RU2464942C1 - Method of sealing interintestinal anastomosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, and can be applied for sealing interintestinal anastomosis. For this purpose before immersion into abdominal cavity and suturing middle wound, application of 30-40 g of dry lyophilised cryoprecipitate is performed on serous cover of small intestine on entire circumference of interintestinal anastomosis. After that, either 2-3 ml of 5% calcium chloride solution or 4-5 ml of sterile thrombin 15 U NIH/ml, dissolved in 5% solution of aminocaproic acid, are added drop by drop into said cryoprecipitate. 60 seconds after formation of gel-like fibrin film re-application of the first or the second two-component composition is carried out.

EFFECT: method ensures increase of strength and biological impermeability of intestinal sutures at the background of extensive peritonitis due to efficient fixation of fibrin, which does not produce damaging impact on tissues, is capable of quick formation of fibrin film, is homologous and safe, penetrates zone of suture, filling holes from needle punctures, making it possible to close anastomosis on circumference evenly.

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Description

The invention relates to medicine, namely to surgery, and can be used to strengthen and additional tightness of the intestinal anastomoses used in patients with advanced peritonitis.

One of the most important problems of clinical medicine is the failure of the intestinal anastomoses in patients with advanced peritonitis. It is known that during the first 4-7 days after surgery, the intestinal suture is leakproof only due to mechanical stitching of tissues and, regardless of the row, it is permeable to microflora located in the lumen of the intestine (Vasilevich A.P., Shott A.V., Zaporozhets A.A. The use of biological adhesive compositions for the application of intestinal suture. Health of Belarus. - 1989. - No. 5. - Pages 4-8). However, the biological reliability of the intestinal anastomosis is achieved only due to the protein and fibrin deposited in the suture zone. In conditions of peritonitis and programmed sanitation of the abdominal cavity, there is a decrease in the amount of fibrin in the area of the intestinal suture with subsequent weakening of the processes of regeneration and biological tightness (Shurkalin B.K., Gorsky V.A., Leonenko I.V.The problem of reliability of the intestinal suture. Consilium medicum. - 2004. - T. 6. - No. 6. - S.17-25). This leads to a high incidence of failure of the sutures of the intestinal anastomoses. The presence of purulent inflammation in the abdominal cavity and the patient’s serious condition often force them to form various intestinal stomas, apply delayed anastomosis during planned sanitation of the abdominal cavity, extraperitonization of the intestinal anastomosis, wrap the intestinal anastomosis area with omentum, mesenteric flap, and use of a dura mater .

There is a method of sealing intestinal sutures by applying Sulfacrylate medical glue on them, registration certificate No. FS 01031444 / 2587-06 dated February 07, 2006 (Marchenko V.T. Clinical and morphological aspects of the use of the new Sulfacrylate adhesive in surgery of the chest and abdominal cavity.Dis.dok.med.Sci. - Novosibirsk. - 2004. - 212 p.).

However, the known method has several disadvantages, namely: 1) the composition of the sulfacrylate adhesive does not include biological substances that stimulate tissue regeneration, but chemical: ethyl - alpha cyanocrylate (a binder component), butyl acrylate (plasticizer), sulfolane methacrylate (anti-inflammatory and antibacterial component ); 2) poor absorption of glue into living tissues; 3) unreliable fixation and rapid peeling; 4) after applying “Sulfacrylate” during its polymerization in the area of intestinal sutures, a zone of aseptic coagulation necrosis is formed, which is caused by the local toxic effect of glue, and this factor in conditions of peritonitis can impede the tightness of the intestinal suture and increase the risk of its failure.

The closest technical result achieved (prototype) is a method of sealing operating joints using fibrous glue “Tissucol Kit”, Baxter A.G., Austria (Abzhueva O.V., Rusanov V.M., Zhidkov I.L. Experimental and clinical study of the effectiveness of a new therapeutic agent - fibrin glue. Hematology and transfusiology. - 2000. - V. 45. - No. 1. - P.35-37; Akhaladze GG. The use of fibrin glue preparations in hepatopancreatobiliary surgery. Consilium medicum. T .4. - No. 6. - 2002; Perelman M.I., Kononenko S.N., Zykov A.S., Limonchikov S. V., Pavlenko I. A. Modern adhesive compositions in toric surgery. Surgery. - 2002. - No. 2. - C.47-49).

