Adhesive disease

Adhesive disease - a syndrome caused by the formation of adhesions in the peritoneal cavity due to the transferred diseases, injuries or surgical operations, is characterized by frequent attacks of relative intestinal obstruction.

Postoperative adhesions usually remain the most difficult part of abdominal surgery. The total number of these complications reaches, according to the published data. 40% or more. Most of them require repeated surgical intervention, often much more traumatic and dangerous than the initial operation.

Despite the abundance of specialized literature on this problem, practical health care does not yet have sufficiently objective, simple and safe methods of diagnosing such a condition as a commissural disease, as well as effective methods of rational treatment and prevention.

Difficulties in diagnosis make it difficult to choose the tactics of treatment, especially when deciding whether to re-operative. In this issue, the opinions of the authors are radically divided - from the necessary early planned (or program) relaparotomy and open-ended abdominal cavity (laparostomy) to the application of late relaparotomies. At the same time, all clinicians agree that relaparotomy belongs to the category of surgical interventions with a high degree of operational risk performed in the most complex and weakened contingent of patients. This, in turn, determines the mortality rates that make up after such operations, according to different data from 8 to 36%.

It should be noted that the absolute majority of practical surgeons remain on the position that the adhesive disease should be treated by a wide relaparotomy. At the same time, the intersection of squeezing cords and the separation of intestinal fusions in intestinal obstruction certainly saves the life of the patient, but inevitably provokes the formation of adhesions in even greater numbers. Thus, the patient is at risk of re-operation, increasing with each intervention.

An attempt to break this vicious circle was the Noble intestinoplication proposed with the help of serous-muscular sutures, designed to prevent the disordered location of the intestinal loops and obstruction. Because of the large number of complications and poor long-term results, this operation is now practically not used.

The methods of conservative influence on the pathogenesis of postoperative adhesions for prevention and treatment are also insufficiently developed.

Adhesive disease is a pathological condition caused by the formation of adhesions in the abdominal cavity after surgery, trauma and some diseases.

Adhesive disease can be of two forms:

• congenital (rare) as an abnormality of development in the form of planar inter-intestinal fusions (Lane's cords) or fusions between parts of the colon (Jackson's membrane);
• acquired after surgery, trauma with hemorrhages in the visceral leaf of the peritoneum, inflammation of the peritoneum (visceritis, peritonitis, transient processes in inflammatory periprocesses of internal organs).

ICD-10 code

• K56.5. Intestinal adhesions [adhesions] with obstruction.
• K91.3. Postoperative intestinal obstruction.

What causes an adhesion disease?

After operations, the formation of a pathological process in the abdominal cavity is facilitated by prolonged intestinal paresis, the presence of tampons and drains, the entry of irritating substances into the abdominal cavity (antibiotics, sulfonamides, talc, iodine, alcohol, etc.), residual blood, especially infected, irritation of the peritoneum during manipulation (for example, not blotting out the exudate, but wiping it with a tuffer).

The prevalence and nature of the pathological process can be different: limited by the zone of operation or inflammation, sometimes delimiting the whole floor of the abdominal cavity, more often the cavity of the small pelvis; in the form of soldering the inflamed organ (gallbladder, bowel loop, stomach, omentum) to the anterior abdominal wall; in the form of separate strands (extrusions) attached at two points and leading to compression of the intestinal loop; in the form of an extensive process that captures the entire abdominal cavity.

How does the adhesion develop?

Adhesion sickness is a very complex pathology, it can not be solved without a clear understanding of the processes taking place in the abdominal cavity.

According to modern researchers, protective cellular processes, initiated by various intraperitoneal injuries - surgery, trauma, inflammatory processes of various genesis develop with the direct participation of the main "generators" of inflammatory cells - the peritoneum and the large omentum. They provide the most important mechanisms of cell defense from the point of view of phylogenesis.

