RU2528973C1 - Method of treating trophic ulcers - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: lipoaspiration cannula of the diameter of up to 1.2 mm is used to sample primary aspirate from subcutaneous fat of an anterior abdominal wall. The produced aspirate is washed with 5% glucose to prepare a lipid fraction to be diluted with 5% glucose in ratio 1:1 of glucose-fat, agitated to prepare a suspension. The skin is punctured to insert a blunt-ended injection cannula of the diameter of up to 1.2 mm into soft tissues surrounding an ulcer and immediately under an ulcerous defect. The cannula is delivered to an end of each marked beam, and the prepared suspension is administered at the output by removing the cannula gradually by simultaneous pressing on a syringe piston. Up to 5 insertions of the suspensions are fan-shaped from one puncture herewith creating a perifocal cushion of the thickness of up to 0.7 cm. A distance of passage beams shall not exceed 2-3 mm.

EFFECT: higher quality of treatment of this pathology by forming the normotrophic scar tissue by stimulating regional microcirculation.

3 tbl, 1 dwg, 1 ex

Description

The invention relates to medicine and can be used in surgery, traumatology, dermatology.

Trophic ulcers are long-term non-healing defects of integumentary tissues (skin or mucous membrane) that occur mainly in case of circulatory disorders, as well as damage to nerves or spinal cord. Most trophic ulcers appear on the lower extremities. A trophic ulcer is characterized by the inability of tissues to self-heal.

In the treatment of trophic ulcers, many different methods and tools are currently used, including hyperbaric oxygenation, ultraviolet radiation, laser blood irradiation, hirudotherapy, plasmapheresis, lymphosorption and other detoxification methods, the use of immunomodulators and other methods that have not undergone high-quality clinical studies. From the perspective of evidence-based medicine, they cannot be used as standard methods of treatment. While local therapy is one of the most important areas of treatment for trophic ulcers. (Clinical surgery. National leadership. TI./ Edited by B.C. Saveliev, A.I. Kiriyenko. - M.: GEOTAR-Media, 2008.)

The principle of complex therapy of trophic ulcers is known, combining conservative treatment (general and local) and various kinds of surgical interventions. Various antiseptics, native and immobilized proteolysis enzymes and their inhibitors, etc. (the use of immobilized enzymes and their natural inhibitors in surgery) / Tolstykh P.I., Gostishchev V.K., Vasilkova Z.F. and other - Surgery. 1983. - No. 6. S.94-96.)

However, despite the wide selection of treatment measures, it is not possible to reduce the time of both inpatient and outpatient treatment of patients with trophic ulcers. Also, during healing, hypertrophic or atrophic scars are formed, which violates the trophism of the surrounding tissues, leads to frequent relapses and the formation of functional and cosmetic defects.

It is safe to say that the treatment of trophic ulcers remains the most important medical and social problem of modern society. (Treatment of trophic ulcers of venous etiology: A manual for doctors / Edited by B.C. Savelyev. - M.: RSMU, 2000.)

A known method of treating trophic ulcers (RF Patent No. 2274479, A61N 5/067 A61K 31/409, bull. No. 11, 04/20/2006), including the introduction of a photosensitizer into the ulcer and its subsequent irradiation with a laser. As a photosensitizer, a gel Phototitazin gel based on the glucurin salt of chlorin E6 Phototitazin gel with a concentration of the active substance of 0.5-1.5% is used, and laser irradiation is carried out continuously at a wavelength of 660 nm, the density applied to energy wound 30-40 J / cm ² , power density 0.8-0.1 W / cm ² . However, this method leads to gross scarring of the skin around the ulcer.

Also known is a method of treating trophic ulcers in a diabetic foot (RF Patent No. 2357772, A61N 5/067, A61K 31/409, A61K 33/08, A61P 17/02, bull. No. 16, 06/10/2009), including the removal of necrotic tissue in the area of the ulcer, excision and cortical layer of bone. Every day for 5-7 days, the area of operation is washed with an antiseptic solution, a gauze dressing impregnated with a 0.5% iodopirone solution is applied. Then, a loose skin flap is transplanted onto the exposed cancellous bone. However, this method has a significant drawback: prolonged healing, the formation of rough inverted skin scars that impede the function of muscles and tendons.

