RU2727867C1 - Treatment method of purulent-necrotic wounds - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to surgery and traumatology and can be used for treating purulent-necrotic wounds of various geneses. First, 100.0 ml of the prepared Klein solution is introduced into the subcutaneous fat of the anterior abdominal wall of the donor zone. After 15–20 minutes aspirate is taken from subcutaneous fat of anterior abdominal wall. Aspirate is washed by 0.9 % ozonized physiological NaCl solution in concentration of 10 mg/l. Obtained fat fraction is dissolved with ozonized physiologic saline in ratio 1:1 fat – ozonized physiologic saline. One performs shaking and obtaining a suspension to be introduced into the paravulnar tissues along the wound perimeter by 1 cm from the edge, using injection cannula 2.0 mm with a blunt end attached to 2 ml syringe in layers, retrograde, each channel 2 mm in thickness, distance between insertion points 5 cm, volume of introduction of suspension 1 ml into each channel. Same amount of the suspension is introduced directly into the center of the wound defect to a depth of not more than 1 mm.EFFECT: method provides reducing the length of wound healing by using aspirate and ozonized physiologic saline.1 cl, 3 ex

Description

The invention relates to medicine and can be used in surgery, traumatology, combustiology for the treatment of purulent-necrotic wounds of various origins.

In the structure of surgical pathology, purulent-inflammatory diseases of soft tissues make up from 15 to 32%. Long-term treatment, significant material costs, frequent complications, cosmetic flaws in the form of hypertrophic or atrophic scars - all this requires finding new ways, improving the existing methods of treating this group of patients. The complex pathogenesis of the wound process necessitates a complex effect on its various stages. While the tactics of surgical treatment of purulent wounds are currently defined, a number of additional factors affecting the wound process require development and improvement.

The results of treatment of purulent diseases of soft tissues and wound infection, despite the use of modern methods and certain successes achieved, do not completely satisfy surgeons, because it is not possible to shorten the terms of both inpatient and outpatient treatment of patients with trophic ulcers, as well as to exclude frequent relapses.

In recent years, applied biomedical research in the framework of cellular technologies, in particular, those associated with the use of multipotent mesenchymal stromal cells (MMSC), has become more and more widespread. Cell technologies, combined with genetic, physiological and clinical approaches, are developing especially rapidly. The use of cellular technologies in the treatment of skin lesions is expanding. In cell dermatoplasty, cultured allogeneic fibroblasts and keratinocytes, MMSCs, both in the form of suspensions (without carriers), and dermal equivalents made using various matrices (from collagen, fibrin gels, etc.) are most often used. MMSCs are found in many tissues of the human body. Adipose tissue (VT) and placenta tissues are the most promising sources of MMSC in the postnatal period. In comparison with other types of progenitor cells of an adult organism, MMSCs of adipose tissue are more accessible and can be obtained in large quantities, sufficient for subsequent use in cell therapy.

The use of mesenchymal stem cells from adipose tissue to restore the integrity of the skin represents a promising strategy in research on the clinical use of local cell transplantation in the complex treatment of patients with chronic wounds of various etiologies, including those with trophic ulcers resistant to traditional methods of treatment (E.V. Baranov, AV Buravsky, IB Vasilevich, SI Tretyak "Comparative assessment of the dynamics of healing of experimental clean wounds with the local use of LED photoregulatory effects and multipotent mesenchymal stem cells of adipose tissue." - Military medicine. - No. 2 (43) 2017 .-- S. 26-34).

Methods for the treatment of purulent-necrotic wounds and trophic ulcers using cell transplantation are described in the scientific, medical and patent literature.

There is a known method for the treatment of trophic ulcers, in which the collection of adipose tissue from a patient is carried out by the method of lipoectomy (excision) of a section of subcutaneous adipose tissue in the umbilical region or along the inner surface of the upper third of the thigh (Treatment method using autologous mesenchymal stem cells from adipose tissue in patients with trophic ulcers , approved by the Ministry of Health of the Republic of Belarus on November 18, 2011, registration No. 093-0911, Instructions for use - see the websites http://celltech.by/index.php/lechenie-troficheskikh-yazv-konechnostej, www.bsmu. by / downloads / vrachu / instrukcii / 093-0911.pdf). The resulting lipoaspirate is transported to the laboratory, where it is purified from the supranatant and poured into a nutrient medium to accumulate a homogeneous cell suspension. After careful research, the cell biomass is transported to a specialized clinic for transplantation. First, a homogeneous cell suspension is applied to the central surface of the wound with a micropipette, and then intradermal injection of cell material is performed to a depth of 2-4 mm along the periphery of the wound surface.

