RU2154997C1 - Method of treating generalized peritonitis - Google Patents

Abstract

FIELD: medicine, particularly, surgery. SUBSTANCE: method includes surgical operation; elimination of peritonitis source; nasointestinal intubation and lavage of small intestine; intraintestine introduction of 15 g of enterosorbent and 1 g of ampicillin; intraintestine introduction during postoperative period through zone of oxygen-containing salt solution, enterosorbent; intraportal reinfusion of oxygenated autoblood; intraportal introduction of metragil. Treatment is carried out 5-6 days after operation up to restoration of intestine peristalsis, obtaining negative results of bacteriological examination of blood from portal vein for presence of microflora. EFFECT: higher efficiency. 6 dwg, 1 ex

Description

 The invention relates to medicine, mainly to abdominal surgery, and can be used to treat patients with acute pathology of the abdominal cavity, complicated by peritonitis.

 Peritonitis is one of the serious and dangerous complications of acute surgical diseases of the abdominal organs. The identification of signs of peritonitis always serves as an absolute indication for the operation of laparatomy, removal or elimination of the source of peritonitis, lavage of the abdominal cavity and its drainage. In the postoperative period, intensive antibacterial, detoxification, corrective therapy of impaired functions of organs and systems is carried out, immunostimulating and immunomodulating agents are used. A very crucial moment of therapeutic therapy is the restoration of motor-evacuation function of the intestine, which also prevents the development of multiple organ failure, and especially the functions of the liver and kidneys.

 Recent studies have shown that with widespread peritonitis of any etiology, damage to the enteric barrier occurs. As a result of this, the penetration of microorganisms, including anaerobes, through the intestinal wall into the portal system and systemic venous blood flow / B.C. is noted. Saveliev et al. "The effect of probe decompression on portal and systemic bacteremia in patients with peritonitis," - Surgery. - 1993. - N 10. - S. 25-29 /. At the same time, the number of anaerobes sharply increases in the lumen of the small intestine, including non-clostridial / E. Coli, Klebsiella spp., Enterobacter spp., Bacteroides spp. and others /, which become pathogenic under these conditions. Their content in the chyme of the small intestine remains high in the early postoperative period / A.A. Greenberg, T.I. Black "Enterosorption in the treatment of common peritonitis." - Sat .: Materials scientific. Conf. 100th anniversary of prof. P.L. Seltsovsky. - M. - 1998. - S. 38-40 /. In addition, splanchnic blood flow sharply decreases in these patients, which reduces the supply of oxygen to the small intestine, liver and other abdominal organs. All this happens against the background of pronounced intestinal paresis, where the processes of decay and fermentation increase significantly, and a large amount of toxic substances accumulate.

 Massive entry into the liver through the portal system of microorganisms and toxic substances damages primarily the stellate reticuloendothelial cells of the liver / Kupffer cells / and when they / Kupffer cells / cannot cope with portal bacteremia, they die and breakthrough microbes from the portal into the systemic circulation / the general circle of blood circulation /, which leads to sepsis and death of patients. Therefore, at present, special attention is paid to the antibacterial effect on the microflora in the portal system and in the lumen of the small intestine, where these microorganisms come from. In this regard, for the treatment of common peritonitis, external decompression of the upper digestive tract with nasointestinal intubation and small intestine lavage during surgery is used, and enterosorbents are introduced into the lumen of the small intestine in the postoperative period. This significantly reduces the content of toxins and microorganisms in the intestinal lumen / A. G. Lebedev et al. "Decompression of the gastrointestinal tract with small bowel obstruction. - Sat .: Materials of the scientific and practical conference., Dedicated to the 100th anniversary of Prof. P. L. Seltsovsky. - M. - 1998. - P. 53-59; A .A. Grinberg, T. I. Chernysh, “Enterosorption in the treatment of peritonitis widespread.” - Ibid., Pp. 38-40 /. In addition, as a general antibiotic treatment, intramuscular antibiotics are used, including those acting on anaerobic microflora / penicillins, clindamycin, chloramphenicol, cefotoxin, etc. / in combination with intravenous administration of nitroimidazole derivatives / metragil, metranide olom and others /, as well as hyperbaric oxygenation, intravenous administration of specific sera / anti-clostridial, anti-negative / and extracorporeal detoxification methods / hemosorption, ultraviolet irradiation of blood, etc. / / A.P. Kolesov et al. "Anaerobic infections in surgery". - L.: Medicine. - 1989. - S. 115-138 /.

