RU2113864C1 - Method for treating the cases of general purulent peritonitis - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves performing abdominal cavity sanation. The abdominal cavity is drained and perfused by means of a device. The device has two separate leaves of flexible perforated hydrophobic film with tubes and electrodes soldered into it in fan-like arrangement. The upper leaf has soldered tubes ends. The upper leaf is placed over intestine. The lower leaf is placed under intestine. The output tubes are united into a tube of greater diameter and brought outside. Dialysis solutions are introduced through the upper tube. Abdominal cavity contents is discharged through the lower tube. In cases of intestinal paresis, electrocoagulation is carried out. EFFECT: enhanced effectiveness of treatment. 2 cl, 3 dwg

Description

 The invention relates to medicine, namely to abdominal surgery, and can be used in the treatment of diffuse purulent peritonitis complicated by dynamic obstruction.

 A known method of peritoneal dialysis is "flow" (Pantsyrev Yu.M. Clinical Surgery, 1988, p. 362, Fig. 127), which includes continuous washing of the abdominal cavity with a large amount of dialysis solution, which is injected into two drainages located in the upper abdominal cavity outflow is carried out through drainages introduced into the lower abdomen.

 The disadvantage of the analogue is prolonged intense hydroperitoneum, which results in deterioration of cardiac activity and respiration, the risk of eventation and failure of anastomotic sutures, the minimum concentration of antibiotics in the abdominal cavity, leaching, loss of electrolytes, fluid and protein.

 The closest set of essential features to the claimed method is the "fractional" (ibid.), The method of peritoneal dialysis, when the dialysis solution is fed simultaneously through all the introduced drains, then they are closed for 1-2 hours and re-opened for the outflow of the introduced liquid.

 The disadvantage of the prototype is the prolonged intense hydroperitoneum, the consequence of which is the deterioration of cardiac activity and respiration, the risk of eventation and the failure of anastomotic sutures, the need for an additional suction device, the abdominal cavity is incompletely and unevenly irrigated.

 The invention is directed to a method for the treatment of spilled purulent peritonitis.

 The solution to this problem leads to the complex treatment of diffuse purulent peritonitis complicated by dynamic obstruction, drainage is carried out using a device that provides coverage of the intestines from above and below, irrigation of the entire abdominal cavity with solutions, creation of an electric field for moving ions, electrical stimulation of the intestine (both in total and various sites), active, passive drainage, full outflow from the abdominal cavity, reduction of treatment time.

 To achieve this result, a method of treating spilled purulent peritonitis contains the following essential features: after sanitation, drainage is carried out with a device containing two separate petals of an elastic perforated hygrophobic film with fan-shaped soldered drainage elastic perforated tubes that are inserted into the abdominal cavity, the upper lobe containing sealed ends the movable part of the drainage elastic perforated tubes, placed on top of the intestine, and the lower lobe containing open working ends, placed below the intestines, the output ends of the tubes, collected in separate tubes of large diameter, lead out, the upper tube in the left hypochondrium, the lower tube in the right iliac region, while dialysis solutions are introduced through the upper tube, and through the lower the contents are removed, with intestinal paresis, electrical stimulation is simultaneously performed until peritonitis resolves with the help of electrodes soldered in parallel with elastic perforated drainage tubes inside the hydrophobic film.

 In relation to the prototype, the claimed inventions have the following distinctive features: after sanitation, drainage is carried out by a device containing two separate petals of an elastic perforated hydrophobic film with fan-shaped soldered drainage elastic perforated tubes that are inserted into the abdominal cavity, the upper lobe containing the sealed working ends of the movable part elastic perforated drainage tubes, placed on top of the intestine, and the lower lobe containing open working ends, they are laid under the intestines, the output ends of the tubes, collected in separate tubes of a larger diameter, are brought out, the upper tube is in the left hypochondrium, the lower in the right iliac region, while dialysis solutions are injected through the upper tube, and the contents are removed through the lower tube, with paresis intestines at the same time conduct electrical stimulation to resolve peritonitis using electrodes soldered in parallel to the elastic drainage perforated tubes inside the hydrophobic film.

