RU2147899C1 - Method for stimulating intestine peristalsis in postoperative period - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves taking blood from peripheral vein in the amount of 2 ml/kg of body mass. The blood is exposed to ultraviolet radiation of 254 nm wavelength. It is subjected to oxygenation during 1 h reinfusion. Oxygen discharge rate is equal to 10 l/min in oxygenator device. Reinfusion process is carried out into the portal vein using catheter set into recanalized umbilical vein when making operation. Ultraviolet irradiation and autoblood oxygenation treatments are carried out in extracorporeal mode with reinfusion into the portal vein once a day during 2 days. The treatment starts beginning from the second - third day after operation. EFFECT: restored intestine peristalsis; reduced endogenous intoxication. 6 dwg, 2 tbl

Description

 The invention relates to medicine, mainly to abdominal surgery, and can be used to restore intestinal motility after operations on the abdominal organs.

 The restoration of intestinal motor activity after operations on the abdominal organs is one of the difficult problems of abdominal surgery. The timely appearance of intestinal motility indicates a favorable course of the postoperative period and, as a rule, in most cases serves as a good prognostic sign. With a delay in its recovery, the condition of patients is significantly aggravated, endogenous intoxication increases, and liver functions are aggravated. In addition, bloating in these cases complicates the adequate function of cardiac activity and lungs. The developing intestinal paresis contributes to the overstretching of its walls by gases, and the processes of fermentation and decay in the chyme contribute to a sharp increase in intoxication, as well as the penetration of microbes through the intestinal wall into the peritoneal cavity with the development of peritonitis or the entry of microbes into the circulatory system, including the portal system of the liver (B .P. Petrov, IA Yeryukhin "Intestinal obstruction." - M .: Medicine. - 1989. - P. 11, 29-35; V. S. Savelyev et al. "The effect of probe decompression on portal and systemic bacteremia in patients with peritonitis. "- X p -. 1993. - N 10. - pp 25-29). All this necessitates careful monitoring of the process of restoration of intestinal motor activity after operations on the gastrointestinal tract, and also forces its stimulation to be applied during delays in restoration of peristalsis.

 Currently, the following methods are known to stimulate intestinal motility in the postoperative period: a - medications; b - novocaine blockades (perinephral, intrathoracic, round ligament of the liver, etc.); in - epidural anesthesia; d - external decompression of the upper digestive tract (stomach, small intestine), which is most often combined with enteral probe nutrition with salt nutrient mixtures (saline enteral solution, Ringer's solution, etc.); d - electrical stimulation; e - oxygenobarotherapy; g - detoxification by extracorporeal methods; h - correction of water-electrolyte shifts in the body; and - exposure to sound waves (V.P. Petrov, I.A. Eryukhin "Intestinal obstruction." - M.: Medicine. - 1989. - S. 70-74). Thus, a "Method for the treatment of postoperative intestinal paresis" (ac N 1197645, class A 61 N 1/36, publ. Bulletin N 46, 1985) is described, which provides for the introduction of the drug mixture through the microirrigator into the retroperitoneal tissue during and after surgery her, as well as "A method of electrical stimulation of motor activity of the gastrointestinal tract" (a.p. N 430861, class A 61 N 1/36, publ. bull. N 21, 1974) and "A method for the treatment of postoperative gastrointestinal paresis intestinal tract "(ac N 1243737, class A 61 N 1/36, publ. bull. N 26, 1986), based on stimulation of the intestine by pulsed current.

 Currently, stimulation of the gastrointestinal tract is most often carried out against the background of external decompression of the upper digestive tract, including nasointestinal. In particular, described the "Method of restoring the motor-evacuation function of the intestine in the postoperative period" (ac 1560231, class A 61 N 1/36, publ. Bull. N 16, 1990), in accordance with which patients with acute bowel obstruction or peritonitis, a special probe is carried out for the entire length of the small intestine and, simultaneously, 20-24 hours after the operation, it is electrostimulated by multiple electrodes located on the probe. Also known is the "Method of electrical stimulation of the gastrointestinal tract in the postoperative period" (patent N 2001401, class A 61 N 1/36, publ. Bull. N 37-38, 1993), providing for the implementation of external decompression of the stomach with enteral tube feeding in the postoperative period and electrical stimulation of the intestine with a half-sinusoidal current when there is a state of electrophysiological readiness of the small intestine to perceive these electrical pulses.

