Authors
Levchuk A.L.
Pirogov National Medical and Surgical Center, Moscow
Abstract
Rationale: gunshot peritonitis, which occurs immediately at the time of injury, differs significantly from peritonitis of other etiology in terms of the mechanism of its development. The accelerated dynamics of the course of various phases of peritoneal inflammation and the early manifestation of enteral insufficiency syndrome are the key points in the progression of diffuse peritonitis after a gunshot injury.
Objective: to study the literature data and conduct a comparative analysis of the currently used methods of treatment of enteral insufficiency syndrome, which improves the outcome of treatment of patients with gunshot wounds of the abdominal cavity.
Result: an analysis of articles, reviews, and studies in the modern scientific medical literature on the problem of the progressive course of gunshot peritonitis has been performed to identify the leading links in its pathogenesis and the severe course of the traumatic disease, the debut of which is the «phenomenon of mutual aggravation» against the background of massive primary alterations of organs and tissues, traumatic endotoxicosis, and maladaptation syndrome. Later, when a traumatic disease manifests, its «leading link in pathogenesis» changes with the appearance of enteral insufficiency syndrome, against the background of intestinal paresis, which inevitably leads to the translocation of bacteria and toxins into the abdominal cavity and systemic bloodstream. This becomes a fundamental source of endogenous intoxication, closing the «vicious circle» in the pathogenesis of abdominal sepsis. When providing surgical and intensive care for gunshot peritonitis, intraoperative nasointestinal drainage of the small intestine, followed by enterosorbtion and antibacterial therapy, becomes the basis for the treatment of enteral insufficiency. However, this technique has been criticized in the foreign literature, pointing out the danger of its use and the rejection of its use in common peritonitis.
Conclusion: having analyzed the available data published in recent years and during previous terrorist attacks and local armed conflicts, despite such serious discrepancies between native and foreign authors on the issue of nasointestinal intubation of the small intestine in peritonitis and enteral insufficiency syndrome, we believe that the complete and categorical rejection of this technique for gunshot wounds of the abdomen is premature and unacceptable.
Keywords: progressive gunshot peritonitis, enteral insufficiency syndrome, nasointestinal intubation.
References
1. Perechodov SN, Levchuk AL, Khanevich MD, Osipov IS, Zubritskiy VF. Features of wounds with modern firearms. Medical Bulletin of the Ministry of Internal Affairs. 2024; 5: 2-8. (In Russ.)
2. Kuritsin AN, Revskoy AK. Gunshot peritonitis. M.: Medicine, 2007. Р.33-89. (In Russ.)
3. Levchuk AL, Ignatiev TI, Vinogradov AV. Widespread peritonitis in penetrating gunshot wounds of the abdomen with damage to internal organs. Bulletin of the NMSC named after N.I. Pirogov. 2025; 20(1): 74-79. (In Russ.)
4. Alisov PG, Samokhvalov IM. Gunshot wounds to the abdomen. Features, diagnosis and treatment in modern conditions. St. Petersburg: Sintez Books, 2018. 320 p. (In Russ.)
5. Jeffery SL. The Management of Combat Wounds: The British Military Experience. Adv Wound Care (New Rochelle). 2016; 5(10): 464-473.
6. Belyi VYa, Rusin VI, Fomin PD, Zhovtonozhko AN. Essays on peritonitis surgery. M.: Karpaty, 2018. Р.40-72. (In Russ.)
7. Livingston DH, Lavery RF, Lopreiato MC, Lavery DF, Passannante MR. Unrelenting violence: an analysis of 6,322 gunshot wound patients at a Level I trauma center. J Trauma Acute Care Surg. 2014; 76(1): 2-9.
8. Nechaev EA, Kurygin AA, Khanevich MD. Drainage of the small intestine in peritonitis and intestinal obstruction. SPb, 1993. Р.98-100. (In Russ.)
9. Waibel BH, Rotondo MM. Damage control surgery: it’s evolution over the last 20 years. Rev Col Bras Cir. 2012; 39(4): 314-321.
10. Maistrenko NA, Sazonov AA. Gunshot peritonitis: features of the course and therapeutic tactics. Corp. health and industry medicine. 2024; 1(1): 20-30. (In Russ.)
11. Clements TW, Tolonen M, Kirkpatrick AW, et al. Secondary Peritonitis and Intra-Abdominal Sepsis: An Increasingly Global Disease in Search of Better Systemic Therapies. Scand. J. Surg. 2021; 110(2): 139-149.
12. Zubritskiy VF, Peredov SN, Levchuk AL, Gardashov NT, Zabelin MV. Military field surgery and the concept of traumatic illness in modern warfare and technology warfare. Medical Bulletin of the Ministry of Internal Affairs. 2025; 1: 58-64. (In Russ.)
13. Björck M, Kirkpatrick AW, Cheatham M, et al. Amended Classification of the Open Abdomen. Scandinavian Journal of Surgery. 2016; 105(1): 5-10.
