RU2456621C1 - Diagnostic technique for postoperative peritonitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: what is described is a diagnostic technique for postoperative peritonitis by biochemical study of blood serum wherein blood serum and peritoneal exudate of the postoperative patients are examined by a ferritin level 100 ng/ml of which is assumed as 1 point, then ferritin scores in exudate and serum is summed, a total ferritin index is calculated; if it increases by 12 points and more, developing postoperative peritonitis is diagnosed.

EFFECT: higher diagnostic sensitivity and accuracy for postoperative peritonitis.

2 ex

Description

The invention relates to medicine, namely to emergency surgery, and can be used to diagnose latent, sluggish postoperative peritonitis (PP).

Postoperative complication is a new pathological condition that is not characteristic of the normal course of the postoperative period and is not a consequence of the progression of the underlying disease. Complications are important to distinguish from operational reactions, which are a natural response of the patient to illness and surgical aggression. Postoperative complications, unlike postoperative reactions, sharply reduce the quality of treatment, delaying recovery, and endanger the patient's life. There are early (from 6-10% and up to 30% with prolonged and extensive operations) and late complications. In the occurrence of postoperative complications, each of the six components matters: patient, disease, operator, method, environment, chance.

Complications may be associated with:

- the development of disorders caused by the underlying disease;

- violations of the functions of vital systems (respiratory; cardiovascular, liver, kidneys) caused by concomitant diseases;

- consequences of defects in the execution of an operation or the use of perverse techniques.

Features of a hospital infection are also important.

Nevertheless, the features of the pathological process, homeostasis disorders, infection, tactical, technical and organizational errors of doctors, the level of technical support - these are a typical set of reasons that require competent prevention and adequate treatment at an early stage in any clinic and hospital.

Postoperative complications are prone to progression and recurrence and often lead to other complications.

The frequency of postoperative complications is about 10% (V.I. Struchkov, 1981), while the proportion of infectious complications is 80% (hospital strains (!), Immunodeficiency). The risk increases with emergency as well as prolonged operations. The factor of the duration of the operation is one of the leading in the development of purulent complications - a marker of trauma and technical problems.

Technical errors: inadequate access, unreliable hemostasis, accidental injuries, accidental (undetected) damage to other organs, inability to delimit the field when opening a hollow organ, leaving foreign bodies, inadequate interventions, suture defects, inadequate drainage, defects in postoperative management.

One of the most pressing problems in the treatment of peritonitis is the timely diagnosis of so-called persistent or recurrent peritonitis. This category of peritonitis is a kind of "intermediate outcome" of treatment of severe secondary widespread peritonitis. It is characteristic of him that after 2-3 days after an adequate surgical allowance and appropriate intensive care, the patient's condition does not improve. This form of peritonitis can be considered a form of opportunistic infection. A feature of PP is the suppression of the local inflammatory reaction, the presence of nosocomial or endogenous infection in the exudate, as well as the state of immunoparalysis. The frequency of this form of peritonitis is 10%. Mortality reaches 60-70%.

At present, differential diagnosis of PP is a very difficult problem. The criteria for early preoperative diagnosis of various forms of peritonitis and indications for surgical treatment are not sufficiently developed.

Also problematic is postoperative monitoring and the choice of patient treatment tactics, in connection with which unnecessary diagnostic laparotomies and open drainage operations are often performed, which, in turn, increases the frequency of purulent-inflammatory complications and leads to an increase in mortality.

A known method for the diagnosis of phases of acute peritonitis according to laparoscopy, while assessing the number and nature of the effusion, the state of the gastrointestinal tract: stomach, duodenum, small intestine, colon (Borisov A.E., 2000). To diagnose peritonitis in patients, the data of the clinical picture are currently being used (Kolesov A.P. et al. 1989, Yuryukhin I.A. et al. 1989, Grinev M.V. et al. 1989, Shurkalin B.K. et al. . 1992, Gologorsky V.A. et al. 1988, Shalimov A.A. et al. 1981, Darling GE 1988), instrumental (Kuzin M.I. et al. 1986, Savchuk B.D. 1979, Fry DE 1988 ) and laboratory indicators (Ender L.A. Negovsky V.A. Zaks I.O. 1987, Semenov V.N. et al. 1989, Obolensky S.V., Malakhova M.Ya. 1991, Gudim V.I. et al. 1993, Schuck JM 1985, Berqstrom Jea 1977).

