RU2770281C1 - Method for selecting the surgical treatment tactics for different appendicular peritonitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, and can be used in choosing the tactics of surgical treatment for widespread appendicular peritonitis based on the results of diagnostic laparoscopy. For this, diagnostic laparoscopy is performed, during which the abdominal cavity is conditionally divided into 6 areas: the small pelvis, the right and left lateral canals, the right subhepatic space, the right and left subdiaphragmatic spaces, in which the prevalence of the pathological process in the abdominal cavity (D), the nature exudate, the presence of fibrin (E), the severity of paresis of the small intestine (P) and the state of the viscero-parietal peritoneum (B), determine the duration from the onset of the disease to surgery (T). In the study of each criterion, gradations are distinguished, which are assigned points. By the value of the score, the surgical treatment option is determined - with laparoscopic access, or laparoscopic access followed by programmed relaparoscopy within 24 to 72 hours after the primary operation, or open intervention.

EFFECT: invention makes it possible to reliably assess the severity and prevalence of appendicular peritonitis and to choose the optimal tactics of surgical treatment, which in turn will reduce the incidence of postoperative complications, mortality and the duration of inpatient treatment of patients.

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Description

The field of technology to which the invention belongs

The invention relates to medicine, namely to surgery, and can be used in the surgical treatment of widespread appendicular peritonitis based on the results of diagnostic laparoscopy.

State of the art

Acute appendicitis is the most common acute surgical disease and, despite the fact that there is a significant reduction in its share in emergency practice (40.3% - 2000, 24.8% - 2019), it still ranks first in terms of occurrence and operative activity. The overall mortality in Russia in 2019 for this nosology was 0.13%, of which 0.12% was postoperative. The perforated form of acute appendicitis with the development of widespread peritonitis increases the incidence of postoperative complications up to 47%, and postoperative mortality - up to 3%. The overall mortality in the case of widespread diffuse purulent peritonitis is from 4.5 to 58%, and in severe forms with the development of sepsis and multiple organ failure, it can be more than 70% [1, 2, 3, 4, 5].

In various domestic and foreign clinical guidelines, the "gold standard" for differential diagnosis and treatment of urgent abdominal pathology, including suspected appendicular peritonitis, is laparoscopy. This access is effective and safe, is accompanied by minimal trauma and reduces the incidence of intra-abdominal and wound complications in the absence of contraindications to its use, the absolute of which is a high operational and anesthetic risk on the ASA V scale. However, in a number of hospitals, the leading access for the treatment of common forms of appendicular peritonitis considered median laparotomy. The choice of this approach is due to its proven safety and efficacy, as well as the possibility of performing surgery in less time [4, 5].

To predict the results of treatment of appendicular peritonitis, various rating scales have been proposed in the literature, which include intraoperative characteristics of the degree of damage and the prevalence of the process. Prognostic indicators that may be used include: P-POSSUM, Mannheim Peritonitis Index (MPI), Altona Peritonitis Index (PIA and PIA II), and WSI Intra-Abdominal Infection Scale (IAI) score from the WISS study. Also, do not forget about domestic scales and systems for assessing the severity of peritonitis: the abdominal cavity index (ICI) and the classification of peritonitis by phases of the course [6, 7, 8, 9]. However, for an objective intraoperative choice of surgical access (laparoscopy, laparotomy), as well as for determining indications for programmable sanitation relaparoscopies, such a scale does not exist. The disadvantage of all these scales is the fact that they predict only the likelihood of postoperative complications and adverse outcomes. These parameters are, of course, the most important for assessing the results of treatment of patients with peritonitis, but at the same time they do not make it possible to offer a differentiated tactics of surgical treatment using minimally invasive methods, which is the key to reducing the number of complications and mortality.

