RU2394574C1 - Method of correcting ischemic liver affection - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to experimental surgery, and can be used for correction of ischemic liver affection. For this purpose 2 hours before operation 5% mexicor solution in dose 10 mg/kg of weight is intravenously jet injected to experimental animal. After that one hour before operation actovegin in dose 10 mg/kg of weight is intravenously jet injected. During operation ischemia is created by temporal extracorporal portacaval shunting. In post-operation period each of preparations is introduced 1 time a day during 7 days. Interval between their introduction is 12 hours: mexicor is introduced at 8 o'clock, actovegin - at 20 o'clock.

EFFECT: method ensures reduction of reperfusion disorders, elongation of safe terms of liver exsanguination up to 30 minutes and prevention of massive hemorrhage in operations on this organ.

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Description

The invention relates to medicine, namely to experimental surgery, and can be used when performing a liver resection.

There is a method for the correction of ischemic damage to the liver under conditions of its bleeding, the essence of which is the intravenous administration of 5 mg of a 1% solution of serotonin-adipinate to the experimental animal (dog) before and within 30 minutes after compressing the hepatoduodenal ligament in order to prevent the development of smooth muscle microcirculatory insufficiency channel of the liver (patent No. 2134576 from 08.20.1999) - analogue, it is also a prototype.

The above method contributes to the elimination of smooth muscle insufficiency of the microvasculature, thereby improving endogenous vasomotor.

The disadvantage of this method is that the authors limited themselves only to the use of a drug that regulates microcirculation. The mechanisms of development of ischemic liver damage are more complex, therefore, the impact on any one link in the formation of the pathological chain is not enough. With liver resections, the problem of hemostasis is one of the most important, since such a formidable complication as massive bleeding often leads to death. The most optimal and effective way to prevent this is by clamping the hepatoduodenal ligament (Zatolokin V.D. Anatomical lobar resections of the liver. Moscow, 1974; Zatolokin V.D., Perkov A.A. et al. New technologies in surgical hepatology. C- Petersburg, 1995). However, it is associated with destabilization of hemodynamics, the development of portal hypertension, hypoxia and ischemia of the liver, which, in turn, with 20 minutes (or more) exposure can lead to irreversible morphofunctional changes in the liver up to necrotic changes in hepatocytes (Antopolskaya E.V. Correction of ischemic lesion of the liver during its resection in conditions of exsanguination. Kursk, 1988). To prevent the deposition of blood in the portal vein system and the correction of hemodynamic disorders, the application of temporary extracorporeal portocaval shunts of various modifications (Zatolokin VD, Perkov AA et al. Actual issues of surgical gastroenterology. Kursk, 1994), which nevertheless does not interfere ischemic lesion of the hepatic parenchyma (Davydov MN On hemostasis with anatomical lobar resections of the liver. Kharkov, 1986). In order to correct it, various medications are used (dibunol, sodium oxybutyrate, cytochrome C, etc.) (Antopolskaya E.V. Correction of ischemic damage to the liver when it is resected under conditions of bleeding. Kursk, 1988; Zatolokin V.D. et al. New technologies in surgical hepatology. St. Petersburg, 1995; Ivanov SV On the prevention of bleeding during liver resection. Moscow, 1981), but their existing arsenal is very limited and many currently known methods for using antioxidants do not always warn and stop the structure functional disorders arising from ischemia of the liver. Given the foregoing, we consider it relevant and promising to use complex methods for the correction of liver ischemia (Zatolokin V.D., Perkov A.A. et al. Actual issues of surgical gastroenterology. Kursk, 1998).

The objective of the invention is the prevention and treatment of ischemia and hemodynamic changes that occur during resection of the liver in the conditions of its temporary shutdown from the blood circulation, relief of reperfusion disorders, prolongation of safe periods of bleeding of the liver in order to prevent massive bleeding during operations on this organ.

The problem is achieved using the proposed method, which consists in the fact that 2 hours before the operation, the animal (dog) is injected intravenously with Mexicor in the form of a 5% solution at a dose of 10 mg / kg weight; 1 hour before the operation, Actovegin is also injected intravenously in the form of a solution for injection at a dose of 10 mg / kg body weight. Then intraoperatively, before squeezing the hepatoduodenal ligament to unload the portal system, a temporary extracorporeal portocaval shunt is applied, which is removed after the blockade of the hepatoduodenal ligament is removed. In the postoperative period, each of the drugs is administered 1 time per day for 7 days. The interval between their administrations is 12 hours: Mexico is administered at 8 ⁰⁰ , Actovegin at 20 ⁰⁰ .

