Влияние морфина на толстый кишечник было впервые описаноPainter в 1963 г. [107]. Внутривенное или внутримышечное его введение приводило к сокращению отдельных сегментов толстого кишечника. Однако Wilson [108] не смог подтвердить воздействие парентерального введения опиоидов на моторику кишечника у оперированных больных. Вполне вероятно, что при эпидуральном введении опиоиды способны и подавлять моторику толстого кишечника, воздействуя на спинальные рефлексы [102].

Усиление двигательной активности толстого кишечника, наблюдающееся после эпидурального введения локальных анестетиков, вероятнее всего, опоредовано развивающейся при этом симпатической блокадой, при ко-

торой отключается эфферентное звено потенциальных спинальных - реф лексов [92]. Сам симпатический блок способствует увеличению пропульсивной эффективности перистальтики и повышает силу мышц кишечной стенки [82]. По имеющимся в настоящее время данным, только одно из исследований не подтвердило усиления моторики толстого кишечника при эпидуральном введении локальных анестетиков, несмотря на выраженный блок симпатических афферентов [109]. Авторы этого исследования предположили, что илеус, возможно, связан с иными механизмами, помимо активации спинальных симпатических рефлексов [109-111].

Влияние эпидурального введения комбинации локальных анестетиков и опиоидов на двигательную активность толстого кишечника было изучено всего лишь в одной работе[112]. Продолжительность послеоперационного илеуса при этом не сокращалась, что позволило авторам объяснять отсутствие моторной стимуляции от опиоидов проведением комбинированной аналгезии. Этот вопрос еще ожидает своего решения.

ЗАКЛЮЧЕНИЕ

Методика балансированной аналгезии обладает высоким потенциалом в отношении ускорения реконвалесценции больных и сокращения сроков их реабилитации после операций на брюшной полости. Однако значение этого метода еще недостаточно изучено. Необходимо уделить больше внимания патофизиологическим механизмам, лежащим в основе болей после абдоминальных операций и их последствий(например, нарушение функции кишеч-

ника), а также активизировать исследования в области балансированной аналгезии, что со временем позволит создать базисную концепцию по реабилитации и реконвалесценции больных после операций на брюшной полости.

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