Melnyk: Comprehensive Treatment of Patients with Constricted Hernias and Metabolic Syndrome Signs



Problem statement and analysis of the recent research

90000 herniotomies are performed in Ukraine every year. They include 13000 surgeries on constricted hernias of abdominal wall. Obesity is detected in almost 30% of people of working-age, overweight is characteristic of every forth citizen. Therefore, the quantity of surgeries in the specified category of patients predictably increases [1, 2].

Hernia with concomitant obesity leads to increase in the relapses to 64% according to various authors. Technical performance of surgeries also causes difficulties [3].

Obesity often is the trigger factor for the development of metabolic syndrome, leading to arterial hypertension and causing peripheral nerves desensitisation to insulin with further increase in overweight [4]. Literature data provide reports about the use of polypropylene mesh in cases of constricted hernia in patients with obesity [5]. However, the results of treatment of patients with metabolic syndrome and performed alloplasty in cases of constricted hernia of the anterior abdominal wall have not been studied yet.

The objective of the research was to study the efficiency of medicamentous correction of lipid, carbohydrate metabolism in order to improve the results of alloplasty of constricted hernia of the anterior abdominal wall in patients with metabolic syndrome.

Materials and methods

The results of complex surgical treatment of 57 patients with abdominal constricted hernia were analyzed. The patients were performed the urgent hernia defect plastics with polypropylene mesh Linteks-Esfil and diagnosed with metabolic syndrome. There were 18 men and 39women. The age of patients ranged from 36 to 89 years. Strangulated incisional hernia was observed in 25 patients, umbilical hernia was detected in 14 cases, inguinal hernia was noted in 15 patients, femoral hernia was found in 3 cases. 38 patients (66.7%) were admitted to the hospital up to 12 hours from the time of the disease, 12 patients (21%) were admitted up to 24 hours, 7 patients (12.3%) were admitted up to a day or more. Patients underwent routine examination before the surgery and ultrasound of hernia defect and content with surface sensor. Body mass index (BMI) or Quetelet index was measured for the diagnosis of metabolic syndrome signs. It is calculated as the ratio of body weight to height and waist circumference:

BMI = Body weight (kg) / Height (m) 2

Lipid metabolism disorder was detected by laboratory determination of total cholesterol (TC) level, low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL cholesterol) and triglycerides (TG). Blood glucose indices in patients undergoing surgery and signs of hypertension were analyzed. “Recommendations of the National Institute of Health of the USA” (2001) and the “Ukrainian Association of Cardiology” (2004) were considered as the criteria of the metabolic syndrome: a) Overweight or obesity: waist measurement > 102 cm in men and > 88 cm in women; b) Arterial hypertension: blood pressure ≥130 / 85 mm of mercury; c) dyslipidemia, TG level ≥ 1.7 mmol / L; HDL cholesterol level <1.04 mmol / L for men and 1.29 mmol / L for women.

The patients were divided into two clinical groups. Patients of clinical group I (20) were treated with comprehensive conventional conservative treatment after surgery. Patients of clinical group II (37) were treated with 2.5% solution of 2 ml tiotriazolini in muscle and metformin in a dose of 500 mg / day for the correction of metabolic syndrome.

Results of the research and their discussion

Alloplasty of hernia defect was performed to all patients after the elimination of constricted hernia. Exudate in hernial sac, inflammation manifesting in edema, infiltration of hernial sac walls were detected in 54.3% of patients during surgery.

Implantation of polypropylene mesh was conducted after the sanitation of serofibrinous peritonitis in 3.5% of cases. Content of hernial sac involved greater omentum strand in 61.4% of patients, small intestinal loop in 33.4% of patients, colon loop in 5.2% of cases. Plastics of inguinal and femoral hernia in patients were performed according to Lichtenstein method. Plastics of umbilical, inguinal and epigastric hernia were performed according to “onlay” technique in 8.7% of cases, “sublay” technique in 87.8% of patients, “inlay” technique in 3.5 % of cases. Wounds were actively drained with vacuum system of “Redon” type. Average body weight of patients ranged from 87 to 138 kg. BMI constituted 33.63 ± 3.55 kg / m2 for women and 35.47 ± 4.25 kg / m2 for men. Laboratory disorders of blood lipids were detected in 97.5% of patients. In particular, abdominal obesity signs were observed during surgery in 18 (31.5%) patients in both clinical groups. This created difficulties in abdomen closure. Taking into account abdominal obesity, “inlay” method for alloplasty of hernia defect was chosen to prevent compartment syndrome in the postoperative period.