 There is a causal relationship between the distinguishing features and the technical result: after sanitation, drainage is carried out with a device containing two separate petals of an elastic perforated hydrophobic film with fan-shaped soldered drainage elastic perforated tubes that are inserted into the abdominal cavity, the upper petal containing the sealed working ends of the movable parts of the drainage elastic perforated tubes are placed on top of the intestine, and the lower lobe containing open slaves The ends are laid under the intestines, which provides the best coverage of the intestines from above and below; the output ends of the tubes, collected in separate tubes of a larger diameter, are brought out, the upper tube is in the left hypochondrium, the lower tube is in the right iliac region, while dialysis solutions are injected through the upper tube, and the contents are discharged through the lower tube, and the abdominal cavity is irrigated various solutions: antibacterial, oxygenated, antiprotease, oncotic and osmotic solutions, hypertonic, solutions with enzymatic activity; with intestinal paresis, electrical stimulation is simultaneously performed until peritonitis resolves with the help of electrodes soldered in parallel with elastic perforated drainage tubes inside the hydrophobic film, which creates an electric field that triggers the effect on the nervous and muscle tissue.

 According to available information, the set of essential features characterizing the essence of the invention is not known from the prior art, which allows us to conclude that the invention meets the criterion of "novelty."

 The essence of the claimed invention does not follow for a specialist explicitly from a known level of medicine, since the above effects on the obtained technical result are not revealed from it, namely, the complex treatment of diffuse purulent peritonitis complicated by dynamic obstruction, drainage is carried out by a device that provides intestinal coverage from above and below irrigation of the abdominal cavity with solutions: antibacterial to fight infection; oxygenated solutions; atomic oxygen toxic effects on anaerobic infection, in addition, mechanically leaches pathogens from cavities to the surface; antiprotease - to inhibit pancreatic enzymes; oncotic and osmotic solutions to normalize the acid-base balance, hypertonic environment toxic effect on microorganisms; microcirculation enhancing solutions; with enzymatic activity to improve the rejection of necrotic tissue; oxygenated - atomic oxygen is detrimental to anaerobes, mechanically leaches particles of necrotic tissue and fibrin, the intestines float in the fluid, which is the prevention of adhesive disease; creation of an electric field for ion movement, electrical stimulation of the intestine, active and passive drainage, the device easily leaves the abdominal cavity through a small contraperture, gathering in the form of a cylinder with a diameter of no more than 1-1.5 cm. Treatment time is reduced. They distinguish the claimed invention from the prototype, which allows us to conclude that it meets the criterion of "inventive step".

 The set of essential features characterizing the essence of the invention, in principle, can be repeatedly used in abdominal surgery to obtain a technical result, which consists in reducing the treatment time, which allows us to conclude that the invention meets the criterion of "industrial applicability".

 Figure 1 shows the design of the device with which drainage and perfusion of the abdominal cavity are carried out; figure 2 - bipolar electrodes and perforated drainage tubes (separately enlarged); figure 3 is a separate petal of the device with a discharge tube in assembled form, where 1 and 2 are the upper and lower petal of the device; 3 - elastic perforated hydrophobic film; 4 - drainage elastic perforated tubes; 5 - bipolar electrodes soldered in parallel with drainage elastic perforated tubes, inside a perforated hydrophobic film; 6 - pulse current generator; 7 - a separate lobe of the device in assembled form, in the form of a cylinder.