 To improve the oxygen supply to the liver, blood is arterialized in the portal vein by connecting it with a temporary or permanent shunt to the artery. In particular, in the patent literature known "Method for the treatment of peritonitis" / ed. St. N 1662511, IPC A 61 B 17/00, publ. bull. N 26, 1991 /, which, in order to increase the effectiveness of treatment, provides for postoperative hemoperfusion in the portal vein - aorta circuit at a speed of 350-500 ml / min until the portocaval pressure gradient normalizes, and if this pressure is increased again, the hemoperfusion is repeated in the same mode. The disadvantage of this method is the lack of a targeted antibacterial effect on the microflora in the portal system and in the small intestine.

 A "Method for the treatment of general peritonitis" / ed. St. N 833230, IPC A 61 B 17/00, publ. bull. N 20, 1981 /, which provides for the decompression of the small intestine and its release from toxic contents by drip flow washing in the retrograde direction through the microcecostoma with adequate drainage through the tube, draining the initial section of the small intestine. However, with this method of treating peritonitis, there is no targeted effect on the microflora in the small intestine with antibiotics or oxygen, as well as by additional oxygenation of the portal blood.

 As a prototype of the claimed technical solution taken "Method for the treatment of liver failure" by ed. St. N 1120980 / IPC A 61 B 17/00. publ. bull. N 40, 1984 /, which provides for blood sampling from the portal system, its oxygenation with detoxification by hemosorption, followed by reinfusion into the portal system of the liver. This method has the following disadvantages: 1 - lack of exposure to the microflora of the small intestine - the main reservoir, from which microorganisms enter the portal vein system; 2 - toxic products and microorganisms are not removed from the small intestine mechanically / nasointestinal intubation, lavage /; 3 - the contents of the small intestine are not oxygenated, which reduces the therapeutic effect on the liver and small intestine, and also does not affect the microflora of the small intestine; 4 - sampling of portal blood in the amount necessary for hemosorption and oxygenation is technically very difficult to do; 5 - with hemosorption of blood, partial destruction of blood cells occurs, which is not desirable in patients with advanced peritonitis.

 These shortcomings are eliminated in the proposed technical solution.

 The purpose of the invention is to increase the effectiveness of treatment of patients with advanced peritonitis by acting on anaerobic microflora in the portal system and in the small intestine, as well as improving blood oxygenation in the portal system.

 This goal is achieved by the fact that during the operation, patients undergo nasointestinal intubation and lavage of the small intestine with the subsequent introduction of enterosorbent and an antibiotic into it in glucose-saline solution, then the intubation probe is replaced with a nasogastrointestinal two-channel tube of smaller diameter and the catheter is inserted into the umbilical cord in the umbilical cord. in the postoperative period against the background of external decompression of the stomach, intrathecal administration of enterosorbent and an oxygen-containing saline solution is carried out, internal triple reinfusions of oxygenated autologous blood taken from a peripheral vein, as well as intraportal infusions of a drug derived from nitroimidazole, for example, metranidazole or metragil 100 ml 3 times a day.