A well-known topical biological hemostatic agent has the following effect: “Tissucol Kit” (Registration number P N 014732/01) consists of a bottle with lyophilized powder Tissucol (component 1), a bottle with lyophilized thrombin of different concentrations (component 2) and 2 bottles with solvents (aprotinin and calcium chloride). The kit includes syringes / Duploject system. To dissolve the Tissucol component, a special device is used for heating to 37 ° C and stirring - Fibrinotherm, which accelerates the dissolution of Tissucol (complete dissolution takes 10-15 minutes). The components of the adhesive can be applied in the following ways: 1. Successive application of each of the components; 2. Simultaneous application using the “Duploject” system (cassette for 2 syringes with a common plunger) and an application needle (short blunt needle at the base of which mixing occurs). To spray the Tissucol solution using the Duplojection system and the spray head, the Tissomat is used: a compressed gas supply control unit, including a foot switch, a pressure gauge, a crane-reducer and a special hose. The applied dose of Tissucol solution depends on the size of the surface that needs to be fixed or coated, as well as on the applied method of application. Usually one set is enough to glue a surface of at least 10 square meters. see. When applying glue by spraying the same amount is enough to close the surface with an area of 25 to 100 square meters. cm.

The known method has the following disadvantages (Severtsev A.N., Brekhov E.I., Mironov N.P., Repin I.G., Ivanova E.N., Bashilov V.P. Use in clinical practice of some pharmacological preparations to achieve of final hemostasis with liver resection. - Clinical Bulletin of the Kremlin Medicine. - No. 2. - 2000. - P.22-26): 1) low adhesive ability of the adhesive, which dictates the need for repeated application in some cases; 2) unreliable fixation of fibrin films; 3) the complexity of use during surgery and the need to comply with certain time for preparing the adhesive and for sufficient fibrin formation depending on the activity of the thrombin used; 4) the availability of additional special equipment (heater and nebulizer); 5) the possibility of spontaneous formation of fibrin in a container containing fibrinogen; 6) the high cost of Tissucol Kit glue, limiting its use in clinical practice.

The technical result of the proposed method is to increase the strength and biological integrity of intestinal sutures, used against the background of peritonitis.

The technical result is achieved by the fact that before immersion in the abdominal cavity and suturing of the middle wound on the serous cover of the small intestine along the entire circumference of the intestinal anastomosis, 30-40 g of dry lyophilized cryoprecipitate are applied, and to obtain stable fibrin and fix it at the site of the anastomosis in dry lyophilized cryoprene dropwise add either 2-3 ml of 5% calcium chloride or 4-5 ml of sterile thrombin 15 units. NIH / ml, dissolved in a 5% aminocaproic acid solution and 60 seconds after the formation of a gel-like fibrin film, reapply the bicomponent composition.

The authors suggest an effective way to strengthen the intestinal anastomoses due to the formation of a fibrin film in the intestinal suture zone by mixing a two-component composition on biological tissues.

The method is illustrated by figures 1-4.

The figure 1 after resection of the small intestine shows the formation of a single-row inter-intestinal enteroenteroanastomosis "end to end" using atraumatic suture material.

The figure 2 presents the application on the serous cover of the small intestine around the circumference of the intestinal enteroenteroanastomosis 30-40 g of dry lyophilized cryoprecipitate (for example, produced by the Rubtsovskaya blood transfusion station) containing fibrinogen and other adhesive plasma proteins.

The figure 3 presents the addition to dry cryoprecipitate dropwise from a syringe or 2-3 ml of 5% calcium chloride or 4-5 ml of sterile thrombin 15 units NIH / ml dissolved in 5% aminocaproic acid solution.

