RU2089234C1 - Method to treat inflammatory diseases of hepatopancreatoduodenal area - Google Patents

Abstract

FIELD: medicine, surgery. SUBSTANCE: during postoperative stage a drainage tube is applied in the upper part of abdominal cavity and subhepatic area. In 2-3 days when subhepatic area is free of bile and blood additional regional subhepatic lavage is conducted with antibiotic or dioxydine solutions. Then sterile wire electrode is introduced through a drainage tube, the length of electrode being slightly larger than that of the drainage. The second electrode is introduced nasagastrally into duodenum. The function of the second probe is fulfilled by conventional duodenal probe with metal plum and conductor inside it. Medicinal mixture is introduced immediately before the procedure. EFFECT: higher efficiency, improved results in surgical treating cholelithiasis, vcholecystitis and other inflammatory diseases.

Description

 The invention relates to medicine and can be used in the treatment of inflammatory diseases of the hepatopancreatoduodenal zone.

 Up to 60 thousand cholecystectomies are performed annually in Russia / Nechay L.N. Sitenko V.N. 1980; Vinogradov V.V. Uld-Slimane M. 1980 /. Currently, cholecystectomy takes second place in urgent surgery, second only to appendectomy / Milonov O.B. Abdullaev A.A. 1977 /. Numerous literature data indicate that the operation does not always relieve patients from suffering. In 5-20% of patients or more, after a certain period of time, the so-called postcholecystectomy syndrome occurs, the treatment of which presents significant difficulties due to the complexity of the pathogenesis and the variety of clinical manifestations / Litsky A.G. 1962; Nogaller A.M. 1969; Filz O.V. 1980; Petrovsky B.V. et al. 1973; Korzhunova P.I. Rozanova Z.I. 1980 /.

 Different authors put different contents into the term "postcholecystectomy syndrome". Some of them believe that the syndrome includes unsuccessful outcomes and complications after surgery / Napalkov P.N. 1965; Gubergrits A.N. 1964 /, inflammation of the hepatopancreatoduodenal zone.

 At the same time, a number of authors believe that the manifestations of this syndrome are not directly related to the errors of surgical intervention, but depend on the concomitant damage to other digestive organs, as a rule, which occur in chronic calculous cholecystitis and worsen after the operation.

 The presence of a long stump of the cystic duct is not uncommon. In the cult, the inflammatory process that was before the operation occurs or progresses; the occurrence of stones in it is described.

 Most authors consider chronic pancreatitis the most common complication after surgery on the biliary tract / Vinogradov V.V. Uld-Slimon M. 1980; Limenko Z. A. Gribenev A.L. 1980; Skuya N.A. et al. 1980; Sokolov Yu.S. 1980; Shirokova K.I. Ivanichenkova R.A. et al. 1980 /.

 Damage to the pancreas accompanies cholelithiasis even before surgery. So, Borodin I.F. et al., 1980, established on the basis of histological examination that already in the early stages of the development of cholelithiasis in the pancreas dystrophic, necrotic and inflammatory changes develop, which increase with the duration of the disease. Surgery may contribute to exacerbation of pancreatitis. The surgical trauma itself, accompanied by a violation of microcirculation, swelling of the gland, casting bile into it, contributes to the onset of a progressive inflammatory process in the pancreas.

 Based on the foregoing, it can be concluded that after cholecystectomy in the organs of the hepatopancreatoduodenal zone, the inflammatory process in the form of chronic cholangitis, papillitis, visceritis, pancreatitis, lymphadenitis, etc. persists for a long time.

 According to Gavenko G.I. / 1969 /, the most frequent complaints in patients with postcholecystectomy syndrome were pain in the right and left hypochondrium of aching nature, dryness and bitterness in the mouth, belching, nausea, heartburn, impaired bowel function, which were noted in 65% of patients. Characterized were increased irritability and fatigue, unstable mood, poor sleep, headaches, fever, and sometimes chills.

 Clinical and biochemical studies have revealed a violation of the functional state of the liver and pancreas, including a change in the physicochemical composition of bile and a decrease in the cholate-cholesterol coefficient in 42% of patients, a violation of the external and intracecretory function of the pancreas.

 The inflammatory process of the hepatopancreatoduodenal zone remaining after removal of the focus in the future can lead to irreversible phenomena in the organs of this zone, which are the cause of postcholecystectomy suffering. Therefore, treatment of these residual effects, begun in the early postoperative period, is the main method for the prevention of postcholecystectomy syndrome.

 It is generally accepted that in the postoperative period, after cholecystectomy for acute destructive cholecystitis, antibiotics are administered into the subhepatic space for only 2-3 days. In chronic cholecystitis, antibacterial and anti-inflammatory therapy is not carried out at all.

 Intramuscular administration of antibiotics is ineffective, because a negligible concentration of the drug is created in the necessary zone.