The disadvantage of this method is that it is expensive, requiring large financial costs and a large number of specialists for the cultivation of a homogeneous suspension from autologous mesenchymal stem cells of the stromal-vascular fraction. In addition, the accumulation of a pure population of stem cells occurs due to their multiple division, which increases the risk of their growth into malignant cells.

In cosmetology, a method is described for autotransplantation of adipose tissue - lipofilling, used for contour plastics ("Autotransplantation of adipose tissue - lipofilling", journal "Experimental and Clinical Dermatocosmetology No. 6, 2011, pp. 19-31). The method includes obtaining viable pure fat, washing the aspirated fat using saline solution, and further injection into the problem area in a 1: 1 ratio of fat and saline solution.

However, it should be noted that the use of this technique has not been previously described in the treatment of purulent-necrotic wounds.

A method for treating patients with trophic ulcers of the lower extremities is described. The introduction of MMSC was carried out under aseptic conditions with the imposition of a special frame protective dressing over the defect. The transplantation consisted in the local injection of autogenous MMSCs into the area of the trophic defect in the form of a suspension containing cells in various amounts, depending on the area of the ulcer defect.The cell preparation was injected along the periphery of the ulcer defect (from 4 points at a distance of 1 cm from the edge of the wound defect). The procedure was repeated at intervals of 7-10 days. Transplantation was carried out both in the phase of proliferation and remodeling. After the procedure, an aseptic dressing was applied, which was a transparent polyurethane-based film attached to an absorbent frame, which provided adequate moisture and gas exchange of the wound surface and protection from bacteria and viruses. (E. V. Baranov, S. I. Tretyak, I. B. Vasilevich, E. S. Lobanok, I. D. Volotovsky "Clinical possibilities of using autogenous multipotent mesenchymal stromal cells of adipose tissue in the treatment of patients with trophic ulcers of the lower extremities" . - Cell transplantology and tissue engineering Volume VIII, No. 2, 2013 - pp. 78-83).

The disadvantage of this technique is the need for re-transplantation of MMSCs of VT, as we assume, due to the death of adipocytes due to a possible lack of oxygen in the tissues.

A known method for the treatment of 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 the subcutaneous fat of the anterior abdominal wall, which is washed with a 5% glucose solution ; the obtained fat fraction is diluted with 5% glucose solution in a ratio of 1: 1 - glucose-fat, shaken and a suspension is obtained; 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 carried out to the end of each marked beam and the resulting suspension is injected at the outlet, gradually removing the cannula by simultaneous pressure on the syringe plunger; up to 5 injections of suspension from one puncture are performed in a fan-like manner, creating a perifocal roller up to 0.7 cm thick; the distance between the channel beams should not exceed 2-3 mm (RF patent No. 2528973, 09/20/2014).

We have taken this method as a prototype.

The disadvantages of the prototype include the complexity of the technique, the need to repeat the procedure, the duration of healing before the formation of a normotrophic scar.

The objective of the proposed method is to improve the quality of treatment for chronic and acute purulent-necrotic wounds of the lower extremities by activating the wound process and reducing the duration of treatment.

The task is carried out due to the fact that Klein's solution is preliminarily introduced into the subcutaneous fatty tissue of the donor zone, after which, after 15-20 minutes, the primary aspirate is taken from the subcutaneous fatty tissue of the anterior abdominal wall, which is subjected to washing with ozonized saline NaCl 0 , 9% at a concentration of 10 mg / l; the resulting fat fraction is diluted with an ozonated saline solution in the same concentration in the ratio 1: 1 - saline-fat, shaken and a suspension is obtained, which is injected into the paraular tissues along the wound perimeter, departing from the edge by 1 cm, using an injection cannula 2.0 mm with a blunt end and a syringe 2 ml layer by layer, retrograde, each channel 2 mm thick, the distance between the injection points is 5 cm, the volume of suspension is 1 ml into each channel; the same amount of suspension is injected directly into the center of the wound defect to a depth of no more than 1 mm.

