EA026585B1 - Method for complex treatment and correction of ischemic genesis impairments during hepatic resection - Google Patents

Abstract

The invention relates to medicine, particularly to experimental surgery, and may be applied to treatment, correction, and prevention of ischemic impact consequences to the liver in conditions of temporary exclusion of blood circulation. Technical result of the invention is treatment, correction, and prevention of ischemic and reperfusion impairments of the liver that can occur during resection thereof in conditions of temporary exclusion of blood circulation, extension of safe period for exsanguination in the liver, and consequently, preventing massive haemorrhages during surgery. The method includes hepatic resection in laboratory animal with no use of temporary extracorporeal portocaval bypass, and intravenous slow-stream infusion during 10 days from the surgery day: claritromycin in 5.0 ml isotonic NaCl, in dose of 5 mg/kg BW twice a day with 12-h interval at 8:00 and 20:00, gentral as solution for injection, in dose of 5 mg/kg BW twice a day with 12-h interval at 8:15 and 20:15, mexicor as 5% solution, in dose of 5 mg/kg BW twice a day with 12-h interval at 8:30 and 20:30, serotonin adipinate in 5.0 ml isotonic NaCl, in dose of 0.15 mg/kg BW twice a day with 12-h interval at 8:45 and 20:45.

Description

The invention relates to medicine, namely to experimental surgery, and can be used when performing liver resections.

With liver resections, the problem of intraoperative bleeding with massive blood loss is one of the most important (Gantsev Sh. Kh. Intraoperative perfusion of the liver during surgical interventions on the abdominal organs // Soviet medicine. - 1987. - No. 10. - P. 10-12. ) The most effective and optimal way to prevent this is to squeeze the hepatoduodenal ligament, which allows the surgeon to perform temporary hemostasis and to carry out important stages of the operation with minimal blood loss (Veronsky GI Anatomical and physiological aspects of liver resection. - Novosibirsk: Nauka, 1983. - 185 s) . But at the same time, portal hypertension, hypoxia and liver ischemia develop, hemodynamics are destabilized, which, when the 20-minute threshold is exceeded, can lead to irreversible morphofunctional changes in the liver, up to necrotic changes in hepatocytes (Antopolskaya E.V. Correction of ischemic liver damage with its resections in conditions of bleeding: Auto-ref. thesis of the candidate of medical sciences. - Kharkov, 1988. - 21 s).

To prevent and correct metabolic disorders in the cell, various drugs with an antioxidant effect are used - dibunol, sodium oxybutyrate, cytochrome C, etc. (Bilenko M.V. Theoretical and experimental justifications for the use of antioxidant therapy for the prevention of acute ischemic injuries in In the book: Bioantioxidants in the regulation of metabolism in norm and pathology. - M., 1982. - P. 195-213; Okovity S.V. Clinical pharmacology of antihypoxants (part II) // PHARMindex-Practician. - 2004, 7 - S. 48-63), but essentially Their arsenal is limited, and many well-known application methods are not always able to prevent the onset and stop the already developed ischemic lesion of the hepatic parenchyma.

Another direction in the fight against hepatic ischemia is the desire to protect the microvasculature of the liver through the use of drugs with different mechanisms of action. In particular, attempts are being made to influence the development of smooth muscle insufficiency of microvessels (A. P. Simonenkov. V. D. Fedorov, V. M. Klyuzhev, V. N. Ardashev. The use of adipinate serotonin to restore impaired smooth muscle function in surgical and therapeutic patients // Intensive care unit - 2005 - No. 1. - P. 1-6; Simonenkov A.P., Fedorov V.D. On the unity of tissue hypoxia and shock // Anest. and resuscitation. - 2000. No. 6. - P. 73-76; Simonenkov A.P., Fedorov V.D., Fedorov A.V. et al. The mechanism of endogenous vasomotorics and smooth echnoy microcirculatory failure // Journal of Medical Sciences -1994 -.. number 6. - 1115 C.). However, the applied methods do not yet allow to significantly increase the duration of liver anoxia.

The closest is a method for correcting ischemic damage to the liver under conditions of bloodlessness, the essence of which is the intravenous administration of 5 mg of a 1% solution of serotonin adipinate to the experimental animal before and within 30 minutes after compressing the hepatoduodenal ligament in order to prevent the development of smooth muscle insufficiency of the microvasculature of the liver (patent No. 2134576 dated 03/11/1998). This method helps to eliminate smooth muscle insufficiency of the microvasculature, thereby improving endogenous vasomotor.

The disadvantage of this method is that the authors limited themselves to the use of a drug that regulates microcirculation, without correcting other inevitable disorders caused by the effects of ischemia, such as activation of lipid peroxidation processes and structural and functional changes of varying severity (Bezugly V.P. Hypoxia and Its role in liver pathology // Advances in hepatology. - Riga, 1971. - Issue 3. - P. 94-110 .; AO Bueverov. Oxidative stress and its role in liver damage // Russian Journal of Gastroente rheology, hepatology, coloproctology. - 2002. - T. XII. - No. 4. - P. 21-25 .; Merzhinsky V.E., Konvay V.D. Effect of stopping regional blood flow in the liver on the state of lipid peroxidation // Violation of regulatory mechanisms in extreme and terminal conditions. - Omsk, 1991. - P. 57-61.), And a twofold administration of serotonin adipate only on the day of surgery is not enough to treat and prevent hypoxic and reperfusion injuries of the liver tissue and its microvasculature.

There is also a known method for the correction of ischemic liver damage (patent No. 2394574 dated 05/20/2009), which, against the background of the application of a temporary extracorporeal portocaval shunt under conditions of bloodlessness of the organ, involves the intravenous administration of actovegin and Mexicor. In addition, each of the drugs, both before and after the operation, is administered once a day. The use of this method helps to improve metabolic processes and reduce the severity of damage to the hepatic parenchyma.

