RU2331367C1 - Method of prevention of commissure formation and relapse thereof - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and can be applied for treatment and prevention of commissure relapse. Laparotomy and laparoscopy are performed. Separation of damaged serous membranes is carried out. Mesothelisation is fulfilled by injecting 5% pectin gel into wound area. The method allows for preventing cohesion of surfaces for term of their mesothelisation.

EFFECT: method of treatment of commissures with prevention of surface cohesion for term of their mesothelisation.

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Description

The present invention relates to medicine, namely to general surgery, gynecology, and can be used when performing abdominal operations.

It is known that one of the unresolved problems of general surgery is the fight against the postoperative adhesive process of the abdominal cavity and the complications associated with it. The main source of formation of adhesions in the abdominal cavity are abdominal purulent-inflammatory diseases of the abdominal cavity. About 1% of operated patients are treated annually in the surgical departments for adhesions. According to the majority of published sources, adhesive disease with the development of adhesive obstruction is most often observed after operations for acute appendicitis - 63%, after operations on the uterus and appendages - 22.8%. In 13.9%, patients are operated on after previous operations for adhesive obstruction. Over the past 20 years, the frequency of adhesive obstruction has increased 1.9 times [R. Zhenchevsky. Adhesive disease. - Moscow: Medicine, 1989. - 191 p.]. According to the International Anti-adhesive Society, relapses of adhesive disease after surgery range from 32% to 71%, mostly young age suffers, causing disability.

To prevent adhesions in the abdominal cavity, methods are being taken that can be divided into three groups: a) surgical; b) physiotherapeutic; c) barrier anti-adhesion agents.

Surgical methods include reducing the invasiveness of the intervention, reducing tissue trauma during surgery, eliminating the abandonment of foreign material in the abdominal cavity.

Physiotherapeutic methods for the prevention of adhesion formation include thermal procedures, electrophonophoresis and various drugs (hyaluronic acid, lidase, novocaine, papaverine, potassium iodide, trilon B, hydrocortisone, heparin). However, these procedures should be recognized as ineffective because of the complexity of the delivery of the active substance to the abdominal cavity.

The basic principle of barrier methods is the delimitation of damaged areas of the peritoneum, direct delivery of the drug and its preservation for the entire healing period of the damaged peritoneum.

An etiopathogenetic orientation of its action is rightly considered to be the key to the high effectiveness of a particular means of prevention or treatment. The most promising in the field of prevention of postoperative adhesions of the abdominal cavity is considered the use of uncoupling wound surfaces of absorbable indifferent agents. This group of methods consists in dividing the wound surfaces of the peritoneum for the period necessary for mesothelization of defects. The results of the studies suggest that the most pronounced preventive anti-adhesion effect has a healthy peritoneum. In this regard, it is believed that all efforts in this direction should be aimed at preventing the consolidation of wound peritoneal surfaces and stimulating their mesothelization.

Recently, for the prevention of postoperative adhesions around the world, they have begun to make wider use of agents whose basis of action is the separation of wound surfaces that arise after surgical interventions for inflammatory diseases of the abdominal organs [Myasnikov AD, Lipatov VA Experimental justification for the use of methyl cellulose gel for the prevention of relapse of adhesive disease. // Proceedings of the 67th scientific session of KSMU and the department of biomedical sciences of the Central Black Earth Science Center of the Russian Academy of Medical Sciences. Part I. - Kursk: KSMU, 2002. - P.94-95; Lipatov V.A. On the issue of prevention of postoperative adhesive process of the abdominal cavity. / Materials of the Third international scientific-practical conference "Health and education in the XXI century" March 29-31, 2002, Moscow, - S.256-257].

