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The diagnostics and treatment of small and large intestines' injuries at the abdominal traumas.

Introduction

Small and large intestines' traumas are still the topical issues in abdominal surgery. Small and large intestines' injuries in the structure of the abdominal traumas make 6-25% (Aliev, 2000; Alontseva et al., 2005; Dvoryankin, 2006; Lokhvitskiy et al., 1992; Naumov et al., 1999). Large intestine's traumas are considered as one of the most negative prognostic factors which are estimated with the maximum values on the various classification scales. Composition of microflora inhabiting the colon intestine leads to rapid expansion of aggressive inflammatory process in the abdominal cavity; and thus it promotes the development of the majority of suppurative and septic complications in the post-operative period, almost in 40-65% of cases (Alontseva et al., 2005; Gavrilov et al., 2001; Egorov et al., 2004; Cherkasov et al., 2005). So, the insufficiency of the sutures of intestinal anastomosis remains the typical complication of the resection of the large intestine and occurs in 4-20% of cases (Kirpatovskiy, 1964; Kulagin, 2006; Saveliev, 2004; Tatyachenco et al., 2006). The surgeons have a difficult task of carrying the medical aid for this type of patients: because still there is not a common classification and treating tactics for the cure of small and large intestines' injuries (Shugaev, 2005). The methods of treating intestine's traumas have been noticeably changed for the last 20 years: the primary closure without colostomy has been popular here in Uzbekistan and abroad, though there is still ongoing debate about the necessity of ostomy surgery in the literature.

Materials and methods

167 patients with small and large intestines' injuries treated in RRCEM from 2001 till 2009 were analyzed and it consisted 25% from all abdominal traumas. There were 106 (63.5%) men and 61 (36.5%) women among the patients. More than 60% of them were overdrunk during the admission. According to the type of the traumas the patients were classified as following: penetrating cut-stab wounds-115 (68.6%), closed abdominal injury -50 (30%), and gunshot wounds in 2 (1.4%) cases. There were 89 (53.8%) patients with isolated traumas of the hollow organs of the abdominal cavity, 14 (8.3%)-cases with multiple wounds, and 64 (37.9%)-patients with combined injuries. Very often the traumas of the hollow organs of the abdominal cavity were combined with the chest injuries, fractures of upper and lower extremities, fractures of coxal bones and craniocerebral injury. Among all the patients the thoracoabdominal wounds with the intestinal traumas occurred in 15 (9%) cases. 70% of the patients with this pathology were admitted in the shock condition.

The clinic investigations, as the rule, were carried against a background of anti-shock and antiphlogistic therapy. The diagnosis was formed on the base of clinic-instrumental data. The volume of the diagnostic measures was carried depending on the weight of the patient's condition and included: X-ray, contrasting X-ray investigation, ultra-sound scanning, ezophagogastroduodenoscopy, CT and diagnostic laparoscopy.

Results and discussions

The efficient tactics of treating the patients with small and large intestines' injuries of various difficulties has been worked-out at our Centre for the last 7 years. It is strictly individual and depends on the type of the injuries, the level of blood supply disturbance of the damaged intestine's part, and the weight of the patient's condition. The primary surgical management of wound and the revision were carried in the open wounds. The penetrating feature of the wound without eventration of the organs or active bleeding were the indications to the diagnostic laparoscopy and then to the conversion, if it was the necessity for it. 55 patients were done the diagnostic laparoscopy and among them the conversion was in 51 (92.8%) cases. In our opinion, the contra-indications to the laparoscopic curing of the abdominal cavity traumas include: gunshot wounds; multiple wounds; non-stable hemodynamics, hemorrhagic shock; eventration of intestine's meshes. The patients of this category were performed the laparotomy. The patients in shock condition and with active bleeding were carried the minimum investigations and they rapidly were delivered to the operational room. All the patients without peritonitis and shock and also with the stable hemodynamics at first were performed the diagnostic laparoscopy. With the late admission of the patients with peritonitis the short preoperational preparation was carried first. In thoracoabdominal injuries before the operation the drain of the pleural cavity was carried obligatory and if it was the necessity, the thoracoscopy was also performed.

The risk factors of intestine traumas are: the heavy shock, massive bleeding, combined injury, fecal pollution of abdominal cavity and peritonitis. The types of small and large intestines' injuries are given in the Table 1.

