Endoscopic Methods for the Treatment and Prevention of Adhesive Peritonitis

The dissertation is dedicated to the development of endoscopic methods for the treatment and prevention of adhesive peritonitis. The work substantiates the use of allogenic peritoneum with anti-adhesive and antimicrobial properties for the prevention of visceral-parietal peritoneal adhesions, develops an algorithm for selecting the strategy and scope of laparoscopic treatment, and a complex of intraoperative and postoperative measures aimed at preventing recurrence of the adhesive process.

Relevance of the Problem. Adhesive peritonitis (AP) represents one of the most complex and as yet unresolved urgent problems of abdominal surgery. Its significance is constantly growing in connection with the increasing number and volume of operations on abdominal organs. Prevention and treatment of patients with AP, especially in cases of repeated recurrence, present a highly complex task in clinical practice, owing to the multifactorial nature of the disease itself, the severity of its clinical manifestations and complications, and the absence of reliable methods for preventing recurrences. The spread of the adhesive process is detected in 50.4%–90% of patients undergoing repeated operations on abdominal organs. (2, 22,24,45,168, 173).

Acute adhesive intestinal obstruction (AAIO) accounts for 4.5% of all surgical diseases of the abdominal organs (139,104) and is the most formidable manifestation of adhesive peritonitis, occupying a leading place among other types of intestinal obstruction. According to data from a number of authors (24,104,139,227), AAIO constitutes no less than 60% of all types of mechanical intestinal obstruction, 94.5% of obstruction of non-neoplastic origin (27,29,31), and 57.5%–79.2% of all types of intestinal obstruction (103). It should be noted that at present, an increase in AAIO within the structure of mechanical obstruction is observed (56). From 39.4% to 84.1% of patients admitted to the clinic with a diagnosis of AAIO are operated on in an emergency order (90,96, 100, 102, 233). Postoperative mortality in this case ranges from 4.6% to 21% (30, 154, 240). At present, increasing attention is being devoted to the study of such a type of AAIO as early obstruction (36, 199, 216). In connection with this, the necessity of planned sanitation of this category of patients is growing.

The success of any operation, when it is necessary to simultaneously resolve issues related to adhesive peritonitis, depends in large measure on the development of recurrence of AP. However, not all authors associate repeated or subsequent operations with the necessity of preventing adhesive peritonitis. The large number of prevention methods rather attests to the fact that none of them fully satisfies surgeons. On the other hand, this provides an opportunity for the creative application of the most rational and effective techniques from the arsenal of methods accumulated by surgeons to date. Special importance is also attached to purulent wound complications. It is generally accepted that the effectiveness of any prevention method is evaluated by remote treatment results (31,32,94,103,104). One of the main criteria in this regard is the absence of recurrence of the adhesive process in the abdominal cavity. The most important motivation for persistent efforts in developing new operative methods and the application of various medicinal preparations is the possibility of sharply reducing the number of AP recurrences (1, 6, 8, 90, 107, 214), which has great practical significance and justifies further research in this direction.

To successfully address the tasks of treatment and prevention of AP and the performance of simultaneous operations, it is necessary to develop an algorithm for clinical examination and determination of the treatment method for this category of patients, using a complex of preoperative diagnostic methods that allow correct planning of the volume and nature of the intra-abdominal stage of visceralolysis, and a system of effective measures for the prevention of AP.

However, the use of traditional methods of treatment and prevention of adhesive peritonitis, including the application of laparotomy, the introduction of oxygen and medicinal solutions into the abdominal cavity after performed visceralolysis, does not yield the desired results. In this regard, an alternative may serve the application of other, minimally invasive intraoperative methods for the prevention and treatment of adhesive peritonitis, as well as the use of plastic materials possessing anti-adhesive and antimicrobial properties that effectively prevent the renewal of intra-abdominal adhesions. (1, 3, 5, 6, 7, 8, 9, 19, 22, 55, 64, 83, 148, 205, 206)

The pathogenetically grounded application of antimicrobial suture material in patients with AP is justified, since the presence of ligature infection in 74.4% of patients creates a real threat of purulent-inflammatory wound complications.

On the basis of the above, the goal and objectives of the present study were formulated.

The goal of the research — improvement of the results of surgical treatment of patients with adhesive peritonitis through the application of a comprehensive diagnostic method, endoscopic treatment, and prevention of the disease.

