RU2491101C1 - Method for prevention of wound complications in abdominoplasty - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely surgery and may be used as the prevention of wound complications in abdominoplasty. For this purpose, the immunotherapy is carried out with underlying administration of antibiotics and wound drainage. At first, 200 ml of patient's blood is taken into Hemacon system and thereafter separated by centrifugation at 3700 rpm for 20 minutes to plasma and leuko-thrombocyte and erythrocyte masses. The erythrocyte mass and plasma are returned into the patient. The leuko-thrombocyte mass is added with 200 ml of 0.9% NaCl solution to repeat centrifugation in the same mode for 20 minutes. A supernatant is removed. The leuko-thrombocyte mass is culture with 500000 IU of recombinant interferon-2 and 200 ml of 0.9% NaCl solution for 60 minutes at 37°C. Then, the centrifugation is repeated in the same mode to recover the supernatant containing an autologous cytokine complex. The prepared liquid is injected into subcutaneous fat within the area of tissue dissection in specific points. The first point is at 5 cm up from the postoperative cicatrix at the midline. The second point is at 5 cm up from the postoperative cicatrix on the left from the midclavicular line. The second point is at 5 cm up from the postoperative cicatrix on the right from the midclavicular line. The fourth point is found in the middle of a segment connecting the xiphoid and umbilicus. The solution is introduced into the first point in parallel to the postoperative cicatrix on the left and right in a dose of 5 ml with needle extraction. The solution is introduced into the second and third points in parallel to the postoperative cicatrix in the lateral direction and perpendicular to the postoperative cicatrix back from the cicatrix in a dose of 5 ml with needle extraction. The solution is introduced into the fourth point along the midline towards the cicatrix and back from the cicatrix in a dose of 5 ml with needle extraction. The solution is introduced on the 1^st and 3^rd postoperative days.

EFFECT: method allows preventing the local wound complications following abdominoplasty by carrying out the local cytokine therapy into specific points that provides higher non-specific immunity and immune responsiveness within the surgical wound.

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Description

The invention relates to medicine, namely to the field of surgery, and can be used to prevent local wound: inflammatory, infectious and purulent complications in patients after abdominoplasty.

A known method of treatment using interleukin-2 for advanced bacterial infections (German patent No. 3910011, AK 37/02, 1990). Therefore, the method of introducing interleukin-2 intravenously, subcutaneously, intraperitoneally, intramuscularly leads to an increase in the nonspecific cellular response, which helps to reduce the number of bacteria in the peritoneal cavity and lower endotoxins in the blood plasma. The method according to the patent can be used by administering interleukin-2 at a dose of 1-3.5 * 10 to the 6th power unit / kg in the postoperative period, conditions after severe trauma, widespread gram-positive and gram-negative infection, peritonitis.

There is also a known method (PCT No. 94/04174, class A61K 37/02, 1992), in which natural xenogenic cytokines are used to enhance the immune response to the pathogen.

However, with these methods of using cytokines, they are rapidly excreted, which necessitates the use of cytokines in high doses, which can cause pronounced adverse toxic reactions.

A known method of adaptive immunotherapy for the treatment of patients with purulent-septic processes (RU No. 2098125 C1, A61K 38/20, A61K 38/00), in which mononuclear cells are isolated, cultured with interleukin-2 and returned parenterally to the patient, and the existing purulent cavities washed with a solution containing a combination of cytokines obtained by culturing mononuclear cells with inteleukin-2.

This method is used only in combination with intravenous administration and is not used as an independent method of local cytokine therapy alone; It is used only in the treatment of purulent wounds, and not for preventive purposes. The low permeability of the drug when washing, requiring a higher concentration of the drug, the frequency and duration of use, as well as increasing the duration of treatment are the disadvantages of this method.

A known method for the prevention of postoperative purulent complications in the field of surgical intervention and treatment of infected postoperative wounds without purulent discharge using a complex of autologous cytokines in which subcutaneous injections are used to create an infiltration shaft in the surgical area at a distance of 1.5 cm from the edges of the wound (RF Patent No. 2394602 , IPC A61M 1/38; A61K 31/7042; A61K 38/19; A61P 37/00; A61P 41/00. Bull. No. 20 dated 07/20/2010).