The figure 4 shows the formation in the zone of intestinal enteroenteroanastomosis gel-like fibrin film, completely covering all intestinal sutures.

The positions noted in figures 1, 2, 3, 4, indicate: 1 - small intestine; 2 - inter-intestinal enteroenteroanastomosis "end to end"; 3 - dry lyophilized cryoprecipitate in the area of intestinal sutures; 4-5% calcium chloride solution or thrombin solution added to dry lyophilized cryoprecipitate; 5 - the formation of a fibrin gel-like film that seals the intestinal sutures.

The method is as follows.

Under endotracheal anesthesia, a laparotomy, resection of the small intestine are performed and an inter-intestinal enteroenteroanastomosis of the end-to-end or side-to-side type is applied in a single-row suture using an atraumatic suture material. The diameter of the anastomosis is 3 cm. The operation is completed by transnasal intubation of the small intestine, debridement and drainage of the abdominal cavity. Before immersion in the abdominal cavity and suturing of the median wound on the serous cover of the small intestine, an application of 30-40 g of dry lyophilized cryoprecipitate (for example, produced by the Rubtsovskaya blood transfusion station) containing fibrinogen and other adhesive blood plasma proteins is made on the serous cover of the small intestine. In order to avoid blood-borne infections, quarantined donor plasma is used in the preparation of cryoprecipitate. To obtain stable fibrin and fix it around the entire circumference of the anastomosis, either 2-3 ml of 5% calcium chloride or 4-5 ml of sterile thrombin 15 units are added dropwise to a dry cryoprecipitate from a syringe. NIH / ml dissolved in 5% aminocaproic acid solution. Thrombin is a protein preparation obtained from quarantined human blood plasma, manufactured by Tekhnologiya-Standart LLC, Barnaul. In 20-30 seconds after the addition of the second solution, in the area of the intestinal anastomosis, the processes of formation of a gel-like fibrin film begin to intensify, the adhesive properties of which gradually increase and reach a maximum of 5 minutes. After 60 seconds in the zone of the anastomosis, repeated application of the two-component composition is carried out (manipulations with the sequential application of dry cryoprecipitate, or 5% calcium chloride, or a solution of thrombin). After the formation of a dense fibrin clot in the form of a sealing seam of a gel-like film, the small intestine is immersed in the abdominal cavity. The middle wound is sutured tightly.

Clinical examples

1. Patient J., 58 years old, was admitted to the purulent surgery department of the Regional Clinical Hospital on 04.04.2010 with complaints of moderate abdominal pain, weakness, malaise, and intestinal contents from drainage wounds on the anterior abdominal wall. From the anamnesis: considers himself ill since 03/23/2010, when with the clinic of a restrained inguinal hernia on the left he entered the central hospital of the Central District Hospital at the place of residence. An emergency procedure was performed - Postemsky hernia repair. A loop of the small intestine was found in the hernial sac, recognized as viable, immersed gray-serous sutures were placed on dubious sections of the small intestine. On the 7th day of intestinal obstruction. March 30, 2010 - laparotomy, nasointestinal intubation, rehabilitation, drainage of the abdominal cavity. On the 5th day, intestinal discharge from the drainage wound appeared in the right iliac region. Consulted by a surgeon at the regional center for disaster medicine. Delivered by ambulance to the purulent surgery department of the Regional Clinical Hospital. Diagnosis at admission: Restrained inguinal hernia on the left. Surgical treatment in the Central Hospital: March 23, 2010 - hernia repair, March 30, 10 - laparotomy, intestinal intubation. Acute perforation and inconsistency of sutures on the small intestine. Postoperative widespread fibrinous-purulent peritonitis. Abdominal sepsis. After preoperative preparation is operated. 04/05/2010 - relaparotomy, obstructive resection of the small intestine with the formation of the adducting and abducting stump of the small intestine and leaving them in the abdominal cavity without applying an intestinal anastomosis, transnasal intubation of the adducting part of the small intestine, sanitation and drainage of the abdominal cavity. Intensive treatment was carried out in the intensive care unit with constant aspiration from the probe. 04/07/2010, reorganization relaparotomy was performed. During the audit, fibrinous overlays with infiltration of the intestinal wall and peritoneum remain on the loops of the small intestine. Stumps of the small intestine are wealthy. It was decided to refrain from imposing an inter-intestinal anastomosis. Sanitation and drainage of the abdominal cavity was performed. 04/09/2010, reorganization relaparotomy was performed. During the audit: fibrinous overlap is insignificant, shiny parietal peritoneum, scanty serous effusion, loops of the small intestine are not expanded, the stumps are wealthy. A delayed double-row side-by-side enteroenteroanastomosis is imposed. Before suturing the anterior abdominal wall in order to seal the intestinal sutures on the interintestinal anastomosis zone, a two-component composition was applied in the sequence: cryoprecipitate - 2 ml of 5% calcium chloride - cryoprecipitate - 2 ml of 5% calcium chloride. After 5 minutes, a dense fibrin clot formed in the anastomotic zone. The intestine is immersed in the abdominal cavity. Layered stitches on the wound. The further postoperative period was uneventful. Signs of failure of the anastomosis were not noted. Passage through the intestines gradually recovered, the temperature returned to normal. The patient was discharged in satisfactory condition.

