Correction of Dysbiosis in Diversion Proctitis: Possibilities of Intraluminal Sanitation and the Prevention of Complications after Reconstructive Surgery
https://doi.org/10.22416/1382-4376-2019-29-6-36-48
Abstract
Background. Repeated surgical interventions aimed at the colostomy closure and restoration of intestinal continuity after obstructive resections are traumatic and complex reconstructive operations on the colon. The complications of recovery operations largely feature wound abscesses (30–60 %) and anastomotic leakage (5–23 %), with the mortality levels from these complications reaching 0.4–2.8 %. Pronounced dysbiotic changes, the progression of catarrhal or erosive diversion colitis and proctosigmoiditis are the risk factors for anastomotic leakage and postoperative bowel dysfunction. This determines the need for a therapeutic algorithm of intestine sanitation and the introduction of methods for preventing the anastomotic leakage after obstructive resection of the distal colon (Hartmann’s operation).
Aim. To evaluate the capability and efficiency of the intraluminal application of rifaximin-α (Alfa Normix® preparation, Alphasigma company) as a sanitising intestinal antiseptic for relieving diversion colitis and prevening postoperative complications of restorative operations after obstructive resection of the colon (Hartmann’s operation).
Material and methods. A prospective comparative controlled study of the results of surgical treatment in 63 patients was conducted. The patients were divided into 2 groups, which were compared using the case-control principle. The operations included the colostomy closure and the restoration of intestinal continuity by applying a colonic anastomosis. In group I (main group, 30 patients), the original “Method of postoperative prevention of colonic anastomotic leakage” (Russian patent No. 2523822) was applied. In the control group (33 patients), routine methods for preventing anastomotic leakage and antibiotic prophylaxis were used. A comparative analysis of the number and severity of purulent-septic complications (taking into account the possibility of their relief), as well as the quality and rate of intestinal dysbiosis relief and the manifestations of diversion proctitis, was carried out.
Results. The main group indicated the best results in terms of the main analysed parameters, fewer complications and anastomotic leakage. Thus, the total number of complications in groups I and II was 16.7 % and 27.3 %, respectively. The proportion of complications associated with the anastomotic leakage, inflammatory changes in this area and impaired patency in groups I and II was 6.7 % and 12.1 %, respectively. Rifaximin-α (Alpha Normix®) intolerance and pathological reactions associated with its use were not observed. The possibility for effective relief of the violations of quantitative and qualitative composition of the microflora in the colon stump was revealed. The main group showed better results in terms of eliminating local manifestations of diversion colitis and anorectal dysfunction compared to group II, where traditional schemes of postoperative therapy were used.
Conclusions. Intraluminal dosed use of the Alpha Normix® suspension with the rifaximin concentration of 100 mg per 5 ml is an effective method of postoperative prevention of purulent-septic complications associated with anastomotic leakage during reconstructive operations on the distal colon. The introduction of Alpha Normix® in the scheme of postoperative treatment allows its results to be stabilised due to the sanitation of the intestinal lumen, the elimination of dysbiosis, the relief of inflammatory reaction and the elimination of factors supporting the development of diversion proctitis.
Aim. To evaluate the capability and efficiency of the intraluminal application of rifaximin-α (Alfa Normix® preparation, Alphasigma company) as a sanitising intestinal antiseptic for relieving diversion colitis and prevening postoperative complications of restorative operations after obstructive resection of the colon (Hartmann’s operation).
Material and methods. A prospective comparative controlled study of the results of surgical treatment in 63 patients was conducted. The patients were divided into 2 groups, which were compared using the case-control principle. The operations included the colostomy closure and the restoration of intestinal continuity by applying a colonic anastomosis. In group I (main group, 30 patients), the original “Method of postoperative prevention of colonic anastomotic leakage” (Russian patent No. 2523822) was applied. In the control group (33 patients), routine methods for preventing anastomotic leakage and antibiotic prophylaxis were used. A comparative analysis of the number and severity of purulent-septic complications (taking into account the possibility of their relief), as well as the quality and rate of intestinal dysbiosis relief and the manifestations of diversion proctitis, was carried out.
