RU2538175C1 - Method for conservative treatment of external colonic fistulas - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: patients keep a diet with reducing an amount of liquid taken up to 1.5l a day that is compensated by the intravenous administration of solutions an amount and composition of which depends on a degree of water-electrolyte disturbances. Additionally, after bandage removal, the wound and edges of the fistulous passage is 5% potassium permanganate, which is then washed with 3% hydrogen peroxide. A mouth of the fistula and the wound edges are dried. That is followed by an aeration of the mouth of the fistula with a cooled plasma flow of nitrogen monoxide at a depth of 0.5cm in the therapeutic mode of 2000 mg/m³ and exposition of 1.5min. The mouth of the fistula and the wound edges are treated with a plasma flow of nitrogen monoxide in the concentration within the contact area with the wound surface of 1500 mg/m³ and time of exposure of 20 seconds per each 1 cm² of the surface. The mouth of the fistula and the wound edges are dried. The mouth is packed with the gauze swab. The fistulous wound is exposed to EHF waves with the pure noise spectrum and the provided integral power on the wound surface of 1.5 mcWt along the perimeter of the mouth at 15mm from the fistulous passage for 30 minutes. The swab is removed. The mouth and the surrounding skin is treated with zinc paste and covered with gauze swabs. The further bandages are performed in the similar way as the bandage wets with the intestinal contents, but no more than 2 times a day and at least once every 3 days.

EFFECT: safe and effective conservative treatment of the intestinal fistulas at any phase of the wound process that enables avoiding risks of surgical intervention and general anaesthesia by rapid reduction of skin maceration and perifocal inflammation surrounding the mouth and prevents them, stimulates the growths of granulocyte tissue and epithelisation of the fistuous wound.

Description

The invention relates to surgery, and in particular to methods for treating intestinal fistulas.

Despite the achievements of modern medicine, treatment of external intestinal fistulas remains an urgent problem of abdominal surgery [Vitsyn B.A., Blagitko E.M. Formed and unformed external intestinal fistulas. - Novosibirsk: Science. - 1983. - 142 p .; Makarenko T.P., Bogdanov A.V. Fistulas of the gastrointestinal tract. - M.: Medicine. - 1986. - 144 p .; Bazaev A.V. Optimization of treatment of patients with external intestinal fistulas. Dis. ... Dr. honey. sciences. - N. Novgorod, 2004 .-- 322 p .; Kanshin N.N. Unformed intestinal fistulas and purulent peritonitis (surgical treatment). - M .: Profile, 2007. - 160 p.].

Persons with this pathology are one of the most difficult categories of patients. The vast majority of them have signs of serious disorders of homeostasis, there are significant violations of water-electrolyte balance and acid-base balance, anemia, hypoproteinemia, wound depletion, failure of the immunocompetent system. Against this background, in a number of cases, there is a persistent, not completely stopped abdominal inflammatory process. As a result of prolonged antibiotic therapy, the selection of the existing microbiota occurs, activation and growth of highly resistant nosocomial flora is noted, a biofilm process develops in the wound. These points determine the very limited effectiveness of a number of measures to combat surgical infection, including the use of antibiotics, antiseptics and sanitizing manipulations. At the same time, the risk of performing any reconstructive and reconstructive interventions aimed at closing the fistula, as well as conducting general anesthesia, greatly increases.

As with most severe surgical diseases, the comprehensive treatment of patients with intestinal fistula includes general and local therapeutic measures. The basis of the general treatment (in addition to observing the basic modern principles of the treatment of purulent-septic diseases) is the fight against the development of water, electrolyte and protein metabolisms developing due to the loss of intestinal contents, the maintenance of homeostasis using infusion therapy, enhanced parenteral and enteral nutrition. Local treatment involves stopping the purulent-inflammatory process in the tissues surrounding the fistula, protecting them from the effects of intestinal secretion, reducing or stopping the loss of intestinal contents [Bogomolov NI, Smolyakova N.Yu., Bogomolova NN, Smolyakov Yu.N. . Device for obstruction and treatment of intestinal fistula. A.S. RF 2224554 C1, cl. A61M 27/00, A61M 31/00. Claim 06/11/02. Publ. 02/27/04; Kanshin N.N. Unformed intestinal fistulas and purulent peritonitis (surgical treatment). - M .: Profile, 2007. - 160 p.].

