Possibilities of resonant stimulation of peristaltic activity of the digestive tract in prevention of motor-evacuatory disorders in the postoperative period

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Possibilities of resonant stimulation of peristaltic activity of the digestive tract in prevention of motor-evacuatory disorders in the postoperative period

Khalidov O.Kh., Fomin V.S.

FSBEI HE "Moscow State Medical Stomatological University n.a. A.I. Evdokimov" of RMH, Moscow, Russian Federation

Abstract

The beginning of the XXI century was marked by an increase in the number of operations in abdominal surgery. The risk of the recurrence of adhesive disease during surgery also increases with edema of the intestinal wall, denudation of the peritoneum, the need for significant adhesiolysis and possible trauma of the intestines. The risk of paresis increases with SIRS (p <0.01), combined pathology (p = 0.02), a high degree of anesthetic risk (p = 0.01), after surgery using laparotomy for intestinal obstruction. These data dictate the need to treat not only acute adhesive intestinal obstruction, but also the prevention of motor-evacuation disorders of the digestive tract in the postoperative period. One of the solutions to this problem should be considered the introduction of the principles of electrophysiological exposure to stimulate the motor-evacuation function of the intestine in the early postoperative period. Application of resonance stimulation is safe for the patient and allows imposing the peristaltic rhythm of the intestine even during the phase of physiological postoperative paresis (during the first 72 hours).

Key words: adhesive intestinal obstruction, surgical treatment, postoperative motor-evacuation disorders, resonance stimulation, prevention of postoperative paresis relapse electrophysiological intestine adhesive

INTRODUCTION

The beginning of the XXI century was marked by an increase in the number of operations in abdominal surgery and patients with peritoneal adhesions. The risk of acute adhesive intestinal obstruction appears in 3067% of peritoneal adhesion cases [1,2,3].

The onset of intra-abdominal adhesions is possible after any surgical intervention: within 67-93% after operations of a general surgical profile and up to 95-97% after laparotomy access operations in gynecology [2, 46]. It is important to point out the significant increase in financial costs for the provision of specialized care to patients with peritoneal adhesions and the need for re-operations [7]. According to the US Department of Health, annual spending on treating such patients exceeds $ 1.3 million [4] per year.

The implementation of operational benefits on the background of abdominal adhesions leads to motorevacuation complications in the early postoperative period. The risk of the recurrence of adhesive disease during surgery also increases with edema of the intestinal wall, denudation of the peritoneum, the need for significant adhesiolysis and possible deserozation of the intestines. Studies have convincingly proved the direct relationship between dynamic intestinal obstruction and the cost of treating such patients: the development of dynamic postoperative intestinal obstruction leads to a prolongation of hospital stay by 1.5-2 times [8,9] with the total annual cost increases more than $ 750 thousands [9,10].

The frequency of postoperative motor-evacuation disorders of the digestive track depends on many factors, including the type of operation: operations with laparotomy access and manipulations with intestinal loops are more likely to develop paresis than operations with minimal aggression in the abdominal cavity (for example, cholecystectomy) [11]. The risk of paresis increases with SIRS (p <0.01), combined pathology (p = 0.02), a high degree of anesthetic risk (p = 0.01), after surgery using laparotomy for intestinal obstruction [11].

These data dictate the need to treat not only acute adhesive intestinal obstruction, but also the prevention of motor-evacuation disorders of the digestive tract in the postoperative period.

THE AIM

The aim of the study was to analyze the effectiveness of resonant electrostimulation of the peristaltic activity of the digestive tract in the complex correction of motor-evacuation disorders in patients in the postoperative period after the elimination of acute non-tumor intestinal obstruction.

MATERIAL AND METHODS

The outcome of the treatment of 65 patients for the period 2015-2018 was analyzed in this study. All patients were hospitalized in the surgical clinics of the Department of Surgical Diseases and Clinical Angiology of the Moscow State Medical Stomatological University n.a. A.I. Evdokimov (Russian Federation). The patients underwent the inclusion criteria (table 1). The criterion for non-inclusion in the study was considered a written refusal of the patient and the refusal of transvesical manometry of intra-abdominal pressure (IAP).