Peritonitis was diagnosed in 84 (51%) patients. Mostly the stomach, liver, pancreas and spleen were injured together with the intestine. It is known that the most complicated group from the diagnostic point of view is the group of patients with the closed abdominal injury. During the laparoscopic diagnostics it is not always available to make the full revision of small and large intestines' meshes; and mostly it takes much time in the hard combined injury. Since 2008, during the diagnostic laparoscopy 55 patients, who had even small quantity of the existing effusion of the abdominal cavity, have been obliged to be examined by the express-analysis for the amylase, ammonia and alkaline phosphatase content ("Vitros-250" apparatus).

The principle of that analyzer functioning as follows: the serum applies to upper layer of slide. For research we use 10-11 uL of material distributed evenly on layer. Liquid quickly interacts with reagent than as result the spectrum changes determining the stream reflection. Range of wave length is from 340 up to 680 nm. It is sufficient to use 0.3ml of exudation from abdominal cavity for 15 minutes testing and following analysis.

The indexes of the presence of the amylase and the ammonia can give the information about the injury of the hollow organs; correspondingly it may help to solve the issue of the conversion and more detailed revision. The concentration of ammonia in the exudation from abdominal cavity in patients without the hollow organs' perforation features did not increase 100 umol NH3/l and the amylase was absent. In the small and large intestines' injuries the ammonia content was increased, and the existence of the amylase in the exudation was more than 40 mg.ml/h. So, exudation from abdominal cavity of patients without hollow organs' perforation (n=25) concentration of ammonia made 87.23 [+ or -] 14.23. Exudation in patients with hollow organs' perforation (n=30) had 509.63 [+ or -] 33.23 (t=11.68, p<0.05); concentration of alkaline phosphatase in patients without hollow organs' perforation consisted 90.87 [+ or -] 14.85 and patients with hollow organs' perforation-644.96[+ or -]35.91 (t=14.26, p<0.05). The results of analysis shows increasing of concentrations of ammonia, alkaline phosphatase in exudation from abdominal cavity of patients with hollow organs' perforation against the same figures of patients without hollow organs' perforation (P<0.001).

During the choice of the operative intervention there were taken into account such factors as the sizes of the wounded intestine defects, peritonitis features, the type of injury, the weight of the patient's condition, hemodynamics's stability. The large intestine's injuries by their clinical course are the most hard in compare with the small ones. The bigger size of large intestine's defect, the more manifested the shock levels, hemorrhage volume and peritonitis development. Besides, the size of wound defects influenced on the final outcome of the treatment.

As the clinical investigations showed, increasing of the wounds' sizes was followed by increasing of the quantity of complications, including the frequency of intra-abdominal infections and the mortality. Peritonitis development by the time of the primary operative intervention influenced noticeably on the trauma's out-come and was followed by the higher frequency of complications. According to that point, the patients pre-operatively and in early post-operative period were carried antibacterial therapy with the medicines of the wide spectrum of two groups as minimum. Then antibacterial therapy was done according to the sensitivity after the bacteriologic investigations.

The main point during the operation is to estimate the adequacy of the vascularization of the damaged part of large intestine and its other parts. It is especially important in the wounds and ruptures of the mesenteric intestine side, mesentery haematomas, and gunshot wounds. The main reason of the large intestine's sutures failure is the false estimation of the adequacy of the blood supply of the suturing intestine's part. We pay great attention to the technique of the anastomosis forming. All anastomosis are applied with hands by the separate double sutures. In 7 cases inter-intestinal anastomosis was applied in accordance to our own methods with the use of wireframe metal ring (Khadjibaev et. al., 2007b). The tests run was done on the laboratory animals using this device with morphologic investigations which have shown that the wireframe itself does not cause bio-structural changes, intestinal obstruction, constriction of anastomosis (Khadjibaev et. al., 2007a; 2007b; 2009; Khodjimukhamedova et. al., 2009). This method allows keeping mechanical strength and containment of intestinal anastomosis because its area is in the stable condition; and also the rise of inter-intestinal pressure does not lead to the exertion and the discrepancy of anastomosis line against a background of "discrediting" abdominal cavity. There was no insufficiency of intestinal anastomosis among patients performed operation according to this method in post-operative period. After all experimental measures now we have begun implementing of with method in our clinic practice.

All cut-stab wounds of small and colonic intestine are closured by double sutures. 4 patients were performed the laparoscopic sewing of the small intestinal wound with forming 1-2 intra-corporal sutures. In all those cases the small intestinal wound was not the penetrating one and its sizes were not more than 1.0-1.5 sm. Those patients were discharged from the hospital in good condition after 5-6 days for out-patient treatment. The proximal colostomy was applied in rare cases.

