急性化脓性广泛性腹膜炎:现代手术策略的概念方面

V. P. Andriushchenko
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To assess the severity of the disease one should assess the general clinical condition of the patient, the source and the site of infection, the presence or absence of organ or multiorgan dysfunction, the characteristics of the pathogen. The assessment of the clinical condition takes into account the patient’s age, physiological status and comorbid diseases, the general scales ASA, SOFA, APACHE, Marshall and peritonitis-specific scales (Mannheim Peritonitis Index, Peritonitis Index Altona). When determining the infection source, it is advisable to determine whether the process is provoked by damage to the upper or lower segment of the gastrointestinal tract. The most common causes of AWP in the own study were acute appendicitis (23 %), perforated gastric ulcer (21 %), acute pancreatitis and pancreatic necrosis (18 %). Acute cholecystitis, intestinal perforation, and anastomosis failure were somewhat less common. Suboperative measures during AWP surgery include detection and assessment of the source of the pathological process, elimination of the detected changes, lavage and adequate drainage of the abdominal cavity, correction of intra-abdominal pathological syndromes, clarification of the feasibility of programmed relaparotomy. Dekasan (“Yuria-Pharm”) is used for lavage. It is a local antiseptic, effective against gram-positive and gram-negative bacteria, viruses, and fungi. Dekasan is a surfactant that removes fibrin, pus, colonies of microorganisms and blood clots. According to V.V. Boiko et al. (2012), abdominal lavage with the help of Dekasan reduces postoperative mortality by almost 9 %, and the frequency of secondary purulent complications – by 16.5 %. Pathological intra-abdominal syndromes that need correction include abdominal compartment syndrome (ACS), intestinal insufficiency, and the excessive colonization of the proximal small intestine by pathological microflora. 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引用次数: 0