The disadvantage of this method is the imposition of an extracorporeal portocaval shunt, when used with small diameters it does not carry a pronounced payload, and with an increase in diameters the development of hepatic toxemia (including azotemia) cannot be ruled out, which can lead to toxic effects on many organs and systems ( D.E. Kutepov, V.N. Semenov, A.Yu. Denisov, I.N. Pasechnik Use of extracorporeal treatment methods in the treatment of liver failure // Herald of intensive care. - 2004. - No. 2. - P. 65- 70; Ltoizoi b., Sasai KS.,

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Kash1P8ku-Ki88 K. s1 a1. Eupssss oT di! rgobysyot ot epodels8 bp / osha / srcz: iprpococci esocialis erythrocopalis // Sa81nophilus oodus. - 1996. - Uo1. 110.- R. 1144). The disadvantages of this method also include the introduction of each of the drugs once a day, which, taking into account their pharmacodynamics and pharmacokinetics, from the point of view of the inventors, is not enough.

In both methods considered, the duration of treatment with the drugs used is insufficient, since the duration of the drug exposure should take into account possible and occurring morphological and biochemical changes in the liver.

The mechanisms of development of ischemic liver damage are complex. With the cessation of blood flow to the organ, intrahepatic cholestasis, dystrophic phenomena in the organ occur, cellular intoxication increases and morphofunctional changes in the liver occur, smooth muscle insufficiency of the microvasculature of the liver develops, the energy-synthesizing function of the respiratory chain of mitochondria is disrupted due to the restriction of aerobic energy production by progressive oxygen deficiency, accumulating oxygen with the formation of free radicals, endogen reserves are depleted antioxidants and lipid peroxidation (LPO) processes are activated with the accumulation of their products, which ultimately leads to damage and destruction of organ cells (Bilenko M.V. Ischemic and reperfusion damage to organs (molecular mechanisms, ways of prevention and treatment). - M .: Medicine, 1989. - 368 p .; Simonenkov A.P., Fedorov V.D. Prevention and treatment of serotonin deficiency in surgical patients // Surgery.Ni Pirogov Journal. - 2003. - No. 3. - S. 76-80 .; Shnevays V.B., Levin G.S. The role of free radical oxidation in the pathogenesis of acute liver necrosis in visceral-ischemic shock // Patol. physiology and experiment. therapy. - 1996. - No. 2. - S. 39-43 .; Yakovenko E.P., Grigoriev P.Ya., Agafonova N.A. et al. Intrahepatic cholestasis - from pathogenesis to treatment // Practicing physician. 1998. No. 13 (2). - S. 20-24). It is obvious that under the influence of ischemia in the liver, interconnected and interdependent processes occur. Therefore, it is necessary to simultaneously affect several key pathological processes at once. Given the foregoing, the authors consider the use of complex methods for the correction of liver ischemia to be relevant and promising.

The technical result of the invention is the treatment, correction and prevention of ischemic and reperfusion damage to the liver that occurs when the organ is resected under conditions of temporary shutdown from the blood circulation, prolonging the safe time for bleeding the liver and, as a consequence, preventing massive bleeding during operations on it.

The technical result is ensured by the fact that the animal undergoes resection of the liver without the use of temporary extracorporeal portocaval bypass surgery; the drugs are administered intravenously, jet slowly, starting from the day of surgery for 10 days: clarithromycin is administered in 5.0 isotonic NaCl solution at a dose of 5 mg / kg of weight twice a day with an interval of 12 hours at 8:00 and 20:00, heptral in in the form of a solution for injection is administered at a dose of 5 mg / kg of weight twice a day with an interval of 12 hours at 8:15 and 20:15, Mexicor in the form of a 5% solution is administered at a dose of 5 mg / kg of weight twice a day with an interval of 12 at 8:30 and 20:30, serotonin adipate is injected into a 5.0 isotonic NaCl solution at a dose of 0.15 mg / kg of weight twice a day with an interval of 12 hours at 8:45 and 20:45.

The pharmacological effect of serotonin adipate is due to the fact that it contributes to the normalization of smooth muscle function of blood vessels (endogenous vasomotoria), reduces local hypoxia of internal organs, improves metabolism in hypoxia zones. It is well absorbed and distributed to organs and tissues, remaining in the blood plasma for 8 hours (Russian Medicines Register of the Radar Station 2008. - M., Radar Station - 2008, 2007. - P. 800-801).

The pharmacological effect of Mexico is determined by the inhibition of lipid peroxidation, increased activity of the antioxidant system, activation of the energy synthesizing functions of mitochondria, improved energy metabolism in the cell, and the ability to maintain macroerg levels, including during hypoxia. It activates the intracellular synthesis of protein and nucleic acids, the enzymatic processes of the Krebs cycle, promotes glucose utilization, the synthesis and intracellular accumulation of ATP, restores the structure and functions of membranes, and has a modulating effect on membrane-bound enzymes, ion channels, and receptor complexes. Mexico improves metabolism and blood supply to internal organs, rheological properties of blood and microcirculation, has anti-ischemic properties: improves blood flow, limits the area of ischemic damage and stimulates reparative processes; increases the body's resistance to extreme factors and oxygen-dependent pathological conditions; promotes regression of signs of vasomotor instability. The half-life of the drug ranges from 8-12 hours (Russian Medicines Radar Register, 2008. - M, Radar - 2008, 2007. - P. 538-540).

The use of heptral compensates for the deficiency of ademetionine and stimulates its production in the body, primarily in the liver and brain; it participates in biological transmethylation reactions - it provides the redox mechanism of cellular detoxification, increases the solubility of bile acids and their removal from hepatocytes, and protects the membranes of liver cells from toxic effects. Heptral acts as a stimulator of cell regeneration and proliferation of hepatocytes, normalizes metabolic reactions in the liver, and has a choleretic effect due to increased

- 026585 mobility and polarization of hepatocyte membranes and helps to restore the synthesis and flow of bile. As a result of heptral exposure, liver functions are restored with an improvement in the metabolic and microsomal oxidation processes occurring in it, and suppression of the formation of fibrous tissue. The wide spectrum of action of this drug is manifested by its hepatoprotective, choleretic, cholekinetic, neuroprotective, antioxidant, detoxifying, regenerating and anti-fibrosing properties. After iv administration of heptral, the pharmacokinetic profile of ademetionine is biexpotential with a rapid distribution phase in tissues and clearance with T _{1/2 of} about 1.5 hours; absorption with i / m administration - 96%, Stax is achieved 45 minutes after application; plasma concentrations decrease to their initial values within 24 hours (Vidal Handbook. Medicines in Russia. - M.: AstraFarmService, 2004. - S. B-350-B-351.).