2. Patient B., 52 years old, was admitted to the purulent surgery department of the regional clinical hospital on 10.10.2010 in a serious condition. From the anamnesis: 10/07/2010 was operated on x / o CRH for mesenteric thrombosis with necrosis of the small intestine. A small bowel resection was performed with side-by-side enteroenteroanastomosis, debridement and drainage of the abdominal cavity. At admission: serious, stable condition. Located on a ventilator. Unconscious (medical sleep). In the nose, a nasogastric tube with congestive discharge. HELL 120/70 mm Hg Pulse - 100 per min. On palpation, the abdomen is soft, infiltrates are not palpable. Middle suture 16 × 2 cm in size with no signs of inflammation. In the iliac areas, silicone drainage with serous hemorrhagic discharge. St. Shchetkin-Blumberg is negative. Additional examination methods were performed: CT scan of the abdominal cavity and retroperitoneal space: Bilateral polysegmental pneumonia. Pneumoperitoneum. Dilation of intestinal loops. Atherosclerosis of the aorta and its branches. APACHI II - 15 points. Tests: HB - 120 g / l, platelets - 144 × 10 ⁹ , leukocytosis - 22 × 10 ⁹ , stab shift to the left - 17, urea - 11.4 mmol / l, creatinine - 148 mmol / l, protein - 40 g / l Clinical diagnosis at admission: Mesenteric thrombosis in the pool of IBA with necrosis of the small intestine. The condition after resection of the small intestine and the application of an inter-intestinal anastomosis in the NRB from 08.10.10. Postoperative sluggish peritonitis. Sepsis. PON Operation 10/11/2010 - programmed relaparotomy. The superior mesenteric artery was isolated from the mouth for 5 cm. With its revision to the border of the mesentery of the small intestine, its pulsation was preserved, there was an inconsistency in the posterior lip of the inter-intestinal anastomosis with leakage of intestinal contents with pressure. Below the anastomosis and to the cecum there remains a portion of the ileum 40-50 cm long. This part of the intestine with ischemic large focal spots of purplish-cyanotic color, its wall is infiltrated, thickened. Ripple mesentery in this place is not determined. During the audit, the cecum with large foci of green necrosis (up to 4-5 cm in diameter / with thinning of the wall as “parchment paper”). An obstructive resection of the intestinal anastomosis, the remaining part of the ileum and the right half of the colon with the formation of stumps of the small and colon, transnasal intubation of the adducting intestine, rehabilitation and drainage of the abdominal cavity was performed. 10/13/2010 - reorganization relaparotomy. The stumps of the transverse colon and jejunum are wealthy, pink in color, there are no additional foci of necrosis. The jejunum is not stretched. The delayed side-by-side transverse anastomosis of the two-row suture / atraumatic thread Monosin 3.0 / was applied. Sanitation and drainage of the abdominal cavity was performed. Prior to suturing the anterior abdominal wall, a sequential application of 40 g of dry cryoprecipitate and a solution of 5% calcium chloride (2–3 ml) was carried out sequentially in the zone of transotransversion anastomosis, followed by the formation of a fibrin film. In the postoperative period, infusion, antibacterial therapy, and physiotherapy were performed. There were no complications. The seam healed by first intention. The patient was discharged in satisfactory condition.

