RU2112429C1 - Method for autotransplantation of splenic tissues - Google Patents

Abstract

FIELD: medicine, surgery, autotransplantation. SUBSTANCE: method deals with anti-ischemic organ protection due to intravenous injection of antioxidant preparations. When splenectomy is over a spleen is perfused by hypersmolar saline solution at addition of antioxidants and calcium antagonists at the highest single dose. Then implants are formed as anatomical subsegments of an organ. Implants are placed via additional transrectal cut at cross-sectional fascia in projection of a lower third of abdominal rectus muscle of a stomach. During postoperative period it is necessary to introduce antioxidant and antibacterial preparations. EFFECT: higher efficiency to be used at urgent splenectomy for autotransplantation of splenic tissues.

Description

 The invention relates to medicine, namely to surgery and can be used for forced splenectomies.

 There are various methods of heterotopic autosplenograft, differing in the methods of treatment of the organ after removal, the formation of implants and the location in the patient's body.

 So known is a method of splenectomy after injury, including replantation of spleen tissue. The removed spleen is placed in sterile physiological saline, then fragments of 20x20x5 mm are formed, which are sutured into a large omentum, after which the wound is sutured (Millikans JS, Moore EE, Moore LE, Stevens RE Alternatives to splenectomy in adult after trauma. Repair partial resection and reimplantation of splenic tissue // Am. J. Surg. - 1982. - Vol. 145, No. 4, P. 711 - 716).

 There is another method for autologous transplantation of spleen tissue, including placing fragments in the formed pocket of the greater omentum (A.S. N 1648390, class A 61 B 17/00). The known method is as follows. After carrying out according to the indications of splenectomy, the abdominal cavity is drained, the left hypochondrium is drained. A pocket measuring 15 x 8 x 8 cm is formed from the left third of the omentum, which is drained with a silicone tube, after which the abdominal cavity is sutured tightly. The surface of the removed spleen is washed from blood clots, then the spleen artery is catheterized in the gate and perfused with saline supplemented with heparin. 150 cubic mm fragments 3–5 cubic mm in size are obtained from the washed spleen tissue by manual dissection, which are processed in a magnetic stirrer. Antibiotics are added to the completely washed fragments of the spleen and the resulting suspension is introduced into the stuffing box pocket through the drainage. Then the drainage is removed.

 The disadvantage of these methods - with the interperitoneal placement of splenic tissue implants - is the high risk of complications, and therefore the impossibility of their use, in the aspect of the formation of intra-abdominal abscesses during autosplenograft in conditions of massive post-traumatic infection of the abdominal cavity and with purulent-inflammatory intra-abdominal processes, pancreatonecrosis.

 Closest to the proposed and adopted as a prototype is a method of autologous spleen tissue transplantation (a.s. N 1551354, class C. A 61 B 17/00). The essence of this method is that the pocket of a large omentum with an autograft is moved to the left subphrenic space and fixed to the dome of the diaphragm.

 The disadvantages of this method, as well as similar ones, include the likelihood of the formation of an intra-abdominal abscess during autotransplantation of spleen tissue removed under conditions of purulent-inflammatory intra-abdominal process, as well as with massive infection and in the case of necrotic changes in the pulp.

 Known methods are applicable for fresh injuries of the spleen outside contamination (infection) with the contents of the colon and for "clean" abdominal operations.

 The technical result of the proposed method is to increase the efficiency of autosplenic tissue transplantation in patients with a highly infected abdominal cavity or with a purulent-inflammatory process in it.

 The technical result is achieved by splenectomy, the formation of fragments and their heterotopic implantation.

 New in the implementation of the technical result of the method is the preliminary intraoperative anti-ischemic patronage of the body, carried out by the intravenous administration of antioxidant drugs.

 The difference of the method also lies in the fact that after splenectomy, the organ is perfused with hyperosmolar saline with the addition of antioxidants and calcium antagonists.

 A distinctive technique of the proposed method is the formation of implants in the form of anatomical subsegment of the organ, which, through an additional transrectal incision, is placed on the transverse fascia in the patronage of the lower third of the rectus abdominis muscle.

 The new in the proposed method is also the introduction of antibacterial and antioxidant drugs in the early postoperative period.

 Preliminary intraoperative administration of antioxidant drugs increases the resistance of spleen tissue to ischemia. The perfusion of the removed spleen with hyperosmolar saline with the addition of antioxidants and calcium antagonists in a single dose is also aimed at this.

 An additional positive aspect of perfusion is the elimination of blood cells from the pulp of the spleen, which prevents the lysis of the implanted tissue.

