RU2432944C2 - Method of preventing postoperative commissural process in abdominal cavity - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, and can be used for prevention of postoperative commissural process in abdominal cavity. For this purpose, by the end of operation organs of abdominal cavity are irrigated with perftoran, preliminarily bubbled with ozone-oxygen mixture with specified concentration of ozone 5000 mcg/l. Irrigation is carried out in dose 1 ml/kg of patient's weight. After that, the same amount of ozoned perftoran is introduced intravenously.

EFFECT: invention makes it possible to prevent formation of postoperastive commissures, contributes to early restoration of intestine peristalsis, improvement of tissue oxygenation, makes it possible to reduce terms of antibiotic therapy.

1 ex, 3 dwg

Description

The invention relates to medicine, namely to surgery, can be used after operations on the abdominal organs in order to prevent the formation of a postoperative adhesive process.

The development of the postoperative adhesive process is considered to be a response of the body to a trauma of the peritoneum, which, in some cases, goes beyond the physiological framework (Karaulov V.V., 2003). Adhesive changes are usually localized in the area of surgical intervention or transferred inflammation (G. Baranov et al., 2006). They are formed even in places where the drains were located (Poroisky S.V., 2003).

According to V.A. Lipatov (2004), the number of patients with the postoperative adhesive process of the abdominal cavity continues to increase in proportion to the number of surgical interventions, and adhesive complications, in the structure of postoperative mortality, occupy one of the first places. Adhesive complications, as the author points out, are not only a medical, but also a social problem, since the disease affects patients mainly of young, able-bodied age. Therefore, the issue of prevention of postoperative adhesions is problematic and very relevant.

A preventive measure to prevent adhesions after appendectomy, B.D. Chomaeva (2003) considers effective rehabilitation of the abdominal cavity in the early postoperative period. To this end, the author recommends treatment of the right iliac region using high-frequency insufflation of drug aerosol with an immunocorrector (immunofan).

An effective way to prevent intra-abdominal adhesion V.A. Lipatov (2004) considers the use of methyl cellulose gel, which creates an indifferent absorbable barrier, but the drug was used only in experiment.

Of particular practical interest are the studies conducted by Z.Z. Nazhmudinov (2000) in the clinic of the Department of Surgical Diseases of the Faculty of Postgraduate Education of the DSEA: the author suggests, as an anti-adhesive agent, a mixture consisting of 400 ml of polyglucin, 125 mg of hydrocortisone, 20 thousand units of fibrolizin, and recommends introducing it into the abdominal cavity for patients operated on for peritonitis widespread. The mixture was pre-magnetized for 10-15 minutes and injected intraperitoneally three times - after the main surgical stage of the operation before suturing the laparotomy wound and another 2 days in a row. For this, the drainage tubes were previously blocked. After 2 hours, the clamps were removed and the mixture flowed out through the drains.

In order to study the comparative effectiveness for the prevention of adhesions, V.V. Karaulov (2003) tested a number of drugs manufactured by the pharmaceutical industry on experimental and clinical material. According to the results of his research, the previously proposed preparations “Argiform-gel” and “Taufon” do not have anti-adhesion effects, and the effect of the drug “Curiosin” (the drug is injected into the abdominal cavity before suturing a laparotomy wound at a dose of 5 ml) exceeds the standard scheme for the prevention of adhesions (intraperitoneal administration a mixture consisting of 0.5% novocaine, hydrocortisone and heparin). The oral administration of the Flogenzim preparation for 21 days (3 tablets 3 times a day for 14 days, and then 2 tablets 3 times a day for another 7 days), according to the author, also had a pronounced anti-adhesion effect.

The same data were provided by S.V. Poroysky (2003) in relation to the preparations “Curiosin” and “Elton”, which, according to the author, ensured the friability of adhesions.

After analyzing the results of an experimental study on guinea pigs, a comprehensive examination and treatment of patients, M.P. Lavreshin (2005) came to the conclusion that the intraperitoneal administration of a 0.5% solution of isoniazid with subsequent phased use of magnetotherapy, laser therapy, ultrasound and electrophoresis with lidase can be used as A method for preventing the development of adhesions in the abdominal cavity.

Criticism of analogues

As can be seen from the descriptions of the proposed methods, in none of them the authors approached the problem from the point of view of the etiology and pathogenesis of postoperative adhesions: some considered postoperative trauma as the cause, and others considered inflammation. Accordingly, prevention was dealt with unilaterally.