Closest to the claimed invention is a method for choosing surgical tactics for peritonitis of any etiology (patent for invention No. 2465810 dated 11/10/2012), including performing diagnostic video laparoscopy, during which the abdominal cavity is conditionally divided into 6 areas: the small pelvis, the right and left lateral channels , right subhepatic space, right and left subdiaphragmatic spaces, in which the following criteria are examined: the spread of pathological contents in the areas of the abdominal cavity (Dissemination, D); the nature of the exudate, the presence of fibrin, the state of the peritoneum (Exudation, E); the severity of paresis of the small intestine (Paresis, P). Criteria have gradations, which are assigned points, D: one area - 1 point; E: serous exudate without fibrinous overlays, injection of peritoneal vessels - 1 point, purulent exudate, minimal fibrin overlays, shiny peritoneum - 2 points, dense fibrin films, dull peritoneum, purulent exudate - 3 points, fecal contents with massive non-removable overlays of fibrin - 4 points; P - diameter of intestinal loops 1.5-2.0 cm, active peristalsis - 1 point, diameter of intestinal loops 2.0-3.0 cm - peristalsis is weakened, actively traced in some areas - 2 points, diameter of intestinal loops 3.0 -4.0 cm - peristalsis is mostly absent, can be traced in some areas - 3 points, the diameter of intestinal loops >4.0 cm - peristalsis is absent - 4 points, obtained as a result of evaluating three criteria, the points are summarized, the minimum amount is 3 points, the maximum amount 14 points, and with a score of 3 to 7 inclusive, a videolaparoscopic operation of the appropriate volume is performed with the possibility of removing the source of peritonitis, and with a score of 8 or more, a laparotomy and the corresponding volume of the operation are performed.

However, the use of only three criteria for deciding on the choice of tactics of surgical treatment using laparoscopy or laparotomy is insufficient, while their uncertainty for practical use in some cases makes it impossible to objectively assess the intraoperative picture and make the right tactical decision that reduces the incidence of postoperative complications and mortality. In addition, the known method does not provide for the possibility of making a decision on the choice of tactics of surgical treatment, taking into account the need to use programmed laparoscopic debridement, which is an important step in surgical treatment - a modern, effective and safe way to treat widespread appendicular peritonitis. Thus, the use of the known method at the present stage makes it impossible to adequately reduce the incidence of postoperative complications and mortality.

The technical problem is the choice of surgical tactics for the treatment of widespread appendicular peritonitis based on the data of intraoperative diagnostic laparoscopy with the determination of the variant of the surgical approach and the determination of indications for dynamic interventions.

Disclosure of invention

The achieved technical result is the possibility of ensuring the choice of optimal surgical access in the surgical treatment of widespread appendicular peritonitis, taking into account the possibility of using programmed laparoscopic sanitation, which increases the effectiveness of surgical treatment.

The technical result is achieved by a method for choosing the tactics of surgical treatment for widespread appendicular peritonitis based on the results of diagnostic video laparoscopy, including performing diagnostic video laparoscopy, during which the abdominal cavity is conventionally divided into 6 areas: the small pelvis, the right and left lateral canals, the right subhepatic space, the right and left subdiaphragmatic spaces, in which the prevalence of the pathological process in the abdominal cavity (Dissemination, D), the nature of the exudate, the presence of fibrin (Exudation, E), the severity of paresis of the small intestine (Paresis, P) are examined, while additionally determining the duration from the onset of the disease to surgery ( time, T), and the state of the viscero-parietal peritoneum (Pryushin, B), while studying each criterion, gradations are distinguished, which are assigned points,

in the study of criterion (D) and the detection of the prevalence of the pathological process in the anatomical regions up to 4 inclusive, 0 points are assigned, in 5 or more regions - 2 points;

in the study of the criterion (E) and the detection of serous exudate without fibrin deposits, 0 points are assigned, serous-fibrinous effusion - 1 point, fibrinous-purulent effusion - 2 points, the presence of interintestinal abscesses, non-removable fibrin deposits - 3 points;

when examining criterion (P), if the bowel loops are not dilated, the wall is edematous, peristalsis is preserved, 1 point is assigned if the loops of the small intestine are dilated in diameter up to 3 cm inclusive, peristalsis is weakened - 2 points if the loops of the small intestine are dilated in diameter more than 3 cm, the wall is edematous, pasty, peristalsis is not traced - 3 points;

in the study of the criterion (T) with a duration from the onset of the disease to surgery less than 24 hours, 1 point is assigned, 24 - 72 hours - 2 points, more than 72 hours - 3 points;

in the study of criterion (B), when hyperemic viscero-parietal peritoneum with petechial hemorrhages is detected, 1 point is assigned; or thickened, dull with fibrin overlay - 2 points; in the case of a pronounced adhesive process between the organs and the peritoneum with the formation of purulent pockets - 3 points;

the scores obtained are summed up, with a score of 3 to 8 inclusive, the operation is performed by laparoscopic access, from 9 to 11 inclusive, surgery is performed by laparoscopic access, followed by programmed relaparoscopy within 24 to 72 hours after the primary operation, with a score of 12 or more, use open intervention.