The technical result obtained as a result of using the proposed method is that the use of lipofilling using auto fat in the complex treatment of purulent-necrotic wounds using an ozonized saline solution can increase the stability of VT adipocytes, eliminate the threat of viability due to oxygen starvation and thereby save more the number of fat cells and their activity, which, in turn, contributes to the acceleration of granulation, marginal epithelialization and scarring.

The result is achieved through the use of the ozonized fat fraction as an optimal biocompatible carrier for fat cells and for creating the necessary microenvironment in the wound, stimulating regeneration processes due to a combination of the ratio of ozonized saline-fat 1: 1.

Adipose tissue, is a heterogeneous mixture of different cell types, including: mature adipocytes, macrophages, stromal cells, which are located in the connective tissue around small capillaries (Zuk P.A. et al. 2001) and is quite fragile and requires delicate handling. Currently, lipofilling (adipose tissue transplantation) is widely used in various fields of surgery and cosmetology, including with the aim of stimulating the healing processes of wound defects of various etiology. In this case, special attention is paid to the methods of sampling the material, preparing it for transplantation and the technique of administration. Each stage of this intervention was, in turn, the subject of direct and painstaking research to determine the factors influencing the viability and survival of adipocytes. While various techniques have been developed and widely used in the technique of VT collection and transplantation by now, the methods of preparation that allow to preserve the viability of VT cells in adipocytes need to be substantially improved. At the same time, all authors point to the special sensitivity of adipose tissue to oxygen "starvation", but do not indicate ways to solve this problem.

According to our technique, Klein's solution is preliminarily injected into the subcutaneous fatty tissue of the donor zone, after which, after 15-20 minutes, the primary aspirate is taken. This time period is necessary for the prevention of bleeding and pain relief. during this time, there is a contraction of blood vessels and nerve endings, as well as swelling of adipocytes, which facilitates aspiration.

Klein's solution is an anesthetic solution used in tumescent liposuction. Developed by American dermatologist Jeffrey Klein in 1985. Klein's solution includes lidocaine (causes a local anesthetic effect), adrenaline or norepinephrine (narrows blood vessels, as a result of which blood loss decreases, the number of edema decreases), saline (acts as a carrier of fat, converting it into a semi-liquid emulsion), which allows evacuation it through cannulas and sodium bicarbonate solution.

In our studies, we came to the conclusion that for the preparation of the material, an ozonized saline solution should be used in order to increase the resistance of adipocytes to oxygen starvation in wounds, and we began to wash out the VT using an ozonized saline solution of NaCl 0.9%, at a concentration of 10 mg / l, and then dilute the fat fraction with ozonized saline solution in the same concentration in a 1: 1 ratio, shake and obtain a suspension for administration.

Khater R. et al studied three groups formed by them: centrifuged, non-centrifuged and washed adipose tissue. Scientists (Khater R. et al. 2009) came to the conclusion that non-centrifuged adipose tissue transplantation can lead to better adhesion of fatty autografts and even de novo fat development.

The resulting suspension of VT is injected into the paralnary tissues of the wound using 2.0 mm cannulas with a blunt end and a 2 ml syringe in layers, retrograde, each channel 2 mm thick, the distance between the injection points is 5 cm.

When injecting adipose tissue, it is preferable to use a blunt cannula with one distal opening attached to a 1 ml - 10 ml syringe. This method also increases the accuracy of the injection of small volumes of adipose tissue, and ensures the safety of the procedure, since the low pressure during injection reduces the risk of damage to the blood vessels. Due to the fact that the blunt cannula pushes the tissues apart, the adipose tissue is distributed and fixed at the injection site. All injections of adipose tissue are carried out retrograde, in layers. This technique stimulates the appearance of stromal cells and fibroblast growth factors in the wound tissues, which contributes to the performance of wound plastics or its healing by secondary intention at an earlier date.

A detailed description of the method and examples of its clinical implementation.

The method is carried out as follows.

The indication for the use of this method is the presence of postoperative purulent-necrotic wounds or trophic ulcers, which are in the second phase of the wound process, after cleansing from necrotic tissues. Immediately before performing the manipulation, prepare Klein's solution: Sol. Lidocaini 10% - 1.0 ml + Sol NaCl 0.9% - 400.0 + Sol. Adrenalini - 0.5 ml.