Among the analyzed patients there was a predominance of males (1.5:1 ratio) with the average age of 53.4 ± 3.7 years. Most patients (n = 62; 95.4%) had a previous story of surgery (2.3 ± 1.1 operations per person). In patients with ventral hernias, the average size of the hernia gate was 8.3 ± 2.4 cm with the duration of the hernia exceeded 3 years. At the final stage of the operation in the case of herniolaparotomy all patients underwent «onlay» or «sublay» non-tensioned hernio- plasty.

For objectification, we identified 2 study groups: group 1 (n - 35, estimated for the period 2017-2018) and group 2 (n - 32, analysis for the period 2015-2016). Both groups were comparable in age, sex and severity of the condition (p>0.05).

The distribution of patients according to the type of disease is presented in the table 2.

Upon admission, all patients showed clinical signs of acute small bowel obstruction. Preoperative preparation, tactics and treatment were carried out in accordance with established regulatory documents.

As part of the preoperative preparation, IAP manometry was performed transvesically according to the method of Kron IL et al. [12,13]. The level and extent of IAP was assessed according to the 4-degree classification of the World Society for the Study of Abdominal Compartment Syndrome [13]. Based on the obtained IAP values, abdominal perfusion pressure (APP) was calculated: difference between mean arterial pressure and IAP.

The obtained parameters of IAP and APP are presented in the table 3.

All patients were operated on after adequate preoperative preparation. Types of operations are presented in the table 2. The surgical intervention was completed in 100% decompression of the upper digestive tract. Intestinal intubation was performed in 26 (78.8%) patients of group 1 and gast25 (78%) in group 2 (p>0.05). The remaining patients underwent nasogastric decompression due to technical difficulties with intestinal intubation (p>0.05).

In group 1, in the postoperative period, for the correction of motor-evacuation disorders, resonant electrostimulation sessions were conducted (RF patent № 2648819). The registration of oscillation curves was performed in the form of graphs of the gastrointestinal tract activity in 4 cannels (gastric, duodenal, small bowel and colonic) [14]. In group 2 the registration of oscillations of peristaltic activity was performed without performing electrical stimulation.

The treatment in the postoperative period was carried out according to generally accepted standards, including infusion-detoxification treatment, enteral lavage, antibiotic therapy, early activation of patients.

Statistical processing of the data was carried out using the Microsoft Excel 2010 software package. The data obtained during the study were processed statistically with the calculation of the arithmetic mean (M) and mean error (m). Quantitative parameters were compared using the t-test.

METHOD OF STIMULATION

After 6-8 hours after the completion of the operative manual, two electrodes were applied to the anterior abdominal wall in the projection of the flanks of the abdomen with the current registration of the peristaltic activity. After that, electrical stimulation was performed to all parts of the digestive tract. This procedure was performed sequentially (stomach ^ duodenum ^ small bowel ^ colon) until all the spectra of oscillations of peristaltic activity were synchronized (figure 1, RF patent № 2648819) [14].

The duration and frequency of such therapy was evaluated in the dynamics of treatment based on the clinical and instrumental data.

Figure 1. Registration ofperistaltic activity curves of the gastrointestinal tract with synchronization of oscillation rhythms (comment in the text of the article)

RESULTS AND DISCUSSION

All patients both groups in the early postoperative period evaluated motor evacuation function of the digestive tract (see materials and methods). Initially, a low amplitude activity of excitable structures of 10.2 ± 2.5 pV (microvolt) with single peaks of chaotic oscillations was noted. The standard protocol of postoperative treatment was implemented in group 2 immediately after registration of the initial motility of the digestive tract.

In the framework of the complex therapy of the postoperative period in group 1 was carried out sequential resonance stimulation (RF patent №2648819). We have received boules of the reaction of all excitable structures of the digestive tract with the subsequent achievement of synchronization of the recorded spectra. Against the background of electrical stimulation, we obtained the amplitude of the recorded signals of 48.3 ± 6.8 pV, which was more than 4 times higher than the initial values. We obtained the reliability of differences in the registered data of groups 1 and 2 during the absence of electrical stimulation (table.3): in group 1, the control registration of motility was carried out strictly not earlier than 2-3 hours after the end of the stimulation session, in group 2 - during the day (27.4 ± 1.8 vs 14.3 ± 2.9;p<0.05).