Results. The main group indicated the best results in terms of the main analysed parameters, fewer complications and anastomotic leakage. Thus, the total number of complications in groups I and II was 16.7 % and 27.3 %, respectively. The proportion of complications associated with the anastomotic leakage, inflammatory changes in this area and impaired patency in groups I and II was 6.7 % and 12.1 %, respectively. Rifaximin-α (Alpha Normix®) intolerance and pathological reactions associated with its use were not observed. The possibility for effective relief of the violations of quantitative and qualitative composition of the microflora in the colon stump was revealed. The main group showed better results in terms of eliminating local manifestations of diversion colitis and anorectal dysfunction compared to group II, where traditional schemes of postoperative therapy were used.
Conclusions. Intraluminal dosed use of the Alpha Normix® suspension with the rifaximin concentration of 100 mg per 5 ml is an effective method of postoperative prevention of purulent-septic complications associated with anastomotic leakage during reconstructive operations on the distal colon. The introduction of Alpha Normix® in the scheme of postoperative treatment allows its results to be stabilised due to the sanitation of the intestinal lumen, the elimination of dysbiosis, the relief of inflammatory reaction and the elimination of factors supporting the development of diversion proctitis.
Keywords
obstructive resection,
colonic anastomosis,
diversion colitis,
Alpha Normix®,
rifaximin-α,
intestinal
antiseptics,
postoperative therapy
Supporting agencies: The publication is supported by the Alphasigma company
About the Authors
V. S. Groshilin
Rostov State Medical University
Russian Federation
Russian Federation
Dr. Sci. (Med.), Prof., Departmental Head, No.2 Surgical Diseases Department
344022, 29 Nahichevansky per., Rostov-on-Don, Russian Federation
D. V. Martynov
Rostov State Medical University
Russian Federation
Cand. Sci. (Med.), Assoc. Prof., Department of Anaesthesiology and Reanimatology
344022, 29 Nahichevansky per., Rostov-on-Don, Russian Federation
Russian Federation
Cand. Sci. (Med.), Assoc. Prof., Department of Anaesthesiology and Reanimatology
344022, 29 Nahichevansky per., Rostov-on-Don, Russian Federation
Yu. L. Naboka
Rostov State Medical University
Russian Federation
Dr. Sci. (Med.), Prof., Departmental Head, No. 1 Department of Microbiology and Virology
344022, 29 Nahichevansky per., Rostov-on-Don, Russian Federation
Russian Federation
Dr. Sci. (Med.), Prof., Departmental Head, No. 1 Department of Microbiology and Virology
344022, 29 Nahichevansky per., Rostov-on-Don, Russian Federation
M. Yu. Bakulyarov
Rostov State Medical University
Russian Federation
Coloproctologist specialist
344022, 29 Nahichevansky per., Rostov-on-Don, Russian Federation
Russian Federation
Coloproctologist specialist
344022, 29 Nahichevansky per., Rostov-on-Don, Russian Federation
G. A. Mrykhin
Rostov State Medical University
Russian Federation
Cand. Sci. (Med.), Assist., No. 2 Surgical Diseases Department
344022, 29 Nahichevansky per., Rostov-on-Don, Russian Federation
Russian Federation
Cand. Sci. (Med.), Assist., No. 2 Surgical Diseases Department
344022, 29 Nahichevansky per., Rostov-on-Don, Russian Federation
References
1. Shelygin Yu.A. Blagodarnyi L.A. Coloproctology reference book. M.: Literra, 2012. 596 p. (In Rus.)
2. Shelygin Yu. A. Coloproctology. Clinical guidelines. Moscow: GEOTAR-Media, 2015;30–53:430–49 (In Rus.)
3. Kalivo E.A., Fridman M.Kh. Surgical treatment of paracolostomy hernias. Achievements and prospects of treatment and rehabilitation in coloproctology: abstracts of All-Russian scientific-practical conference with the international the participation. St. Petersburg, 2007;143–44. (In Rus.)