The nutrition of patients with intestinal fistula should include enteral (with stopped bowel paresis), parenteral nutrition. The principles of enteral nutrition are the predominance of mechanically sparing, easily digestible, high-calorie foods with limited carbohydrates. They recommend striving to alternate during the day relatively dense protein-rich dishes with low-calorie liquid dishes that inhibit the secretion of the glands of the stomach and pancreas and do not stimulate bile formation and bile secretion.

To protect the skin from the action of intestinal secretions, physical, mechanical and biochemical methods are used.

Known methods of treating intestinal fistulas, including the use of ointment dressings, temporary obstruction of the fistula and the use of an active aspiration system to stop purulent-destructive processes in the wound, eliminate maceration around it. However, these methods are not always effective and have several disadvantages. Introduction to the fistulous course of the obturator leads to an increase in the size of the intestinal wall defect. The use of active aspiration systems contributes to an increase in the size of the fistulous course, to an increase in the loss of fluid and electrolytes, which subsequently leads to the formation of a lip-shaped fistula and the expansion of the volume of surgical intervention.

Physical methods are based on the use of Lassar paste, BF-2 glue, BF-6 glue, silicone paste, polymerizable film and other means that are applied to the skin around the outer opening of the fistula [N. Kanshin Unformed intestinal fistulas and purulent peritonitis (surgical treatment). - M .: Profile, 2007. - 160 p .; Ishenko O.V. The use of fibrin glue in the treatment of patients with unformed intestinal fistulas. Abstract. dis. ... cand. honey. sciences. - M., 2011].

A known method of treating unformed fistulas, including obturation of a cavity or wound with a fistula with polymeric material [Rechen D.G. The rationale for the tactics of treatment of patients with postoperative external small intestinal fistulas in the formation stage. Dis. ... cand. honey. sciences. - Saratov, 2003. - 162 p.]. The disadvantage of this method is that the obturator prevents the growth of granulation tissue and the narrowing of the fistulous course, which further leads to the formation of a labial fistula, which requires complex surgical intervention.

A known method of treatment of unformed fistulas, including the use of a vacuum aspirator [Bazaev A.V. Optimization of treatment of patients with external intestinal fistulas. Dis. ... Dr. honey. sciences. - N. Novgorod, 2004. - 322 p.]. The disadvantage of this method is that when creating a vacuum in the fistulous course, the content enters through the drainage, so it is possible to increase the loss of fluid and electrolytes. In some cases, it is recommended to return the intestinal contents evacuated with the help of a drainage-foam system and a vacuum aspirator into the intestinal lumen through a probe distal to the fistula [Bazaev A.V. Optimization of treatment of patients with external intestinal fistulas. Dis. ... Dr. honey. sciences. - N. Novgorod, 2004. - 322 p.].

The therapeutic efficacy of exogenous nitric oxide (NO) in the treatment of a number of diseases is known, which is based on the properties of endogenous NO as a multifunctional physiological regulator and consists in the following:

- normalization of microcirculation due to vasodilation, antiplatelet and anticoagulant effects of NO;

- the bactericidal action of both its own and indirect peroxynitrite, which is formed in tissues during the interaction of NO with superoxidion;

- the induction of phagocytosis of bacteria by neutrophils and macrophages;

- activation of antioxidant protection;

- improvement of nerve conduction (neurotransmission);

- regulation of specific and non-specific immunity;

- direct induction of fibroblast proliferation, vascular growth, collagen synthesis, formation and maturation of granulation tissue, epithelial proliferation;

- modulation of apoptosis and prevention of pathological scarring.

