RU2675996C1 - Method of endoscopic hemostasis in ulcer gastroduodenal hemorrhages - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, methods for stopping bleeding from gastroduodenal ulcers in gastric ulcer and duodenum ulcer. Perform injection compression infiltration of the periulcerous zone. Previously, PRP (platelet autoplasma) is obtained from the patient's blood and injected in an amount of 2 ml endoscopically into the submucosal layer of the periulcerous zone in a volume of 2 ml.EFFECT: method provides stable hemostasis and significantly reduces the number of relapses, which helps to improve the quality of life of patients and reduce treatment costs.1 cl, 2 ex

Description

Appointment

The invention relates to medicine, in particular to methods of stopping bleeding from gastroduodenal ulcers, and can be used to implement hemostasis in patients with peptic ulcer of the stomach and duodenum.

The invention relates to medicine, in particular to abdominal endoscopic surgery, and may find application in the treatment of gastroduodenal bleeding.

Relevance

Acute gastroduodenal peptic ulcer bleeding (HUD) is the most formidable complication of peptic ulcer of the stomach and duodenum. Advances in clinical surgery, endoscopic diagnostic and treatment methods, anesthesiology, resuscitation and the expansion of the arsenal of drug anti-ulcer therapy did not lead to a decrease in mortality in this disease. According to various authors, the overall mortality rate is 10-14%, postoperative - from 12 to 35%. (Alekberzade. A.V., Lipnitsky E.M. 2004). While postoperative complications and mortality in repeated bleeding increase one and a half two times. The proportion of patients with recurrence of acute obstructive pulmonary obstruction among all those who died from gastroduodenal bleeding is 60-80%. All this indicates the importance of adequate treatment and prevention of recurrence of ulcerative gastroduodenal bleeding. (S.V. Dobrokvashin, P.P. Yakupov, 2008). It is generally recognized that gastroduodenal bleeding should be considered as an indication for emergency endoscopic examination, the diagnostic effectiveness of which is higher, the earlier it is carried out. This position can be almost fully attributed to the use of local therapeutic effects on the source of bleeding through the endoscope. The potentialities of endoscopic hemostasis have to some extent expanded the indications for endoscopic examination, endoscopy, gastroscopy in the most severe contingent of patients with serious concomitant diseases. The selection of an arsenal of methods primarily depends on their clinical results, and if this indicator is equal, it depends on the ratio: efficiency / ease of implementation, safety / cost, availability. To date, the analysis has not provided clinicians with evidence of the unconditional dominance of any of the methods of hemostasis. Therefore, the choice of a particular method or combination thereof for a particular patient is mainly carried out in accordance with the characteristics of the bleeding source. It is important to remember that for the reliability of hemostasis, all endoscopic ones are still inferior to transabdominal interventions. Nevertheless, therapeutic endoscopy for acute gastrointestinal bleeding in general has a fairly high efficiency. (E.S. Katanov, L.L. Spiridonov, 2010)

Thus, the assessment of the potential for endoscopic stopping of bleeding in terms of achieving stable hemostasis in each specific situation should be carried out separately, first of all, on the objectively established probability of developing a relapse of bleeding, and not on the endogemostasis method used. Despite some reports of the successful implementation of a new endohemostasis method in clinical practice, there is no fundamental change in the management strategy for patients with acute obstructive pulmonary hypertrophy: it is still quite often that patients are operated on an emergency and urgent basis due to unstable hemostasis and relapse of bleeding. Therefore, the endoscopist and, especially, the surgeon should apriori restrain the very possibility of achieving final hemostasis with ulcerative bleeding and carefully evaluate all prognostically unfavorable factors for the occurrence of recurrent hemorrhage, regardless of the method of the proposed or performed endogemostasis.

The prior art / analogues and their disadvantages /

The prior art method of endoscopic hemostasis for ulcerative bleeding of the gastroduodenal zone by introducing solutions containing 5% ascorbic acid into the mucosal space of the ulcerous defect, characterized in that a 1% solution of hydrogen peroxide with a volume of 10-40 ml is administered in combination with 2 ml of ascorbic acid, with the introduction of repeating every 8-12 hours until the formation of local stable hemostasis, (RF patent No. 2229881, 10.06.2004)

The disadvantages of this method include the fact that when performing this method, there is a need for repeated repeated endohemostasis within 24 hours to achieve stable hemostasis, which is extremely inconvenient for both the patient and the endoscopist and increases the time to achieve hemostasis, in addition, the use of data solutions can lead to the formation of a zone of necrosis at the injection site with the formation of acute erosion, which in themselves will become a source of bleeding. The use of this method is unreasonable for bleeding with profuse gastric bleeding.