This method is used to prevent only purulent complications and treat infected postoperative wounds.

There is a method of treating purulent wounds, including pre-treatment of the wound with an antiseptic followed by the introduction of Superlimph (a heterologous complex of natural cytokines obtained from cultures of stimulated peripheral blood leukocytes) into the wound with a thymogen in a volume ratio of 1:10, once in the first, second, third, the seventh, fourteenth and twenty first days by chipping the inner surface of the wound with preparations at the rate of 0.1 ml of solution per 1 cm of wound (RU No. 2228763 C1, A61K 38/19).

With this method of local cytokine therapy, a heterologous complex of cytokines, which is less specific for each individual organism, is used to treat purulent wounds.

Also, this method uses six-time administration of the drug, and to achieve the result of treatment of purulent wounds, the use of thymogen is necessary.

The main way to prevent wound complications in surgical practice, including during abdominoplasty, is antibiotic prophylaxis (Clinical Surgery, National Guide, edited by V.S. Savelyev, M., 2008, Volume 1, pp. 158-162). When abdominoplasty is performed, prophylactic antibiotic therapy is carried out according to the generally accepted scheme. One therapeutic dose of the antibiotic should be administered once intravenously immediately before the skin incision and simultaneously with the start of introductory anesthesia, i.e. before bacterial contamination of tissues. Ideal antibiotics for perioperative prophylaxis are cephalosporins of 1-3 generations: cefazolin, ceftriaxone, cefoperazone, cefotaxime. After surgery, antibiotic therapy is continued with the same drug (in the absence of purulent complications, in preventive doses) (Plastic Surgery Course: Manual for Doctors. 2 volumes / Edited by K.P. Pshenisnov. Yaroslavl; Rybinsk: Rybinsk Press House, 2010) .

The disadvantages of antibiotic prophylaxis include insufficient effectiveness in conditions of polyantibiotic resistance of nosocomial microflora, the possibility of the formation of antibiotic resistance of microbes in the wound due to short-term exposure to the antibiotic, the need for systemic exposure to the antibiotic, and the high cost of the method with its routine use. Randomized trials have not shown a significant decrease in the incidence of infection in the surgical field with antibiotic prophylaxis (Perioperative antibiotic prophylaxis in abdominal surgery. A manual for doctors. Edited by V.D. Fedorov, V.G. Pleshkov, L.S. Strashunsky, M. , 2004).

The objective of the present invention is to increase the effectiveness of methods for the prevention of local wound complications in patients after abdominoplasty using local cytokine therapy, by increasing the non-specific immune response and immunological reactivity in the field of postoperative wounds.

The problem is solved by the method of preventing local wound complications after abdominoplasty, including antibiotic prophylaxis, drainage. Immunotherapy is carried out, for which a patient is taken 200 ml of blood into the Gemakon system, the blood obtained is separated by centrifugation at 3700 rpm for 20 minutes into plasma, leukotrombocytic and erythrocyte masses. The erythrocyte mass and plasma are returned to the patient, 200 ml of 0.9% NaCl solution are added to the leukotrombocyte mass, centrifugation is repeated in the same mode for 20 minutes, the supernatant is removed. The platelet mass is cultured with 500,000 IU of recombinant interleukin-2 and 200 ml of 0.9% NaCl solution for 60 minutes at a temperature of 37 ° C. Then centrifuged again in the same mode with the release of the supernatant containing a complex of autologous cytokines. The resulting supernatant is injected into the subcutaneous fat in the tissue dissection zone at the points located as follows: the first point is 5 cm up from the postoperative scar along the midline; the second point is 5 cm up from the postoperative scar along the midclavicular line on the left; the third point is 5 cm stepping up from the postoperative scar along the midclavicular line to the right; the fourth point in the middle of the segment connecting the xiphoid process and the navel. At the first point, the solution is injected in parallel to the direction of the postoperative scar 5 ml to the right and left on the needle extraction, at the second and third points the solution is administered parallel to the postoperative scar in the lateral direction and perpendicular to the postoperative scar in the direction from the scar of 5 ml on the needle extraction, to the fourth point the solution is introduced along the midline towards the scar and from the scar 5 ml each by removing the needle on the 1st, 3rd day after the operation.

