Resonant stimulation in the prevention and treatment of intestinal motility disorders in patients with secondary peritonitis

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Resonant stimulation in the prevention and treatment of intestinal motility disorders in patients with secondary peritonitis

Fomin V.S.

FSBEIHE "Moscow State Medical Stomatological University n.a. A.I. Evdokimov" of RMH,

Moscow, Russian Federation

Abstract

intestinal motility peritonitis

The problem of treating patients with peritonitis remains relevant, despite the significant progress in the pharmacological treatment and nursing of patients in the intensive care units. 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 and high Mannheim peritonitis index. These data dictate the need of the prevention of intestinal motility disorders in the early 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 72-96 hours).

Key words: peritonitis, postoperative intestinal motility disorders, resonance stimulation, prevention of postoperativeileus

Introduction

The frequency of registration of motor-evacuation disorders and complications developing in the postoperative period after the elimination of the source of peritonitis retains occurrence and has no tendency to decrease, despite the rapid development of surgical programs and anesthesiology and reanimation service, the introduction of fast-track principles in the rehabilitation of patients, the use of a wide range of drugs and minimally invasive patient treatment technologies [1-3].

Endotoxicosis, which develops with anastomotic failure, bacterial translocation, increased intra-abdominal pressure, against a background of paretic ileus, which leads to the risk of other abdominal complications and deaths in patients, should be considered an important link in such changes [4-7]. At the same time, such a scenario is quite possible in patients who have undergone laparotomy for general peritonitis, despite the elimination of the source of infection. In this case, a cascade of pathophysiological breakdowns is launched, leading to multiorgan dysfunction, abdominal sepsis, and, accordingly, the risk of death [4,6,8]. The above conditions are based on pathophysiological mechanisms of intestinal motility disorders, and therefore, an increase in intra-abdominal pressure and visceral edema, which is one of the scenarios of high postoperative mortality in these patients [6,8,9].

AIM

The aim of this work was the introduction and analysis of the first results of transcutaneous resonant electrostimulation in a complex scheme for the correction of motor-evacuation disorders in the postoperative period in patients with common forms of secondary peritonitis.

MATERIALS AND METHODS

In the course of the work, the outcome of the treatment of 125 patients who were hospitalized at 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) for the period 2015-2018.

All patients met the inclusion criteria: patients from 18 to 60 years old were examined with a picture of secondary peritonitis, without required programmed re-operations (Mannheim peritonitis index less than 20 points [8]), as well as completed intestinal decompression during a laparotomy surgical intervention.

As a criterion for non-inclusion, a written waiver, the need for a “under the program” repair, as well as the refusal to measure intra-abdominal pressure transvesically was considered.

Among the included patients, there was a predominance of a male (ratio 2.7:1), and the average age was 35.5 ± 2.02 years, which once again indicates the social significance of the study in people of working age. All surgical interventions were carried out in compliance with the requirements of generally accepted standards of the Moscow Health department.

In order to objectify data, 2 study groups were identified: 1^st (main, n-67) and 2^nd group (comparisons, n-58). Both groups were commensurate by sex, age, volume of operation, as well as the initial severity of the patients' condition (p>0.05). In the comparison group, postoperative management of patients was carried out according to the regulatory documentation, while in the main group it was supplemented using resonant electrical stimulation according to the original method (RF patent 2648819) from the first day after surgery. 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) [10].

In the postoperative period, all patients were monitored for peristaltic activity on a “selective gastrointestinal polygraph”, which for patients of the main group was the first stage before the start of resonance stimulation. In group 2 the registration of oscillations of peristaltic activity was performed without performing electrical stimulation.

As part of the preoperative preparation, intra-abdominal pressure (IAP) manometry was performed transvesically according to the method of Kron IL et al [11], and later IAP was controlled on days 1, 3, 5 and 7 of the postoperative period (table 1). The level and extent of IAP was assessed according to the 4-degree classification of the World Society for the Study of AbdominaICompartment Syndrome [9].

Based on the obtained IAP values, abdominal perfusion pressure (APP) was calculated. The APP is calculated as is the difference between mean arterial pressure and AP.-l

Table 1 DYNAMICS OF IAP, APP andPusajo PRI IN THE STUDIED GROUPS

For the objectification of the postoperative period in the study groups, we analyzed the calculated index of the prognostic re-laparotomy index (PRI) according to Pusajo [12] and carried out the stratification of complications according to the Clavien-Dindo scale [13].

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 (p<0.05).

Results and discussion

In the early postoperative period, after 6 hours from the moment of laparotomic intervention, all 125 patients underwent electrophysiological monitoring of spontaneous peristaltic activity, which was reflected in the low amplitude of oscillation according to the “selective polygraph of the gastrointestinal tract”, not exceeding 9.4 ± 1.0 and 9.8 ± 0.9^V flor the 1^st and 2^nd study groups (p>0.05).

