RU2092107C1 - Method for treatment hepatic insufficiency in patients affected with ascites - Google Patents

Abstract

FIELD: surgery. SUBSTANCE: ascitic fluid is drained out in single flash operation in full volume, followed by sorbing fluid, lyophilizing it and dissolving before re-infusion in such manner that two liters of resulting fluid would correspond to eight liters of ascitic fluid, remaining fluid being re-infused portion-wise every other day. EFFECT: effective approach to treatment of ascites cases complicated with hepatic insufficiency. 1 tbl

Description

 The invention relates to medicine, namely to surgery of the abdominal organs.

Existing methods of treating liver failure in patients with cirrhosis with ascites, along with traditional drug therapy, hemosorption (Lopukhin Yu. M. Molodenkov M.N. "Hemosorption" M. "Medicine" 1978, p. 208-219), lymphosorption (Panchenkov P.T. Vyrenkov, Yu.E. Yarema, I.V. N. Hemosorption, "Medicine" 1978, pp. 128-136) includes reinfusion of ascitic fluid passed through sorbents (Tupchiev SB - Method of detoxification of the body by reinfusion of ascites bone passed through the adsorbents. Pats. N81218 proposal issued by the Dagestan Medical Institute 22.06.81g.) Tupchiev SB Brouss I.Yu.-Detoxification in patients with ascites. Materials of the X Congress of Surgeons of Dagestan, Makhachkala, 1984. p. 157; Sitnikov V. A. - Hemosorption, lymphosorption, ascites and enterosorption in the complex treatment of liver cirrhosis [1]
In this case, ascitic fluid containing a large number of toxic products is exposed to detoxification. The toxicity of ascitic fluid is determined by chemical analysis and biological tests for the duration of the life of the simplest paramecium (Paramecium test).

 The level of toxic metabolites in ascitic fluid is higher, the higher it is in the patient’s blood. In ascitic fluid passed through sorbents, the amount of toxic substances is significantly reduced.

 Along with the resulting positive effect, each of the known methods has its negative sides. So, the time of hemosorption or soon after its completion may develop the following characteristic complications: collaptoid reactions; chills; violation of the blood coagulation system; recoma; destruction of blood cells; violation of the immune status. In addition, this method is characterized by: relative technical complexity, the need for equipment, heparinization.

 Lymphosorption is a serious surgical intervention with complex biological effects, which, although rare, can cause unwanted complications and reactions. The latter can be divided into three groups: complications arising from external drainage of the thoracic lymphatic duct; complications that develop during reinfusion of purified lymph; complications associated with the purification of toxic lymph. In addition to the aforementioned, attention is drawn to the complexity of the lymph harvest, its preservation and storage, a decrease in the immune status, limitation of indications for lymphosorption and its low controllability.

 With plasma sorption, there are no many complications arising from hemosorption and lymphosorption, however, the process is accompanied by thrombocytopenia and chills. The introduction of plasma sodium citrate causes a violation of the heart rhythm up to a stop, in addition, has a toxic effect on the liver. The process of plasma sorption is complicated by the technical difficulties of separation.

 Closest to the claimed solution is the method of ascitesorption (Tupchiev S. B. Bruss I.Yu.- “Detoxification in patients with ascites.” Materials of the Xth Congress of Surgeons of Dagestan, Makhachkala, 1984, p. 157). This method is taken as a prototype.

 It consists in the fractional removal of ascitic fluid. The latter is collected in a glass dish with the addition of the TSOLIPK-12-A blood preservative at a rate of 50.0 per 1 liter of liquid, then it is passed through SKN sorbents at a rate of 10-20 ml per minute and transfused intravenously in an amount of 2-3 liters per day. In this case, an improvement in the general condition of the patient, an increase in daily urine output, an increase in the total protein of blood serum, a decrease in the content of total bilirubin, and residual nitrogen in the blood were noted.

 The disadvantages of the prototype include technical difficulties associated with the multiple evacuation of ascitic fluid from the abdominal cavity, a limited amount of reinfused fluid, a slight decrease in the volume of the abdomen, the possibility of allergic reactions, and the limited shelf life of the reinfused ascitic fluid.

 The purpose of the invention is to increase the effectiveness of the treatment of patients with liver failure due to cirrhosis with ascites, to improve the immunological and rheological characteristics of blood, to reduce the loss of auto protein, colloids, enzymes, hormones due to reinfusion of ascites fluid in a concentrated form, while reducing its volume, improving cardiopulmonary activity, by reducing the volume of the abdomen.

