Clinical and Functional Characteristics of Abdominal Syndrome in Children Who Have Undergone Surgical Interventions on the Abdominal Cavity

The dissertation is devoted to the clinical and functional characteristics of abdominal syndrome in children who have undergone surgical interventions on the abdominal cavity. The role of the adhesion process, disorders of the motility-evacuation function of the gastrointestinal tract, and regulatory influences of the vegetative nervous system in the formation of abdominal syndrome after laparotomy is investigated. Special attention is given to risk factors, including connective tissue dysplasia syndrome, as well as the development of approaches to diagnosis and prediction of postoperative complications.

RELEVANCE OF THE SCIENTIFIC INVESTIGATION

One of the complex problems of medicine remains diseases accompanied by abdominal syndrome, the share of which, according to various authors, amounts to 5 to 25 percent in emergency diagnostics (Roshal L.M., 1996; Khodueva A.M., Rybkin A.I., Reshetova T.G., 2002; Baranov A.A., 2002).

The diversity of clinical manifestations often causes significant difficulties in the differential diagnosis of abdominal syndrome in various diseases in children. For many physicians, this is one of the most difficult sections of differential diagnosis. It is especially difficult to establish the cause of abdominal syndrome if surgical intervention on the organs of the abdominal cavity was previously performed (Dronov A.F., Al-Mashat N.A., Chelak O.A., 2006), since the latter in such cases may be associated with motility-evacuation disorders of various sections of the digestive tract as a result of the adhesion process in the abdominal cavity (Isakov Yu.F., Stepanov E.A., 1990; Dronov A.F., Blinnikov O.I., 1990; Baklanov V.V., Burov I.S., 1998; Kamagantseva A.L., 1999), organic and functional diseases of the gastrointestinal tract, the clinical picture of which often simulates acute surgical pathology. An important role in the development of abdominal syndrome in children is played by disorders of regulatory influences from the vegetative nervous system (Kopylova E.B., 2004; Mandrov S.I., Zhdanova L.A., Selezneva E.V., Vasilenko L.A., 2006).

Often in children, phenomena of chronic adhesive intestinal obstruction are observed. In such cases, the postoperative pain syndrome takes on a chronic character (Gantsev Sh.Kh., 1981; Dronov A.F., Poddubny I.V., Kotlobovsky V.I., 2002).

These disorders lead to significant polymorphism of clinical manifestations of adhesive intestinal obstruction, which in turn determines the difficulties in differential diagnosis with a number of somatic diseases accompanied by painful abdominal syndrome.

The investigation of the nature of motility-evacuation disorders in various diseases accompanied by abdominal syndrome in children who have previously undergone surgical interventions is based on modern non-invasive research methods, such as computer phonenterography.

However, works of this kind are few, and this problem, especially in childhood, remains insufficiently developed. In particular, contradictory information exists regarding the prevalence and risk factors of diseases manifesting as abdominal syndrome in children who have undergone laparotomy.

Undoubtedly, the trauma of the performed operation and the inflammatory process in the abdominal cavity play an important role in the development of the adhesion process, but it is necessary to take into account other factors influencing adhesion formation. Otherwise, how can one explain the development of complications associated with a pronounced adhesion process even after so-called "benign" operations for so-called "catarrhal appendicitis," while changes in the abdominal cavity in such cases may be more significant than after interventions performed for destructive forms of appendicitis (Kovalev M.M., Roy V.P., 1977; Topuzov V.S., Brelikh L.M., Sheludko Yu.A., 1978; Baklanov V.V., Burov I.S., 1998). Therefore, the study of factors contributing to excessive adhesion formation in a certain category of patients is especially relevant, as it will make it possible to predict possible complications after laparotomy.

OBJECTIVE OF THE SCIENTIFIC INVESTIGATION: to identify the clinical and functional features of abdominal syndrome in children who have undergone surgical interventions on the abdominal cavity, and to determine individual contributing factors for the improvement of the diagnosis of diseases accompanied by its development.

TASKS OF THE SCIENTIFIC INVESTIGATION

1. To establish the structure of diseases and the clinical and functional features of variants of the course of abdominal syndrome in patients who have previously undergone surgical interventions on the abdominal cavity.

