RU2303263C1 - Method for selecting treatment method and surgical access in suppurative inflammatory uterine appendages diseases - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves determining alpha-2-macroglobulin MG and lactoferrine LF in blood serum. Coefficient K value is calculated from formula K=MG/LF. The value being greater than 1.2, no purulent necrotic destruction is considered to be available in uterine appendages and without neighboring organs being dragged into inflammatory process and surgical treatment method with laparoscopic access is to be selected. The value being less than 0.5, generalized purulent destructive is diagnosed and surgical treatment method with laparotomy access is to be selected.

EFFECT: improved diagnosis and treatment method.

Description

The invention relates to medicine, namely to gynecology.

Purulent forms of inflammatory diseases of the uterine appendages account for up to 10% of all inflammatory lesions of the internal genital organs, and the peak incidence, as a rule, falls on the reproductive age (Strizhakov AN, Podzolkova NM "Purulent inflammatory diseases of the uterine appendages", Moscow , "Medicine", 1996 - p.10). Recovery of patients with purulent tubo-ovarian formations can occur only after surgical treatment. The choice of the method of surgical treatment, access, volume of operation depends on a number of factors: the severity of the patient’s condition, the presence of complications and the involvement of neighboring organs in the inflammatory process, and in each case is determined individually. The most effective and modern method of surgical treatment for some complicated purulent processes of the uterine appendages (pyosalpinx, pyovar, tubo-ovarian formations) is laparoscopy. Due to the low morbidity, endoscopic access is optimal in young, especially nulliparous women. At the same time, with pustules abscesses involving the pelvic peritoneum, the walls of the underlying loops of the intestine, omentum, and parametric fiber, laparoscopy is contraindicated (Krasnopolsky V.I., Buyanova S.N., Schukina N. A. "Purulent inflammatory diseases uterine appendages ", Moscow, MEDpress, 1999 - S.165, 76, 149). Attempts to perform endoscopic intervention in the conditions of a purulent-infiltrative process involving neighboring organs can lead to serious complications and may lead to urgent laparotomy. The polymorphism of clinical symptoms significantly complicates the diagnosis and selection of the optimal treatment program. Diagnostic errors ultimately lead to tactical errors. The inadequacy of the volume and access of surgical intervention, on the one hand, leads to the appearance of interoperative complications, chronicity of the disease, an increase in the length of hospital stay, and, on the other hand, an unreasonably radical amount of surgical intervention in young women leads to the loss of menstrual and reproductive functions.

Thus, today there are no ways to objectively choose the optimal method for the treatment of purulent inflammatory diseases of the uterine appendages, to assess the need, to determine the volume and access of surgical intervention.

Among all non-invasive research methods, the most informative and diagnostically significant in patients with purulent diseases of the genital organs is computed tomography (CT) (V.I. Krasnopolsky et al. "Purulent inflammatory diseases of the uterine appendages", Moscow, MEDpress, 1999 - C .72).

With standard CT, the transverse and longitudinal dimensions of the pathological formation, the upper and lower border, the position relative to the anterior abdominal wall, posterior vaginal fornix are determined, and its density is measured using the absorption coefficient in Hounsfield units. Resolution increases with the use of intravenous contrast techniques (contrast medium is injected into the cubital vein). The different ability to accumulate contrast medium in healthy and pathological tissues makes it possible to differentiate ovarian abscess and pyovar, functional cysts and benign tumors. On the tomograms, tubo-ovarian formations are defined as round or ovoid formations with fuzzy contours, various capsule thicknesses, heterogeneous structure and density from 16 to 40 Hounsfield units. Cavities with reduced density correspond to purulent contents, can communicate with each other, involvement of neighboring organs, perifocal inflammation of the fiber is noted.

The method is expensive and inaccessible, for a good study, careful preparation of the intestine (cleansing enemas) is necessary, which can provoke the development of peritonitis, thereby aggravating the patient's condition.

A known method for predicting surgical treatment for inflammatory processes of the female pelvic organs (Kuznetsova V.A., Bogatova I.K., Aminodova I.P. Method for predicting the surgical treatment of inflammatory diseases of the female pelvic organs that occur against the background of intrauterine contraception. RU application for an invention 2000115563 / 14 m. C. (51) 7 G01N 33/50, BIPM No. 18, 06/27/2002 P.92). The essence of the method is to study the indicators of leukocytes in capillary blood and the content of malondialdehyde (MDA) in venous blood and with an increase in the number of leukocytes over 10.2 g / l and MDA values of more than 5.3 nmol / ml, surgical treatment is predicted.