 At the same time, vascular spasm and microcirculatory disorders play an important role in the pathogenesis of postoperative intestinal paresis, as a result of which the blood supply to the small intestine and liver decreases sharply. Moreover, hypoxia in these organs reaches its most pronounced value (V.P. Petrov, I.A. Eryukhin "Intestinal obstruction." - M .: Medicine. - 1989. - P. 33-34; V.A. Popov "Peritonitis ". - L.: Medicine. - 1985. - S. 24-25). This causes severe metabolic changes in the liver, small intestine and in the body as a whole. Therefore, the corrective effects on these pathogenesis links of postoperative intestinal paresis will be important in restoring intestinal motility. In this regard, ultraviolet irradiation of autologous blood with a complex therapeutic effect on the body, as well as oxygenation of portal blood, deserves attention. It is known that ultraviolet irradiation of blood has a detoxifying, vasodilating, anti-inflammatory, antioxidant effect, improves microcirculation, rheological properties of the blood and its saturation with oxygen, activates respiratory enzymes, specific protection factors, stimulates regeneration (I. G. Dutkevich et al. "Changes in hemostatic potential of blood after autohemotransfusions with UV radiation ". - B Sat: The mechanism of the effect of blood irradiated by ultraviolet rays on the human and animal body. - L.: Science. - 1986. - P. 97-103; AE Gromov et al. "The effect of reinfusion of autologous blood irradiated with UV rays on the rheological properties of blood." - Ibid., Pp. 207-211; VV Levanovich, D. M. Vorypin "Autotransfusion of ultraviolet radiation in the treatment of purulent peritonitis in children. - Vestn. Khir. - 1986. - N 7. - P. 7-10; V.I. Rotar et al." The effect of ultraviolet irradiation of blood on its oxygen transport function . - Clin. Chir. - 1990. - N 3. - S. 29-30).

 As a prototype of the claimed technical solution, the method described by A.P. Vlasov and I.G. Rumyantsev in the article "Methods of increasing the tolerance of intestinal anastomosis to circulatory hypoxia", published in the collection "Efferent methods in medicine" - Part 1. - Izhevsk. - 1992. - S. 24-25. The essence of the method, taken as a prototype, is that in order to increase the tolerance of the intestinal anastomosis to circulatory hypoxia during surgery on the intestine and in the postoperative period, extracorporeal ultraviolet irradiation of autologous blood with reinfusion into the peripheral vein is performed every other day. They noted a more rapid elimination of oxygen deficiency in the intestine, improved wound healing along the anastomotic sutures, which was important to increase the tolerance of the intestinal anastomosis to motor activity and chyme passage. This method has several disadvantages: 1 - unexpressed therapeutic effect on the intestine to restore its motor activity, because after reinfusion, the ultraviolet irradiated blood is diluted in the vascular bed; 2 - a weaker detoxification effect, reducing the effectiveness of the restoration of intestinal motility; 3 - low blood oxygenation in the portal system, delaying the restoration of liver and small intestine functions.

 These disadvantages are eliminated in the proposed method of stimulation of intestinal motility. Its essence is that in order to increase the efficiency and reliability of the method of stimulating intestinal motility, blood is taken from the peripheral vein at a rate of 2 ml / kg, it is subjected to ultraviolet irradiation and oxygenation in extracorporeal conditions, and then it is returned to the body intraportally through a catheter performed during portal vein surgery through recanalized umbilical vein.

 A detailed description of the method and examples of its practical implementation.