 To create a greater local concentration of the drug in domestic medicine, the electrophoresis method is used / Sosin I.N. 1973; Kuleshova Z.S. 1983 /, adopted by us for the prototype. The device is brought to the organs of the hepatopancreatoduodenal zone from the plates located cutaneous.

 A feature of electrophoresis is that with its help it is possible to create a high concentration of the injected drug / in the area of the pathological focus / in the necessary parts of the body without saturating the whole body.

 As you know, drugs introduced by other methods are relatively evenly distributed throughout the body or accumulate in individual tissues, which exhibit a certain tropism. This makes it difficult to create a high concentration of the drug in the necessary restrictions / any according to localization / areas without first saturating it with blood, which is not indifferent to the body. In addition, the penetration of drugs from the blood into tissues prevents their binding to plasma proteins and red blood cells.

 Using electrophoresis in the skin and underlying tissues, it is possible to create a concentration of substances that significantly exceeds it with intravenous administration of the same dose of the drug / Barsukov N.A. 1971; Ulashchik V.S. 1973; Shablovskaya K.A. 1959; Strelkova R.N. 1967 et al.

 The effect of a drug substance introduced into the body by electrophoresis develops in two ways. First of all, medicinal substances cause continuous and prolonged irritation of the nerve endings laid at the site of exposure. It is important that irritation of nerve receptors by various medicinal substances is accompanied by the occurrence of differentiated tissue reactions with a change in biochemical processes that go in the direction characteristic for the action of this pharmacological drug.

 Along with irritation of receptors, medicinal substances can also enter into metabolic processes and have a direct effect on the course of pathological reactions in the tissues and cells of the affected area. This side of action is especially pronounced in local anesthetics, antibiotics, and sulfonamides.

 The action of direct current is also diverse and consists of interconnected local changes and general shifts arising in connection with the involvement of the nervous, endocrine and other body systems in the response.

 The passage of direct current through the tissues is accompanied by the occurrence of polarization, which decays within a few hours after the procedure. The accumulation of ions at the membranes observed during polarization affects the dispersion of protoplasm colloids, the swelling and permeability of cells, their electrical efficiency, etc.

 In the mechanism of action of drug electrophoresis, a direct role is played by the direct influence of current on the peripheral nervous system, accompanied by an improvement in basic functions / excitability and conduction / nerves. Galvanization also increases the sensitivity of receptors to changes in the internal environment. Obviously, therefore, during electrophoresis, reactions of the nervous system appear at a concentration of a substance that is insufficient to act on receptors that are in a normal state.

 Changes in the ratio of ions, the formation of electrolysis products, the accumulation of bioactive compounds, and in the method of electrophoresis and drugs administered lead to irritation of nerve receptors and the occurrence of afferent impulses.

 The action of direct current on internal organs, as a rule, is normalizing and most pronounced with local low-intensity exposure. The stimulating effect of therapeutic dosages of direct current is manifested in the activation of trophic and energy processes, an increase in the phagocytic activity of leukocytes, an increase in the protective properties of tissues, an increase in antibody production and activation of the reticuloendothelial system.

 As shown by numerous experimental clinical studies, the method of drug electrophoresis has several features compared with other methods of introducing drugs into the body. First of all, they relate to the distribution of drugs administered, the duration of their stay in the body and pharmacological activity.

 Unlike pharmacotherapeutic methods, electrophoresis can be applied to a pathological focus in the area of which microcirculation is impaired (due to capillary stasis, vascular thrombosis, necrosis or infiltration). Theoretically, by electrophoresis, drugs, regardless of the state of blood circulation, can be introduced into any area located along the direct current path. Conventional techniques provide this opportunity for skin, mucous membranes and other tissues. Intracavitary electrophoresis and combined techniques allow you to bring medicinal substances in sufficient quantities to some internal organs.

 An important feature of the method of drug electrophoresis is that the drugs administered by it are much less likely to cause negative reactions than oral and parenteral administration. This often serves as the main reason for the development of the electrophoresis technique of a given substance.

 The decrease or complete absence of adverse reactions during electrophoresis is due to several reasons.

 Firstly, the introduction of small doses of medicinal substances and their slower entry into the blood and organs, which, of course, inhibits the manifestation of the general effect of the drugs.

 Secondly, by electrophoresis, the drug substance is administered in the purest (ionic) form, thereby eliminating the side effects of impurities.

 Thirdly, direct current favorably affects the reactive properties and immunobiological activity of the body, and prevents the side effects of drugs.

 For electrophoresis, a constant continuous current of low voltage (galvanic) is mainly used. Its source is a galvanization apparatus, which is a network AC rectifier, equipped with a filter to smooth the ripple, an output adjustment potentiometer and a measuring device (mA milliammeter).

 Methods of electrophoresis.