Attempts made by different researchers to act on the humoral link of adhesiogenesis (introducing heparin, hyaluronidase (lidase), fibrinolytic enzymes, as well as plasmin system activators and antiplasmin inhibitors, etc.) into the abdominal cavity cannot be used in a clinic with a guarantee of effectiveness. This is primarily due to the fact that it is rather difficult to calculate the magnitude of the necessary corrective effect on one or another humoral link. The restriction of the use of dextrans is associated with their rapid elimination from the abdominal cavity, which requires repeated administration, the films are mechanical irritants that can cause an aseptic reaction, both from the damaged and intact peritoneum. In the absence of peritonitis in the patient, drainage of the abdominal cavity is not indicated [Lipatov V.A. On the pathogenetic orientation of anti-adhesive preventive measures]. Intraperitoneal administration of glucocorticosteroids for prophylactic purposes is not effective enough, since studies prove that drugs of this group in the postoperative period, in addition to inhibiting the activity of fibroblasts, have a number of significant side effects (inhibit all parts of the immune system, inhibit the regeneration of damaged peritoneum, etc. )

A known method of preventing the formation of adhesions of the abdominal cavity using cellulose - a material obtained from viscose treated with nitrogen tetroxide, produced in the form of a commercial preparation Interceed [Ethicon Inc., Somerville, NJ, USA; Enrico S. Et al., 1996]. The drug is a membrane that completely dissolves within 28 days. The clinical use of the drug showed a decrease in the number and severity of postoperative adhesions. The disadvantage of this method is the decrease in its effectiveness in the presence of blood or an excess of peritoneal fluid [DiZerega GS., 1994; Wiseman D., 1999].

The method [Lipatov V.A., Grigoryan V.V. Assessment of the severity of adhesions by the method of semantic differential // Mat. 2nd Russian scientific - prakt. conf. "Actual issues of ecology, experimental and clinical medicine." - Eagle. - 2002 - P.85-86] consisting in the introduction into the abdominal cavity of water-soluble methylcellulose (Russian anti-adhesion barrier agent "Linteks-Mesogel"), the gel based on it is pseudo-plastic, does not have toxicity, has good surface-active properties, wetting ability , biological resistance, physiologically inert. The gel acts as an artificial temporary “barrier” between damaged serous surfaces, providing effective separation of surfaces during their healing, and then resolves [Verbitsky D.A., Krasilnikov D.E., Zhukovsky V.A., Lipatov V.A., Sleptsov I.V. The possibility of reducing the adhesion process in conditions of abdominal surgical infection. - Internet resources. - http://www.mmed.ru/prod/prod_antiadhesion21.shtml]. Reducing the adhesion of the surfaces of organs and tissues helps to maintain their mobility and prevents the formation of adhesions.

The disadvantage of this method is that methyl cellulose and sodium methyl carboxymethyl cellulose do not have antiseptic properties, but only "do not contribute to the growth and reproduction of microorganisms" [Lipatov VA, Pecheny OD, Kobzareva EV Microbiological examination of cellulose ethers used for the prevention of postoperative adhesions of the abdominal cavity. // Actual issues of military and preventive medicine. / Sat Proceedings of the IV scientific-practical conference of doctors of the Volga-Ural military district. Orenburg, November 28-29, 2003 - P.217-219] and their use in the presence of an inflammatory or purulent process in the abdominal cavity (peritonitis) is limited.

Tasks: preventing the development of adhesions and their relapses after various operations, reducing treatment time, reducing the cost of treatment.

To prevent the formation of postoperative adhesions, a method is proposed which consists in the intraperitoneal injection of 5% pectin gel, which is a biopolymer of polygalacturonic acid and known for its bactericidal enterosorbent properties [Potievsky E.G., Shavakhabov Sh.Sh., Bondarenko V.M., Abushaeva Z.D. . Experimental and clinical study of the effect of pectin on pathogens of acute intestinal infections // Journal of Microbiology, Epidemiology and Immunobiology. - 1994. - Appendix. - S.106-109]. Pectin gel has unique surface-active properties. The technical result of the method is that when pectin is introduced onto the wound surface at the final stage of the operation, the effect of hydroflotation of wound surfaces develops, thereby preventing their consolidation, gluing by fibrin deposited from the peritoneal effusion, and then mesothelization of the surface. Pectin is biodegradable and excreted. By preventing the formation of adhesions and the subsequent withdrawal of the gel components, pectin provides an increase in the treatment effect, a reduction in the duration of treatment, and, consequently, the cost of medical and social rehabilitation of the patient. In this case, there are no side effects characteristic of analogues. In addition, pectin has an antimicrobial effect, which allows us to solve the tasks.