 The method is as follows. After performing the main stages of surgical treatment (laparotomy, revision of the abdominal cavity, eliminating the causes of peritonitis, sanitation of the abdominal cavity, etc.), the abdominal cavity is drained and perfused using a device that is inserted into the abdominal cavity. Having previously sterilized the device’s petals in a chlorhexidine solution, it is adjusted with scissors and, if necessary, they intersect both elastic perforated hydrophobic film and fan-shaped elastic perforated tubes soldered into it, 0.1-0.2 cm in diameter. The upper lobe 1 covers the intestine from above , the intestines are laid on the petal 2, the mesentery is carried out at the dissection sites of the elastic perforated hydrophobic film 3. The upper petal 1 contains the sealed working ends of the movable part elastic perforated tubes 4, and the lower lobe 2 of the device has open working ends of the movable part of the elastic drained perforated tubes 4. The output distal ends of the elastic drained perforated tubes 4, assembled in separate tubes of a larger diameter, lead out, the upper tube into the left hypochondrium, lower - in the right iliac region. In this case, dialysing solutions are injected into the abdominal cavity through the upper tube in the flow-drop mode in the amount of 5-6 l in the first days, in the next 3-4 l. Dialysis solutions are distributed along the drainage elastic perforated tubes and irrigate the abdominal cavity, and through the lower tube discharge from the abdominal cavity, as well as spent dialysate, are both passively due to negative pressure and actively due to the formation of films 3 between adjacent surfaces and in drainage elastic perforated tubes 4 to capillary forces, if necessary, an electric pump is connected. Various solutions are used as dialysate - antibacterial, sensitive to the seeded microflora of the abdominal cavity, solutions with protease inhibitors, with enzymatic activity, saline, oxygenated and improving microcirculation, as well as combined ones. Bipolar electrodes are connected to a pulse current generator giving unidirectional rectangular pulses of 5-7 m / s duration, with a repetition rate of 40-50 Hz, mode 1 s - irritation, 3 s - pause, session 25-40 min, which serve intestinal stimulation, also due to which there is a transition of ions back from the liquid deposited in the abdominal cavity into the blood.

 On the next day after surgery, the intestines begin to act with electric pulses, both vertically and horizontally. The electrodes are connected to a pulse current generator, in the mode of 1 s - irritation, 3 s - pause, session 25-40 minutes. The criterion for the restoration of intestinal motility is clinical data - the appearance of intestinal noise, the passage of stools and gases, x-ray data.

 At the end of treatment, the device easily leaves the abdominal cavity through a small contraperture, gathering in the form of a cylinder with a diameter of not more than 1-1.5 cm.

 Example 1. Patient D. was admitted four days after the operation of laparotomy, resection of the small intestine, suturing of the dome of the cecum and stomach, drainage of the abdominal cavity due to a gunshot wound to the stomach with damage to the stomach, large and small intestines, shock of the 2nd degree.

 On admission, there is soreness throughout the abdomen, moderate bloating, auscultation - a slight noise of peristalsis. A positive symptom of Shchetkin-Blumberg. HELL 110/60 mm RT. Art., PS - 120 beats in 1 min. White blood cells - 20 thousand, PO - 16%.

 The diagnosis was established: the state after laparotomy, resection of the small intestine, suturing of the dome of the cecum and stomach, diffuse peritonitis. A laparotomy was performed, it was found that the colon sutures were inconsistent. Spilled purulent peritonitis. Resection of the ileocecal angle was performed, and the ileocolostomy was superimposed according to Lachey. Sanitation of the abdominal cavity. Drainage of the abdominal cavity by a device for the treatment of diffuse purulent peritonitis. The lower lobe of the device is dissected between the tubes where the root of the small intestine is held. The intestines are laid on a petal. The upper one is also dissected between the tubes where the ostomy of the intestine is performed. Immediately in the intensive care unit, dialysis solutions were established in the flow-drop mode through the upper lobe into the abdominal cavity.

 1. 1 liter of a 2% solution of hydrogen peroxide and 1 liter of a solution of furatsilina 1: 5000.

 2. 1 liter of distilled water, 5 g of sodium chloride, 1 g of potassium chloride, 4 g of sodium bicarbonate, 50 ml of a 1% solution of dioxidine.

 At the same time, intestines were electrostimulated by means of a device, in the mode of 1 s - irritation, 3 seconds - pause, session 40 minutes, until intestinal noises, discharge of stool and gases. In conclusion, when the entire injected solution was withdrawn, an additional 100 ml of Ringer's solution with 50 mg of trypsin was added to the upper drainage, with the lower drainage blocked for 2 hours to dissolve the fibrinous deposits. In the first three days, up to 5-6 liters of dialysis solution were injected, in the following - 2-3 liters. At the same time, conventional methods of treating peritonitis were also carried out.

