RU2445130C2 - Method for prevention of postoperative enteroparesis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, and can be used for prevention of postoperative enteroparesis. For this purpose, by the end of a technical part of the surgery, a standard sanation procedure is followed by abdominal irrigation with ozonised Perftoran with the ozone concentration 5000 mcg/l. The irrigation volume is measured at 1 ml/kg of weight. Thereafter ozonised Perftoran is intravenously introduced at the same basis.

EFFECT: ensured technical simplicity, effective prevention of postoperative enteroparesis, considerable reduction of length of gastrointestinal motility recovery, antibiotic therapy and hospital stay.

2 ex

Description

The invention relates to medicine, namely to surgery, can be used after operations on the abdominal organs and in the complex treatment of acute peritonitis in order to prevent and treat postoperative intestinal paresis.

In patients who underwent surgery on the abdominal organs, intestinal paresis develops in 40-96% of cases in the early postoperative period (Milonov O.B., Toskin K.D., Zhebrovsky V.V., 1990; Belokurov Yu.N., 1996; Evdokimov V.V., Magomedov M.R., 2002; Bloechle S., Emmermann A., Strate T. et al., 1997).

Intestinal dysfunction, impaired motility (persistent or progressive) is the most common and alarming symptom after the completion of surgical treatment of peritonitis and plays a crucial role in the pathogenesis of intra-abdominal complications. Intestinal paresis is one of the manifestations of bowel dysfunction, a standard condition that accompanies every case of widespread inflammation of the peritoneum. It requires the use of all means of intensive care: protectors of translocation of bacteria and toxins through the intestinal wall, probe enteral detoxification and decontamination, and with the right choice of surgical tactics and intensive care, restoration of bowel function occurs no earlier than 3-4 days (Savelyev BC, Gelfand B.R., Filimonov M.I., 2006). However, standard methods of intestinal stimulation are not always effective, and the lack of effect for 8-12 hours serves as an indication for relaparotomy, otherwise endogenous intoxication progresses and multiple organ failure develops (Filimonov M.I., Gelfand B.R., Podachin P.V. ., 1998; Yarema I.V. et al., 1998; Shurkalin B.K., Fuller A.P., Gorsky V.A., 2007, etc.).

Widely used introduction of a solution of novocaine into the mesentery of the small intestine, blockade with a solution of retroperitoneal novocaine and the mesentery of the transverse colon, according to A.P. Chadayev et al. (1995) and B.A. Shlevkova et al. (2000), have a weak irritating effect on nerve endings, anesthetic effect, favorably affect the course of the pathological process. But solutions of novocaine are ineffective for resolving postoperative intestinal paresis and especially developed against the background of secondary or tertiary peritonitis.

The prototype of the proposed method is "A method for the treatment of postoperative intestinal paresis" (patent for the invention No. 2336079 dated 10/20/2008 with a priority of 10/30/2006, authors: Zagirov U.Z., Ragimov R.M., Magomedov Z.M. ., Dalgatov G.M., Salikhov M.A. and Manasova Z.Sh.).

The prototype method proposed by the authors is as follows.

During surgery, after completion of the intra-abdominal technical stage of the operation, before closing the wound of the abdominal wall, the intestinal mesentery is blocked by introducing a mixture of the following composition into its root: 100 ml of a 0.25% solution of novocaine and 50 ml of perftoran emulsion.

The disadvantages of the prototype:

1. The introduction of 150 ml of the mixture can cause increased swelling of the inflamed mesentery of the intestine, poor circulation, microcirculation in the tissues and trophism.

2. The drug mixture introduced into the root of the mesentery of the intestine has an effect on a limited area, and not on the entire peritoneum.

3. The proposed mixture has no antiseptic or antibacterial properties, and its introduction into an infected peritoneum is unsafe.

4. Perftoran, which is part of the mixture introduced into the mesentery, is limited in the manifestation of such functions as stimulation of migration of peritoneal macrophages and their functional activity, sorption properties, cytoprotective and membrane-stimulating effects on the peritoneal mesothelium cells, since the mixture is introduced not into the peritoneal cavity, but between its leaves in connective tissue.

The aim of the present invention is to develop a method for the prevention and treatment of postoperative intestinal paresis.

The goal is realized by connecting to the standard treatment the introduction of ozonated perfluorane into the abdominal cavity and intravenously. Perftoran ozonation is carried out by bubbling it with an ozone-oxygen mixture for 20 minutes at a speed of 0.5 l / min and a predetermined ozone concentration of 5000 μg / l on the ozonizer. The ozonizer Medozons-BM AOT-N-01-Arz-91 was used by the company Arzamass Instrument-Making Plant OJSC.