The novelty of the invention:

- Immunotherapy is carried out, for which a patient is taken 200 ml of blood into the Gemakon system, the blood obtained is separated by centrifugation at 3700 rpm for 20 minutes into plasma, leukocyte and erythrocyte masses, erythrocyte mass. The plasma is returned to the patient, 200 ml of 0.9% NaCl solution are added to the platelet mass, centrifugation is repeated in the same mode for 20 minutes, the supernatant is removed. The platelet mass is cultured with 500,000 IU of recombinant interleukin-2 and 200 ml of 0.9% NaCl solution for 60 minutes at a temperature of 37 ° C. Then centrifuged again in the same mode with the release of the supernatant containing a complex of autologous cytokines.

- The resulting supernatant is injected into the subcutaneous fat in the tissue dissection zone at the points located as follows: the first point is 5 cm upward from the postoperative scar along the midline; the second point is 5 cm up from the postoperative scar along the midclavicular line on the left; the third point is 5 cm stepping up from the postoperative scar along the midclavicular line to the right; the fourth point in the middle of the segment connecting the xiphoid process and the navel.

- At the first point, the solution is injected in parallel to the direction of the postoperative scar 5 ml to the right and left on the needle extraction, at the second and third points the solution is administered parallel to the postoperative scar in the lateral direction and perpendicular to the postoperative scar in the direction from the scar of 5 ml on the needle extraction, in the fourth the solution point is introduced along the midline towards the scar and from the scar 5 ml each on the extraction of the needle on the 1st, 3rd day after the operation.

This volume of the solution, which amounts to 40 ml in total, is sufficient to impregnate the tissues in the area of their dissection.

The introduction of a solution with a complex of autologous cytokines in the first and third days of the postoperative period is explained by the duration of the phase of inflammation in the postoperative wound, which is 5-7 days, while the highest severity of inflammation is observed in 1-4 days of the postoperative period.

The proposed method allows to avoid additional surgical actions associated with puncture, developed seromas and / or hematomas, as well as actions regarding the development of purulent complications from the wound, which is a new technical result of this invention.

The method allows to avoid additional costs for drug provision, improve treatment results, reduce hospitalization and the period of disability, provide earlier recovery of physical activity.

Our proposed method of introducing autologous cytokines into subcutaneous fat, in the area most susceptible to trauma, allows optimizing inflammation processes, stimulating immune-dependent repair reactions, thereby preventing the development of wound complications and accelerating the healing process.

For the first time in surgical practice, local cytokine therapy was used to prevent the development of local complications from the postoperative wound of the anterior abdominal wall after abdominoplasty with the introduction of a complex of autologous cytokines into the subcutaneous fat. The selected points for the injection of the solution and the technique used for its administration allows for uniform distribution of the drug directly in the zone of interest. The introduction of the drug in the calculation of 10 ml of solution for each intended point, with a total volume of 40 ml, is due to the fact that this creates sufficient impregnation of tissues in the area of their dissection.

The introduction of a complex of autologous cytokines into subcutaneous fat, unlike intravenous, intramuscular and application, allows you to quickly create a higher concentration of the drug in the area of interest to us, which seriously increases the effectiveness of the action. The drug is injected directly into the area of injured tissues, where a local immune response and an increase in immunological reactivity are formed.

The set of essential features in the literature available to us was not found, therefore, the invention meets the criterion of "novelty."

The invention is illustrated in the drawing presented in figure 1.

Figure 1 shows the location of the points for injection relative to the postoperative scar and the arrows show the direction of movement of the needle during removal.

Figure 1 points for injection 1, 2, 3, 4, postoperative scar 5.

The method is as follows:

When abdominoplasty is performed in the postoperative period, local cytokine therapy is used by introducing a complex of autologous cytokines into subcutaneous fat.

Methods for preparing a complex of autologous cytokines:

A 200 ml sample is taken from the patient. blood system "Gemakon", divide the blood obtained by centrifugation at 3700 rpm for 20 min on plasma, leukotrombocyte and erythrocyte masses, erythrocyte mass and plasma are returned to the patient, 200 ml of 0.9% NaCl solution is added to the leukotrombocyte mass, repeat centrifuging in the same mode for 20 min, remove the supernatant; the platelet mass is cultured with 500,000 IU of recombinant interleukin-2 and 200 ml of 0.9% NaCl solution for 60 minutes at a temperature of 37 ° C. Then the solution is centrifuged in the previous mode, the supernatant containing autologous cytokines is taken into sterile vials, and the remaining leukotrombocyte mass is returned to the patient.