In accordance with the set goal, the following objectives of the research were determined:

1. To conduct an analysis of clinical material of surgical treatment of patients with AP in order to develop indications for laparoscopic adhesiolysis.

2. To develop a method of obtaining an allogenic peritoneal transplant with anti-adhesive and antimicrobial action for the prevention of visceral-parietal peritoneal adhesions. To study the tissue reaction upon application of an allogenic peritoneal transplant with anti-adhesive and antimicrobial action and its influence on the local adhesive process.

3. To develop a complex of intraoperative measures and postoperative guidelines aimed at early restoration of gastrointestinal tract functions and prevention of recurrence of adhesive peritonitis.

4. To develop an algorithm for selecting the strategy and scope of laparoscopic treatment and prevention of adhesive peritonitis.

5. To study the immediate and remote results of endoscopic treatment of adhesive peritonitis.

Scientific Novelty. For the first time, a method of prevention of AP using the application of separating allogenic peritoneum with anti-adhesive and antimicrobial action into the abdominal cavity was used during laparoscopic operations (Russian Federation Patent No. 2240053). During laparoscopic visceralolysis operations, a method of intra-mesenteric catheter placement for the prevention of postoperative ileus in the postoperative management of patients, early prolonged autonomous electropulsative stimulation of the gastrointestinal tract, was applied for the first time (Russian Federation Patent No. 2216362). An algorithm for selecting the strategy and scope of laparoscopic treatment and prevention of adhesive peritonitis was developed. In comprehensive preoperative examination, a method of conducting a study for early diagnosis of the type and level of acute adhesive intestinal obstruction was used (Russian Federation Patent No. 2223037).

Practical Significance of the Work. A system of examination, selection, and determination of the method of endoscopic treatment of patients with AP was developed. Technical techniques of laparoscopic visceralolysis and prevention of adhesive adhesions were developed and introduced into practice. A complex of endoscopic intraoperative methods for the prevention of adhesive peritonitis was developed depending on the degree of expression of the adhesive process and the results of visceralolysis, and the advisability of performing simultaneous operations in this category of patients was substantiated.

Positions for Defense.

1. The advisability of using, after adhesiolysis, an allogenic peritoneal flap with anti-adhesive and antibacterial properties for the purpose of implantational prevention of purulent wound complications and visceral-parietal peritoneal adhesions.

2. The possibility of using separating polymer films as drainage of the abdominal cavity, providing adequate evacuation of exudate from the abdominal cavity and effective prevention of the formation of visceral-parietal adhesive adhesions.

3. The necessity of including in the complex of measures and the possibility of technical performance during operative treatment of AP of methods of prolonged blockade of the root of the mesentery of the small intestine and electrostimulation of the intestine, as methods of effective correction of ischemic disorders of the intestinal wall and stimulation of motility of the gastrointestinal tract.

4. The substantiation of the algorithm of diagnosis, endoscopic treatment, and prevention of adhesive peritonitis.

Implementation of the Results of the Work. The main provisions and developments of the research were introduced into the practice of surgical departments of the Bashkir State Medical University clinic, City Clinical Hospital No. 21. Based on the materials of the work, 3 Russian Federation patents for inventions were obtained.

Presentation of the Work. The materials of the dissertation were reported at the All-Russian Scientific and Practical Conference of Surgeons "New Technologies in Surgery" (Ufa, 2004), a meeting of the Association of Surgeons of the Republic of Bashkortostan (2005), a meeting of the Association of Endoscopists of the Republic of Bashkortostan (2005), a clinical conference of the Bashkir State Medical University clinic (2005), a profile interdepartmental meeting of Bashkir State Medical University (2006), the All-Russian Conference of Surgeons "Actual Questions of Modern Surgery" (Astrakhan, 2006), and an interdepartmental meeting of profile departments of Bashkir State Medical University (June 27, 2007).

Publications. Five scientific works on the topic of the dissertation were published, two of them in publications indexed by the Higher Attestation Commission (ВАК).

Volume and Structure of the Dissertation. The dissertation is presented in 122 pages. It consists of an introduction, 5 main chapters (a literature review, materials and methods of research, three chapters analyzing clinical material and the results of experimental and clinical studies), conclusion, conclusions, practical recommendations, and a reference list (148 domestic and 98 foreign authors).