RU2107466C1 - Method to prevent hepatic failure at acute intestinal obstruction - Google Patents

Abstract

FIELD: medicine, abdominal surgery. SUBSTANCE: method deals with intestinal intubation and decompression followed by introducing medicinal products into its lumen. At the same time in the course of operation it is necessary to estimate liquid volume sequestrated into intestinal lumen and abdominal cavity. Glucosoelectrolytic mixture is introduced into intestinal lumen, the mixture contains sodium chloride, potassium chloride, glucose, enterodes, kanamycin at the volume which corresponds to the half of evacuated one. Then at postoperative period intestinal-portal hemodilution by simultaneous by-drop injection of mentioned mixture into intestinal lumen and necessary medicinal substances into portal vein. EFFECT: higher efficiency of acute hepatic failure in patients with acute intestinal obstruction. 1 dwg

Description

 The invention relates to medicine, mainly to emergency surgery, and can be used to treat patients with acute intestinal obstruction complicated by peritonitis.

 These patients make up over 30% of all patients with acute obstruction of the small intestine (ONTK) (Lutsevich E.V. et al. - Surgery 1982, N 8. p. 25-30). Mortality in this group of patients is 44-50% (Savelyev V.S., Acute intestinal obstruction. M, 1977. 7-12; Teryaev V.G. et al. Acute surgical diseases of the abdominal organs. Rostov-on-Don 1991, p. 141-142; Frazee Rsetal 1989).

 With ONTC complicated by peritonitis, severe intoxication, severe water-electrolyte disturbances, a decrease in BCC and other changes in homeostasis are observed, which cause long-term treatment in the postoperative period due to the development of hepatic and then multiple organ failure (Kukeev T.K. et al., 1983; Petrov V.P., Eryukhin I.A., 1989 and others). According to most researchers (Sinovets A.S., 1969; Dederer Yu.M., 1971; Halperin Yu.M., 1975; Karimov Sh.I. et al., 1983), the main source of intoxication is the contents of the intestine, abdominal cavity, swollen and thickened wall of the leading loop of the intestine, parietal and visceral peritoneum (Rusakov V.I. et al., 1985).

 Known methods of combating intoxication and impaired water-electrolyte balance by using intubation and decompression of the intestine with the introduction of various mixtures into its lumen (G. Alexandrovich et al., 1979; Karimov Sh.I. et al., 1984; Petrov V. P., Eryukhin I.A., 1989). However, the use of these methods does not exclude the possibility of developing liver failure and often leads to complications requiring repeated surgical interventions (Shchalkov Yu.L. et al., 1977; Misharev OS, Troyan V.V. 1980 and others). The reason for this is that with all possible options for intubation and decompression of the intestine, the toxic contents of the lumen of the intestine and abdominal cavity are removed. Toxins contained in the edematous, thickened wall of the intestine, in a huge parietal and visceral peritoneum, are washed out by the blood stream and enter the liver through the portal vein system. These toxins determine the development of liver and multiple organ failure.

 The prototype of the present invention is selected as the method of auth. 1699432 AI MKI A 61 B 17/00 "Method for the treatment of intestinal paresis." The essence of the method, selected as a prototype, is that in order to accelerate the restoration of intestinal function, intubation, decompression and the introduction of nutrients into the small intestine are used in the autoperfusion mode, during which the solution is saturated with oxygen.

 The specified method has an imperfection: conditions are not created for the effective protection of hepatocytes from the damaging effects of toxic substances, lysosomal enzymes contained in the tissues of the intestine, visceral and parietal peritoneum (Rusakov V.I. et al., 1985). At the same time, an effective and adequate correction of water and electrolyte losses in the shortest possible time in the postoperative period is not provided, which, in turn, often leads to the development of liver failure.

 The aim of the present invention is to prevent the development of liver failure resulting from endotoxemia in acute intestinal obstruction complicated by peritonitis, as well as in peritonitis of another etiology.

 This goal is achieved by creating intestinal portal hemodilution (reducing the concentration of toxins in the portal vein due to dilution with medicinal substances). Intestinal portal hemodilution is achieved by the fact that after total intubation and decompression of the intestine, the contents of the intestine and abdominal cavity are evacuated, a glucose-electrolyte mixture consisting of sodium chloride, potassium chloride, enterodesis, glucose, kanamycin and distilled water is introduced into the intestinal lumen. The volume of injected fluid, as practice has shown, should be equal to half the evacuated volume. Intestinal portal hemodilution is achieved one hour after surgery by simultaneous drip of the specified solution into the intestinal lumen, and other medicinal substances into the portal vein.