Most researchers are guided by the study of laboratory tests, such as the number of leukocytes, leukocyte formula, the level of substances of average molecular weight (SCM), leukocyte intoxication index (LII), osmolarity of blood plasma, effective concentration of albumin (Grdchik I.E., Zakirov D. B., Par V.I. To the prognosis of the course of abdominal sepsis // Bulletin of Intensive Care, 2004, No. 1, pp. 32-36), determination of the level of procalcitonin, etc. (Savelyev V.S., Gelfand B.R., Filimonova M.I. Peritonitis. - M., Litter, 2005, p. 58). However, none of the above laboratory parameters diagnoses postoperative peritonitis at its early stage. With a sluggish form of peritonitis, all these indications are blurred or absent altogether.

As the closest analogue, a METHOD FOR DIAGNOSTICS OF POSTOPERATIVE PERITONITIS is proposed // RF Patent No. 2077058 of 04/10/1997, P. Bryusov. et al.), which consists in identifying a diagnostically significant indicator: in the blood, the tumor-associated antigen CA-125 is determined by enzyme immunoassay and, with an increase in its level relative to the norm, PP is diagnosed. However, one of the main disadvantages of this method is that it cannot be used in patients suffering from cancer.

The invention is aimed at increasing the sensitivity and accuracy of the method.

The specified technical result is achieved by the fact that in the blood serum and peritoneal exudate of postoperative patients, the level of ferritin is determined, 100 ng / ml of which is taken as 1 point, then the points of ferritin in the exudate and serum are summed up, the total ferritin index is determined and, with an increase of more than 12 points, diagnosed the development of postoperative peritonitis.

In the diagnosis of many destructive conditions, ferritin, which, according to many researchers, is considered an indicator of tissue destruction, has proven itself well. So, ferritin is introduced in the diagnosis of destructive conditions in traumatology and orthopedics (Korablev SB, Lebedev M.Yu., Tenilin N.A. Method for differential diagnosis of relapse of dystrophic bone cysts and residual bone cavities // RF Patent No. 2086985 from 05.1994) in the diagnosis of traumatic brain injury (Sumnaya DB et al. Method for diagnosing the severity and course of traumatic brain injury // Patent of the Russian Federation No. 2213967 dated 07.22.02), tuberculosis (OK Malysheva et al. Method for differential diagnosis of pulmonary tuberculosis / / RF patent №2027191 from 12.29.90), the disease liver (Parshikov V.V., Nemov V.V. Method for assessing the degree of damage to the liver // Patent of the Russian Federation No. 2132071 dated 04/21/98), the thyroid gland (Panova TN, Epinetov MA Method for the differential diagnosis of malignant neoplasms thyroid gland and nodular non-toxic goiter // RF Patent No. 2075085 dated 05/26/93).

An analysis of the literature indicates that currently there is an accumulation of information about the biological and clinical significance of metalloproteins - ferritin.

Metalloproteins - serum proteins involved in the deposition, transport and disposal of metal ions of variable valency. Interest in the study of these proteins, which has grown significantly in recent years, is due to their role in the functioning of the antioxidant system of the body (Belaya, OL, Fomina, I.G., Bayder, L.M. et al. Effect of the bioflavonoid diquvertin on the antioxidant system ceruloplasmin / transferrin and lipid peroxidation in patients with stable forms of coronary heart disease with dyslipidemia (Clin. honey. - 2006. - No. 7. - P.46-50), as well as the possibility of using acute phase inflammation as biochemical markers (Aleshkin, B .A., Novikova, L.I., Lyutov, A.G. et al. Proteins acute phase and their clinical significance. Clin. honey. - 1988. - No. 8. - P.39-48; Ilyukevich, GV, Smirnova, LA Ferroproteins as markers of a systemic inflammatory response in acute peritonitis. National Academy of Sciences of Belarus, Ser. Medical Bi-Biological Science - 2002. - No. 2. - P.23-25; Al-Delaimy, WK, Jansen, EH Reliability of biomarkers of iron status, blood lipids, oxidative stress, vitamin D, C-reactive protein and fructosamine in two Dutch cohorts. - Biomarkers. - 2006 .-- 11 (4): 370-382).

The concentration of ferritin in blood serum and peritoneal exudate was determined by indirect enzyme-linked immunosorbent assay and radial immunodiffusion in ng / ml with commercial test systems of CJSC BioChemMak (Moscow).