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

 In a patient with widespread peritonitis under general anesthesia, laparatomy is performed with the elimination of the source of peritonitis, and lavage of the abdominal cavity. Then perform intraoperative intubation of the small intestine. To do this, take a double-lumen non-absorbable probe / ZZHKS-33 / N 33 with a diameter of 10.3 mm. The distal end is lubricated with liquid paraffin or glycerin and the anesthetist inserts the probe through the patient’s mouth into the esophagus and moves it into the stomach. A surgeon with his hands detects it in the patient’s stomach and directs it through the bend of the duodenum into the jejunum. As soon as the distal end of the probe enters the initial part of the jejunum, an electric suction pump, for example, OP-01, is connected to the proximal / outer / end of the probe and aspirated contents from the intestinal lumen in a dilution mode of 20-60 cm water column. By adjusting the aspiration with the free operation of the electric suction pump, one section of the intestine after another, approximately 30-40 cm, is gradually pushed to the distal end of the probe and the contents of the entire small intestine are gradually aspirated to the boogin gate. As a result, the entire small intestine is freed from intestinal contents and strung on a probe. After that, lavage / washing of the lumen / small intestine is performed. For this, an electric pump is temporarily disconnected from the proximal part of the probe. Instead, a Janet syringe is connected to the probe and 300-400 ml of Ringer's solution or glucose-electrolyte solution is injected. A section of the small intestine filled with the injected solution is shaken gently, and then an electric suction pump is again attached to the probe and the washing liquid is aspirated. After that, 50-80 ml of a suspension of enterosorbent with an antibiotic / 15 g of enterosorbent enteros-gel or 15 g of enterosorbent SKN or another is injected into the washed area of the intestine through the same probe, diluted into 400-600 ml of glucose-electrolyte solution or Ringer's solution and added 1.0 g of an antibiotic, to which, according to the literature, anaerobes are most sensitive, for example, ampicillin /. Step by step, removing 40-50 cm of the small intestine from the distal end of the intubation probe, wash its lumen throughout and introduce the above enterosorbent and antibiotic into it. Then the intubation probe is removed from the digestive tract. Instead, through one of the nasal passages, a two-channel probe is inserted into the stomach: one of its channels is located in the lumen of the stomach for external decompression, the other channel is carried out into the initial section of the small intestine 30-50 cm below the duodenojunal junction. After that, the umbilical vein is recanalized and an umbilical catheter is inserted into it, for example, N 8 or N 10 / TU 25-1961.032-87 / and 2.0 ml of blood is taken from the portal vein with a sterile syringe for bacteriological examination / blood is introduced into the Blaurock medium and immediately sent to the baclaboratory.

 On the day of the operation and in the first 5-6 days after it, an oxygen-containing / oxygenated / saline solution, for example, Ringer's solution, is administered dropwise / 20 drops per 1 min / 2 times a day through the probe channel located in the lumen of the small intestine . In the intervals between these infusions 3 times a day, enterosorbent in 150 ml of Ringer's solution in the above dose is injected through the same channel of the probe with a Janet syringe. The outer part of the channel is then blocked for 30 minutes to prevent this solution from leaking out. The second channel of the probe serves to remove contents from the stomach and wash it with a solution of soda.

 Against the background of intrathecal administration of an oxygen-containing saline solution, intraportal reinfusion of autoblood oxygenated under extracorporeal conditions is performed daily once a day. For this / FIG. 1 / in the infusion system with a cannula 1 and a needle 2, a blood oxygenator 3 is connected in series, for example, a membrane dialyzer type DIP-02-02, a roller pump 4, for example, UAG-2-01, a 250 ml bottle 5 with a blood stabilizer, for example , glyugitsirom, to prevent its coagulation. A peripheral vein 6, for example, an ulnar vein, is punctured with a needle 2, a cannula 1 of the mounted infusion system is connected to it, and blood is collected from a vein at the rate of 2 ml / kg body weight into a vial 5 using a roller pump 4. Oxygenator 3 is not included during blood sampling. Then, the sampled blood in the vial 5 is mounted on a tripod, the needle 2 is removed from the peripheral vein 6, and the cannula 1 of the infusion system is connected / Fig. 2 / to umbilical catheter 7 for intraportal reinfusion. Using a roller pump 4, blood from the vial 5 is fed to oxygenator 3, through which gaseous oxygen begins to flow at a flow rate of 10 l / min for 1 hour of reinfusion. At the end of blood reinfusion, a weak heparin solution is introduced into the umbilical catheter 7 to prevent catheter thrombosis. Additionally, 100 ml of a preparation of a nitroimidazole derivative, for example, metranidazole or metragil, is administered dropwise 40 times per 1 hour 3 times a day / every 8 hours /. After 4-5 days after surgery, 2.0-2.5 ml of blood is taken from the portal system through a umbilical catheter 7 for bacteriological examination with a syringe in a patient under sterile conditions. With an improvement in the general condition of the patient, restoration of intestinal motility and a negative result of microscopy and blood culture from the portal system to anaerobic microorganisms / 5-6 days after surgery / the introduction of an oxygen-containing saline solution and enterosorbent through a naso-intestinal probe is stopped, the probe is removed from the digestive tract. Intraportal infusions of a nitroimidazole derivative and oxygenated autologous blood are also canceled. The umbilical vein catheter is stored for administration of glucose-electrolyte solutions, vitamins, blood substitutes and donated blood as necessary, and then removed with the observance of aseptic rules and measures to prevent bleeding from the recanalized umbilical vein.