 By the beginning of the third day, the general condition of the patient began to improve: the pulse rate and body temperature decreased, hemodynamics and blood counts improved, bloating decreased, and peristalsis appeared.

 Example 2. Patient K., 60 years old, was admitted to the clinic on the third day from the onset of the disease. Complaints of pain throughout the abdomen, bloating, nausea, and vomiting. The skin and visible mucous membranes of normal color, dry. The tongue is dry, coated with a white coating. PS - 120 beats per 1 min, rhythmic, blood pressure 90/60 mm Hg The abdomen is moderately swollen, palpation painful in all departments, the Shchetkin-Blumberg symptom is positive in all departments. Auscultatory peristalsis is not heard. Er-3 million Hb-90 g / l - 0.8 Ht-45%. White blood cells - 23 thousand, PO - 16%. Diagnosed with diffuse peritonitis. Laparotomy performed, detected; diffuse purulent peritonitis of appendicular etiology. Appendectomy, sanitation of the abdominal cavity, drainage of the abdominal cavity by a device for the treatment of diffuse purulent peritonitis were performed. The intestines are laid on the lower lobe of the device, the upper lobe is spread over it. Immediately in the intensive care unit, dialysis solutions were established in countercurrent-drop mode through the upper lobe into the abdominal cavity.

 1. 1 liter of a 2% solution of hydrogen peroxide and 1 liter of a solution of furatsilina 1: 5000.

 2. 1 liter of distilled water, 5 g of sodium chloride, 1 g of potassium chloride, 4 g of sodium bicarbonate, 50 ml of a 1% solution of dioxidine.

 At the same time, intestines were electrostimulated by means of a device, in the mode of 1 s - irritation, 3 s - pause, session 30 minutes, until intestinal noises, discharge of stool and gases. In conclusion, when the entire injected solution was withdrawn, an additional 100 ml of Ringer's solution with 50 mg of trypsin with an overlapped lower drain for 2 hours was added to the upper drainage to dissolve the fibrinous deposits. In the first two days, up to 5-6 l of dialysis solution was administered. On the third day, the dialysate was replaced with a different composition.

 1. 1 liter of distilled water, 5 g of sodium chloride, 1 g of potassium chloride, 4 g of sodium bicarbonate, 50 ml of a 1% solution of dioxidine.

 2. 1 liter of reopoliglyukin with 2000 heparin.

 The proposed method was applied in 20 patients with diffuse purulent peritonitis of various etiologies. By the end of the third day, the majority of patients had a subsidence of the purulent-inflammatory process in the abdominal cavity, which was confirmed by the presence of a transparent, sediment-free discharge from the drainage device and the absence of pathological microflora during microbiological examination. In the majority of observations, by the end of the third or fourth day peritoneal phenomena stopped, peristalsis appeared, and stool and gas escaped. There were no complications and mortality associated with the application of the proposed method.

Claims (2)

 1. A method of treating spilled purulent peritonitis, including debridement, drainage and perfusion of the abdominal cavity using the device, removing the distal portions of the device through contraperture to the outside, characterized in that drainage and perfusion is carried out by a device containing two separate lobes of elastic perforated hydrophobic film fan-welded into her drainage elastic perforated tubes, in parallel with which the electrodes are soldered, when the upper lobe containing the solder is inserted into the abdominal cavity the working ends of the tubes are laid on top of the intestines, and the lower lobe containing the open working ends of the tubes is laid below the intestines, the outlet ends of the tubes are collected in separate tubes of a larger diameter, brought out, the upper in the left hypochondrium, the lower in the right iliac area, while through the upper tube enter dialysis solutions, and through the lower tube output the contents of the abdominal cavity.  2. The method according to p. 1, characterized in that with intestinal paresis it is electrostimulated using electrodes.

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