Closest to the attached is the method of autotransplantation of adipose tissue - lipofilling, previously not used in the treatment of trophic ulcers, but used for contour plastics (Scientific and Practical Journal “Experimental and Clinical Dermatocosmetology No. 6”, 2011). The method includes obtaining viable pure fat, washing off the aspirated fat with a physiological saline solution, and also subsequent injection (using an injection syringe, to the lobby of which a special lipofilling cannula is attached to introduce fat with an inner diameter of up to 2 mm and a blunt tip) into the problem area in the ratio 1: 1 fat and saline.

The objective of the proposed method is to improve the quality of treatment due to the formation of normotrophic scar tissue and reduce the treatment time of trophic ulcers.

The task is carried out due to the fact that using a lipoaspiration cannula up to 1.2 mm in diameter, a primary aspirate is taken from the subcutaneous fat of the anterior abdominal wall, which is washed with a 5% glucose solution; the resulting fat fraction is diluted with 5% glucose solution in a ratio of 1: 1 - glucose-fat, shaken and get a suspension; through punctures on the skin up to 1.5 mm into the soft tissues around the ulcer and directly under the ulcer defect, an injection cannula up to 1.2 mm in diameter with a blunt end is passed to the end of each marked beam and the resulting suspension is introduced at the exit, gradually removing the cannula by simultaneously pressing on the syringe plunger; up to 5 injections of suspension from one puncture are made fan-shaped, creating a perifocal roller up to 0.7 cm thick; the distance between the beam-channels should not exceed 2-3 mm.

The method is as follows.

Before surgery, a patient with trophic ulcers that are in the second or third phase of the wound process, after cleansing from necrotic tissue, mark the donor zones. On the operating table in the patient’s supine position after treatment of the skin with an antiseptic solution, the sites for the introduction of cannulas in the donor and recipient areas are marked, as well as the traces of the cannula excursion during lipofilling in recipient areas.

After processing the surgical field, under local infiltration anesthesia with 0.1% lidocaine solution with the addition of an adrenaline solution (1: 200000), skin punctures up to 1.5 mm are performed using an eye scalpel, 3-5 cm away from the border of the donor zone. Tumorscence of the donor area is carried out, for example, when 50 ml of fat is taken, the infiltration volume should be 200 ml. Between infiltration and lipoaspiration there should be a 15-minute exposure to realize the vasoconstrictive effect of adrenaline. Then, using a lipoaspiration cannula up to 1.2 mm in diameter, careful tunneling is carried out with minimal effort. Previous tumescence contributes to the unhindered and easy penetration of the lipoaspiration cannula into the tissue of the donor zone.

Syringes for microlipoaspiration should be no more than 20 ml, and the negative pressure in them is minimal. It is created by pulling the piston of a single syringe attached to the suction cannula. The resulting fat is the primary aspirate. The primary aspirate is subsequently washed with a 5% glucose solution. The resulting fat fraction is diluted with 5% glucose solution in a ratio of 1: 1 - glucose-fat, shaken and get a suspension.

Through punctures on the skin up to 1.5 mm, an injection cannula up to 1.2 mm in diameter with a blunt end is passed to the end of each marked beam and fat is injected at the exit, gradually removing the cannula by simultaneously pressing the syringe plunger. Up to 5 injections of suspension from one puncture into the soft tissues around the ulcer are carried out fan-shaped, creating a perifocal roller up to 0.7 cm thick. The distance between the beam-channels should not exceed 2-3 mm. Suspension is also introduced fan-shaped and directly under the ulcer defect.

After removing the cannula, the beam-path of the channel is gently massaged through the skin. An aseptic wound dressing is then applied. With extensive ulcerative defects, the procedure is repeated after 14 days.

Healing takes place within 30-38 days with the formation of normotrophic scar.

Figure 1 shows the directions of suspension in soft tissues around a trophic ulcer, where:

1 - trophic ulcer;

2 - injection cannula up to 1.2 mm in diameter with a blunt end;

3 - ray paths of introductions of suspension from one puncture into soft tissues around a trophic ulcer.