We would like to describe in more detail the tactics at the injury of the posterior wall of ascending and descending colon. It mostly happens in the cut-stab wounds of lumbar region. We observed 5 typical cases. It is difficult to reveal such damage. As a rule, while doing the primary wound management it is impossible to revise the wound bottom. While performing laparoscopy it is only possible to observe partially the retroperitoneal haematoma located in lateral area. The damage may be suspected if the gas and fecal mass come from the wound, but it rarely occurs. Contrast radiography can serve as the only way of the diagnostics in the wide wound hole in intestinal wall and also if the hole is not covered by fecal stones. The contrast substance is input into the wound and radiography is performed. At the wound of intestine wall we can see the contrast in intestine empty space. But mostly the diagnostic mistake is made. In the clinic course of the lumbar region phlegmon we drain all purulent leakages, the wound is managed in the opened way and fecal fistula is closed by conservative way. In old-aged weak patients with diabetes we apply proximal colostomy with full cutting off the damaged part from the passage. The types of performed operative interventions on small and large intestines at the isolated and combined injuries are given in the Table 2.

In the post-operative period all the patients were done USD-monitoring of the abdominal cavity, the investigation of the exudation from abdominal cavity for the content of the ammonia, the amylase in 3-5 days with the aim of the early diagnostics of development of intestine sutures' failure. At the rising of those indexes we could charge about the possible appearance of the failure and to determine the posterior patient's treatment. The different complications were noted in 50 (30%) patients after the operation. In 12 of them it was observed the post-operative wound abscess, 4 patients had the early peritoneal intestinal obstruction. In 5 cases it was the abdominal cavity abscess and in 32 patients it was the postoperative pneumonia. The hardest group of complications is intestine sutures' failure: in 4 cases it was intestine sutures' failure and 3 patients had the failure of anastomosis sutures. All patients with the early peritoneal intestinal obstruction, the abdominal cavity abscess and sutures' failure at the early stage were performed re-laparotomy, sanation and abdominal cavity drain. At the failure of inter-intestinal anastomosis it was done the re-resection of the intestine's part with applying the second anastomosis or intestinal ostomy was led out. The total mortality consisted 26.8%. Most of them died in the first day because of the hard combined injury, traumatic shock. Large and small intestine injuries' complications were the lethal cause for 4(2%) patients. They died of the continuing peritonitis and poly-organic insufficiency. Analyzing the results of complications and mortal out-comes two types of tactic mistakes were found. In most of cases the volume of operative intervention was "set too high" and it led to aggravation of the patients' hard condition. In other cases the volume of operative intervention was "set too low" and it led mostly to the rising of the sutures' failures quantity and to the developing of peritonitis.

Conclusion

So, primary wound suture or anastomosing can be done practically in any types of small and large intestines' injuries maintaining definite rules of applying sutures and providing the blood supply adequacy. The following conditions must be fulfilled at the performing of operations: adequate abdominal cavity sanation, pre-operative antibiotic therapy with the wide spectrum medicines and the decompression of the intestine.

References

Aliev, S., 2000. "Injury of large intestine in emergency surgery," Surgery [Hirurgiya], in Russian, No.10, pp.35

Alontseva, N., Andreev, Yu., rasyukevich, A., 2005. "The choice of operational method in case of duodenum injury," Medical Academy journal [Medicinskiy Akademicheskiy Zhurnal], in Russian, No.2, pp.42-44

Cherkasov, M., Yuskov, V., Sitnikov, V., Sarkisyan, V., 2005. Damage of abdomen in case of multiple or combined trauma [Povrezhdeniya zhivota pri mnozhestvennoy i sochetannoy travme], in Russian, Rostov on Don Novocherkassk: UPS "Nabla"

Dvoryankin, D., 2006. "Surgeon tactics in case of damage of colon in peace time," Bulletin of Surgery [Vestnik Hirurgii], in Russian, No.6, pp.91

Egorov, V., Turusov, R., Schastlivcev, I., Baranov, I., 2004. Intestinal anastomoses: Physical mechanical aspects [Kishechnie anastomozi: Fiziko-mehanicheskie aspekti], in Russian. Moscow: Vidar-M