Clarithromycin, a 14-membered macrolide antibiotic, has a number of properties that are required for liver resections. It is characterized by pronounced antimicrobial activity, which also acquires special significance under the conditions of exposure to ischemia, is active against many microorganisms, including intracellular ones. Like all macrolides, clarithromycin has not only anti-inflammatory, but also immunomodulatory effects. After intravenous administration, clarithromycin is rapidly distributed throughout all tissues and body fluids and penetrates well into them, creating concentrations several times higher than the level in blood plasma. When used in our dosage of _{T1 / 2,} clarithromycin is from 5-7 to 7-9 hours (Russian Medicines Radar Register, 2011. - M., 2010, - S. 412-419). The use of macrolide antibiotics, in particular clarithromycin, has a pronounced endothelio and cardioprotective effect, helps to reduce the level of malondialdehyde, ketodienes, diene conjugates, which are markers of the LPO intensity in the blood (Chernomortseva ES, A.S. 2226101 KP C2, A61K 31/7048 A method for limiting the necrosis zone when modeling coronary occlusal myocardial infarction in animals with a reduced antioxidant background. Kursk State Medical University No. 2002104522; Bull. 9. - 30 p.). They are distinguished by their ability to inhibit the initiation of free radical reactions of lipid peroxidation, to prevent a whole cascade of negative oxidative reactions leading to a violation of the integrity of cell membranes, which is associated with their own antioxidant properties of drugs (Chernomortseva ES, Effect of macrolides on the functional capabilities of endothelium and myocardium in experimental modeling 1 -pate-induced endothelial dysfunction // Kursk Scientific and Practical Bulletin Man and His Health. - 2010, No. 1. - P. 30-33).

Given the pharmacological effects of Mexico, serotonin adipate, heptral and clarithromycin, it is obvious that when used in combination, these drugs are mutually complementary, while simultaneously affecting the main links of pathological processes in liver ischemia.

The method is as follows.

On the day of surgery, clarithromycin is injected slowly to the experimental animal (rabbit) into the marginal vein of the ear with 5.0 isotonic NaCl solution at a dose of 5 mg / kg of animal weight at 8:00, heptral in the form of an injection solution at a dose of 5 mg / kg of body weight animal at 8:15, mexicor in the form of a 5% solution at a dose of 5 mg / kg of the animal’s weight at 8:30, serotonin adipate at 5.0 isotonic NaCl solution at a dose of 0.15 mg / kg of the animal’s weight at 8:45. After treating the surgical field with a 1% solution of chlorhexidine bigluconate under intravenous hexenal anesthesia (0.03 g / kg), a laparotomy is performed, the hepatoduodenal ligament is infiltrated with 4.0 ml of a 0.25% novocaine solution and squeezed with an elastic intestinal clamp for 30 minutes. Then, a resection of the left external lobe of the liver is performed. After eliminating the blockade of the hepatoduodenal ligament, the abdominal cavity is drained, hemostasis is monitored, and the wound of the anterior abdominal wall is sutured in layers tightly. On the same day, the animal is injected intravenously slowly clarithromycin with 5.0 isotonic solution No. C1 at a dose of 5 mg / kg of the animal’s weight at 20:00, heptral in the form of an injection solution at a dose of 5 mg / kg of the animal’s weight at 20:15, Mexico in the form of a 5% solution at a dose of 5 mg / kg of the animal’s weight at 20:30, serotonin adipate in 5.0 isotonic NaCl solution at a dose of 0.15 mg / kg of the animal’s weight at 20:45. In the postoperative period, in the next 9 days, not counting the day of the operation, clarithromycin is injected intravenously slowly at 5.0 isotonic NaCl in a dose of 5 mg / kg of animal weight twice a day with an interval of 12 hours at 8:00 and 20:00, heptral in the form of a solution for injection at a dose of 5 mg / kg of the animal’s weight twice a day with an interval of 12 hours at 8:15 and 20:15, Mexicor in the form of a 5% solution at a dose of 5 mg / kg of the animal’s weight twice a day with an interval at 12 h at 8:30 a.m. and 8:30 p.m., serotonin adipate per 5.0 isotonic NaCl solution at a dose of 0.15 mg / kg of animal weight twice a day with an interval of waste in 12 hours at 8:45 and 20:45.

The study was performed on 19 rabbits of both sexes of the Chinchilla breed weighing from 2.5 to 3 kg. Experimental animals were observed up to 30 days, including blood sampling from the marginal ear vein for biochemical studies and a liver biopsy to determine the content of lipid peroxidation products (LPO) in the liver tissue homogenate. The determination of the level of transaminases - the activity of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) in the blood serum - was carried out according to the Reitman-Frenkel method, lactate dehydrogenase (LDH) - according to Savel, the bilirubin concentration - according to the Endrashik method, Ilroteye cholesterol, according to Ilurkein, β-lip urea - diacetylmonoxime method. In addition, according to generally accepted methods, the levels of alkaline phosphatase (ALP), total protein, prothrombin index (IPT), and fibrinogen were determined using a thymol test. Indicators of cytolysis syndrome were the activity of ALT, AST and LDH. Indicators of cholestasis syndrome are alkaline phosphatase activity, the concentration of bilirubin, cholesterol and β-lipoproteins. Indicators of hepatosuppressive syndrome were the concentration of total protein, fibrinogen content and prothrombin index; mesenchymal-inflammatory syndrome - thymol test. The content of lipid peroxidation products - diene conjugates (DC) and malondialdehyde (MDA) - was determined by the method of I.D. Steel et al. (1977). Before all experiments, all animals were sampled from the marginal ear vein for biochemical studies (control). Heptral, mexicor, serotonin adipate and clarithromycin were administered to 15 animals throughout the study period according to the scheme proposed by the authors. The surgical field was treated with a 1% solution of chlorhexidine bigluconate, under intravenous hexenal anesthesia (0.03 g / kg), a mid-median laparotomy was performed, the hepatoduodenal ligament was infiltrated with 4 ml of a 0.25% novocaine solution and squeezed with an elastic intestinal clamp for 30 min. Then the elements of the glisson and caval systems of the left external lobe of the liver were bandaged. Following this, a resection of the left external lobe of the liver was performed with its blunt and sharp separation along the interlobar sulcus, imposition of liver sutures on the organ stump and plastic wound surface with a lock of a large omentum on the leg. After removing the clamp from the hepatoduodenal ligament, hemostasis was controlled and the wound of the anterior abdominal wall was sutured in layers tightly. Four rabbits underwent clamping of the hepatoduodenal ligament for 30 min and resection of the left external lobe of the liver without administration of the studied drugs.

