RU2269345C1 - Method for treating intestinal deficiency in patients with acute abdominal surgical pathology - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should perform Novocain blockade presacrally before operation and not less than one time after operation. Solution for blockade is being a 200 ml 0.25%-novocaine solution supplemented with 1.0 g antibiotic and 40 mg low-molecular heparin. The method enables to improve motor-evacuatory intestinal function, conduct microbiocenosis correction of small intestine, decrease the risk of the development of enterogenic purulent-septic complications, improve microcirculation and hemostasiological profile in mesenteric vessels of small intestine and its wall.

EFFECT: higher efficiency of therapy.

1 ex, 3 tbl

Description

The invention relates to medicine, namely to methods for treating intestinal failure in patients with acute abdominal surgical pathology (acute complicated cholecystitis, acute destructive pancreatitis, acute complicated appendicitis, acute obstructive small bowel obstruction).

There is a method of treating intestinal failure in patients with acute abdominal surgical pathology (acute pancreatitis and acute peritonitis) (see Vishnevsky A.V., Vishnevsky A.A. Novocain blockade and oil-balsamic antiseptics as a special type of pathogenetic therapy. // Publ. Academy of Medical Sciences of the USSR. - Moscow. - 1952. - S.25-51), which consists in the implementation after operation paranephral novocaine blockade.

The disadvantage of this method is the low efficiency of treatment of patients using this method. The application of the known method is associated with the possibility of complications due to the fact that the blockade is performed based only on the qualifications and sensations of the surgeon, without proper control of damage to other organs. As a result of this, a needle injury to the parenchyma of the kidneys, colon, spleen or blood vessels: renal artery or inferior vena cava.

In addition, treatment is carried out once only after surgery, while preoperative prevention of intestinal insufficiency is excluded due to the fact that patients endure paranephric blockade, it is not possible to repeat it repeatedly during postoperative treatment.

The use of novocaine alone for blockade is limited solely by its ganglion-blocking effect. At the same time, there is a risk of purulent complications at the site of the blockade.

In the long-term period, patients who underwent paranephric blockade develop sclerosis of paranephral fatty tissue in 40-50% of cases;

For the most part, the administered novocaine remains imprisoned in the paranephral fatty tissue without properly affecting the mesentery of the small intestine and, therefore, the intestine itself;

The present invention more simply, reliably and effectively solves the problem of the treatment of intestinal failure in patients with acute abdominal surgical pathology.

The resulting technical result consists in increasing the effectiveness of treatment. The implementation of the proposed method of blockade presacral allows you to improve bowel function, including motor evacuation function, to correct the small intestine microbiocenosis, reduce the risk of enterogenic purulent-septic complications, improve microcirculation and hemostasis profile in the vessels of the mesentery of the small intestine and its wall, respectively, its oxygenation and metabolic processes in enterocytes.

The ability to repeatedly perform a blockade both before surgery and in the postoperative period allows to increase the effectiveness of treatment.

The implementation of the blockade with a multicomponent solution, including novocaine, an antibiotic and low molecular weight heparin, provides comprehensive protection of the blockade zone, has a bactericidal effect on the allochthonous microflora of the small intestine, provides an anticoagulant effect with a pronounced antithrombotic, and, what is very important, long-term therapeutic effect - 20 hours.

The proposed method of treatment is safe, simple and affordable for use by a surgeon of any skill.

The specified technical result is achieved by the fact that in the method of treating intestinal failure in patients with acute abdominal pathology, which consists in performing a multicomponent novocaine blockade after the operation, the blockade is performed presacrally additionally before the operation and after the operation at least once, and in the blockade solution to 200 ml A 0.25% solution of novocaine is added with 1.0 g of antibiotic and 40 mg of low molecular weight heparin.

A method for the treatment of intestinal failure in patients with acute abdominal pathology is as follows.

To prepare a solution for blockade under sterile conditions, 1.0 g of antibiotic and 40 mg of low molecular weight heparin are added to a vial of 200 ml - 0.25% novocaine solution. Cefobide or Fortum is used as an antibiotic, and clexane is used as a low molecular weight heparin.

The blockade is carried out preacrally before the operation and one or more times in the postoperative period, for which the second finger of the left hand is inserted into the rectum and groped for the coccyx (os coccyges). After double-treatment of the injection site with a 2% iodine alcohol solution, a 10 cm long needle is injected under the tip of the coccyx and 20 ml of the prepared blocking solution are injected with a syringe under the control of a finger, which excludes injury to the rectum. Novocaine exfoliates the posterior rectal wall, which is well felt by the surgeon’s finger. The needle is carried out towards the sacral cape to a depth of 8-9 cm and the remaining dose of novocaine is administered. By removing the needle, the injection site is treated with iodine.

