are localized in the jejunum and ileum, or right-sided hemicolectomy, when ulcers are localized in the terminal ileum.

Departing in the proximal and distal direction from the perforated tuberculous ulcer (s), 10 cm each, the intestine is transected using linear GIA staplers with a staple height of 3.8 mm, the mesentery of the intestine is mobilized using GIA staplers with a staple height of 2.5 mm.

Nasointestinal intubation with an Abbott-Miller probe to the proximal stump of the intestine, sanitation and drainage of the abdominal cavity is performed.

2-4 programmed sanitation relaparotomies are performed until the symptoms of peritonitis are stopped. In case of intraoperative detection of pre-perforation of tuberculous ulcers, resection of the small intestine is performed with re-formation of stumps.

If during relaparotomy there are no signs of peritonitis and pre-perforation of tuberculous ulcers, then the abdominal cavity is sanitized, fibrin and clots are removed. The intestinal contents are aspirated to the stump of the adductor loop of the intestine. An interintestinal anastomosis is applied antiperistaltic - after the stumps of the small intestine are brought together, a hole in the intestine is made using coagulation, below the clips, 8 mm in size. The intestines are compared along the antimesenteric edge and the branches of the stapler are inserted into the hole. The intestinal walls are stitched with a stapling-cutting apparatus. Then, 5 threads of holders are placed on the formed single stump, the holes of the intestine are necessarily captured, through which the branches were wound. The threads of the holder are tightened and the stump is sutured with the same apparatus below the holders. Strengthening of anastomoses with threads is not lead. A hole in the mesentery is sutured. The Miller-Abbott nasointestinal probe is carried out by 20 cm behind the anastomosis, the abdominal cavity is sutured tightly. Infusion, antibacterial, anti-tuberculosis therapy, nutritional support - parenteral nutrition with a mixture of amino acids and fat emulsions, enteral tube feeding with combined mixtures are carried out. After 48-72 hours, the probe is removed.

The efficiency of the proposed method is confirmed by the following clinical examples:

Example 1.

Patient Sh-s, 29 years old, was inpatient treatment from 22.06.2018 to 25.09.2018, was admitted with complaints of abdominal pain, nausea, fever up to 39.5 ° C, weakness. From the anamnesis: HIV infection was detected in 2014, was in prison, did not receive treatment. I took narcotic drugs. On April 28, 2018, complaints of weakness, cough, and hyperthermia appeared. Chest X-ray revealed pulmonary tuberculosis, the patient was transferred to a specialized hospital, where he was from 28.04.2018 to 22.06.2018. Anti-tuberculosis and antiretroviral therapy was carried out. During treatment, the patient began to notice abdominal pain for a week. 06/22/2018 abdominal pain increased sharply, the patient was transferred to a surgical clinic. On admission: a serious condition caused by the phenomena of peritonitis. Abdominal X-ray - free gas detected.

06/22/2018 the operation was performed according to the claimed method. A midline laparotomy was performed, after the evacuation of the exudate, the revision of the abdominal cavity was performed, a tuberculous ulcer was found in the terminal ileum, a right-sided hemicolectomy was performed, the intestine was transected using linear GIA staplers with a height of 3.8 mm staples, the mesentery using GIA mobilizing devices height of staples 2.5 mm. Performed nasointestinal intubation with an Abbott-Miller probe to the proximal intestinal stump, sanitation and drainage of the abdominal cavity.

On June 24, 2018 and June 26, 2018, programmed sanitation laparotomies and sanitization of the abdominal cavity were performed. On June 28, 2018, another relaparotomy was performed, the abdominal cavity was sanitized, a large amount of fibrin and clots were removed from the abdominal cavity. The intestinal contents are aspirated to the stump of the adductor loop of the intestine. Due to the absence of a clinical picture of peritonitis, an antiperistaltic interintestinal anastomosis was imposed - after the stumps of the small and large intestine were brought together, the coagulator made holes in the intestine, below the staples, 8 mm in size. The intestines are aligned along the antimesenteric edge, the branches of the stapler are inserted into the hole. The walls of the intestines are stitched with a stapling-cutting apparatus. On the formed single stump, 5 threads of holders are superimposed, the holes of the intestine are necessarily captured, through which the branches of the stapler are inserted. The threads of the holder are tightened and with the same apparatus below the holders a single stump is sutured. The hole in the mesentery is sutured. The Miller-Abbott nasointestinal probe was passed 20 cm below the anastomosis. The abdominal cavity is sutured tightly.