With a 30-minute liver ischemia without pharmacological protection in the postoperative period, animals showed adynamia, lethargy, and lack of appetite, which indicated the severity of changes in the rabbit's body. One animal died on the 2nd day after surgery, three rabbits survived up to 3 days.

Animals that were injected with a complex of drugs consisting of heptral, mexicor, adipinate serotonin and clarithromycin well underwent surgery, the postoperative period was satisfactory, without complications, the animal survival was 100%.

A morphological study of liver tissue after exposure to 30-minute ischemic anoxia without the use of heptral, mexicor, adipinate serotonin, and clarithromycin revealed that in the first two days of the experiment, hemodynamic disorders were aggravated, interstitial edema was increased, plethora of triads and central veins was determined, and the area of liver sites increased parenchyma with dystrophic and necrobiotic changes. In the zone of triads and in the central zones of the hepatic lobules, widespread stasis was observed in the portal and central veins, ruptures of their walls against the background of increasing discomplexation of the lobules themselves. The cytoplasm of hepatocytes was swollen, separate foci of plasmorrhagia were observed. Lipoidosis was combined with granular and hydropic dystrophies with a predominance of the latter. By 3 days, discirculatory disorders - vascular dilatation and plethora increased in the liver tissue, cells with signs of coagulation necrosis were visualized, leukocyte infiltration was observed between the liver lobules and beams, and there was practically no glycogen in hepatocytes.

Morphological study of the liver parenchyma in the group of animals using the studied drugs after 30 minutes of reperfusion revealed a weakly expressed plethora of the central veins with single zones of granular dystrophy around them. In the zone of triads, single round-cell infiltrates appeared, phagocytic particles were found in the cytoplasm of macrophages from the composition of infiltrates, and in some cases, whole red blood cells, there were no necrotic changes in hepatocytes. The glycogen content in the cytoplasm of hepatocytes on the first day after the operation decreased moderately, which was manifested by a slight decrease in the number of large granules of SHIK-positive substances. During the first three days, the expansion of the central veins in the liver stopped, the zones of vacuole dystrophy around them already disappeared. By 7 days of observation of vascular congestion, which was previously insignificant, was no longer noted. The glycogen content in hepatocytes was quite high, and the amount of SHIK-positive substances increased rapidly. The 14th day after the operation was characterized by a further accumulation of glycosaminoglycans, at this stage the liver tissue actually returned to its original state and subsequently practically did not differ from normal. Thus, although moderate morphological changes were noted in the liver parenchyma, nevertheless, the recovery period was rather short, during which pronounced positive changes took place, characterized, in particular, by the significant preservation of glycogen granules in the cells and accelerated restoration of its stores.

Without the complex use of heptral, mexicor, adipinate serotonin and clarithromycin with a 30-minute ischemic liver anoxia, the simultaneous development of cytolytic, cholestatic and hepatosuppressive syndromes was observed, as evidenced by the results of biochemical studies. After 30 minutes of anoxia, after half an hour of reperfusion, a significant increase in the digital values of transaminases was observed (Table 1; units of measure: ALT, AST and LDH - mmol / (ppm), DC and

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MDA - mmol / g; p <0.05; n = 19) and serum bilirubin (table. 2; units: bilirubin μmol / l, alkaline phosphatase - mmol / (h-l), cholesterol - mmol / l, β-lipoproteins - g / l; p <0, 05; n = 19). In the same time interval, the content of alkaline phosphatase (Table 2) and urea increased, simultaneously accompanied by a decrease in the amount of fibrinogen, IPT, and total protein (Table 3; units: fibrinogen - mg / L, IPI -%, total protein - g / l, urea - mmol / l; thymol test - unit; p <0.05; n = 19). The most significant changes in these indicators occurred on the 3rd day of observation. Compared with the control data, the increase in ALT, AST and LDH on the 3rd day amounted to 4.39; 4.57 and 2.33 times, respectively, which indicates the severity of the cytolytic syndrome (table. 1). Over the same period of time, the bilirubin content increased 2.24 times (Table 2). The post-ischemic 3-day period was also characterized by an increase in alkaline phosphatase values of 1.26 times, β-lipoproteins - by 1.22 times and a decrease in cholesterol concentration by 1.02 times compared with the control (Table 2). These changes indicate the development of cholestasis syndrome. Hepatodepressive syndrome at the end of the third day of the postoperative period was manifested by a quantitative decrease in fibrinogen by 1.30 times, IPT by 1.31 times and total protein by 1.16 times compared with the initial data. By the third day, the urea content also sharply increased - 1.43 times with respect to the initial values (Table 3). The limiting values of lipid peroxidation products were recorded on day 3 with an increase in DC and MDA by 1.97 and 2.38 times, respectively, compared with the control (Table 1).

During a biochemical study of the blood serum of experimental animals that underwent ischemia correction with the proposed complex of drugs, after a 30-minute liver ischemia after 30 minutes of reperfusion, a slight increase in cytolytic syndrome was observed: ALT 1.30 times, AST 1.28 times, LDH 1.01 times compared to control. The peak of enzyme activity was recorded on day 3: ALT 1.76 times, AST 2.22 times, LDH 1.34 times, after which there was a decrease in values. In the remaining follow-up periods, a significant decrease in transaminase activity was observed against the background of indices in pharmacologically unprotected individuals: by the seventh day, ALT activity decreased by 1.16 times, AST by 1.24 times, LDH by 1.14 times with normalization of these indicators by 14 days (tab. 1).