 In a patient with ONTK complicated by peritonitis, the abdominal cavity is revised, the obstruction that caused ONTK is detected and eliminated. Total intestinal intubation and decompression of the intestine is performed transnasally or retrograde through the enterotomy opening, the total amount of fluid sequestered into the intestinal lumen and the abdominal cavity is determined. A glucose-electrolyte mixture is introduced into the intestinal lumen in an amount equal to half of the evacuated, consisting of sodium chloride, potassium chloride, glucose, enterodesis, kanamycin and distilled water. Perform recanalization and cannulation of the umbilical vein. Immediately after the operation, intestinal portal hemodilution is carried out by simultaneous drip injection of this solution into the intestinal lumen, and other drugs into the portal vein. The stages of intestinal portal hemodilution are illustrated in the drawing.

 Intestinal portal hemodilution ensures dilution, reduction in the concentration of toxic substances in portal vein 1, washed out by a blood stream from tissues of the adducting intestine 2, parietal and visceral peritoneum 3, which reduces the damaging effect of toxins on hepatocytes 4 and prevents the development of liver and multiple organ failure.

 To achieve intestinal-portal hemodilution, total (ante- or retrograde) intubation and decompression of the adducting intestine 2 with a two-channel probe 6 are carried out, intestinal contents and exudate of the abdominal cavity are evacuated. The total volume of fluid loss is determined.

 In order to compensate for fluid loss, a glucose-electrolyte mixture consisting of sodium chloride, potassium chloride, glucose, enterodesis, kanamycin and distilled water in a volume equal to half evacuated is introduced into the intestinal lumen through a probe 6. The umbilical vein is recanalized and cannulated. 5. Intestinal portal hemodilution is performed one hour after the operation by simultaneous drip injection of this mixture into the intestinal lumen and other pharmacological agents into the portal vein.

 Example 1. Patient L-in G.I. 61 years old, case history No. 1055, was operated on 04/12/93 in the surgical department of BSMP No. 1 named after ON THE. Semashko, Rostov-on-Don, with a diagnosis of acute small bowel obstruction. Spilled peritonitis. During the operation, adhesions (formation of a "double-barreled shotgun") obstruction were found at a distance of 25 cm from the ileocecal angle. Obstruction is eliminated. A total retrograde intubation and decompression of the small intestine was made through the cecostomy. 2.4 l of fluid was evacuated, 0.8 l of hemorrhagic exudate was evacuated from the abdominal cavity. The diameter of the small intestine reached 8 cm, the wall of the intestine was sharply swollen, thickened, hyperemic. coated with fibrin. 1.6 l of a glucose-electrolyte mixture was introduced into the intestinal lumen, consisting of, g: sodium chloride 9; potassium chloride 15; glucose 50; enterodesis 15; kanamycin 5; distilled water up to 1000. Lavage and drainage of the abdominal cavity. Recanalization and cannulation of the umbilical vein. In the postoperative period, an intestinal-portal hemodilution was started by dropping the mixture into the intestinal lumen (1.2 L per day) and dropping the necessary drugs into the portal vein. A day later, the level of acid phosphatase decreased from 0.570 mg% (before surgery) to 0.150 mg% after intestinal portal hemodilution. Peristalsis recorded in a day. Departure of gases on the 2nd day, an independent chair on the 5th day. Intra-intestinal administration of the mixture was stopped after 52 hours. Intra-portal drug administration was stopped on the 7th day. Discharged on the 10th day. Examined after 1 month. He works by profession.

The inventive method is tested at the Department of General Surgery of the Russian National Medical Research Institute and in comparison with the prototype has the advantages:
the implementation of intestinal portal hemodilution provides a decrease in the destructive effect of toxic substances by diluting and reducing their concentration and prevents the development of liver and then multiple organ failure. This was confirmed by a decrease in the level of acid phosphatase in our example by more than 3 times;
provides the normalization of indicators of homeostasis in the first day after surgery, while when using the prototype for 2-3 days;
The method of intestinal portal hemodilution reduces the number of postoperative complications and mortality.

Claims (1)

 A method for the prevention of liver failure in acute bowel obstruction and peritonitis, including intubation, decompression of the intestine and the introduction of drugs into its lumen, characterized in that the operations determine the volume of fluid sequestered into the lumen of the intestine and abdominal cavity and introduce a glucose-electrolyte mixture into the intestinal lumen, containing sodium chloride, potassium chloride, glucose, enterodesis, kanamycin in an amount equal to half the evacuated, and in the postoperative period entero-portal hemodilution by simultaneous drip of said mixture into the intestinal lumen and the required drugs in the portal vein.