After blockade is completed, novocaine spreads up the retroperitoneal tissue upward, washes plexus sacralis and plexus hypogastricus, and envelops the root of the mesentery of the small intestine.

The method has proven to be highly effective, cheap, easy to perform, eliminating the dangers and complications that occur in the above prototype.

After blockades, an improvement in intestinal motor-evacuation function was noted in all patients, which was confirmed by electrogastroenterography and gastrointestinal ultrasonography (GIT). Microbiological examination of the contents of the small intestine results in normalization of the species spectrum of bacterial populations. The frequency of purulent-septic complications (sepsis, peritonitis, abscesses of the abdominal cavity, suppuration of the postoperative wound, phlebitis, pneumonia, pleurisy) is reduced by 20-35%. In the group of patients with blockages, there were no thrombohemorrhagic complications (generalization of DIC, pulmonary artery thrombosis and limb veins, bleeding - nasal, uterine, hemorrhoidal).

Table 1, 2, 3 show the indicators characterizing the effectiveness of the treatment of intestinal failure in patients with acute abdominal surgical pathology by the proposed method.

Clinical example

As an illustration, we give an example. Patient D., 38 years old, medical history N15341, was admitted to the MUZ KB 25.10.10.02. 20 ⁴⁵ with complaints of acute pain in the epigastrium and hypochondria, which had a "girdle" character, bloating, nausea, indomitable vomiting, which does not bring relief. The patient considers himself within 20 hours, when severe pain in the epigastrium and hypochondria, radiating to the left rib-vertebral angle, suddenly suddenly first appeared for the first time, bloating. The pain did not subside after the administration of analgesics and antispasmodics. The last 4 hours began to increase weakness, excessive sweating.

Objectively: a serious condition. The skin and sclera of the eyes are slightly jaundiced. HELL 120/80 mm Hg, pulse 114 in 1 min. The tongue is dry, the back is covered with a white-brown coating. The abdomen is swollen, palpation is sharply painful in the epigastrium, where the infiltrate is not clearly defined. In the right hypochondrium, a compacted, painful liver protruding 2 cm from under the costal arch is palpated. Symptoms of Ortner, Murphy and Georgievsky-Mussi are negative. A positive symptom of Mayo-Robson and Kera. Peristalsis is single, in the lower sections "splash noise" is determined. Symptoms of peritoneal irritation are negative. The total indicator of liver function was 24.9 units, kidneys - 23.2 units, which corresponds to hepatorenal syndrome of the 1st art. gravity.

In terms of hemostasis, activation of blood coagulation by type I stage of DIC was observed: recalcification time was 158 s, APTT was 35 s. Platelet aggregation was 52.1%. Thrombin time reduced to 15 s. Fibrinogen was increased to 6.43 g / L. The concentration of AT-III was reduced to 72.6%. FA in the patient was reduced and amounted to 26.4 minutes

Ultrasound of the hepatoduodenopancreal zone: Pancreatic necrosis, fluid in the stuffing bag and abdominal cavity, more on the right flank. Biliary hypertension.

Ultrasound of the gastrointestinal tract: diameter of the small intestine - 38 mm, wall thickness - 4.5 mm. Folding of the mucous membrane is pronounced, peristalsis in some areas is pendulum-like. Intraluminal deposition of fluid is noted in the small intestine, a symptom of a “stagnant” stomach is positive. Fluid in the abdomen. Conclusion: the patient has a syndrome of intestinal failure.

Conclusion of electrogastroenterography: a pronounced decrease in the total power of the electrical signal to 3.5 μV due to a decrease in the relative electrical activity of each gastrointestinal tract by 2–3 times. Duodeno-gastric and gastro-colic reflexes were practically not determined. The comparison coefficient, which determines the propulsive ability of the gastrointestinal tract, is also reduced by a factor of 3.5 at the level of transition of the duodenum 12 into the jejunum and ileum into the colon. The rhythm of the pulsations of all sections of the gastrointestinal tract is reduced by 3-4 times and is completely unbalanced relative to each other.

Clinical diagnosis: Sterile pancreatic necrosis. Omentobursitis. Enzymatic peritonitis. Intestinal failure. Obstructive jaundice. Hepatorenal syndrome of the 1st Art. gravity.

