RU2296570C2 - Method for treating suppurant residual hepatic cavities after echinococcectomy - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: after echinococcectomy it is important to treat residual hepatic cavities with the ozonized 0.9%-NaCl solution, moreover, one should apply finely divided suspension of this solution at ozone concentration being 5 mg/l, at particles size being 0.5-10 mcm. The innovation provides increased active surface of solution's action and, as a result, efficient penetration of antiseptic preparation into the folds of residual cavity without traumatizing the walls of fibrous capsule.

EFFECT: higher efficiency of terapy.

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Description

The invention relates to medicine, namely to surgery, and can be used in the treatment of suppurative residual cavities of the liver, as well as in the prevention of infectious and inflammatory complications of the surgical treatment of liver echinococcosis.

Echinococcosis of the liver is a serious parasitic disease; its surgical treatment with traditional methods is accompanied by frequent infectious and inflammatory complications (27%). (A.Z. Vafin, E.V. Levchenko, A.N. Aidemirov. Prediction and prevention of infectious and inflammatory postoperative complications in the surgery of liver echinococcosis. Problems of echinococcosis. Materials of the international scientific-practical conference. Makhachkala, 2000, p.32- 33). One of the main reasons for the high percentage of complications of the surgical treatment of liver echinococcosis is the insufficient effectiveness of the antibacterial drugs used against the background of the wide spread of antibiotic-resistant microflora. In this regard, there is a need to search for new, more effective and pathogenetically substantiated methods of complex action on the causative agents of surgical infections in the residual cavity of the liver after a semi-closed echinococcectomy.

According to the literature, there are a number of different methods for antiseptic treatment of fibrous (residual) cavities of the liver after echinococcectomy. In a generalized form, they can be classified as follows: the use of chemical, physical and biological factors in the fight against infectious and inflammatory complications. This is the use of 2% formalin solution; 96% ethanol solution; 5% solution of iodine; 30% solution of sodium thiosulfate; 1% solution of dioxidine; 0.05% chlorhexidine; 0.1% furagin; laser irradiation; ultrasonic cavitation; steam heat treatment; cryodestruction (M.E. Nichitailo et al. Surgical treatment of liver echinococcosis // Annals of surgical hepatology, 2001, T.6, No. 1, pp. 40-41. Use of a carbon dioxide laser, Ordabekov S.O. Surgical treatment of an echinococcal cyst using high-energy carbon laser. // Surgery, 1991, No. 11). In order to prevent purulent-septic complications of the surgical treatment of liver echinococcosis, plasma technologies were applied - plasma treatment of the fibrous capsule, when powerful ultraviolet radiation is produced simultaneously with high-temperature plasma in an inert gas medium, ozone is formed from oxygen in the air in the exposure zone, a combination of these factors has a pronounced antiseptic impact. (A.P. Aidemirov. Echinococcectomy from the liver using plasma technology // Surgery, 2000, No. 8). The use of locally "antiseptic sponge with gentamicin", a drug that was made on the basis of gelatinous substance (P.N. Zubarev, S.A. Ivanov, I.G. Ignatovich. New methods of surgical treatment of echinococcal liver cysts // Herald of Surgery, 2001 , No. 6). The use of various biological factors is also known (V.K.Gostishchev, A.V. Strelyaeva, N.V. Chebyshev, etc. The biological approach to the surgical treatment of liver echinococcosis // Annals of surgery, 1998, No. 6, p. 45-50) .

However, in our opinion, the use of 2% solution of furatsilin with 0.05% chlorhexidine, 1% dioxidine and proteolytic enzymes continues to remain the most traditional and most widely used at present time means of preventing and combating infectious and inflammatory complications of the surgical treatment of liver echinococcosis. (trypsin, chymotrypsin, etc.).

The above analogues have the following disadvantages.

For the purpose of antiseptic treatment in case of purulent-septic complications from the residual cavity of the liver, the most commonly used chemicals are: 2% r-solution of furatsilin, 1% r-solution of dioxidine (K.K. Kurbanberdyev, N.Kh. Komekov, A.P. Pashykov et al. Percutaneous transhepatic puncture treatment of a suppurating residual cavity of the liver under the control of ultrasound imaging and computed tomography. Problems of echinococcosis. Materials of the international scientific and practical conference. Makhachkala, 2000, pp. 74-75). Elimination of suppurative residual cavities after echinococcectomy from the liver (F.A. Ilkhamov, A.I. Ikramov. Problems of echinococcosis. Materials of the international scientific and practical conference. Makhachkala, 2000, p. 59-60).

