Despite the long history of the peritoneal regeneration and the peritoneal adhesions formation pathogenesis studies, as well as a large number of clinical and experimental trials, so far, many questions about the pathophysiology of postoperative adhesions remain controversial. Postoperative formation of peritoneal adhesions is considered to be part of a pathological regeneration process that occurs after any peritoneum injury, especially in connection with surgery. Factors that lead to formation of adhesions are different (mechanical, physical, chemical, infectious, implantation). Inflammatory mediators, free radical oxidation processes, and oxidative stress also play an important role in the modulation of adhesions. A key role in the formation of adhesions belongs to pathological decrease in peritoneal fibrinolytic activity in response to inflammation and surgery. Studies on both animal models and humans have shown that two major factors lead to a decrease in fibrinolysis: a decrease in local tPA activity and an increase in PAI‑1 activity locally and systemically. It is the balance between the activity of tPA and PAI‑1 that plays a central role in the pathological adhesion formation, and the imbalance correlates with the severity of the adhesive process. Thus, pathological adhesion is a multifactorial condition, the development of which is due to a combination of various factors, many of which are genetically determined by local and systemic reactions of the body, and features of surgical treatment. To develop effective methods for prevention and treatment of adhesions, a more complete understanding of this process is needed at both the cellular and molecular genetic levels. The key to preventing post‑operative adhesion formation is likely to be the selective suppression of one or more critical factors that are necessary for its formation. There are practically no works in literature to study the features of adhesions pathogenesis in children.
Introduction. It has been established that adhesions in the abdominal cavity are a natural protective and adaptive reaction in response to peritoneal damage, but excessive adhesions are not only a pathological process, but also causes intestinal obstruction in children in 62%. Purpose: to study the pathogenetic aspects of prevention of surgical adhesions. Results. A large number of preventive strategies have been proposed, which are aimed at certain adhesion etiopathogenesis zones, such as inflammation and exudation reduction; coagulation cascade inhibition, fibrin matrix and fibrin deposition formation; fibrinolysis process potentiation; fibroblast proliferation inhibition; neoangiogenesis inhibition; free radical oxidation prevention caused by hypoxia; prevention of contact between damaged peritoneal areas. Conclusions. The problem of prevention of excessive intra-abdominal adhesions remains relevant due to imperfection of the existing variety of methods of prevention and treatment of adhesive intestinal obstruction, and one of the main tasks of its solution in children is to find a sparing and, at the same time, effective way to prevent excessive intraabdominal adhesions at preoperative, intraoperative and postoperative stages.
It was considered expedient to study the effectiveness of intraoperative prevention of adhesion formation in children based on the results of our own experimental and clinical studies on the effectiveness of using an anti-adhesive gel based on cross-linked sodium hyaluronate. Purpose - to evaluate clinical efficacy and safety of cross-linked sodium hyaluronate gel (SHG) usage as a barrier agent for primary prevention of postoperative peritoneal adhesions formation in children. Materials and methods. This is a prospective, randomized, controlled, patient blinded observational study, which includes 62 children. All patients underwent laparotomy for appendicular peritonitis and were randomly divided into two equal groups. Patients from group A (n=31) received conventional surgical treatment, SHG was additionally applied in group B (n=31) before abdominal closure. Immediate and long-term effects of SHG usage were investigated to evaluate the influence on adhesions reformation. The average period of postoperative observation was 14.0±2.4 months. Results. SHG application was associated with no increase in complications rate: duration of postoperative ileus, need in nasogastric decompression, intensive care unit state, hospital state, the incidence of surgical site infection, and need for relaparotomy did not differ significantly between compared groups. The prevalence of peritoneal adhesions at the end of in-hospital treatment differs significantly between groups according to the ultrasound data (χ2=10.930; p=0.005). The incidence of small bowel obstruction (SBO) developed during the follow-up period in group A (16.1%) was significantly higher than in group B (3.23%) where the anti-adhesive gel was applied (χ2=4.026; p=0.045). Conclusions. Intraoperative use of SHG based on sodium hyaluronate allows reduction of postoperative adhesions formation in children without worsening the postoperative course. The research was carried out in accordance with the principles of the Helsinki declaration. The study protocol was approved by the Local ethics committee of all participating institutions. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors. Key words: sodium hyaluronate, adhesions, small bowel obstruction.
Хірургія дитячого віку – одна з найскладніших дисциплін, що викладається у вищих медичних навчальних закладах.<br />Однак кількість аудиторних навчальних годин за фахом “Лікувальна справа” в цьому навчальному році зменшилася на<br />37,8 % порівняно з 2005/2006 н. р., а за фахом “Педіатрія” – на 44,4 %.<br />Удосконалення організації й методики підвищення якості підготовки студентів може здійснюватися за рахунок, насам-<br />перед, збільшення навчальних годин із навчального плану, що дасть можливість у майбутньому лікарям загального<br />профілю виявляти провідні клінічні синдроми при хірургічних захворюваннях у дітей і уникати несприятливих ситуацій<br />й дефектури. Дитяча хірургія має потребу в постійній підтримці й допомозі з боку держави й громадськості й повинна бути<br />пріоритетною галуззю в системі охорони материнства й дитинства.
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