1 ГБУЗ Кемеровской области «Новокузнецкая городская клиническая больница № 1» (654057, г. Новокузнецк, пр-т Бардина, 30, Россия); 2 Новокузнецкий государственный институт усовершенствования врачей -филиал ФГБОУ ДПО «Российская медицинская академия непрерывного профессионального образования» Минздрава РФ (654005, г. Новокузнецк, пр-т Строителей, 5, Россия); 3 ГБУЗ Кемеровской области «Новокузнецкая городская клиническая больница № 22» (654034, г. Новокузнецк, ул. Петракова, 71, Россия); 4 ГБУЗ Кемеровской области «Новокузнецкая городская клиническая больница № 29» (654038, г. Новокузнецк, пр-т Советской Армии, 49, Россия) Автор, ответственный за переписку: Лещишин Ярослав Миронович, e-mail: apple-fish@yandex.ru резюме Обоснование. Лапаростомия является агрессивным хирургическим методом лечения перитонита и требует обоснования своей эффективности. Цель исследования: определить эффективность лапаростомии и плановых санаций у пациентов с распространённым гнойным перитонитом. Методы. Использован ретроспективный анализ результатов применения лапаростомии и плановых санаций у пациентов с распространённым гнойным перитонитом. В исследование включена 101 история болезни. Критерии включения: установленный диагноз распространённого гнойного перитонита при первичном оперативном вмешательстве, потребовавшем выполнения лапаротомии. Из исследования исключались иммунокомпрометированные пациенты; пациенты на гемодиализе. Кроме того, критериями исключения являлись: панкреонекрозы; закрытые травмы живота; цирроз печени класса С; канцероматоз, раковая кахексия; диссеминированный туберкулёз; тотальный мезентериальный тромбоз. В статистике использовались показатели медиан и интерквартильных размахов, методы непараметрической статистики (критерий Манна -Уитни). Уровень значимости α = 0,05. Результаты. Вся группа разделена на три подгруппы по шкале оценки Мангеймского индекса перитонита (MPI): I подгруппа -20 человек; II подгруппа -57 человек; III подгруппа -24 человека. Метод плановых санаций брюшной полости в сочетании с наложением лапаростомы был применён в 34 (33,6 %) случаях: в первой подгруппе -в 2 (10 %) случаях, во второй -в 18 (31,6 %); в третьей -в 14 (58,3 %). Умершие вне зависимости от выбранной хирургической методики характеризовались более высокими значениями интегральных шкал. Тяжесть состояния выживших пациентов, оперированных с использованием методики, при поступлении была статистически значимо выше, чем тяжесть выживших пациентов, оперированных без применения лапаростомии SAPS II (р = 0,4716), однако их возраст был также статистически значимо ниже (р = 0,5476). Умершие пациенты были старше 60 лет и имели высокие показатели по вышеперечисленным интегральным шкалам. Заключение. Полученные результаты показали, что пациенты старше 60 лет, имеющие II и III степени тяжести по шкале оценки MPI и высокие значения интегральных шкал, требуют более взвешенного и дифференциального подхода при использовании лапаростомы. Ключевые слова: распространённый гнойный перитонит, лапаростома, плановые санации, Мангеймский индекс перитонита ...
Treating bowel injuries is challenging. Although the failure of anastomosis or suture of the intestine remains a dangerous complication and multiplies in conditions of peritonitis, multistage tactics before the tactics of maintaining intestinal continuity during the first operation is becoming an increasingly preferred strategy. The aim of the research. To evaluate the treatment results for delayed formation of the inter-intestinal anastomosis in patients with bowel injury complicated by peritonitis. Material and Methods. A total of 69 patients were enrolled in the study, among which 40 were included in the retrospective group and 29 were included into the prospective group. All included patients underwent surgery for bowel injuries at the NCHKH 29 and at the NCHKH 1 within the period from 2011 to 2019. The patients’ mean age amounted to 33.4±9.2 years. A total of 35 patients were admitted with blunt trauma and 34 had stab wounds. The retrospective group received treatment with bowel resection with application of anastomosis during the initial surgery while patients of the prospective group had their anastomosis formation delayed to the time after peritonitis management. The postoperative course was analysed in regard to the frequency and severity of postoperative complications and mortality. Results. Among the 69 patients, 78% had a small bowel injury and 47% had a colon injury. A total 39.1% of the lesions in the small intestine and 21.7% of the lesions in the colon were treated with wound closure or bowel resection with primary anastomosis, regardless of the site of injury (p = 0.381). Mortality was 33%, of which 47.5% in the control group and 13.8% in the comparison group. A severe course of the disease was noted in 32% and complications in the abdominal cavity occurred in 32% of patients. The risk factors for severe course of the disease were formed intestinal stomas (p = 0.036), massive blood loss (p = 0.005) and delayed seeking medical care (p = 0.023). The incidence of intestinal suture incompetence was 28.2%. All failures occurred in the early postoperative period. Conclusion. Multi-stage surgical tactics in treatment of patients with intestinal injury complicated by peritonitis should be the preferred option, regardless of the site of injury – small or large intestine. The imposition of an intestinal stoma is an important factor in the development of postoperative complications, which can be compared with the risk of an intestinal suture or anastomosis in peritonitis
Objective. The treatment of necrosis, perforation and traumatic damage to the small intestine has always attracted the attention of surgeons due to the high incidence of complications and mortality that occur during treatment. However, there is very little research on this paper.Purpose of the study: to compare the results of treatment of patients using the tactics of suturing wounds or perforations and resection of the intestine with the imposition of a primary anastomosis with obstructive resection of the intestine with the formation of an anastomosis in a delayed manner.Material and methods. The clinical study was conducted at Novokuznetsk City Clinical Hospital No. 1 named after G.P. Kurbatov and Novokuznetsk City Clinical Hospital No. 29 named after A.A. Lutsik in the period of January 2011 to February 2019. A retrospective and prospective study was conducted, including an analysis of 835 patients treated for necrosis, perforation and traumatic damage to the small intestine. All patients were randomly distributed into groups with the imposition of a primary anastomosis and bowel resection with the formation of a delayed anastomosis. The estimated indicators were lethality and developed complications associated with the chosen treatment tactics during the patient's stay in the hospital.The results. The most common cause of surgical interventions on the small intestine was acute intestinal obstruction – 58.0%, followed by acute mesenteric circulation disorder (27.1%), inflammatory bowel perforation (6.7%) and intestinal trauma (8.3%): and the most common operation in the retrospective group was resection of the intestine with the imposition of a primary anastomosis (64.0%), then suturing of the perforations of the inte stine (5.5%) and the imposition of a stoma (4.3%), in the prospective group group anastomosis after resection of the affected area was applied in a delayed order (100%). The most common complication in the retrospective group was anastomosis or bowel suture failure (64.3%), which was only 8% in the prospective group, however, in the latter group, superficial wound infection was most common (26.8%), accompanied by wound suture dehiscence. in 11.3% of individuals. The incidence of anastomotic leaks significantly decreased after delayed formation. Intestinal fistulas/stoma leaks were detected in 11.5% of patients in the retrospective group. Patients in the prospective group had a longer median ICU stay (11 days vs 4; p < 0.001) and a longer median hospital stay (27 vs 14 days; p < 0.008). Overall mortality in the retrospective group was 47.1%, in the prospective group – 14.8%.Conclusion. Patients in the group with bowel resection and delayed anastomosis had a significantly lower rate of mortality and complications associated with anastomosis or bowel suture failure in conditions of peritonitis compared with the group with primary anastomosis, but had a longer stay in the hospital and a greater number of surgical operations.
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