A known method of endoscopic hemostasis in case of bleeding complications of chronic gastroduodenal ulcers, including endoscopic injection of drugs into the area of the ulcer defect and application of the bottom of the ulcer defect with a drug, characterized in that a 0.01% solution of adrenaline hydrochloride is used as the injection drug, which administered in an amount of 10 ml, while the injection of the drug is carried out from 4-6 points of 1.6-2.5 ml per point, and 1 mg of dalargin, diluted in 2 ml of physiological p solution, while the injection of the drug is carried out from 4 points of 0.5 ml per point, and the administration of drugs is carried out in the submucosal layer of the periulcerogenic shaft, and TakhoKomb, which is pressed to the bottom of the ulcer defect for at least 2 minutes, is used as an application agent. . (RF patent No. 2266752, publ. 27.12.2005).

The disadvantages of this technical solution are unreasonably cumbersome arsenal of means for infiltration into the zone of a peptic ulcer. In addition, the use of this method ultimately leads to a decrease in the plugging effect upon resorption of the infiltrate and the disappearance of vasoconstriction as resorption of adrenaline with a possible relapse of bleeding.

A known method of endoscopic hemostasis, including contact laser photocoagulation with a laser with a wavelength of 1064 nm, a power of 6-10 W, exposure exposure of 2-4 s, characterized in that, in addition to laser exposure, autologous injections are performed along the periphery of the bleeding source (RF patent No. 2280482, publ. . 07.27.2006)

Its disadvantages - this method of endohemostasis is inconvenient in the following positions: performing laser photocoagulation necessarily requires good visibility of the source of bleeding and the absence of a large amount of blood in the stomach, which is almost impossible with profuse bleeding. The second disadvantage is the high cost of the equipment and low efficiency in case of intense ulcerative bleeding, which significantly limit the use of the method in wide clinical practice.

Known 1. A method of endoscopic hemostasis in gastroduodenal bleeding by injection compression infiltration of the paravasal and periulcerous zones, characterized in that they use polyglucin, which is introduced into the area of the hemorrhage source and against this background, argon plasma coagulation is performed. 2. The method according to claim 1, characterized in that polyglucin is heated to 40-50 ° C in a water bath before injection and injected4 through an endoscopic injector in an amount of 3-5 ml at 3-5 points, 0.5-1.0 ml per 1 injection into the paravasal and periulcerous zones into the submucosal and muscle layers of the organ, 1-2 mm away from the source of hemorrhage, (RF patent No. 2410035, 01/27/2011)

The disadvantages include the prolonged preparation of the solution for performing endohemostasis, which is impractical in urgent surgical practice, as well as multiple injections in the area of the ulcer defect, which can lead to the formation of additional acute erosion in the area of existing necrosis.

A known method of endoscopic hemostasis in gastroduodenal hemorrhages by thermal action on the bleeding site, characterized in that the site of bleeding is affected by a laminar flow of injected air heated to a temperature of 350 ° -750 ° C with a thermocouple located at the end of the endoscope ( RF patent No. 2482812, 05.27.2013)

The disadvantages of this method are the high cost of equipment, specially trained personnel, which is not always appropriate in some clinics, as well as the large size of the equipment.

A known method of endoscopic hemostasis for non-varicose gastroduodenal bleeding, including endoscopic injection of drugs into the area of a peptic ulcer, characterized in that a 0.2% solution of norepinephrine in an amount of 1 ml per injection is paravasally injected into 3 points around the source of bleeding, as well as into the submucosal layer the edges of the defect, with a total volume of the injected solution of 7-8 ml. (RF patent No. 2552934, 06/10/2015)

The disadvantages of this method of endohemostasis include the development of necrosis in the area of a peptic ulcer, which can lead to the development of erosion, as with most injection methods of hemostasis.