Against the background of resonance stimulation in group 1, a faster recovery period of intestinal motor- evacuation function was observed, an increase in oscillations in all departments, the achievement of spectra synchronization, which differed from the identical parameters of 2^nd group, which was reflected in a significant difference in electrophysiological monitoring indices (18.3 ± 1 , 3 vs 12.1 ± 1.9 |rV and 29.3 ± 1.4 vs 16.8 ± 1.8 ^V on days 3 and 5 after surgery in groups 1 and 2, respectively (p<0.05).

The frequency of resonance therapy averaged 4.0 ± 0.9 sessions with the duration of each stimulating series from 51 to 165 minutes, an average of 97 minutes ± 11 minutes. Based on the analysis of graphical spectra and the rate of restoration of the propulsiveness of the digestive tube (figure 1), it became possible to objectify the treatment carried out with the elimination of physiological postoperative paresis and the onset of nutritional oral support in standard modes.

Figure 1. The dynamics of the spectra of peristaltic oscillations before and after resonant stimulation sessions. a-gastric, b-duodenal, c-smallboweland d-colonicperistalticcurves

Free discharge of gases and self-defecation were observed in almost all patients of the 1^st group by 3 days of treatment, and full recovery of the motor-evacuation function of the digestive tract by the 5th day of treatment in group 1 was observed in 63 (96.9%) patients. In the comparison group, on day 3, less than 2/3 of the patients had an independent chair, and by the end of 5 days, the restoration of motility was observed in only 48 patients (82.7%; p<0.05).

Analyzing the data obtained by IAP in the study groups (table 1), statistically significant dissociation of the compared parameters was observed from the 3rd day of treatment (p<0.05) and until the end of the measurement in favor of group 1. A similar trend was observed for abdominal perfusion pressure and filtration gradient, which is reflected more early recovery ofsplanchnic blood flow in group 1 and, as a result, a smoother postoperative course.

The above data is echoed by the Pusajo PRI calculated individually for each patient: the growth dynamics of the latter in group 2 was tracked, while the PRI values in the 1^st group were almost unchanged at the same time (p<0.05, table 1). On the 5th days in group 2 the PRI was almost to 2 times higher (p<0.05) than in group 1, which was combined with an increase in the percentage of complications in these patients on the Clavien-Dindo scale (table 2).

Table 2 Postoperative complications in 1st and 2nd groups Clavien-Dindo Scale

Postoperative complications in 1^st and 2^nd groups were analyzed according to the Clavien-Dindo scale of surgical complications [2004] wich is presented in table2.

A significantly larger number of wound complications was noted in group 2 vs group 1 (12 vs 5; p<0.05), as well as an increase in the proportion of motor-evacuations disorders in the form of paresis (9 vs 0, p<0.05). Such a distribution of minor complications can be interpreted as a violation of the perfusion of tissues with microcirculatory insufficiency, as well as visceral edema and edema of the intestinal wall due to higher parameters of IAP and lower values for APP in patients of the 2^nd group in contrast to group 1 (table 1).

In this work, we focused on the so-called “large” complications (table 2), which required 10 patients in 2^nd group (17.2%) to perform re-operations in (p<0.05) about 6 cases of perforations of acute ulcers of the small intestine and 4 dynamic paresis resistant to conservative therapy. In turn, in 5 cases, similar motor-evacuation complications in the comparison group were resolved conservatively. In the 1^st clinical group, only in one observation was the re-operation due to the perforation of acute ulcers of the small intestine on the 4th day of treatment.

Analyzing the data on the duration of postoperative inpatient treatment, there was a reduction in hospital stay in the 1^st group (7.4 ± 0.7 days), in contrast to 2^nd group (10.3 ± 0.8 days; p<0.05), which also did not at least due to the number and nature of postoperative complications.

In both groups, 7 deaths were registered, while pulmonary embolism caused one case in the 1st group and two deaths in the 2nd group. Another case of mortality in group 1 was acute type 2 infarction, a similar complication was also found in three observations of group 2. In addition, three thromboembolic complications occurred in total in group 2, which with a certain probability can also be attributed to the effects of redistribution of blood flow, stasis and, as a result, phleboth- rombosis with pulmonary embolism.

Conclusion

intestinal motility peritonitis

The introduction of resonant electrostimulation for the prevention of motor-evacuation disorders in the postoperative period in patients with common forms of secondary peritonitis helps to accelerate the recovery of intestinal motility, normalize the physiological passage of chyme, reduce the risk of multiorgan failure.

All the above indicates the feasibility of including electrophysiological non-invasive methods in complex patient monitoring schemes in the postoperative period after the elimination of the source of peritonitis.

Such a scheme of post-operative management will improve the results of treatment of such a severe category of patients.

Reference

1. Mabewa A, Seni J, Chalya PL. et al. Etiology, treatment outcome and prognostic factors among patients with secondary peritonitis at Bugando Medical