The claimed method allows to reliably assess the severity and prevalence of appendicular peritonitis during diagnostic laparoscopy (intraoperatively), and make the right decision on the tactics of surgical treatment with the choice of the required surgical access by determining a set of criteria that reflects the stage of development of peritonitis, which cannot be assessed at the preoperative stage, which will reduce the frequency of postoperative complications, mortality and terms of inpatient treatment of patients.

Implementation of the invention

The inventive method is carried out as follows.

All patients, in the absence of absolute contraindications, with a diagnosis of "acute appendicitis", "peritonitis", in order to verify the diagnosis and determine the surgical access, perform diagnostic laparoscopy according to the generally accepted method. Why intraoperatively, according to the proposed criteria, the state of the abdominal cavity is assessed, while the data obtained are correlated with the duration of the disease. The method includes an assessment of 5 main criteria:

Criterion 1 - duration from the onset of the disease to surgery (time, T), gradations of the criterion:

- less than 24 hours - 1 point,

- 24 - 72 hours - 2 points,

- more than 72 hours - 3 points;

Criterion 2 - the prevalence of the pathological process in the abdominal cavity (Dissemination, D), gradations of the criterion:

- up to 4 anatomical regions inclusive - 0 points,

- 5 or more areas - 2 points;

3 criterion - the nature of the exudate, the presence of fibrin (Exudation, E):

- serous exudate without fibrin deposits - 0 points,

- serous-fibrinous effusion - 1 point,

- fibrinous-purulent effusion - 2 points,

- the presence of inter-intestinal abscesses, non-removable fibrin overlays - 3 points;

4 criterion - the severity of paresis of the small intestine (Paresis, P):

- intestinal loops are not dilated, the wall is edematous, peristalsis is preserved - 1 point,

- loops of the small intestine are expanded in diameter up to 3 cm inclusive (there is paresis of the intestine), peristalsis is weakened - 2 points,

- loops of the small intestine are expanded in diameter more than 3 cm (pronounced paresis of the intestine), the wall is edematous, pasty, peristalsis is not traced - 3 points;

5 criterion - the state of the viscero-parietal peritoneum (Bryushina, B):

- hyperemic, with petechial hemorrhages - 1 point,

- thickened, dull, fibrin overlay - 2 points,

- a pronounced adhesive process between the organs and the peritoneum with the formation of purulent pockets - 3 points.

The scores obtained as a result of evaluating the five criteria are summarized. The minimum score is 3, the maximum is 14. With a score of 3 to 8 inclusive, the operation is performed by laparoscopic access. With a score of 9 to 11 inclusive, surgery is performed by laparoscopic access, followed by programmed relaparoscopy within 24 to 72 hours after the primary operation. With a score of 12 or more, open intervention is used.

The sum of points characterizes three stages of development of widespread appendicular peritonitis. The minimum set of points, allowing the implementation of laparoscopic surgery (grade 1), corresponds to the initial stages of the development of widespread appendicular peritonitis (reactive phase). The average value of the scores (grade 2) corresponds to the onset of the toxic phase of the course of peritonitis, and, under certain conditions, suggests laparoscopic access with repeated programmable relaparoscopy. The maximum value of the total score (3rd degree of severity) corresponds to the late stages of peritonitis and involves the implementation of laparotomy access.

The fulfillment of these conditions provides a reduction in the number of postoperative complications, terms of inpatient treatment and mortality in patients with widespread appendicular peritonitis.