The proposed method for the treatment of liver failure in patients with cirrhosis and ascites is as follows: in patients under local anesthesia with a 0.5% 5.0-10.0 novocaine solution by laparocentesis at the Monroe point simultaneously, all ascites fluid is taken directly into sterile vials with a capacity of 200.0-250.0 with the addition of glyugitsir (15.0 in each bottle). Vials are immediately subjected to ascitesorption through one or two (depending on the quantity and toxicity of ascites fluid) serially connected columns with SKS hemosorbent at a rate of 20-50 ml per minute. After ascitesorption, the liquid undergoes lyophilization. Lyophilization of ascitic fluid is carried out in the same way as blood plasma in 250 ml vials by the open method under sterile conditions in the KS-30 apparatus of the Yusifrua company. In this case, the pressure decreases to 5 • 10 ^-1 5 • 10 ^-2 mm Hg. respectively, the temperature of the frozen liquid is from -35 to -50 ^o C. The lyophilization process lasts 25-32 hours. Lyophilized ascitic fluid after adding 50.0 physiological saline or 5% glucose solution to each vial is infused dropwise to 2 l (20- 30 vials) per infusion, which corresponds to 8 l of non-lyophilized liquid, the remaining liquid is administered fractionally after 1-2 days. Storage of lyophilized and ascitic fluid passed through sorbents at room temperature.

 Example. 1. Patient M. N (IB) 4656 was transferred from the therapeutic department to the General Surgery Clinic on 12.12.90 with complaints of weakness, dry mouth, sleep disturbance, aching constant pain in the right hypochondrium, shortness of breath, skin itching, an increase the abdomen. He considers himself sick for about 10 years, when there were pains in the liver, jaundice, an increase in the abdomen in volume has been observed for the last 6 months. In the history of bleeding from the veins of the esophagus was six months ago, previously noted excessive drinking, a sharp deterioration in the last 2 months. Conducted conservative treatment with diuretics is not effective, there was a deterioration, an increase in ascites, drowsiness.

Objectively: the abdomen is increased in volume due to ascites, the ictericity of the skin from the sclera, the skin has a pronounced vascular pattern, there is an umbilical hernia, the liver is significantly reduced in size, and the abdominal circumference is 119 cm. Daily diuresis is 250-300.0. In blood tests upon admission: HB-100 G / l SOE-48 mm / h; white blood cells-5.2 • 10 ⁹ ; lymphocytes-13; platelets-120 thousand; total protein 49 g / l; albumin 51; globulins-49; urea-2.60 mmol / l; prothrombin-63 g / l; fibrinogen-5.33 G / l; total bilirubin -98 μmol / l; direct 26 μmol / l; thymol-4 units in urine Z-2-5 in p / er. A clinical diagnosis was made: coarse cirrhosis of the liver, dystrophic stage, portal hypertension, progressive ascites, and liver failure (precomatous stage). The treatment with diuretics is not effective. 12/25/90 performed surgery, plastic of the thoracic lymphatic duct. 01/02/91 produced laparocentesis with a fence of 12 000 ml. ascitic fluid in 50 sterile bottles with a capacity of 250 ml with the addition of 15 ml of glucicir. in each. The vials were immediately subjected to ascitesorption through two serially connected columns with SKS hemosorbent at a rate of 20 ml per min. After ascitesorption, the liquid was lyophilized. Passed through sorbents and lyophilized ascitic fluid was dissolved in a 50.0-5% glucose solution and 20 vials (1 L) were intravenously dripped. The remaining 30 vials were stored at room temperature and subsequently poured into 2 stages. In blood tests after treatment: HB-110 G / l ESR-42 mm / h; white blood cells-5.0 • 10 ⁹ g / l; lymphocytes-13; platelets-140 thousand; LII-1,4; total protein-58 g / l; albumin 56; globulins-44; urea-1.40 mmol / l; prothrombin-72 G / l; fibrinogen-5.33 G / l; total bilirubin-25.5 μmol / l no direct; thymol-2 units abdominal circumference is 8cm.

