Laparostomy and Scheduled Sanitizations of Abdominal Cavity in Complex Treatment of Perforated Ulcer Associated with Diffuse Purulent Peritonitis

P.G. Kondratenko, Ye.A. Koychev

Abstract


The aim of the study: to study effectiveness of laparostomy combined with scheduled sanitizations of abdomen in complex treatment of perforated ulcer of the stomach and duodenum associated with diffuse purulent peritonitis.
Materials and methods. We observed 105 patients with perforated ulcer of the stomach and duodenum associated with diffuse purulent peritonitis. 60 (57.1 %) of them were men and 45 (42.9 %) were women. The age of the patients varied from 28 to 86 years. Stomach ulcers were detected with 23 (21.9 %) patients, duodenal ulcer — in 81 (77.14 %) and double localization of the ulcers — in 1 (1 %). Concomitant pathology was observed in 83 (79.1 %) patients. 35 (33.4 %) patients seeked medical help within 24 hours after onset of abdomen pain, 29 (27.6 %) — within 25–72 hours and 41 (39 %) — after 72 hours. Index of abdominal cavity in all patients, included in main group, was over 13 points. The first degree of Mannheim Peritonitis Index (MPI) was detected in 29 (27.6 %) patients, second — in 55 (52.4 %), third — in 21 (20 %). Abdominal sepsis was observed in 71 (67.6 %) patients and multiple organ failure — in 32 (30.48 %).
Excision of perforated ulcer was performed in all the patients. In localization of the perforated ulcer on the front semicircle of the duodenum, the Judd — Tanaka and the Judd — Horsley methods were applied. When the perforated ulcer was associated with stenosis, the method of widen pyloro- and duodenoplasty according to Barry — Hill was used. When the duodenum ulcer excision took place, the preference was given to duodenal plasty.
Except surgical procedure all the patients were given complex therapy before, during and after the operation. This included correction of hemodynamic, water-electrolytic balance and metabolic disorder, antibacterial therapy, energetic and plastic body necessities supply, provision of normal interchange of gases and elimination of microcirculation abnormalities, detoxification therapy, natural body resistance rise, and intestine functional insufficiency elimination.
Results and discussions. Depending on a therapeutic approach the patients were divided in two groups. In the first grout there were 59 (56.2 %) patients who after the operation had abdominal region sutured tightly. If complications took place relaparotomy was performed (relaparotomy as required). In postoperative period 15 (25.4 %) patients had complications: 7 (11.9 %) patients had suture failure and peritonitis, 3 (5.1 %) had the abdomen region abscess, 3 (5.1 %) had postoperative wound infection, 1 (1.7 %) patient had eventration, and 1 (1.7 %) had suppurative omentitis. 32 (54.2 %) patients died.
In the second group there were 46 (43.8 %) patients who had the method of laparostomy suggested by V.S. Savelyev (2006) for diffuse purulent peritonitis treatment. 15 (32.6 %) patients without lethal outcomes had the first degree of MPI. The second degree of MPI was detected in 23 (50 %) patients, 6 (26.1 %) patients died. The third degree was observed in 8 (17.4 %) patients, 6 (75 %) patients died. All the patients who had MPI more than 33 points died. Postoperative complications were detected in 5 (10.9 %) patients: postoperative wound infection was observed in 3 (6.5 %) patients, 2 (4.3 %) patients had suture failure and peritonitis. General lethality was 26.1 % (12 people died).
Conclusion. Applying of laparostomy with partial wound lips joining combined with scheduled abdominal sanitizations decrease lethality in 2.1 times in patients with diffuse purulent peritonitis accompanied by perforated ulcer of the stomach and duodenum. It also decreases the number of postoperative complications in 2.4 times. The development of such complications as abdominal abscess or eventration was not observed. The optimal interval between scheduled abdominal sanitizations is 24–48 hours. For majority of patients 2–3 scheduled abdominal sanitizations were enough. The critical index MPI during perforated ulcer accompanied by diffuse purulent peritonitis is 33 points. One of the advantages of applying laparostomy with partial laparotomic wound lips joining with patients with diffuse purulent peritonitis is absence of intra-abdominal hypertension syndrome during postoperative period.


Keywords


perforated ulcer of the stomach and duodenum; diffuse purulent peritonitis; laparostomy; scheduled sanitizations of abdominal cavity

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DOI: https://doi.org/10.22141/1997-2938.1.20.2013.87715

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