On the operating table, in the supine position of the patient, after treatment of the skin of the anterior abdominal wall with an antiseptic solution, mark the places of cannula introduction into the donor area. After performing local anesthesia with 1.0 ml of 0.25% novocaine solution or 1% lidocaine solution, retreating 3-5 cm from the border of the donor zone using a scalpel, punctures are made on the skin up to 2.5 mm long. Next, 100.0 ml of the prepared Klein solution is injected into the subcutaneous fatty tissue of the donor zone under pressure using standard 2.0 ml syringes and a cannula 2.5 mm in diameter. After entering the solution, you must wait about fifteen to twenty minutes.

At this time, an ozonized physiological NaCl solution of 0.9% is prepared, at a concentration of 10 mg / l. Ozonation of a physiological solution by bubbling a physiological solution with an ozone-oxygen mixture with an ozone concentration at the outlet of the ozonizer of 10 mg / l on an ozone therapy apparatus ASGOKSf5-020 OZON. The method is carried out as follows: a generator (ozone therapy apparatus) is connected to an oxygen source and to an electrical network, a predetermined ozone concentration in an ozone-oxygen mixture and exposure are set on the device panel. A long needle that reaches the bottom and a short needle that does not reach the surface of the solution is inserted into the stopper of 100.0 ml of a vial with saline. A polyvinyl chloride tube is attached to the long needle from the outlet of the apparatus, an ozone destructor is attached to the short needle, the apparatus is turned on and bubbling is carried out for up to 10 minutes.

After exposure to Klein's solution, careful tunneling is performed using a lipoaspiration cannula up to 2.5 mm in diameter with a blunt end with minimal effort. Further, mechanically, by pulling the plunger of a disposable 20.0 ml syringe and a 2.5 mm cannula, adipose tissue is aspirated. The processing of auto fat is carried out by washing with ozonated saline solution in NaCl 0.9%, concentration 10 mg / l, separating intact adipocytes from fat cells destroyed during collection by settling and removing the upper oily layer.

The resulting fat fraction is diluted with an ozonated saline solution in a ratio of 1: 1 saline-fat, shaken and a suspension is obtained, which is injected into the paraular tissues around the wound perimeter, departing from the edge by 1 cm, using an injection cannula of 2.0 mm with a blunt end and a syringe 2 ml in layers, retrograde, each channel 2 mm thick, the distance between the injection points is 5 cm, the volume of suspension is 1 ml in each channel; the same amount of suspension is injected directly into the center of the wound defect to a depth of no more than 1 mm. After removing the cannula, apply an aseptic wound dressing for 10 days.

The efficiency of the claimed method is confirmed by the following clinical examples.

Example 1.

Patient K., 42 years old. Diagnosis: type 2 diabetes mellitus type neuroischemic form 4 st CINC 4Ast. Wet gangrene 1p of the left foot, phlegmon of the foot. On admission under conduction anesthesia, amputation of 1p of the left foot was performed, at the level of the head of the 1st metatarsal bone, the abscess was opened. In the postoperative period, complex therapy was carried out according to national recommendations. By day 5, there were no signs of the spread of the process. After consulting an angiosurgeon, on the 7th day after admission to the hospital, balloon angioplasty of the leg arteries was performed. By the 8th day after angioplasty, the wound was cleared of necrotic tissues (the second phase of the wound process), the patient underwent autotransplantation of adipose tissue (lipofilling) according to the proposed method. After 10 days: the wound was filled with active granulations. Repeated lipofilling was performed. By the 20th day, after admission, the wound decreased by 75%. By the 25th day, the n / a surgical wound healed with the 2nd tension. The clinical dynamics of the wound process correlated with the data of cytological and histological studies. After 1 month: 100% wound epithelialization, normotrophic scar.

Example 2.

Patient T-ova, 28 years old. Diagnosis: type 1 diabetes. SDS neuropathic form 3 tbsp. Charcot's foot: acute purulent osteoarthropathy. Phlegmon of the median space of the right foot. Upon admission, an abscess was opened under conduction anesthesia. In the postoperative period, complex therapy was carried out according to national recommendations. After cleaning the wound by day 8, no signs of epithelialization were observed. Autotransplantation of adipose tissue was performed according to our proposed technique. On the 10th day, active marginal epithelialization of the postoperative wound was noted. The patient was discharged for outpatient treatment. Examined after 2 weeks. after discharge from the hospital. The postoperative wound was completely epithelialized, and there was a normotrophic scar. The clinical dynamics of the wound process correlated with the data of cytological and histological studies.

