RU2844508C1 - Method of treating persistent wounds of anal canal - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention refers to medicine, namely to coloproctology. Platelet-rich autoplasma is administered into the wound walls and bottom in a fan-like manner at pitch of 3-4 mm in dose of 0.1-0.2 ml. Outpatient stage involves administering preparation Superlymph 25 units 2 times a day, one rectal suppository in the morning and at bedtime for 20 days with autoplasma administered on the first and fourteenth days of treatment.

EFFECT: method enables activating the regenerative processes, reducing the reparation time, providing higher clinical effectiveness in persistent anal canal wounds, reducing a risk of developing postoperative complications.

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Description

Field of technology

The invention relates to medicine, namely to proctology, and can be used to treat anal fissures and long-term non-healing wounds of the anal canal.

An anal fissure is a painful proctological disease. It significantly worsens the quality of life and requires emergency care.

State of the art

There is no consensus regarding the time period during which a fissure becomes chronic, but most sources suggest that it is between 4 and 12 weeks [1]. The duration of the disease history may be ≥ 2 months [2].

Its pathophysiology remains controversial, but in most cases it results from trauma from the passage of hard stool through the hypertonic anus.

Anal fissure ranks 3rd in terms of frequency of occurrence in the structure of diseases of the colon (11-15%), and the incidence is from 20 to 23 cases per 1000 adult population [3].

Depending on the chronic or acute course, treatment options vary: from local and conservative treatment to surgery.

Despite advances in wound treatment, chronic wound healing remains a major challenge for the clinical community due to the complexity of the healing process, which requires the presence of a huge number of different regulatory substances - cytokines, chemokines, growth factors, antimicrobial peptides, angiogenic factors, protease inhibitors, hormones, lipids, microRNA, exosomes, etc. [4].

Autologous platelet-rich plasma is a blood product that has three to five times the platelet count and can be used for restorative purposes [5].

Autologous plasma with increased platelet content contains protein factors, growth factors that activate the regenerative process [6]. The therapeutic effect is achieved through the secretion of alpha-granules of platelets, which increases the release of growth factors, adhesion molecules and chemokines, which, in turn, interact with the local environment, promote differentiation, proliferation and regeneration of cells [7].

Modern studies of the content of regulatory molecules in autoplasma with an increased platelet content show the presence of more than 1100 different proteins [8].

Among them are tumor necrosis factor alpha (TNF-α), IL-1 anti-inflammatory receptor antagonist protein (IRAP), fibroblast growth factor (FGF-basic), platelet-derived growth factor (PDGF-BB), transforming growth factor-beta 1 (TGF-β1), antimicrobial protein of the defensin family – hBD-1, chemokine SDF-1 (CXCL12), HMGB-1 protein, EGF-α and EGF-β1, EGF-β2, TGF-α and TGF-β1, TGF-β2, PDGF, HGF, FGF-β, IGF, pro- and antiangiogenic factors (e.g. VEGF-F), angiopoietins Ang-1 and Ang-2, etc. [9, 10].

The combination of the above molecules has been shown to modulate angiogenesis, remodel the extracellular matrix, and influence the recruitment, proliferation, and differentiation of stem cells [11]. For this reason, the use of autologous plasma to promote tissue growth and repair has found application in several areas of regenerative medicine, including orthopedics, dental and plastic surgery, ophthalmology, and dermatology. It should be noted that the key role of platelet-rich plasma is to attract leukocytes to the wound. Successful tissue repair occurs when platelets reach the wound site, degranulate, and release growth factors and cytokines, which in turn attract leukocytes to the damaged tissue. Leukocyte behavior is adaptive, and depending on the environment, leukocytes can inhibit or stimulate healing [12].

Considering that stimulation of regeneration in autoplasma rich in platelets occurs due to the content of biological molecules in platelets, similar effects are achieved by a similar technology using peripheral blood mononuclear cells (PBMC). Cultured autologous mononuclear cells (PBMC) initiate, accelerate and improve granulation and epithelialization [13]. PBMC are known to play an important role in innate and adaptive immunity. They synthesize cytokines, antimicrobial peptides and other regulatory molecules.

The closest analogues (prototypes) to the claimed are:

Research conducted on patent and scientific medical literature revealed a significant number of patent documents protecting methods of treating acute and chronic anal fissure using autologous platelet-rich plasma.