 Perfusion is performed through segmental veins of that part of the organ whose tissue will be reimplanted.

 The perfusate is introduced at a rate of 300 - 400 ml / min, as a result of which there is a clear allocation of sub-segment contours.

 The criterion for the end of perfusion is the appearance of an unpainted blood solution.

 It was established that implantation of tissue in the form of sub-segments provides the best functional and morphological result. This is expressed in the preservation of the structures of the red pulp, the appearance of accumulations of lymphocytes, periarterial lymphatic couplings.

 While autologous transplantation using known methods (implants “cubes”, “segments”, “minced meat”) revealed areas of parenchyma sclerosis with diffuse spread of lymphocytes and the absence of their grouping (see the act of experimental tests).

 The contours of the implants are determined by intersegmental notches, grooves and during perfusion.

 Decapsulation makes it possible to remove infected material from the surface of the implant and improve tissue regeneration by removing the mechanical obstacle to the growth of capillaries.

 The volume of transplanted tissue is 30% of the volume of the removed organ, which is 3-4 subsegments. This is consistent with published data (Goldthorn JF, Schwartz AD, Swift AJ, Winkelstein JA Protective effect of residual splenic tissue after subtotal splenectomy. // J. Pediatr. Surg. - 1978. - Vol. 13, N 6. P. 587 - 590).

Improving the efficiency of autotransplantation is achieved by placing the implants extraperitoneally - on the transverse fascia of the abdomen in the rectus muscle bed. Extraperitoneal placement of implants makes it possible:
1) to eliminate the risk of the formation of intraperitoneal abscesses, which can occur in conditions of intra-abdominal inflammation;
2) timely recognize and effectively stop the complications of auto transplantation - lysis and suppuration of the implant;
3) act on the transplanted tissue in the postoperative period in view of the availability of the implantation zone for medical and physiotherapeutic procedures;
4) to conduct a “delayed” autosplenograft - after stabilization of the general condition of the patient or after the necessary treatment of the organ.

 For this, an additional transrectal incision is necessary.

 Systemic and local administration of antioxidant and antibacterial drugs in the early postoperative period makes it possible to stimulate the regeneration of implanted tissue, to avoid complications in the form of lysis and suppuration of implants, which improves the compensation of post-splenectomy hyposplenism.

 A comparative analysis of the proposed solution and the prototype shows that the proposed method differs from the known one in that they preliminarily conduct anti-ischemic protection of the spleen by intravenous administration of antioxidant drugs during surgery after the decision to splenectomy is made.

 After removal, the spleen is perfused with hyperosmolar solutions with the addition of higher single doses of antioxidants and calcium antagonists.

 The implant is formed in the form of anatomical sub-segments of the organ, which, through an additional transrectal incision, is placed on the transverse fascia in the projection of the lower third of the rectus abdominis muscle. In the early postoperative period, the introduction of antibacterial and antioxidant drugs.

 The above allows us to judge the compliance of the proposed method with the criteria of the invention of "novelty."

 A new set of essential features provides the ability to correct post-splenectomy hyposplenism in patients with surgical infection of the abdomen.

 To date, reports on the correction of post-splenectomy disorders by autotransplantation of spleen tissue in this category of patients in the available literature have not been found by the author.

 The proposed invention is intended for use in healthcare; an independent claim confirms the possibility of its implementation using the described techniques and means; the method embodying the proposed invention in its implementation, is able to ensure the achievement of the perceived technical result. Therefore, the considered method meets the criteria of the invention of "industrial applicability".

 When analyzing known methods for autologous transplantation of spleen tissue, it was revealed that they lack information on the influence of the distinguishing features of the method on the achievement of a technical result, which makes it possible to conclude that the proposed invention meets the requirement of "inventive step".

 The proposed method for heterotopic extraperitoneal autologous transplantation of splenic tissue is as follows. A patient who has undergone a forced splenectomy due to trauma or with purulent-destructive diseases of the abdomen (pancreatic necrosis, peritonitis, etc.) is first subjected to pharmacological intraoperative anti-ischemic protection of the spleen.

 For this, antioxidant drugs (an oil solution of tocopherol acetate in the muscle, unitiol, calcium antagonists intravenously) are administered 30 minutes before the cessation of splenic blood flow.

 The spleen removed under conditions of paralyenal inflammation or with massive infection of the abdominal cavity (rupture of the colon with injuries to the abdomen, etc.) is lowered into C-4 solution for 1-2 minutes, and then placed in physiological saline cooled to + 4 degrees Celsius (200 - 300 ml) with the addition of the highest single dose of broad-spectrum antibiotics and antioxidants.

