RU2283095C1 - Method for preventing postischemic tissue shock in plastic ophthalmosurgery - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves applying solution, possessing gas-exchange function, for treating autotransplants. Perfluoran is used as the solution, possessing gas-exchange function preoxygenized by introduced 5 ml of oxygen per 5 ml of Perfluoran. Intraoperationally prepared bed for making autotransplantation and the autotransplant are treated twice with the solution. The autotransplant is immersed into the solution for 20 min before being transplanted. Superficial transplant irrigation with oxygenized Perfluoran continues when the operation is over in placing sutures. After having dressed the wound with immobilizing bandage, the latter is wetted with oxygenized Perfluoran twice a day during 5-7 days.

EFFECT: enhanced effectiveness of treatment; avoided anaerobic metabolism processes development.

Description

The method relates to medicine, in particular to reconstructive ophthalmoplasty and can be used for the prevention of postischemic tissue shock with free skin autoplasty, reconstruction with local rags on the leg, acute or round stem from potential donor zones.

Reconstructive operations in ophthalmoplasty are performed using free skin autografts from donor areas, with local rags on the stem from the temple, forehead, cheek with an acute or round stem (M.V. Zaykova / Plastic ophthalmosurgery. M .: Medicine. 1980, p.240 ) However, given the topographic and anatomical structure of the periorbital region and regional blood supply, the use of islet, atrialized flaps with the formation of a microvascular anastomosis is sharply limited and not always justified due to the sharp difference in the structure and color of the skin of the potential donor and recipient zones to maintain the principle of cosmeticity. Any ophthalmoplastic operation is associated with a high risk of tissue ischemia of the autograft in the acute postoperative period until the formation of its own microvasculature, which causes anaerobic metabolic processes in the autograft and has an inhibitory effect on the revitalization of the autograft with its subsequent partial or complete necrosis. In order to prevent necrotic changes in the autograft, a clear dressing regimen is prescribed, which stipulates energy-saving peace, the dynamism of the operated zone, hypothermia of the operated zone to increase the resistance of the autograft to hypoxia, and drug therapy that improves microcirculation of the autograft bed.

An analogue of the prototype of the proposed method is the use of ozonated distilled water during the operation, compresses with ozonated distilled water in the postoperative period (2-3 days), phonophoresis with ozonated oil - for 5-7 postoperative days (P.I. Ivasenko, V. P. Konev et al / Cosmetic surgery of the maxillofacial region. N. Novgorod. Publishing house of the Novosibirsk State Medical Academy, 2002, p. 96).

The disadvantages of the prototype are:

- insufficient oxygen intensity of the ozonized water molecule;

- the impossibility of reducing the degree of acidosis due to the lack of binding of the ozonated water molecule to the carbon dioxide molecule;

- the inability to improve the gas transport function of the red blood cell and mitochondria of tissues undergoing hypoxia, because ozonated water molecule cannot produce gas exchange;

- ozonated distilled water does not improve the rheology, blood flow in the microvasculature.

In recent years, in connection with the advent of the Perftoran gas transport blood substitute, the results of clinical observation of various methods of its application are described. Perftoran has a high oxygen consumption, gas exchange and membrane-stabilizing function. It is used in combustology - for the treatment of large burns of the skin, general surgery - for the treatment of postischemic conditions of the internal organs of the abdomen and resulting peritonitis, as well as for the protection of the myocardium during dry heart, in neurosurgery - for the treatment of ischemic brain disorders after traumatic brain injuries, in emergency conditions - for infusion-transfusion therapy of acute mass apparent blood loss, in transplantology - for anti-ischemic protection of donor organs, for example, a kidney when it is taken from asystolic donors and preservation of organs for transplantology (Perfluorocarbon compounds in medicine and biology. Proceedings of the XII International Conference. Pushchino, June 2003, p. .266).

The objective of the invention is the prevention of tissue ischemia and necrobiosis of autografts of the skin during ophthalmoplastic operations by prolonged local intraoperative and postoperative oxygenation of the autograft with oxygenated gas perforator "Perftoran".

The problem is solved in the following way. After thawing, Perftoran from the factory packaging is packaged in small doses of 5 ml in glass vials under sterile pharmaceutical conditions and sealed with a rubber stopper and metal run-in, then each bottle is enriched with oxygen in an amount of 5 ml, for example, by taking oxygen from an artificial lung ventilation apparatus (Mechanical ventilation) in a single syringe 5 ml. Oxygen is introduced into the bottle with liquid "Perftoran" at least 30 minutes before use.

An intraoperatively prepared bed for autologous transplantation is twice treated with the required amount of Perftoran oxygenated solution, depending on the bed area, and the prepared autograft is immersed in perfluoran solution for 20 minutes, when the operation is completed by fixing sutures on the edges of the autograft, then surface irrigation of the autograft to prevent perforation is continued drying it out.