Considering clinical and laboratory data, enterographic and sonographic changes in the gastrointestinal tract, indicating intestinal insufficiency, presacral multicomponent novocaine blockade is included in the standard preoperative preparation (200 ml - 0.25% novocaine solution + 1.0 g fortum and 40 mg clexane).

When examining the patient after 4 hours, there was a decrease in bloating due to excessive discharge of gases, pathological noises disappeared, and weakened peristalsis appeared.

During control electrogastroenterography, a significant improvement in all indicators was determined. So the total power of the electrical signal increased to 5.2 μV, and the relative electrical activity of all sections of the gastrointestinal tract by 1-1.5 times. Duodeno-gastric and gastro-colic reflexes began to be determined. The propulsive ability of the gastrointestinal tract increased by 1.5-2 times. The rhythm of impulsations of all sections of the gastrointestinal tract increased by 1-2 times.

Ultrasound of the gastrointestinal tract was determined: the diameter of the small intestine was 29 mm, the wall thickness was 4.0 mm. The folding of the mucous membrane remained pronounced, weakened peristalsis appeared, and the pendulum was not determined. The amount of intraluminal fluid deposition decreased, the symptom of a “stagnant” stomach was not determined.

From hemostasis, significant positive changes were noted. Markers of stage I of the DIC syndrome ceased to be registered. So the recalcification time increased to 178 seconds, APTV - up to 41 seconds. Platelet aggregation decreased to 23.7%. Thrombin time increased to 32 seconds. Fibrinogen decreased to 4.08 g / l. AT-III increased to 84.3%. FA in the patient increased and amounted to 16.6 ± 1.1 min.

The total indicator of liver function after 6 hours in hospital increased to 27.2 units, kidneys - 26.5 units.

Nevertheless, despite an 8-hour intensive therapy of the underlying disease, the patient retained a clinical-sonographic picture of sterile pancreatic necrosis, omentobursitis, and biliary hypertension. The prognostic criterion for the severity of acute pancreatitis on the Ranson scale corresponded to 4 points. The patient was operated on for urgent reasons.

Under endotracheal anesthesia, the patient was examined through the gastro-colon ligament through the pancreas, where a local hemorrhagic pancreatic necrosis was diagnosed in the area of the pancreatic head. The small intestine is swollen up to 32-34 mm, hyperemic, the wall is thickened. The mesentery of the small intestine is moderately edematous. Peristalsis is weakened, on the wall of the intestine a slight plaque of easily removable fibrin. Remediation and drainage of the omental bursa, abdominal cavity were performed, cholecystostomy was applied. The round ligament of the liver and the inguinal lymph node on the right are drained for subsequent drug injections.

Postoperative diagnosis: Sterile pancreatic necrosis. Omentobursitis. Enzymatic peritonitis. Intestinal failure. Obstructive jaundice. Hepatorenal syndrome of the 1st Art.

In the postoperative period, on the 1st and 2nd day, presacral multicomponent novocaine blockades with the same prescription of drugs were performed.

Already on the 2nd day of the postoperative period, the patient's abdominal distension disappeared, a distinct peristalsis appeared, and the gases began to independently discharge.

When electrogastroenterography performed on the 2nd day after the operation, a significant improvement in all indicators was determined. So the total power of the electrical signal increased to 7.8 μV. The relative electrical activity of the stomach and duodenum came to normal. The duodeno-gastric and gastro-colic reflexes were clearly defined. The propulsive ability of the gastrointestinal tract was reduced only due to the large intestine. The rhythm of the impulses of all sections of the gastrointestinal tract relative to each other was restored.

Ultrasound of the gastrointestinal tract was determined: the diameter of the small intestine - 25 mm, the wall thickness - 3.8 mm. Folding of the mucous membrane is not expressed, peristalsis is distinct. There is no intraluminal deposition of fluid; the symptom of a “stagnant” stomach is negative.

On the part of hemostasis, normalization of all indicators was noted. Recalcification time increased to 194 seconds, APTV - up to 54 s. Platelet aggregation decreased to 18%. Thrombin time increased to 34 seconds. Fibrinogen decreased to 3.66 g / l. AT-III remained unchanged at 84%. FA in the patient increased and amounted to 12 ± 1.0 min.

The patient was transferred from intensive care for 3 days, the state of moderate severity, the ictericity of the skin and sclera of the eyes completely disappeared, intestinal motility was restored, there was an independent chair. On day 5, hepatorenal syndrome ceased to be recorded. The hemostasis profile returned to normal. Gallbladder drainage removed at 14 days. Wound healing per prima. The patient was discharged in satisfactory condition for 16 days from the moment of admission to the hospital.