14. Zubarev PN. Modern gunshot wound and the principle of its treatment. Propaedeutics of surgery. Moscow, 2007. Р.214-238. (In Russ.)
15. Military field surgery. Manual. E.K. Gumanenko, editor. SPb: Heotar-Media, 2022. 451p. (In Russ.)
16. Alvarez РS, Betancourta AS, Fernаndez LG. Negative pressure wound therapy with instillation in the septic open abdomen utilizing a modified negative pressure therapy System. Annals of Medicine and Surgery. 2018; 10: 54-62.
17. Demko AE, Shlyapnikov SA, Batyrshin IM, et al. The use of “damage control” tactics in the treatment of patients with advanced peritonitis and septic shock. Bulletin of Surgery named after I.I. Grekov. 2021; 180(6): 74-79. (In Russ.)
18. Carlson GL, Patrick H, Amin AI, et al. Management of the open abdomen: a national study of clinical outcome and safety of negative pressure wound therapy. Ann. Surg. 2013; 257(6): 1154-1159.
19. Zharikov AN, Lubyansky VG, Aliev AR. Assessment and surgical correction of intra-abdominal hypertension in patients with postoperative peritonitis // Clinical and Experimental surgery. 2022; 10(1): 98-107. (In Russ.)
20. Linev KA, Torba AV. Tactics of surgical treatment of gunshot wounds of the abdomen. Clinical medicine. 2016; 24(1): 93-98. (In Russ.)
21. Ermetov AT, Iskhakov BR, Saidmetov SM, Iskhakov NB. Gunshot wound to the abdomen with multiple injuries to hollow organs. Bulletin of Emergency Medicine. 2017; 1: 58-61. (In Russ.)
22. Yeryukhin IA, Alisov PG. Gunshot and explosive abdominal injuries. Issues of mechanogenesis, diagnostic and therapeutic tactics based on the experience of providing surgical care to the wounded during the war in Afghanistan. Bulletin of Surgery named after Grekov. 1998; 5: 53-61. (In Russ.)
23. Lubyansky VG, Zharikov AN. Correction of enteral insufficiency syndrome in patients with postoperative advanced peritonitis // Bulletin of the National Medical and Surgical Center named after N. I. Pirogov. 2010; 5(3): 106-110. (In Russ.)
24. Gonchar-Zaikin AP. Pathogenetic substantiation of surgical treatment of endotoxicosis in progressive gunshot peritonitis. [Abstract of the dissertation] Orenburg, 2005. (In Russ.)
25. Korymasov EA, Ivanov SA, Kenarskaya MV. Algorithm of the diagnosis and treatment of enteral insufficiency syndrome in peritonitis. Grekov’s Bulletin of Surgery. 2021; 180(2): 28-36. (In Russ.)
26. Sinenchenko GI, Tulupov AN, Peregudov SI. Intestinal decompression in peritonitis: pros and cons of M. Peritonitis from A to Z. 2016. Р.411-413. (In Russ.)
27. Catena F, Di Saverio S, Kelly MD, et al. Bologna Guidelines for Diagnosis and Management of Adhesive Small Bowel Obstruction (ASBO): 2010 Evidence-Based Guidelines of the World Society of Emergency Surgery. World J Emerg Surg. 2011; 6: 5-11.
28. Gelfand BR, Protsenko DN, Podachin PV, et al. Intraabdominal hypertension syndrome: the state of the problem. Emergency medicine. 2010; 3: 36-43. (In Russ.)
29. Fazel MZ, Jamieson RW, Watson CJ. Long-term follow-up of the use of the Jones’ intestinal tube in adhesive small bowel obstruction. Annals of the Royal College of Surgeons of England. 91(1): 50-54.
30. Meissner K. Effectiveness of intestinal tube splinting: a prospective observational study. Dig Surg. 2000; 17(1): 49-56.
31Saidmuradov AS. Enteral insufficiency and its correction in peritonitis. [Abstract of the dissertation] Dushanbe, 2009. (In Russ.)
32. Ge D. The Safety of Negative-Pressure Wound Therapy on Surgical Wounds: An Updated Meta-analysis of 17 Randomized Controlled Trials. Adv Skin Wound Care. 2018; 31(9): 421-428.
33. Sakakibara T, Harada A, Yaguchi T, et al. The indicator for surgery in adhesive small bowel obstruction patient managed with long tube. Hepatogastroenterology. 2007; 54(75): 787-790.
34. Cherdantsev DV, Pervova OV, Trofimovich YuG, et al. Possibilities of improving the effectiveness of perioperative abdominal rehabilitation in peritonitis. Siberian Medical Review. 2018; 1: 20-26. (In Russ.)
35. Aysan E, Demir M, Kinaci E, Basak F. Complications of intestinal milking: experimental model. ANZ J Surg. 2005; 75(5): 322-325.
36. Vlasov AP, Malanichev MYu, Pogosyan DA, Bolushev PA, et al. Possibilities of predicting enteral insufficiency in peritonitis. Moscow Medical Journal. 2018; 3: 6-10. (In Russ.)