Thus, the effectiveness of the proposed method lies in the fact that the two-component composition used to increase the biological integrity of the intestinal anastomoses in conditions of widespread peritonitis: 1) does not have a damaging effect on the tissue; 2) has the ability to quickly form a fibrin film (within 20-30 seconds); 3) has homology and safety in relation to human tissues; 4) has an affinity for tissues, as a result of which it penetrates into the seam area and fills the holes from the injections of the needle; 5) allows you to evenly close the anastomosis around the circumference; 6) has a cost of 5-7 times lower in comparison with the prototype, which leads to its greater availability for the medical network.

3. Patient Ch., 43 years old, was admitted to the purulent surgery department of the Regional Clinical Hospital KGBUZ on 11/11/2011 in an extremely serious condition with complaints of abdominal pain, nausea, and vomiting. From the anamnesis of the disease it was established that on 05.08.11 there was a blunt trauma to the abdomen. He sought medical help at the Central District Hospital only on 08/08/2011. He was operated on as an emergency. The operation revealed multiple ruptures of the jejunum, common fibrinous-purulent peritonitis. Laparotomy, suturing of jejunum tears, debridement and abdominal drainage were performed. In the postoperative period, the phenomena of ongoing peritonitis, sepsis. He was consulted at the center for disaster medicine; he was transported by ambulance transport to the regional hospital. Blood test at admission: HB - 80 g / l, white blood cells 9.5 × 10 ⁹ , neutrophils 32, Potassium - 3.9 mmol / L, Sodium - 149 mmol / L, creatinine - 112 mmol / L, total protein - 43 g / l. After preoperative preparation 12.11.2011 was reoperated. Performed relaparotomy. On the operation, hemoperitoneum and inconsistency of sutures on the small intestine, continuing widespread fibrinous-purulent peritonitis, were found. An obstructive resection of the jejunum was performed with the formation and leaving of the stump of the small intestine in the abdominal cavity without anastomosis. Adductors were drained by intestinal intubation. Given the severe course of peritonitis, on November 14, 2011, 2 rehabilitation reaparotomy was performed, during which acute perforation of the small intestine was sutured and a controlled laparostomy was formed. November 15, 2011, an additional rehabilitation relaparotomy was performed. November 17, 2011, 4 programmed rehabilitation of the abdominal cavity was performed. During the audit, it was noted that the phenomena of peritonitis began to decrease. Given the positive dynamics, a delayed duodenoenteroanastomosis “side to side” was applied to the patient. After installing the drainage and before suturing the anterior abdominal wall in order to seal the intestinal sutures, a two-component composition was applied to the duodenoenteroanastomosis zone in the sequence: cryoprecipitate - 4-5 ml of sterile thrombin 15 units. NIH / ml - cryoprecipitate - 4-5 ml of sterile thrombin 15 units. NIH / ml. After 7 minutes, a dense fibrin clot formed in the anastomotic zone. The intestine is immersed in the abdominal cavity. Rare sutures were laid on the wound, mainly on the skin. The subsequent period was difficult. For 10 days was in the intensive care unit. Passage through the intestines gradually recovered, the patient's condition stabilized. Insufficiency of delayed duodenoenteroanastomosis was not noted. In satisfactory condition, the patient was discharged on December 13, 2011 for aftercare in the Central Hospital.