The invention is illustrated by drawings:

Figure 1 - histological structure of the liver of a dog N 3 30 minutes after clamping the hepatoduodenal ligament. Parenchyma necrosis. Without correction of ischemia. Coloring: hematoxylin and eosin. Microphoto 400 ^x .

Figure 2 - histological structure of the liver of a dog N 2 30 minutes after clamping the hepatoduodenal ligament in combination with the introduction of Mexico and Actovegin with the imposition of a temporary extracorporeal portocaval shunt. Saving structure. Coloring: hematoxylin and eosin. Microphoto 500 ^x .

Figure 3 - histological structure of the liver of a dog N 8 30 minutes after clamping the hepatoduodenal ligament in combination with the introduction of Mexicor and Actovegin with the application of a temporary extracorporeal portocaval shunt. Saving structure. Coloring: hematoxylin and eosin. Microphoto 400 ^x .

The method is as follows.

The experimental animal (dog) 2 hours before the operation is injected intravenously with Mexico in the form of a 5% solution at a dose of 10 mg / kg; 1 hour before surgery, Actovegin is also injected intravenously in the form of a solution for injection at a dose of 10 mg / kg body weight. After that, laparotomy is performed under intravenous hexenal anesthesia (0.03 g / kg). One of the loops of the small intestine (the initial section) is removed into the wound and one of the small intestinal veins of large diameter, lying near the duodenum-small intestine ligament, is distinguished, as having the largest diameter and denser wall (vein of the portal pool). Three ligatures are brought under the selected vein: proximal, middle, distal. The peripheral ligature is used to fix the silicone cannula (then it ligates the distal end of the vein). The lumen of the vein is opened between the two master ligatures in an oblique direction and one end of the silicone tube shunt is inserted into it, which is fixed with a middle ligature on the vein. The other end of the shunt is inserted into a vein on the anterior extremity of the animal (the superior vena cava system), for which a 1.5–2 cm long skin incision is made on the inner surface of the animal’s extremities, the vein is carefully dissected stupidly and sharply, three ligatures are brought under it (similar to ligatures in the small intestine vein). Before work, the shunt is filled with 5% glucose solution with heparin to reduce the likelihood of thrombosis of the small intestine vein and the shunt device. Heparin is administered at a rate of 120 U / kg animal weight. Then the hepatoduodenal ligament is infiltrated with 10 ml of a 0.25% novocaine solution and clamped with an elastic intestinal clamp for 30 minutes. After the hepatoduodenal ligament is released, the superimposed shunt is removed, the cannulated veins are ligated with proximal and distal ligatures. Wounds on the anterior abdominal wall and anterior limb of an animal are sutured tightly.

The study was performed on 12 outbred dogs. Before the start of the experiment, all animals had blood taken from the femoral vein for biochemical studies (control). 9 animals were injected with Mexicor and Actovegin according to the scheme we proposed, applying a temporary extracorporeal portocaval shunt and clamping the hepatoduodenal ligament for 30 minutes. 3 experimental dogs made up the group in which they only clamped the hepatoduodenal ligament for 30 minutes without administering drugs or applying a shunt. 1 dog from the group without correction of ischemia and 3 dogs from the group of complex treatment of ischemia were withdrawn from the experiment after 1 day of the experiment. They performed a blood sampling for biochemical studies and a morphological study of liver tissue. Pieces of material 1 × 0.5 × 0.5 cm in size were taken from the liver for morphological studies. Their processing was carried out according to standard methods with fixation in 10% neutral formalin, dehydration in ascending concentration of alcohols, and the formation of paraffin blocks with subsequent production of histotopographic sections 5-7 μm thick on a sled microtome. The media were stained with hematoxylin and eosin. The drugs were studied at a light-optical level with an increase of 280 ^x -500 ^x . The 6 remaining experimental animals were observed up to 7 days inclusive, they took blood for biochemical studies. The determination of the level of transaminases - the activity of aspartate and alanine notransferases in blood serum - was carried out according to the Reitman-Frenkel method, lactate dehydrogenase - according to Savel, residual nitrogen - according to the Rappoport-Eichhorn method, bilirubin concentration - according to the Endrashik method. In addition, levels of alkaline phosphatase, total protein, prothrombin index, and fibrinogen were determined. Indicators of cytolysis syndrome were lactate dehydrogenase, the activity of alanine and aspartate aminotransferases. Indicators of cholestasis syndrome are alkaline phosphatase activity, bilirubin concentration. Indicators of hepatosuppressive syndrome were the concentration of total protein, fibrinogen content, and prothrombin index. An indicator of hemodynamic changes was blood pressure, measured by the intravascular method by cannulation of the femoral artery.