Table 1

experience conditions time after ischemia (days) ALT AST LDH Yes MDA 1. control - 0.74 * 0.08 0.46 * 0.06 1.37 * 0.15 0.87 * 0.081 0.072 * 0.009 2. liver ischemia - 1.47 * 0.12 1.14 * 0.07 1.69 * 0.19 1.31 * 0.082 0.121 * 0.006 3. liver ischemia; complex of drugs - 0.96 * 0.04 0.59 * 0.07 1.39 * 0.16 0.98 * 0.083 0.089 * 0.005 4. liver ischemia one 2.95x0.15 1.72 * 0.09 2.48 * 0.11 1.62 * 0.093 0.164 * 0.009 5. liver ischemia; complex of drugs one 1.28 * 0.11 0.71 * 0.13 1.57 * 0.09 1.07 * 0.072 0.097 * 0.007 6. liver ischemia 3 3.25 * 0.26 2.10 * 0.29 3.19 * 0.21 1.71 * 0.087 0.171 * 0.011 7. liver ischemia; complex of drugs 3 1.30 * 0.14 1.02 * 0.06 1.83 * 0.12 1.15 * 0.089 0.104 * 0.009 8. liver ischemia; complex of drugs 7 1.12 * 0.13 0.82 * 0.08 1.61 * 0.06 1.09 * 0.084 0.088 * 0.004 9. liver ischemia; complex of drugs 14 0.75 * 0.05 0.47 * 0.03 1.39 * 0.07 0.89 * 0.075 0.076 * 0.006 10. liver ischemia; complex of drugs thirty 0.73 * 0.03 0.45 * 0.07 1.35 * 0.09 0.86 * 0.081 0.073 * 0.008

Significant changes in cholesterol, β-lipoproteins, alkaline phosphatase and thymol samples were not observed at all periods of observation.

table 2

experience conditions time after ischemia (days) bilirubin alkaline phosphatase cholesterol β-lipo proteids 1.control - 13.46 * 0.27 2.46 * 0.29 3.94 * 0.42 0.32 * 0.017 2. liver ischemia - 18.44 * 0.79 2.91 * 0.37 3.85 * 0.91 0.36 * 0.024 3. liver ischemia; complex of drugs - 13.77 * 0.78 2.63 * 0.31 3.92 * 0.66 0.33 * 0.027 4. liver ischemia one 25.11 * 1.64 3.02 * 0.24 3.76 * 0.95 0.37 * 0.018 5. liver ischemia; complex of drugs one 15.08 * 0.64 2.82 * 0.14 3.89 * 0.81 0.33 * 0.016 6. liver ischemia 3 30.12 * 1.04 3.11 * 0.28 3.87 * 0.79 0.39 * 0.021 7. liver ischemia; complex of drugs 3 15.12 * 0.87 2.84 * 0.21 3.84 * 0.69 0.34 * 0.012 3. liver ischemia; complex of drugs 7 13.68 * 0.63 2.51 * 0.16 3.91 * 0.75 0.32 * 0.018 9. liver ischemia; complex of drugs 14 13.47 * 0.87 2.48 * 0.22 3.93 * 0.41 0.32 * 0.015 10, liver ischemia; complex of drugs thirty 13.46 * 0.92 2.45 * 0.27 3.94 * 0.43 0.32 * 0.021

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A 30-minute shutdown of the liver from the bloodstream was also accompanied by a slight decrease in IPT, total protein and fibrinogen, and an increase in the content of bilirubin and urea during the first three days after surgery with full recovery by 14 days (Tables 2, 3).

Therefore, the complex effect of heptral, mexicor, adipinate serotonin and clarithromycin against a background of 30-minute liver ischemia contributed to a pronounced normalization of biochemical processes, as evidenced by the dynamics of cytolytic indicators and the complete relief of cholestatic and hepatodepressive syndromes.

Table 3

experience conditions time after ischemia (days) fibrinogen PTI common protein urea thymol try 1. control - 3.88 ± 0.18 81.7 ± 2.11 70.1 ± 1.12 3.82 ± 0.29 1.43 + 0.07 2. liver ischemia - 3.12 ± 0.14 80.3 ± 1.97 68.4 ± 2.03 3.97 ± 0.25 1.38 + 0.07 3. liver ischemia; complex of drugs - 3.77 ± 0.16 81.1 ± 1.98 69.8 ± 1.74 3.84 ± 0 ^ 8 1.36 + 0.04 4. liver ischemia one 3.09 ± 0.15 62.7 ± 1.47 61.3 ± 1.08 4.89 ± 0.33 1.47 + 0.03 5. liver ischemia; complex of drugs one 3.71 ± 0.13 80.2 ± 1.94 68.7 ± 1.85 3.87 ± 0.26 1.37 + 0.08 b. liver ischemia 3 2.97 ± 0.23 62.5 ± 1.39 60.4 ± 1.12 5.47 ± 0.25 1.51 + 0.04 7. liver ischemia; complex of drugs 3 3.62 ± 0.14 79.7 ± 1.73 6b, 9 ± 1.16 3.91 + 0.24 1.43 + 0.06 8. liver ischemia; complex of drugs 7 3.80 + 0.13 81.2 ± 2.01 68.8 ± 2.09 3.86 + 0.30 1.44 + 0.03 9. liver ischemia; complex of drugs 14 3.86 + 0.16 81.6 ± 2.09 69.7 ± 1.76 3.83 + 0.19 1.43 + 0.05 10. liver ischemia; complex of drugs thirty 3.88 + 0.21 82.4 ± 2.14 70.5 ± 1.18 3.82 + 0.25 1.43 + 0.04

Studying changes in the level of accumulation of lipid peroxidation products in liver tissue after 30-minute ischemia against the background of complex administration of heptral, mexicor, adipinate serotonin and clarithromycin at all periods of observation, we found a lower content of DC and MDA compared with data obtained under the same conditions, but without the use of drugs (table. 1). So, after 30 minutes the reperfusion of DC and MDA did not significantly increase, while at the same time being 1.34 and 1.36 times lower than the corresponding values without pharmacological support. And on the third day, the gap in readings has grown to 1.49 (DK) and 1.64 (MDA) times. The same period corresponds to the maximum numerical values of the studied LPO products. Comparison with the control data revealed a positive effect of the proposed complex of drugs: compared with the control on the 3rd day, the content of DC increased only 1.32 times, MDA - 1.44 times. In the future, the considered indicators quickly normalized to 14 days.

The results obtained indicate that, against the background of the introduction of the proposed complex of drugs with ischemic exposure to the liver for 30 minutes, the intensity of LPO processes was significantly slowed down, which impeded the development of ischemic changes in the organ, significantly reduced the risk of possible liver damage due to hypoxia, and provided both preventive and and therapeutic effect.