Subsequently, the resulting solution containing a complex of autologous cytokines is injected into the subcutaneous fat in 10 ml each at the intended points (total 40 ml).

The points are located as follows: the first point is 5 cm back up from the postoperative scar along the midline; the second point is 5 cm up from the postoperative scar along the midclavicular line on the left; the third point is 5 cm stepping up from the postoperative scar along the midclavicular line to the right; the fourth point in the middle of the segment connecting the xiphoid process and the navel. At the first point, the solution is injected in parallel to the direction of the postoperative scar 5 ml to the right and left on the needle extraction, at the second and third points the solution is administered parallel to the postoperative scar in the lateral direction and perpendicular to the postoperative scar in the direction from the scar of 5 ml on the needle extraction, to the fourth point the solution is introduced along the midline towards the scar and from the scar 5 ml each by removing the needle on the 1st, 3rd day after the operation.

Clinical example No. 1

Patient F., 41 years old (medical history No. 578), was admitted to the surgical department No. 3 on a planned schedule 07.12.2011. at 08.00 with a diagnosis of Excess subcutaneous tissue of the anterior abdominal wall and lateral abdomen. Diastasis of the rectus abdominis muscles of a moderate degree. Sagging stomach III degree.

About 15 years ago, she drew attention to the appearance of an excess of subcutaneous tissue in the region of the anterior abdominal wall and lateral sections of the abdomen, diastasis of the rectus abdominis muscles after weight loss.

General condition is satisfactory. Body temperature 36.0 C. The pulse is 72 beats per minute, good filling and tension, rhythmic. Heart sounds are clear, rhythmic, no noise, blood pressure 130/90 mm. Hg The volume of the abdomen is 110 cm. There is an excess of subcutaneous tissue in the anterior abdominal wall and lateral parts of the abdomen, maximally in the meso- and hypogastrium, along the midline, and other volume formations in the subcutaneous tissue are not clearly defined. The thickness of the altered (moderate cicatricial changes in the skin in hypogastrium) skin-fat fold up to 10.5 cm (in the hypogastric region and maximally along the midline). Skin turgor reduced. Sagging stomach III degree. There is also diastasis of the rectus abdominis muscles along the midline up to 5 cm throughout. BMI = 38.8.

Complete blood count: Er. - 5.1 * 10 ¹² / l; Hb - 145 g / l; Lx - 9.0 * 10 ⁹ / l; L - 28%; M - 6%; PO Box - 5%; s / s - 60%; eos. - 0%; ESR - 3 mm / h;

Biochemical blood test: protein total. - 67 g / l; urea - 4.8 mmol / l; bilirubin commonly - 8.8 μmol / l;

amylase - 37 U / l; glucose - 5.6 mmol / l; potassium - 4.3 mmol / l; sodium - 138 mmol / l; fibrinogen - 3.75 g / l;

ECG: Sinus rhythm, moderate dystrophic changes in the myocardium.

After preoperative preparation, antibiotic prophylaxis by the intravenous administration of cefazolin 2.0 g, the operation was performed as planned on 12/07/2011: Liposuction of the anterior abdominal wall and lateral abdomen. Abdominoplasty with suturing of diastasis of the rectus abdominis muscles. Lipoaspiration of a fat suspension in a volume of 4000 ml. The excess subcutaneous fat flap was cut off, the size of the flaps was 22 × 31 × 23 cm on the left and 21.5 × 36 × 22 cm on the right, the total mass of the resected flap was 1300 g. To the right and to the left below the corner of the wound, 2 drainage tubes with an inner diameter of 5 mm type Redon, draining subcutaneous tissue along the upper and lower edges of the detachment zone.

Diagnosis after surgery: Excess subcutaneous tissue of the anterior abdominal wall and lateral abdomen. Diastasis of the rectus abdominis muscles of a moderate degree. Sagging stomach III degree.

Further treatment in the surgical department No. 3. Antibiotic prophylaxis: cefazolin 2.0 g 2 times a day intramuscularly for 5 days. Infusion therapy for 2 days, hemostatic therapy: ethamsylate 12.5% 2.0 × 3 times a day intramuscularly for 2 days. Compression underwear.