Prototype

As a prototype of the proposed method is the "Method for the prevention of the formation of postoperative adhesions with peritonitis in the experiment", which was proposed by I.V. Yarema and M.A. Magomedov (Yarema I.V., Magomedov M.A. Perftoran in the prevention of the formation of postoperative adhesions with peritonitis (experimental study) Bulletin of experimental biology and medicine, 2003, No. 12. - S.661-663).

The prototype method proposed by the authors is as follows.

After opening the abdominal cavity, the authors reproduced the experimental model of peritonitis according to M.V.Buyanov (damage to the mesothelium of the loops of the small intestine in 10 sections of 0.25 cm ² , i.e., multiple deserting of loops of the small intestine). Then, after washing from pus, animals of the experimental group to prevent the formation of postoperative adhesions in the abdominal cavity were injected with 2 ml of perftoran emulsion. To visualize changes in the wound surface, peritoneal fluid and intestinal wall were taken on the 3rd, 5th, 7th and 14th days and stained with monoclonal antibodies.

It was found that an increase in resorptive cell resistance (migration of phagocytic cells to the site of inflammation), which is considered one of the mechanisms of the barrier functions of the body, was a limiting factor in the activation of fibroblast cells. In addition, perfluorane, which has a membrane-stabilizing effect, contributed to early epithelization, due to which, according to the authors, the adhesive processes were halved compared to the group where traditional methods of treating the abdominal cavity were used.

Criticism of the prototype:

1. The introduction of 2 ml of perftoran as well as standard lavage for washing the abdominal cavity does not ensure its sanitation with purulent peritonitis, since neither perfluorane nor saline, which is standardly used for washing, have antiseptic or antibacterial properties.

2. Perftoran promotes only the migration of mononuclear phagocytes, but does not prevent or treat intestinal paresis, which develops with any common purulent process in the abdominal cavity.

3. There is a need for additional use of antibacterial agents for the treatment of an ongoing infectious process or the prevention of postoperative (tertiary) peritonitis.

4. Prevention of postoperative adhesions according to the prototype is more suitable in cases of aseptic inflammation in the abdominal cavity, and not common purulent.

The purpose of the proposed method

The aim of the present invention is to develop an adequate method for the prevention of postoperative adhesive process in the abdominal cavity, which allows for effective prevention.

The goal is realized by the introduction of ozonized perftoran into the abdominal cavity and intravenously. Ozonation is carried out by sparging perftoran with an ozone-oxygen mixture for 20 minutes at a rate of 0.5 l / min and a predetermined ozone concentration of 5000 μg / l on the ozonizer. We used the ozonizer "Medozons - BM AOT - N - 01 - Arz - 91" of the company OJSC "Arzamas Instrument-Making Plant".

The essence of the proposed method.

The result of the experiment using the proposed method for the prevention of adhesions is shown in photo 1, and for comparison, the results of the use of physiological saline (photo 2) and pure perftoran as in the prototype (photo 3) are given.

Photo 1, 2, and 3 show the organs of the rat abdominal cavity on the 14th day of fecal peritonitis development: photo 1 after application of ozonated perfluorane, i.e. by the proposed method, where it is clearly seen that there are no adhesions. On a photo 2 after application of physiological saline where the expressed adhesive conglomerate is clearly visible. In photo 3, after applying pure perfluorane, i.e. by the prototype method, where one pronounced cord-like adhesion is visible, which stretches along the front wall of the abdomen.

The essence of the invention is as follows: carry out irrigation of the abdominal organs and intravenous (drip) administration of ozonated perfluorane after completion of the initial operation and standard rehabilitation, before suturing the surgical wound.

During the surgical intervention, after the completion of the technical stage of the operation, before closing the laparotomy wound, the patient’s abdominal organs are irrigated with 50-100 ml of ozonated perfluorane (based on 1 ml / kg of weight). Prior to irrigation, the remnants of an antiseptic or other solution that has been sanitized are washed off with 0.5-1 l of physiological saline (so that there is no mixing of the solution used for standard sanitation and ozonated perftoran). For irrigation use a 20 ml syringe with a large diameter needle. Before irrigation, if drainage tubes are left in the lower floor of the abdominal cavity, then they are temporarily placed (for 1.5-2 hours) so that the ozonated perfluorane does not leak out. After all, another 50-150 ml of ozonated perfluorane is administered intravenously (based on 1-1.5 ml / kg of weight), depending on body weight, severity of the condition and phase of peritonitis.

