Effect of Violations Regional Hemodynamics and Microcirculation of the Intestinal Wall on the Occurrence of Acute Perforation of the Small Intestine

Relevance One of the main causes of postoperative diffuse peritonitis (PDP) are acute perforation of the various divisions of the small intestine and failure interintestinal enteroenteroanastomosis. The occurrence of these complications significantly reduces the severity of the patients and contributes to mortality up to 60 – 90%. The purpose of the study To study the influence of hemodynamic mesenteric circulation and microcirculation of the intestinal wall on the occurrence of acute perforation of the small intestine. Materials and methods For registration of normal blood flow values 16 volunteers routinely performed transabdominal ultrasound duplex scanning of the celiac trunk (TC), the superior mesenteric artery (AMS) and its branches (ram). In comparison, 20 patients with PDP duplex scanning of the same pools performed intraoperatively during the first sanation relaparotomy, including 6 before and after intestinal intubation. Subsequently, the dynamics of changes of blood flow in the specified pools in all patients with PDP was carried out with repeated intraoperative ultrasound duplex scanning (IUDS) during 2 or 3 programmed rehabilitation abdomen. The second stage using laser doppler flowmetry intraoperative (ILDF) were determined normal microcirculation wall of the small intestine. For this were examined in 10 patients operated on in a planned way and no signs of peritonitis. In comparison, the same investigation was carried out with 10 patients during the first PDP relaparotomy (including 6 before and after intestinal intubation), and the dynamics during programmed sanations abdomen. Results and their discussion Transabdominal and intraoperative ultrasound duplex scanning visceral abdominal vessels of volunteers and patients with PDP showed that the maximum values of blood flow velocity (Vmax, Vd, TAMAX) in both groups recorded at TC and AMS with a significant reduction of the periphery against the background of increasing peripheral resistance index (RI). When comparing the same levels of blood flow in volunteers and patients with PDP at AMS and ram it was noted a significant decrease significantly peak systolic (Vmax), increase in end-diastolic (Vd) blood flow velocity, TAMAX, as well as reduced RI in patients with PDP. However, the IUDS level branches AMS performed after intestinal intubation in patients with PDP, revealed a significant increase in RI and reduced TAMAX. These changes are interpreted as microcirculation disturbances manifested visual appearance petechial hemorrhages in the intestinal wall overstretched, with a reduction in central hemodynamics during this period due to reperfusion syndrome. In assessing ILDF wall of the small intestine in patients with PDP compared with the volunteers had significant microcirculatory disorders, manifested by reduced microcirculation, standard deviation, performance index microcirculation bypass indicator. In evaluating these parameters in patients with PDP 36 hours during programmed relaparotomy had significantly their growth. At the same time, the analysis of the amplitude - frequency spectrum ILDF performed after intestinal intubation in patients with first relaparotomy in patients with PDP index was decreased with increasing the efficiency of microcirculation index bypass due to an increase of neurogenic and myogenic tone of blood vessels, which indicates a lean microvasculature and worsening of metabolic disorders in the intestinal wall. Conclusion Using IUDS ILDF and visceral arteries in patients with PDP reveals significant violations mesenteric circulation and microcirculation, more pronounced at the level of branches of the AMS. Registration of changes in mesenteric blood flow in patients with PDP after intestinal intubation allows to fix the further deterioration of microcirculatory pool associated with the occurrence of reperfusion syndrome. On the background of the planned sanations abdomen in patients with PDP, along with relief of the inflammatory process, there is significant improvement in the mesenteric circulation and microcirculation. Key words Acute bowel perforation, postoperative peritonitis, microcirculation, intraoperative duplex scanning, intraoperative laser doppler flowmetry