А. С. Ибадильдин, Б. М. Нокербекова, Н. Е. Сарманов, М. С



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Generalized peritonitis -principles of treatment

A.S. Ibadildin, B.M. Nokerbekova, N.E. Sarmanov, M.S. Zyablitskaya

KazNMU named after Asfendiyarov, Department of Surgical diseases № 3
Жайылмалы перитониттің емдеу қағидалары

А. С. Ибадильдин, Б. М. Нокербекова, Н.Е.Сарманов, М.С.Зяблицкая

Негізгі сөздер: перитонит, ағза жетіспеушілігінің шкалалары, жүйелі қабыну реакциясының синдромы, перитонеальді шок, абдоминальді сепсис.

Мақалада авторлар 2007-2011 жылдар аралығында перитонитпен асқынған құрсақ қуысы мүшелерінің жарақаттары мен аурулары бар науқастарды емдеу тәсілдерімен бөліседі. Перитониттің клиникалық ауырлығын идентификациялау үшін сепсистің клиникалық жіктемесін есепке ала отырып жіктеменің соңғы жаңа тәсілдерімен АРАСНЕ ІІ, SAPS жүйе-шкалаларымен науқастардың ауырлық жағдайын және аурудың болжамын бағалауын объективтеу, клиникалық сатыларды, перитонеальді сепсистің синдромдарын дәлірек анықтауға, емдеу тактикасын оптимальді етіп және аурудың ағымын болжауға мүмкіндік берді.


Принципы лечения распространенного перитонита

А. С. Ибадильдин, Б. М. Нокербекова, Н.Е.Сарманов, М.С.Зяблицкая

В статье авторы делятся опытом лечения 511 больных с заболеваниями и травмами органов брюшной полости, осложненными перитонитом за 2007-2011гг. Использование современных классификаций с обновленным подходом к идентификации клинической тяжести перитонита с учетом клинической классификации сепсиса, систем-шкал прогнозирования течения РП - АРАСНЕ ІІ, SAPS позволило прогнозировать возможность местных и внутрибрюшных осложнений, связанных с острой хирургической патологией и внебрюшинных осложнений как проявление абдоминального сепсиса и/или вследствие отягощения течения фоновых заболеваний; оптимизировать активную хирургическую тактику, своевременно предпринимать повторные оперативные вмешательства, использовать методы экстракорпоральной детоксикации; снизить летальность при перитоните.



Ключевые слова: перитонит, шкалы органной недостаточности, синдром системной воспалительной реакции, перитонеальный шок, абдоминальный сепсис
Key words: peritonitis, the scale of organ failure, systemic inflammatory responsesyndrome, peritoneal shock, abdominal sepsis

Summary: This issue based on a clinical trial of 511 patients with peritonitis summoned by traumas and abdominal cavity diseases due to period of 2007-2011 years. Using a modern classification with regards to severity of peritonitis and sepsis classification (РП - АРАСНЕ ІІ, SAPS), scales predicting the course of disease helped prognoses the complications local and intraperitoneal. Furthermore, this approach, associated with acute surgical pathology and extraperitoneal complications as a manifestation of abdominal sepsis and / or due to complication of the current baseline conditions, to optimize the active surgical tactics in a timely manner to make repeat surgery, use of extracorporeal methods of detoxification to reduce mortality in peritonitis

Relevance. Rate: Primary peritonitis is a rare case only in 1%. Secondary peritonitis as a complication of surgical pathologies. Mortality for generalized peritonitis, though new methods and technique options for treatment is still not decreasing. Thus, for purulent peritonitis is 25-30%, 80-90% those with multiple organ dysfunction syndrome. Several centers in Republic of Kazakhstan are responsible for implementing new techniques in treatment of generalized peritonitis (GP), based on a approved classification (accepted 21 22.04.99., Rostov, the Association of Surgeons of CIS countries - in 2003.) which is widely used in CIS and foreign countries (V.S.Savelev, N.I.Izimbergenov).

