RU2368389C1 - Preventive treatment and treatment method of suppurative complications at acute destructive pancreatitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine and namely gastroenterology and surgery and deals with preventive treatment and treatment of suppurative complications at acute destructive pancreatitis. For that purpose against complex conservative drug therapy there performed is sanation diagnostic abdominoscopy, and polyethylene cannula is installed in the round hepatic ligament. 70-80 ml of leukosuspension is obtained from the patient's blood on the 1st, 3rd, and 5th days of the post-operation period by means of plasmapheresis, which is then incubated with Ronkoleukin in quantity of 500000 units. Leukosuspension incubation lasts for 60 minutes at the temperature of 37°C. Then leukosuspension with Ronkoleukin is injected through the above cannula to the round hepatic ligament.

EFFECT: method provides effective treatment of acute destructive pancreatitis and namely owing to increase of local immunity, and as the result, quick normalisation of clinic laboratory values.

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Description

The invention relates to medicine, namely to the fields of surgery and resuscitation, and can be used in the treatment of patients with acute destructive pancreatitis, confirmed intraoperatively.

A known method of immunotherapy for acute destructive pancreatitis with the drug "Roncoleukin", in a single dose with a body weight of <70 kg, 250,000 units are introduced, and with a body weight> 70 kg - 500,000 units of roncoleukin. The drug is administered slowly intravenously (20 drops per minute), and a single dose of roncoleukin is diluted in 450 ml of physiological saline, to which 5-10 ml of a 10% albumin solution are previously added. In the postoperative period, in the presence of SIRS syndrome, a minimum of 1 infusion is indicated, and in the case of CARS type, 2-3 infusions with an interval of 48-72 hours are indicated (see Sinchenko G.I., Tolstoy A.D., Panov V.P., Peregudov SI, Dvoinov VG Purulent necrotic pancreatitis and parapancreatitis. Educational-methodical manual. - SPb .: "ELBI-SPb", 2005. 51-54 p.).

The disadvantage of this method is the creation of a predominantly systemic immune response, but insufficient formation of a specific immune response in the upper floor of the abdominal cavity with systemic administration, which leads in most cases to infection of foci of pancreatic necrosis, and therefore to an increase in mortality.

The objective of the present invention is to increase the effectiveness of the method for the prevention of purulent complications in acute destructive pancreatitis and reduce the number of deaths in patients with this pathology by increasing the specific immune response in the upper floor of the abdominal cavity.

The problem is solved by the prevention and treatment of purulent complications in acute destructive pancreatitis, including complex conservative drug therapy of acute pancreatitis. When performing diagnostic, sanitation laparoscopy, a polyethylene catheter is inserted into the round ligament of the liver, through which additionally 70-80 ml are added on the 1st, 3rd, 5th day of the postoperative period of Roncoleukin 500,000 U, incubated at 37 ° C for 60 min with the obtained plasmapheresis leukemia suspension of the patient.

The novelty of the invention:

- When performing diagnostic, debridement laparoscopy, a polyethylene catheter is placed in a round ligament of the liver. Combining these medical procedures allows you to avoid additional surgical operations.

- Through the installed catheter, an additional 500,000 IU of roncoleukin is introduced, incubated at a temperature of 37 ° C for 60 min with plasmapheresis of the patient’s leukeweed suspension in an amount of 70-80 ml in 1, 3, 5 days of the postoperative period. This allows you to quickly create a higher concentration in the zone of interest, which increases the effectiveness of the drug. The drug is administered directly to the gate of the liver, where the lymph nodes are located, responsible for the formation of the immune response in case of pancreatic inflammation. In addition, the introduction of roncoleukin stimulates the production of intrinsic interleukin-2, which significantly increases local immunity.

For the first time in surgical practice, locoregional immunotherapy was used to treat and prevent purulent complications in acute destructive pancreatitis.

The combination of essential features can significantly increase local immunity, which significantly improves the prevention of purulent complications in acute destructive pancreatitis.

The method is as follows.

When performing diagnostic, debridement operations from the mini-access, using the “mini-assistant” apparatus or laparoscopy, after confirming the diagnosis, acute destructive pancreatitis, 1-2 cm in the midline of the abdomen and 1 cm to the right, inject the needle perpendicular to the skin, needle injected into the depths, piercing the aponeurosis of the broad muscles of the abdomen to the sensation of failure, insert the needle into the round ligament of the liver, controlling the position of the needle visually. A conductor is inserted through the lumen of the needle and a polyethylene catheter is inserted. The drug is administered for 60 minutes in the amount of 70-80 ml in 1, 3, 5 days of the postoperative period.