Diabetes mellitus was diagnosed in 9 (15.7%) patients of group II. Thus, complex of conservative treatment included medication to correct hypertension, blood sugar and lipid metabolism indices. Special diet, early activity of patients was prescribed to improve these deviations. Indices of cholesterol, LDL-C, HDL cholesterol decreased in 16 patients (59.2%) of clinical group II and only by 15% in clinical group I. The average duration of wound drainage was 5.8 days. Drainage used for 8 days in 7 patients due to intensive serous discharge from the wound. Wound complications such as seromas, infiltrates developed in 6.3% of patients eliminated by means of conservative method of treatment. Patients of clinical group II tolerated postoperative period better, rehabilitated faster. Average duration of hospital stay of clinical group II patients was 8.6 days. Our results are consistent with previous studies, where the polypropylene mesh was proved to be the most resistant to infection and could be applied in emergency surgery of abdominal hernia [6] and medicamentous correction of metabolic syndrome signs improves postoperative period.

The influence of lipid, carbohydrate metabolism disorders, including abdominal obesity on the improvement of alloplasty of constricted hernia requires further study.

Conclusions

  1. 1. The use of polypropylene mesh in case of constricted hernia in terms of infection shows high effectiveness of the method and it is advisable to be used in emergency surgery of hernia.

  2. 1. Treatment of such patients should be in complex with the mandatory diagnostics of metabolic syndrome and medicamentous correction.

References

1 

VV Zhebrovskiy, ER Dzhemileeva, NM Torotadze, PA Rezanov. Uschemlennyie posleoperatsionnyie gryizhi. In: Suchasni sposoby khirurhichnoho likuvannya hryzh zhyvota. Materialy III Vseukr.nauk.-prakt. konf. z mizhnar. uchastyu.; 2006 kvit. 14-15; Kyiv. Kyiv; 2006. p. 35-36. Available from: http://www.surgukraine.com.ua

2 

AS Lavryk, OS Tyvonchuk, OA Lavryk. Khirurhichne likuvannia ozhyrinnia. Zdorovia Ukrayiny. 2013;1):10-11.

3 

YuI Yashkov, MS Sineokaya. Khirurgicheskoe lechenie ozhireniya i metabolicheskikh narusheniy. In: Materialyi Pyatogo ros. simp. s mezhdunar. uch. [internet]; 2009 iyun 25-27; Samara. Samara: Samarskiy goss.med. un-t; 2009. p. 90. Available from: http://lib2.znate.ru/docs/index-351681.html

4 

AM Diehl. Nonalcoholic steatosis and steatohepatitis IV Nonalcoholic fatty liver disease abnormalities in macrophage function and cytokines. Am J Physiol Gastrointest Liver Physiol. 2002;282(1):1-5. doi:10.1152/ajpgi.00384.2001

5 

OV Storozhenko, OV Lihonenko, AB Zubakha, II Dihtyar, AV Yaroshenko. Nash dosvid likuvannia pisliaoperatsiynykh ventralnykh hryzh cherevnoii stinky u khvorykh na ozhyrinnia. Khirurhiia Ukrayiny. 2011;3(39):103-4.

6 

MI Tutchenko, VM Lysenko, VP Babiy, SM Byshovets. Vykorystannia polipropilenovoii sitky yak metodu vyboru hernioplastyky pry velykykh zashchemlenykh hryzhakh perednioii cherevnoii stinky. In: Suchasni sposoby khirurhichnoho likuvannya hryzh zhyvota. Materialy III Vseukr.nauk.-prakt. konf. z mizhnar. uchastyu.; 2006 kvit. 14-15; Kyiv. Kyiv; 2006. p. 118-119. Available from: http://www.surgukraine.com.ua



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