When using the Plazon apparatus, the therapeutic effect is carried out by supplying to the biological tissues gas streams of various temperatures, but with a constant content of nitric oxide (NO) in the stream [Kruglov E.E., Nalivkin A.E., Mashkov A.E., Nasedkin A.N., Golubovsky G.A. A method of treating intestinal fistula. A.S. RF 2233123 C2, cl. A61B 17/00, A61K 33/08, A61P 1/00. Claim 09/12/02. Publ. 07/27/04; Kirshina O.V. Klimenko I.G. Physical methods in the complex treatment of purulent diseases of soft tissues. // Siberian. honey. review. - 2009. - No. 5. - S. 55-58].

A known method of treating intestinal fistula, including the installation of drainage and drug therapy with exposure through the distal end of the drainage, installed at a distance of 0.2-1.0 cm from the fistula, by air-gas flow of nitric oxide (NO-therapy) from the apparatus "Plazon" in therapeutic regimen for 2-3 minutes daily for a course of 6-10 sessions [Kruglov E.E., Nalivkin A.E., Mashkov A.E., Nasedkin A.N., Golubovsky G.A. A method of treating intestinal fistula. A.S. RF 2233123 C2, cl. A61B 17/00, A61K 33/08, A61P 1/00. Claim 09/12/02. Publ. 07/27/04].

The disadvantage of this method is the need to drain the fistula using x-ray control, which cannot be performed under the dressing or laparoscopic method, which cannot be used in the dressing daily, due to the cumbersome equipment and in some cases the absence of specially trained personnel.

EHF-therapy is known to treat a number of diseases. The correction and restoration of impaired functions through the use of EHF-therapy is based on the principle of influencing the body’s own information-control system, the principle of “imposing” healthy rhythms lost on the body during the illness. It is believed that in pathological conditions, external EHF radiation acting on the altered body mimics the signals produced by the body itself, helping it to quickly and efficiently eliminate alteration. Cells and organs of a weakened body that are not able to independently restore impaired homeostasis can be normalized by external EHF radiation and continue to function normally. One of the mechanisms of action of EHF waves in the treatment of wounds is an increase in the amount of connective tissue, mainly due to the formation of collagen fibers.

There is a method of treating trophic ulcers of the lower extremities, based on these principles, in which local exposure to the EHF waves with a spectrum of the "white noise" type is performed for 10-15 minutes and an additional effect on biologically active points [Baltschugov VA, Polyakova A.G., Anisimov S.I., Efimov E.I., Kornaukhov A.V. EHF-therapy with low-intensity noise radiation. N. Novgorod: Publishing House of the Nizhny Novgorod State University. N.I. Lobachevsky, 2002. - S. 68-69]. Moreover, the total duration of the session is up to 30 minutes, and the duration of the course depends on the effectiveness of the treatment and includes 10-12 sessions.

The last two methods are taken as prototypes.

The aim of the present invention is a safe and effective treatment of intestinal fistulas using only conservative methods that avoid the risks of surgery and general anesthesia.

The set goal is achieved by a set of measures, including diet, medicinal restorative therapy and local treatment - treatment of the wound and edges of the fistulous passage with 5% potassium permanganate solution and 3% hydrogen peroxide solution, treatment and tamponing of the fistulous passage with zinc paste, exposure of the fistula to exogenous nitric oxide (NO ) obtained using the Plazon domestic air-plasma apparatus, and local irradiation of the fistulous wound with millimeter waves of the EHF range with a white noise spectrum in the frequency range 5 3.57-78.33 GHz using the AMFIT-0.2 / 10-01 apparatus).

The proposed method is as follows.

