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Fibrinferments and embolisms of mesenteric vessels belong to rare complications of appendectomy and, according to our data, make 0,04% (2 patients on 5100 operations). As the reason of lethal outcomes this complication has big specific weight — 1,79%. Discrepancy of these indicators confirms situation that fibrinferments and embolisms of mesenteric vessels — one of the most dangerous acute diseases of abdominal organs. The lethality at the same time, despite considerable achievements of surgery of the last years, continues to remain very high — 85 — 92% (E. V. Kurlikov, 1958; A. E. Norenberg-Charkviani, 1967; V. S. Savelyev and I. V. Spiridonov, 1970).
Development of arterial and venous thrombosis of mezenterialny vessels is possible. Their fundamental difference is defined not only localization of process, but also character of etiological factors, pathomorphologic changes, clinical manifestations that, in turn, defines various medical tactics.
At supervision of 50 patients with thromboses and embolisms of mesenteric vessels we paid attention that embolisms as complications of diseases of cardiovascular system are most characteristic of arterial system (a myocardial infarction, an endocarditis, the inborn and acquired defects). They arise usually at the expense of a separation of endocardiac blood clot and its transfer in peripheral arteries: in that specific case such embolus is brought in system of an upper mesenteric artery. If establish thrombosis of arterial system, then it can be considered as continuation of an embolus which makes in this case a blood clot basis. Primary thrombosis is not characteristic of arterial system in view of a fast blood-groove in it. Only at atherosclerotic defeat of an arterial wall fibrinferments as the reason of arterial impassability are possible.
On the contrary, the fibrinferments arising at a direct injury of venous vessels of intestines and a mesentery are characteristic of venous system. Delay of a blood-groove at a paretic condition of intestinal loops and change of chemism of blood, disturbance of a functional condition of coagulant and anticoagulative system are the factors contributing to thrombosis.
Distinction of defeats of arterial and venous vessels is reflected also in a clinical picture of a disease. For an embolism of mezenterialny arteries (large arterial trunks most often are surprised: and. mesenterica superior or its branches) is characteristic sudden emergence of sharp pain up to abdominal shock. Differential diagnosis is carried out with such diseases as a ruptured ulcer of a stomach and duodenum, hemorrhagic pancreatitis. V. S. Savelyev and I. V. Spiridonov point to an important symptom, sudden increase of arterial pressure upon 60 — 70 mm of mercury., that connect with switching off from blood circulation of huge arterial fields.
Thrombosis of mezenterialny veins develops gradually from emergence of not clear pains in a navel, on all stomach, sometimes in flanks.
The following symptom characteristic of embolisms of mezenterialny arterial vessels, fast disappearance of a vermicular movement is. Despite the most vigorous conservative measures, it is not possible to recover it. At venous fibrinferments the total disappearance of a vermicular movement is observed only in late stages of a disease when it is complicated by the expressed peritonitis. Under the influence of conservative actions (lumbar novocainic blockade, parenteral stimulation of intestinal activity, siphon enemas etc.) the peristaltics is recovered to usual; there is a chair, gases depart, it leads to considerable improvement of the general condition of the patient.
During impassability of intestines as consequences of arterial embolisms two-staging is characteristic: the first hours of a disease can be designated a spastic stage what there correspond the sharp abdominal pain, increase of arterial pressure, tachycardia to. The spastic stage is replaced paralytic, it is followed by considerable deterioration in the general condition of the patient, the accruing peritonitis phenomena, then lowering of arterial pressure and symptoms of the general intoxication. At a blood analysis during the first hours diseases of change are observed seldom, indicators of coagulant and anticoagulative systems at most of patients are normal.
Slow and gradual development in which it is difficult to consider accurate stages of pathological process is characteristic of venous thromboses. The pain in the beginning moderated, which is periodically decreasing, later amplifying to cruel. The chair with blood impurity in the form of "crimson jelly" is very characteristic.
The expressed paresis of upper parts of a digestive tract is followed by the stagnation phenomenon in a stomach, the vomiting reminding a coffee thick. At venous thrombosis a pathognomonic symptom is the tumor in an abdominal cavity — according to localization of a hemorrhagic heart attack and an edematous mesentery.