In this issue, we should dwell on the derivatives of monocytes - peritoneal macrophages. These are the so-called stimulated peritoneal macrophages, i.e. Phagocytes, which are part of the inflammatory exudate of the abdominal cavity. In the literature it is shown that during the first hours of the inflammatory reaction, mainly neutrophilic leukocytes appear in the abdominal cavity, and by the end of the first or beginning of the second day, monoculars that activate and differentiate into peritoneal macrophages migrate into the exudate. Their functions are determined by the ability to intensively absorb various biological substrates and actively participate in the catabolism of the intraperitoneal process. That is why the state of macrophage reactions in the pathogenesis of adhesions can be considered indisputable.

When studying the state of protective cellular reactions in humans, the most informative method is the study of an aseptic inflammatory reaction (AVR) in the "cutaneous window".

To carry out this investigation, a sterile slide is applied to the scarified surface of the test subject to fix the prints after 6 and 24 hours, thus obtaining the cellular material of the first and second phases of the ATS. Subsequently, they are stained and studied under a microscope, assessing the timeliness of the phase change (chemotaxis), the percentage cellular composition, the quantitative relationship of various elements and cytomorphology.

The studies conducted using this technique showed that in healthy people in the first phase of AVP neutrophils make up on the average 84.5%, and macrophages - 14% in the second phase of ATS observe the opposite ratio of cells: neutrophils - 16.0%, and macrophages - 84%, eosinophils do not exceed 1.5%.

Lymphocytes are not detected at all. Any kind of deviation in this sequence of output and the percentage of cells indicates a violation of cellular defense mechanisms.

Recently, clinical and experimental studies have appeared, which state that adhesions are the result of a disruption in the exchange of connective tissue, in particular collagen. Stabilization of collagen chains is carried out with the participation of copper-containing enzyme lysyl oxidase, which catalyzes the conversion of lysilodeoxylizine to aldehydes. These aldehydes, in turn, form transverse covalent bonds, forming a three-helix molecule of insoluble mature collagen. The activity of lysyloxidase is directly related to the activity of N-acetyltransferase, a constitutional enzyme that catalyzes the process of inactivation of toxic metabolic products and ligands imported from outside.

It is well known that the human population by the activity of N-acetyltransferase is divided into so-called "fast" and "slow" acetylators. At the same time, slow acetylators include persons with an acetylation percentage of less than 75, to fast acetylators with an acetylation percentage exceeding 75.

The process of regeneration of the peritoneum the formation of collagen fibers in individuals with different rates of acetylation occurs in different ways.

• Acetylation substrates accumulate in slow acetyleners (endogenous and exogenous chelate complexes), which bind the copper ions that make up the lysyloxidase. The speed of synthesis of cross-links decreases, the number of formed fibers is small. Accumulating lateran collagen on the principle of feedback activates endogenous collagenase.
• Rapid acetylators do not accumulate acetylation substrates. Ions do not bind, the activity of lysyloxidase is high. There is active synthesis and deposition of collagen fibers on the available fibrin overlays. On these fibers, in turn, fibroblasts settle, which perverts the normal course of regeneration of the peritoneum and leads to the formation of a commissural disease.

Adhesive disease develops due to the presence of a causal relationship between cytodynamic, cytomorphological shifts in the normal course of local and general cellular defense reactions in disorders of reparative collagen synthesis.

These complications in clinical practice are represented by such conditions as: early intestinal obstruction (RSNC), late intestinal obstruction (PKNK) and adhesions (SB).

Proceeding from the foregoing, in patients who have an adhesion disease, it is necessary to carry out a complex study including phenotyping by the rate of acetylation, the study of cytodynamic processes and cytomorphology of phagocytic cells in peritoneal exudate (local cellular reaction), in the "skin" window according to Rebuk (general cellular reaction). Verification of the obtained data should be performed by methods of ultrasonic echography (ultrasonography) of the abdominal cavity and video laparoscopy.

Adhesive disease is characterized by the presence of changes in the investigated parameters characteristic only for this pathology.

