Adhesions

Adhesive disease is a syndrome caused by the formation of adhesions in the peritoneal cavity as a result of illnesses, injuries or surgeries, characterized by frequent attacks of relative intestinal obstruction.

Postoperative adhesive disease traditionally remains the most difficult section of abdominal surgery. The total number of the above complications reaches, according to literary data, 40% and more. Most of them require repeated surgical intervention, often much more traumatic and dangerous than the initial operation.

Despite the abundance of specialized literature devoted to this problem, practical healthcare does not yet have sufficiently objective, simple and safe methods for diagnosing a condition such as adhesive disease, as well as effective methods for its rational treatment and prevention.

Difficulties in diagnostics complicate the choice of treatment tactics, especially when deciding on the need for repeated surgical intervention. In this matter, the opinions of the authors are radically divided - from the need for early planned (or programmed) relaparotomies and open management of the abdominal cavity (laparostomy) to the use 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 on the most complex and weakened contingent of patients. This, in turn, determines the mortality rates after such operations, which, according to various sources, range from 8 to 36%.

It should be noted that the absolute majority of practicing surgeons remain in the position that adhesive disease should be treated by wide relaparotomy. At the same time, the intersection of compressive bands and separation of interintestinal adhesions in intestinal obstruction certainly saves the patient's life, but inevitably provokes the formation of adhesions in even greater quantities. Thus, the patient is exposed to the risk of repeated surgery, which increases with each intervention.

An attempt to break this vicious circle was the Noble-proposed intestinal plication using seromuscular sutures designed to prevent the disordered arrangement of intestinal loops and obstruction. Due to the large number of complications and poor long-term results, this operation is now practically not used.

Methods of conservative intervention on the pathogenesis of postoperative adhesive disease for the purpose of prevention and treatment have also not been sufficiently developed.

Adhesive disease is a pathological condition caused by the formation of adhesions in the abdominal cavity after operations, injuries and certain diseases.

Adhesive disease can be of two forms:

• congenital (rare) as a developmental anomaly in the form of flat interintestinal adhesions (Lane's cords) or adhesions between parts of the colon (Jackson's membranes);
• acquired after operations, injuries with hemorrhages in the visceral layer of the peritoneum, inflammation of the peritoneum (visceritis, peritonitis, transient processes during inflammatory periprocesses of internal organs).

ICD-10 code

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

What causes adhesive 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.), blood residues, especially infected blood, irritation of the peritoneum during manipulations (for example, not blotting the exudate, but wiping it with a swab).

The prevalence and nature of the pathological process may vary: limited to the area of surgery or inflammation, sometimes delimiting an entire floor of the abdominal cavity, most often the pelvic cavity; in the form of soldering of the inflamed organ (gall bladder, intestinal loop, stomach, omentum) to the anterior abdominal wall; in the form of separate strands (rods) attached at two points and leading to compression of the intestinal loop; in the form of an extensive process, capturing the entire abdominal cavity.

How does adhesive disease develop?

Adhesive disease is a very complex pathology; it cannot be solved without a clear understanding of the processes occurring in the abdominal cavity.

According to modern researchers, protective cellular processes initiated by various intraperitoneal damaging events - surgical intervention, trauma, inflammatory processes of various genesis - develop with the direct participation of the main "generators" of inflammation cells - the peritoneum and the greater omentum. They are the ones that provide the greatest significance from the point of view of phylogenesis of the mechanisms of cellular protection.

In this issue, we should dwell on the derivatives of monocytes - peritoneal macrophages. We are talking about the so-called stimulated peritoneal macrophages, i.e. phagocytes that are part of the inflammatory exudate of the abdominal cavity. The literature shows that in the first hours of the inflammatory reaction, mainly neutrophilic leukocytes enter the abdominal cavity, and by the end of the first or beginning of the second day, mononuclears migrate into the exudate, activating and differentiating into peritoneal macrophages. Their functions are determined by the ability to intensively absorb various biological substrates and actively participate in the catabolism of the intraperitoneal process. This is why the state of macrophage reactions in the pathogenesis of adhesive disease can be considered indisputable.

When studying the state of protective cellular reactions in humans, the most informative method is considered to be studying the aseptic inflammatory reaction (AIR) in the “skin window”.

To carry out this study, a sterile glass slide is placed on the scarified surface of the subject and fixed to take prints after 6 and 24 hours, thus obtaining cellular material of the first and second phases of the AVR. They are then stained and studied under a microscope, assessing the timeliness of the phase change (chemotaxis), percentage cellular composition, quantitative relationship of various elements and cytomorphology.