In the postoperative period, immobilizing an autograft, the dressing is moistened with the necessary, depending on the area of the four-layer gauze, covered with a cellophane pad, the amount of Perftoran 2 times a day, morning and evening, for 5-7 days, i.e. the entire period of acute tissue hypoxia of the autograft.

The advantages of the proposed method:

- the degree of acidosis decreases when a skin autograft is cut out, caused by the intersection of blood vessels of its natural circulation, due to the active intake of carbon dioxide by perfluorane molecules having a small size and a large total surface;

- enrichment of the immobilized microcirculatory bed of the cut autograft with oxygen by maintaining the caliber of the vessels of the microcirculatory bed with its own backbone of non-deformable (unlike the red blood cell) Perftoran micromolecules carrying two, three oxygen molecules on their surface;

- preventing the development of anaerobic metabolic processes in the mitochondria of ischemic tissues of autografts, eliminating severe scarring or the transition to necrobiosis;

- reducing the degree of aseptic inflammatory reaction due to gas transport of oxygen from the surface of the perfluorane molecule through the cell membrane of the macrophage intracellularly with the formation of a vacuolated macrophage - perfluorophage;

- ensuring the physiological type of reparative regeneration of the autograft in the recipient bed due to the relief of pathological fibro- and cologenogenesis by perfluorophages;

- ensuring a minimum degree of ischemic edema due to the prevention of collapse of the venous link of arteriovenous anastomoses in the emerging microcirculatory bed between the autograft and the graft bed;

- prevention of microtrombination of the vessels of the recipient bed in the surgical and postoperative period due to the disaggregation and membrane-stabilizing properties of oxygenated Perftoran molecules.

Example 1

Patient V., 37 years old, was admitted to the hospital with DZ: congenital subtotal coloboma of the upper eyelid of the left eye. From the anamnesis she underwent plastic surgery three times by Filatovsky, a round stalk of the congenital coloboma of the nose wing on the left. According to the results of which, the reconstruction of the nose wing ended with the engraftment of a hypotrophic fragment of the graft, which differs sharply from a healthy nose wing in color, skin structure and elasticity, postoperative graft fibrosis significantly reduced its surface area and changed its shape. Patient V. underwent plastic surgery of a congenital subtotal coloboma of the upper eyelid with a rotary autograft on the leg from the temple and free plastic surgery of the inner surface of the formed upper eyelid mucosa from the lip. During the operation and in the postoperative period, the Perftoran gas transport blood substitute was used according to the proposed method along with observing all the principles of transplantology. In the early postoperative period, there were no signs of acute ischemia and hypoxia, which was characterized only by blanching of the proximal autograft without cyanosis. Swelling of the edges of the recipient bed was completely stopped on the 5-6th day due to adequate restoration of the venous outflow. On day 7, the autograft had vital signs of pink color, the absence of diastases and hyperproliferation of the contour scar, the absence of deformation or shortening of the “free” edge of the upper eyelid held by blepharography sutures. The sutures that fix the transplant to the edges of the recipient bed were removed on the 10th postoperative day. The patient was discharged from the hospital with blepharraphic sutures, providing further immobilization of the recreated upper eyelid. An independent replacement of immobilizing monocular bandage dressings once every 2 days with compresses of oxygenated Perftoran was recommended. Two months later, blepharoraphic sutures were removed. The pink autograft is practically no different from the periorbital tissues of the brow region and lower eyelid of the left eye. It retains the previous size of the area, there is no deformation of the free edge of the upper eyelid, which characterizes the complete microcirculation of the recreated upper eyelid. A weak motor function of the upper eyelid appeared due to the muscle fibers of the eyelid lifter in the cult of an underdeveloped upper eyelid. After 8 months, the patient underwent ptosis reconstruction of the upper eyelid due to the frontal muscle. With a patient's total observation period of 2 years, the normal functional and anatomical structure of the upper eyelid is retained, a slight lag of the upper eyelid blinking movements, compared with the right eye due to different neuromuscular transmission of blinking movements of the recreated and own upper eyelid.