The method is time-consuming, the study is associated with an explosion hazard, because the use in clinical practice is limited.

Closest to the claimed is a method for determining the depth and degree of tissue destruction with purulent lesions of the internal genital organs (Krasnopolsky V.I., Poletaev A. B., Efimenko N. A., Budykina T. S., Buyanova S. N., Schukina N.A. RU patent No. 2206895 m. C. (51) 7 G01N 33/53, BIPM No. 17, 06/20/2003, p. 789. A method for determining the depth and degree of tissue destruction in purulent lesions of the internal genital organs). When implementing this method in the blood serum, the level of autoantibodies to the proteins OBM, S-100, ASBR 14/18, MP-65 is additionally measured at a value of 0-40 conventional units determine the state of a localized purulent process, with a value of more than 40 conventional units determine the condition of the chronic purulent process, and with less than 1 conditional unit determine a purulent-destructive process with depression of the immune system and the risk of sepsis.

The above indicators are subject to significant individual fluctuations and are not specific markers of inflammation. In particular, autoantibodies to MBP and S-100 are markers of damage, primarily of nerve tissue and not only inflammatory genesis.

Moreover, the relatively low level of autoantibodies can be caused not only by the localization of the process, but also by the weak immune response of the body against the background of a severe lesion, as well as high levels of autoantibodies can indicate not so much chronicity as systematic lesions, especially of nerve tissues. Among the shortcomings, it is necessary to note the very high cost of the proposed method.

The objective of this invention is to improve the results of treatment of purulent forms of inflammation of the uterus by choosing the optimal treatment method: laparotomy, laparoscopy or conservative therapy, by additionally determining acute serum proteins such as lactoferrin, alpha-2-macroglobulin in the blood serum.

The task is achieved in that in women with clinical signs of purulent inflammatory diseases of the uterine appendages in the blood serum, the concentration of two proteins is determined - alpha-2-macroglobulin and lactoferrin. The concentration of alpha-2-macroglobulin (MG) by rocket immunoelectrophoresis and lactoferrin (LF) by enzyme-linked immunosorbent assay and calculate the coefficient K by the formula:

where MG is the concentration of α-2-macroglobulin, g / l;

LF is the concentration of lactoferrin, μg / ml.

With K values of more than 1.2, the absence of purulent-necrotic destruction in the uterine appendages is determined and a conservative method of treatment is selected, with values of 0.5-1.2, a localized focus of purulent-necrotic destruction in the uterus is determined without involving adjacent organs in the inflammatory process and choose surgical method of treatment with laparoscopic access, with a value of less than 0.5, a common purulent-destructive process involving adjacent organs is determined and the surgical method of treatment with laparotomy access is chosen.

The novelty of the method:

- in patients with purulent inflammatory diseases of the uterus, to determine the presence of purulent-necrotic destruction and determine the extent of the process, determine the concentration of α-2-macroglobulin (MG) and lactoferrin (LF).

MG, a protein inhibitor of proteinases, is an important factor in protecting connective tissue from the destructive effects of endogenous proteinases - elastase and neutrophil collagenase. An increase in the concentration of a proteinase inhibitor (MG) in inflammatory processes provides a favorable outcome, a decrease in the content results in a breakdown of compensatory and protective mechanisms. LF mediates surface tension reactions on cell membranes and repulsive forces between them. The biological role of this effect is to retain neutrophils in the inflammatory focus, neutrophils aggregate with each other and adhere to the vascular endothelium (Pathological Physiology and Experimental Therapy, 1992, No. 3 - P.57, Sukharev A.E. Laktoferrin, his properties and significance in pathology). With an excessively long persistence of the neutrophilic phase, there is a real threat of purulent fusion of the tissue and the development of abscesses. A high concentration of LF affects the change of cell phases in the focus of acute inflammation, this was the reason for the study of this particular protein in women with purulent-destructive processes of the uterine appendages.

A feature of the acute phase proteins is their non-specificity and a high correlation between the activity of inflammation, the massiveness of tissue damage and their concentration, while the concentration of several proteins should be measured. The coefficient K is calculated by the formula:

where MG is the concentration of alpha-2-macroglobulin, g / l;

LF is the concentration of lactoferrin, μg / ml.

With a value of K more than 1.2, the absence of purulent-necrotic destruction is determined and a conservative treatment method is selected, with a value of K 0.5-1.2, a localized site of purulent-necrotic destruction is determined and surgical treatment and laparoscopy are chosen as surgical access with removal of only the lesion purulent-necrotic destruction, by performing the smallest possible volume (adnexectomy, salpingoectomy), with a value of K less than 0.5, a common purulent-destructive process involving adjacent organs is determined and selected laparotomy as access and radical surgery (panhisterectomy).