Gavrilov, S., Gerasimov, G., Boyarincev, V. et al., 2001. "Acute insufficiency of gastrointestinal organs in case of heavy bullet wound," Bulletin of Surgery [Vestnik Hirurgii], in Russian, No.5, pp.89-93

Khadjibaev, A., Baybekov, I., Khodjimukhamedova, N., Khadjibaev., 2007a. "Features of tissue and suture materials interaction with metal ring during experiment," Issues of clinical medicine [Problemi Klinicheskoy Medicini], No.3, pp.64-67

Khadjibaev, A., Baybekov, I., Khodjimukhamedova, N., Khadjibaev, F., 2009. "Experiment on applying of intestinal anastomoses using frame metal ring," Biological journal of Uzbekistan [Biologicheskiy Zhurnal Uzbekistana], in Russian, No.1, pp.17-21

Khadjibaev, A., Khodjimukhamedova, N., Khadjibaev, F., 2007b. "The device for applying anastomosis of gastrointestinal tract" [Ustroistvo dlya nalojeniya mejkishechnogo anastomoza], Patent No.FAP 00305

Khodjimukhamedova, N. and Khadjibaev, F., 2009. "Using of frame on inter-intestinal anastomoses in emergency surgery," The Bulletin of Emergency Medicine [Bjulleten Associacii Vrachej Uzbekistana], in Russian, No.1, pp.25-27

Kirpatovskiy, I., 1964. Intestine suture and its theoretical aspects [Kishechniy shov i ego teoreticheskie voprosi], in Russian, Moscow: Medisina

Kulagin, V., 2006. Traumatic intramural haematomas of large intestine [Intramuralnye gematomi tolstoy kishki travmaticheskogo proishozhdeniya], Materials of international conference, pp.204-205

Lokhvitskiy, S. and Darvin, V., 1992. "Prevention of colon sutures failure in case of it damage," Surgery [Hirurgiya ], in Russian, No.9-10, pp.51-56

Naumov, N. et. al., 1999. Causes of inter-intestinal anastomoses insufficiency and prevention method [Prichina nesostojatelnosti mezhkishechnogo anastomoza i metod profilaktiki], in Russian, Novosibirsk: Nauka

Saveliev, V., 2004. Guidance on abdominal organs emergency surgery [Rukovodstvo po neotlozhnoy hirurgii organov brjushnoy polosti], in Russian, Moscow: Triada-x

Shugaev, A., 2005. "Diagnostics and treatment of large intestine damage," Scientific Bulletin of Kostanay Social Technical University [Vestnik Nauki Kostanajskogo Socialno-Tehnicheskogo Universiteta], in Russian, No.8, pp.123-30

Tatyachenco, V., sarkisyan, V., Chubaryan, K., 2006. "Detection methods of extraperitonial colon parts of colon damage," Russian journal of gastroenterology, hepatology and coloproctolog [Rossiyskiy Zhurnal Gastrojenterologii, Gepatologii i Koloproktologii], No.5, pp.62

Abdukhakim Khadjibaev, Nigora Khodjimukhamedova, Ravshan Yangiev, Farkhod Khadjibaev

Republican Research Centre of

Emergency Medicine (RRCEM),

Uzbekistan
Table 1. The types of small and large intestines' injuries

                                        n     %

Penetrating injuries of duodenum        5     3

Rupture of duodenum                     2     1.2

Penetrating injury of small intestine   90    53.9

Multiple ruptures of small intestine    5     3

Penetrating injury of large intestine   46    27.5

Small and large intestines' injuries    19    11.4

Total:                                  167   100

Table 2. The types of performed operative interventions
on small and large intestines

                                                      n

Small intestine wound closure                         46

Laparoscopic wound closure of small intestine         4

Large intestine wound closure                         24

Small and large intestines wound closure              16

Small intestine's resection with applying             11
entero-entero-anastomosis

Large intestine's resection with applying             4
colon-colon-anastomosis

Small intestine's resection with applying ileostomy   4

Large intestine's resection with applying colostomy   3

Duodenum wound closure                                7

Wedge-shaped small intestine's resection              15

Wedge-shaped large intestine's resection              6

Intestine wound closure combining with                5
stomach wound closure

Total:                                                167
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Author:Khadjibaev, Abdukhakim; Khodjimukhamedova, Nigora; Yangiev, Ravshan; Khadjibaev, Farkhod
Publication:Medical and Health Science Journal
Article Type:Report
Geographic Code:9UZBE
Date:Apr 1, 2012
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