All the above methods are accompanied by the use of highly effective agents that have undeniable side effects of hepatotoxicity on the liver parenchyma itself. In most cases, the need for antiseptic treatment of the fibrous capsule arises mainly when there is a complication from the parasitic cyst - its suppuration, i.e. in the third phase of life (M.Yu. Gilevich), or in the presence of late complications of surgical treatment of liver echinococcosis - with suppuration of the residual cavity. It is known that it is in the III phase of helminth life and during suppuration of the residual cavity that the most pronounced changes in the pericystic zone develop, periportal chronic hepatitis with fibrotic interlobular stroma, with reversible small focal changes (AM Shakhnazarov, M.A. Khamidov, Kh.A. Shakhnazarova, Kh.A. Khamidova. Morphological and histochemical changes in the liver with echinococcosis depending on the biological state of the parasite. Problems of echinococcosis. Materials of international scientific and practical Conference oh. Makhachkala, 2000, s.139-140). As can be seen from the above, the use of drugs and active antiseptic factors, which have pronounced hepatotoxic effects, that are extremely undesirable in order to aggravate the developing dystrophic, metabolic disorders in the liver parenchyma - dysregenerative, cirrhotic processes during this period, for the treatment of the fibrous capsule of the liver.

Prototype Characterization

Closest to our method is the method proposed by Y. A.Parhisenko, A.A. Glukhov, V.V.Novlinsky, I.P. Moshurov, used to treat liver abscesses. (Diagnosis and treatment of liver abscesses. // Surgery, 2000, No. 8, p. 35-38).

Prototype description

The prototype method consists in the following: in order to treat liver abscesses in the postoperative period after the establishment of a multichannel washing system, a programmed hydro-pressure washing of the residual cavity with ozonated solutions is performed. The duration of hydropressive ozone exposure is 4-7 minutes. The average duration of treatment is 4.7 days. Before and after treatment, the results of bacteriological analysis were studied.

Prototype criticism

For the purpose of the most pronounced antiseptic effect, the use of hydropressive technologies was used, i.e., washing the residual cavity with high-pressure ozonated solutions.

The use of high-pressure hydropressive treatment of the residual cavity can contribute to trauma to the walls of the fibrous capsule, the opening of bile fistulas, bile leakage, the development of cholangitis, bleeding into the fibrous cavity, and also adversely affect the reduction of the residual cavity.

The purpose of the proposed invention as a method is to develop a method for antiseptic treatment of the residual cavity after echinococcectomy of the liver, which has a pronounced antimicrobial effect and the least traumatic and hepatotoxic effect.

SUMMARY OF THE INVENTION

The essence of the invention lies in the fact that a method for the treatment of suppurative residual cavities of the liver after an echinococcectomy using ozonized 0.9% NaCl solution in an amount of 200.0 ml, in an ozone concentration of 5 mg / l, in a finely divided phase is proposed.

With suppuration of the residual cavity of the liver after a semi-closed echinococcectomy, the residual cavity is treated with an ozonated solution: 0.9% NaCl. Ozone due to its high oxidizing properties has a bactericidal effect. As a result of the oxidation of proteins and lipids, the destruction of the cytoplasmic membranes of microorganisms occurs when they are exposed to ozone (E.A. Aptasarov, S.A. Zhamalov, A.K. Alimzhanov. Ozone therapy for surgical infection. In collection: Actual issues of surgical infection. Semipalatinsk. 1991, p.16-17).

Ozonation of saline is achieved by bubbling 200.0 ml for 15 minutes with an ozone-oxygen mixture at a concentration of 5000 μg / L. Ozonation was carried out using the apparatus ((AOT-N-01-Arz-01/1) Medozons VM, manufactured by Arzamassky Instrument-Making Plant OJSC; certificate of conformity No. POCC.RV. (ME 34B 00214). The concentration of ozone in saline is 5 mg / L. The ozone concentration in a 0.9% NaCl solution was measured immediately after bubbling on the ozone concentration meter “Non-selective photometer NF-254/1”, manufactured by ZAO NPP Cyclone-Pribor. To increase the effect obtained after washing the residual cavity with 200.0 ml ozonized physiological saline at a concentration of 5 mg / l, we additionally processed the fibrous capsule with a finely dispersed suspension of ozonized 0.9% NaCl, with particle sizes of 0.5-10 μm. The use of ozonized physiological solution in the finely dispersed phase contributes to an approximately 200-fold increase in the active surface of the resulting antiseptic solution, as well as the effective penetration of the antiseptic into the sweets and pockets of the residual cavity, which always take place, which is almost impossible using traditional washing methods.