37. Laberko LA, Kuznetsov NA, Aronov LS, at al. Correction of manifestations of enteral insufficiency syndrome in advanced peritonitis. Surgery. 2004; 9: 25-28. (In Russ.)
38. Talamin LA. Diagnosis and treatment of intestinal insufficiency syndrome in advanced peritonitis. [Abstract of the dissertation] Kazan, 2007. (In Russ.)
39. Kostyuchenko KV, Rybachkov VV, Kolobanov AA, Khrabrov DN. Strategic aspects of surgical treatment of common peritonitis. Biochemistry and medicine. 2005: 38-43. (In Russ.)
40. Khrupkin VI, Alekseev SA. Enteral insufficiency syndrome in patients with advanced peritonitis: assessment of the severity and outcome of the process. Bulletin of Surgery named after I.I.Grekov. 2004; 163(2): 46-49. (In Russ.)
41. Gorsky VA, Volenko AV, Krivikhin DV, Cherevatenko AM, Armashov VP. Technical features of nasointestinal decompression in peritonitis. Practical medicine. 2017; 107(6): 27-31. (In Russ.)
42. Zemlyanoi VP, Sigua BV, Vovk AV, Kurkov AA, Ignatenko VA. Abbott-Miller probe. Should I bet or not? Bulletin of Surgery named after I.I. Grekov. 2017; 176(4): 100-103. (In Russ.)
43. Vlasov AP, Timoshkin SP, Abramova SV, et al. Indicators of endogenous intoxication – criteria of enteral insufficiency in acute peritonitis. Foundation. researches. 2014; 10(6): 1066-1070. (In Russ.)
44. Papavramidis TS, Marinis AD, Pliakos I, Kesisoglou I, Papavramidou N. Abdominal compartment syndrome – Intra-abdominal hypertension: Defining, diagnosing, and managing. J Emerg Trauma Shock. 2011; 4(2): 279-291.
45. Savelyev VS, Gelfand BR, Filimonov MI. Peritonitis. M.: Litterra, 2006. 205 p. (In Russ.)
46. Vinokurov MM, Gogolev NM, Savelyev VV. Gunshot wounds to the abdomen. Bulletin of the VNC RAS. 2005; 3: 175-178. (In Russ.)
47. Maslyakov VV, Dadaev AYa, Kulikov SA, Allakhyarov ChA, Shikhmagomedov MA. Improving the results of treatment of gunshot wounds to the abdomen of civilians sustained in local paramilitary conflicts. Bulletin of the Medical Institute “REAVIZ”. 2020; 2: 51-56. (In Russ.)
48. Ayushinova NI, Sviridyuk NV, Grigoriev EG. Stage-by-stage treatment of gunshot polytrauma. Polytrauma. 2023; 4: 40-44. (In Russ.)
49. Kotiv BN, Samokhvalov IM, Chuprina AP, et al. Guidelines for Military field surgery. M., 2020. 488 p. (In Russ.)
50. Trishkin DV. One thousand days of a special military operation. Selected issues of medical care. M.: GVMU, 2024. 321 p. (In Russ.)
51. Midlenko VI, Belonogov NI, Midlenko OV, Charyshkin AL. Comparative assessment of intestinal decompression methods during operations for common peritonitis in the toxic phase. Ulyanovsk Medical and Biological Journal. 2019; 3: 74-80. (In Russ.)
52. Sazhin AV, Ivakhov GB, Teplykh AV, Kalinina AA. Vacuum -assisted laparotomy in the complex treatment of common peritonitis. Moscow Surgical Journal. 2020; 4: 65-74. (In Russ.)
53. Sazonov AA, Romashchenko PN, Makarov IA, Aliev RK, Maistrenko NA. Differential approach to vacuum-assisted laparostomy for gunshot wounds of the abdomen. Bulletin of Surgery named after I.I.Grekov. 2023; 186(6): 11-18. (In Russ.)
54. Khadjibaev AM, Madiev RZ, Khemshilov AS. A differentiated approach to the use of nasoenteral intubation in acute intestinal obstruction and peritonitis. Bulletin of Emergency Medicine. 2015; 2: 54-59. (In Russ.)
55. Mazurok VA, Golovkin AS, Gorelov II. Intestinal oxygen therapy in critical conditions. General intensive care. 2017; 6: 74-91. (In Russ.)
56. Mendel NA, Volostnikov EV, Plotnikov YuV, Sheiko VD, Schmidt Ya. Is intestinal intubation effective in acute intestinal obstruction? Old dogmas and the evolution of views. Bulletin of Surgery named after I.I.Grekov. 2013; 4: 100-104. (In Russ.)
57. Bely VYa, Zarutsky YaL, Zhovtonozhko AI, Aslanyan SA. Essays on surgery of combat abdominal injury. MP-Lesya, 2016. 212 p. (In Russ.)