The technical novelty of the invention is that to prevent the formation of adhesions in the wound area using 5% pectin gel, which is injected into the damaged areas laparoscopically or directly.

The method is performed as follows. At the end of the laparotomy, 5% pectin gel is introduced into the wound area and the damaged areas of the parietal and visceral peritoneum are treated with it. Intestinal loops are immersed in the abdominal cavity and the laparotomy wound is sutured. Pectin in the abdominal cavity biodegrades in the period of 7-10 days, during which time the processes of mesothelization have time to end.

Experimental data. The method was tested on the model of the adhesive process of the abdominal cavity, proposed by V. A. Lipatov and A. I. Bezhin [2000]. Under aseptic conditions, two series of Wistar rats (20 animals each) reproduced the adhesion process by trauma to the peritoneum. The first group was the control, the second experimental. Median laparotomy was performed in two series of rats weighing 160-180 g under aseptic conditions under thiopental anesthesia, after which an organocomplex consisting of loops of the small and large intestine was removed to the laparotomy wound. Two sections of the parietal peritoneum were excised at 2 cm on both sides. The organs of the abdominal cavity and the parietal peritoneum were treated with 0.3% potassium permanganate solution, the organocomplex was dried for 30 minutes. Thus, the peritoneum was subjected to mechanical damage and drying, then the laparotomic wound was sutured in the control group, and the parietal and visceral peritoneum was treated with 5% pectin gel before suturing, 3 animals in the control group died on the 6-7th day due to the development of a massive adhesion process intestinal obstruction and the formation of external intestinal fistulas. Animals were taken out of the experiment on the 10th day by overdose of sodium thiopental. Before removing from the experiment, the general condition was assessed, and a general blood test (OAK) was performed. Rats underwent autopsy, the severity of the adhesive process was assessed visually and using the method of semantic differential [Lipatov V.A. On the issue of prevention of postoperative adhesive process of the abdominal cavity. / Materials of the Third international scientific-practical conference "Health and education in the XXI century" March 29-31, 2002, Moscow, - S.256-257]. The parietal peritoneum and abdominal organs underwent histological examination according to the generally accepted technique with formalin fixation, paraffin embedding, hematoxylineosin staining, and Van Gieson staining. The results of the study were statistically processed. There is no statistically significant difference in the general condition and OAK between the control and the main groups. In the control group, adhesions occurred in all animals with massive soldering of the small and large intestines to deserted areas, the middle scar, with the formation of external fistulas in 5 rats. The severity of the adhesion process using the semantic differential method was 3.4 ± 15 points, in the main group - only 3 rats had loose soldering of the omentum to the middle scar, and the severity of the adhesion process was 0.003-0.001 points. During histological examination in animals of the first group, the parietal and visceral peritoneum are fibrously altered. In the area of adhesions, a collagen network with fibroblasts and fibrocytes. In the main group studied the morphology of the peritoneum from the area of the defect. According to its histostructure, the peritoneum did not differ from intact; there were local fields of fibrosis. On the 5th day there was a small amount of gel in the abdominal cavity, and on the 7th day the gel in the abdominal cavity was not determined. Thus, the use of pectin gel reliably effectively reduces the likelihood of an postoperative adhesive process of the abdominal cavity, prevents the risk of adhesions, which opens up the prospects for its use in the clinic for the prevention of postoperative adhesions and complications.