 The essence of the technique of drug electrophoresis boils down to the location of solutions of drugs on the path of the current (between the patient’s body and current-carrying electrodes). Depending on the relationship of the patient’s body, electrodes and medication, several methods of conducting drug electrophoresis are distinguished.

 1. In physiotherapeutic practice, the most widely used electrophoresis from medicinal solutions, which are wetted with special medicinal pads.

 A pad moistened with a solution of the injected substance is applied to the skin surface, and a current-carrying plate electrode is placed on top of it. The latter is connected by a wire to the pole of the galvanizing apparatus of the same name with the polarity of the introduced ion. The second or passive electrode (gasket moistened with water, plus a current-carrying electrode) is superimposed (transversely or longitudinally) at a distance from the first and connected to the opposite current source. Both electrodes are fixed in one way or another on the patient's body.

 2. Electrophoresis can be carried out from solutions introduced into the cavity organs of a person. In this case, the body cavity is filled with a solution of a medicinal substance, then an electrode is inserted into it, connected to the corresponding pole of the current source. This electrophoresis method is used in the treatment of diseases of the stomach, rectum, bladder, vagina.

 The cutaneous arrangement of the electrodes does not create an optimal electric field. The presence of the skin, a sufficiently large thickness of the tissues on the way creates the conditions for a negligible small penetration and accumulation of the drug, which lengthens the course of treatment and reduces its effectiveness.

 The desire to improve the effectiveness and quality of treatment of inflammatory diseases of the organs of the hepatopancreatoduodenal zone in the early postoperative period, which leads to a reduction in the treatment time and, in a large percentage of cases, to the prevention of postcholecystectomy syndrome, led to seek new methods of treatment.

 The aim of the invention is to improve the results of surgical treatment of cholecystitis, cholelithiasis, and, in some cases, postcholecystectomy complications.

 The essence of the proposal is that at the end of surgery on the upper floor of the abdominal cavity (usually on the biliary tract), a drainage tube is placed in the subhepatic space through a separate puncture on the right. After 2-3 days, when the subhepatic space is cleansed of blood and bile, an additional regional subhepatic lavage is produced with solutions of Baliz-2, antibiotics, dioxidine or an aqueous solution of plavecept. Then, a sterile wire electrode of somewhat larger length is introduced through the drainage than the drainage tube so that the electrode extends beyond it and is located in the free abdominal cavity directly near the hepatoduodenal ligament.

 The second electrode is inserted non-gastrointestinally into the duodenum to the Vater papilla. This electrode is a conventional duodenal probe with a metal olive, inside which a conductor is located.

 Immediately before the procedure, a drug mixture is introduced through a drainage tube. Given the polarity of the preparations, the electrodes are connected to the Potok-1 apparatus. A direct current electric field of 0.3-0.8 mA is created, the duration of the session is 10-15 minutes. After the session, the electrode is removed, the drainage tube is aspirated, squeezed.

 The session is carried out once a day, until the final relief of the inflammatory process (usually) 5-8 days.

 For electrophoresis, various preparations can be introduced into the abdominal cavity with the condition of general polarity.

 From the cathode are introduced: heparin, hydrocortisone, penicillin, nicotinic acid, aminocaproic acid, aloe, etc.

 From the anode are introduced: novocaine, norsulfazole, papaverine, platyphyllium, lidase, ronidase, streptomycin, tetracycline, zinc, trypsin, chymotrypsin, etc.

 In the presence of a pronounced inflammatory process, preference is given to antiseptics, antibiotics, sulfonamides and anti-inflammatory drugs.

If there is or a tendency to adhesions, strictures, due to trauma or "exposure" of the common bile duct, lidase and ronidase (dissolved in acetate buffer solution) are used along with anti-inflammatory drugs
ratio of 64 UE in 30 ml of solution).

 We used the following solutions for electrophoresis: 1) the domestic antibacterial drug Baliz-2; 2) sodium hypochloride; 3) dioxidine; 4) plivacept; 5) antibiotics (ampicillin, levomycetin succinate, gentamicin), etc.

 A good effect was obtained from the use of the drug "Baliz-2". It is a product of microbiological synthesis and has a bactericidal effect. This drug is effective mainly against gram-positive cocci with pronounced resistance to antibiotics of the penicillin group, erythromycin, tetracycline and others. Along with the bactericidal action, it has the ability to lyse rejected tissues, blood clots and, thereby, eliminates reparative processes.

 In cases where Baliz-2 was not used for electrophoresis, it is indispensable for regional subhepatic lavage on the eve of electrophoresis.

 The best result in electrophoresis of the proposed method was obtained from a mixture of the following composition: kanamycin 500000 units or streptomycin 500,000 units. fibrinolysin 10000 units. trypsin 10 mg; norsulfazole 0.5% 2.0; platifillin 0.3% 1.0 per 50 ml of hemodez or 0.1% novocaine solution. The mixture was injected from the anode.