Examples of specific performance.

Example No. 1. Dog No. 3. Operation 11/14/2008. Under intravenous hexenal anesthesia (0.03 g / kg), a mid-median laparotomy was performed. The hepatoduodenal ligament is infiltrated with 10 ml of a 0.25% solution of novocaine. It was clamped with an elastic intestinal clamp for 30 minutes. After the release of the hepatoduodenal ligament, the abdominal cavity is sutured in layers tightly. The animal was withdrawn from the experiment after 1 day.

This example illustrates figure 1, which shows the histostructure of the liver of dog No. 3 30 minutes after clamping the hepatoduodenal ligament. Coloring: hematoxylin and eosin. Microphoto 400 ^x . Violation of the architectonics of the hepatic parenchyma is combined with discompletion of hepatocyte beams. Sine waves are expanded. The hepatocyte cytoplasm is swollen. In all parts of the lobules, pronounced granular and vacuolar degeneration of hepatocytes in combination with lipoidosis, and extensive areas of coagulation parenchyma necrosis are observed. Between the hepatic lobules and beams, the appearance of a large number of leukocytes, a sharp decrease in the number of SHIK-positive substances in hepatocytes up to their absence, is noted.

Example N 2. Dog N2. Operation November 17, 2008. 2 hours before the operation, the animal was injected intravenously with Mexico in the form of a 5% solution at a dose of 10 mg / kg; 1 hour before the operation, Actovegin was also injected intravenously in the form of a solution for injection at a dose of 10 mg / kg of body weight. Under intravenous hexenal anesthesia (0.03 g / kg), a laparotomy was performed. To unload the portal system imposed a temporary extracorporeal portocaval shunt. Then hepatoduodenal ligament was infiltrated with 10 ml of 0.25% novocaine solution and pinched with an elastic intestinal clamp for 30 minutes. After elimination of the temporary blockade of the hepatoduodenal ligament, the temporary extracorporeal portocaval shunt was removed. The abdominal cavity was sutured in layers tightly. In the postoperative period, each of the drugs was administered 1 time per day. The interval between their administration is 12 hours: mexicor administered 8 ⁰⁰ aktovegin - 20 ^00. The animal was withdrawn from the experiment after 1 day.

This example illustrates figure 2, which shows the histological structure of the dog’s liver N 2 30 minutes after clamping the hepatoduodenal ligament in combination with the introduction of Mexico and Actovegin with the application of a temporary extracorporeal portocaval shunt. Coloring: hematoxylin and eosin. Microphoto 500 ^x . The structure of the hepatic parenchyma is not broken, the beam architectonics is preserved. Hepatocytes with clear boundaries, cytoplasm homogeneous, fine-grained, nuclei isomorphic with preserved structure. The central veins and sinusoids are moderately full-blooded, mainly in centrolobular areas.

Example No. 3. Dog No. 8. Operation 20.11.2008, 2 hours before the operation, the animal was injected intravenously with Mexico in the form of a 5% solution at a dose of 10 mg / kg body weight; 1 hour before the operation, Actovegin was also injected intravenously in the form of a solution for injection at a dose of 10 mg / kg of body weight. Under intravenous hexenal anesthesia (0.03 g / kg), a laparotomy was performed. To unload the portal system imposed a temporary extracorporeal portocaval shunt. Then hepatoduodenal ligament was infiltrated with 10 ml of 0.25% novocaine solution and pinched with an elastic intestinal clamp for 30 minutes. After elimination of the temporary blockade of the hepatoduodenal ligament, the temporary extracorporeal portocaval shunt was removed. The abdominal cavity was sutured in layers tightly. In the postoperative period, each of the drugs was administered 1 time per day. The interval between their administration is 12 hours: mexicor administered 8 ⁰⁰ aktovegin - 20 ^00. The animal was withdrawn from the experiment after 1 day.

