İntraperitonal PEG-4000 Uygulanmasının İnce Barsak Anastomozuna Etkileri: Deneysel Çalışma

Abdominal cerrahi girişim sonrası ortaya çıkan peritoneal adezyonlar halen önemini korumaktadır. Postoperatif peritoneal adezyonu önlemeye yönelik yapılan PEG-4000 ile ilgili çalışmalardan anlamlı sonuçlar alınmıştır. Ancak PEG-4000’in gastrointestinal anastomozlarda yara iyileşmesi üzerindeki etkilerine yönelik yeterince deneysel veya klinik çalışma yapılmamıştır. Bu çalışma 64 adet tavşan (16 denekten oluşan 4 grup) üzerinde kontrollü deneysel çalışma olarak planlandı. Grup 1, 2 ve 3'deki deneklere laparotomi yapılarak ileokolik bileşkenin 10 cm proksimalinden transeksiyon ve ileo-ileal uç uca anastomoz yaptık. Grup 1'e 20 ml intraperitonal olarak %40'lık PEG-4000, Grup 2'ye 20 ml %20'lik PEG-4000 ve Grup 3'e 20 ml serum fizyolojik uyguladık. Grup 4'e ise sadece laparotomi yaptık. Her bir grubu kendi içinde sekizer denekten oluşan iki alt gruba (a ve b) ayırdık, a grubuna postoperatif ikinci gün, b grubuna ise postoperatif yedinci gün relaparotomi yaptık. Aanastomozun 5 cm proksimalini ve 4 cm distalini içine alacak şekilde ileum rezeksiyonu yaptık. Kontrol grubuna ileokolik bileşkenin 10 cm proksimalinden 10 cm'lik ileum rezeksiyonu yaptık. Çıkarılan dokularda anastomozdaki doku hidroksiprolin düzeylerini ölçtük, histopatolojik inceleme yaptık ve postoperatif yedinci gün anastomoz ayrılma basınçlarını ölçtük. Kontrol grubu ile çalışma grupları karşılaştırıldığında, hidroksiprolin miktarlarının, histopatolojik inceleme sonuçlarının ve anastomoz ayrılma basınçlarının kontrol grubunda anlamlı olarak yüksek olduğunu tespit ettik. İntraperitoneal olarak %40'lık PEG-4000 uygulanmasının serum fizyolojik uygulanmasına göre yara iyileşmesi üzerinde hem postoperatif ikinci günde hem de postoperatif yedinci günde olumsuz etki yaptığını tespit ettik. %40'lık PEG-4000 kullanımının %20'lik PEG-4000 kullanımına göre yara iyileşmesi üzerinde postoperatif ikinci günde olumsuz etkisinin olmadığını, postoperatif yedinci günde yara iyileşmesi üzerinde anlamlı olarak olumsuz etkisinin olduğunu gördük.

Anahtar Kelimeler:

PEG-4000, Adezyon, Anastomoz, İnce Bağırsak, Yara İyileşmesi

Effects of Intraperitoneal PEG-4000 Administration on Small Bowel Anastomosis: Experimental Study

Peritoneal adhesion, which is seen after abdominal operations, is still an important problem. Studies showed that PEG-4000 could prevent abdominal adhesions, but the effects of PEG-4000 on anastomotic healing are unclear. To research these effects an experimental study was performed. Sixty-four rabbits were divided into 4 groups, each of containing 16 rabbits. In groups 1-3, 10 cm proximal to ileocecal valve the ileum was transected and anastomosis was performed. In group 4, only laparotomy was performed. Animals received 20 ml 40% PEG-4000 in group 1, 20 ml 20% PEG-4000 in group 2, 20 ml saline solution in group 3 intraperitoneally. Each group was divided into two subgroups, each containing 8 rabbits. On the 2nd postoperative day in subgroups 1a, 2a, 3a after laraparotomy, 5cm proximal and distal to previous anastomosis, ileal resection and ileoileal anastomosis, and in group 4a 10cm proximal to ileocecal valve a-10cm-ileal segment was resected and anastomosis was performed. The same procedures were performed in subgroups 1b, 2b, 3b, and 4b on the 7th postoperative day. Tissue hydroxyproline levels and anastomotic brust pressures were measured in resected intestinal segments, and histopathologic examination was performed. Wound healing scores and hydroxyproline levels were significantly higher in group 4 compared to other groups. 40% PEG-4000 has more negative effects on anastomotic healing on the 2nd and 7th postoperative days compared to saline solution. There were no significant differences between 40% and 20% PEG-4000 solutions on the 2nd postoperative day, but some significant ones on the 7th postoperative day. There were no significant differences between 20% PEG- 4000 and saline solutions on the 2nd and 7th postoperative days. Further studies are needed to prove the clinical use of PEG-4000.