Studies conducted using this method have shown that in healthy people in the first phase of AVR, neutrophils make up an average of 84.5%, and macrophages – 14%; in the second phase of AVR, the opposite ratio of cells is observed: neutrophils – 16.0%, and macrophages – 84%, eosinophils do not exceed 1.5%.

Lymphocytes are not detected at all. Any deviations in the specified sequence of output and percentage ratio of cells indicate a violation of cellular defense mechanisms.

Recently, clinical and experimental studies have appeared stating that adhesive disease is the result of a disorder of connective tissue metabolism, in particular collagen. Collagen chains are stabilized with the participation of the copper-containing enzyme lysyl oxidase, which catalyzes the conversion of lysyl deoxylysine into aldehydes. These aldehydes, in turn, form transverse covalent bonds, forming a three-spiral molecule of insoluble mature collagen. The activity of lysyl oxidase is directly related to the activity of N-acetyl transferase, a constitutional enzyme that catalyzes the process of inactivation of toxic metabolic products and ligands introduced from outside.

It is well known that the human population is divided into so-called "fast" and "slow" acetylators based on N-acetyltransferase activity. Slow acetylators include individuals with an acetylation percentage of less than 75, and fast acetylators include individuals with an acetylation percentage exceeding 75.

The process of peritoneal regeneration (formation of collagen fibers) occurs differently in individuals with different acetylation rates.

• Slow acetylators accumulate acetylation substrates (endogenous and exogenous chelate complexes) that bind copper ions that are part of lysyl oxidase. The rate of cross-link synthesis decreases, and the number of fibers formed is small. Accumulating laterant collagen activates endogenous collagenase by the feedback principle.
• In fast acetylators, accumulation of acetylation substrates does not occur. Mineral ions are not bound, and lysyl oxidase activity is high. Active synthesis and deposition of collagen fibers on existing fibrin deposits occurs. Fibroblasts in turn settle on these fibers, which distorts the normal course of peritoneal regeneration and leads to the formation of adhesive disease.

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

The above complications in clinical practice are represented by such conditions as: early intestinal obstruction (EIO), late intestinal obstruction (LIO) and adhesive disease (AD).

Based on the above, in patients with adhesive disease, it is necessary to conduct a comprehensive study, including phenotyping by acetylation rate, study of cytodynamic processes and cytomorphology of phagocytic cells in peritoneal exudate (local cellular reaction), in the "skin window" according to Rebuck (general cellular reaction). Verification of the obtained data must be carried out by ultrasound echography (ultrasonography) of the abdominal cavity and video laparoscopy.

Adhesive disease is characterized by the presence of changes in the studied parameters that are characteristic only of the specified pathology.

Cytodynamic reactions in the postoperative period in these patients had their own characteristics both in the peritoneal exudate and in the imprints of the "skin window". Thus, in the peritoneal exudate, a reduced number of macrophage elements was observed, during AVR - a violation of macrophage chemotaxis and an increased content of fibrin fibers in the wound of the "skin window". The average acetylation rate in children with RSNK was significantly higher than in patients with a favorable course of the postoperative period, and amounted to; 88.89 ± 2.8% (p < 0.01).

The results of the conducted research allowed us to come to the following conclusion.

If surgical intervention on abdominal organs is performed in a child with a rapid acetylation phenotype and at the same time he has a deficiency of the macrophage reaction caused by a violation of the chemotactic activity of mononuclear phagocytes, then, on the one hand, there will be increased fibrin formation and accelerated collagen synthesis due to intensive proliferation of fibroblasts, outpacing the rate of normal fibrin catabolism, and on the other hand, an inadequate macrophage reaction, distorting the kinetics of inflammation, which will lead to long-term persistence of peritoneal degradation products, causing sensitization of the body with tissue decay products and the formation of delayed-type hypersensitivity, chronic inflammation on an immune basis with the involvement of an even larger number of fibroblasts in the inflammation focus. Thus, all the noted processes together will lead to excessive synthesis of connective tissue - the formation of such a condition as adhesive disease. It should be noted that concomitant pathology of the gastrointestinal tract will greatly increase the risk of pathological fibrin formation.

How does adhesive disease manifest itself?

According to the clinical course, adhesive disease is divided into acute, intermittent and chronic.

The acute form is accompanied by sudden or gradual development of pain syndrome, increased peristalsis, clinical picture of dynamic intestinal obstruction, which in most cases can be resolved. Growing pain and its change to a constant character indicate the development of mechanical obstruction.

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

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

How is adhesive disease recognized?