Thus, under the influence of the complex effect of heptral, mexicor, adipinate serotonin, and clarithromycin, almost all of the studied parameters after the third day of observation had pronounced positive dynamics in their changes, which manifested itself in reaching the initial values by 14 days of observation.

Examples of specific application.

Example No. 1. Rabbit N2. Operation 07/22/2014.

After treating the surgical field with a 1% solution of chlorhexidine bigluconate under intravenous hexenal anesthesia (0.03 g / kg), a mid-median laparotomy was performed, the hepatoduodenal ligament was visualized and infiltrated with 4.0 ml of 0.25% novocaine solution, squeezed with an elastic intestinal clamp of 30 min Then, the elements of the glisson and caval systems of the left external lobe of the liver were ligated. Following this, a resection of the left external lobe of the liver was performed with its blunt and sharp separation along the interlobar sulcus, imposition of liver sutures on the organ stump. After removing the clamp from the hepatoduodenal ligament, hemostasis was controlled and the wound of the anterior abdominal wall was sutured in layers tightly.

Results of biochemical studies:

07/22/2014: before surgery: ALT - 0.78 mmol / (tsp); AST - 0.45 mmol / (ppm); LDH - 1.42 mmol / (ppm); bilirubin - 13.61 μmol / l; Alkaline phosphatase - 2.37 mmol / (ppm); cholesterol - 3.82 mmol / l;

β-lipoproteins - 0.29 g / l; fibrinogen-3.95 mg / l; IPT - 83.1%; total protein 71.6 g / l; urea - 3.64 mmol / l; thymol test - 1.38 units; DC - 0.94 mmol / g; MDA - 0.068 mmol / g.

07/22/2014: after 30 minutes of reperfusion: ALT - 1.58 mmol / (tsp); AST - 1.19 mmol / (ppm); LDH - 1.83 mmol / (ppm); bilirubin - 18.54 μmol / l; Alkaline phosphatase - 3.03 mmol / (tsp); cholesterol - 3.94 mmol / l;

- 6 026585 β-lipoproteins - 0.52 g / l; fibrinogen - 3.07 mg / l; IPT - 79.3%; total protein - 57.9 g / l; urea - 4.12 mmol / l; thymol test - 1.41 units; DK - 1.38 mmol / g; MDA - 0.126 mmol / g.

07/23/2014 .: ALT - 3.02 mmol / (tsp); AST - 1.79 mmol / (ppm); LDH - 2.56 mmol / (ppm); bilirubin 26.67 μmol / l; Alkaline phosphatase - 3.18 mmol / (h-l); cholesterol - 3.85 mmol / l; β-lipoproteins - 0.49 g / l; fibrinogen - 3.02 mg / l; IPT - 62.3%; total protein - 59.4 g / l; urea - 4.71 mmol / l; thymol sample -1.49 units; DK - 1.64 mmol / g; MDA - 0.172 mmol / g.

07/25/2014: ALT-3.41 mmol / (tsp); AST - 2.33 mmol / (ppm); LDH - 3.29 mmol / (ppm);

bilirubin - 30.76 μmol / l; Alkaline phosphatase - 3.27 mmol / (tsp); cholesterol - 3.71 mmol / l; β-lipoproteins 0.45 g / l; fibrinogen - 2.82 mg / l; IPT - 61.4%; total protein - 59.6 g / l; urea - 5.58 mmol / l; thymol test - 1.53 units; DK - 2.07 mmol / g; MDA - 0.179 mmol / g.

By the end of the third day of observation, the animal died.

Example No. 2. Rabbit N7.

On the day of surgery 04.08.2014, the rabbit was injected slowly into the marginal vein of the ear with clarithromycin 5.0 of the отαΟ isotonic solution at a dose of 5 mg / kg of animal weight at 8:00, heptral in the form of an injection solution at a dose of 5 mg / kg of animal weight in 8:15, Mexicor in the form of a 5% solution at a dose of 5 mg / kg of the animal’s weight at 8 °, serotonin adipate at 5.0 isotonic solution of ΝαΟ at a dose of 0.15 mg / kg of the animal’s weight at 8:45. After treating the surgical field with a 1% solution of chlorhexidine bigluconate under intravenous hexenal anesthesia (0.03 g / kg), a laparotomy was performed, the hepatoduodenal ligament was visualized and infiltrated with 4.0 ml of 0.25% novocaine solution, squeezed with an elastic intestinal clamp for 30 min . Then, the elements of the glisson and caval systems of the left external lobe of the liver were ligated. Following this, a resection of the left external lobe of the liver was performed with its blunt and sharp separation along the interlobar sulcus, imposition of liver sutures on the organ stump. After eliminating the blockade of the hepatoduodenal ligament, the abdominal cavity was drained, hemostasis was controlled, and the wound of the anterior abdominal wall was sutured in layers tightly. On the same day, the animal was injected intravenously slowly clarithromycin with 5.0 isotonic solution of ΝαΟ at a dose of 5 mg / kg of animal weight at 20:00, heptral in the form of an injection solution at a dose of 5 mg / kg of animal weight at 20:15, Mexico in the form of a 5% solution at a dose of 5 mg / kg of the animal’s weight at 20:30, serotonin adipate at 5.0 isotonic solution Ναί ', Ί at a dose of 0.15 mg / kg of the animal’s weight at 20:45. In the postoperative period, for the next 9 days, not counting the day of the operation, clarithromycin was administered intravenously slowly at 5.0 isotonic solution Ναί ', Ί at a dose of 5 mg / kg of animal weight twice a day with an interval of 12 hours at 8:00 and 20 : 00, heptral in the form of a solution for injection at a dose of 5 mg / kg of the animal’s weight twice a day with an interval of 12 hours at 8:15 and 20:15, Mexicor in the form of a 5% solution at a dose of 5 mg / kg of the animal’s weight twice day with an interval of 12 hours at 8:30 and 20:30, serotonin adipate in 5.0 isotonic solution of ΝαΟ in a dose of 0.15 mg / kg of animal weight twice a day with shaft 12 at 8:45 h and 20:45.