A method for treating anal fissure using a blockade with autologous plasma saturated with an ozone-oxygen mixture is known (RU Patent No. 2558995 C1, published on 10.08.2015, Bulletin No. 22, “Method for Treating Acute Anal Fissure,” authors: Baghdasaryan L.K., Titov A.Yu., Baghdasaryan S.L.). The method is carried out as follows: blood is taken from the patient’s vein (8 ml). The latter is centrifuged in monovets with Li-heparin and a separating gel for 5 minutes at a speed of 1700 rpm. 2-2.5 ml of platelet-rich plasma is collected in a 20-gram syringe. The plasma is bubbled in the syringe with an ozone-oxygen mixture with a concentration of 3000 μg/l for 5 minutes. Next, under local or caudal anesthesia, autoplasma in a volume of 2-2.5 ml is injected under the crack. If there is a spasm of the anal sphincter, pneumo- or cone-divulsion is performed.

A method for treating acute anal fissure and long-term non-healing wounds of the anal canal is known (RU Patent No. 2578853 C1, 03/27/2016 Bulletin No. 9, "Method for Treating Acute Anal Fissure and Long-Term Non-Healing Wounds of the Anal Canal", authors Bagdasaryan L.K., Titov A.Yu., Bagdasaryan S.L.), which includes the introduction of autoplasma enriched with platelets under the anal fissure, differs in that the autoplasma is bubbling with an ozone-oxygen mixture for 5 minutes and converted into a gel form in order to prolong the therapeutic effect, after which the plasma gel is introduced under the fissure in a volume of 2.5-3.0 ml.

A method for treating chronic anal fissure is known (RU Patent No. 2639039 C1, 19.12.2017 Bulletin No. 35 "Method for Treating Anal Fissure" by Achkasov E.E., Solomka A. Ya., Ulyanov A.A., Zharikova T.M.), which includes its excision together with the surrounding scar tissue and sentinel tubercle by two semilunar incisions within healthy tissues, characterized in that autoplasma enriched with platelet growth factors (TGF) is introduced into the walls and bottom of the wound with a mesh in increments of 3-4 mm at 0.1 ml, then, having spread the edges of the wound with a rectal speculum, a film of TGF-enriched autoplasma is applied to its bottom, and TGF-enriched autoplasma is introduced under the wound in a volume of 1 ml to a depth of 5-7 mm, the next step is to inject botulinum toxin A at a dose of 15-20 U into the internal sphincter at three points to a depth of 5-7 mm, for a posterior fissure at 5, 7 and 12 o'clock, for anterior - at 11, 1 and 6 o'clock, on the 4th day the procedure for introducing TGF-enriched autoplasma is repeated.

A method for treating acute and chronic anal fissure complicated by sphincterospasm is known (RU Patent No. 2644753 C1, 13.02.2018 Bulletin No. 5 "Method for Treating Acute and Chronic Anal Fissure Complicated by Sphincterospasm" by Belik B. M., Kovalev A. N., Khatlamadzhiyan A. L.). Autologous plasma enriched with platelets is administered. In the preoperative period, autologous plasma is obtained from 20-100 ml of the patient's peripheral blood by two-stage centrifugation. At the first stage, erythrocytes and leukocytes are removed, and at the second stage, platelets are concentrated. The isolated fraction is then converted into a gel form by adding thrombus formation activators, after which the plasma gel is injected into the internal and external sphincter of the anal canal at four points corresponding to 1, 5, 7 and 12 o'clock on a conventional clock face. Then the anal fissure is excised.

A method for treating acute and chronic anal fissures is known (RU Patent No. 2689310 C 1, 05/27/2019 Bulletin No. 15 "Method for Treating Acute and Chronic Anal Fissures" by L. P. Barashova, A. N. Burkov), which includes obtaining plasma and introducing it into the fissure, characterized in that Botox is injected into the base of the fissure in a dose of 10-30 units, then venous blood is collected in a test tube containing sodium citrate in an amount of 18 ml, centrifuged at 3600 rpm for 16 minutes, the upper layer in an amount of 2.0 ml is taken from the resulting plasma and disposed of, after which the remaining plasma layer is transferred to a sterile test tube, a calcium chloride solution is added to the plasma at a rate of 1.0 ml of a 10% solution calcium chloride per 10 ml of autoplasma and injected into the base of the crack.

Disadvantages of analogues

The disadvantages of methods using autologous platelet-rich plasma include two significant biological aspects.

