RU2001612C1 - Method for postoperative adhesive sickness prophylaxis - Google Patents

Abstract

The invention relates to medicine, in particular to surgery. The purpose of the invention is to increase the effectiveness of prevention by reducing the number of relapses and shortening the treatment time. For this, 100-120 ml of a 20% solution of mannitol containing 5-10 mg methotrexate are injected into the subcutaneous lymph vessel at a rate of 5-6 ml / h every other day for 10-15 days. after operation..

Description

The invention relates to medicine and can be used in surgery and postoperative intensity of therapy for the prevention of adhesive disease. It is known that adhesive disease is the prime of 35-70% of cases of intestinal obstruction. Mortality in adhesive intestinal obstruction ranges from 8-19%.

Known methods for the prevention of postoperative adhesive disease, based on anti-inflammatory therapy, prevention of postoperative intestinal paresis.

The disadvantages of these methods include primarily low efficiency

Closest to the claimed and accepted for the prototype is a method for the prevention of postoperative adhesive disease, including prolonged administration of a solution of drugs into the abdominal cavity According to this method, the patient at the end of the operation and for the next 3 days intraperitoneally (2-10 drops in 1 min through a microirrigator) fibrinolysin (20,000 IU) with trypsin 20-30 kg and hydrocortisone (50-125 mg), prolonged by hemedes, is introduced

The disadvantages of the prototype are low efficiency (does not completely hinder the development of adhesions in the abdominal cavity); the presence of complications associated with the effect of npoTeo TH4ecKHv farmer oe on the abdominal organs, as well as with a decrease in reactivity of the aneurysm (anism on the background of the use of hydrocortisone (ematomas in the postoperative wound, suppuration of the postoperative wound, intestinal fistula, subhepatic abscesses, fistula fistula, etc. ); the presence in a number of patients of contraindications to the use of Fibrinolysin: the usefulness of the treatment.

The purpose of the invention is the prevention of the formation of adhesions by iodine shadow GM-proliferative processes in the intestinal mesothelium

This is achievable. for the prevention of postoperative intraperitoneal buds, including prolonged administration of drugs acting on the intestinal messtel, according to the invention, and a solution containing methotrexet e in an amount of 5-Ohm and 20% mannitol in an amount of 100-1 O ml which is injected into the subcutaneous lymph vessel is used as medicaments thighs with a prolonged infusion pool at a rate of 5-6 ml / h during 20-24 hours every other day for 10-15 days

The chosen route of administration into the subcutaneous lymph vessel of the thigh is due to the fact that the lymph flowing from the lower extremities then enters the lymphatic system of the abdominal organs. In patients undergoing abdominal operations, the presence of lymphatic lymphatic return from the lymphatic vessels to the intestinal mesothelium is proved. Thanks to this phenomenon

methotrexet, injected into the subcutaneous lymph vessel of the thigh, enters directly into the site of the potential commissure

The developed regime of prolonged infusion at a rate of 5-6 ml of solution per 1 hour for 20-24 hours ensures the maintenance of a constant concentration of methotrexate in the intestinal mesothelium during infusion and on the next day. A lower infusion rate will not allow the methotrexate concentration to be achieved to provide a prophylactic antiproliferative effect. If the infusion rate is exceeded, a significant part of methotrexate will be discharged together with the lymph into the i ore lymphatic duct, and from it into the subclavian vein. Since the volume of human circulating blood is much greater than the volume of circulating

Lymph concentration of methotrexate will decrease significantly, the drug will begin to be distributed with blood throughout all organs and systems of the body, not getting the right dose in the intestinal mesothelium.

Considering the high toxicity of cytosygatic agents. the dose of methotrexet is 10 times lower than generally accepted. Thanks to the regimen of prolonged endolymphatic infusion, the drug even at a dose of 5-10 mg has

prophylactic antiproliferative effect without toxic effects observed when using conventional doses of motofexag.

The timing of the administration of methotrexate is due to the peculiarities of the pathogenesis of adhesive disease since the hyperproliferative processes in the intestinal mesothelium are most intense in the first 10-15 days. after surgery.

Clinical Observations

in the treatment of 12 patients by the proposed method fully confirm the above provisions.