Comparative analysis of the features of the prototype and proposed as an invention of the method

1. In the proposed method using ozonated perfluorane, exhibiting the properties of both perfluorane and ozone, and in the prototype use pure perfluorane.

Ozonated perfluorane used by the proposed method has antioxidant, bactericidal, viricidal and fungicidal effects, and pure perfluorane according to the prototype does not have these properties.

2. According to the prototype, perfluorane is injected only into the abdominal cavity, and according to the proposed method, the abdominal cavity is irrigated, in addition, it is also administered intravenously, which allows to achieve the desired effect.

3. According to the proposed method, perfluorane is preliminarily ozonized (sparged) with an ozone-oxygen mixture with a predetermined ozone concentration of 5000 μg / L and, at the end of the operation, the abdominal cavity is irrigated with ozonized perftoran at the rate of 1 ml / kg of patient weight, then ozonized perfluorane is administered intravenously from the same calculation, and Perftoran is introduced according to the prototype without any calculation.

Examples of specific performance of the method

Extract from the laboratory journal of the Department of Human Anatomy of the DSEA.

To study in the experiment the effectiveness of the use of ozonated perftoran for the prevention of adhesions in the abdominal cavity, a model of acute purulent peritonitis was reproduced according to S. S. Remennik (1965) by introducing 5% fecal suspension in physiological solution at the rate of 1 ml per 100 g of animal weight. White rats of 3-4 months of age weighing 140-160 g were used.

Under chloroform anesthesia, a 5% fecal suspension was introduced into the abdominal cavity, after which the rats were seated in cells in separate series:

- I series (12 rats). A 5% fecal suspension and physiological saline solution was immediately introduced into the abdominal cavity (control series).

- II series (12 rats). Perftoran was introduced into the abdominal cavity immediately after the injection of fecal suspension (1st control series).

- III series (12 rats). Ozonized perfluorane was introduced into the abdominal cavity immediately after injection of fecal suspension (experimental series 1).

- IV series (12 rats). Perftoran is injected into the abdominal cavity the next day, i.e. against the background of developing daily fecal peritonitis (2nd I control series).

- V series (12 rats). Ozonated perfluorane was injected into the abdominal cavity the next day, i.e. against the background of developing daily fecal peritonitis (2nd experimental series).

Saline, perftoran and ozonated perftoran to rats were injected into the abdominal cavity at the rate of 1.5 ml per 100 g of animal weight. In the experiment, the effectiveness of ozonized perfluorane in comparison with physiological saline and pure perfluorane was studied, introducing them as in the prototype, i.e. only in the abdominal cavity and about the same amount per animal.

After 48, 72 hours, 7 and 14 days, the rats were removed from the experiment (3 rats from each series for each period) by decapitation under chloroform anesthesia.

Smear-prints from the pleural and abdominal cavities are stained according to Romanovsky - Giemsa for cytological examination.

A comparative analysis of the experimental results showed:

1. In the case of intraperitoneal administration of saline with fecal suspension, a pattern of peritonitis was developed and 7 (58.3%) rats died on days 2-14 of peritonitis. In the abdominal cavity were found on the 2nd day - tender, and later - pronounced adhesions, which sometimes walled up the organs in a single conglomerate. In smears of peritoneal exudate: on the 2nd day - there were completely microorganisms, neutrophilic white blood cells (26-48.6%), many destructive cells (13-15%), fibroblasts (5.3-8.5%), and 3 and 7 days - the number of fibroblasts was 12.8% and 13.6%, respectively.

2. With the introduction of perftoran immediately after an intraperitoneal injection of fecal suspension, widespread peritonitis developed in about half of the rats; in most rats, peritonitis was limited by the appearance of a weak fibrin plaque, minor adhesions and two or three clotted pustules between the loops of the intestines and on the lower surface of the liver on the 2nd and subsequent days. On day 14, cord-like adhesions were detected in individual rats. On day 2-14, 4 rats (33.3%) fell. Single microbes, many white blood cells and macrophages (perfluorophages) were noted in smear impressions from the abdominal cavity, fibroblasts (from 1.1% to 5.6%) and destructive cells were found, but much less than in the 1st series.