Known microdispersed histoequivalent bioplastic material, including hyaluronic acid, a buffer system, clarithromycin and a proton pump inhibitor, characterized in that hyaluronic acid is nanostructured, lyophilized and dispersed to a powdery substance with a particle size in the range of 50-100 μm, as a buffer Buffer-G is used with a pH of 6.8-8.0, and the proton pump inhibitor is the N + - K + -ATPase inhibitor pantoprazole in the following ratio of components, wt. %: hyaluronic acid nanostructured, lyophilized and dispersed to a powdery substance with a size

individual particles in the range of 50-100 microns 95, Buffer-G pH 6.8-8.0 3 pantoprazole one, clarithromycin one,

moreover, the microdispersed histoequivalent bioplastic material is placed in capsules made of material that melts under the influence of body temperature. (patent of the Russian Federation No. 2557529, 07.20.2015)

The disadvantages of this method are the cumbersome preparation and the high price of drugs for performing this type of endohemostasis.

A known method of stopping gastroduodenal bleeding, including the combined application of a hemostatic agent and a biologically active granular sorbent to a bleeding defect, characterized in that during the therapeutic endoscopy with a pneumatic insufflator, a powder polyhemostat in the amount of 0.2 g is applied from a distance of 1.5 cm from the defect, and then anilodiovin is insufflated in an amount of 0.4 g from a distance of 2.0 cm from the defect to cover the entire bleeding surface, (RF patent No. 26184 06, published on 05/03/2017).

Its disadvantages - the use of this method increases the time for hemostasis, because the execution goes through several stages (analysis of the coagulation system of the patient’s blood and preparation of the mixture for endohemostasis).

Prototype and its shortcomings

Closest to the claimed technical solution is, in our opinion, the Method of endoscopic hemostasis for gastroduodenal bleeding described in the patent of the Russian Federation No. 2410035, 01/27/2011.

The disadvantages of this technical solution are eliminated by the claimed technical solution.

Object of the invention

The objective of the study is to develop a new effective method for the treatment of acute ulcerative gastroduodenal bleeding.

The solution of the problem

This problem is solved due to the fact that the method is based on the use of the patient’s own blood - PRP (platelet autoplasma) is obtained from the patient’s blood and injected in a volume of 2 ml endoscopically into the submucosal layer of the periulcerous zone.

The whole procedure is carried out under the control of an endoscope, this ensures the administration of the drug with great accuracy directly to the affected area.

Technical result

The technical result provided by the given set of signs is to reduce the risk of bleeding recurrence in patients with gastric ulcer and duodenal ulcer, as well as surgical intervention, due to the use of PRP in patients with acute gastroduodenal bleeding. This leads to a reduction in the length of stay of patients in the hospital, and thus helps to increase the effectiveness of treatment.

Causal relationship / between the features of the invention and those. result /

The mechanism of infiltration hemostasis is to stop bleeding due to hydraulic compression of blood vessels, vascular spasm, increased local thrombosis and sclerosis in the immediate vicinity of the source of hemorrhage achieved by perifocal injection of drugs. For carrying out infiltration hemostasis, the following can be used: 0.1% solution of adrenaline hydrochloride, 3% solution of NaCl, 70% solution of ethyl alcohol alone or in combination with novocaine, oil solutions, fibrin glue, cyanocrylates, two-component silicone compositions, sclerosants, antioxidant preparations activity. Thus, infiltration hemostasis can be used both as an independent (main) method of hemostasis, and as a preparatory stage for the main hemostatic effect, as well as to enhance the hemostatic effect in combination with other methods of endoscopic hemostasis. The proven benefits of certain drugs used for infiltration endogemostasis, to date, not shown.

Our studies have shown that to achieve the best results when using the infiltration method, endohemostasis can be used as an independent way to stop bleeding.

In this case, you should use funds to create perivasal infiltrate and vasoconstrictors to stop active bleeding, which are conditions of distinct aiming are introduced in minimal doses. It is known that the body has a self-healing function, and, as our studies have shown, in conjunction with

the preparation we receive, which contains concentrated platelets, the natural potential of the body increases, which leads to the rapid healing and restoration of affected tissues. The introduction of a protein substrate in the submucosal layer of the periulcerous zone, in contrast to the physical. a solution to a greater extent and for a longer time creates a compression by tissue infiltration due to the attraction of water from interstitium in accordance with the laws of osmosis. The introduction of a drug into the bleeding zone, namely into the submucosal layer of the periulcerous zone of a powerful hemostatic substrate - PRP, promotes the formation of a clot, which leads to persistent hemostasis and prevents the development of relapses. A sharp activation of reparative processes in the zone of a mucosal ulcer is due to the specific effect of platelet autoplasma. The “growth factors” contained in it provoke an intensive restoration of the affected area of the mucous and submucosal layers.