Early enough it is possible to find an exudate in an abdominal cavity which has serous, and then hemorrhagic character in the beginning. Dynamic intestinal impassability at venous fibrinferments is followed by inertly current peritonitis which develops not so promptly, as at embolisms of mesenteric arteries. At them in early hours hypercoagulation is defined. In clinical blood test signs of acute inflammatory process quickly appear. The following supervision is of interest.
Sick Sh., 45 years, came to clinic of 21/III 1971 g concerning an acute appendicitis. From the anamnesis it is known that the patient for the previous 2 weeks had an acute respiratory infection. In day of receipt there was an abdominal pain in this connection it was hospitalized with the diagnosis of an acute appendicitis, pneumonia. Appendectomy. Phlegmonous appendicitis is defined. The abdominal cavity is trained. The postoperative period proceeded hard. Due to bilateral pneumonia and dynamic intestinal impassability to the patient carried out an intensive care — antibiotics, disintoxication means, anticoagulants, systematically carried out stimulation of activity of intestines which was effective and was followed by the general improvement of a condition of the patient.
Since 25/03 1971 the condition of the patient improved: temperature decreased, the peristaltics, a chair with blood impurity appeared. Next day the state worsened again: sharp oppression of a vermicular movement, pain on all stomach, on a drainage tube from an abdominal cavity arrives plentiful amount of serous liquid. In an abdominal cavity define a tumor of a pasty consistence. Under the influence of conservative therapy the otkhozhdeniya of fecal masses with blood impurity was succeeded to achieve again. The stomach is washed out, contents — congestive masses in the form of a coffee thick.
27/03 1971 condition of the patient extremely heavy. The consciousness confused it is aggressive. Arterial pressure — 100/70 mm of mercury. Pulse to 100 blows 1 minute, is arrhythmic. Thrombosis of vessels of a mesentery is suspected. Operational treatment which he and relatives refused is offered to the patient. By the end of day of the patient died. On opening: the multiple, merging hemorrhagic heart attacks of a small bowel and pristenochny blood clots of a portal vein. An associated disease — bilateral influenzal pneumonia.
The diagnosis of defeat of mezenterialny vessels is extremely important as only in the justified way of treatment both arterial embolisms, and venous thromboses, operation which it is necessary to appoint in perhaps early terms is. At arterial embolisms an operative measure should be carried out immediately without any preparatory activities. Venous fibrinferments also demand urgent operation, some waiting is justified only in the absence of reliable data about defeat of vessels. At establishment of the diagnosis any attempts of conservative treatment both concerning recovery of activity of intestines, and concerning thrombolytic and anticoagulating therapy are senseless and absolutely unjustified. Even temporary improvement of a condition of the patient which quite often disorients the doctor cannot be the basis for postponement of terms of operation. Unreasonable prolongation of intervention leads to aggravation of pathological process and increase of necrotic changes of an intestinal wall, emergence of symptoms of peritonitis.
Operational treatment for arterial embolisms and venous thromboses various. For arterial defeats the choice of a method of operation depends on the term of its carrying out. Essentially perhaps 2 types of operations: the tromboembolektomiya executed in early terms of operation (in the first 4 — 6 hours), and a resection of the struck gut within viability — in late terms. The last is considered palliative and therefore some surgeons recommend to carry out it, combining with a thrombectomy (V. S. Savelyev, I. V. Spiridonov, 1970; Hridlicka, 1961).
At patients in especially serious condition carrying out palliative operations is possible; bowel resections without forming of an anastomosis and removal of oral and aboral sites of intestines on a front abdominal wall. Removal of the affected intestines out of limits of an abdominal cavity without resection, from our point of view, pathogenetic and technically is unjustified. At venous fibrinferments operation of the choice is the resection of the struck department — a zone of a hemorrhagic necrosis and adjacent sites.
Postoperative actions have to be directed to fight against peritonitis, intoxication and dynamic intestinal impassability, retrombozy.
In our supervision, as well as according to other authors, the lethality was very high. So, from 50 observed patients 42, 8 patients are operated not operated in connection with extreme weight of their state. At 21 of 42 operated were limited to a trial laparotomy; all these patients died in the early postoperative period. At 19 patients bowel resection is made, at 1 it it was combined with an embolectomy. 7 patients drove out of operated.