Ключевые слова: острый перитонит, сочетанная патология, патогенез, диагностика, лечение.
Grynchuk F.V.Features of Treatment and Prophylaxis of Acute Peritonitis at Diabetes Mellitus and Other System Pathology. (Experimental–Clinical Investigation).–Manuscript.
Thesises in order to receive doctorate degree on the specialty 14.01.03 – surgery. Vinnitsa National Medical University named after M.I.Pirogov, Ministry of Health of Ukraine, Vinnitsa, 2007.
The dissertation comprises theoretical generalization of clinic–experimental investigation of the patterns with acute peritonitis developing on the background of concomitant pathology and new solution of important scientific–practical problem – improvement of the results of patients' treatment with associated pathology which imply working out its classification, substantiation, working out and efficacy estimation of new diagnostic, treatment and complication prophylaxis methods.
Comparative assessment of peritoneal cavity microbial contamination dynamics, small and large intestine microbiocenosis, proteolytic, fibrinolytic, cytokine, immune– and redox system, endotoxicosis in the course of the peritonitis development on the background of different concomitant pathology has been done in experiment. Some general conformities irrespective of the type of concomitant diseases have been found. It was stated that two stages in the course of acute peritonitis – reactive and toxic is expedient to mark out.
Comparative study of the course of acute inflammatory – destructive diseases of the peritoneal cavity organs complicated by peritonitis in the patient with concomitant pathology has been made. It was found that general clinical traits in concomitant pathological processes are grows of the amount of patient with obliterated and nontypical symptomcomplex, deterioration of the patient gravity status, delay in the regression of inflammatory process in postoperative period. The incidence of wound complications grows up in the patients with concomitant pathological processes and depending on its nature comprises 9,89% in cases of perforated ulcers complicated by diffuse peritonitis and 33,3% in cases of acute destructive appendicitis complicated by local peritonitis; number of intraabdominal septic complications also increases varying from 20% in cases of perforated ulcers complicated by general peritonitis of the II grade of gravity up to 100% in cases of intestinal obstruction and perforated ulcers complicated by general peritonitis of the III grade degree of gravity.
By means of complex evaluation of experimental and clinical data pathogenic foundation for the changing of the course of acute surgical pathology in the patient with concomitant diseases was revealed. It was proofed that regulatory dysfunction is one of the mechanisms in the development of the mutual deterioration syndrome. It was reveled also that there is a staging in the development of mutual deterioration syndrome that made it possible to work out the classification of concomitant pathology with distinction of 4 classes.
The methods of spectrophotometric and photoluminescent diagnostic procedures of acute inflammatory – destructive diseases of abdominal cavity organs have been worked out which allow to improve substantially diagnostic process on account of high sensitivity which for the spectrophotometry comprise 81,01% and specificity which riches 93,58%.
Treatment tactic has been worked out for the cases with associated diseases which specifies differential choice or the measures scope on all staged of the treatment of acute peritonitis with the regards or concomitant pathology. Indications for preoperative preparation have been widened which should be done for the patients attributed to the II – III class of associated pathology.
For substantiation of the scope of operation choice and points of intestinal sutures placement methods of viability determination has been worked out which predispose the evaluation of photoluminescence index.
To improve the reliability of organs connection zone original one – row suture has been worked out which possessed high haemostatic capacity and provide for sufficient physical hermetism.
On the patient referred to the I and II classes of associated pathology to the protection and reinforcement of suture lines method of the local influence has been proposed. It is advisable to use allogen materials in the patients with the III class of associated pathology for this purpose.
Indications as to the use of repeated programmed sanations of peritoneal cavity in the patients with associated pathology also have been widened. In cases of the II class of associated pathology such interventions have to be used starting with the II grade of general peritonitis severity and in cases of the III class even with the I grade severity. Method of peritoneosorption has been improved with resulting grows of its efficacy.
Worked out method of peritoneal cavity sanation which consist of washing it out with polycomponent solution under pressure allow to increase clearance of aerobic microflora up to 90,7% and for anaerobic – to 64,9%.
For the prophylactics of wound complication in the course of repeated programmed sanations of peritoneal cavity method of operative wound closure with implication of vulneosorption has been worked out.
Application of the developed treatment tactic in the patients with associated pathology with local and diffuse peritonitis made it possible to avoid the development of intraabdominal and wound complications and lethality, and in the patients with the II and III classes with generalized peritonitis reduced lethality up to 24,4%, and frequency of wound suppuration to 16,6%.
Key words: acute peritonitis, associated pathology, pathogenesis, diagnostic, treatment.
ПЕРЕЛІК УМОВНИХ СКОРОЧЕНЬ
гострі хірургічні захворювання
ішемічна хвороба серця
Мангеймський перитонітний індекс
молекули середньої маси
оптична густина плазми
окиснювальна модифікація білків
поєднані патологічні стани
синдром взаємного обтяження
фактор некрозу пухлин б
циркуляційні імунні комплекси