 After performing the main stage of the operation and suturing the laparotomy wound, the surgical field is re-treated with an antiseptic. Extracted from physical. solution of the spleen is placed on the manipulation table with the visceral surface up. Separate veins of the most preserved - suitable for autotransplantation parts of the organ are isolated, through which a hyperosmolar (1.12%) sodium chloride solution is pumped at a speed of 300 - 400 ml / min, flowing through the segmental arteries. As a result, the perfused segment is contoured, its boundaries are clearly visualized during fluid supply. Rinsing is carried out until an unpainted blood solution appears. Then the segments are cut off with a sharp scalpel and decapsulate. The total volume of implanted tissue is 30% of the mass of the removed organ, which is 3-4 segments.

 A vertical transrectal incision is made, beginning 1 to 2 cm below the navel (lower third of the rectus abdominis muscle). After dissection of the outer leaf of the fascial case, the muscle is pushed apart sharply by the dense transverse fascia, i.e. harvested fragments of spleen tissue are laid in the rectus muscle bed. The implantation area is drained by a rubber graduate. Rare seams on the aponeurosis and skin. The graduate is removed on the 2nd day after the operation.

 In the case of the formation of an infiltrate or local abscess at the implantation site, the sutures are removed and the inflammatory process is quickly stopped.

 In the early postoperative period, post-implantation correction is carried out, including drug treatment with antioxidant, antibacterial and anti-inflammatory drugs as in systemic; and in local application (physiotherapy).

 As was stated, autologous transplantation of spleen tissue can be performed both after the main stage of the operation and in the early postoperative period (in the intensive care unit), depending on the severity of the general condition of the patient, requiring immediate completion of the operation.

 The proposed method is illustrated by examples.

 Example 1. Patient K., 31 years old, was operated on 19.12.92 for a knife wound penetrating into the stomach with damage to the stomach and pancreas (transverse wound with the intersection of the main pancreatic duct in the body of the organ). Against the background of severe hemorrhagic shock, an operation was performed: suturing wounds of the stomach, corpus caudal resection of the pancreas, debridement and drainage of the abdomen, because of the severity of the general condition of the patient, intraoperative autosplenotransplantation was not performed.

 Autotransplantation of splenic tissue in an extraperitoneal position in the early postoperative period.

From the moment of removal to the beginning of the pre-transplant treatment, the organ was preserved in 800 ml of saline with the addition of 80 mg of sisomycin after its separation from the pancreas fragment; the vessels of the spleen remained open. Preservation in glassware while maintaining sterility at a temperature of +4 ^o C.

 3 hours after pancreatic resection and splenectomy, perfusion was started through well-defined segmental veins 800 ml of phys. a solution with the addition of 25 mg of pankipsin, 5 mg of veropamil and 80 mg of sisomycin at a rate of 300 ml / min. Perfusion carried out using a roller pump. After washing, a "blanching" of the parenchyma was noted, the flowing perfusate in the last portions was not stained with blood. Four subsegmental implants were prepared from the central parts of the spleen. The prepared implants are decapsulated. Placed in 400 ml of physical. solution with the addition of veropamil 5 mg and transported to the intensive care unit, where the patient was placed after surgery. After processing the operas. fields of first-year under intravenous and then endotracheal anesthesia transrectal access was made to the left of the navel and down. The transverse fascia is exposed, on which the prepared implants are laid, over which the front sheet of the rectus sheath is then reduced. Stitches to the skin. Aseptic sticker. Before implantation, 15 mg of veropamil and 20 ml of 10% GHB (antioxidant and antihypoxanthane protection) were injected into a vein in 15 min. In the early postoperative period, the drug was protected by implanted tissue, including intramuscular administration of tocopherol acetate 30% - 2.0 twice a day, unitiol 5 ml and GHB 20% - 10.0 twice a day; electrophoresis with unitiol and dimexide to the implantation area during the first 4 days after surgery. The postoperative period is severe, an abscess has formed in the upper floor of the abdominal cavity with generalization of inflammation (peritonitis) and a progressive increase in intoxication. 3 repeated interventions (debridement relaparotomy) were performed, during the first of which, during revision of the implantation zone from the peritoneum, lysis of the implanted tissue, regarded as suppuration, was revealed. Produced drainage "abscess" from the incision on the skin. Evacuated up to 30 ml of lysed tissue, culture and bacterioscopic examination of which did not reveal microbial flora. The patient's condition progressively worsened and death was ascertained on January 16, 93.