Under our supervision, there were 52 patients with trophic ulcers of the lower extremities receiving inpatient treatment in the conditions of the surgical department No. 2 at the City Clinical Hospital No. 7 MBUZ and the surgical department No. 2 at the Road Clinical Hospital at Krasnoyarsk station of JSC Russian Railways ′

Patients were divided into two groups (Table 1).

Table 1 The distribution of patients in groups Groups Number of patients Treatment method Duration of treatment (days) 1 group (comparison group) 25 Traditional therapy 63 ± 12 2 group (main group) 27 Lipofilling 34 ± 4

The first group (25 patients) received traditional therapy, including surgical treatment of a wound and, depending on the etiology of a trophic ulcer, appropriate infusion, anticoagulant, disaggregant therapy, prostaglandins E1, antispasmodics, analgesics, vitamins and their analogues, antibiotics if necessary. Patients underwent daily dressings and local treatment. Also, physiotherapy (UHF, magnetotherapy) was included in the complex of therapeutic measures.

In the second group (27 patients), against the background of similar traditional management, patients underwent additional lipofilling of trophic ulcers.

The microcirculation status of the pathological lesion was studied by laser Doppler flowmetry (LDF) in the red emission spectrum using a BLF-21 laser analyzer of capillary blood flow. LDF-grams were recorded once every 3 days starting from 9 days after lipofilling, directly at the edge of a chronic ulcer and at symmetrical points of a healthy limb (Table 2).

table 2 Changes in tissue perfusion in the wound in patients of the 1st and 2nd group Measuring point Perfusion (perf. Unit) Groups before
treatment 9 days 12 days 15 days Edge of the wound 1 group 2 group 1.79 ± 0.13 1.72 ± 0.11 1.81 ± 0.15 1.87 ± 0.16 1.84 ± 0.11 2.04 ± 0.18 1.93 ± 0.14 2.32 ± 0.2 Healthy limb 1 group 2 group 3.1 ± 0.47 3.2 ± 0.43 3.6 ± 0.46 3.6 ± 0.4 3.7 ± 0.45 3.8 ± 0.42 3.7 ± 0.43 3.7 ± 0.45

9 days after the introduction of suspension into the soft tissues around the ulcer and under the ulcer defect in patients of the second group, an increase in the microcirculation index by 8.7% compared with the initial values was noted (Table 2). During a 2-week monitoring of the microcirculation index in patients of the first group, there was no significant increase in perfusion of the edge of the pathological focus, while in patients of the second group by 15 days of observation this indicator increased by 35% (from 1.72 perf. Units to 2.32 perf. Units) from the initial value (Table 2).

Thus, the use of auto-fat lipofilling in the complex treatment of chronic ulcers allows to increase the microcirculation of the pathological focus, which, in turn, helps to increase granulation, marginal epithelization and scarring.

When cytological examination of an imprint from a trophic ulcer (Romanovsky-Giemsa stain, 400 magnification) revealed significant differences in the cellular composition before and after treatment in the first and second groups. After treatment, a few neutrophils, a significant number of macrophages, reticuloendothelial cells, and fibroblasts were found in the second group relative to the first.

One of the indicators of the effectiveness of the local treatment of trophic ulcers was a thorough planimetric study of wound defects. The dynamics of the area of trophic ulcers in patients of the first and second groups during treatment was significantly different and was associated with the acceleration of regional epithelization and scar formation in patients of the second group (Table 3)

Table 3 Relative indicators of reduction in the area of chronic wounds depending on the method of treatment Before treatment 1st week 2nd week 3rd week 4th week 5th week 1 group one hundred% 92% 79% 67% 60% 52% 2 group one hundred% 78% 53% 38% 26% 13%

Based on planimetric indicators, in the patients of the second group, by the end of the 5th week of treatment, a decrease in the area of the wound defect was noted by almost 7.7 times compared with the initial values due to marginal epithelization, while in patients of the first group the wound area decreased only in 2 times. Final scarring and epithelization of chronic ulcers in patients of the first group was observed on 65 ± 16 days of outpatient treatment, and in patients of the second group - on 34 ± 4 days.