In this case, a complex of relatively minimally invasive methods is used to determine the presence of purulent-necrotic destruction in organs and determine the extent of the process, and therefore, to assess the need, volume and optimal access of surgical intervention, to select the optimal management tactics for patients with inflammatory diseases of the uterine appendages. This makes it possible to exclude unreasonable radical operations with the subsequent loss of menstrual and reproductive functions in young women, and in the presence of an initially irreversible process, timely surgical treatment is performed.

The essence of the method is as follows:

In women with established clinical signs (hyperthermia, abdominal pain syndrome, the presence of volumetric formations in the uterine appendages with a vaginal examination), inflammatory diseases of the uterine appendages take 5 ml of blood from the ulnar vein. After the formation of a blood clot, serum is separated. In the obtained serum sample, the concentration of alpha-2-macroglobulin (Zorin N.A., Zhabin S.G., Lykova O.F., Zorina PM, Gorin BC, Belogorlova T.I., Chirikova T.S. is determined by the method of missile immunoelectrophoresis). , Krajushkina N.A. Proteins of plasma and blood serum of donors // Clin. Lab. Diagn. 1992, No. 9-10 - S.13.15) and the method of enzyme-linked immunosorbent assay determine the concentration of lactoferrin (Konysheva T.V., Lykova S.F. ., Arkhipova SV, et al. "Enzyme-linked immunosorbent assay for determining lactoferrin" // Klin. Lab. Diagn. 1998, No. 4 - S.33-34), and then the coefficient the ratio of these 2 proteins by dividing the concentration of MG by the concentration of LF and when the obtained value of K is more than 1.2, the absence of purulent-necrotic destruction is determined and a conservative treatment method is chosen, with a value of K from 0.5 to 1.2, a localized focus of purulently is determined necrotic destruction in organs and choose a surgical method of treatment, and as an surgical approach laparoscopy, with a value of K less than 0.5, determine the presence of purulent-destructive common process and choose a surgical method of treatment of laparot ohm access.

Example 1

Patient S., 24 years old, was hospitalized in the gynecological department of hospital No. 1 of Novokuznetsk on an emergency basis with complaints of aching pain in the lower abdomen, an increase in body temperature in the evening to 38 ° C, the somatic history is aggravated, hypothalamic syndrome, neuro-exchange endocrine form. The menstrual function is not impaired, the pregnancy is one, it ended in an urgent delivery, during a gynecological examination of the formations in the area of the appendages it was not determined, a detailed examination is difficult due to obesity. According to ultrasound in the area of the left appendages, the formation was determined up to 6 cm in diameter, with heterogeneous contents, a general blood test, the leukoformula was not changed, ESR 56 mm / h, anti-inflammatory therapy was carried out during the day, after the infusion therapy, an increase in body temperature was observed to 39 C °, chills. The determination of the level of α-2-macroglobulin, lactoferrin, the level of α-2-macroglobulin was 2.76 g / l, lactoferrin 2.51 μg / ml. The calculated coefficient of their ratio is 1.09, which corresponds to the presence of a localized purulent lesion, laparoscopy was performed, pyosalpinx, oophoritis was found on the left, oophoritis, salpingitis in the right appendages, left salpingoectomy. The result of a subsequent histological examination (pyosalpinx) confirmed the correctness of the diagnosis, the postoperative period proceeded correctly, was discharged with recovery on the 12th day.

Example 2

Patient K., 20 years old, was hospitalized in the emergency operative gynecological department of the hospital No. 1 of Novokuznetsk with a diagnosis of pelvioperitonitis, 2-sided tube-ovarian tumors, endometritis 12 hours after the onset of the disease. Complaints upon receipt of pulling pains in the lower abdomen, purulent-blood discharge from the genital tract, fever up to 37.8 ° C. Menstrual function is not impaired, there were no pregnancies. A gynecological examination of the appendages from 2 sides revealed painful tumor-like formations of 6 × 4 × 6 cm with a soft consistency, pronounced inflammatory changes according to clinical and laboratory data (leukocytosis 24 thousand, LII 4.3, ESR 38 mm / h). During an ultrasound scan, a conglomerate formation of up to 6 cm in diameter, pronounced tissue edema, and a similar formation on the right were determined on the left. The algorithm of therapeutic measures for pelvic peritonitis in combination with the presence of inflammatory formations in the uterine appendages involves surgical treatment after a short preoperative preparation. In this clinical case, a surgical treatment plan was drawn up after a short preoperative preparation. The level of α-2-macroglobulin 4.23 g / l, lactoferrin 2.85 μg / ml, coefficient 1.48, it was decided to abstain from surgical treatment, amid intensive anti-inflammatory therapy, pelvioperitonitis was stopped after 6 hours, was discharged from the department with 14 recovery day, a control ultrasound study confirmed the regression of pathological education in the uterus.