For the entire period of treatment, a patient with an external colonic fistula is prescribed a diet with a limitation of the total volume of fluid consumed to 1.5 liters per day, which is compensated by the intravenous administration of solutions, the amount and composition of which depend on the degree of violation of water-electrolyte disturbances. After removing the dressing, the wound and the edges of the fistulous passage are treated with a 5% solution of potassium permanganate, which is then washed off with a 3% solution of hydrogen peroxide, the fistula hole and the edges of the wound are drained, the fistula hole is aerated to a depth of 0.5 cm with a cooled plasma stream of nitric oxide using standard manufactured apparatus "Plason"("Scalpel-coagulator-stimulator air-plasma SCSWP / NO") in a therapeutic regimen of 2000 mg / m ³ with an exposure of 1.5 minutes, then the fistulous opening and the edges of the wound are treated with a monoxox plasma stream nitrogen ide with a concentration in the zone of contact with the wound surface of 1500 mg / m ³ and an exposure time of 20 seconds for each 1 cm ^{2 of the} surface, drain the fistulous hole and the edges of the wound, the hole is plugged with a gauze cloth, the area of the fistulous wound is irradiated with EHF waves with a spectrum of the type “White noise” and provided with integrated power on the wound surface of 1.5 μW along the perimeter of the fistulous opening at a distance of 15 mm from the edges of the fistulous course for 30 minutes through the horn nozzle using the commercially available device “AMFIT-0.2 / 10-01” napkin have removed the opening of fistula and the skin around it is treated with zinc paste, cover the gauze, the subsequent ligation is performed in the same way as getting wet bandages intestinal contents, but not more than 2 times a day and at least once in 3 days.

The described method was used in the surgical department of the branch No. 5 of the FKSU "1586 Military Clinical Hospital" of the Ministry of Defense of the Russian Federation.

According to the claimed method treated a group of patients (n = 12), clinical observation showed high efficiency of the method using the recommended treatment parameters. There were no complications, in all cases it was possible to close the intestinal fistulas using the proposed method, while it did not require surgical interventions and general anesthesia.

During the application of this method revealed the following advantages:

- rapid relief of skin maceration and perifocal inflammation around the fistulous opening and their further prevention;

- stimulation of growth of granulation tissue and acceleration of epithelialization of the fistulous wound;

- the possibility of applying the method for any phase of the wound process;

- the method allows to reduce the time of inpatient treatment and to avoid surgical intervention in this category of patients;

- the method is easily accessible, simple to perform, does not require large financial costs for the implementation of the method and staff training.

Claims (1)

A method of conservative treatment of external colonic fistulas, including the appointment of a special diet with a limitation of the total volume of fluid consumed to 1.5 liters per day, which is compensated by the intravenous administration of solutions, the amount and composition of which depend on the degree of violation of water-electrolyte disturbances, characterized in that after removal dressings the wound and the edges of the fistulous course are treated with 5% potassium permanganate solution, which is then washed off with a 3% hydrogen peroxide solution, the fistulous hole and the edges of the wound are drained, and eradication of the fistulous opening to a depth of 0.5 cm with a cooled plasma stream of nitric monoxide using the Plason mass-produced apparatus (Scalpel-coagulator-stimulator air-plasma SCSWP / NO) in a therapeutic regimen of 2000 mg / m ³ with exposure 1, 5 min, then the fistulous opening and the edges of the wound are treated with a plasma stream of nitrogen monoxide with a concentration in the zone of contact with the wound surface of 1500 mg / m ³ and exposure time of 20 seconds for each 1 cm ^{2 of the} surface, the fistulous hole and the edges of the wound are drained, the hole is plugged with gauze with a napkin, the region of the fistulous wound is irradiated with EHF waves with a “white noise” type spectrum and provided with integrated power on the wound surface of 1.5 μW around the fistulous opening at a distance of 15 mm from the edges of the fistulous passage for 30 minutes through the horn nozzle using commercially available apparatus "AMFIT-0.2 / 10-01", the napkin is removed, the fistulous opening and the skin around it are treated with zinc paste, covered with gauze napkins, subsequent dressings are carried out in the same way as the dressing gets wet with intestinal soda Římov, but not more than 2 times a day and at least once in 3 days.