3. With the introduction of ozonized perftoran immediately after the introduction of fecal suspension, widespread peritonitis in rats practically did not develop, limiting on the 2nd and subsequent days to the formation of insignificant 1-2 small roundish formations in the gland folds. Adhesions on days 2–7 were absent, and on day 14, 2 rats showed one threadlike adhesion between the omentum and the anterior abdominal wall at the injection site. At the same time, in the course of the entire experiment, 1 rat died (8.3%) on the 5th day.

In the smear smears there is no free flora, foamy macrophages (perfluorobphages) and leukocytes (neutrophilic leukocytes on 2 - 3 days were 3-4 times less than in the 1st and 1.5 times less than in the 2nd series). The number of fibroblasts is from 0.7 to 3%.

4. If perftoran was administered against the background of daily fecal peritonitis, ie 24 hours after injection of fecal suspension, a detailed picture of common peritonitis in most rats developed; 6 (50%) rats died on the 4-7th day. In smears from the abdominal cavity and pleural sinuses, free coccal flora and Escherichia coli were observed on the 2nd-3rd day. On days 7-14, single cord-like and arachnoid adhesions were found in most rats.

5. If ozonated perfluorane was administered against the background of daily peritonitis, ie 24 hours after an intraperitoneal injection of fecal suspension, the pattern of peritonitis widespread developed in 25% (3) of the animals. In another 2 (16.7%) animals, small clumped abscesses between the gland folds were found on the 2-3 days. There are either no adhesions, or they are very delicate (on the 3rd-7th day), which are easily destroyed when the intestinal loops move. Fibrin plaque on the peritoneum was not determined, pleural sinuses without features. Free microbial flora was not detected in fingerprint smears; cell density is significantly lower than in the previous series, but relatively many macrophages with foamy cytoplasm ("perfluorophages") and monocytes. The survival rate of animals was 83.3% (1 rat died on the 3rd and another on the 5th day of the experiment).

Clinical example

Patient E. (medical card No. 4796/322), 48 years old, was taken by ambulance to the 2nd surgical department of the Republic of Belarus No. 2 (RC SEMP) on 05/18/2008 at 21.20. (by Ambulance), 70 hours after the onset of the disease with complaints of abdominal pain, dry mouth, weakness, nausea and vomiting. Upon admission, the temperature is 37.8 ° C, the patient is conscious, inhibited. The skin is pale. The tongue is coated with white plaque. Ps - 124 beats / min. Medium filling, blood pressure - 100/60 mm Hg Heart sounds are somewhat muffled. Hard breathing, isolated single rales are caught. The abdomen is moderately swollen, painful on palpation on the right. Symptoms of Shchetkin - Blumberg, Bartomier - Michelson and Sitkovsky are positive. There was no stool in the last day. The patient notes frequent urination. In a blood test: white blood cells - 9.6 × 10 ⁹ / l, red blood cells - 5.1 × 10 ¹² / l, hemoglobin - 140 g / l, ESR - 47 mm / h; in the leukocyte formula: stab leukocytes - 38%, segmented leukocytes - 45%, lymphocytes - 14%, monocytes - 3%, LII - 7.1. A clinical diagnosis was made: acute destructive appendicitis complicated by peritonitis. After preoperative preparation, having previously obtained the patient’s informed written consent for surgery, the patient is operated on. Laparotomy was performed by median access at 22 h 40 min.

In the abdominal cavity about 200 ml of purulent effusion with fibrin. The appendix is black in color, walled up by the omentum, pus leaked from the omentum. The cecum is also soldered to the omentum, inflamed, bluntly separated. Loops of the small intestine expanded to 4.5-5 cm, in the lumen of the liquid foamy contents, fibrin clots on the surface. UPS rated at 13 points, MIP - 22 points. Appendectomy, periappendicular abscess drainage, lavage with a warm solution of furatsilin (4 l), abdominal drainage were performed.

On the 1st day after surgery, the patient felt slightly better.

On the 2nd day against the background of the therapy, the body temperature increased to 39 ° C, chills appeared, the condition worsened. He complained of weakness, abdominal pain, bloating, nausea, and dry mouth. A nasogastric tube was installed along which the stomach was washed. The patient felt some relief.