GoalTo attain knowledge in GP treatment, which severs other surgical diseases, traumas of abdomen and value of APACHE and SAPS use in prognozing the morbidity and  severity of pathologic conditions.

Materials and methods. 511 patients (245 female, 266 male) in the age of 16-79 y with acute surgical pathology, causing peritonitis (source of inflammation: appendicitis – 63%, ventricle and duodenum 12%, gall bladder, organs of lesser pelvis – 1%, intestine – 9%, pancreas -5%) has been treated in clinic due to period of 2007- 2011 During the last 5 year period 511 patients with acute secondary peritonitis has been operated.

Among them:



  • Acute destructive appendicitis complicated by peritonitis -322

  • perforated gastric ulcer and 12 sc – 61

  • Acute destructive cholecystitis –49

  • Acute necrotizing pancreatitis – 25

  • Acute intestinal obstruction, including tumor genesis, incarcerated hernia – 29

  • Traumatic injuries of the abdomen and other diseases - 25

Tertiary peritonitis перитонит: forms of purulent peritonitis that develop and occur without marked clinical manifestations due to the ongoing treatment of debilitated patients with secondaryperitonitis and often - with violations immunogenesis different nature. Before known as Slow Progressive or Persistent peritonitis.

To identify the clinical severity of RP as abdominal sepsis, the last was used as a systemic inflammatory response syndrome (SIRS, Chicago,1991), which approved the four features has been accepted before: 1-body temperature of more than 380or less 360S, 2-tachycardia more than 90 in 1 minute, tachypnea over 20 in a minute or Pa CO 2 lower than 32 mmHg, leukocytosis or leukopenia 12000/mm3 - more than 4000 mm3 or greater than 10%, immature forms). Esxistence of 2 of four signs SIRS if diagnosed with destructive process contemplated as sepsis sign. In addition severe sepsis, as a manifestation of uncontrolled hypotension below 90 mm ​​Hg. of Art. - A sign of the terminal phase of sepsis, expressed in infectious-toxic shock(ITS) completed with multiple organ dysfunction syndrome.

Instead of grading the severity of GP, we used a gradation in phases:

Peritonitis with no signs of sepsis - 352 patients,

Pperitoneal sepsis SIRS3 - 73,

Peritoneal severed by sepsis SIRS4 -33, 

Infectious - toxic shock syndrome (ITS) - 53.

Analyzing the material we used a classification based on pathology process severity taking into account SAPS and other relevant scales.

The classification of peritonitis (adopted 21 22.04.99., Rostov, the Association of Surgeons of CIS countries - in 2003.)

І. Underlying disease

ІІ. Etyology:

Primary

Secondary

• Tertiary

III. Prevalence:


  1. Localized

А) Circumscribed (abscess)

Б) non-circumscribed

2. Generalized

ІV.By exudate:


  • Serous

  • Fibro serous

  • Purulent

  • Fecal

  • Hemorrhagic

  • Chemical (urine, bile, chyle peritonitis и др.)

V. Stages:

  • Peritonitis with no signs of sepsis 

  • Peritoneal sepsis SIRS3

  • Peritoneal severed by sepsis,  SIRS4

  • Sever peritoneal sepsis

  • Infectious - toxic shock syndrome (ITS) 

VІ Complicated and uncomplicated forms

Extraperitoneal complications - are due to contamination (Suppuration of the wound, abscess of retroperitoneal fat) or hematogenous translocation (nosocomial pneumonia destructive forms or bacterial endocarditis caused by peritoneal sepsis, etc.).

In order to object estimation of patient severity and prognosis morbidity has been used scales to determine syndromes of peritoneal sepsis. АРАСНЕ ІІ (Аcute Physiology and Chronic Health Evaluation Usa, Canada) - measures a patient condition in every given time and operations previoused towards increasing and SAPS(Simpliefied Acute Physiology Score- Europe).  