摘要

背景。急性广泛性腹膜炎(AWP)问题的重点领域包括术语和分类的标准化、过程严重程度的评估、感染源的控制和病理腹内综合征的纠正。目标。根据共识指南和自己的研究,概述AWP手术治疗的概念方面。材料和方法。该研究涉及371例AWP患者。患者接受了必要的临床、实验室、生化、细菌学、放射学、仪器学和病理形态学检查。结果和讨论。评估疾病的严重程度应评估患者的一般临床情况、感染的来源和部位、有无器官或多器官功能障碍、病原体的特征。临床状况的评估考虑了患者的年龄、生理状况、合并症、ASA、SOFA、APACHE、Marshall通用量表和腹膜炎特异性量表(Mannheim Peritonitis Index, Peritonitis Index Altona)。在确定感染源时,最好确定感染过程是由胃肠道上段损伤还是下段损伤引起的。在自己的研究中,AWP最常见的原因是急性阑尾炎(23%),胃溃疡穿孔(21%),急性胰腺炎和胰腺坏死(18%)。急性胆囊炎、肠穿孔和吻合失败较少见。AWP手术的亚手术措施包括发现和评估病理过程的来源,消除发现的变化,腹腔灌洗和充分引流,纠正腹腔内病理综合征,明确程序化再开腹手术的可行性。Dekasan(“Yuria-Pharm”)用于冲洗。它是一种局部防腐剂,对革兰氏阳性和革兰氏阴性细菌、病毒和真菌有效。Dekasan是一种表面活性剂,可以去除纤维蛋白、脓液、微生物菌落和血凝块。根据V.V. Boiko等人(2012)的研究,在Dekasan的帮助下进行腹部灌洗可使术后死亡率降低近9%,继发性化脓性并发症发生率降低16.5%。需要纠正的病理性腹腔内综合征包括腹腔隔室综合征(ACS)、肠道功能不全和病理性菌群对近端小肠的过度定植。延长小肠管减压、高压氧、vaca治疗和负压应用可用于降低ACS的腹腔内高血压。AWP中使用的管道技术包括肠内灌洗、肠吸收、选择性药理学净化和腔内经孔电泳。建议尽早引入肠内营养。对于额外的解毒和纠正水电解质平衡,使用高渗透压溶液(Reosorbilact,“Yuria-Pharm”)的小容量输注治疗。山梨糖醇含有山梨糖醇、乳酸钠和必要的离子。结论:1。解决AWP问题的现代方法应基于现代术语和分类原则,并提供对手术内容和抗生素治疗有效性的理解。2. 控制腹膜炎的来源包括彻底消除腹膜炎,对腹腔进行灌洗和引流,确保消化道的减压,实施输卵管计划措施。3.抗生素治疗和输液治疗是治疗的重要组成部分。4. 这些声明的实施将提高AWP治疗的有效性。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Acute purulent widespread peritonitis: conceptual aspects of modern surgical tactics
Background. The priority areas of the problem of acute widespread peritonitis (AWP) include the standardization of terminology and classification, assessment of the severity of the process, control of the infection source and correction of pathological intra-abdominal syndromes. Objective. To outline the conceptual aspects of AWP surgical treatment based on consensus guidelines and own research. Materials and methods. The study involved 371 patients with AWP. Patients underwent the necessary clinical, laboratory, biochemical, bacteriological, radiological, instrumental and pathomorphological studies. Results and discussion. To assess the severity of the disease one should assess the general clinical condition of the patient, the source and the site of infection, the presence or absence of organ or multiorgan dysfunction, the characteristics of the pathogen. The assessment of the clinical condition takes into account the patient’s age, physiological status and comorbid diseases, the general scales ASA, SOFA, APACHE, Marshall and peritonitis-specific scales (Mannheim Peritonitis Index, Peritonitis Index Altona). When determining the infection source, it is advisable to determine whether the process is provoked by damage to the upper or lower segment of the gastrointestinal tract. The most common causes of AWP in the own study were acute appendicitis (23 %), perforated gastric ulcer (21 %), acute pancreatitis and pancreatic necrosis (18 %). Acute cholecystitis, intestinal perforation, and anastomosis failure were somewhat less common. Suboperative measures during AWP surgery include detection and assessment of the source of the pathological process, elimination of the detected changes, lavage and adequate drainage of the abdominal cavity, correction of intra-abdominal pathological syndromes, clarification of the feasibility of programmed relaparotomy. Dekasan (“Yuria-Pharm”) is used for lavage. It is a local antiseptic, effective against gram-positive and gram-negative bacteria, viruses, and fungi. Dekasan is a surfactant that removes fibrin, pus, colonies of microorganisms and blood clots. According to V.V. Boiko et al. (2012), abdominal lavage with the help of Dekasan reduces postoperative mortality by almost 9 %, and the frequency of secondary purulent complications – by 16.5 %. Pathological intra-abdominal syndromes that need correction include abdominal compartment syndrome (ACS), intestinal insufficiency, and the excessive colonization of the proximal small intestine by pathological microflora. Prolonged tubal decompression of the small intestine, hyperbaric oxygenation, VAC-therapy, and application of negative pressure are used to decrease intra-abdominal hypertension in ACS. Tube techniques used in AWP include enteral lavage, enterosorption, selective pharmacological decontamination, and intraluminal transtubal electrophoresis. It is advisable to introduce enteral nutrition early. For additional detoxification and correction of water-electrolyte balance, low-volume infusion therapy with hyperosmolar solutions (Reosorbilact, “Yuria-Pharm”) is used. Reosorbilact contains sorbitol, sodium lactate and the necessary ions. Conclusions. 1. Modern approaches to solving the problem of AWP should be based on modern terminological and classification principles and provide an understanding of the content of surgery and the validity of antibiotic therapy. 2. Control of the source of peritonitis includes its complete elimination, lavage and drainage of the abdominal cavity, ensuring the decompression of the digestive tract with the implementation of a tubal program of measures. 3. Antibiotic therapy and infusion therapy are the important components of treatment. 4. The implementation of these statements will increase the effectiveness of AWP treatment.
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