The frequency of resonant therapy averaged 3.9 ± 1.2 sessions, with each session continuing for 48-170 minutes (95 minutes ± 12 minutes). It is important to note that the analysis of the curves made it possible to verify the elimination of physiological postoperative paresis and the implementation of nutritional oral support in standard regimens (termination of enteral lavage).

According to the clinical picture, enteral lavage was performed for 3.1 ± 1.2 days in group 1 and 5.3 ± 0.7 days in group 2 (p<0.05).

Full recovery of the motor-evacuation function of the digestive tract after 72-96 hours of treatment (active peristalsis, discharge of gases and defecation) was observed in 33 patients (100%) in group 1, which was significantly different from those of group 2 (n-26; 81, 25%; p<0.05).

One of the methods for assessing the effectiveness of the therapy was the determination of IAP and APP

Figure 2. Dynamics of intra-abdominal pressure (IAP) and abdominal perfusion pressure (APP) in study groups

The main complications in the 1^st group were not noted, and re-operations were not required. In group 2, four (12.5%) complications of the major gradation were recorded, and these patients required reoperation due to paralytic ileus (n-2) and perforation of acute ulcers of the small intestine (n-2.) Phenomena of paralytic ileus, as well as postoperative complications in the form of the formation of acute ulcers should be interpreted as a manifestation of local splanchnic hypoperfusion, which correlates with the parameters of the IAP and APP in study groups (p<0.05, figure 2, table 3).

Exposure of intestinal intubation in the 1^st group was 3.1 ± 1.2 days.; in group 2 - 5.3 ± 0.7 days (p<0.05). Drains from the abdominal cavity were removed in group 1 by all patients by the end of the 2^nd postoperative day vs 3.3 ± 0.6 days exposure in group 2 patients.

The duration of postoperative treatment in 2^nd group was significantly higher (9.3 ± 1.3 days) than in the group 1 (6.2 ± 0.8 days; p<0.05).

In the study, 2 deaths were recorded, one in each group. The causes of death were thromboembolism of the branches of the pulmonary artery in both cases. In initially and in the dynamics of treatment (table 3, figure 2). Faster elimination of IAP improved intestinal perfusion, which reduced the risk of motor-evacuation disorders and other postoperative complications.

Postoperative complications in groups 1 and 2 were analyzed according to the Clavien-Dindo classification of surgical complications [15]. A significantly larger number of wound complications was noted in group 2 vs group 1 (8 vs 2; p<0.05), as well as an increase in the proportion of ventilation disorders in the form of pneumonia (5 vs 2). Such a distribution of minor complications can be interpreted as a violation of the perfusion of tissues with microcirculatory insufficiency, as well as a violation of the excursion of the diaphragm due to higher parameters of IAP in patients of the 2^nd group in contrast to group 1.

the 1^st group, there were no signs of edema of the intestinal wall or other markers of splanchnic hypoperfusion and IAP on the autopsy. Microscopic examination of autopsy in 2^nd group revealed multiple stasis and edema of the submucosal layer of the intestine, as well as desquamation of enterocytes and signs of splanchnic ischemia due to hypoperfusion. Such changes were interpreted as a possible consequence of the high values of IAP and APP, with leads to similar morphological changes.

CONCLUSION

The obtained data indicate a high prognostic value of dynamic control over the period of restoration of intestinal motility in the early postoperative period. The use of resonant stimulation in complex therapy contributes to the normalization of peristalsis and the restoration of the motor-evacuation function of the intestine. We also achieved the earliest normalization of intra-ab- dominal pressure, which is considered as prevention of multiple organ failure.

We consider it possible to use resonant electrostimulation of the digestive tract as an effective measure for the prevention and treatment of motor-evacuation disorders in the postoperative period after extensive laparotomic interventions.

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