Example 3.

B-naya L-eva, 65 years old. Diagnosis: Post-thrombophlebitis syndrome. Ulcerative pain form Chronic venous insufficiency 3 tbsp. Purulent-necrotic circular trophic ulcer of the lower third of the right leg. Against the background of the ongoing complex therapy: angiotropic, anti-inflammatory, local treatment - vacuum therapy, compression therapy), the ulcer cleared, the ulcerative surface was completed by the 6th day with flaccid granulations. Despite the ongoing complex therapy in accordance with the treatment standards for this category of patients, by the 14th day, there were no signs of activation of the wound process: there were no active granulations, marginal epithelialization. On the 15th day, from the moment of admission, autotransplantation of adipose tissue (lipofilling) was performed, according to our proposed method. By day 20, active granulation tissue appeared. The patient was discharged for outpatient treatment: taking diosminic acid preparations in standard doses, compression stockings, dressings with zinc paste. Examined 1 week after discharge. Up to 90% of the ulcerative surface is represented by active granulations, the rest (closer to the center) is flabby. Marginal epithelialization appeared. Lipofilling was repeated using the claimed method. The patient was examined after 10 days: the ulcerative surface is completely filled with active granulations, with marginal epithelization. The ulcer defect was reduced by 25%. The patient refused the proposed autodermoplasty. The ongoing complex therapy continued. Examined after 3 months. The ulcer defect healed completely with the 2nd tension.

The effectiveness of adipose tissue transplantation was assessed using the following research methods. Clinical characteristics of the course of the wound process: assessment of the appearance of the wound, wound bed, characteristics of exudate and surrounding tissues. Planimetric research methods: determination of the wound area, dynamics of healing and the rate of epithelialization using the Scion Image software. Methods of morphological examination, which included histological examination with hematoxylin and eosin staining and by the Van Gieson method and morphometric examination using Nikon hardware-software complex (Japan) with software. Cytological examination using the method of "superficial biopsy of wounds" M.F. Kamaev, the staining of the slides after drying was carried out according to the Romanovsky-Timza method.

Statistical research methods were performed using Statistica 6.0. Differences were considered statistically significant at p <0.05.

The proposed method was used in 24 patients with purulent-necrotic and trophic wounds, in all cases, as a result, a significant positive effect was achieved, including complete wound healing. After the first manipulation (already on the 10th day), the appearance of active epithelialization of the wound, a decrease in size by 47% was noted. One manipulation was enough for complete wound healing.

The relative simplicity and low invasiveness of the procedure for obtaining adipose tissue, the possibility of isolating from it a significant number of stem / progenitor cells capable of selective reproduction in an undifferentiated state with subsequent differentiation into cells of various tissues, allow us to consider this method as a promising object for autologous transplantation.

The proposed method for the treatment of purulent-necrotic wounds increases the effectiveness of treatment, shortens the epithelialization of the ulcer, promotes the formation of a normotrophic scar, improves the conditions of regional microcirculation.

The method is simple, effective, affordable, clearly fulfills the assigned 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 purulent-necrotic wounds, including autotransplantation of adipose tissue-lipofilling, characterized in that 100.0 ml of the prepared Klein solution is preliminarily injected into the subcutaneous fatty tissue of the anterior abdominal wall of the donor zone, after which, after 15-20 minutes, the aspirate is taken from the subcutaneous - adipose tissue of the anterior abdominal wall, the aspirate is subjected to washing with an ozonized saline solution of NaCl 0.9% at a concentration of 10 mg / l; the resulting fat fraction is diluted with ozonated saline in a ratio of 1: 1 fat-ozonated saline solution, shaken and a suspension is obtained, which is injected into the paraular tissues along the wound perimeter, departing from the edge by 1 cm, using an injection cannula of 2.0 mm with a blunt end attached to a syringe 2 ml layer by layer, retrograde, each channel 2 mm thick, the distance between the injection points is 5 cm, the volume of suspension is 1 ml into each channel; the same amount of suspension is injected directly into the center of the wound defect to a depth of no more than 1 mm.