1. Introduction

Treatment of disseminated peritonitis is one of the most complex and intractable problems of emergency abdominal surgery. Disseminated purulent peritonitis (DPP) is a severe variant of complicated intra-abdominal infection and is a life-threatening complication of most acute surgical diseases of abdominal cavity [1,2,3]. Despite all the achievements of clinical medicine, this pathology is accompanied by inexorably high figures of postoperative complications and mortality without a tendency to decrease over the last few decades. Postoperative mortality in widespread peritonitis is 15.1-18%, and when septic shock develops, the mortality reaches 70-80% [4,5,6,7]. In the light of the above, the need to improve the known and develop new effective measures of prevention and treatment of this formidable disease becomes obvious.

Analysis of modern literature shows that there are several directions in the treatment of DPP: traditional surgical interventions, videolaparoscopic interventions. “However, the most accessible direction in everyday practice remains open surgical interventions for widespread purulent peritonitis” [8,9,10,11].

The analysis of the literature shows that at the present time the therapeutic and diagnostic tactics in DPP P is one of the urgent and unresolved problems of modern healthcare [12,13,14]. In this regard, there is a necessity to revise the sanation interventions in DPP depending on the informativeness of non-invasive methods of medical imaging, which allow preoperatively to assess the character of exudate and to detect signs of disease aggression, in this connection, the optimization of diagnostic algorithm to choose the most complete tactics of surgical treatment in each specific case becomes especially urgent.

Despite a lot of ongoing studies and seemingly solved problems, the development of modern methods of treatment of widespread peritonitis and, first of all, the use of laparoscopic surgery, has led to a lot of new unexplored issues, the need to solve which confirms the relevance of the present research topic.

2. The Purpose of Study

To improve the results of surgical treatment of disseminated purulent peritonitis on the basis of a differentiated approach to the choice of treatment depending on the degree of abdominal sepsis.

3. Materials and Methods

The study is based on the results of treatment of 276 patients with widespread purulent peritonitis admitted to the surgical department of the Samarkand branch of RCEMP in the period from 2015 to 2024. Patients were conditionally divided into two groups: In 2015-2019, 132 (47.8%) patients who constituted the comparison group were operated on, they underwent traditional methods of treatment, elimination of the source, sanation of the abdominal cavity with antiseptics and drainage of the abdominal cavity by both open and laparoscopic methods. From 2020 to 2024, 144 (52.2%) patients were under our observation and were included in the main group. Depending on the severity of peritonitis stage, the patients of the main group were conditionally divided into two subgroups. The 1st subgroup consisted of 78 (54,2% out of 144) patients, they used ozonized sodium hypochlorite solution as an antiseptic for the purpose of abdominal cavity lavage. Subgroup 2 consisted of 66 (45.8% out of 144) patients, in this subgroup patients with severe form of abdominal sepsis, who required intravenous injection of ozonated sodium hypochlorite solution in addition to abdominal cavity lavage with ozonated sodium hypochlorite solution.

Disseminated purulent peritonitis was of different genesis. The most frequent cause of peritonitis in both groups of patients was destructive forms of acute appendicitis (38.8%) and perforated gastric and duodenal ulcer (22.1%). Preoperatively, the severity of the patients' condition was determined according to the APACHE II scale, SOFA and the severity of abdominal sepsis. The indicators of preoperative examination of patients are presented in Tables 1. Both groups were comparable in terms of the severity of the condition and severity of peritonitis.

Table 1. Indicators of preoperative examination of patients with widespread purulent peritonitis according to APACHE II and SOFA scales

For detailed characterization of quantitative indicators, the patients in the studied groups were categorized by manifestations of abdominal sepsis according to the degree of systemic inflammatory response syndrome (SIRS):

SIRS- 0 no sepsis;

SIRS- Abdominal sepsis without organ dysfunction;

SIRS-1 - Abdominal sepsis with monorgan dysfunction;

SIRS-2 - Abdominal sepsis with multiorgan dysfunction.

Abdominal sepsis was absent in only 33 (11.9%) patients. Abdominal sepsis without organ dysfunction was found in 127 (46.0%), with monorgan dysfunction - in 74 (26.8%), with multiorgan dysfunction - in 42 (15.2%) patients (Table 2).

Table 2. Distribution of patients with disseminated purulent peritonitis by severity of abdominal sepsis

Sodium hypochlorite solution was obtained on an electrochemical unit EDO-4) by oxidation of isotonic sodium chloride solution. In order to enhance the effect of the solution and improve microcirculation in the peri-dental tissues, we ozonized the solution. An ozone-oxygen gas mixture was passed through a vial with sodium hypochlorite solution by the barbotage method using a clinical ozonator “UOTA-60-01-Medozon” for 10 min, then the vial was placed in a household refrigerator (6-8°C).

All patients underwent radial methods of investigation, such as ultrasound and CT. In case of doubt in the diagnosis, 160 patients underwent diagnostic videolaparoscopy. In 140 (87,5%) observations laparoscopy allowed to establish the diagnosis of general diffuse peritonitis and to put indications for conversion and only in 20 (12,5%) cases diagnostic laparoscopy was transformed into therapeutic benefit.

We reviewed the main aspects of surgical treatment of disseminated peritonitis, from preoperative preparation to postoperative management and evaluation of treatment results.

Standard methods of preoperative preparation were applied to the patients in the comparison group. Infusion therapy was performed for hemodynamic stabilization. Crystalloid and colloid solutions were administered to restore circulating blood volume (CBV), prevent and correct hypotension. If necessary, vasopressors were used to maintain blood pressure and organ perfusion. Blood pressure, heart rate, central venous pressure and diuresis were continuously monitored.