Cytodynamic reactions in the postoperative period in these patients had their own peculiarities both in peritoneal exudate and in the "skin window" prints. Thus, in a peritoneal exudate a reduced amount of macrophage elements was observed, in the course of AVP - a disturbance of macrophage chemotaxis and an increased content of fibrin fibers in the wound of the "cutaneous window". The average rate of acetylation in children with RSNC was significantly higher than that of patients with a favorable course of the postoperative period, and was; 88.89 ± 2.8% (p <0.01).

The results of the conducted studies led to the following conclusion.

If surgery on the abdominal cavity is performed in a child with the phenotype of rapid acetylation and at the same time he suffers from a macrophagal reaction due to a violation of the chemotactic activity of mononuclear phagocytes, then on the one hand, enhanced fibrinogenesis and accelerated collagen synthesis due to the intensive proliferation of fibroblasts , ahead of the rate of normal catabolism of fibrin, and on the other hand - an inadequate macrophage reaction, distorting the kin inflammation, which will lead to a long persistence of the products of abdominal degradation, causing sensitization of the body by products of tissue decay and the formation of delayed type hypersensitivity, chronic inflammation on the immune basis, involving even more: the amount of fibroblasts in the inflammatory focus. Thus, all the noted processes together will lead to an excessive synthesis of connective tissue - the formation of a condition such as a commissural disease. It should be noted that the concomitant pathology of the gastrointestinal tract will repeatedly increase the risk of pathological fibrinogenesis.

How does the adhesive disease manifest itself?

The clinical course distinguishes between acute, intermittent and chronic adhesions.

The acute form is accompanied by a sudden or gradual development of pain syndrome, an increase in peristalsis, a clinic of dynamic intestinal obstruction, which in most cases can be resolved. Growing pains and changing their character to permanent evidence of the development of mechanical obstruction.

Intermittent form is accompanied by periodic attacks, which are accompanied by various pains, dyspeptic disorders, constipation, alternating diarrhea, a feeling of discomfort. As a rule, it occurs with limited pathological processes. Bowel obstruction develops rarely.

The chronic form is manifested by aching pain in the abdomen, a sense of discomfort, constipation, weight loss, bouts of dynamic intestinal obstruction, but a mechanical form of obstruction can develop.

How is the adhesion seen?

Diagnostics is based on dynamic radiographic examination of the passage of barium suspension in the intestine, sometimes resorting to irrigoscopy, if the colon is involved in the process. Simultaneously with the definition of the character of bowel deformation and the presence of an obstacle for passage of intestinal contents, the relief of the intestinal mucosa is also determined:

This is necessary for differential diagnosis with intestinal cancer and carcinomatosis.

Adhesive disease is characterized by deformation of the mucosal relief, but it is not interrupted, as in cancer. In doubtful cases, laparoscopy is performed, but during a period of exacerbation it may present certain difficulties, and even the danger of damage to the swollen loops of the intestine.

The success of the treatment of patients with postoperative adhesions is largely dependent on timely diagnosis. Well-known and widely used methods of diagnosis do not always lead to the desired results, prompted clinicians to develop a comprehensive diagnostic program for predicting this pathology. This program includes the use of a chemical method for determining the type of acetylation of a particular patient, pathomorphological techniques for studying local and general cellular reactions, ultrasound of the abdominal cavity, a traditional radiographic examination, and laparoscopy.

Ultrasonic diagnostics with suspicion of adhesions are applied to the conditions of using modern equipment. It makes it possible to obtain a characteristic echographic picture practically non-invasively.

It should be remembered, however, that ultrasound diagnosis of intestinal obstruction due to adhesive disease can not be guided only by a static picture. More reliable data are obtained during real-time echoscopy, which allows to detect the translational movement of particles in the intestinal tube in normal and the phenomenon of reciprocating - with signs of mechanical intestinal obstruction. This phenomenon was detected in almost all patients and is called the "pendulum symptom". Nevertheless, with all the information and the possibility of ultrasound diagnosis, they are largely limited by the concomitant phenomena of the intestinal paresis. To solve this problem, a method for differential diagnosis of mechanical and dynamic intestinal obstruction was developed. For this purpose, ultrasound of the abdominal cavity is performed, in which the enlarged loops of the small intestine are filled with liquid contents, indicating a violation of the passage through the intestinal tube. Introduce neostigmine methyl sulfate in the age-related dosage followed by percutaneous electrostimulation of the intestine and repeatedly conduct echographic examination. If, as a result of the stimulation performed, the gut lumen decreases and the particles move forward, it is possible to reject with confidence the diagnosis of mechanical intestinal obstruction and treat the patient conservatively. With mechanical obstruction