The diagnostics are based on dynamic X-ray examination of the passage of barium suspension through the intestines; sometimes irrigoscopy is used if the colon is involved in the process. Simultaneously with determining the nature of the intestinal deformation and the presence of an obstacle to the passage of intestinal contents, the relief of the intestinal mucosa is also determined:

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

Adhesive disease is characterized by deformation of the mucous membrane relief, but it is not interrupted, as in cancer. In doubtful cases, laparoscopy is performed, but during an exacerbation it can present certain difficulties, and even the risk of damage to the swollen intestinal loops.

The success of treatment of patients with postoperative adhesive disease largely depends on timely diagnostics. Well-known and widely used diagnostic methods do not always lead to the desired results, prompting 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 specific patient, pathomorphological methods for studying local and general cellular reactions, ultrasound of the abdominal cavity, traditional X-ray examination, laparoscopy.

Ultrasound diagnostics in case of suspected adhesive disease is used in conditions of using modern equipment. It allows to obtain a characteristic echographic picture practically non-invasively.

It should be remembered, however, that in the ultrasound diagnostics of intestinal obstruction due to adhesive disease, one cannot rely only on a static picture. More reliable data are obtained by performing echoscopic examination in real time, which allows one to detect the progressive movement of particles in the intestinal tube in the norm and the phenomenon of reciprocating - with signs of mechanical intestinal obstruction. This phenomenon was detected in almost all patients and was called the "pendulum symptom". Nevertheless, despite all the information content and capabilities of ultrasound diagnostics, they are largely limited by concomitant phenomena of intestinal paresis. To solve this problem, a method for differential diagnostics of mechanical and dynamic intestinal obstruction was developed. For this purpose, an ultrasound examination of the abdominal organs is performed, which visualizes dilated loops of the small intestine filled with liquid contents, which indicates a violation of passage along the intestinal tube. Neostigmine methylsulfate is administered in an age-related dosage, followed by percutaneous electrical stimulation of the intestine and an echographic examination is repeated. If the stimulation results in a contraction of the intestinal lumen and progressive movement of particles, the diagnosis of mechanical intestinal obstruction can be confidently rejected and the patient can be treated conservatively. In case of mechanical obstruction

After stimulation, pain increases, vomiting often occurs, and during an echographic examination, the intestinal loops do not decrease in size, and a progressive movement of chyme is noted - the "pendulum symptom", which allows for the diagnosis of mechanical intestinal obstruction and the formulation of indications for its surgical resolution.

A fairly typical picture of X-ray diagnostics of intestinal obstruction is well known (in the form of both plain X-rays of the abdominal cavity and X-ray contrast studies with barium suspension). In this regard, with all due respect to the old proven method, its negative aspects should be mentioned: radiation exposure, duration of the diagnostic process, difficulties in differential diagnostics of dynamic intestinal patency from mechanical.

How is adhesive disease treated?

When speaking about the methods of treatment of both early and late postoperative adhesive disease, it should be noted that there is no unification in the problem.

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

In this case, the primary goal should be to avoid wide laparotomy, and in the case of absolute indications for surgical treatment, to achieve a cure using endosurgical intervention or minilaparotomy.

Speaking about the treatment of children with adhesive disease, the following should be noted. It is well known that until now all clinicians, with rare exceptions, have tried in every possible way to avoid surgical treatment of children with adhesive disease, especially without obstruction, giving preference to conservative methods of treatment, usually ineffective.

At the present stage, treatment tactics should consist of active identification of children with adhesive disease, preoperative treatment, and then complete elimination of the adhesive process in the abdominal cavity using laparoscopic techniques.

Indications for surgical treatment of adhesive disease include the following symptom complex:

• Frequent attacks of pain, accompanied by symptoms of intestinal obstruction (vomiting, stool and gas retention).
• Recurrent abdominal pain, especially when jumping and running (Knoch's symptom, or "tight omentum").
• Intense abdominal pain, often accompanied by vomiting, that occurs after a dietary violation in the form of overeating.
• Phenomena of complete intestinal obstruction resolved during the course of conservative measures.

Naturally, the basis and guarantee of subsequent success here are the diagnostic methods discussed above. Moreover, the components of the specified diagnostic program allow not only to establish the presence of such a condition as adhesive disease, but also to determine the differentiated tactics of subsequent treatment. Based on the above, all fast acetylators must be prescribed preoperative preparation aimed at transforming adhesions in order to reduce the trauma of subsequent laparoscopic intervention and prevent relapse of adhesive disease.