Results of biochemical studies:

08/04/2014: before surgery: ALT - 0.76 mmol / (tsp); AST - 0.48 mmol / (ppm); LDH - 1.35 mmol / (ppm); bilirubin - 13.49 μmol / l; Alkaline phosphatase - 2.51 mmol / (ppm); cholesterol - 3.93 mmol / l; β-lipoproteins 0.32 g / l; fibrinogen - 3.84 mg / l; IPT - 81.6%; total protein - 70.2 g / l; urea - 3.83 mmol / l; thymol test - 1.41 units; DK - 0.89 mmol / g; MDA - 0.075 mmol / g.

08/04/2014: after 30 minutes of reperfusion: ALT - 0.95 mmol / (tsp); AST - 0.61 mmol / (ppm); LDH 1.38 mmol / (ppm); bilirubin - 13.66 μmol / l; Alkaline phosphatase - 2.59 mmol / (tsp); cholesterol - 3.91 mmol / l; β-lipoproteins - 0.33 g / l; fibrinogen - 3.79 mg / l; IPT - 81.1%; total protein - 69.8 g / l; urea 3.77 mmol / l; thymol test - 1.39 units; DC - 0.95 mmol / g; MDA - 0.086 mmol / g.

08/05/2014: ALT - 1.29 mmol / (tsp); AST - 0.67 mmol / (ppm); LDH - 1.55 mmol / (ppm); bilirubin 15.02 μmol / l; Alkaline phosphatase - 2.76 mmol / (tsp); cholesterol - 3.89 mmol / l; β-lipoproteins - 0.34 g / l; fibrinogen - 3.73 mg / l; IPT - 80.7%; total protein - 69.2 g / l; urea - 3.85 mmol / l; thymol test - 1.38 units; DK - 1.01 mmol / g; MDA - 0.094 mmol / g.

08/07/2014: ALT - 1.31 mmol / (tsp); AST - 0.94 mmol / (ppm); LDH - 1.78 mmol / (ppm); bilirubin 15.09 μmol / l; Alkaline phosphatase - 2.81 mmol / (ppm); cholesterol - 3.83 mmol / l; β-lipoproteins - 0.35 g / l; fibrinogen - 3.64 mg / l; IPT - 80.1%; total protein - 67.3 g / l; urea - 3.89 mmol / l; thymol test - 1.41 units; DK - 1.13 mmol / g; MDA - 0.102 mmol / g.

08/11/2014: ALT - 1.09 mmol / (tsp); AST - 0.76 mmol / (ppm); LDH - 1.58 mmol / (ppm); bilirubin 13.54 μmol / l; Alkaline phosphatase - 2.49 mmol / (tsp); cholesterol - 3.86 mmol / l; β-lipoproteins - 0.31 g / l; fibrinogen - 3.73 mg / l; IPT - 81.3%; total protein - 68.8 g / l; urea - 3.85 mmol / l; thymol test - 1.43 units; DK - 1.05 mmol / g; MDA - 0.087 mmol / g.

08/18/2014: ALT - 0.78 mmol / (tsp); AST - 0.46 mmol / (ppm); LDH - 1.41 mmol / (ppm); bilirubin 13.49 μmol / l; Alkaline phosphatase - 2.48 mmol / (ppm); cholesterol - 3.89 mmol / l; β-lipoproteins - 0.32 g / l; fibrinogen - 3.81 mg / l; IPT - 81.5%; total protein - 70.6 g / l; urea - 3.84 mmol / l; thymol test - 1.43 units; DK - 0.86 mmol / g; MDA - 0.095 mmol / g.

09/06/2014: ALT - 0.75 mmol / (tsp); AST - 0.44 mmol / (ppm); LDH - 1.36 mmol / (ppm); bilirubin - 7 026585

13.46 μmol / L; Alkaline phosphatase - 2.47 mmol / (ppm); cholesterol - 3.94 mmol / l; β-lipoproteins - 0.30 g / l; fibrinogen - 3.85 mg / l; IPT - 81.9%; total protein 71.3 g / l; urea - 3.82 mmol / l; thymol test - 1.42 units; DK - 0.87 mmol / g; MDA - 0.074 mmol / g.

The postoperative period was satisfactory.

Example No. 3. Rabbit N14.

On the day of surgery, 08/18/2014, clarithromycin was injected slowly into the marginal vein of the ear into a rabbit 5.0 ml of отαΝ'Ί isotonic solution at a dose of 5 mg / kg of animal weight at 8:00, heptral in the form of a solution for injection at a dose of 5 mg / kg of the animal’s weight at 8:15, Mexicor in the form of a 5% solution at a dose of 5 mg / kg of the animal’s weight at 8:30, serotonin adipate at the 5.0 отαΝ'ί isotonic solution at a dose of 0.15 mg / kg of the animal’s weight at 8 : 45. After treating the surgical field with a 1% solution of chlorhexidine bigluconate under intravenous hexenal anesthesia (0.03 g / kg), a laparotomy was performed, the hepatoduodenal ligament was visualized and infiltrated with 4.0 ml of 0.25% novocaine solution, squeezed with an elastic intestinal clamp for 30 min . Then, the elements of the glisson and caval systems of the left external lobe of the liver were ligated. Following this, a resection of the left external lobe of the liver was performed with its blunt and sharp separation along the interlobar sulcus, imposition of liver sutures on the organ stump. After eliminating the blockade of the hepatoduodenal ligament, the abdominal cavity was drained, hemostasis was controlled, and the wound of the anterior abdominal wall was sutured in layers tightly. On the same day, the animal was injected intravenously slowly clarithromycin with 5.0 отαί'Ί isotonic solution at a dose of 5 mg / kg of animal weight at 20:00, heptral in the form of an injection solution at a dose of 5 mg / kg of animal weight at 20:15 , Mexicor in the form of a 5% solution at a dose of 5 mg / kg of animal weight at 20:30, serotonin adipate at 5.0 isotonic solution No. C1 at a dose of 0.15 mg / kg of animal weight at 20:45. In the postoperative period, for the next 9 days, not counting the day of the operation, clarithromycin was administered intravenously slowly at 5.0 isotonic Ναί'Ί solution at a dose of 5 mg / kg of the animal’s weight twice a day with an interval of 12 hours at 8:00 and 20: 00, heptral in the form of a solution for injection at a dose of 5 mg / kg of the animal’s weight twice a day with an interval of 12 hours at 8:15 and 20:15, Mexicor in the form of a 5% solution at a dose of 5 mg / kg of the animal’s weight twice a day with an interval of 12 hours at 8:30 and 20:30, serotonin adipate in 5.0 isotonic solution No. C1 at a dose of 0.15 mg / kg of animal weight twice a day with inter at 12 a.m. at 8:45 a.m. and 8:45 p.m.