4. Brian J. Miller. Colonic injury: does colostomy still have a place? Injury — Int. J. Care Injured. 2001;32:433–4. DOI: 10.1016/s0020-1383(00)00238-2
5. Yaitskiy N.A., Chaniya Z.D., Sopiya R.A. et al. Rehabilitation of patients with a single-barrel colostomy. The first congress of coloproctologists of Russia. Relevant issues of coloproctology. 2003;381–82 (In Rus.)
6. Topuzov E.G., Plotnikov Yu.V., Abdulaev M.A. Complicated colon cancer: diagnosis, treatment, rehabilitation. St. Petersburg, 2006;154 (In Rus.)
7. Allahyarov T.Ch. Analysis of the incidence of colorectal cancer in the Saratov region. Bulletin of Medical Internet Conferences. 2013;3(3):804 (In Rus.)
8. Vorob’ev G.I. Issues of organising a rehabilitation service for ostomy patients. Coloproctology. 2005;2(12):46–52 (In Rus.)
9. Oomena V.A., Cuestab A.F. Engela J.L.T. Reversal of Hartmann’s Procedure after Surgery for Complications of Diverticular Disease of the Sigmoid Colon Is Safe and Possible in Most Patients. Digestive Surgery. 2005;22(6):419–25. DOI: 10.1159/000091444
10. Banerjee S. Feasibility and morbidity of reversal of Hartmann’s. Colorectal Disease. 2005;7 (5):454–9. DOI: 10.1111/j.1463-1318.2005.00862.x
11. Vorob’ev G. I. Colon surgery. 50 lectures on surgery. Moscow. 2003;183 (In Rus.)
12. O’Connor G. Discharge planning in rehabilitation following surgery for a stoma. Br. J. 33 Nurs. 2003;12(13):800–7. DOI: 10.12968/bjon.2003.12.13.11348
13. Anaya D. A., Flum D.R. Risk of emergency colectomy and colostomy in patients with diverticular disease. Arch. Surg. 2005;140:681–5. DOI: 10.1001/archsurg.140.7.681
14. Vasil’ev V.V. Surgical rehabilitation of patients with temporary colostomy: PhD Thesis of dissertation Cand. Sci. (Med.): 14.00.27/V.V. Vasil’ev. St. Petersburg, 2008;23 (In Rus.)
15. Khaikin M., Zmora O., Rosin D., Bar-Zakai B., Goldes Y., Shabtai M., Ayalon A., Munz Y. Laparoscopically assisted reversal of Hartmann’s procedure. Surg. Endosc. 2006;20(12):1883–6. DOI: 10.1007/s00464-005-0848-4
16. Haugen V., Bliss D.Z., Savik K. Perioperative factors that affect long-term adjustment to an incontinent ostomy. Journal of Wound, Ostomy and Continence Nursing. 2006;33(5):525–35.
17. Groshilin V.S. Modern aspects of the prevention of complications after obstructive resections of the distal colon. Fundamental research. 2013;9(1):24–7 (In Rus.)
18. Longatti T.S., Acedo S.C., de Oliveira C.C., Miranda D.D., Priolli D.G., Ribeiro M.L., Gambero A., Martinez C.A. Inflammatory alterations in excluded colon in rats — a comparison with chemically-included colitis. Scand Gastroenterol. 2010;45:315–24. DOI: 10.3109/00365520903471572
19. Hundorfean G., Chiriac M. T., Siebler J., Neurath M.F., Mudter J. Confocal laser endomicroscopy for the diagnosis of diversion colitis Endoscopy. 2012;44(2):358–9. DOI: 10.1055/с-0032-1310019
20. Akopyan A.S., Manukyan E.V., Bagdasaryan T.G., Abramyan A.F., Akopyan A.A. The quantitative characteristic of morphological and structural changes in the diverted regions of the large intestine. Ross z gastroenterol gepatol koloproktol. 2011;21(6):69–73 (In Rus.)