2. To provide a comparative characterization of the motility-evacuation function of the digestive tract in interrelation with regulatory influences of the vegetative nervous system in healthy children and patients with abdominal syndrome, based on data from computer phonenterography and heart rate variability.

3. To determine the prevalence of connective tissue dysplasia syndrome in children with abdominal syndrome who have previously undergone laparotomy, and to assess the role of connective tissue dysplasia and other factors influencing the development of the adhesion process in the abdominal cavity.

4. To clarify the features of the motility-evacuation function of the digestive tract in interrelation with regulatory influences of the vegetative nervous system in children with connective tissue dysplasia syndrome.

5. To supplement the algorithm for the diagnosis of diseases proceeding with abdominal syndrome in children who have undergone surgical interventions on the abdominal cavity.

6. To develop formalized tables for predicting the development of the adhesion process of the abdominal cavity in children who have undergone laparotomy.

SCIENTIFIC NOVELTY OF THE INVESTIGATION

The allocation of clinical variants of abdominal syndrome in children who have undergone laparotomy has been proposed, which include a ball-point assessment of the severity, duration, and character, objective and subjective localization of pain and its dynamics over time, and the presence of dyspeptic disorders.

The features of vegetative regulation of the motility-evacuation function of the gastrointestinal tract in healthy children fasting, after physical exercise, and after a test breakfast, as well as in patients with gastroduodenal diseases and late adhesive intestinal obstruction, have been presented.

The prognostic significance of connective tissue dysplasia as one of the factors contributing to the development of the adhesion process of the abdominal cavity after previously performed surgical interventions has been determined.

A risk group for the development of adhesive disease of the abdominal cavity has been identified, comprising children who have undergone laparotomy and have signs of connective tissue dysplasia, sympathicotonic vegetative dysfunction, causing intestinal hypomotility.

PRACTICAL SIGNIFICANCE OF THE INVESTIGATION

An algorithm for the differential diagnosis of diseases accompanied by abdominal syndrome in children who have undergone laparotomy has been validated, which is based on the identification of its clinical variant, the assessment of the type of peristalsis according to computer phonenterography, the investigation of heart rate variability and hemogram, supplemented as indicated by contrast radiographic and ultrasonic examination, fibroeosophagogastroduodenoscopy, which makes it possible to reduce the frequency of diagnostic procedures associated with radiation exposure and to decrease the number of diagnostic errors.

The possibility of predicting the development of the adhesion process in the abdominal cavity in children has been determined.

VALIDATION OF THE INVESTIGATION

The materials of the investigation were reported and discussed at scientific-practical conferences of physicians of the State Unitary Enterprise "Ivanov Regional Clinical Hospital" (2005); final conferences of the scientific society of students and young scientists of Ivanov State Medical Academy "Science Day" (2004, 2005), the XIII Congress of Russian Pediatric Gastroenterologists "Actual Problems of Abdominal Pathology in Children" (Moscow, 2006).

The dissertation passed initial validation at an expanded interdepartmental conference of the departments of pediatric surgical diseases with resuscitation and anesthesiology; pediatric diseases of the treatment faculty; polyclinic pediatrics with a course of healthy child; surgical diseases of the pediatric faculty, topographic anatomy, and operative surgery; pediatrics of the postgraduate education program; pediatric diseases of the pediatric faculty (propaedeutics of pediatric diseases, faculty, hospital pediatrics, endocrinology, and physiotherapy), clinical laboratory diagnostics of the postgraduate education program of the State Educational Institution of Higher Professional Education "Ivanov State Medical Academy" of the Federal Agency for Healthcare and Social Development.

IMPLEMENTATION INTO PRACTICE

Eleven scientific works have been published on the topic of the dissertation. The results of the investigation have been implemented into the educational process and practical work of the department of pediatric surgical diseases with resuscitation and anesthesiology of the State Educational Institution of Higher Professional Education Ivanov State Medical Academy of the Federal Agency for Healthcare and Social Development, and the departments of pediatric surgery and pediatric resuscitation of the State Unitary Enterprise "Ivanov Regional Clinical Hospital."

STRUCTURE AND SCOPE OF THE DISSERTATION

The dissertation is presented on 208 pages of typed text and consists of an introduction, a literature review, a description of materials and research methods, three chapters of original research, a conclusion, findings, and practical recommendations. The bibliography includes 356 sources. The work is illustrated with 58 tables and 2 figures.