4. Patient V., 58 years old, was admitted to the purulent surgery department of the Regional Clinical Hospital KGBUZ on December 8, 2012, with complaints of moderate abdominal pain, the presence of a colostomy on the anterior abdominal wall and its poor functioning, and the intestinal contents from the drainage wound were isolated. in the left hypochondrium, temperature increase up to 38 ° С. From the anamnesis of the disease, it was found that on 02.11.2011, he was urgently operated on in the cold central hospital for a restrained diaphragmatic hernia on the left. The elimination of infringement, suturing of the left dome of the diaphragm, splenectomy, and the imposition of a loop colostomy were performed. Against the background of further almost a month-long treatment in the RCH, the patient had an intestinal fistula in the drainage wound of the left hypochondrium, the temperature began to rise to 38 ° С. Consulted at the regional center for disaster medicine, taken to the regional hospital. Upon admission, the condition is serious, due to sluggish peritonitis and abdominal sepsis. Blood test at admission: HB - 78 g / l, leukocytes 21.7 × 10 ⁹ , p-neutrophils - 25, Potassium - 4.5 mmol / l, Sodium - 134 mmol / l, creatinine - 95 mmol / l, total protein - 50 g / l. After preoperative preparation, December 9, 2011, relaparotomy was performed. During the operation, many interlobular abscesses, phenomena of widespread purulent peritonitis, colostomy failure, destruction of the small intestine with the formation of an unformed small intestinal fistula were found. Intestinal drainage, drainage of interloop abscesses, left-sided hemicolectomy with a colostomy, obstructive resection of the small intestine (zone of an unformed small intestinal fistula), rehabilitation and drainage were performed. Stumps of the small intestine, a stump of the colon, were formed, leaving them in the abdominal cavity. The colostomy was not excreted, the intestinal anastomosis was not superimposed. Considering the phenomena of widespread peritonitis, severe abdominal sepsis, on December 12, 2011, a reorganization relaparotomy was performed. 12/14/2011, when performing 3 reanimation relaparotomy, positive dynamics was noted during postoperative peritonitis. The patient was formed terminal transversostomy and superimposed delayed enteroenteroanastomosis "side to side". Before the end of the operation and the formation of a laparostomy in order to seal the intestinal sutures, a two-component composition was applied to the area of enteroenteroanastomosis in the sequence: cryoprecipitate - 4-5 ml of sterile thrombin 15 units. NIH / ml - cryoprecipitate - 4-5 ml of sterile thrombin 15 units. NIH / ml. After 6 minutes, a dense fibrin clot formed in the anastomotic zone. The intestine is immersed in the abdominal cavity. Formed laparostomy by rare sutures on the skin. However, the subsequent postoperative period was complicated by the formation of an unformed stomach fistula. The patient was operated repeatedly. 12/21/2011, 4 relaparotomy was performed with suturing of the unformed stomach fistula, debridement and drainage of the abdominal cavity. During this operation, it became possible to revise the reinforced intestinal anastomosis. It was noted that in the area of the inter-intestinal anastomosis there is a dense non-removable fibrin film that completely closes the joints and seals the fistula. In the subsequent patient, 12/23/2011, the final 5 programmed sanitation of the abdominal cavity was performed. The postoperative period was difficult. Against the background of intensive therapy, the patient's condition stabilized, the passage through the intestines was restored, the colostomy began to function. Laparostomy wound healed by secondary intention. Insolvency of superimposed enteroenteroanastomosis was not noted. The patient 02/01/2012, in satisfactory condition was discharged for aftercare in the Central Hospital.

Claims (1)

A method of sealing an intestinal anastomosis by adding local biological hemostatic drugs to the intestinal suture zone, characterized in that before immersion in the abdominal cavity and suturing of the middle wound onto the serous cover of the small intestine, 30-40 g of dry lyophilized cryoprecipitate are applied to the intestinal anastomosis, and to obtain stable fibrin and fix it at the site of the anastomosis, dry or lyophilized cryoprecipitate is added dropwise or 2-3 ml of a 5% solution of calcium chloride Do 4-5 ml of sterile thrombin 15. NIH / ml dissolved in a 5% solution of aminocaproic acid and 60 seconds after the formation of a gel-like fibrin film reapply the two-component composition.

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