A fine suspension of ozonized 0.9% NaCl was obtained using a special installation, which consists of an ultrasonic inhaler IUP-01 M, designed to create fine fine aerosols with particle sizes of 0.5-10 microns, into which 50.0 ml of physiological saline and the ozone-oxygen mixture is supplied in a concentration of 5000 μg / l from the apparatus ((AOT-N-01-Arz-01/1) Medozons VM ". At the output of the installation, a fine suspension of ozonized physiological solution is obtained, which is connected to the drainage tube from the residual cavity of the liver through a PVC pipe through an adapter.

The first stage was the washing of the residual cavity through a drainage tube with an ozonized solution of 0.9% NaCl 150.0 ml, at a concentration of 5 mg / l, then the drainage tube was connected through a special adapter to the unit to obtain a fine suspension and the fibrous capsule was processed for 15 minutes fine suspension of ozonized physiological solution. In parallel with the local use of ozonized physiological saline, a course of infusion therapy was carried out by intravenous drip of an ozonized 0.9% NaCl solution of 200.0 ml at a concentration of 3 mg / l, once a day. The course of treatment is 9-11 days.

Prior to and at the end of the course of treatment, the sown flora separated from the residual cavities was monitored. In the results of bacteriological analysis, before application of ozonized physiological saline by species, it is possible to note the seeded flora: staphylococcus (38.5%), Pseudomonas aeruginosa in the form of monoculture and in associations (26%), pseudomonas aeregenosae (13%), kiebsiella pneumoniae (12, 5%), streptococci (4.5%), E. coli (4%), hemophilic bacillus (1.5%).

Further, to study the effect of ozonized physiological saline on the walls of the fibrous capsule, histological studies were carried out, where it was noted: activation of the macrophage reaction, increased proliferation of fibroblasts, growth of granulation tissue, increased phagocytosis of bacteria and necrotic detritus by macrophages. In the analysis of crops separated from the residual cavities, against the background of the use of ozonized physiological saline, an increase in the sensitivity of the flora to antibiotics was noted. The hepatotoxic effect of ozonized physiological saline at a concentration of 5 mg / l, used to treat the fibrous capsule, was not observed. After the course of treatment, the crops of the discharge and washings from the residual cavities of bacterial growth were not given.

An example of a specific implementation of the method.

The method proposed as an invention was applied with the aim of antiseptic treatment of suppurating residual cavities of the liver to 17 patients at the Department of General Surgery of the Dagestan State Medical Academy, on the basis of the Republican Hepatoscopy Center. The course of treatment averaged 9.7 k / d.

Example: Patient Ildarov M.M., 31 years old, was admitted to hospital 8/12/04 with a direct diagnosis: Condition after semi-closed echinococcectomy of the right lobe of the liver, postechinococcectomy syndrome, suppuration of the residual cavity of the right lobe of the liver. Upon admission, the patient complains of an increase in body temperature to 37.8 degrees Celsius, constant dull moderate pain in the right hypochondrium, decreased appetite, weakness. Anamnesis morbi: 5/10/04 half-closed echinococcectomy of the right lobe of the liver was performed. Was discharged with a drainage tube under dynamic observation. I was on outpatient treatment, received a wash of the residual cavity with 2% r-rum of furatsilin 100.0 ml, 1% r-rum of dioxidine 20.0 ml, once a day, every other day. On drainage per day, up to 50.0 ml of dense discharge, greenish in color. Separated from the residual cavity sent for bacteriological examination. Sowing gave rise to flora - kiebsiella pneumoniae. On ultrasound: the liver is 16.5 cm, the contours are uneven, the parenchyma is diffusely heterogeneous, hyperechoic, in the right lobe in the projection of segment VII an oval fluid formation with a thick to 5 mm loose wall, with a heterogeneous “dense” internal structure, up to 8.8 in size is determined × 8.5 cm in diameter.