This example illustrates figure 3, which shows the histological structure of the liver of a dog N 8 30 minutes after clamping the hepatoduodenal ligament in combination with the introduction of Mexico and Actovegin with the application of a temporary extracorporeal portocaval shunt. Coloring: hematoxylin and eosin. Microphoto 400 ^x . Histoarchitectonics of the hepatic parenchyma with preserved beam structure. Hepatocytes are isomorphic, their structure is intact, the nuclei are well structured. The cytoplasm is homogeneous, fine-grained. Sinusoids are moderately dilated, plethora of the central veins is moderate.

During a biochemical study of the blood serum of experimental animals after a 30-minute blockade of the hepatoduodenal ligament without correction of ischemia, signs of the development of cytolytic and, to a lesser extent, cholestatic and hepatosuppressive syndromes were noted. After 30 minutes of reperfusion, the activity of transaminases and bilirubin increased, reaching their maximum values on the 3rd day after the operation. Moreover, they did not return to their initial values until the end of the experiment. Such changes are characteristic of acute lesions of the liver, which include its ischemia, especially if they are accompanied by stasis of bile in the intrahepatic ducts.

The use of our proposed method for the correction of liver ischemia contributed to a lower activity of transaminases in comparison with the non-correctable period after surgery for all observation periods (table 1; units of measurement are mmol / (h · l); p <0.05; n = 12.). So, after 30 minutes of reperfusion, the values of lactate dehydrogenase, alanine and aspartate aminotransferases were lower than those without complex anti-ischemic protection. The most pronounced changes occurred on the third day of the experiment. By the end of 7 days, their values returned to normal. It should be noted that when drawing parallels between series of experiments using the method of correcting liver ischemia and without it, it becomes obvious that the timing of increases and decreases in the activity of enzymes coincided, however, the amplitude of the changes against the background of the use of complex protection was much smaller.

After applying anti-ischemic protection, a slight increase in the values of bilirubin and alkaline phosphatase was observed only during the first three days after the operation with normalization by the seventh day, in contrast to the data obtained with 30-minute ischemia without the introduction of antioxidant drugs and portocaval bypass surgery (table 2; units measurements: bilirubin - mmol / l, alkaline phosphatase - mmol / (h · l); p <0.05; n = 12.).

Table 1 experience conditions time after ischemia (days) alanine aminotransferase aspartate transferase lactate dehydrogenase 1. control - 0.74 ± 0.08 0.46 ± 0.06 1.37 ± 0.15 2. without protection 30 minutes 1.47 ± 0.12 1.14 ± 0.07 1.69 ± 0.19 3. comprehensive protection 30 minutes 0.86 ± 0.04 0.53 ± 0.08 1.42 ± 0.16 4. without protection one 2.95 ± 0.15 1.72 ± 0.09 2.48 ± 0.11 5. comprehensive protection one 0.98 ± 0.11 0.71 ± 0.13 1.51 ± 0.09 6. no protection 3 3.25 ± 0.26 2.10 ± 0.29 3.19 ± 0.21 7. comprehensive protection 3 1.12 ± 0.14 0.92 ± 0.06 1.74 ± 0.12 8. no protection 7 2.81 ± 0.09 1.54 ± 0.07 2.72 ± 0.18 9. comprehensive protection 7 0.76 ± 0.13 0.47 ± 0.08 1.39 ± 0.06

table 2 experience conditions time after ischemia bilirubin alkaline phosphatase 1. control - 13.46 ± 0.27 2.46 ± 0.29 2. without protection 30 minutes 18.44 ± 0.79 2.91 ± 0.37 3. comprehensive protection 30 minutes 13.57 ± 0.78 2.53 ± 0.31 4.without protection one 30.12 ± 1.04 3.11 ± 0.28 5. comprehensive protection one 14.08 ± 0.64 2.72 ± 0.14 6. no protection 3 25.11 ± 1.64 3.02 ± 0.24 7. comprehensive protection 3 14.72 ± 0.87 2.81 ± 0.21 8. no protection 7 20.24 ± 0.73 2.61 ± 0.14 9. comprehensive protection 7 13.45 ± 0.63 2.49 ± 0.16