 At autopsy: the inflammation in the transplantation zone was stopped, mainly in the lower parts of the implantation zone tissue was found that was recognized as a regenerate of implanted spleen fragments with dimensions of 2 x 3 x 2 cm in a rounded shape with a clear focus of a whitish tissue (necrosis?) Up to 1 x 1 , 5 x 1 cm in the center.

 Histological examination: The autograft has undergone decay and is represented by eosinophilic masses and nuclear detritus. On the periphery of necrotic tissue, sections up to 0.4 mm wide are determined, consisting of capillaries, surrounding reticular cells, lymphocytes, monocytes, hemosiderin. Red blood cells are determined both in the vessels and in the reticular tissue. The vessels of the described tissue are connected with the vessels of the surrounding tissue. Small sections of the collagen capsule that separate the surrounding tissue from the graft. In some places, necrotic autosplenograft tissue is located next to the adipose tissue; at the same time, small groups of neutrophilic leukocytes, single macrophages are detected near necrotic tissue.

Thus, despite the complication of autosplenotransplantation in the form of splenic tissue lysis and the grave condition of the patient due to peritonitis, regeneration of the splenic structures took place. Implantation did not cause the development of generalized intra-abdominal inflammation
The lethal outcome is caused by peritonitis, complicating the course of the underlying disease.

 Example 2. Patient I., 17 years old, operated on 12/25/92 for a closed abdominal injury with rupture of the spleen, intraperitoneal bleeding.

 Splenectomy was performed in view of the failure of organ-preserving manipulations (suturing a rupture, ligation of segmental vessels of an organ).

 Autograft protocol for splenic tissue. After removal, the spleen is lowered in 400 ml of physical. solution with the addition of 80 mg of amikacin and 10 mg of isoptin and remained so for 15 minutes, then removed and washed transpulparically physical. solution (400 ml) with the addition of 10 mg of isoptin, the most surviving part with the contouring of the segments after washing. After decapsulation, 4 implants were selected in the form of plates 5 x 3 cm in size and not thicker than 0.4 cm and 2 sub-segmented implants. Separate pararectal access was performed on the right at the navel and after exposing the transverse fascia by dividing the rectus muscle and forming a pocket under the rectus abdominis, implants were placed on the fascia and covered with muscle from above. The front sheet of the vagina of the rectus abdominis muscle, the seams on the skin, are brought together from above. The total period of complete spleen ischemia is not more than 30 minutes.

 In the postoperative period, hyperthermia persisted at subfebrile numbers in the afternoon. Antibacterial, anti-inflammatory treatment, antioxidant (tocopherol acetate, nicotinic acid preparations in higher single doses) and immunostimulating therapy (autohemotherapy according to the generally accepted scheme), correction of rheological disorders were carried out.

 01/10/93 a puncture of the implantation zone was performed under CT - up to 50 ml of lysate was evacuated without signs of infection (bacteriological examination - no flora growth, bacteria - Oscopy and cytological examination - aseptic necrosis - autolysis). These hemostasiograms dated 01/10/93 - hyperfibrinogenemia (7.8 g / l) is preserved, platelet aggregation is sharply impaired - 0. No other violations were detected. Immunography from 5.01.93 - leukocytosis with a moderate shift to the left, an imbalance in regulatory populations of T-lymphocytes, a moderate increase in CEC Thrombocytosis (5.01.93) 802.5 x 10 Er 3.21 x 10, HB 100 g / l CP 0.9 L 12.1 x 10/9 p / 1 s / 58 e / 1 m / 1 l28 Discharged in satisfactory condition on the 12th day after the operation. Indicators of hemostasis and immunograms returned to normal by the 30th day of the postoperative period.

 Examined after 3 months - healthy, no complaints. There are no signs of hyposplenism.

 Thus, clinical trial data demonstrate the possibility of prosthetics of a remote organ by performing autotransplantation of splenic tissue in patients undergoing splenectomy due to trauma or inflammatory lesions of the pancreas, including the development of purulent (parapancreatitis, peritonitis) intraabdominal processes, in an extraperitoneal position according to the proposed methodology.

Claims (1)

 A method for autologous transplantation of splenic tissue, including splenectomy, the formation of fragments and their heterotopic implantation, characterized in that the antiischemic protection of the organ is preliminarily carried out by the intravenous administration of antioxidant drugs, after splenectomy, the spleen is perfused with hyperosmolar saline solution with the addition of higher doses of calcium and antioxidant, and then form implants in the form of anatomical sub-segments of the organ, which through additional transre tal section disposed on the lateral fascia in the lower third projection rectus, followed by the introduction in the early postoperative period, antibacterial and antioxidant preparations.