From the day of admission, the patient began daily washing of the residual cavity with ozonized 0.9% NaCl 150.0 ml, in the concentration of ozone in physiological saline 5 mg / L. After washing the residual cavity, the fibrous capsule was treated with a fine suspension of ozonized physiological saline. Local treatment was combined with intravenous drip infusion of ozonized 0.9% solution of NaCl 200.0 ml, at a concentration of 3 mg / l, once a day. On the fourth day after the start of the course of treatment, body temperature returned to normal and appetite improved. On the tenth day, an ultrasound examination was performed: the liver was 16 cm, the contour was uneven, the parenchyma with diffusely heterogeneous changes, hyperechoic, in the right lobe in the projection of segment VII, a hypoechoic formation with dimensions 2.2 × 1.8 cm was determined, with uneven fuzzy contours, a drainage tube in cavity formation. There is no discharge for drainage on the tenth day. The washout from the residual cavity was sent for bacteriological examination. Under the control of the endoscope, a biopsy was taken from the wall of the fibrous capsule for histological examination. Drain pipe removed. The patient in satisfactory condition was discharged home for 11 days. The result of a bacteriological study of flushing from the residual cavity - the inoculation of bacterial growth did not give.

Utility of invention

The proposed method allows for the antiseptic treatment of the residual cavity of the liver by the method with the highest antibacterial activity and the least trauma and toxicity to the liver parenchyma.

The invention uses features that allow us to solve the goal, namely, to develop a method for antiseptic treatment of the residual cavity after echinococcectomy, which has a pronounced antimicrobial effect and the least traumatic and hepatotoxic effect.

The used concentrations of ozone in physiological saline (5 mg / l) do not have a toxic effect on the liver parenchyma, but, on the contrary, contribute to a more favorable course of the infectious and inflammatory process both due to the high bactericidal effect of ozone on the microflora in the residual cavity and due to the protective effect ozone on the liver. When using ozonized physiological saline, the permeability of hepatocyte membranes increases, the glycogenolytic pathway of energy supply is stimulated, the state of the microvasculature of the liver improves, the activity of catalase is increased, the microsomal system of the liver is activated, the detoxification function is increased, the effects of tissue hypoxia in the pericystic zone are eliminated.

The use of ozonized physiological solution in the finely dispersed phase during the programmed treatment of suppurating residual cavities of the liver promotes effective and non-traumatic sanitation of the fibrous capsule, preventing the opening of bile fistulas, bile leakage, the development of cholangitis, and bleeding into the fibrous cavity. Fine suspension of ozonized saline does not affect the timing of the reduction of the residual cavity, but rather contributes to its more rapid involution due to the stimulation of reparative processes in the liver. Studying hepatocytes at the subcellular level one day after ozonation, hypervesiculation and hypertrophy of the endoplasmic reticulum cisterns, microparticle hyperplasia (peroxisomes) and mitochondria, glycogen neoplasms in resorbable fat inclusions, signs of increased functional activity of the nuclei were found.

The proposed method for the treatment of suppurative residual cavities of the liver after a semi-closed echinococcectomy allows to weaken or eliminate the antibiotic therapy used, which is of no small importance for the functional “unloading” of the liver, since there are already functional disorders in the presence of an intraorgan inflammatory process. In the study of sensitivity to antibiotics, isolated cultures from crops from residual cavities in most cases were characterized by multiresistance. On the third or fourth day of treatment with ozonized physiological solution, antibioticograms showed a significant increase in the sensitivity of microorganisms to antibiotics.

Features distinguishing from the prototype:

1. Apply ozonized saline;

2. Use the concentration of ozone in 200 ml of 0.9% NaCl solution - 5 mg / L.

3. Ozonized saline solution is used in a finely dispersed phase, with particle sizes of 0.5-10 microns, which contributes to a 200-fold increase in the active surface of the resulting antiseptic solution, as well as the effective penetration of the antiseptic into the folds and pockets of the residual cavity, which is almost impossible when using traditional washing techniques.

4. The use of fine suspension prevents trauma to the walls of the fibrous capsule.

Information taken into account

Yu.A. Parkhisenko, A.A. Glukhov, V.V. Novomlinsky, I.P. Moshurov. Diagnosis and treatment of liver abscesses. // Surgery, 2000, No. 8, p. 35-38. - prototype.

Claims (1)

A method for the treatment of suppurative residual cavities of the liver after an echinococcectomy, comprising treating the residual cavities of the liver with an ozonized 0.9% NaCl solution, characterized in that they use a fine suspension of this solution with an ozone concentration of 5 mg / l, with a particle size of 0.5-10 μm .