Keywords:

PEG-4000, Adhesion, Anastomosis, Smoll Bowel, Wound Healing,

PDF

___

1. Thoronton FJ, Barbul A. Healing in the gastrointestinal tract. Surg Clin North Am. 1997;77(3):549-73.
2. Riou JPA, Cohen JR, Johnson H. Factors nfluencing wound dehiscence. Am J Surg. 1992;163(3):324-30.
3. Oguma J, Ozawa S, Morikawa Y, et al. Knot-tying force during suturing and wound healing in the gastrointestinal tract. Journal of Surgical Research. 2007;140(1):129-34.
4. Weibel MA, Majno G. Peritoneal adhesions and their relation to abdominal surgery: A postmortem study. Am J Surg. 1973:126(3):345-53.
5. Thompson JN, Whawell SA. The pathogenesis and prevention of adhesion formation. Br J Surg. 1995;82(1):3-5.
6. Barmparas G, Branco BC, Schnüriger B, Lam L, Inaba K, Demetriades D. The incidence and risk factors of post-laparotomy adhesive small bowel obstruction. J Gastro Surg. 2010;14(10):1619-28.
7. Garibay-González F, Navarrete-Arellano M, Moreno-Delgado F, Salinas-Hernández EL, Rodríguez-Ayala E, Cleva-Villanueva G. Incidence of intestinal obstruction due to post-surgical adhesions in the Central Military Hospital. Associated risk factors. Rev San Militar. 2018;71(6):534-44.
8. Cheadle WG, Garr EE, Richardson JD. The importance of early diagnosis of small bowel obstruction. Am Surg. 1988;54(9):565-9.
9. Milligan DW, Raftery AT. Observations on the pathogenesis of peritoneal adhesions:A light and electron microscopical study. Br J Surg. 1974;61(4):274-80.
10. Buckman RF, Woods M, Sargent L. A unifying pathogenetic mechanism in the etiology of intraperitoneal adhesions. J Surg Res. 1976;20(1):1-5.
11. Harris ES, Morgan RF, Rodeheaver GT. Analysis of the kinetics of peritoneal adhesion formation in the rat and evaluation of potential antiadhesive agents. Surgery. 1995;117(6):663-9.
12. Vipond MN, Whawell SA, Thompson JN. Peritoneal fibrinolytic activity and intraabdominal adhesions. Lancet. 1990;335(8698):1120-2.
13. DeChemey AH, di Zerega GS. Clinical problem of inraperitoneal postsurgical adhesion formation following general surgery and the use of adhesion prevention barriers. Surg Clin North Am. 1997;77:671-88.
14. Cai H, Qiao L, Song K, He Y. Oxidized, regenerated cellulose adhesion barrier plus intrauterine device prevents recurrence after adhesiolysis for moderate to severe intrauterine adhesions. Journal of minimally invasive gynecology.2017;24(1):80-8.
15. Nagelschmidt M, Saad S. Influence of polyethyleneglycol 4000 and dextran 70 on adhesion formation in rats. J Surg Res. 1997;67(2):113-8.
16. Arakawa J, Timasheff SN. Mechanism of polyethyleneglycol interaction with proteins. Biochemistry. 1985;24(24):675-8.
17. O'Sullivan D, O'Riordain M, O'Connell RP. Peritoneal adhesion formation after lysis: Inhibition by polyethyleneglycol 4000. Br J Surg. 1991(4);78:427-9.
18. Punnonen R, Viinamaki O. Polyethyleneglycol 4000 in the prevention of peritoneal adhesions. Fertil Steril. 1982;38(4):491-2.
19. Sakarya A, Ilkgul O, Aydede H, Erhan Y. Effect of polyethylene glycol 4000 on adhesion formation following thyroid surgery in rats. Indian J Med Res. 2002;115:255-9.
20. Merck madde kataloğu. 1997; sayfa:1002. M807490.1000.
21. EBSCO&MED medline (CD), 1982-1997.
22. Burns JW, Skinner K, Colt MJ. A hyaluronate based gel for prevention of postsurgical adhesions: evaluation in two animal species. Fertil Steril. 1996;66(5):814-21.
23. Woessner JB. The determination of hidroxyproline in tissue and protein samples cotaining small proportions of this aminoacid. Arch Biochem Biophysics. 1961;93(2):440-7.
24. Sunar H, Uysal H, Barut G. Kolon anastomozlarının iyileşmesinde yüksek ve düşük doz metilprednisolon etkisinin 'flowcytometric DNA content analizi' hidroksiprolin, patlama basıncı ve histopatolojik değerlendirilmesi. Klinik Den Cer Der. 1995;3:110-3.
25. Ehrlich HP. Collagen considerations in scarring and regenerative repair. In Scarless wound healing. 2016;115-130.1a ed. New York. CRC Press.
26. Cronin K, Jackson DS, Dundhy JE. Changing bursting strength and collagen content of the healing colon. Surg Gynecol Obstet. 1968;126(4):747-51.
27. Zhao L, Zhou Y, Song C, Wang Z, Cuschieri A. Predicting burst pressure of radiofrequency-induced colorectal anastomosis by bio-impedance measurement. Physiol Meas. 2017;38(3):489-500.
28. Hdngstrom H, Haglund U. Postoperative decrease in suture holding capacity in laparotomy wounds and anastomoses. Acta Chir Scand. 1985;151(6):533-5.
29. Hawley PR. Causes and prevention of colonic anastomotic breakdown. Dis Colon Rectum. 1973;16(4):272-7.