RU2199121C2 - Method for diagnosing purulent necrotic complications in the cases of pancreatic necrosis - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves determining concentration of one of end POL-malonic dialdehyde products in blood serum of pancreatic necrosis patient at the tenth day after surgical intervention. The value being greater than 4,64±0,21 nmole/ml, suppuration process is to be predicted in pancreas zone. EFFECT: simplified diagnosis method. 1 dwg, 1 tbl

Description

 The invention relates to medicine, namely to surgery, to the section for assessing the severity of the destructive process in pancreatic necrosis, and can be used to diagnose purulent-necrotic complications in this disease.

 It is known that acute destructive pancreatitis (ODP) is one of the urgent problems of urgent surgery. Despite a large number of studies on the diagnosis, prognosis and treatment of NDP, mortality in this pathology remains very high.

 The prognosis for ARP is always serious and is largely due to the prevalence of purulent-necrotic process in the pancreatic tissue (pancreas), parapancreatic space, which indicates the need for early diagnosis of purulent complications and, accordingly, the intensification of therapeutic measures for pancreatic necrosis.

 In the literature studied, the work on the diagnosis of purulent complications is based on the use of ultrasound imaging, computed tomography (V. S. Saveliev, V. A. Kubyshkin, G. B. Kazantsev, Surgery, 1988, 9, pp. 72-79; V. S. . Savelyev, V.A. Kubyshkin, Surgery, 1993, 6, p. 22-28, S.A. Shulyak, diss. Candidate of medical sciences, Chelyabinsk, 1997), prognostic severity index (Sh.N. Karimov, Herald of Surgery, 1993, 3-4, pp. 46-47), determining the level of leukocyte intoxication index, parameter time, concentration of molecular weight toxins (B.K. Shurkalin, V.A. Gorsky, Surgery, 1988, 9, p. 83-87).

 As a prototype, we took a method for diagnosing purulent-necrotic complications described by B.K. Shurkalin, V.A. Gorsky (Surgery, 1988, 9, p. 83-87). The essence of the method is to determine the level of medium-weight molecules (MSM) in the blood serum (N.I. Gabrielyan, 1981) in patients with pancreatic necrosis. The occurrence of purulent complications leads to an increase in endogenous intoxication, which is accompanied by a significant increase in the level of MSM (up to 0.72 ± 0.04 conventional units) compared with the first and second periods (0.46 ± 0.01 and 0.48 ± 0 , 02 srvc units respectively).

 The above method is based on the analysis of a marker of endogenous intoxication syndrome, which indirectly reflects the development of purulent complications, and its magnitude depends on other causes (microcirculation disorders, insufficiency of parenchymal organs, etc.).

 The novelty of the proposal is to determine the concentration of one of the end products of LPO - malondialdehyde (MDA) in the blood serum of a patient with pancreatic necrosis on the 10th day of the postoperative period.

 A significant difference is that on the 10th day of the postoperative period, the patient determines the level of malondialdehyde in the blood serum, and with indicators above 4.64 ± 0.21 nmol / ml, the development of a purulent process in the pancreas is diagnosed.

 Violation of the mechanisms of regulation of free radical oxidation is the main cause of damage to biological membranes under extreme conditions (hypoxia, stress), leading to the development of a chain reaction that can cause oxidation of various substrates and thereby damage proteins and lipids of biomembranes, inactivate enzymes, change the structure of macromolecules, integrity cells and intracellular organelles, leading to the development of tissue destruction in the focus of inflammation. The important role of lipid peroxidation processes in the pathogenesis of pancreatic necrosis is known. In addition, it was proved that the activation of a neutrophilic pool of leukocytes during a purulent process is accompanied by the progression of free radical oxidation. (Yu. A.Vladimirov, A.I. Archakov. Lipid peroxidation in biological membranes. M.: Science, - 1972. - 525 p., Yu. A.Vladimirov // Vestn. Ros. AMN. - 1998. - 7. - p. 43-51).