Using platelet autoplasma (PRP), we concentrate platelets and, accordingly, “growth factors” that promote rapid regeneration.

Detailed description of the method

The method is as follows. In patients with gastric ulcer bleeding coming in as an ambulance on an emergency basis, blood was drawn from a peripheral vein on the day of admission.

To perform the method, a set of containers YCELLBIO (China) is used. Their features are that they have a conic-shaped shape (due to which there is a clear separation of plasma, red blood cell mass and PRP), a rotary cap (makes it possible to change the level

erythrocyte mass), narrowed neck (allows accurate extraction of the leukotrombocyte layer), as well as the universal size of the container (suitable for all types of centrifuges). Implementation of the method: in a disposable syringe with a volume of 20 ml, a blood sample is taken from a patient in a volume of 13 ml and 1.5 ml of an anticoagulant (sodium citrate) is collected in the same syringe. Then this blood is introduced into the YCELLBIO container, the container is placed in a centrifuge (model СМ-6, number of revolutions 2750 rpm) where the blood is divided into 3 fractions (blood plasma, PRP and erythrocyte mass). By centrifugation in these containers, the result is a plasma with a platelet count of 7–9 times that of the plasma before separation. Next, we take 2 ml from the PRP container and perform an injection - we inject into the submucosal layer of the periulcerous zone using an OLYMPUS QS40 endoscope, thereby performing endohemostasis.

The performance of the proposed method is confirmed by the following clinical examples:

Example 1. Patient Sh-ev, 69 years old, was admitted to the surgical department as an ambulance with signs of gastrointestinal bleeding. When performing primary EFGDS - there is an ulcer of the antrum, 0.3 cm in size and a depth of 0.1 cm, with active bleeding (Forrest Ia). The patient was injected with PRP in a volume of 2.0 ml or nevertheless into the submucosal layer of the patient’s periulcerous zone; visible hemostasis was achieved. Subsequently, he received a complex of antiulcer therapy for 4 days. At the control EFGDS in 5 days - there are signs of scarring of the ulcer. No recurrence of bleeding.

Example 2. Patient Peninsula, 33 years old, was admitted to the Department of Surgery with signs of gastrointestinal bleeding in an emergency. At

EFGDS - ulcerative defect with dimensions of 0.5 cm, depth up to 0.1-0.2 cm on the front wall of the duodenum 12, with leakage of fresh blood (Forrest Ia). An injection of PRP was performed, in the submucous layer of the ulcerous defect zone with a total volume of 2.0 ml, hemostasis was achieved. After a course of conservative anti-ulcer therapy, on the control EHFDS after 7 days - ulcerative scarring and epithelization.

Statistics

The claimed method treated 19 patients, aged 30 to 70 years with peptic ulcer of the stomach and 12 duodenal ulcer, complicated by bleeding. The results showed that the use of this method as a single method of endogemostasis allowed to stop bleeding in 17 patients (88.9%), in 2 patients (11.1%) they used combined endogemostasis - PRP injection combined with argon plasma coagulation. Relapse of bleeding was not detected during the observation period of 12 months.

Method Advantages

Injection hemostasis is the most widespread method of endoscopic hemostasis. The injection method can be applied in almost all cases of ulcerative bleeding. There are no absolute contraindications to its use, the relative contraindication to the use of the injection method is the diffuse nature of the mucosal lesion.

Thus, the use of this technique contributes to the fact that:

- the introduction of a powerful hemostatic substrate into the bleeding zone in the submucosal layer of the periulcerous zone - PRP provides persistent hemostasis and significantly reduces the number of relapses, which helps to improve the quality of life of patients and reduce treatment costs.

Claims (1)

The method of endoscopic hemostasis in gastroduodenal bleeding by injection compression infiltration of the periulcerous zone, characterized in that PRP (platelet autoplasma) is obtained from the patient’s blood and injected in a volume of 2 ml endoscopically into the submucous layer of the periulcerous zone.