After stimulation, pain is increased, often vomiting occurs, echography of the intestinal loops does not decrease in size, the chyme movement is noted as a "pendulum symptom", which allows to diagnose mechanical intestinal obstruction and formulate indications for its surgical resolution.

A fairly typical picture of the radiographic diagnosis of intestinal obstruction (in the form of both an overview radiography of the abdominal cavity and radiopaque studies with barium suspension) is well known. In this regard, with all due respect to the old tried and tested method, its negative aspects should be mentioned: the radiation load, the duration of the diagnostic process, difficulties in the differential diagnosis of dynamic intestinal patency from mechanical.

How is it treated?

Speaking about the methods of treatment of both early and late postoperative adhesions, one should point out the inadequacy of unification in the problem

Choice of therapeutic tactics for this pathology. In this part of the solution to the problem, the principle of a differentiated approach must be adopted, depending on the presence of a specific clinical form of postoperative complication.

In this case, the priority task should be considered the desire to avoid a wide laparotomy, and in the case of absolute indications for surgical treatment, achieve cure with endosurgical intervention or minilaparotomy.

Speaking about the treatment of children who have an adhesive disease, the following should be noted. It is common knowledge that until now all clinicians, with rare exceptions, have tried to avoid all surgical treatment of children with adhesive disease, especially without the phenomena of obstruction, preferring conservative methods of treatment, usually ineffective.

At the present stage, therapeutic tactics should be composed of active detection of children with adhesive disease, preoperative treatment, and then complete elimination of the adhesive process in the abdominal cavity with the help of laparoscopic techniques.

Indications for surgical treatment of adhesions include the following symptom complex:

• Frequent painful attacks, accompanied by the phenomena of intestinal obstruction (vomiting, stool and gas retention).
• Recurrent pain in the abdomen, especially when jumping and running (a symptom of Knoeh, or "strained gland").
• Intensive pain in the abdomen, often accompanied by vomiting, resulting from a violation of the diet in the form of overeating.
• Phenomena of total intestinal obstruction permitted during conservative measures.

Naturally, the basis and guarantee of subsequent success are the diagnostic methods discussed above. Moreover, the components of this diagnostic program allow not only to establish the presence of such a condition as a commissural disease, but also to determine the differentiated tactics of subsequent treatment. Proceeding from the above, all fast acetylators need to be prescribed preoperative preparation aimed at transformation of adhesions in order to reduce the traumatism of subsequent laparoscopic intervention and to prevent recurrence of adhesions.

The adhesion is treated as follows. In parallel with the examination of the patient in terms of preparation for surgical intervention on the abdominal cavity, penicillamine is prescribed in the age-related dose once a day during meals (preferably during lunch). Mandatory components of treatment are drugs. Normalizing the intestinal microflora (bifidobacteria bifidum, bifidobacteria bifidum + intestinal sticks), and vitamin E as an antihypoxant. Other medication is used only to correct any pathological changes found during the examination. At the same time, physiotherapeutic procedures are performed, consisting of phonophoresis with Iruxol ointment on the anterior abdominal wall. Depending on the expected degree of prevalence and timing of adhesions, the course of preoperative treatment usually takes 10 to 12 days. If there is a full-fledged polyclinic service at the patient's place of residence, this treatment can be performed on an outpatient basis.

After the preoperative examination and treatment, a therapeutic laparoscopy is performed, at which the prevalence of the adhesion disease is finally assessed, the positive effect of the preoperative medical preparations is noted and the adhesions are properly separated.