The methodology of the proposed method is that on the 10th day of the postoperative period, a patient was sampled with 10.0 ml of peripheral venous blood, which was centrifuged to obtain serum. The concentration of MDA was determined by the reaction with thiobarbituric acid (TBA) according to the method of R. Mc. Knight, FE Hunter (1966). For this, 1.0 ml of a 10% trichloroacetic acid solution, 1.0 ml of a 0.5% TBA solution, 0.5 ml of a 0.1 N HCl solution were added to 0.5 ml of the studied blood serum. The mixture was stirred and placed in a water bath at 60 ^{° C.} for 30 minutes. Proteins were precipitated by centrifugation for 15 minutes at 3000 rpm. Then the mixture was cooled to room temperature and the optical density of the supernatant was determined at a wavelength of 532 nm on an SF-46 spectrophotometer. The control sample instead of serum contained 0.5 ml of distilled water.

где С - концентрация МДА;
Е - разность оптической плотности контрольной и опытной пробы;
Р - разведение сыворотки крови;

- молярная экстинция МДА, которая при длине волны 532 нм равна 1,56•10⁵ м^-1 см (R. Sinnhuber, 1958), 1 см³ - емкость кюветы в спектрофотометре СФ-46. Результаты выражали в нмоль/мл сыворотки крови.The calculation of the content of MDA in serum was carried out according to the formula:

where C is the concentration of MDA;
E is the difference in optical density of the control and experimental samples;
P - dilution of blood serum;

- molar extinction MDA, which at a wavelength of 532 nm is 1.56 • 10 ⁵ m ^-1 cm (R. Sinnhuber, 1958), 1 cm ³ is the cell capacity in the SF-46 spectrophotometer. The results were expressed in nmol / ml of blood serum.

 A study was made of the MDA level before surgery and in the dynamics of the postoperative period (1, 3, 5, 7, 10, 14 days) in 92 patients with pancreatic necrosis, which were retrospectively divided into two groups: I - patients without purulent complications (36 people); II - patients who developed purulent complications in the pancreas area (56 people, 22 of them died in a period of more than 14 days after surgery). All patients underwent standard surgical intervention (laparotomy, pancreatic abdomination, marsupialization and drainage of the omental bursa, drainage of extrahepatic bile ducts). In the postoperative period, all patients received the same multicomponent intensive therapy, including active infusion-transfusion therapy, the use of protease inhibitors, cytostatics, antibiotics, extracorporeal detoxification methods.

 The data obtained are presented in the table and in the drawing.

 An analysis of the results indicates a significant increase in the level of MDA above the norm in all cases, and up to 7 days the concentration of this indicator is almost the same in both groups. However, on the 10th day after the operation, the content of MDA in the II group was significantly higher than in the I group, with an even more pronounced tendency on the 14th day.

 In the postoperative period, a comprehensive laboratory monitoring, in addition to the generally accepted methods for examining patients with PDP, included the determination of the leukocyte intoxication index (LII) (Ya.Ya. Kalf-Kalif, 1941), (MSM). A strong direct correlation between the level of MDA and these markers of endotoxemia was revealed.

 Clinical example 1.

 Patient O., 39 years old. Diagnosis: acute total hemorrhagic pancreatic necrosis, diffuse serous-hemorrhagic peritonitis. Operated on an emergency basis upon admission after preoperative preparation. The operation was performed - laparotomy, cholecystostomy, pancreatic abdominization, marsupialization, omental bursa drainage, rehabilitation, abdominal drainage. The level of MDA in serum on the 10th day is 7.33 nmol / ml. Relaparotomy on day 13 - abscessing of the stuffing box, parapancreatic phlegmon.

 Clinical example 2.

 Patient S., 46 years old. Diagnosis: acute total hemorrhagic pancreatic necrosis, diffuse serous-hemorrhagic peritonitis. Operated on an emergency basis upon admission after preoperative preparation. The operation was performed - laparotomy, cholecystostomy, pancreatic abdominization, marsupialization, omental bursa drainage, rehabilitation, abdominal drainage. The level of MDA in serum on the 10th day of 4.23 nmol / ml. There were no purulent complications in the postoperative period.

 Thus, the proposed method is effective, simple, affordable, allows you to accurately diagnose the addition of purulent complications in pancreatic necrosis, which accelerates the re-surgical intervention in this group of patients.

Claims (1)

 A method for the diagnosis of purulent-necrotic complications in pancreatic necrosis by biochemical studies, characterized in that on the 10th day after the operation, the concentration of malondialdehyde in the blood serum of the patient is determined and, if it is above 4.64 ± 0.21 nmol / ml, the development of purulent complications is diagnosed.

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