SUMMARY OF THE INVENTION

The essence of the invention is as follows: carry out intraperitoneal (by irrigation) and intravenous (drip) administration of ozonated perfluorane after completion of the initial operation, before suturing the surgical wound of the abdominal wall.

The method provides additional sanitation of the abdominal cavity, promotes early restoration of intestinal motility, improves tissue oxygenation, reduces indications for relaparotomy and shortens the duration of antibiotic therapy and postoperative treatment of acute peritonitis.

During the surgical intervention, after completion of the intra-abdominal technical stage of the operation, before abdominal wall wounds are closed, the abdominal organs are irrigated with 50-100 ml of ozonized perftoran (based on 1 ml / kg of weight), and then the laparotomy wound is sutured. Prior to irrigation, the remnants of an antiseptic or other solution that was sanitized are washed off with 0.5-1 l of physiological saline (so that there is no mixing of a solution of furatsilin, an antiseptic or other solution used for standard sanitation, and ozonated perftoran). For irrigation use a 20 ml syringe with a large diameter needle. Before irrigation, the drainage tubes left in the lower floor of the abdominal cavity are temporarily clamped (for 1.5-2 hours) so that the ozonated perfluorane does not leak out. After all, another 50-100 ml of ozonated perfluorane is administered intravenously (based on 1-1.5 ml / kg of weight) depending on body weight, severity of the condition and phase of peritonitis.

COMPARATIVE ANALYSIS OF THE SIGNS OF THE PROTOTYPE AND THE PROPOSED INVENTION

1. In the proposed method, ozonized perfluorane is used, exhibiting the properties of both perfluorane and ozone, and in the prototype a mixture of perfluorane and novocaine is used.

2. According to the prototype, a mixture of perftoran and novocaine is injected into the mesentery and its action is localized in a limited area of the peritoneum, and according to the proposed method, the entire abdominal cavity is irrigated, which allows to achieve the necessary therapeutic effect.

3. According to the proposed method, perfluorane is preliminarily ozonized with an ozone-oxygen mixture with a predetermined ozone concentration of 5000 μg / l and at the end of the operation, the abdominal cavity is irrigated with ozonized perfluorane at the rate of 1 ml / kg of patient weight, then ozonized perfluorane is administered intravenously from the same calculation, and according to the prototype is injected with 150 ml of a mixture of novocaine and perftoran regardless of the patient's weight.

EXAMPLES OF SPECIFIC IMPLEMENTATION

Example 1

Patient A. (M. card No. 4957/560), 50 years old, was taken by ambulance to the 2nd surgical department of the Republic of Belarus No. 2 (RC SEMP) 05/22/2008 at 13 h 10 min, 28 hours after the onset of the disease, with complaints of abdominal pain, dry mouth, weakness, nausea, and vomiting. Upon admission, the temperature is 38.5 ° C, the state of moderate severity, the patient is conscious, excited. The skin is pale, slightly moist. The tongue is coated with white plaque. Ps - 118 beats / min, BP - 110/60 mm Hg Heart sounds are somewhat muffled. Hard breathing, isolated wheezing is caught. The abdomen is moderately swollen, pain on palpation is noted, more on the right. Symptoms of Shchetkin-Blumberg, Bartomier-Michelson and Sitkovsky are positive. During the day 2 times was loose stools. The patient notes frequent urination. In a blood test: white blood cells - 7.5 × 10 ⁹ / l, red blood cells - 5.2 × 10 ¹² / l, hemoglobin - 157 g / l, color indicator - 0.9, ESR - 18 mm / h; in the leukocyte formula: stab leukocytes - 14%, segmented leukocytes - 64%, lymphocytes - 19%, monocytes - 3%, LII - 4.2. There is no history of allergy. A clinical diagnosis was made: acute destructive appendicitis complicated by peritonitis.

After preoperative preparation, having previously obtained written informed consent of the patient for surgery and intraperitoneal and intravenous administration of ozonated perfluorane, the patient was operated on with mid-laparotomy at 15 hours 30 minutes.

In the abdominal cavity about 450 ml of purulent effusion mixed with fibrin and intestinal contents. The appendix is about 8 cm long gangrenous, at the base there is a perforated opening with a diameter of about 4 mm. The cecum is inflamed. The loops of the small intestine are expanded to 4.5 cm, are atonic, there is liquid foamy content in the lumen, and peristalsis is sluggish. UPS rated at 14 points, MIP - 25 points. Appendectomy, lavage with a warm solution of furatsilin (about 4 l), drainage of the abdominal cavity (2 pairs of drainages - upper and lower) were performed. After that, the residues of furatsilin were washed with 1 l of physiological saline, clamps were placed on the drainage tubes, and abdominal organs were irrigated with 100 ml of ozonized perfluorane (patient weight was about 100 kg) and the laparotomy wound was closed. On the operating table, intravenous administration of ozonated perfluorane has been started. After 15 minutes from the start of the infusion, the pulse rate decreased from 112 to 98 beats / min, and after 45 minutes to 89 beats / min.