 The general condition improved, sleep was restored, skin itching passed, and daily diuresis of 2 liters increased. Patient K. (NI.B.885) was admitted to the clinic of general surgery 03.03.89g. with complaints of pain in the right hypochondrium, a dull aching character, heaviness in the abdomen, weakness, drowsiness, lack of appetite, inappropriate behavior. A patient 22 years ago suffered an infectious hepatitis. Since 1984, there were pains in the right hypochondrium, swelling on the lower extremities, weakness, periodic bloating. She was treated in a therapeutic hospital. For 2 years she lost 15 kg. 1.5 months before admission, the condition worsened sharply, the abdomen increased in volume, the amount of daily urine decreased to 200 ml per day against a background of diuretics, and itching of the skin appeared.

 Objectively: the skin is icteric, dry, spider veins on the chest. In the lungs, weakened breathing, insomnia, nausea, a periodic increase in temperature. The abdomen is increased in volume due to ascites (circle-108cm), a pronounced venous pattern on the skin of the abdomen, edema on the lower extremities. Ultrasound revealed coarse-grained cirrhosis of the liver.

In blood tests: HB-110 G / l; ESR-36mm / h; white blood cells 6.0 • 10 ⁹ g / l; lymphocytes-15; platelets-140 thousand; total bilirubin-120 mmol / l; direct-31 mmol / l; urea - 4.2 mmol; prothrombin -68 G / l; fibrinogen 6.55 g / l; LII-1.8; total protein-58; thymol-20 units. albumin 47; globulins-53. In urine: leukocytes-20-30 in n / a. A clinical diagnosis was made: coarse-grained cirrhosis of the liver, dystrophic stage, portal hyperetensia, ascites resistant to diuretics, subtotal insufficiency. 03/14/89 plastic of the mouth of the thoracic lymphatic duct. 03/16/89 Laparocentesis was performed with the intake of 1400 oascitic fluid in 60 sterile bottles with a capacity of 250 ml with the addition of glucicer of 15 ml each. The bottles were immediately subjected to ascitesorption through two SKN connected in series with the hemosorbent at a rate of 20 ml per minute. After ascitesorption, the liquid was lyophilized. Passed through sorbents and lyophilized ascitic fluid is dissolved in a 50.0 -5% glucose solution and infused intravenously in 20 vials (1 l) every other day. In the analyzes: HB-110 G / l; ESR-30mm / h; white blood cells-5.8 • 10 ⁹ l; lymphocytes-20; platelets-180 thousand LII-1,5; total protein 6.8; total bilirubin-43 mmol / l; direct 12.5 mmol / l; albumin 58; globulins 42; urea-2.6; prothrombin-72 G / l; fibrinogen-5.75 g / l; in urine Z -2-4-6 p / sp; abdominal circumference is 86cm.

 The condition improved, sleep normalized, itching of the skin and ictericity disappeared, the temperature was within normal limits, vesicular respiration in the lungs, and swelling on the lower extremities were gone. Daily diuresis is 1.5-2 liters.

 Long-term result after 4 years. The patient's condition is satisfactory, against the background of periodic intake of diuretics.

 In contrast to the known methods for the treatment of liver failure due to cirrhosis with ascites, the proposed method is the most simple and effective. Autoascitic fluid, as an important component with a high content of protein, amino acids, hormones, vitamins and electrolytes, undergoes reinfusion with minimal loss of qualitative characteristics, close to the composition of blood plasma, due to ascitesorption followed by lyophilization. The method allows to fill the deficiency with its own protein, stabilize the immune status, improve blood rheology and cardiopulmonary activity. The advantage of the method is the safety, simplicity and effectiveness of the method.

 Ascitic fluid is taken in sterile 250 ml vials containing glucicir, ascites and lyophilize. Before reinfusion, the purified and lyophilized ascitic fluid is stored at room temperature. After dilution in 50.0 physiological saline or 5% glucose solution, an intravenous drip is infused to 2 L after 1 day.

 3 patients were treated. The immediate long-term results confirm the positive effect of the implementation of the goals set by the invention.

 The research materials were discussed at a clinical conference of the Department of General Surgery, based in the surgical department of the Department Hospital of Art. Makhachkala North Caucasian Railway. The introduction of the developed method into the clinic was recommended.

Claims (1)

 A method of treating liver failure in patients with ascites by evacuating ascitic fluid and its subsequent sorption and reinfusion in a volume of two liters, characterized in that the ascitic fluid is evacuated simultaneously in full, and after sorption, they are lyophilized and dissolved before reinfusion in such a way that two liters of obtained fluids correspond to eight liters of ascitic fluid, while the remaining fluid is administered fractionally every other day.

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