Table 1.
The effect of multicomponent novocaine presacral blockade on coagulation and anticoagulation in patients with acute abdominal surgical pathology complicated by intestinal failure (n ₁ - without blockade; n ₂ - with blockade) Indicators Qty
n ₁ -142
n ₂ -104 Before surgery After operation 1-2 days 3-4 days 5-6 days Recalcification time, sec with blockade 216 ± 8 * 186 ± 12 * 218 ± 22 * 204 ± 12 * without blockade 145 ± 7 128 ± 6 112 ± 10 176 ± 14 Activated partial thromboplastin time, sec with blockade 52.8 ± 2.9 * 50.6 ± 4 * 54.3 ± 6 * 56.4 ± 4 without blockade 44.6 ± 3 32.5 ± 3 34.5 ± 4 46.5 ± 3 Prothrombin index,% with blockade 84.4 ± 3 82.6 ± 2.3 83.4 ± 1.8 83.2 ± 2.4 without blockade 92.6 ± 4 88.5 ± 2.9 82.2 ± 2 81.2 ± 2 Thrombin time, sec with blockade 34.6 ± 1.4 * 27.2 ± 2 * 32.3 ± 2 * 30.6 ± 2 * without blockade 22.3 ± 1.2 20.9 ± 2 21.5 ± 3 26.7 ± 3 Fibrinogen
g / l with blockade 4.6 ± 0.2 * 5.1 ± 0.1 * 3.6 ± 0.2 * 2.5 ± 0.2 * without blockade 5.8 ± 0.4 6.6 ± 0.5 6.2 ± 0.1 5.9 ± 0.2 Antithrombin - 10% with blockade 82.4 ± 4.1 * 70.4 ± 3 * 75.2 ± 3 * 78.3 ± 2 * without blockade 65.8 ± 12.1 57.4 ± 2 58.2 ± 1 61.3 ± 2 Spontaneous platelet aggregation,% with blockade 22.6 ± 1.8 * 36.3 ± 4 * 24.7 ± 2 * 16.6 ± 2 * without blockade 46.4 ± 2.8 58.6 ± 3 76.5 ± 5 48.4 ± 3 Fibrinolytic blood activity, min with blockade 12 ± 2 * 14 ± 1 * 12 ± 2 * 13 ± 1 * without blockade 20 ± 2 26 ± 2 18 ± 1.8 16 ± 1,5 Note - * - shows the degree of significant differences between groups of patients with blockade and without blockade;

Table 2.
The effect of a presacral multicomponent novocaine blockade on the sonographic picture of the gastrointestinal tract in patients with acute abdominal surgical pathology complicated by intestinal failure (with blockade - 62; without blockade - 44) Sonographic signs Before surgery After operation 1-2 days 3-4 days 5-6 days with blockade without blockade with blockade without blockade with blockade without blockade with blockade without blockade The diameter of the small intestine, mm 21.5 ± 1.2 28.4 ± 1.3 24.6 ± 1.1 32.5 ± 1.0 23.7 ± 0.9 30.7 ± 1.2 22.1 ± 1.5 26.3 ± 1.2 Wall thickness mm 3.5 ± 0.3 4,5 ± 0,2 3.7 ± 0.2 5.1 ± 0.2 3.8 ± 0.2 5.2 ± 0.2 3.6 ± 0.1 4.4 ± 0.2 Folding mucus. shell:
- not expressed
- expressed not expressed expressed not expressed expressed not expressed expressed not expressed not expressed Peristalsis
- norm
- weakened
- pendulum norm weakened weakened pendulum or missing weakened pendulum or missing norm weakened - absent Interqualification liquid deposition: no there is no there is no there is no no - no
- there is Symptom "congestive" stomach: no there is no there is no there is no no - no
- there is

