Діагностика, профілактика та лікування внутрішньочеревної гіпертензії у хворих на гостру хірургічну патологію органів черевної порожнини

Abstract

The dissertation is devoted to the actual problem of the emergency surgery of abdominal organs - increase of intra-abdominal pressure (IAP) or intra-abdominal hypertension (IAH), which has attracted the attention of researchers in recent years. Acute surgical diseases and abdominal injuries are accompanied by an increase in intra-abdominal pressure (IAP), part of them develops the abdominal cavity syndrome or, as it is called, abdominal compartment syndrome (ACS), which is accompanied by the development of severe organ dysfunction in patients and causes mortality in more than half of patients. That is why the improvement of the methods for determining IAP, as well as development of new methods for the correction of IAH and prevention of the development of ACS is relevant, despite the current advances in medical science. The purpose of this study is to improve the results of the treatment of patients with acute pathology of organs of the abdominal cavity through the prevention and treatment of IAH. To achieve the goal the results of treatment of 187 patients with acute surgical pathology, accompanied by an increase of IAP, which were in the Clinic of Surgery Department # 2 of the Bogomolets National Medical University (on the basis of the surgical wards of the Kyiv City Clinical Hospital #4) in the period from 2013 to 2018 were analyzed. The following nosologies were assigned to this category: 1) pinched hernias (ventral hernias of the anterior abdominal wall of large and giant size); 2) abdominal injuries; 3) acute pancreatitis; 4) acute peritonitis; 5) acute intestinal obstruction; 6) acute surgical pathology of abdominal organs, which was eliminated by laparoscopic surgery (acute cholecystitis, acute appendicitis). There were 117 men (62.6%) and 70 women (37.4%). Patients were divided into two groups depending on the chosen diagnostic and therapeutic tactics: comparison and main. The comparison group (85 individuals (45.5%)) included patients who were using standard methods for diagnosis and treatment according to existing protocols. The main group (102 persons (54.5%)) included patients who were treated using the advanced diagnostic and therapeutic algorithm. Patients’ age ranged from 21 to 85 years, with an average age of 46.25±1.12 years. Concomitant diseases were diagnosed in 122 patients (65.2%). The groups were representative by age, sex, major and related pathology. Surgery was used in 149 patients (79.7%): 82 patients in the main group (80.4%) and 62 patients in the comparison group (78.8%). An indirect method of BP monitoring was used to determine the IAP; during laparoscopic interventions the pressure was measured by the direct method by using an insufflator manometer. A technique for long-term measurement of IAP by using a two-balloon catheter (sensitivity of the method - 95.2%, specificity - 85.7%) was developed (patent for utility model No. 114666 "Method for determining intra-abdominal pressure"). The treatment tactics for patients with acute surgical pathology of abdominal organs, accompanied by IAH, were selected depending on the underlying disease. Therefore, firstly the primary factor for the increase of IAP was identified. Usually there were two groups of reasons: 1) an increase in the volume of the abdominal cavity content (increase in the volume of intestinal contents due to paresis, swelling of the intestine, accumulation of fluid, gas in the abdominal cavity, etc.) - 159 patients, 2) reduction of the volume of the abdominal cavity due to surgery on the anterior abdominal wall (hernia, abdominoplasty), its compression in the early postoperative period with bandages, etc.), as well as a combination of these factors. - 28 patients. The advanced diagnostic-therapeutic algorithm was used to optimize the treatment of IAH and prevent the development of ACS. It included a three-stage complex treatment of patients depending on the cause of IAH (external, internal) and the nature of the patient's breathing (mechanical ventilation, spontaneous breathing). The choice of methods for treatment of IAH was individualized. The use of the advanced diagnostic and therapeutic algorithm for the prevention and treatment of IAH allowed to limit the measures of the first level in 67.6% of cases, the second level - in 22.5%, avoid performing decompression laparotomy. At the same time, the need for the intervention arose in 11.1% of patients in the comparison group who were treated conservatively. In the third stage, a method of laparolifting without intervention on the abdominal cavity was developed as an alternative to decompression laparostomy. This method uses an exolift, which is a special plastic sleeve 15 cm wide (50 μm thick) wrapped around the patient's trunk at the umbilical level (Model No. 120553 "Method for the correction of intra-peritoneal hypertension by laparolifting"). The use of the proposed laparolifting system in complex conservative treatment of IAH in patients with acute pancreatitis allowed to normalize IAH in the vast majority of patients, to