 In severe patients, during surgery on the organs of the abdominal cavity, recanalization of the umbilical vein is performed with the introduction of a special catheter into its lumen. For this (Fig. 1), a peritoneum 2 3 cm long is longitudinally dissected on a round ligament 1 of liver 8 at a distance of 4-5 cm from the anterior abdominal wall. Obliterated umbilical vein 3 is found in the fatty tissue of this ligament in the form of a strand with a diameter of 5-9 mm. The umbilical vein 3 is taken onto the ligature-holder 4. Then, under the umbilical vein 3, the index finger 5 of the left hand covered with a gauze napkin is brought 6. A frontal wall of the umbilical vein 3 is dissected in the transverse direction in the projection 7 of index finger 5 to the obliterated lumen. A mosquito clamp is carried out along the obliterated lumen of the umbilical vein 3 in the direction of the liver 8 to enter the proximal end of the umbilical vein 3 and raise its front wall. Two clamps (Fig. 2) of the type "mosquito" 9 capture the free edges of the raised front wall of the umbilical vein 3 for holding. Then, a uterine probe 10 with an olive diameter of 2-3 mm enters the obliterated lumen 11 of the umbilical vein 3 towards the liver 8 to a depth of 12-13 cm. Overcoming the obstacle by “sinking” the uterine probe 10 and freeing it 1-1.5 cm deep moves about its passage into the lumen of the portal vein. This is confirmed by the appearance of blood from the recanalized lumen 11 of the umbilical vein 3 when the uterine probe 10 is removed. A special umbilical catheter 12, for example N 8 or 10 (TU 25-1961.032-87), previously washed with a weak solution of heparin, is introduced into the recanalized lumen 11 of the umbilical vein. and immediately, for example, Ringer's solution or a weak heparin solution of 3-4 ml is injected into the umbilical catheter 12 with a syringe to prevent thrombosis. An additional ligature 13 bandages the umbilical vein 3 in the transverse direction to fix the umbilical catheter 12 in it (Fig. 3). Another ligature 14 is carried out around the umbilical vein 3, but it is not tied, and the ends are brought out to the front abdominal wall through the laparotomy wound and fixed on the gauze ball in an unstressed state. Mosquito clamps 9 are removed. The peritoneum 2 of the round ligament 1 is sutured with separate sutures. The outer part of the umbilical catheter 12 is brought to the front abdominal wall (Fig. 4) through the surgical wound and fixed to the skin with separate ligatures 16.

 In the postoperative period, glucose-electrolyte solutions, blood substitutes, vitamins are introduced intravenously through the umbilical catheter 12, donor blood and its preparations are transfused.

 By the 2-4th day after the operation, when there are obvious signs of postoperative intestinal paresis (bloating, obstruction of gases through the rectum, regurgitation or vomiting, or abundant stagnant contents through a nasogastric tube, absence of intestinal peristalsis during abdominal auscultation), the patient there is a need to stimulate intestinal motility. For this purpose (Fig. 5), the patient is punctured with a peripheral vein 17, for example an ulnar vein, and with the help of an infusion system 18, a low-flow blood oxygenator 19, for example, a DIP-02-02 membrane dialyzer adapted for these purposes, is subsequently connected to it, then the apparatus for ultraviolet irradiation of autoblood 20, for example, Isolde MD-73M, and at the end of a vial 21 for collecting blood containing a stabilizer, such as Glugin, to prevent its coagulation. Using a roller pump of the Isolda MD-73M apparatus 20, blood was sampled from the peripheral vein 17 at the rate of 2 ml / kg and irradiated with ultraviolet rays with a wavelength of 254 nm. Oxygen is not connected to a low-flow blood oxygenator 19 during blood sampling from a peripheral vein 17. Then (Fig. 6), the blood collected in the vial 21 is mounted on a tripod and, using the same infusion system 18 and a roller pump, is returned to the portal vein by connecting the cannula 22, through which blood was taken from the peripheral vein 17, to the umbilical catheter 12. Simultaneously through low-flow oxygenator 19 begin to supply gaseous oxygen with a flow rate of 10 l / min continuously for 1 h, necessary for the complete completion of reinfusion of blood. In this case, blood from vial 21, passing through the Isolda MD-73M apparatus 20, is again subjected to ultraviolet irradiation, and then oxygenation when passing through a low-flow oxygenator 19. Sessions of ultraviolet irradiation of autologous blood with subsequent oxygenation and reinfusion into the portal vein are carried out daily in the next 2 of the day.