After a decision is made to perform a minimally invasive intervention (3-8 points), an aspiration of the effusion from the abdominal cavity is performed, including sampling for microbiological examination. Next, a typical appendectomy is performed, the intersection of the mesentery of the appendix is performed using bipolar electrocoagulation, the treatment of the stump is carried out by the ligature method. In case of perforation in the region of the base of the appendix, as well as in case of inflammatory changes in the dome of the caecum, the base of the appendix is additionally peritonized with an intracorporeal suture according to the Rusanov method. The removed appendix is removed from the abdominal cavity through a trocar in the left iliac region or using an endocontainer through a trocar hole in the left iliac region. Subsequently, the effusion is re-aspirated, the abdominal cavity is drained with sterile wipes, which also help to remove loose fibrin films. The operation ends with drainage of the abdominal cavity using silicone tubes. A more detailed description of the operation performed is presented in the clinical guidelines for the treatment of acute appendicitis [2].

With a total score of 9 to 11, the operation is performed in the manner described above, and upon completion of the intervention, the patient is transferred to the intensive care unit (ICU). Antibacterial, infusion therapy is carried out in the intensive care unit, and, if necessary, extracorporeal detoxification sessions are performed [1, 3]. After stabilization of the condition and obtaining laboratory results within 24 to 72 hours from the completion of the first operation, depending on the severity of the condition, programmed relaparoscopy is performed. In the course of this intervention, the state of the abdominal organs is assessed, directly the area of operation, the abdominal cavity is sanitized, the drainage is corrected if necessary [1, 2, 3].

With a total score of 12 points or more, the patient undergoes surgery from the median approach according to the generally accepted method: appendectomy using the submersible method, debridement and drainage of the abdominal cavity, nasointestinal intubation for decompression, and enteral lavage [1, 2, 3].

The proposed method is convenient in practical use and is focused on solving a specific practical problem: the choice of the method of operational benefits, which plays a big role against the background of many proposed classifications.

For the period 2016-2019 GBUZ "NII SP im. N.V. Sklifosovsky DZM" operated on 1410 patients with acute appendicitis. Diagnostic laparoscopy in 554 patients revealed various forms of appendicular peritonitis, 104 patients had its widespread form.

During this period, patients were treated using the claimed method of choosing the tactics of surgical treatment for widespread appendicular peritonitis based on the results of diagnostic laparoscopy. Out of 104 patients with generalized peritonitis, in 83 (79.8%) surgical intervention was performed and completed by laparoscopic access, and in 19 (18.3%) patients with generalized diffuse form of peritonitis, indications for an open median approach were established. In two patients (1.9%) with generalized diffuse peritonitis, laparoscopic surgery was supplemented with programmed sanation relaparoscopy.

The overall incidence of postoperative complications in the group of patients operated on according to the developed method was 6%. For the previous similar period, the average complication rate was 11.2%. Terms of inpatient treatment of patients with widespread appendicular peritonitis after using the claimed method was reduced from 16.3 to 8 days.

Case Study #1

Patient B., aged 35, was admitted to the emergency department 36 hours after the onset of the disease (T=2). Clinical and instrumental examination suspected a complicated form of acute appendicitis. In order to clarify the diagnosis, determine the prevalence of the process and further surgical tactics, an urgent diagnostic laparoscopy was performed. Intraoperatively, it was revealed that in the right lateral canal, right and left iliac fossae, in the small pelvis there is a cloudy effusion with fibrin (E=2). In these areas, there is also hyperemia of the viscero-parietal peritoneum (D=0, B=1). Loops of the small intestine with weakened peristalsis, diameter less than 3 cm (P=2). A gangrenous appendix was found. Intraoperative diagnosis: Acute gangrenous appendicitis, diffuse serous-fibrinous peritonitis. Taking into account the sum of points according to the developed scale (T+D+E+P+B=7), indications for the laparoscopic method of surgery were established. Performed laparoscopic appendectomy, debridement and drainage of the abdominal cavity. The postoperative period proceeded without complications. The patient was discharged for outpatient treatment on the 5th day.