We studied the level of ferritin in blood plasma and exudate from the abdominal cavity in 63 patients with advanced peritonitis. Changes in serum ferritin concentration in the majority of examined patients correlated with mediator levels in peritoneal exudate from drainage systems. Studies were performed at the time of surgery, as well as 3-4 days after the postoperative period. The study showed that the concentration of ferritin in blood serum and exudate in patients with advanced peritonitis at the time of surgery varied between 295.8 ± 31.52 ng / ml and 701.1 ± 179.22 ng / ml, respectively. In the case of a favorable course, with stopping peritonitis, on 3-4 days the concentration of ferritin in the blood serum and exudate obtained from the drains was 264 ± 26.58 ng / ml and 547.5 ± 79.51 ng / ml, respectively. In a complicated course that does not stop PP, the level of ferritin in the blood serum and exudate was 373.8 ± 62.68 and 1173.2 ± 79.06 ng / ml, respectively. Statistical processing of the results was carried out using Student's criterion.

To increase the reliability of the method, the numbers of ferritin in exudates and in serum were converted to points, 100 ng / ml were taken for 1 point. The scores of ferritin in exudates and serum were summarized (total ferritin index - CIF). In patients with postoperative peritonitis, the total score was 12 or more, with a reliability of p <0.05. This was noted in 31 cases, the causes of postoperative peritonitis were inconsistency of sutures, perforation of acute ulcers of the gastrointestinal tract, progression of peritonitis, etc., which required relaparotomy.

The proposed method was tested on 63 patients who received treatment in the surgical department of the Municipal Clinical Hospital № 3 named after S.M. Kirov, Astrakhan. Below are the results of testing.

Example 1. Patient K. (history No. 23565/1456), 36 years old, was admitted to the surgical department of the Municipal Clinical Hospital No. 3 on October 13, 2009, 4 days after the onset of the disease with a diagnosis of Perforated duodenal ulcer. Spilled fibrinous-purulent peritonitis. After preoperative preparation, an operation was performed - suturing of a perforated ulcer, debridement and drainage of the abdominal cavity. The operation is completed by laparostomy. During the operation, CIF amounted to 9 points (306 ng / ml - blood, 598 ng / ml - exudate, total - 904 ng / ml). After 24 hours, programmed sanitation of the abdominal cavity was performed, relief of peritonitis was noted, the abdominal cavity was sutured tightly. On the 3rd day after the operation, clinical signs of PP appeared. CIF was 13 points (408 ng / ml - blood, 926 ng / ml - exudate, total - 1334 ng / ml). Performed relaparotomy. Perforation of an acute ileal ulcer that was sutured was detected. In the future, the postoperative period proceeded smoothly without complications. Discharged on the 18th day after receipt in satisfactory condition.

Example 2. Patient M. (history No. 13467/975) is 42 years old. He entered the surgical department of the Municipal Clinical Hospital No. 3 on August 23, 2009, 1.5 hours after receiving a stab in the stomach. Diagnosis: Penetrating stab wound of the anterior abdominal wall. Through wound of the sigmoid colon. Local serous peritonitis. Operation: laparotomy, suturing of the sigmoid colon wound, sanitation and drainage of the abdominal cavity. CIF was 5 points (186 ng / ml - blood, 344 ng / ml - exudate, total - 530 ng / ml). On the 3rd day after the operation, the patient's condition worsened, clinical signs of postoperative peritonitis appeared. CIF - 13 points (431 ng / ml - blood, 918 mg / ml - exudate, total - 1339 ng / ml). Relaparotomy was performed - suture of the sigmoid colon, widespread serous-fibrinous peritonitis was found. Performed a sigmoidostomy, debridement and drainage of the abdominal cavity. In the future, the postoperative period proceeded without complications, was discharged on the 14th day in a satisfactory condition. After 4 months, reconstructive colonoplasty was performed.

When using our proposed method, it is achieved:

- improving the accuracy of differential diagnosis and increasing the sensitivity of the method for identifying postoperative peritonitis;

- increase reliable diagnosis of postoperative peritonitis, when diagnosis by other instrumental and laboratory methods is difficult;

- for diagnosis, special conditions and patient preparation are not needed;

- allows you to diagnose latent postoperative peritonitis in need of surgical treatment;

- reduction of economic costs due to the timely diagnosis of postoperative peritonitis, which will reduce mortality in this group of patients.

Claims (1)

A method for the diagnosis of postoperative peritonitis by biochemical examination of blood serum, characterized in that the serum and peritoneal exudate of postoperative patients determine the level of ferritin, 100 ng / ml of which is taken as 1 point, then the points of ferritin in the exudate and serum are summed up, the total ferritin index is determined and with its increase of more than 12 points, the development of postoperative peritonitis is diagnosed.