 The advantage of this technique is that the treatment of inflammatory diseases of the organs of the hepatopancreatoduodenal zone in the early postoperative period is the most effective way of administering drugs by electrophoresis for this pathology, the most important being that the effect directly affects the inflammatory focus.

 The proposed method of treatment does not require special technical and medical support, it is easily performed in medical institutions.

 Along with the treatment method described above in the early postoperative period, it is also possible, if necessary, to introduce an irrigation tube, medicinal mixtures and an electrode outside the operation using a laparoscope. Indications may include postcholecystectomy pain, cholangitis, papillitis, pancreatitis and other inflammatory diseases of the organs of the hepatopancreatoduodenal zone.

 The proposed method was used in 14 patients operated on for cholecystitis and cholelithiasis in the Regional Hospital of the Medical Department of the Department of Internal Affairs. Acute cholecystitis was in 6 patients, chronic in 8. Local unlimited peritonitis was noted in four patients. The age of patients ranged from 38 to 73 years. All operated patients underwent cholecystectomy; in three, bledoch according to Robson-Witkowski was also drained.

 The clinical efficacy of the method was evaluated in comparison with the control group (10 people) with identical pathology in the treatment of which applied dermal electrophoresis with the location of the electrodes on the lumbar region and above the liver.

 Another control group (10 people) consisted of patients who did not use electrophoretic treatment at all in the postoperative period, and the treatment was carried out by intramuscular administration of antibiotics.

 The evaluation criteria were clinical and laboratory indicators of intoxication.

 It was found that when using the proposed method as a component of the complex surgical treatment of complicated cholecystitis, the relief of the inflammatory process, according to the totality of indicators, occurred on average 3.6 and 3.1 days earlier than in the control groups of patients. There were no fatal outcomes or complications during the application. The average postoperative bed-day when using the proposed method was 11.7 days, and in patients in the control groups, respectively, 15.2 and 15.8 days.

 The clinical results of the treatment can be assessed as quite favorable. This was also supported by positive changes in the functional state of the liver, its hemodynamics and improvement of bile formation and bile secretion, which was reflected even under the action of a single procedure, in which there was a significant increase in the level of cholic acid and cholesterol.

 The effectiveness of the use of this method in the treatment of inflammatory diseases of the organs of the hepatopancreatoduodenal zone in the early postoperative period is not in doubt. But no less important is the fact that the modern early elimination of sources and foci of infection does not make it possible to affect nearby organs, tissues and intramural neural formations, which is invaluable in the prevention of postcholecystectomy suffering.

 Thus, the proposed method for the treatment of acute complicated cholecystitis does not require special technical and medical support, it is easy to perform in surgical hospitals of various parts of practical health care, and it improves the results of surgical treatment of this category of patients.

 Example. Patient D., 58 years old, was hospitalized in the surgical department of the hospital of the Department of Internal Affairs on May 10, 1993 with a diagnosis of chronic calculous cholecystitis. Suffers from this disease for 7 years. Over the past year, four attacks of intense pain in the right hypochondrium, stopping after an injection of antispasmodics. Out of attacks, a feeling of heaviness in the right hypochondrium, discomfort after eating, smack of bile in the mouth.

 Surveyed. Identified calculous cholecystitis, the phenomenon of duodeno-gastric reflux.

 May 13th operation: cholecystectomy. Drainage of the subhepatic space. During the operation, an adhesion process was detected in the gate of the liver, the phenomenon of periduodenitis. From 2 days in terms of the generally accepted volume of therapy in the postoperative period, electrophoresis was applied by the proposed method with a therapeutic mixture of the following composition: kanamycin 500,000 units. fibrinolysin 10000 units. trypsin 10 mg; norsulfazole 0.5% 2.0; platifilin 0.3% 1.0 per 50 ml of 0.1% novocaine solution. The drug mixture was introduced into the drainage tube, then an electrode (anode) was introduced into the drainage tube and an electrophoresis session (current strength 0.5 mA) was carried out for 10 min. Electrophoresis was performed 1 time per day for 5 days. No complications from electrophoresis were noted. Drainage from the abdominal cavity was removed on the 6th day. The postoperative course is smooth. There were no symptoms of intestinal paresis in the postoperative period. Discharged in satisfactory condition on the 11th day from the day of surgery.

 Examined after 3 months. No complaints. Able to work.

Claims (1)

 A method for the treatment of inflammatory diseases of the hepatopancreatoduodenal zone, including the impact on the area of a number of drugs administered by electrophoresis, characterized in that the effect is directly on the affected area by approaching the electrodes to it, the first electrode being introduced through an irrigation tube through the right hypochondrium to the Vinslov hole, after preliminary irrigation zones with drugs, and the second - on the sugastric, to the Vater papilla.