21. Gorburov G.F., Merezhko A.M., Babenko A.K. The optimal time for surgical rehabilitation of patients after obstructive surgery for complicated colorectal cancer. Abstracts of the conference dedicated to the memory of Professor V.I. Knysh. Moscow; 2011:33–4 (In Rus.)
22. Martinez C.A.R., Nonose R., Spadari A.P.P., Máximo F.R., Priolli D.G., Pereira J.A., Margarido N.F. Quantification by computerized morphometry of tissue levels of sulfomucins and sialomucins in diversion colitis in rats. Acta Cir Bras. 2010;25(3):231–40. DOI: 10.1590/S0102-86502010000300004
23. Darvin V.V. Il’kanich A.Ya. Time of recovery operations in ostomy patients: is it possible to reduce it? Abstracts of scientific conference with the international participation, dedicated to the 40th anniversary of SSC of Coloproctology. Moscow. 2005;205–7 (In Rus.)
24. Afendulov S.A., Vvedenskiy V.S., Mishin A.S. Algorithm for performing operations of colostomy closure. Bulletin of Experimental and Clinical Surgery. 2010;(3): 242–245. (In Rus.)
25. Dezortsev T. L. Reconstructive surgery on the colon during colostomy closure: PhD Thesis of dissertation Cand. Sci. (Med.): 14.00.27 / T.L. Dezortsev. Nizhny Novgorod. 2005;140 (In Rus.)
26. Ermolov A.S. Complications after Hartmann’s operation. Surgery. 2007;9:11–4 (In Rus.)
27. Nijhof H.W., Claassen A.T., Delemarre J.B. Colostomy as a cause of deveriation colitis in a blind — ended bowel segment.Ned Tijdshr Geneeskd. 2006;11(150):559–62.
28. Nielsen O.H., Vainer B., Rask-Madsen J. Non-IBD and noninfectious colitis. Nature Clinical Practice Gastroenterology & Hepatology. 2008;5:28–39. DOI: 10.1038/ncpgasthep1005
29. Ardatskaya M.D., Kitchieva G.M., Achkasov S.I. The role of microflora in the development of colitis in excluded sections of the colon. Kremlin medicine. Clinical Herald. 2011;(3):48–54 (In Rus.)
30. Potora A. Colitides. Eur Rev Med Pharmacol Sci. 2012;16(13):1795–805.
31. Tsironi E., Irving P.M., Feakins R.M., Rampton D.S. “Diversion” colitis caused by Clostridium difficile infection: report of a case. Dis Colon Rectum. 2006;49(7):1074–7. DOI: 10.1007/s10350-006-0577-3
32. Kitchieva G.M. Preparation of excluded sections of the colon for reconstructive surgery: Thesis of dissertation Cand. Sci. (Med.): 14.01.17 / G. M. Kitchieva. Moscow. 2011;24 (In Rus.)
33. Scarpignato C., Pelosini I. Experimental and clinical pharmacology of rifaximin, a gastrointestinal selective antibiotic. Bacterial flora in digestive disease. Focus on rifaximin. 2006;15–39. DOI: 10,1159/000089776
34. Steffen R., Sack D.A., Riopel L., Jiang Z.D., Stürchler M., Ericsson C.D., Lowe B., Waiyaki P., White M., DuPont H.L. Therapy of travelers diarrhea with rifaximin on various continents Am. J. Gastroenterol. 2003;98:1073–8. DOI: 10.1111/j.1572-0241.2003.07283.x
35. Groshilin V.S., Sultanmuradov M.I., Kharagezov A.D., Khoron’ko R.Yu. Method of postoperative prevention of colonic anastomotic leakage. Russian patent. No. 2523822. 2013. Bull. No. 14.
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For citations:
Groshilin V.S., Martynov D.V., Naboka Yu.L., Bakulyarov M.Yu., Mrykhin G.A. Correction of Dysbiosis in Diversion Proctitis: Possibilities of Intraluminal Sanitation and the Prevention of Complications after Reconstructive Surgery. Russian Journal of Gastroenterology, Hepatology, Coloproctology. 2019;29(6):36-48. (In Russ.) https://doi.org/10.22416/1382-4376-2019-29-6-36-48
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