Adhesive disease is treated as follows. In parallel with the examination of the patient in preparation for abdominal surgery, penicillamine is prescribed in an age-appropriate dosage once a day during meals (preferably during lunch). Mandatory components of treatment are drugs that normalize intestinal microflora (bifidobacteria bifidum, bifidobacteria bifidum + E. coli), and vitamin E as an antihypoxant. Other drug therapy is used only to correct any pathological changes detected during the examination. Physiotherapy procedures are simultaneously carried out, consisting of phonophoresis with Iruksol ointment on the anterior abdominal wall. Depending on the expected degree of prevalence and duration of adhesive disease, the course of preoperative treatment usually takes from 10 to 12 days. If there is a full-fledged outpatient service at the patient's place of residence, this treatment can be carried out on an outpatient basis.

Upon completion of the preoperative examination and treatment, a therapeutic laparoscopy is performed, during which the prevalence of adhesive disease is finally assessed, the positive effect of the preoperative drug preparation is noted, and the actual separation of adhesions is carried out.

First of all, it is necessary to eliminate adhesions between the parietal visceral peritoneum. In this case, most of them are usually separated bluntly and almost bloodlessly.

Only individual long-standing and well-vascularized adhesions should be cut sharply after electrocoagulation, using only bipolar instruments. Subsequently, a thorough revision is carried out, aimed at detecting interintestinal strands, which also need to be eliminated. Individual interintestinal planar adhesions that do not cause intestinal obstruction may not be separated, since they do not determine any pathological phenomena in the future.

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

As a rule, on the 2nd day of the postoperative period, children practically do not experience abdominal pain, begin to walk and are discharged home in a short time (5-7 days).

In the follow-up study, patients are examined after 1 week, 1, 3, 6 months and 1 year. The peculiarities of this follow-up group include a tendency to develop intestinal dysbacteriosis and various gastroduodenal pathologies in the form of gastritis and gastroduodenitis, which requires additional participation of a gastroenterologist in monitoring these children.

It should also be noted that a small clinical group of patients (slow acetylators) do not require preoperative treatment, since their adhesive disease is caused by fixation of the free edge of the greater omentum to the anterior abdominal wall in the projection of the laparotomy access or to intestinal loops during surgery due to previous intraoperative technical errors. Such patients should undergo laparoscopic surgery 2-3 days after admission to the hospital. When performing laparoscopy using the already described technique, it is necessary to determine the location of fixation of the greater omentum, coagulate it along the line of the expected intersection, and then cut it off with endosurgical scissors. Children from this group are usually prone to relapses, and therefore do not require special treatment.

How is adhesive disease prevented?

When speaking about how to prevent adhesive disease, it is necessary to give credit to the opinion of many authors who believe that these measures should be started already during the first surgical intervention. Adequate surgical approaches, gentle, tender manipulations with tissues and organs of the abdominal cavity, strict adherence to the rules of asepsis and antisepsis significantly reduce the risk of pathological adhesion formation, but do not eliminate it completely.

Prevention of RSK is very promising when using the information obtained in the process of a comprehensive study of this problem. As was said, two conditions are necessary for the development of this complication: the phenotype of rapid acetylation and inadequate macrophage reaction. Thus, studying the parameters in patients on the first day of the postoperative period, it is possible to quite clearly identify a group of patients at risk of developing RSK.

If the probability of developing RAS is predicted in a specific patient, he should be prescribed preventive treatment, including penicillamine in an age-appropriate dosage once a day for 7 days, prodigiosan 0.005% solution in an age-appropriate dosage - 3 intramuscular injections every other day, vitamin E orally 3 times a day and ultrasound phonophoresis on the anterior abdominal wall with Iruksol ointment (bacterial collagenase-clostridiopeptidase A).

Prevention of PSA should be considered mandatory dispensary observation of children who have undergone surgery on the abdominal organs. Moreover, the greater the technical difficulties or the greater the pathological changes in the abdominal cavity, the more carefully it is necessary to carry out postoperative monitoring in order to identify such a pathological process as adhesive disease and eliminate it before intestinal obstruction occurs.

The most complete results are obtained by examining patients using ultrasonography at 1 week, 1.3, 6 months and 1 year after abdominal surgery. Clinical experience shows that the risk of developing postoperative intra-abdominal complications is greatest among children with the rapid acetylation phenotype in the presence of inadequate cellular inflammatory reactions and post-inflammatory reparation of the peritoneum. In this regard, in patients who have undergone abdominal surgery, especially those accompanied by significant trauma and peritonitis, the above-mentioned indicators must be carefully examined in the postoperative period.

If there are data indicating cytodynamic and cytomorphological disorders, especially in “fast acetylators”, the above-mentioned preventive treatment must be carried out.

The entire complex of described preventive measures reliably protects patients of an abdominal surgeon from such a condition as adhesive disease.