Table 3
The effect of presacral multicomponent novocaine blockade on the amplitude of gastrointestinal biopotentials in patients with acute abdominal surgical pathology complicated by intestinal failure (with blockade - 62; without blockade - 44) Options GIT Department Before surgery After operation 1-2 days 3-4 days 5-6 days SIEC (μV) with blockade 8.85 ± 1.4 * 5.36 ± 0.7 * 6.19 ± 1.1 * 7.94 ± 0.9 * SIEC (μV) without blockade 7.63 ± 1.3 3.53 ± 0.4 3.87 ± 0.8 4.88 ± 0.5 CJSC (μV) with blockade stomach
12 p.m.
skinny
ileum.
thick 2.15 ± 0.2 *
0.38 ± 0.04 *
0.42 ± 0.05 *
0.94 ± 0.08 *
4.96 ± 0.3 * 1.54 ± 0.2 *
0.29 ± 0.03 *
0.28 ± 0.03 *
0.66 ± 0.07 *
2.59 ± 0.2 * 1.71 ± 0.2 *
0.32 ± 0.04 *
0.36 ± 0.03 *
0.72 ± 0.08 *
3.08 ± 0.2 * 1.96 ± 0.2 *
0.34 ± 0.03 *
0.37 ± 0.02 *
0.78 ± 0.05 *
4.49 ± 0.2 * EAO (μV) without blockade stomach
12 p.m.
skinny
ileum.
thick 1.85 ± 0.3
0.18 ± 0.02
0.22 ± 0.03
0.84 ± 0.06
4.54 ± 0.4 1.04 ± 0.2
0.09 ± 0.01
0.13 ± 0.02
0.39 ± 0.03
1.88 ± 0.2 1.09 ± 0.1
0.10 ± 0.02
0.14 ± 0.02
0.42 ± 0.04
2.12 ± 0.1 1.28 ± 0.2
0.15 ± 0.02
0.19 ± 0.01
0.53 ± 0.03
2.73 ± 0.2 CS (μV) with blockade stomach
12 p.m.
skinny
ileum. 5.65 ± 0.2 *
0.90 ± 0.1 *
0.44 ± 0.02 *
0.18 ± 0.3 * 5.32 ± 0.1 *
1.03 ± 0.01 *
0.42 ± 0.01 *
0.25 ± 0.01 * 5.34 ± 0.1 *
0.88 ± 0.01 *
0.50 ± 0.01 *
0.23 ± 0.01 * 5.76 ± 0.2 *
0.91 ± 0.02 *
0.47 ± 0.02 *
0.17 ± 0.02 * CS (μV) without blockade stomach
12 p.m.
skinny
ileum. 10.2 ± 0.3
0.81 ± 0.1
0.26 ± 0.04
0.18 ± 0.2 11.5 ± 0.3
0.69 ± 0.07
0.33 ± 0.04
0.20 ± 0.02 10.9 ± 0.4
0.71 ± 0.06
0.33 ± 0.03
0.19 ± 0.02 8.53 ± 0.3
0.78 ± 0.05
0.35 ± 0.03
0.19 ± 0.02 KR (μV) with blockade stomach
12 p.m.
skinny
ileum.
thick - 3.57 ± 0.6 *
0.92 ± 0.1 *
1.22 ± 0.2 *
2.17 ± 0.3 *
7.99 ± 0.5 * 1.25 ± 0.1 *
0.30 ± 0.04 *
0.41 ± 0.06 *
0.81 ± 0.09 *
2.36 ± 0.2 * 1.89 ± 0.2 *
0.54 ± 0.08 *
0.72 ± 0.1 *
1.23 ± 0.1 *
3.92 ± 0.2 * 3.24 ± 0.3 *
0.76 ± 0.09 *
1.12 ± 0.1 *
1.96 ± 0.2 *
7.16 ± 0.4 * KR (μV) without blockade stomach
12 p.m.
skinny
ileum.
thick 3.26 ± 0.6
0.87 ± 0.1
1.09 ± 0.2
1.99 ± 0.3
6.84 ± 0.5 1.18 ± 0.1
0.32 ± 0.04
0.39 ± 0.06
0.77 ± 0.09
2.44 ± 0.2 1.24 ± 0.2
0.35 ± 0.08
0.43 ± 0.1
0.92 ± 0.1
2.56 ± 0.2 2.02 ± 0.3
0.52 ± 0.09
0.61 ± 0.1
1.08 ± 0.2
3.80 ± 0.4 СМЕС - total power of the electric signal;
OEA - relative electrical activity
КС - comparison coefficient;
KR - rhythm coefficient
Note - * - shows the degree of significant differences between groups of patients with and without blockades;

Claims (1)

A method for the treatment of intestinal insufficiency in patients with acute abdominal surgical pathology: acute complicated cholecystitis, acute destructive pancreatitis, acute complicated appendicitis, acute obstructive small bowel obstruction, which consists in performing post-nocaine blockade, characterized in that the blockade is performed preacral and not less than before once after surgery, and in a solution for blockade - to 200 ml - 0.25% solution of novocaine, add 1.0 g of antibiotic and 40 mg of low molecular weight molecular weight heparin.