Comparative analysis with the prototype showed that the claimed method is different

new for the treatment of adhesive disease drugs (methotrexate), a foliar acid antagonist that suppresses cellular

mitosis and inhibitory hyperlroliferative processes

new to this nosological form by administration of the drug (into the lymphatic vessel of the thigh).

a decrease in the generally accepted single dose of methotrexate from 50-100 mg to 5-10 mg,

a decrease in the course dose of methotrexate from 0.5-1 g to 25-50 mg

prolonged administration of a single dose of methotrexate (0.3-0.5 mg / h) over a period of 20-24 hours, allowing over 48 hours to maintain a constant concentration of methotrexate in the methothelium:

intermittent treatment (infusion every other day for 10-15 days after surgery);

use for therapeutic purposes (for delivery of methotrexate to mesothelium against natural lymphatic flow) of the pathological phenomenon of lymphatic backflow.

Thus, the claimed method meets the criteria of the invention of novelty.

Comparison not only with the prototype but also with other well-known technical solutions in this field of medicine did not allow them to identify features that distinguish the claimed method from the prototype and, therefore, they provide the claimed technical solution that meets the criterion of significant differences

Prevention of postoperative adhesive disease is as follows: under local anesthesia, novocaine under aseptic conditions catheterizes the subcutaneous lymph vessel of the thigh. On the day of the operation or on the first day after the operation, a prolonged endolymphatic infusion of the solution is carried out using an automatic injector; the solution is prepared, a solution of 5-10 mg of methotrexate in 100-120 ml of 20% mannitol. The final concentration of methotrexate in the solution was em 0.00005-0.0001% Set the infusion rate of 5-6 ml of solution per 1 h with a duration of administration of 20-24 hours Endolymphatic infusions are repeated every other day for 10-15 days after surgery. Between infusions, the catheter is inserted t 5-6 ml of heparinized isotonic solution of sodium chloride and adjusted plug after completion of the catheter is removed from the lymphatic vessel (provided completely vosstanovivshegos passage through the gastrointestinal tract and the total elimination of phenomena ileus) After discharge is carried out ambulatory monitoring of patients

An example of B-Noya V.Yu. M 1947 r / b M1 4132 about 1970 suffered a resection of the stomach according to the Billroth-N method for gastric ulcer. In 1982, 5 patients were operated on for an illness of the operated stomach with chronic partial intestinal obstruction (as established on adhesive surgery) Reconstructive surgery performed

In the Republic of Uzbekistan, dissection of ODNRKO adhesions within a month after the operation of partial intestinal obstruction showed regression and resolved only due to the formation of small intestinal fistula. 10 07 89 patients were operated on for chronic adhesive intestinal obstruction, small intestinal fistula. An intestine carrying fistula and dissection of adhesions were resected. In the postoperative period, the only method for preventing relapse of adhesive disease was the endolymphatic administration of methotrexate. On the first day after surgery, a lymphatic vessel was catheterized in the upper third of the right thigh with 0.5% novocaine solution using local anesthesia. automatic injectors Linesmat (GDR) started the introduction of methotrexate in a dose of 10 mg dissolved in 100 ml of 20% mannitol with

0 at a rate of 5 mg / h. The infusion continued for 20 hours. Repeated endopymphatic infusions of the same mixture in the previous regimen were carried out on 3 5 7 9 days after surgery

5 At the same time the patient was

traditional postoperative therapy, including correction of disorders of water-electrolyte and protein-nitrogen metabolism, acid-base state,

0 preventive antibacterial as well as symptomatic therapy.

The course of the postoperative period without features. Intestinal motility recovered by 3 days. independent stool for 6 days. after surgery The patient was discharged in satisfactory condition for 19 days. Outpatiently observed for 1 year. No signs of relapse of adhesive disease were found

0 By the proposed method treated

12 patients aged 37 to 59 years. The average age was 48.0 ± 3.6 years. In 7 patients (i / b No. N 8343, 896, 2385 4132, 2077, 2031 5943), adhesive disease developed after gastric resection in 2 ( and / b No. 312 5341) - after bowel resection for neoplasms, in 1 (and / b N 1416) - after hepatikojejunostomy for stenosing papillitis in 1 (and / b M; 3966) - after removal of the pancreatic cyst, 1 (i / b 349) - after removal of the cyst of the right ovary. In all cases, a favorable course of the postoperative period was noted. No complications were noted. The passage through the gastrointestinal tract (independent stool) was fully restored within 4.6 ± 1.5 days. the length of stay on the bed averaged 21.4 ± 3.1 days. After discharge, patients underwent outpatient monitoring. None of the operated signs of relapse of adhesive disease over 1 year of outpatient observation was found.