 After the first session of ultraviolet irradiation of autologous blood with its additional oxygenation after 18-20 hours, the patient shows signs of restoration of intestinal motility: vomiting disappears, with auscultation of the abdomen, intestinal murmurs of peristalsis are heard. After the second session, gases begin to escape through the rectum, bloating disappears, an independent stool appears. Endogenous intoxication is sharply reduced. After that, the catheter 12 is removed from the umbilical vein 3 (Fig. 4). To do this, the skin around the umbilical catheter 12 is treated with a solution of an antiseptic, for example 1% iodonate. Sterile scissors release the umbilical catheter 12 from the fixing ligatures 16 on the anterior abdominal wall. The ligature 14 brought to the front wall is pulled by both ends to slightly raise the umbilical vein 3 anteriorly. The umbilical catheter 12 is taken with tweezers and pulled out when the ligature 14 is stretched to squeeze the lumen and prevent reverse blood flow through the recanalized umbilical vein 3 into the abdominal cavity. Then the ligature 14, without relaxing, is tied on a gauze ball 15 placed on the skin in the area of the sutured surgical wound, and left in this state for three days (the time required for thrombosis and fixation of blood clots in a recanalized umbilical vein). After three days, the skin in the area of the sutured surgical wound is treated with an antiseptic solution, for example, 1% iodonate, and a gauze ball 15 is slightly lifted over the skin with tweezers, one of the ends of the ligature 14 is found and it is crossed with sterile scissors directly above the skin, in the area shown from subcutaneous tissue. After that, for the second end, the ligature 14 is removed from the abdominal cavity.

 The inventive method is illustrated by the following clinical examples.

1. Patient No, 16 years old (IB No. 3271), was admitted to the surgical department of the Rostov BSMP No. 1 with a diagnosis of gangrenous-perforated appendicitis, diffuse peritonitis. The patient underwent an emergency operation - laparatomy, appendectomy, lavage of the abdominal cavity with its drainage, umbilical vein catheterization. In the postoperative period, the patient's condition is serious. By the second day after the operation, the phenomena of endogenous intoxication and intestinal paresis increased: pulse 118 in 1 min, blood pressure 110/70 mm Hg, abundant congestive discharge departed along the nasogastric tube, bloating, gas escaping, absence of intestinal noises of intestinal motility with auscultation of the abdomen. In the analysis of blood leukocytes 9.9 • 10 ⁹ / l, the blood formula: stab neutrophils - 30%, segmented - 59%, lymphocytes - 7%. In this regard, the patient underwent a session of extracorporeal ultraviolet irradiation of autologous blood with its subsequent oxygenation and reinfusion into the portal vein according to the described method. The oxygen tension in the blood reinfused into the umbilical vein was 310 mm Hg. The study of volumetric blood flow in the vessels of the splanchnic channel by ultrasound dopplerography testified to an increase in the level of blood supply (Table 1).

 The next day (18 hours after the first session), the patient's condition improved: with auscultation of the abdomen, intestinal murmurs of peristalsis were detected. On the electroenterogram (Fig. 7, pos. B), an increase in the amplitude of the waves was noted compared with the state before reinfusion with irradiated ultraviolet rays and oxygenated blood (Fig. 7, pos. A).

The patient was re-performed a session of ultraviolet irradiation of blood with its oxygenation and intraportal reinfusion. By the next day (the fourth after the operation), the patient had pronounced intestinal motility, the gases passed through the rectum, and bloating disappeared. On the electroenterogram (Fig. 7, pos. B), the normal wave amplitude was observed. In the general analysis of blood: leukocytes 6.6 • 10 ⁹ / l, stab neutrophils - 12%, segmented - 58%, lymphocytes - 24.5%, monocytes - 5.5%.