 Example 1. B-noy X-in, 50 years old / b. N 230 / was admitted to the surgical department of BSMP N 1 in Rostov-on-Don with a diagnosis of acute gangrenous appendicitis, local peritonitis. Appendectomy, drainage of the right half of the abdominal cavity were urgently performed on the patient. The patient's condition has improved. However, by the fourth day after the operation, signs of intoxication and intestinal paresis began to increase, and cramping abdominal pains appeared. Diagnosed with early adhesive intestinal obstruction with the progression of peritonitis. In this regard, the patient underwent relaparatomy with dissection of adhesions, lavage of the abdominal cavity and removal of fibrinous deposits. Intubation of the entire small intestine with intra-intestinal lavage and the introduction of enterosorbent / enteros-gel / 15.0 g and 1.0 g of ampicillin in 400 ml of Ringer's solution were performed. Intubation naso-intestinal probe removed. Instead, through the nose into the stomach and further into the initial section of the jejunum, a two-channel probe was carried out, one channel of which is located in the lumen of the stomach for its external decompression. The umbilical vein was recanalized with the umbilical catheter inserted into it. 2.0 ml of blood was taken from the portal vein through an established catheter with a syringe for bacteriological examination. Microscopy of a blood smear / Fig. 3 / microorganisms 1, similar to bacteroids, were found. Baksev / Fig. 4 / under anaerobic conditions confirmed the presence of Bacteroides spp. 1.

 Immediately after the end of the operation and within the first five days after it, oxygenated Ringer's saline solution and enterosorbent enteros gel were introduced through the nasointestinal channel of the probe according to the described method. Reinfusion of oxygenated autologous blood taken from a peripheral vein at a rate of 2 ml / kg was carried out daily according to the proposed method, as well as intraportal infusion of the metragil preparation 100 ml 3 times a day. Gradually, the patient's condition improved. Significantly decreased intoxication, intestinal motility restored after 3 days. Bacteriological blood culture from the portal system, taken on the 4th day after the operation, was sterile. In this regard, from the sixth day after the operation, intraportal infusions of metragil and reinfusion of oxygenated autologous blood were discontinued, as well as the intraintestinal administration of oxygen-containing saline and enterosorbent was canceled. The patient was prescribed liquid food through the mouth. The patient's condition continued to improve. On the 8th day after the operation, aseptic rules were followed, the catheter was removed from the umbilical vein. Its lumen is clamped for 3 days for hemostasis by pulling up the ligature fixing it. There were no postoperative complications. The patient was discharged from the hospital.

 Example 2. B-noy A-in, 61 g / i.b. N 109 / was admitted to the surgical department of BSMP N 1, Rostov-on-Don with a diagnosis of preoperative widespread peritonitis, abscess of the abdominal cavity. Sick 5 days. In the anamnesis, about a month ago, hernia of the right inguinal region was plastic using a laparoscopic method. In connection with the signs of widespread peritonitis, the patient was urgently operated on. During the operation, stitching of the small intestine with tantalum clips at a distance of 110 cm from the bougain damper was detected with the formation of an interloop abscess with its subsequent breakthrough into the free peritoneal cavity. The patient underwent removal of purulent exudate with lavage of the abdominal cavity, removal of tantalum clips from the small intestine, suturing of the defect of the wall of the small intestine. Then, nasointestinal intubation of the small intestine was carried out with a lavage of its lumen and the introduction of enteric gel enterosorbent and the antibiotic ampiox by the described method. After that, the endotracheal tube was replaced with a thin two-channel nasogastrointestinal tube. An umbilical vein was recanalized with an umbilical catheter No. 8 inserted into it. 2.0 ml of blood was taken from the portal vein with a syringe, which was immediately sent for bacteriological examination. When smear microscopy / Fig. 5 / microorganisms 1 were found, similar to peptostreptococci. When bakseva in anaerobic conditions / Fig. 6 / Gram-positive non-clostridial anaerobes of peptostreptococcus 1 were found.