For comparative analysis, we examined a group of 12 patients aged 16 to 70 years (mean age 44.0 ± 11.2 years), operated on for adhesive intestinal obstruction and treated using the prototype method (intraperitoneal administration of hydrocortisone, trypsin, fibrinolysin), as well as other generally accepted methods for the prevention of postoperative intraperitoneal adhesions (stimulation of peristalsis with calcium pantotonate, fractional doses of chlorpromazine, prozerin. aceclidine. peridural anesthesia: peritoneal dialysis). Operations for gastric ulcer (i / b No. 2660, 7455. 7719) and intestinal tumors (i / b No. N; 2584, 7116. 11587) were mentioned as the primary causes of adhesions. acute cholecystitis (and / b Ms 3353, 11359), acute appendicitis (and / b No. 3329, 11646). acute pancreatitis (i / b Nf 11064), skin wound of the small intestine (i / b No. 12348).

In the early postoperative period, a number of complications were recorded. Relapse of the adhesive process was noted in 2 cases. In one case (b / w No. 12348), re-developed adhesions were confirmed and disconnected during relaparotomy 14 days after the first operation. In the second case (and / b No. 2584), the patient died on the 9th day.

after surgery, from bilateral abscessing pneumonia complicated by pneumothorax. Relapse of the adhesion process was confirmed during pathoanatomical examination. The early postoperative complications can also include the development of an external pancreatic fistula (I / N N 11064) and a complete tubular fistula of the small intestine, followed by

late or late diagnosed relapse of the adhesive process (and / b No. 11587). The last patient re-operated, after 10 months. In all 4 patients with an aggravated postoperative course, these complications developed against the background of flowing peritonitis and in 3 patients (i / b No. 11064, 11587, 12348) caused disability (all three were group II invalids). Complete restoration of the passage through the gastrointestinal tract occurred after 6.2 ± 2.5 days. The average duration of a patient's stay in bed was 31.2 ± 4.2 days.

The specific parameters of therapy and the results of treatment of patients by the proposed method are given in table. 1. For comparison in table. 2 shows the results of treatment of patients according to the prototype method,

(56) Gataullin N.G. Khunafin S.N. Adhesive disease of the peritoneum (review). Wedge. honey. 1986. N 10. p. 20-25.

Brezhnev V.P., Captains A.S. Etiologists, pathogenesis and prevention of postoperative adhesive disease of the abdominal organs (review). Klin, hir., 1988, No. 2. p. 39-42.

Zhenchevsky R.A. Treatment of adhesive disease. Surgeons 1988, M 12, p. 63-68.

Dzhumabaev S.U., Dzhumabaev Z.S. To the mechanism of the effect of endolymphatic and lymphotropic therapy in diseases of the abdominal organs. Clinical lymphologists. First All-Union Conference Thesis dokl. M ,, Podolsk, 1985, p. 54-55.

Table 1

The list of patients treated by the claimed method in the period 1.02.89 - 1.02.90. parameters used and treatment results

Continuation of the table. 1

List of patients treated by the prototype method and other traditional methods

for the period 20.03.89-20.03.90

Claims (1)

The claims METHOD FOR PREVENTION OF POSTOPERATIVE ADHESIVE DISEASE, including prolonged administration of drug solutions, characterized in that, in order to increase the effectiveness of prevention due to table 2 To reduce the number of relapses and shorten the treatment time, 100-120 ml of a 20% solution of mannitol containing 5-10 mg of methotrexate is injected into the subcutaneous lymph vessel of the thigh at a rate of 5-6 ml / h after 1 day for 10-15 days after operation.