Results of biochemical studies:

08/18/2014: before surgery: ALT - 0.75 mmol / (tsp); AST - 0.44 mmol / (ppm); LDH - 1.36 mmol / (ppm); bilirubin - 13.38 μmol / l; Alkaline phosphatase - 2.47 mmol / (ppm); cholesterol - 3.88 mmol / l; β-lipoproteins 0.30 g / l; fibrinogen - 3.85 mg / l; IPT - 82.1%; total protein 71.3 g / l; urea - 3.83 mmol / l; thymol test - 1.41 units; DK - 0.85 mmol / g; MDA - 0.071 mmol / g.

08/18/2014: after 30 minutes of reperfusion: ALT - 0.94 mmol / (tsp); AST - 0.56 mmol / (ppm); LDH - 1.33 mmol / (ppm); bilirubin - 13.72 μmol / l; Alkaline phosphatase - 2.64 mmol / (tsp); cholesterol - 3.90 mmol / l; β-lipoproteins - 0.32 g / l; fibrinogen - 3.82 mg / l; IPT - 80.9%; total protein - 70.1 g / l; urea - 3.85 mmol / l; thymol test - 1.35 units; DK - 0.89 mmol / g; MDA - 0.091 mmol / g.

08/19/2014: ALT - 1.27 mmol / (tsp); AST - 0.68 mmol / (ppm); LDH - 1.56 mmol / (ppm); bilirubin 15.05 μmol / l; Alkaline phosphatase - 2.79 mmol / (tsp); cholesterol - 3.91 mmol / l; β-lipoproteins - 0.33 g / l; fibrinogen - 3.74 mg / l; IPT - 80.1%; total protein - 67.9 g / l; urea - 3.87 mmol / l; thymol test - 1.34 units; DK - 1.05 mmol / g; MDA - 0.096 mmol / g.

08/21/2014: ALT - 1.29 mmol / (tsp); AST - 1.03 mmol / (ppm); LDH - 1.81 mmol / (ppm); bilirubin - 15.10 μmol / l; Alkaline phosphatase - 2.83 mmol / (h-l); cholesterol - 3.82 mmol / l; β-lipoproteins 0.35 g / l; fibrinogen - 3.63 mg / l; IPT - 80.3%; total protein - 65.8 g / l; urea - 3.90 mmol / l; thymol test - 1.39 units; DK - 1.14 mmol / g; MDA - 0.105 mmol / g.

08/25/2014: ALT - 1.10 mmol / (tsp); AST - 0.81 mmol / (ppm); LDH - 1.63 mmol / (ppm); bilirubin - 13.59 μmol / l; Alkaline phosphatase - 2.52 mmol / (ppm); cholesterol - 3.84 mmol / l; β-lipoproteins 0.32 g / l; fibrinogen - 3.76 mg / l; IPT - 80.9%; total protein - 67.5 g / l; urea - 3.87 mmol / l; thymol test - 1.42 units; DK - 1.07 mmol / g; MDA - 0.086 mmol / g.

09/04/2014: ALT - 0.75 mmol / (tsp); AST - 0.45 mmol / (tsp); LDH - 1.38 mmol / (ppm); bilirubin 13.45 μmol / l; Alkaline phosphatase - 2.47 mmol / (ppm); cholesterol - 3.90 mmol / l; β-lipoproteins - 0.33 g / l; fibrinogen - 3.83 mg / l; IPT - 81.2%; total protein - 68.9 g / l; urea - 3.85 mmol / l; thymol sample 1.44 units; DK - 0.90 mmol / g; MDA - 0.077 mmol / g.

09/20/2014: ALT - 0.74 mmol / (tsp); AST - 0.42 mmol / (ppm); LDH - 1.34 mmol / (ppm); bilirubin 13.39 μmol / l; Alkaline phosphatase - 2.44 mmol / (tsp); cholesterol - 3.89 mmol / l; β-lipoproteins - 0.33 g / l; fibrinogen - 3.86 mg / l; IPT - 81.7%; total protein - 70.2 g / l; urea - 3.79 mmol / l; thymol sample 1.44 units; DK - 0.86 mmol / g; MDA - 0.075 mmol / g.

The postoperative period was satisfactory.

The results obtained indicate that the use of our proposed method for the prevention and treatment of the consequences of ischemic effects on the liver with complex intravenous administration of heptral, mexicor, adipinate serotonin and clarithromycin according to our scheme with a 30-minute liver ischemia reduced the intensity and contributed to the normalization of bio-8 026585 chemical processes, impeded the violation of the structure of the hepatic parenchyma, the development of cytolytic, cholestatic and hepatosuppressive syndromes and OF DATA them functionally expressed morphological changes, thereby preventing the development of ischemic changes in the body, significantly reduced the severity of potential liver damage due to oxygen starvation and provides not only shielding but also a therapeutic effect.

Thus, the proposed method allows you to extend the safe period of blood exsanguination of the liver up to 30 minutes, provides treatment, correction and prevention of ischemic and reperfusion injuries of the liver tissue and its microvasculature that occur during resection of this organ under conditions of temporary shutdown from the blood circulation, helps to prevent massive bleeding during operations on the liver.

Claims (1)

CLAIM A method for the complex treatment and correction of ischemic genesis disorders in liver resections, including liver resection in an experimental animal without the use of temporary extracorporeal portocaval bypass grafting and intravenous slow injection, starting from the day of surgery for 10 days, clarithromycin in 5.0 ml of isotonic NaCl solution in a dose 5 mg / kg of weight twice a day with an interval of 12 hours at 8:00 and 20:00, heptral in the form of a solution for injection at a dose of 5 mg / kg of weight twice a day with an interval of 12 hours at 8:15 and 20: 15, mexico in the form of a 5% solution at a dose of 5 mg / kg of weight twice a day with an interval of 12 hours at 8:30 and 20:30, serotonin adipate in 5.0 ml of isotonic NaCl solution at a dose of 0.15 mg / kg of weight twice a day with an interval of 12 hours at 8:45 and 20:45.