Example 3

Patient R., 43 years old, was hospitalized in the emergency operative gynecological department of the city clinical hospital No. 1 with a diagnosis of pelvioperitonitis, acute endometritis, adnexitis on the background of the IUD. Upon receipt of a complaint of intense pain in the lower abdomen, lower back, weakness, fever up to 38 ° C, loose stools up to 6 times a day, tenesmus. Before hospitalization in the gynecological hospital, within 3 days, treatment in the infectious ward of hospital No. 29 with a diagnosis of gastroenterocolitis left the hospital without permission. A history of chronic inflammatory process of the uterus and appendages, last exacerbation 2 years ago, IUD 5 years, regular menstruation. Four pregnancies, one of them ended in childbirth, 3 medical abortions, in 1989 and 2001, laparotomy, resection of the right ovary for ovarian apoplexy of the hemorrhagic form, appendectomy in 1972, operated on for small bowel obstruction, resection of the small intestine. Somatic history is burdened, obesity 2-3 tbsp. Vaginal examination is not very informative and difficult due to severe soreness, obesity, adhesions in the pelvis. According to ultrasound data, an ovarian cyst up to 4 cm in diameter with an inhomogeneous suspension, a thickened capsule is determined on the left, examination of the appendages is difficult on the right due to adhesions. According to clinical and laboratory data, leukocytosis is 20 thousand, LII 7. Initially, conservative tactics, infusion, anti-inflammatory, therapy were selected when receiving the results of an additional study: α-2-macroglobulin 1.17 g / l, lactoferrin 3.97 μg / ml. The calculated coefficient of their ratio was 0.2, which corresponds to the presence of a focus of purulent-necrotic destruction in the uterine appendages with the involvement of neighboring organs. After a short preoperative preparation, an abdominal dissection, panhysterectomy, and a 2-trunk anus were performed, since a Douglas pocket abscess and an epidiopulmonary fistula were interoperatively diagnosed. The result of histological examination confirmed the presence of 2-sided purulent salpingoophoritis with abscessing and perforation on the right, panmetritis, peritonitis. The postoperative period was uneventful. Discharged with recovery on the 18th day.

This method has been tested in the gynecological clinic GOU DPO GIUV Novokuznetsk.

Thus, it was possible to develop a method for choosing a treatment method and surgical access for purulent inflammatory diseases of the uterine appendages in women, which allows timely and adequate clinical situation to determine treatment tactics, assess the need for surgical intervention and justify the feasibility of using laparoscopy or laparotomy as an access to surgical intervention.

Moreover, the method allows to improve the quality of diagnosis and treatment of purulent inflammatory processes of the uterine appendages due to a more accurate determination of the degree of damage and the prevalence of the process, which significantly reduces the number of unjustified radical operations with the subsequent loss of reproductive and menstrual functions in young women. In addition, the use of endoscopic access, if indicated, reduces surgical trauma, provides a favorable course of the postoperative period and contributes to the rapid recovery of patients, reducing the period of disability.

Claims (1)

A method for selecting a treatment method and operative access for purulent inflammatory diseases of the uterine appendages, including clinical signs and a blood test with determination of blood serum proteins, characterized in that the concentration of alpha-2-macroglobulin is determined in the blood serum of women with clinical signs of inflammatory processes in the uterus ( MG) by the method of missile immunoelectrophoresis and lactoferrin (LF) by the method of enzyme-linked immunosorbent assay and calculate the coefficient K by the formula

where MG is the concentration of alpha-2-macroglobulin, g / l; LF - concentration of lactoferrin, μg / ml, and with its values of more than 1.2, the absence of destruction in the organs is determined and a conservative treatment method is chosen, with values from 0.5 to 1.2, a localized focus of purulent-necrotic destruction in the uterine appendages without involving neighboring organs in the inflammatory process is determined and the surgical method is chosen treatment with laparoscopic access, with values less than 0.5, a common purulent-destructive process involving adjacent organs is determined and the surgical method of treatment with laparotomy access is chosen.