The drug is prepared as follows.

450-500 ml of the patient’s blood is drawn into the Gemakon system. Blood is centrifuged at 3700 rpm for 20 minutes. Then, plasma is removed from the system so that the leuko-platelet layer remains above the red blood cells. Next, 200 ml of 0.9% NaCl physiological saline solution is added to the cell mass, after which centrifugation is performed in the same mode and the supernatant is removed, leaving the same leuko-platelet layer. In the resulting cell mass add 500,000 units of roncoleukin and 200 ml of physical. NaCl solution of 0.9%, incubated for one hour at a temperature of 37 ° C. Then we centrifuge in the same mode and distribute the supernatant of 70-80 ml into sterile bottles, and utilize the remaining cell mass or return it to the patient.

Subsequently, the preparation obtained is administered at 70-80 ml on the 1st, 3rd and 5th day of the postoperative period through a polyethylene catheter installed in a round liver ligament.

Clinical example.

Male, 41 years old (medical history 5516). He was admitted to the emergency surgical department of the MLPU GKB 1, Novokuznetsk on 12/18/07 with a diagnosis of Acute pancreatitis, severe course. Pancreatic necrosis?

Severe condition, severe pain abdominal syndrome in all departments, requiring the introduction of narcotic analgesics (despite a series of conservative measures, including perirenal procaine blockade), tachycardia up to 110 beats. per minute, leukocytosis up to 14 billion / l, amylasemia up to 4000 units / l (N up to 220 units / l).

On the ARACN II scale - 10 points.

From the moment of admission, a comprehensive conservative therapy of acute pancreatitis was carried out: infusion, detoxification, antibacterial and antisecretory therapy, sandostatin. Despite all the therapy, the patient's condition remained serious without positive dynamics.

1st day by ultrasound of the abdominal cavity: the contours of the pancreas are uneven, fuzzy, the echogenicity of the gland is reduced, the structure is heterogeneous with foci of discharge, the presence of free fluid in the stuffing bag, in the pelvis and interloop.

12/19/07 the operation was performed: laparoscopic debridement, drainage of the abdominal cavity, catheterization of the round ligament of the liver. The intraoperative diagnosis was established: Fatty pancreatic necrosis. Total defeat. Omentobursitis. Enzymatic peritonitis.

12/20/07 a probe for enteral nutrition was established, early nutritional support.

According to CT scan of the abdominal cavity from 12/20/07: diffuse enlargement of the pancreas with fuzzy contours, the structure is moderately heterogeneous with a density of up to 20-30 units N. No distinct focal changes were found.

Treatment with the proposed method was started on 12/20/07. There were 3 procedures for incubating fractionated blood of a patient with roncoleukin and introducing the resulting mixture through a catheter into a round liver ligament according to the proposed scheme three times.

After completion of therapy by the proposed method, the patient's condition improved, temperature, appetite normalized, the patient became active, and abdominal pain did not bother with the abolition of pain relief. According to laboratory tests: normalization of leukoformula, ESR, regression of hyperamylasemia. 12/28/07 the patient was transferred from the intensive care unit to the surgical department. Subsequently, the patient adequately responded to all therapy.

According to CT scan of the abdominal cavity from 12.29.07: the pancreas is uniformly enlarged, of a homogeneous structure, moderate accumulation of contrast up to 60-70 units. The contours of the gland are even and clear. In the stuffing bag, soft-tissue infiltrate is 34 × 56 mm. In retro-pancreatic fiber, a similar infiltrate is up to 24 mm thick, density is 6 + 15 U.

01/06/08 the patient was discharged in satisfactory condition.

Thus, the method allowed to prevent the development of purulent complications and death.

Claims (1)

A method for the prevention and treatment of purulent complications in acute destructive pancreatitis, including complex conservative drug therapy of acute pancreatitis, characterized in that when performing diagnostic, sanation laparoscopy, a polyethylene catheter is inserted into the round ligament of the liver, through which 70-80 ml are additionally introduced into 1, On the 3rd, 5th day of the postoperative period, roncoleukin 500,000 units incubated at a temperature of 37 ° C for 60 min with the patient's plasmapheresis suspension.