prevent the occurrence of ACS by reducing the frequency of complications associated with IAH from 52.9% to 16.7%, as well as overall mortality rates from 35.3% to 5.6% (p = 0.03). A number of laparoscopic interventions were improved, taking into account the introduction of mini-invasive technologies into urgent abdominal surgery. A technique for predicting the possibility of performing laparoscopic intervention in the conditions of urgent surgery by registering the initial parameters of IAP by a direct method was invented (patent for utility model 132013 "Method for predicting the possibility of performing laparoscopic intervention in the conditions of urgent surgery"). This allowed expanding the indications for laparoscopic surgery in pathology of abdominal organs (sensitivity of the technique was 85.7%, specificity - 95.5%). Method for topical application of stereoselective non-steroidal anti-inflammatory drugs (NSAIDs) at the end of laparoscopic interventions for the treatment of postoperative pain was developed and implemented (utility model patent 135218 Ukraine “A method of treating postoperative pain after laparoscopic interventions”). The topical use of stereoselective NSAIDs at the end of laparoscopic intervention, followed by it’s intramuscular injection, demonstrates a high analgesic effect, which is reliably confirmed by pain scores (visual analogue scales, blood plasma cortisol, and respiratory function) (p <0.0001) and it’s safety in relation to other classes of painkillers (χ2=17,7, p <0.0001). Laparoscopic appendectomy was performed in 17 patients with destructive forms of acute appendicitis under conditions of infiltrative changes of the caecum and the close location of the stump of the appendix to the bauginium flap, where the peritonization of the stump of the appendix was performed by the final department of the ileum (patent for utility model 123796 "Method of laparoscopic appendectomy for acute destructive appendicitis complicated by typhlitis"). This method allowed to reduce the incidence of purulent complications by 13.04% χ2=3,9, р=0,048) and to shorten three times the patient's stay in the hospital (t=3,1, р=0,003). The incidence of systemic postoperative complications was 31.0% (58 cases). Systemic complications included acute heart failure, acute respiratory failure, liver failure, multiple organ failure, thromboembolic complications. Systemic complications occurred in 12 patients in the main group (11.8%) and in 46 patients in the comparison group (54.1%). Acute respiratory (12.8%) and acute heart failure (7.5%) had the highest incidence of systemic complications. The absence of a differentiated pathogenetic approach in monitoring and correction of the increase of IAP triggers the complex pathogenetic mechanism of systemic disorders of the organs and systems of the organism. That’s why the next systemic complication in the frequency of development is the multiple organ failure (7.0%), which develops when two or more systems of the body are involved in the pathological process. In this case, the third degree of IAH in three patients was combined with the development of insufficiency of two organs and systems, in 2 patients - three, and in one patient - four and more organs and systems. Mortality rate was 20 patients (10.7%) (2 patients in the main group (1.96%) and 18 patients in the comparison group (21.2%) (χ2 = 17.85, CI 10.4-29.18, p <0 , 0001). Acute pancreatitis (1 patient) and closed abdominal trauma (1 patient) were the cause of death in the main group, in the comparison group acute pancreatitis (33.3%) and pinched hernias (22.2%) prevailed in the mortality structure. Postoperative mortality in patients with acute surgical pathology of abdominal organs was a total of 11.4% (17 patients out of 149 operated patients): 2 of 82 operated patients (2.4%) died in the main group, 15 of 67 patients died in the comparison group (22,4%) (χ2 = 14,51, CI 9,73-31,45, p = 0.0001). The leading place among the causes of death of this category of patients belongs to multiple organ failure (6.4%), which means that the death of the majority of patients (60%) occurred as a result of the development of ACS. A considerable percentage of patients (25%) among all lethal cases were persons with thromboembolic complications. There is no doubt that IAH was the cause that started mechanism for the development of those pathological processes by the organs and systems that caused the death. The implementation of laparoscopic surgery in the emergency surgery has made it possible to improve the prognosis for the disease and to avoid the development of lethal outcomes. Thus, the use of the proposed diagnostic-therapeutic algorithm in the complex treatment of patients with acute pathology of abdominal organs, accompanied by IAH allowed to achieve the intended goal of improving the treatment results of this category of patients by reducing the frequency of development of systemic complications from 54.1% to 11.8 % (χ2 = 38.6, CI 29.3-53.6, p <0.0001), total mortality from 21.2% to 1.96% (χ2 = 17.9, CI 10.4-29, 18, p <0.0001), and postoperative mortality rates - from 22.4% to 2.4% (χ2 = 14.5, CI 9.73-31.45, p = 0.0001).