 At the end of the operation and during the first 6 days of the postoperative period, the oxygen-containing Ringer's saline solution, as well as the enterosorbent enteros-gel, were introduced dropwise through the nasointestinal channel of the probe according to the proposed method. In addition, intraportal reinfusion of autologous blood taken from a peripheral vein at a rate of 2 ml / kg was performed 1 time per day, and metragil was administered 3 times a day according to the description of the method. The patient's condition remained serious: the effects of endotoxemia persisted. The leukocyte intoxication index on the second day after surgery was 5.67. On the fourth day after surgery, intestinal motility was restored in the patient. The patient's condition has improved. The leukocyte intoxication index decreased to 2.12. On the 5th day after the operation, blood was again taken from the portal vein for bacteriological examination. Microscopic examination of the smear did not reveal any microorganisms; preliminary and final results of bacterial inoculation under anaerobic conditions confirmed the absence of anaerobic microorganisms in the portal blood. In this regard, on the 7th day after the operation, the nasogastrointestinal probe was removed from the digestive tract, reinfusion of intraportally oxygenated blood and intraportal administration of metragil were stopped. The umbilical vein catheter was stored for another 2 days for the introduction of protein preparations and blood substitutes, and then removed in compliance with aseptic rules and measures to prevent retrograde bleeding from the umbilical vein.

 However, by the 9th day after the operation, the infiltrate in the area of the operative wound began to be determined, upon opening of which a small amount of small intestinal contents was obtained. An aspiration-washing system was established in the area of the small intestinal fistula, which allowed it to be gradually closed. The patient was discharged from the hospital.

 The proposed method of treatment is tested on 6 patients. All of them recovered and were discharged from the hospital.

Compared with the prototype, the proposed method has the following advantages:
1) intraoperative nasointestinal intubation and lavage of the small intestine are carried out with the enteric administration of enterosorbent and antibiotic, which eliminates the reservoir of microbial aggression, removes toxic products from the intestinal lumen, and the remaining microorganisms and toxins are affected by the drug substance;
2) additionally, oxygenated saline solution and enterosorbent are introduced into the small intestine after surgery, which create unfavorable conditions for the development of microorganisms and adsorb toxins from the intestinal lumen and additionally saturate the blood flowing from the intestine with oxygen;
3) the intestinal administration of oxygenated saline solution promotes earlier restoration of peristalsis of the small intestine;
4) a drug substance acting on anaerobic microorganisms is additionally introduced intraportally;
5) blood for oxygenation and reinfusion is taken intraportally from the peripheral vein, which greatly simplifies the procedure for obtaining oxygenated blood.

Claims (1)

 A method of treating common peritonitis, including intraportal reinfusion of oxygenated blood, characterized in that the patients undergo a surgical operation, during which they remove the source of peritonitis, nasointestinal intubation and lavage of the entire small intestine, followed by intracutaneous administration of 16 g of enterosorbent and the antibiotic ampicillin at a dose of 1.0 g, replacement of the endotracheal probe with a thin two-channel probe, catheterization of the umbilical vein and the drainage tubes in the abdominal cavity, and in the postoperative period In the irradiation period, against the background of external decompression of the stomach, 400 ml of an oxygen-containing saline solution are administered intracutaneously 2 times a day through a probe at a rate of 20 drops in 1 min and 3 times a day, 15 g of enterosorbent in 150 ml of saline, and also once a day intraportal reinfusion of autologous blood taken from a peripheral vein at a rate of 2 ml / kg and oxygenated for 1 h of reinfusion in an oxygen generator at a flow rate of gaseous oxygen of 10 l per 1 min, and also 100 ml of metragil is administered intraperitoneally 3 times a day with at a rate of 40 drops in 1 min, treatment is carried out within 5-6 days after surgery and stopped to improve the patient's condition, restore intestinal motility and obtain a negative result of bacteriological blood tests from the portal vein for the presence of anaerobic microflora.

Images