Firstly, since the regenerative effect is not due to the presence of concentrated platelets in the plasma obtained after centrifugation, but to the content of regulatory molecules secreted by platelets. This is precisely why the expected therapeutic effect is absent, and, accordingly, the effectiveness of therapy, since it has been determined that the concentration of growth factors, cytokines, angiogenic factors, etc. in the resulting autoplasma is affected by a number of circumstances - the volume and content of platelets, the content of leukocytes, the content of erythrocytes, the volume and shape of containers, the speed and duration of centrifugation, the type of anticoagulant, the activated or non-activated state of plasma, the type of activating agent, the patient's condition [14].

Formed elements, growth factors and cytokines in autologous platelet-rich plasma samples have been shown to vary depending on the centrifugation technique used [15]. It has also been shown that male patients have higher levels of cytokines and growth factors in autologous platelet-rich plasma compared to female patients for inflammatory cytokines, with gender being a more important factor than age. Furthermore, proteomic variability has also been observed within groups [16,17]. There is also a difference in blood factor content between healthy and diseased individuals.

Secondly, after being released by producer cells, cytokines, growth factors, chemokines and other messengers have a very short half-life in the bloodstream. The half-life of most cytokines is measured in minutes (from a few seconds to max 30 min. [18]. Accordingly, the therapeutic period of the administered autologous platelet-rich plasma is unknown and expectedly short. Considering that wound healing is a complex dynamic process supported by multiple cellular events that must be closely coordinated for effective restoration of damaged tissue [19], the constant presence of regulatory messengers is required for full-fledged healing. Dysregulation of the immune system during the wound healing process leads to persistent inflammation and delayed healing, which ultimately leads to chronic wounds [20]. In turn, the chronic process is characterized by an immune imbalance, where a number of cytokines are deficient [21]. In this regard, to stimulate regenerative processes, it is necessary to simultaneously apply growth factors and cytokines, genetic constructs, etc. to the tissue for a relatively long period of time from 1 to 3 weeks, which is necessary to ensure regenerative process [22].

Paracrine factors secreted by cells are called the "secretome" and can be isolated from the cell and used as a drug [23]. The secretome consists of serum proteins, growth factors, angiogenic factors, antimicrobial peptides, hormones, cytokines, matrix proteins, proteases and enzymes, as well as extracellular vesicles that transport lipids, proteins, RNA and DNA subtypes, chemokines and lipid mediators.

One of the most accessible secretomes in the isolation and production of medicinal forms is considered to be the secret of peripheral blood mononuclear cells (PBMC) [24]. The PBMC secretome has therapeutic effects necessary for tissue regeneration, such as proangiogenic, antiapoptotic, antifibrotic, anti-inflammatory and immunomodulatory [24-27].

MNC secret is used in patients with diabetic foot ulcers, skin wounds [28], after experimental acute myocardial infarction [29], burns, nerve damage, etc.

In Russia, since 1987, there has been a technology for extracting the secretome from MNC, its lyophilization and therapeutic use. [IMMUNOSTIMULATORY AGENT Russian patent of 2000 under IPC A61K35/14 A61K38/19 RU2145500C1; Patent No. 1494274 of 20.03.97. "Method for obtaining a factor inhibiting the migration of macrophages and leukocytes", Gankovskaya L.V., Kovalchuk L.V]. Since 2010, there has been a single commercial drug in civil circulation, created on the basis of the allogeneic secretome of the MNC "Superlymph" in vaginal and rectal suppositories, with the INN "Protein-peptide complex from swine blood leukocytes" [LP-No. (004385) - (RG-RU)]. The drug Superlymph® is a natural complex of natural antimicrobial peptides and cytokines with the activity of a factor inhibiting the migration of macrophages, IL-1, IL-6, TNF, and transforming growth factor. The drug has an immunomodulatory, antiviral and antimicrobial effect, stimulates the functional activity of phagocytic cells (monocytes and neutrophils): activates phagocytosis, production of cytokines (IL-1, TNF), induces antitumor cytotoxicity of macrophages, regulates cell migration to the site of inflammation, increases the activity of natural killers. The mechanisms of action of the drug in accordance with the level of implementation of the effect are supported by clinical data. According to the State Register of Medicines of 2023, the drug Superlymph is defined by the pharmacotherapeutic group as a tissue reparation stimulator [30].

Accordingly, it is advisable to use this drug as an outpatient prolongation of the regenerative therapeutic effect of platelet-rich autoplasma procedures in patients with acute and chronic anal fissure.