Example 2

Patient K., 65 years old, was admitted to the hospital with DZ: recurrent basal cell carcinoma T3N0M0 of the lower eyelid, outer corner of the right eye, skin of the temple on the right. On examination, the invasive-destructive nature of the tumor process is determined. The patient underwent tumor excision surgery within healthy tissues with simultaneous defect plasty with a free skin autograft from the inner surface of the shoulder. Intraoperatively and in the postoperative period, prolonged oxygenation of the autograft was performed according to the proposed method against the background of the implementation of all the principles of transplantology. The free autograft ischemia was long - 5 days, expressed in blanching of the color, however, cyanosis, ischemic edema was not observed. By the 7 postoperative days, there were distinct signs of autograft revitalization over the entire surface area, edema in the edges and bottom of the graft bed decreased due to the resumption of the venous outflow of the microvasculature. On the 10th day, it became possible to partially remove the sutures due to the formed full-fledged tender scar. On the 12th day, the stitches fixing the autograft were removed, the patient was discharged from the hospital with stitches of temporary blepharography, which allows to continue the immobilization of the free edge of the lower eyelid in the course of further reorganization of scars. It is recommended to wear a monocular bandage for 1 month with wet compresses of oxygenated Perftoran 1 time per day. After 2 months at the control examination, the normal position of the reconstructed lower eyelid, external cantus and temple area was determined, with palpation, the tissues are elastic, there are no signs of fibrosis and collagenogenesis. The scar is tender, weakly contoured only due to pallor, however, the graft does not differ in color from the surrounding periorbital tissues. A physiological type of regeneration of a free skin autograft was ascertained, treatment completed.

Example 3

Patient N., 28 years old, was admitted to the hospital with DZ: post-burn scar of the skin of the upper eyelid, eyebrows, temple on the right, lagophthalmos, epithelial-endothelial dystrophy of the cornea of the right eye. On examination, an aggravating cause of the course of corneal dystrophy with the threat of perforation in conditions of an unclosed upper eyelid was revealed. A reconstructive plastic surgery of layer-by-layer incision of a widespread post-burn scar, cicatricial contractures of the upper eyelid with free plastic by a split dermal flap from the back of the shoulder was performed. Intraoperatively and in the postoperative period, prolonged oxygenation with the Perftoran gas transport blood substitute was used according to the proposed method against the background of transplantology principles. Split dermal flap of the upper eyelid, eyebrow, external cantus, temple for 3 days had signs of acute ischemia with cyanosis, signs of marginal necrobiosis. Against the background of ongoing immobilization of the eyelids and application of prolonged oxygenation by Perftoran, there was no edema in the recipient bed, microthrombosis of the microvasculature, or low neutrophil-macrophage cell response. Revitalization of the split dermal flap was traced from 5 postoperative days, color change to pink, reduction in the area of marginal necrobiosis. From day 7, active epithelization of the marginal necrotic areas of the split dermal autograft due to the dermal edges of the bed was noted. On day 10, the complete engraftment of the integumentary dermal autograft without reducing the surface area made it possible to remove the stitches fixing the autograft, against the background of the ongoing immobilization of the upper eyelid with blepharography sutures. The patient was recommended outpatient wearing a monocular bandage dressing for 1 month with wet compresses of oxygenated Perftoran once a day. After 1 month, upon examination, the complete engraftment of the split dermal autograft was determined, the motor activity of the upper eyelid was restored, which required the removal of blepharraphic sutures. After removing the seams of blepharoraphy, the excursion of the upper eyelid is fully defined, there is no closure of the eyelids (lagophthalmos). Examination of the cornea showed a decrease in the manifestations of epithelial-endothelial dystrophy and an increase in its transparency. It is recommended that instillation of dedistrophic eye drops up to 2 months after the postoperative period is performed during the day and according to the scheme and the Aktovegin eye jelly is inserted into the cleft at night, on top of the closed eyelids, continue the nightly immobilizing monocular bandage dressings with wet compresses on the autograft of the upper eyelid skin, external cantus temple with oxygenated "Perftoran." On examination, 2 months after the operation, complete engraftment of the split dermal autograft was observed, almost imperceptible contour scars of the implanted autograft were available only on a slit lamp (AL). On palpation, the autograft is elastic, there are no underlying tissue contractures. There is no lagophthalmus, there is no slowdown of the blinking movements of the right eye. The physiological type of regeneration was ascertained, and the deystrophic treatment of epithelial-endothelial dystrophy of the cornea was continued in the absence of the risk of its drying out (xerosis) and perforation.

Claims (1)

A method for the prevention of postischemic tissue shock in plastic ophthalmic surgery, including the use of a solution having a gas exchange function, for processing autografts, characterized in that a solution of gas exchange function using a solution of perftoran pre-oxygenated with 5 ml of oxygen per 5 ml of perftoran, which is treated twice intraoperatively prepared bed for autotransplantation and an autograft, immersing it before transplantation for 20 min in a solution of ox of perfused fluoride, moreover, at the end of the operation, while the fixation sutures are applied, the autograft is irrigated superficially with oxygenated perfluorane, and after the application of an immobilizing dressing, it is moistened with oxygenated perfluorane 2 times a day for 5-7 days.