First of all, it is necessary to eliminate the adhesions between the parietal visceral peritoneum. In this case, most of them are usually divided in a blunt way and almost bloodless.

Only a single long-existing and well-vascularized adhesions should be crossed sharply after electrocoagulation, using exclusively bipolar instruments. In the future, a thorough audit is carried out to detect interintestinal stunts, which must also be eliminated. Individual interintestinal planar fusion, which does not cause intestinal obstruction, can not be separated, since they do not subsequently determine any pathological phenomena.

The procedure is completed with a final audit of the abdominal cavity to evaluate the result and check the usefulness of hemostasis, after which gas of pneumoperitoneum is evacuated, laparoscopic ports are removed and sutured.

As a rule, on the 2nd day of the postoperative period, children do not feel any pain in the abdomen, they start walking and go home at short notice (5-7 gout).

In a catamnesis, patients are examined after 1 week. 1, 3, 6 months and 1 year. The peculiarities of this group include the propensity to develop intestinal dysbiosis and various gastroduodenal pathologies in the form of gastritis and gastroduodenitis, which requires the additional involvement of the gastroenterologist in the observation of these children.

It should also be noted that a small clinical group of patients (slow acetylators) does not require preoperative treatment, since they have a commissural disease due to fixation of the free edge of the large epiploon to the anterior abdominal wall in the projection of laparotomy access or to the intestinal loops during surgical intervention due to previous intraoperative technical of errors. Such patients should perform laparoscopic surgery 2-3 days after admission to the hospital. Performing laparoscopy according to the method already described, it is necessary to determine the place of fixation of the large omentum, coagulate it along the prospective intersection line, and then cut off with endosurgical scissors. Children from this group are usually prone to relapse, and therefore do not require special treatment.

How is the adhesion prevented?

Speaking about the prevention of adhesions, it is necessary to give due credit to the opinion of many authors who believe that these measures should be started already during the first operative intervention. Adequate surgical approaches, gentle, gentle manipulations with tissues and abdominal organs, strict adherence to aseptic and antiseptic rules significantly reduce the risk of pathological adhesion, but do not completely eliminate it.

Prevention of RSNC is very promising when using the information obtained in the course of a comprehensive study of this problem. As it was said, two conditions are necessary for the development of this complication: phenotype of rapid acetylation and inadequate macrophage reaction. Thus, when examining the parameters in patients on the first day of the postoperative period, it is possible to clearly identify a group of patients threatened by the development of the RCSC.

If the likelihood of developing a PCN in a particular patient is predicted, he should be prescribed prophylactic treatment, including penicillamine preparations at the age-related dose once a day for 7 days, prodigiosan 0.005% solution at age dosage - 3 intramuscular injections every other day, vitamin E 3 times inside day and ultraphonophoresis on the anterior abdominal wall with the ointment "Iruksol" (bacterial collagenase-clostridio peptide A).

Prevention of PNOC should be considered mandatory follow-up care for children who have undergone surgery on the abdominal organs. And than with great technical difficulties or with large pathological changes in the abdominal cavity, operative intervention occurred, the more carefully it is necessary to carry out postoperative monitoring with the purpose of revealing such a pathological process as a commissural disease and eliminating it before the onset of intestinal obstruction.

The most complete results are given by the examination of patients using ultrasonography within a period of 1 week, 1.3 months, and 1 year after surgery on the abdominal cavity. Clinical experience shows that the risk of developing postoperative intraperitoneal complications is greatest among children with the phenotype of rapid acetylation in the presence of inadequate cellular inflammation and postinflammatory peritoneal repair. In this regard, patients who have undergone surgery on the abdominal cavity, especially accompanied by significant traumatism and peritonitis, in the postoperative period, it is necessary to carefully study the above indicators.

In the presence of data indicating a disorder of cytodynamics and cytomorphology, especially in "fast acetylators", it is necessary to carry out the above prophylactic treatment.

The whole complex of the described preventive measures reliably protects the patients of the abdominal surgeon from such a condition as a commissural disease.