 On the fifth day after the operation, ingestion through the mouth is allowed, an active motor regimen is prescribed. A day later, the patient appeared independent stool. The postoperative period was uneventful. The patient was discharged from the hospital in satisfactory condition.

2. Patient 3-nd, 62 years old (IB No. 2882), was admitted to the surgical department of BSMP N 1 in Rostov-on-Don due to venous thrombosis of the vessels of the mesentery of the small intestine, dynamic intestinal obstruction. In an emergency, after preoperative infusion preparation, an operation was performed - laparatomy, cecostomy with intubation of the small intestine, umbilical vein catheterization. By the third day after the operation, the patient's condition worsened significantly, the effects of endotoxemia and intestinal paresis increased: bloating, abundant stagnant discharge from the nasogastric tube, intestinal peristalsis was not detected during auscultation of the abdomen. Pulse 112 in 1 min, HELL 140/60 mm Hg In the general analysis of leukocyte blood 9.0 • 10 ⁹ / l, the leukocyte formula: stab neutrophils - 33%, segmented - 47%, lymphocytes - 17%, monocytes - 7%, ESR 48 mm / h. Blood urea rose to 13.6 mmol / L.

 To stimulate intestinal motility, a session of extracorporeal ultraviolet irradiation of blood was performed with its oxygenation and subsequent reinfusion into the portal vein according to the proposed method. Doppler ultrasound examination of the splanchnic blood flow showed a significant increase in blood supply to the liver and small intestine (Table 2).

 20 hours after the first session, the patient began to listen to intestinal motility. On the performed electroenterogram (Fig. 8, pos. B), an increase in the amplitude of the waves was detected compared with the previous study before the session of stimulation of intestinal motility (Fig. 8, pos. A).

 The ultraviolet irradiation of blood with its oxygenation in extracorporeal conditions and reinfusion into the portal vein is repeated. The next day (20 hours after the second session), good intestinal motility was auscultated, there was no bloated abdomen, gases and loose stools passed through the cecostomy. The normal amplitude of the waves was detected on the electroenterogram (Fig. 8, pos. B). The patient's condition improved significantly: pulse 88 in 1 min, blood pressure 140/80 mm Hg In the general blood test, the shift of the leukocyte formula to the left sharply decreased: stab neutrophils - 15%, segmented - 57%, lymphocytes - 20%, monocytes - 6%. Blood urea decreased to 8.6 mmol / L. During further treatment, the patient's condition continued to improve. Discharged from the hospital in satisfactory condition with good motor-evacuation function of the intestine.

 The proposed method for the stimulation of intestinal motility in the postoperative period was tested in four patients. Intestinal motility recovered in all. The negative effects of intraportal reinfusion irradiated with ultraviolet rays and additionally oxygenated autologous blood were not noted.

 Thus, compared with the prototype of the claimed method has the following advantages: 1 - a pronounced effect on blood flow in the small intestine and the saturation of the blood flowing from it with oxygen, leading to the restoration of peristalsis in the next 18-20 hours after 1-2 sessions of the proposed treatment; 2 - a significant reduction in endogenous intoxication, contributing to the restoration of intestinal motility; 3 - improvement of the blood supply to the liver and the saturation of the blood flowing to it with oxygen, increasing its protective functions.

Claims (1)

 A method for stimulating intestinal motility in the postoperative period, including extracorporeal ultraviolet irradiation of autologous blood, characterized in that blood taken from a peripheral vein at a rate of 2 ml / kg of body weight is irradiated with 254 nm ultraviolet rays in an Isolda MD-73M apparatus, and then during 1 h of reinfusion additionally subjected to oxygenation with an oxygen flow rate in the oxygenator of 10 l / min and the reinfusion process is carried out in the portal vein through a catheter installed in recanalization bath umbilical vein during surgery, sessions of ultraviolet irradiation and oxygenation of autologous blood in extracorporeal conditions with reinfusion into the portal vein is carried out 1 time per day for 2 days, starting from 2 to 3 days after surgery.

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