In the postoperative period, infusion, anti-tuberculosis, antibacterial therapy was carried out. 06/30/2018 the nasogastric tube was removed. After adaptation to anti-tuberculosis therapy, antiviral therapy was continued. The wound healed by primary intention. For further treatment he was transferred to a general phthisiatric hospital.

Example 2.

Patient E-ev, 36 years old, was inpatient treatment from 04.09.2019 to 11.10.2019. He was admitted with complaints of abdominal pain. From the anamnesis: HIV infection since 2011, has been suffering from pulmonary tuberculosis since 2013, he was treated with a positive effect. The deterioration of the condition was observed since January 2019, lymphadenopathy in the abdominal cavity of tuberculous etiology was revealed. From 08/07/2019 he was treated in a specialized hospital. On September 1, 2019, in the evening, acute pains appeared throughout the abdomen, which after a while concentrated in the right iliac region. The patient was transferred to a surgical clinic. On admission: a state of moderate severity, the abdomen is flat, the right half of the abdomen lags behind in the act of breathing, on palpation, severe pain and muscle tension in this area, positive peritoneal symptoms are determined. Computed tomography of the abdominal cavity revealed an inflammatory process in the ileum of a specific etiology, signs of reactive inflammation of the peritoneum, mesentery, regional intra-abdominal and retroperitoneal lymphadenopathy, local gas accumulation (suspected intestinal perforation), intra-abdominal and retroperitoneal lymphadenopathy. 09/04/2019 performed the operation according to the claimed method.

A midline laparotomy was performed, after the evacuation of the exudate, the abdominal cavity was revised, and a tuberculous ulcer was found in the terminal ileum. A right-sided hemicolectomy was performed, the intestine was transected using linear GIA staplers with a staple height of 3.8 mm, the mesentery of the intestine was mobilized using GIA staplers with a staple height of 2.5 mm. Performed nasointestinal intubation with an Abbott-Miller probe to the proximal intestinal stump, sanitation and drainage of the abdominal cavity.

On September 6, 2019 and September 8, 2019, programmed sanitization relaparotomies and sanitization of the abdominal cavity were performed. On September 28, 2019, a programmed relaparotomy revealed an ulcer of the abducting intestinal stump, and repeated resection of the intestinal stump was performed.

On October 2, 19, a programmed sanitization relaparotomy was performed, the abdominal cavity was sanitized, a large amount of fibrin and clots were removed from the abdominal cavity. The intestinal contents are aspirated to the stump of the adductor loop of the intestine. Due to the absence of a clinical picture of peritonitis, an antiperistaltic interintestinal anastomosis was imposed - after the stumps of the small and large intestine were brought together, the coagulator made holes in the intestine, below the staples, 8 mm in size. The intestines are aligned along the antimesenteric edge, the branches of the stapler are inserted into the hole. The walls of the intestines are stitched with a stapling-cutting apparatus. On the formed single stump, 5 threads of holders are superimposed; the holes of the intestine are necessarily captured through which the branches of the stapler are inserted. The threads of the holder are tightened and the stump is sutured with the same apparatus below the holders. The hole in the mesentery is sutured. The Miller-Abbott nasointestinal probe was passed 20 cm below the anastomosis. The abdominal cavity is sutured tightly.

Anti-tuberculosis therapy was carried out, the probe was removed on 05.10.2019.The postoperative course was without complications, the sutures were removed on day 12 For further treatment he was transferred to a general phthisiatric hospital.

Example 3.

Patient S-yan, 51 years old, was inpatient treatment from 12/24/2018 to 01/21/2019. Prior to that, from 12/11/2018, he was treated at an anti-tuberculosis facility at his place of residence. From the anamnesis: pulmonary tuberculosis was first detected, the pulmonary process is interpreted as infiltrative tuberculosis of the upper lobe of the right lung in the phase of decay and seeding, MBT (+). Anti-tuberculosis therapy was started. On 24.12.2018, there were sharp abdominal pains, and was transferred to the surgical department. Was admitted with complaints of abdominal pain, dry mouth.

Upon admission: a state of moderate severity, the abdomen is flat, does not participate in the act of breathing, on palpation, severe pain and muscle tension, positive peritoneal symptoms. Computed tomography of the abdominal cavity revealed free gas, intra-abdominal and retroperitoneal lymphadenopathy. 12/24/2018 the operation was performed according to the claimed method.