The presented microphotographs of the experiment demonstrate the pathomorphological status of the peritoneum after treatment with 5% pectin gel. The presented micrographs show that the mesothelial lining of the peritoneum is preserved, mesotheliocytes have slight signs of degeneration, expressed in moderate vacuolization of the cytoplasm of individual cells, compaction and karyopicnosis of their nuclei. The basement membrane of the mesothelium is slightly thickened, the underlying connective tissue is characterized by a weak disorganization of its fibrous component and moderate amorphous swelling. The adjacent smooth muscle tissue is almost intact (Figs. 1, 2, 3). Figure 1. Mesothelium of the serous membrane. Hematoxylin-eosin stain. SW Ob.90x approx.6.3x. Figure 2. Mesothelium of the serous membrane. Hematoxylin-eosin stain. SW Ob.40x approx.6.3x. Figure 3. Mesothelium of the serous membrane. Hematoxylin-eosin stain. SW Ob.40x approx.6.3x.

Clinical example 1. Patient K., 34 years old, was hospitalized in the surgical department from 06/26/06 to 01/01/06, ist. disease number 1347. Diagnosis: recurrent small intestinal adhesive obstruction. 06/26/06. An operation was performed - laparotomy, dissection of adhesions, elimination of adhesive small bowel obstruction. Parts of the loops of the small intestine that underwent adhesiolysis were treated with 300 ml of 5% pectin gel. Loops of the small intestine are laid in the abdominal cavity and a drainage is left in the small pelvis, removed through a puncture of the right side wall of the abdomen. The drainage is closed. The postoperative period was uneventful, intestinal motility restored on the 2nd day. The chair is marked on the 3rd day. On the 3rd day after the operation, the drainage is open, 300 ml of gel-like liquid with an admixture of lysed blood are released through it. Drainage removed. The patient was discharged on the 7th day in a satisfactory condition. Examined after 1 month. No complaints.

Clinical example 2. Patient A., 32 years old, September 14, 2006. Hospitalized in the surgical department with complaints of cramping pains throughout the abdomen, repeated vomiting of gastric contents, lack of gas discharge during the day. From the anamnesis: in 2005 she was operated on an emergency basis for an ectopic pregnancy from laparotomy access. Over the next year, attacks of cramping pains in the lower abdomen, nausea were noted. At the time of admission, the abdomen will succumb, soft, moderately painful in all departments, splashing noise on palpation is noted, multiple arcades and fluid levels, swollen loops of the small intestine are determined on the radiograph. Diagnosed with acute adhesive obstruction. The patient was operated on after preoperative preparation. Diagnostic laparoscopy was performed, the diagnosis of adhesive obstruction due to soldering of a loop of the small intestine to the uterus (the site of the resected right fallopian tube) and strangulation of the small intestine around the commissure was confirmed. The commissure is dissected laparoscopically, strangulation is eliminated, loops of the small intestine are straightened. 40 ml of 5% pectin gel was added to the adhesion dissection site. Control drainage was not left. The postoperative period is without features, the patient is active from the first day, with the control of pelvic ultrasound, there were no fixed loops of the small intestine to the anterior abdominal wall and pelvic organs, the loops are mobile. The patient in satisfactory condition was discharged on the 5th day for outpatient treatment.

In this way, 7 patients were diagnosed with diagnoses - acute phlegmonous appendicitis, tubo-ovarian abscess, adhesive small bowel obstruction. There were no complications in the postoperative period. Patients were discharged with recovery.

Medical and social effect: the use of the proposed method allows you to create the most favorable conditions for the mesothelization of the damaged peritoneum, which almost completely eliminates the formation of adhesions, as well as such a formidable complication as adhesive intestinal obstruction.

Claims (1)

A method for the treatment of adhesions and prevention of relapse of adhesions, including laparotomy or laparoscopy, the introduction of a gel, characterized in that they dissociate the damaged serous membranes and carry out mesothelization by introducing 5% pectin gel into the wound area.

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