Without anti-ischemic protection, changes in the indicators of the hepatosuppressive syndrome (fibrinogen, prothrombin index, total protein) were expressed quite sharply, and at the end of the experiment they did not return to their original values. Thirty-minute shutdown of the liver from the bloodstream with the use of Mexico and Actovegin with temporary extracorporeal portocaval bypass surgery was accompanied by a slight decrease in the prothrombin index, total protein and fibrinogen with full normalization of these parameters by 7 days (table 3; units: fibrinogen - mg / l, prothrombin index - %, total protein - g / l; p <0.05; n = 12).

Table 3 experience conditions time after ischemia (days) fibrinogen prothrombin index total protein 1.control - 3.88 ± 0.18 81.7 ± 2.11 70.1 ± 1.12 2.without protection 30 minutes 3.12 ± 0.14 80.3 ± 1.97 68.4 ± 2.03 3. comprehensive protection 30 minutes 3.82 ± 0.16 81.2 ± 1.98 69.6 ± 1.74 4.without protection one 2.97 ± 0.23 62.5 ± 1.39 61.3 ± 1.08 5. comprehensive protection one 3.77 ± 0.13 80.4 ± 1.94 69.1 ± 1.85 6.without protection 3 3.09 ± 0.15 62.7 ± 1.47 60.4 ± 1.12 7. comprehensive protection 3 3.73 ± 0.14 79.8 ± 1.73 68.3 ± 1.16 8.without protection 7 3.41 ± 0.14 75.8 ± 2.05 67.8 ± 1.09 9. comprehensive protection 7 3.85 ± 0.13 81.6 ± 2.01 69.8 ± 2.09

When comparing blood pressure values (table 4; units of measurement - mmHg; p <0.05; n = 12), it can be noted that when exposed to complex protection, pronounced hemodynamic shifts did not occur, unlike the group of animals to which the introduction antioxidants against the background of temporary extracorporeal portocaval bypass surgery were not used.

Table 4 the control intraoperatively after the onset of ischemia 30 min after restoration of blood flow 1 hour after surgery 2 hours after surgery without protection 114.2 ± 1.9 67.4 ± 2.7 75.1 ± 3.4 89.3 ± 3.1 112.5 ± 2.3 comprehensive protection 114.2 ± 1.9 96.8 ± 1.5 110.4 ± 1.2 113.7 ± 0.9 115.2 ± 1.7

The results obtained indicate that the application of the proposed anti-ischemic protection method with the intravenous administration of Mexico and Actovegin according to the scheme and hemodynamic correction by applying a temporary extracorporeal portocaval shunt with 30-minute liver ischemia contributed to the normalization of biochemical processes, prevented the disruption of the structure of the hepatic parenchyma, the development of cytolytic cholesterol and hepatosuppressive syndromes, thereby preventing the development of ischemic changes body, which significantly reduced the severity of liver damage due to the possible oxygen deficiency and provides not only shielding but also a therapeutic effect.

Thus, our proposed method for the correction of ischemic damage to the liver under conditions of its bleeding allows prolonging the safe period of clamping the hepatoduodenal ligament up to 30 minutes and preventing massive bleeding during liver surgery, which justifies its use for therapeutic and prophylactic purposes.

Claims (1)

A method for the correction of ischemic damage to the liver under conditions of temporary shutdown of the liver, including the intravenous administration of a drug, characterized in that 2 hours before the operation, the experimental animal is injected with mexicor in the form of a 5% solution at a dose of 10 mg / kg body weight, then 1 hour before surgery, actovegin is injected intravenously in the form of an injection solution at a dose of 10 mg / kg body weight, then a temporary extracorporeal portocaval bypass grafting is applied intraoperatively, and in postoperative During the period, each of the preparations is administered 1 time per day for 7 days, the interval between their administrations is 12 hours: Mexico is administered at 8 hours, Actovegin at 20 hours.

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