On the 3rd day, the patient's condition worsened again. There was a fever. Pulse - 120 beats / min, weak filling, heart rate - 130 / min, NPV - 29 / min, blood pressure - 90/60 mm Hg The skin is pale, moist to the touch. In the lungs, hard breathing, in the lower parts of the scattered rales. The abdomen is bloated, painful on palpation, the muscles of the abdominal wall are tense. When phonoenterography - increased peristaltic murmur in the upper abdomen. According to the nasogastric tube, 1000 ml of stagnant gastric contents were released per day. In blood tests: hemoglobin - 150 g / l, white blood cells - 8.4 × 10 ⁹ / l, ESR - 54 mm / h, stab shift - 47%. After receiving informed written consent for the reoperation and for connection to treatment, the introduction of ozonated perfluorane, relaparotomy was performed on 05/22/2008 at 07.10 a.m.

In the abdominal cavity about 600 ml of turbid fibrinous effusion with an unpleasant odor. The small intestine is edematous, the loop in n / 3 is tightened by the adhesive cord and impassable, below this inflection the intestinal lumen has fallen. There is fibrin plaque. Seams on the dome of the cecum are wealthy. UPS rated at 16 points, MIP - 28 points. The commissure is dissected. Nasointestinal intubation, debridement (5.5 l of furatsilin solution used) of the abdominal cavity and its repeated drainage were performed. Before suturing the laparotomic wound, the residues of furatsilin washed with saline. By applying clamps to the drainage tubes, the abdominal cavity was irrigated with 100 ml of ozonated perfluorane (patient weight 103 kg). On the operating table, intravenous administration of ozonated perftoran (100 ml) was connected, 20 minutes after this, the pulse rate decreased from 115 beats / min to 100 beats / min.

On the 3rd day after relaparotomy with the inclusion of ozonated perftoran in treatment, the patient's condition improved. Body temperature - 37.6 ° C. The abdomen is soft, not swollen, painful in the wound area. Gases depart from the 2nd day of repeated operation, after an enema appeared stool. Peristaltic noises during phonoenterography indicated restoration of motor activity of the gastrointestinal tract (by the amplitude and frequency of the detected noise, after computer processing of the recording according to Blackman-Harris, it was possible to judge the completeness of intestinal motility). There is no discharge through the drainage tubes.

Antibacterial therapy was discontinued for the patient on the 6th day.

No ultrasound adhesions were found, intestinal motility was active.

On the 8th day after relaparotomy, the patient was discharged from the hospital in satisfactory condition.

The positive effect of the application of the proposed method

The usefulness of the developed method, proposed as an invention, is based on the following properties of ozonated perftoran. Ozonated perfluorane exhibits the properties of both perfluorane and ozone, and ozone in "perfluorane" dissolves "better and more stably than in physiological saline. The method provides prevention of the formation of postoperative adhesions, additional and reliable sanitation of the abdominal cavity during operations for widespread purulent peritonitis and promotes early restoration of intestinal motility, improves tissue oxygenation, reduces indications for relaparotomy and reduces the duration of antibiotic therapy and postoperative treatment of acute peritonitis.

The developed method is technically simple to perform and allows to prevent the postoperative adhesion process in the abdominal cavity and significantly reduce the recovery time of gastrointestinal motility and blood counts and other body systems, antibiotic therapy and the patient’s hospital stay.

The proposed method was used in the experiment and in the clinic of 3 surgical departments of the Republic of Belarus No. 2 (RC SEMP) during the period from 04.2008 to 11.2008. in the complex treatment of 24 patients with acute purulent peritonitis for the prevention of postoperative adhesive process in the abdominal cavity. Proposed as an invention, the method prevented the formation of adhesions, as well as significantly reduce the recovery time of gastrointestinal motility and blood counts and other body systems. Also reduced the duration of antibiotic therapy and the patient's stay in the hospital.

The proposed method can be used in clinical practice and in experimental surgery for the prevention of postoperative adhesive process of the abdominal cavity.

Information sources

Yarema I.V., Magomedov M.A. - Perftoran in the prevention of the formation of postoperative adhesions with peritonitis (experimental study). // Bulletin of experimental biology and medicine. - 2003, No. 12. - S.661-663. - prototype.

Claims (1)

A method for the prevention of postoperative adhesions in the abdominal cavity, including surgery and the use of perftoran, characterized in that the perftoran is pre-sparged with an ozone-oxygen mixture with a given ozone concentration of 5000 μg / l and by the end of the operation they are irrigated with abdominal organs, based on the calculation of 1 ml / kg the patient’s mass, then the same amount of ozonized perftoran is administered intravenously.

Images