After a day (05/23/08), the patient's condition is better. Consciousness is clear. Notes pain in the area of postoperative wounds. The abdomen is soft, with palpation painful along the wound. When phonoenterography recorded peristaltic noises. About 50 ml of a clear liquid separated through drainage tubes per day. Pulse - 86 bpm, temperature - 37.8 ° C, blood pressure - 110/70 mm Hg Single moist rales are heard in the lungs. In a laboratory blood test: leukocytes - 8.7 × 10 ⁹ / l, ESR - 11 mm / h, stab shift - 10%, LII - 2.8.

05/24/08, 9 h 30 min. The patient is active, the patient's condition is better. In the area of the postoperative wound with palpation, slight pain. The abdomen is soft, the gas escapes, a chair appeared. There is no discharge (traces) along the drainage tube. Pulse - 76 beats / min, good filling; body temperature - 37.2 ° C, blood pressure - 120/80 mm Hg Blood test: leukocytes - 7.3 × 10 ⁹ / l, ESR - 10 mm / h, stab shift - 7%, LII - 1.6.

In connection with the improvement of the patient's condition, gastrointestinal motility, normalization of body temperature, indicators of the main blood parameters, LII (1,3), May 25, 2008, antibacterial drugs were canceled.

The patient was discharged from the hospital on May 29, 2008 (recovery).

Example 2

Patient K. (medical card No. 4385/286), 32 years old, was admitted to the 1st surgical department of the Republic of Belarus No. 2 (CS and EMF) 05/05/2008 at 10 h 10 min from FGU - IK No. 7 (prisoner) 24 hours after the onset of the disease in a state of endotoxic shock III tbsp. The disease began on 05.06.08 with acute pains in the epigastrium, which became diffuse, and an increasing general weakness joined. Objectively: acrocyanosis, a pulse at the periphery is not determined, heart rate - 130 beats / min, respiratory rate - 31 beats per minute, blood pressure - 20/0 mm Hg, the abdomen is uniformly swollen, sharply painful and tense, dullness is determined in percussion places . From the anamnesis it turned out that since 1997, suffers from peptic ulcer of the duodenum. A nasogastric tube was introduced; the contents in the form of “coffee grounds” were released on it. In a blood test: white blood cells - 14 × 10 ⁹ / l, red blood cells - 3.6 × 10 ¹² / l, hemoglobin - 97 g / l, ESR - 22 mm / h; in the leukocyte formula: stab leukocytes - 17%, segmented leukocytes - 67%, lymphocytes - 12%, monocytes - 3%, LII - 7.3. The patient immediately started infusion therapy, and against this background, at 11 hours 10 minutes laparocentesis was performed (with the informed written consent of the patient). Under local anesthesia, 3 cm below the navel in the midline, a drainage tube was introduced into the abdominal cavity along the tube of the trocar. A cloudy effusion with flakes of fibrin stood out along the tube. The Neymark test is positive. A clinical diagnosis was made: perforated duodenal ulcer, complicated by bleeding, purulent-fibrinous peritonitis. Endotoxic shock III Art.

After some stabilization of hemodynamic parameters (blood pressure - 90/60 mm Hg) against the background of the ongoing infusion therapy, an informed written consent was obtained from the patient for surgery and for the administration of ozonated perftoran. At 13 hours and 40 minutes, the patient was operated on with median laparotomy access.

In the abdominal cavity about 1100 ml of turbid fluid with flakes of fibrin and an admixture of blood. The duodenum is edematous, with overlays of fibrin. On the lower wall in the area of the bulb is a peptic ulcer with a diameter of 1.0 cm with swollen uneven edges of a dark purple color, surrounded by an infiltrated shaft. UPS rated at 14 points, MIP - 24 points. After removing the liquid with an electric suction pump, after partial processing the perforated hole of the bulb is sutured. The abdominal cavity was sanitized with 5.5 l of furatsilin, loose fibrin deposits were removed, the drainage of the lower floor, subhepatic and suprahepatic spaces was performed. Given the prescription of peritonitis (more than 24 hours), a sharp weakening of peristalsis and pronounced atony of the small intestine, a nasointestinal probe was installed, having carried out up to 50 cm for the ligament of Treitz. After washing the residues of furatsilin with physiological saline, then applying clamps to the ends of the drainage tubes, the abdominal cavity was irrigated with ozonated perfluorane (60 ml was used). 140 ml was injected intravenously over 1 hour (an increase in the amount of perfluorane injected into the venous bed to 2 ml / kg of body weight is due to the fact that the patient had a loss of blood).