АРАСНЕ-П system has some advantages in patient admission to ICU. Following by this system it has been measured an age, chronic disease pertinence and psychophysical disorders. The total coefficient of less than 7 corresponds to mild disease, whereas a higher ratio to a more severe form respectively. It’s revealed that, compared with the SAPS APACHE II score in patients with abdominal sepsis has a higher sensitivity.

SAPS is a familiar clinical information more accessible to general practice  

Table1


APACHE II


Our estimations

Literature

SAPS

Our datas



Literature

Peritoneal sepsis  - SIRS - 3

- SIRS - 4


7,3


9,5

9,3 + 3,3

13,6 + 2,8

4,5


6,9

5,4 + 1,5

8,9 + 1,7


  • Sever peritoneal sepsis




11,2

18,4+ 2,1

8,2

13,2+ 1,4

Infectious - toxic shock syndrome 

34,5

21,5+ 2,5

18,9

17,6+ 1,3

After establishing a preliminary diagnosis, examination of the patient continues inconjunction with preoperative training. In this case the main purpose of diagnosis is to determine the severity of the process, the phases of its development, the presence of symptoms of peritoneal sepsis and multiple organ failure, and identifying the individual characteristics of pathogenesis.

The decision on what type of peritonitis makes by anamnesis data and clinical trials.

Along with a comprehensive laboratory testing and functional diagnosis if needed used an ultrasound of the abdomen, be sure to run the ECG and X-rays(-, chest X-ray abdomen.

All 511 patients underwent surgery: removal or exclusion made ​​the source of peritonitis, intra-and postoperative rehabilitation of the abdominal cavity, decompression of the small intestine. 

In the complex of therapeutic measures included massive antibiotic therapy (the most appropriate empirical antibiotic therapy before microbiological verification  - a combination of cephalosporins (mandola), aminoglycosides (gentamicin or vancomycin) and metronidazole), pharmacological correction of disorders of homeostasis, stimulation of either the temporary replacement of the major detoxification systems of the body methods haemocorrection

plasmapheresis, UV blood, HBO,  immune therapy, using a broad-spectrum antibiotics with

 immunosuppression.

Improving  immunoreactive abilities of the body, used intravenous immune globulin, 

antistaphylococcal gamma-globulin, and (if indicated) leukocyte mass, antistaphylococcal plasma, levamisole, timalin.


Severed forms of peritonitis in 14 cases undergo programed laparotomy - in order to conduct a systematic postoperative rehabilitation, second-look and drainage of the abdominal cavity. Indications:

  • Peritoneal severed by sepsis SIRS 3 – 5 cases

  • Peritoneal sepsis  – SIRS 4 – 5 cases

  • Sever peritoneal sepsis - 4 cases

Morbidity shown in Table2

Table2


Phase gradation

Amount

Total mortality (n = 511)

IN GP group

( n=159)

Peritonitis with no signs of sepsis 


352

0




Peritoneal sepsis  SIRS3

73

4%


12%

Sever peritoneal sepsis SIRS4

33


6%

20 %

Infectious - toxic shock syndrome 

53

11%



34%

Total

511

21%

66%

Conclusion: Thus, the use of modern classification systems, scales, predicting the course of GP allowed to evaluate the prognosis of the disease, predict the possibility of local and intra-abdominal complications (associated with acute surgical pathology) and extraperitoneal complications as a manifestation of abdominal sepsis and / or due to complication of the current baseline conditions, to optimize the active surgical tactics, time to take repeated surgical interventions, and reduced the mortality rate in peritonitis

Rusults of research:

Evaluting systems-scale prediction of severity and prediction of GP showed its relevance scale

APACHE II and SAPS.

The use of modern classifications possible to optimize the treatment of GP to choose the optimal time of active surgical tactics and efferent methods of treatment, reduce total mortality by 21%


The results obtained showed the feasibility of treatment of wide introductionin to practice of modern classification and compilation of a new protocol to the RC of diagnosis and treatment of GP
Reviewed literature

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