A midline laparotomy was performed, after the evacuation of the exudate, a revision of the abdominal cavity was performed, a perforated tuberculous ulcer of the ileum was found, at a distance of 90 cm from the ileocecal angle. A section of the ileum was resected, 10 cm apart in the distal and proximal direction, the intestine was transected using linear GIA staplers with a staple height of 3.8 mm, the mesentery of the intestine was mobilized using GIA staplers with a staple height of 2.5 mm. Performed nasointestinal intubation with an Abbott-Miller probe to the proximal intestinal stump, sanitation and drainage of the abdominal cavity.

On December 26, 2018, a relaparotomy and sanitation of the abdominal cavity were performed. 12/28/2018 with programmed relaparotomy, the positive dynamics of the course of peritonitis can be canceled - an insignificant amount of exudate is determined, the appearance of intestinal motility. In connection with the clinical picture of regressing peritonitis, an antiperistaltic interintestinal anastomosis was imposed - after the stumps of the small intestine were brought together by a coagulator, holes were made in the intestine, below the staples, 8 mm in size. The intestines are aligned along the antimesenteric edge, the branches of the stapler are inserted into the hole. The walls of the intestines are stitched with a stapling-cutting apparatus. On the formed single stump, 5 threads of holders are superimposed, the holes of the intestine are necessarily captured, through which the branches of the stapler are inserted. The threads of the holder are tightened and the stump is sutured with the same apparatus below the holders. The hole in the mesentery is sutured. The probe is held 20 cm below the anastomosis. The abdominal cavity is sutured tightly.

Anti-tuberculosis therapy was continued. The probe was removed on December 30, 2018. The postoperative course was without complications, the sutures were removed on the 15th day. For further treatment he was transferred to a general phthisiatric hospital.

Histological examination of the operating material, infiltrative-ulcerative intestinal tuberculosis with a predominance of the phenomena of organization and fibrosis, perforation of tuberculous ulcers, peritonitis, tuberculous mesentericitis, mesenteritis, omentitis.

Surgical treatment was performed in 136 patients with perforated tuberculous ulcers of the small intestine, who were treated in the tuberculosis surgical department of the Moscow City Scientific and Practical Center for Tuberculosis Control in 2013-2020.

An analysis of the treatment results showed that in patients who underwent bowel resection with delayed anastomosis, the frequency of complications was 5.6 times, and the mortality rate was 3.2 times lower than with suturing of perforated tuberculous ulcers of the small intestine, which is associated with radical removal of the intestine. carrying tuberculous ulcers. Refusal to apply the primary anastomosis and the technique of suturing perforated tuberculous ulcers in conditions of progressive sluggish peritonitis, as well as visual monitoring of the treatment of peritonitis in relaparotomies, allows timely identification and elimination of new perforations, as well as to evaluate the effectiveness of treatment.

The advantages of the proposed method for the surgical treatment of perforated tuberculous ulcers of the small intestine are: reduction in the time of stay of patients in the clinic, improvement of the results of treatment of patients in the early postoperative period, reduction of mortality.

The method has been tested in the clinic on significant clinical material and can be recommended for use in surgical practice in specialized hospitals.

Claims (2)

1. A method of surgical treatment of perforated tuberculous ulcers of the small intestine, complicated by peritonitis, including resection of the small intestine or right-sided hemicolectomy and the imposition of a stitched interintestinal anastomosis, characterized in that a section of the small intestine with perforated tuberculous ulcers is resected within 10 cm and healthy tissues distal direction or right-sided hemicolectomy is performed, the small intestine stumps are sutured using linear staplers with two rows of staples with a staple height of 3.8 mm and the mesentery is treated with staplers with a staple height of 2.5 mm, the small intestine is intubated to its proximal stump with a nasointestinal probe Miller-Abbott with active aspiration, perform sanitation of the abdominal cavity, perform 2-4 programmed sanitation relaparotomies before stopping the phenomena of peritonitis; during programmed relaparotomy, in the absence of peritonitis phenomena, an antiperistaltic delayed interintestinal anastomosis "side to side" is applied using staplers, making holes in the intestine using coagulation, below the staples, 8 mm in size, the intestines are compared along the antimesenteric edge and branches of the stapling device are inserted into the opening , stitch the intestinal walls with a stapling-cutting apparatus, put 5 threads of holders on the formed single stump, capturing the holes of the intestine through which the branches were inserted, and stitching a single stump with a stapling-cutting apparatus, without additional reinforcement with anastomosis sutures, the nasointestinal probe is carried out for 20 cm behind the anastomosis , the abdominal cavity is sutured tightly, after 48-72 hours the probe is removed. 2. The method according to claim 1, characterized in that during intraoperative detection of preperforations of tuberculous ulcers, resection of the small intestine is performed.