During this time, heart rate decreased from 110-112 bpm / min to 93-95 bpm / min, NPV - by 5 (18.5%), i.e. after the introduction of ozonated perftoran, an NPV of 20 was established in 1 minute.

A day after the operation, the patient became much better. About 100 ml of fluid was released by the nasointestinal probe. When phonoenterography peristaltic noise was detected. Body temperature - 37.5 ° C (the night before, 7 hours after the operation, there was a high temperature - 38.6 ° C). The main hemodynamic parameters improved, heart rate - 85 beats per minute, blood pressure - 110/70 mm Hg. On palpation, the abdomen is soft, painful along the laparotomy wound. In blood tests: leukocytes - 8.7 × 10 ⁹ / l, erythrocytes - 4.0 × 10 ⁹ / l, Hb - 108 g / l, ESR - 7 mm / h, stab shift - 10%, LII - 3, 5.

30 hours after the operation (05/08/2008), the patient was transferred to a hospital at FGU - IC No. 7 to continue treatment. Before that, taking into account some hematological parameters and circumstances associated with the inability to monitor this patient, they decided to reintroduce 100 ml of ozonated perftoran repeatedly. Further treatment proceeded without complications (constantly, until the patient was discharged, they kept in touch with the doctor of IC No. 7). In connection with the improvement of the patient’s condition, gastrointestinal motility, normalization of body temperature, indicators of the main blood parameters, LII (1,4), antibacterial drugs were canceled. On the 9th day after the operation, the patient was discharged at the place to continue serving the sentence.

USEFULNESS OF THE INVENTION

The usefulness of the developed method, proposed as an invention, is based on the following properties of ozonized perftoran. Ozonated perfluorane exhibits the properties of both perfluorane and ozone, and ozone in "perfluorane" dissolves "better and more stably than in physiological saline.

The developed method is technically simple to perform and can significantly reduce the time: restoration of gastrointestinal motility and blood counts and other body systems, antibiotic therapy, and the patient’s hospital stay.

The positive effect of ozonated perfluorane is achieved due to: increased migration and functional activity of peritoneal mononuclear phagocytes (Askerkhanov G.R. et al., 2000), additional rehabilitation and purification of the abdominal cavity (Golubev AM, Ragimov PM and Osmanov A.O., 2005) , improvement of tissue oxygenation, microcirculation, rheological properties of blood (Ragimova D.M., 1999).

In addition, ozonated perfluorane corrects factors of nonspecific immunity: the phagocytic activity of leukocytes, the number of cytochemically detected cationic proteins and the level of neutrophilic granulocyte myeloperoxidase, the bactericidal activity of blood serum (Golubev AM, Ragimov PM, Manasova Z. Sh., Saidov MZ, 2008) ; possesses membrane-stabilizing and cytoprotective properties (Khrupkiy V.I., Moroz V.V., Pisarenko L.V., Khomenchuk A.I., 1997), activates pro- and antioxidant systems, has bactericidal, viricidal, fungicidal and analgesic effects.

The proposed method was used in 3 surgical departments of the Republic of Belarus No. 2 (RC SEMP) in the period from 04.2008 to 11.2008. in the complex treatment of 24 patients with acute purulent peritonitis for the prevention and treatment of postoperative intestinal paresis. The method proposed as an invention made it possible to significantly reduce the recovery time of gastrointestinal motility and blood counts and other body systems. The terms of antibiotic therapy and the patient’s hospital stay also decreased.

The proposed method can be used in clinical surgical practice and in experimental surgery for the prevention and treatment of postoperative intestinal paresis. The method is technically simple to perform.

Information sources

1. Patent for the invention "A method for the treatment of postoperative intestinal paresis" (patent for the invention No. 2336079 dated 10/20/2008 with a priority of 10/30/2006, authors: Zagirov U.Z., Ragimov R.M., Magomedov Z.M. ., Dalgatov G.M., Salikhov M.A., Manasova Z.Sh.).

Claims (1)

A method for the prevention of postoperative intestinal paresis, which consists in the use of perftoran, characterized in that the perfluoran is preliminarily ozonized with an ozone-oxygen mixture with a predetermined ozone concentration of 5000 μg / l and, at the end of the operation, the abdominal cavity is irrigated with ozonized perftoran at the rate of 1 ml / kg of the patient’s mass, then ozonized is administered intravenously perfluorane from the same calculation.