Surgical management in intestinal resection with implementation of primary or delayed anastomosis for necrosis, perforation or damage of the small intestine complicated by peritonitis

Objective. The treatment of necrosis, perforation and traumatic damage to the small intestine has always attracted the attention of surgeons due to the high incidence of complications and mortality that occur during treatment. However, there is very little research on this paper.

Purpose of the study: to compare the results of treatment of patients using the tactics of suturing wounds or perforations and resection of the intestine with the imposition of a primary anastomosis with obstructive resection of the intestine with the formation of an anastomosis in a delayed manner.

Material and methods. The clinical study was conducted at Novokuznetsk City Clinical Hospital No. 1 named after G.P. Kurbatov and Novokuznetsk City Clinical Hospital No. 29 named after A.A. Lutsik in the period of January 2011 to February 2019. A retrospective and prospective study was conducted, including an analysis of 835 patients treated for necrosis, perforation and traumatic damage to the small intestine. All patients were randomly distributed into groups with the imposition of a primary anastomosis and bowel resection with the formation of a delayed anastomosis. The estimated indicators were lethality and developed complications associated with the chosen treatment tactics during the patient's stay in the hospital.

The results. The most common cause of surgical interventions on the small intestine was acute intestinal obstruction – 58.0%, followed by acute mesenteric circulation disorder (27.1%), inflammatory bowel perforation (6.7%) and intestinal trauma (8.3%): and the most common operation in the retrospective group was resection of the intestine with the imposition of a primary anastomosis (64.0%), then suturing of the perforations of the inte stine (5.5%) and the imposition of a stoma (4.3%), in the prospective group group anastomosis after resection of the affected area was applied in a delayed order (100%). The most common complication in the retrospective group was anastomosis or bowel suture failure (64.3%), which was only 8% in the prospective group, however, in the latter group, superficial wound infection was most common (26.8%), accompanied by wound suture dehiscence. in 11.3% of individuals. The incidence of anastomotic leaks significantly decreased after delayed formation. Intestinal fistulas/stoma leaks were detected in 11.5% of patients in the retrospective group. Patients in the prospective group had a longer median ICU stay (11 days vs 4; p < 0.001) and a longer median hospital stay (27 vs 14 days; p < 0.008). Overall mortality in the retrospective group was 47.1%, in the prospective group – 14.8%.

Conclusion. Patients in the group with bowel resection and delayed anastomosis had a significantly lower rate of mortality and complications associated with anastomosis or bowel suture failure in conditions of peritonitis compared with the group with primary anastomosis, but had a longer stay in the hospital and a greater number of surgical operations.

1. Alekseev T.V., Movchan K.N., Alborov A.Kh. Nereshennye zadachi okazaniya medicinskoy pomoschi bolnym s mezenterialnym trombozom v munitsipalnyh bolnitsah malyh gorodov I selskih posaeleniy [Unresolved problems of providing medical care to patients with mesenteric thrombosis in municipal hospitals of small towns and rural settlements]. Vestnik hirurgicheskoy gastroenterologii – Bulletin of Surgical Gastroenterology. 2009;4:18-24. (In Russ.).

2. Darwin V.V., Babaev M.S. Pervichno-otsrochennye ananstomozy v ekstrennoy hirurgii tonkoy kishki: ocenka blizhayshih rezultatov [Primary delayed anastomoses in emergency surgery of the small intestine: assessment of immediate results]. Vestnik eksperimentalnoy i klinicheskoy mediciny – Bulletin of Experimental and Clinical Surgery. 2013;VI(3):422-425 (In Russ.).

3. Zavada N.V., Volkov O.E., Ladutko I.M., et al. Etapnoe hirurgicheskoe lechenie peritonita pri zakrutoy travme zhivota i povrezhdenii kishechnika [Staged surgical treatment of peritonitis with closed abdominal trauma and intestinal damage]. Ekstrennaya meditsina – Emergency Medicine. 2013;1(5):68-83 (In Russ.).

4. Lebedev A.G., Yartsev P.A., Makedonskaya T.P., et al. Povrezhdeniye kishechnika pri zakrutoy travme zhivota, osobennosti diagnostiki I lecheniya Intestinal injury in closed abdominal trauma, features of diagnosis and treatment. Vestnik hirurgicheskoy gastroenterologii – Bulletin of Surgical Gastroenterology. 2018;1:54-61 (In Russ.).

5. Totikov V.Z., Kalitsova M.V., Amrillaeva V.M. Lechebno-diagnosticheskaya programma pri ostroy spaechnoy obturacionnoy tonkokishechnoy neprohodimosti [Therapeutic and diagnostic program for acute adhesive obstructive small bowel obstruction]. Hirurgiya – Surgery. 2006;2:38-43. (In Russ.).

6. Adesunkanmi A.R., and Ajao O.G. The prognostic factors in typhoid ileal perforation: a prospective study of 50 patients. J R Coll Surg Edinb. 1997;42:395-399.

7. Ajao O.G. Typhoid perforation: factors affecting mortality and morbidity. Int Surg. 1982;67:317-319.

8. Akgun Y., Bac B., Boylu S., Aban N., Tacyildiz I. Typhoid enteric perforation. Br J Surg. 1995;82:1512-1515.

9. Ayite A., Dosseh D.E., Kotakoa G., Tekou H.A., James K. Surgical treatment of the single non traumatic perforation of small bowel: excision-suture or resection-anastomosis. Ann Chir. 2006;131:83-84.

10. Memon A.S., Siddiqui F.G. Causes and management of postoperative enterocutaneous fistula. J Coll Physicians Surg Pak. 2004;14:25-28.

11. Onen A., Dokucu A.I., Ciğdem M.K., et al. Factors affecting morbidity in typhoid intestinal perforation in children. Pediatr Surg Int. 2002;18:696-700.

12. Pal D.K. Evaluation of best surgical procedure in typhoid perforation – an experience of 60 cases. Trop Doc. 1998;28:16-18.

13. Shah A.A., Wani K.A., Wazir B.S. The ideal treatment for typhoid enteric perforation: resection anastomosis. Int Surg. 1999;84:35-38.

14. Timerbulatov V.M., Urazbakhtin I.M., Sagitov R.B., et al. Posleoperacionnoye monitorirovaniye abdominalnoishemicheskogo sindroma i trombozamezenterialnyh sosudov [Postoperative monitoring of abdominal ischemic syndrome and thrombosamesenteric vessels]. Klinicheskaya i eksperimentalnaya hirurgiya – Clinical and Experimental Surgery. 2013;2(1):6-10 (In Russ.).

15. Timerbulatov Sh.V., Sagitov R.B., Sultanbaev A.U., Asmanov D.I. Diagnostika ishemicheskih povrezhdeniy kishechnika pri ostryh hirurgicheskih zabolevaniyah organov bryushnoy polosti [Diagnosis of ischemic damage to the intestines in acute surgical diseases of the abdominal cavity]. Klinicheskaya i eksperimentalnaya hirurgiya – Clinical and Experimental Surgery. 2012;3:40-52 (In Russ.).