Preoperative preparation of patients with widespread peritonitis in the main group was differentiated, i.e. the degree of systemic inflammatory response (SIRS) was taken into account, as the severity of the patient's condition and necessary measures for its stabilization depended on it. The degree of SIRS requires an individualized approach to stabilize the patient's condition and prepare him for surgery. The inclusion of infusion of ozonated sodium hypochlorite solution for patients with abdominal sepsis with mono-organ and multi-organ dysfunction adds an additional dimension to standard management. The main aspects of preoperative preparation for each patient category are summarized below.

Choice of access method, which was determined by the patient's condition and the prevalence of peritonitis. In both the main and comparison groups, laparotomic and laparoscopic accesses were performed in patients with widespread peritonitis depending on the patients' condition. Whenever possible, diagnostic laparoscopy was not missed (Fig. 1) and then it was decided to continue the operation or to proceed to conversion.

Figure 1. Diagnostic laparoscopy in spilt purulent peritonitis

Further elimination of the source of peritonitis was performed, i.e. resection of necrotized tissues, removal of the perforated organ, drainage of abscesses and other purulent foci, nasointestinal intubation of the small intestine. As a rule, identification of the source of peritonitis in these diseases, as well as in intestinal obstruction due to a pinched hernia, twisting or nodular formation does not present significant difficulties. However, revision of abdominal cavity organs in peritonitis on the background of intestinal obstruction has its specific features. After laparotomy, swollen paretic loops of intestine lie in the wound and sometimes fall out of it.

The third stage was sanation of the abdominal cavity. Patients in the comparison group (2015-2019) were washed with conventional antiseptics, such as decasan, 0.02% furacilin solution, etc. Patients in the main group (2020-2024) had their abdominal cavity sanitized with ozonized sodium hypochlorite solution (0.03%). In this group, a pulsating jet of ozonized sodium hypochlorite solution (0.03%) was used for peritoneal lavage. To create a pulsating jet of liquid, an insufflator of the “Letel doctor” company was used. The aquapurator and the insufflator were connected by an inelastic catheter, the liquid was 0.03% ozonized sodium hypochlorite solution. Using the insufflator of “Letel doctor” company maximum 500 ml of antiseptic was effective for complete sanation of the abdominal cavity, also the time of the washing stage was reduced. The proposed method of abdominal cavity sanation by pulsating jet of 0.03% ozonized sodium hypochlorite solution using “Letel doctor” insufflator allowed to reduce the duration of the operation from 86.5±4.9 to 62.4±2.9 minutes (t-criterion =4.23; p<0.001) (Fig. 2).

Figure 2. Comparative indices of operation duration (min) depending on the access undertaken

The patients in both groups underwent programmed laparotomy or video-endoscopic sanation as indicated. 0.03% ozonized sodium hypochlorite solution and conventional antiseptics Decasan, 0.02% furacilin solution were used as antiseptics in the patients of the main and comparison groups, respectively. The patients in the main group underwent programmed video-endoscopic sanation using the Letel doctor insufflator.

4. Results of the Study

In case of disseminated purulent peritonitis, 5 (3.5%) patients with abdominal sepsis underwent repeated interventions on demand in the main group. In the comparison group, 16 (12.1%) patients with abdominal sepsis underwent repeated interventions on demand (Table 3).

Table 3. Surgical interventions performed on patients in the study groups

The use of the Letel doctor insufflator for flushing the abdominal cavity through drainage tubes with ozonized sodium hypochlorite solution reduced the number of programmed sanation interventions from 18.9% to 6.9% (Fig. 3).

Figure 3. Number of programmed sanitary surgical interventions

The frequency of postoperative complications and mortality in patients with widespread purulent peritonitis is presented in Table 4. We observed such complications as wound suppuration in 16.7% of cases, pneumonia was observed in 8.7% of cases, abdominal cavity abscess was observed in 0.7% of cases, eventure - 0.7%, pleural empyema - 0.7%, pleurisy - 1.1% and thrombophlebitis in 1.15 cases.

Table 4. Frequency of symptoms of intestinal motor evacuation dysfunction

In the comparison group 41 (31.1%) patients developed 45 complications, and in the main group 32 (22.2%) patients registered 37 complications. Consequently, the number of complications in the main group was reduced by 8.9%. Postoperative mortality in the main group was 4.2% lower than in the comparison group.

In general, complex application of ozonized sodium hypochlorite solution in the postoperative period contributes to faster recovery of patients, reduction of complications and improvement of overall clinical results.

5. Funding

A study of the results of combination therapy using ozonated 0.03% sodium hypochlorite solution for abdominal cavity sanitation and intravenous management in patients with abdominal sepsis showed encouraging results. There was a marked reduction in the rate of postoperative purulent inflammatory complications from 32.4% to 16.7% in SIRS - 0 and SIRS abdominal sepsis (p<0.05), and from 51.5% to 41.4% and from 70.6% to 36.0% in SIRS - 1 and SIRS - 2 abdominal sepsis (p<0.05), respectively. In addition, there was a reduction in the mean duration of hospitalization from 12.9 days to 10.1 days for abdominal sepsis SIRS - 0 and SIRS (p<0.05) and from 21.1 days to 16.6 days for abdominal sepsis SIRS - 1 and SIRS - 2 (p<0.05). Lethality decreased from 15.1% to 4.9% and from 41.2% to 20.0% in abdominal sepsis SIRS - 1 and SIRS - 2 (p<0.05), respectively.

Information about the source of support in the form of grants, equipment, and drugs. The authors did not receive financial support from manufacturers of medicines and medical equipment.

Conflicts of interest. The authors have no conflicts of interest.