Case Study #2

Patient B., aged 48, was admitted to the emergency department 90 hours later (T=3) from the onset of the disease. The clinical picture and ultrasound data corresponded to the widespread form of peritonitis. To determine the surgical tactics and verify the diagnosis, diagnostic laparoscopy was prescribed. During laparoscopy along the right lateral canal, in the right and left iliac fossae, in the small pelvis and between the loops there is a cloudy effusion with fibrin threads (E=2). The viscero-parietal peritoneum in these areas is thickened, dull, with massive fibrin overlays (D=2, B=2). The small intestine is pneumatized up to 3 cm, edematous, peristalsis is weakened (P=2). A purple-black appendix with a perforated hole in the apex area was found. Intraoperative diagnosis: Acute gangrenous appendicitis. Perforation of the appendix. Widespread diffuse fibrinous-purulent peritonitis. Taking into account the sum of scores according to the developed scale (T+D+E+P+B=11), indications for the laparoscopic method of surgery with programmed relaparoscopic sanitation after 24 hours were established. Relaparoscopy was performed, sloping places of the abdominal cavity were sanitized. The postoperative period was uneventful. One session of the extracorporeal detoxification method (EMD) was performed. After 60 hours from the first intervention, after stabilization of the condition, the patient was transferred from the intensive care unit for further treatment to the hospital department. On the 11th day of hospitalization, the patient was discharged for outpatient treatment.

Case Study #3

Patient B., aged 26, was admitted to the emergency department 60 hours later (T=2) from the onset of the disease. The clinical picture corresponded to the widespread form of peritonitis, according to ultrasound, the source was a destructive form of acute appendicitis. To determine the surgical tactics, diagnostic laparoscopy was prescribed. During laparoscopy along the right and left lateral canals, in the right and left iliac fossae, in the small pelvis there is a cloudy effusion with fibrin threads (E=2). The viscero-parietal peritoneum in these areas is thickened, dull, with massive overlays of fibrin and the formation of purulent pockets (D=2, B=3). The small intestine is pneumatized for more than 3 cm, edematous, spontaneous peristalsis is not traced (P=3). A purplish-black appendix with a perforated hole at the base was found. Intraoperative diagnosis: Acute gangrenous appendicitis. Perforation of the appendix. Widespread diffuse fibrinous-purulent peritonitis. Taking into account the sum of points according to the developed scale (T+D+E+P+B=12), indications for laparotomy were established. The postoperative period was uneventful. The patient spent the first 72 hours after the operation in the intensive care unit. One EMD session was performed. On the 10th day of hospitalization, the patient was discharged for outpatient treatment.

Bibliography

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Claims (7)

A method for choosing the tactics of surgical treatment for widespread appendicular peritonitis based on the results of diagnostic laparoscopy, including performing diagnostic laparoscopy, during which the abdominal cavity is conventionally divided into 6 areas: the small pelvis, the right and left lateral canals, the right subhepatic space, the right and left subdiaphragmatic spaces, in which the prevalence of the pathological process in the abdominal cavity (D), the nature of the exudate, the presence of fibrin (E), the severity of paresis of the small intestine (P), characterized in that they additionally determine the duration from the onset of the disease to surgery (T), and the state of viscero- parietal peritoneum (B), while in the study of each criterion, gradations are distinguished, which are assigned points, in the study of criterion (D) and the detection of the prevalence of the pathological process in the anatomical regions up to 4 inclusive, 0 points are assigned, in 5 or more regions - 2 points; in the study of the criterion (E) and the detection of serous exudate without fibrin deposits, 0 points are assigned, serous-fibrinous effusion - 1 point, fibrinous-purulent effusion - 2 points, the presence of interintestinal abscesses, non-removable fibrin deposits - 3 points; when examining criterion (P), if the bowel loops are not dilated, the wall is edematous, peristalsis is preserved, 1 point is assigned if the loops of the small intestine are dilated in diameter up to 3 cm inclusive, peristalsis is weakened - 2 points if the loops of the small intestine are dilated in diameter more than 3 cm, the wall is edematous, pasty, peristalsis is not traced - 3 points; in the study of the criterion (T) with a duration from the onset of the disease to surgery less than 24 hours, 1 point is assigned, 24 - 72 hours - 2 points, more than 72 hours - 3 points; in the study of criterion (B), when hyperemic viscero-parietal peritoneum with petechial hemorrhages is detected, 1 point is assigned; or thickened, dull with fibrin overlay - 2 points; in the case of a pronounced adhesive process between the organs and the peritoneum with the formation of purulent pockets - 3 points; the scores obtained are summed up, with a score of 3 to 8 inclusive, the operation is performed by laparoscopic access, from 9 to 11 inclusive, surgery is performed by laparoscopic access, followed by programmed relaparoscopy within 24 to 72 hours after the primary operation, with a score of 12 or more, use open intervention.