The objective of the present invention is to develop an effective method for treating acute and chronic anal fissures, providing a prolonged action of the regenerative therapeutic effect of procedures using autologous plasma rich in platelets.

Disclosure of invention

The technical result consists in increasing the effectiveness of treatment of patients with acute and chronic anal fissure by ensuring the presence of immune regulatory molecules in the wound surface area during the healing period.

The specified technical result is achieved by the following techniques. The patient with acute or chronic anal fissure is injected with prepared autoplasma enriched with platelets into the walls and bottom of the wound fan-shaped with a step of 3-4 mm by 0.1-0.2 ml, at the outpatient stage the drug "Superlymph" 25 U containing the secretome of peripheral blood mononuclear cells is used, one suppository rectally twice a day for 20 days. In this case, the introduction of autoplasma is carried out on the first, fourteenth day of treatment, if necessary - upon completion of therapy with the wound process organization drug. The maximum number of autoplasma procedures is three injections.

Implementation of the invention

Prepared autoplasma enriched with platelets is injected into the walls and bottom of the wound fan-shaped with a step of 3-4 mm by 0.1-0.2 ml, at the outpatient stage the use of the drug "Superlymph" 25 U, containing the secretome of peripheral blood mononuclear cells, one suppository rectally twice a day for 20 days in the morning and evening. In this case, the introduction of autoplasma is carried out on the first, fourteenth day of treatment, if necessary, after completion of therapy with the drug "Superlymph" 25 U on the 20th day of treatment. The number of injections depends on the course and organization of the wound process. The maximum number of autoplasma procedures is three injections.

Examples

Clinical case No. 1

Patient R., 44 years old, diagnosed with: Chronic wounds of the anal canal, condition after dearterialization of internal hemorrhoids, laser vaporization of internal hemorrhoids. During examination, circular deep wound defects were noted, with pronounced spasm of the internal sphincter. The patient had pain syndrome,

Combined treatment was performed using antibacterial drugs, local therapy included washing the wound with antiseptic solutions, ointment applications. Autoplasma enriched with platelets was used. Autoplasma was administered on the first day and on the 14th day of treatment. At the outpatient stage, the drug "Superlymph" 25 U, one suppository rectally 2 times a day from the first day of treatment for 20 days between the procedures of autoplasma administration. After 4 months, complete clinical recovery was recorded, tissue regeneration occurred without surgical treatment.

Clinical case #2

Patient N., 32 years old Chronic anal fissure of the anus

During the examination, a defect of the anoderm at 6 o'clock with cicatricial edges was determined, the patient was recommended to regulate stool using psyllium preparations, combined therapy was carried out using autoplasma on the first day and on the 14th day of therapy and Superlymph suppositories 25 U for 20 days, 2 times a day. A control examination of the patient was carried out on the 7th and 14th days. On the 14th day, significant regeneration of the defect was noted. Complete clinical recovery in a month.

Clinical case #3

Patient R., 39 years old Chronic hemorrhoids grade 3-4, condition after open hemorrhoidectomy with an ultrasonic scalpel, to improve tissue regeneration, Superlymph suppositories 25 U were recommended for 20 days 2 times (morning-evening) to accelerate tissue reparation in the postoperative period. Autologous plasma was administered on the 1st and 14th day of therapy. On the 20th day, persistent healing of postoperative wounds was recorded. Examination after a month - complete clinical recovery.

Clinical case #4

Patient M., 42 years old. Acute anal fissure. Therapy with autoplasma was performed once under the defect in a fan-shaped manner, administration on the first day of treatment, on the 14th day of treatment and on the 20th day, upon completion of therapy Superlymph 25 U for 20 days. In this case, the patient received therapy in the form of Superlymph 25 U suppositories for 20 days, the effect was achieved, during the control examination there was no pain syndrome and bleeding.

Claims (3)

1. A method for treating long-term non-healing wounds of the anal canal, including the introduction of autoplasma enriched with platelets into the walls and bottom of the wound in a fan-shaped pattern with a step of 3-4 mm at 0.1-0.2 ml; at the outpatient stage, the drug "Superlymph" is administered 25 U 2 times a day, one suppository rectally in the morning and at night for 20 days, while the introduction of autoplasma is carried out on the first and fourteenth days of treatment. 2. The method according to paragraph 1, characterized in that the number of courses of autoplasma is three. 3. The method according to paragraph 1, characterized in that autoplasma is administered on the first, fourteenth, and, upon completion of therapy with the drug “Superlymph”, on the twentieth day of treatment.