Predicting the risk of postoperative adhesive intestinal obstruction in children

Abstract

Postoperative adhesive intestinal obstruction (PAIO) in children is one of the most common serious emergencies in abdominal surgery. The frequency of this pathology reaches 6% in children who underwent surgery on the abdominal organs. Up to 60% of all relaparotomies in children are performed for PAIO, among them 90% are performed in the first year after primary surgery. The most common pathology in children, which leads to PAIO, is acute appendicitis complicated by peritonitis. Prognosis and treatment of PAIO in children today is an urgent problem of abdominal pediatric surgery due to its high frequency, high rate of complications and high recurrence rate and relaparotomies, which lead to a significant reduction in the quality of life of patients. Peritoneal adhesions are pathological formations of connective tissue in the area of surgery. N-acetyltransferase plays an important role in the excessive development of connective tissue and formation of abdominal joints, because the fibrinogenesis of connective tissue is determined by genetically determined polymorphism by the phenotype of N-acetyltransferase. Given its important role in the formation of abdominal adhesions, today there are promising methods of prediction and drugs for pathogenetic prevention of cancer.

Purpose – to study features of the clinical course of disseminated appendicular peritonitis in children depending on the phenotype of acetylation (FA) and the prognostic value of FA in the development of PAIO.

Materials and methods. Examination and analysis of medical records of 18 children treated at the Pediatric Surgery Clinic of Ivano-Frankivsk NMU for widespread appendicular peritonitis was performed. The age of patients ranged from 6 to 18 years. Among the examined patients were 12 boys and 6 girls (2:1). All children underwent a set of standard examinations: assessment of anamnestic and clinical data, laboratory tests of blood and urine, X-ray and ultrasound examination of the abdominal cavity. The type of acetylation was determined in the postoperative period by the method of Prebsting–Gavrilov in the modification of M. M. Anilova and N. F. Tolkachevskaya. Assessment of the postoperative period was performed according to the following parameters: duration of gastric stasis, recovery period of peristalsis, duration of pain, duration of hospital treatment. Follow-up data for 1–5 years were also assessed: presence of peritoneal adhesive disease, presence of PAIO episodes and relaparotomies for PAIO. Depending on the established type of acetylation, patients were divided into 2 groups: the first – children with a slow type of acetylation (13 patients, 72.2%), the second – children with a fast type of acetylation (5 patients, 27.8%). All examined children underwent traditional treatment of disseminated peritonitis, accepted in the clinic, and standard intra- and postoperative methods of adhesions prevention. Anti-adhesive barrier agents for the prevention of malignancy in the examined children of both groups were not used.

Results. All patients in both groups recovered. It was found that in children with slow acetylation type the postoperative course was more severe than in children with fast type (second group). The average duration of gastric stasis after surgery in patients of the first group was 57.5±4.8 hours, in children of the second group 25.4±3.0 hours. In patients with a rapid type of acetylation, recovery of auscultation peristalsis was faster – in 26.0±3.2 hours after surgery, in children of the first group – in 52.8±4.2 hours. The average duration of pain was higher in children of the first group (108.8±8.6 hours) than in children of the second group (78.8±4.6 hours). The more favorable course of the postoperative period in patients with a rapid type of acetylation led to a lower average duration of hospital treatment (10.5 days), in children of the first group duration was 12.9 days. Early postoperative complications in children of the second group were not observed. Two children of the first group (15.4%) had complications: one child had early PAIO, the other had suppuration of postoperative wound. In the study of catamnesis in patients of both groups it was found that two children with slow acetylation had signs of peritoneal adhesive disease (periodic abdominal pain, delayed defecation and flatulence, delayed evacuation of contrast in contrast study of the digestive tract). In one of them PAIO was diagnosed, which was treated conservatively. One child in the same group underwent relaparotomy for early PAIO. In children with rapid acetylation PAIO or peritoneal adhesive disease and relaparotomies were not observed. Thus, preliminary data on the significant prognostic value of determining the activity of the enzyme N-acetyltransferase, a product of the NAT2 gene, in determining the degree of risk of PAIO in patients operated on for peritonitis, were received. Children with a slow type of acetylation have a significantly higher risk of PAIO developing than children with a rapid type of acetylation, which reflects an individual, genetically determined predisposition to excessive adhesion formation. This allows to form a high-risk group of PAIO among children operated on for peritonitis. In such patients, it is advisable to carry out a full range of adhesions prevention, and in case of PAIO, be sure to use intraoperative barrier medicines to prevent recurrence of PAIO. It was also noted that in children with a fast type of acetylation the postoperative course is significantly better than in patients with a slow type of acetylation.

Conclusions. Among children operated on for widespread appendicular peritonitis, children with a slow type of acetylation are more common. In the group of children with rapid acetylation, operated on for widespread peritonitis, found a more favorable course of postoperative period (less time to stop gastric stasis and restore intestinal motility, reduce the duration of pain, reduced duration of inpatient treatment). Determining the type of acetylation by determining the biochemical activity of the enzyme N-acetyltransferase is a promising method for diagnosing the genetic predisposition of the patient to adhesions formation and the degree of PAIO risk. Patients with a slow type of acetylation should be given a full set of prevention of adhesions formation, and in case of PAIO, be sure to use intraoperative barrier medications to prevent recurrence of PAIO.

The study was conducted in accordance with the principles of the Declaration of Helsinki. The study protocol was approved by the Local ethics committee of all participating institutions. Informed consent of parents and children was obtained to conduct the research.

The authors declare no conflict of interest.