Clinical example: Patient N., 53 years old, was admitted to the surgical department No. 2 in MBUZ ″ City Clinical Hospital No. 7 ″ with DS: Trophic ulcer of the lower third of the left leg. Upon admission, the patient was treated with a purulent wound of the lower third of the left lower leg, 3 × 4 cm in size, chlorhexidine, an aseptic dressing was applied. The patient was prescribed infusion, vascular, antibacterial, analgesic therapy.

The patient underwent daily dressings and treatment of a purulent wound with chlorhexidine. On the 5th day, after cleansing from necrotic tissue (in the second phase of the wound process), the patient underwent lipofilling.

Before the operation, the patient was labeled with donor zones. On the operating table in the patient’s position, lying after the skin was treated with an antiseptic solution, the places for the introduction of cannulas into the donor and recipient areas, as well as the paths of the excursion of the cannulas for lipofilling into the recipient areas, were marked.

After processing the surgical field, under local infiltration anesthesia with a 0.1% lidocaine solution with the addition of an adrenaline solution (1: 200000), a puncture was performed on the skin up to 1.5 mm using an eye scalpel, departing 3-5 cm from the border of the donor zone. We performed tumescence of the donor zone. Between infiltration and lipoaspiration, a 15-minute exposure took place to realize the vasoconstrictive effect of adrenaline. Then, using a lipoaspiration cannula up to 1.2 mm in diameter, careful tunneling was carried out with minimal effort. Previous tumescence contributed to the unhindered and easy penetration of the lipoaspiration cannula into the tissue of the donor zone.

Using a 20 ml disposable syringe attached to the suction cannula, due to the minimum negative pressure created by pulling the piston, fat was collected - the primary aspirate, which was subsequently washed with a 5% glucose solution. The resulting fat fraction was diluted with a 5% glucose solution in the ratio 1: 1 - glucose-fat, shaken and got a suspension.

Through punctures on the skin up to 1.5 mm, an injection cannula up to 1.2 mm in diameter with a blunt end was drawn to the end of each marked beam and a suspension was introduced at the exit, the cannula was gradually removed by simultaneously pressing the syringe plunger. Up to 5 injections of suspension from one puncture into the soft tissues around the ulcer were made fan-shaped, creating a perifocal roller up to 0.7 cm thick. The distance between the beam-channels did not exceed 2-3 mm. Just introduced a fan-shaped suspension and directly under the ulcer.

After removing the cannula, the beam-path of the channel was gently massaged through the skin. Then an aseptic wound dressing was applied.

On the 10th day after lipofilling: satisfactory condition; no complaints; the bottom of the trophic ulcer is made by bright granulation, hyperemia, there is no edema around, 32% epithelization of the wound; no fibrin.

On the 20th day after lipofilling: satisfactory condition; no complaints; the bottom of the trophic ulcer is made by bright granulation, hyperemia, there is no edema around, 62% of wound epithelization and scarring.

After 1 month: 100% wound epithelization, normotrophic scar.

The proposed method for the treatment of trophic ulcers increases the effectiveness of treatment, reduces the time of ulcer epithelization, promotes the formation of normotrophic scar, improves the conditions of regional microcirculation. The method is simple, effective, affordable, clearly performs the task, does not require expensive special equipment and can be widely used not only in large medical institutions, but also in regional centers and clinics.

Claims (1)

A method of treating trophic ulcers, including autotransplantation of adipose tissue - lipofilling, characterized in that using a lipoaspiration cannula up to 1.2 mm in diameter, a primary aspirate is taken from subcutaneous fat of the anterior abdominal wall, which is washed with a 5% glucose solution; the resulting fat fraction is diluted with 5% glucose solution in a ratio of 1: 1 - glucose-fat, shaken and get a suspension; through punctures on the skin up to 1.5 mm into the soft tissues around the ulcer and directly under the ulcer defect, an injection cannula up to 1.2 mm in diameter with a blunt end is passed to the end of each marked beam and the resulting suspension is introduced at the exit, gradually removing the cannula by simultaneously pressing on the syringe plunger; up to 5 injections of suspension from one puncture are made fan-shaped, creating a perifocal roller up to 0.7 cm thick; the distance between the beam-channels should not exceed 2-3 mm.

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