In the first and third days of the postoperative period, blood was taken in a volume of 200 ml and a solution of autologous cytokines was prepared according to the method described above.

The introduction of a complex of autologous cytokines into the subcutaneous fat was carried out twice by the proposed method on the first and third days of the postoperative period, 40 ml per administration. Complications during administration were not observed.

After the operation, the general state of moderate severity, subfebrile condition in the first two days after the operation, the maximum rise in body temperature to 37.3 ° C. Hyperleukocytosis and neutrophilic stab shift in the general analysis of blood was not observed, biochemical parameters within normal limits.

The postoperative period is favorable. Drainage tubes removed on the 3rd day. No complications from the postoperative wound were observed, wound healing by primary intention. The patient was discharged on the 6th day after surgery in a satisfactory condition.

Clinical example No. 2

Patient B., 47 years old (medical history No. 4), was admitted to the surgical department No. 3 on a planned schedule 11.01.2012. at 08.45 with a diagnosis of: Excess subcutaneous tissue of the anterior abdominal wall and lateral abdomen. Sagging stomach III degree. Diastasis of the rectus abdominal muscles of a moderate degree. Concomitant: Arterial hypertension of the II degree, compensation.

After childbirth, 10 years ago, she drew attention to an excess of subcutaneous tissue in the area of the anterior abdominal wall and lateral abdomen, diastasis of the rectus abdominis muscles.

General condition is satisfactory. Body temperature 36.6 C. The pulse is 68 beats per minute, good filling and tension, rhythmic. Heart sounds are clear, rhythmic, no noise. HELL 140/90 mm Hg The volume of the abdomen is 115 cm. There is an excess of subcutaneous tissue in the anterior abdominal wall and lateral parts of the abdomen, a coarse retracted postoperative scar from the womb to the xiphoid process 31 × 1.1 cm in size, and other volume formations in the subcutaneous tissue are not clearly defined. The thickness of the skin-fat fold is up to 3.5 cm (maximum in the hypogastric region and the lateral abdomen). Skin turgor reduced. Sagging stomach III degree.

Moderate diastasis of the rectus abdominis muscles mainly in mesogastrium. BMI = 38.1.

Complete blood count: Er. - 4.7 * 10 ¹² / l; Hb - 137 g / l; Lx - 6.3; * 10 ⁹ / l L - 47%; M - 9%; PO Box - 3%; s / i - 40%; eos. - 0%; ESR - 3 mm / h.

Biochemical blood test: protein total. - 79.2 g / l; urea - 3.2 mmol / l; bilirubin commonly - hemolysis; amylase - 60 U / l; glucose - 5.5 mmol / l; potassium - 4.6 mmol / l; sodium - 149 mmol / l;

ECG: Sinus rhythm, metabolic-dystrophic changes.

After preoperative preparation, antibiotic prophylaxis by the intravenous administration of cefazolin 2.0 g, the following operation was performed on a planned order 11.01.2012: Liposuction of the anterior abdominal wall and lateral abdomen. Abdominoplasty with suturing of diastasis of the rectus abdominis muscles. Lipoaspiration of a fat suspension in the amount of 4300 ml. The excess subcutaneous fat flap was cut off, measuring 38.5 × 31.5 × 28 cm, the total mass of the resected flap was 1700 g. To the right below the wound angle through a separate puncture, a drainage tube with an inner diameter of 5 mm was removed according to Redon’s type, draining the subcutaneous tissue.

Diagnosis after surgery: Excess subcutaneous tissue of the anterior abdominal wall and lateral abdomen. Sagging stomach III degree. Diastasis of the rectus abdominal muscles of a moderate degree. Concomitant: Arterial hypertension of the II degree, compensation.

Further treatment in the surgical department No. 3. Antibiotic prophylaxis: cefazolin 2.0 g 2 times a day intramuscularly for 5 days. Infusion therapy for 3 days, hemostatic therapy: ethamsylate 12.5% 2.0 × 3 times a day intramuscularly for 2 days. Therapy aimed at improving microcirculation, rheological properties of blood: pentoxifylline 100 mg 2 times a day intravenously for 3 days. Compression underwear.

In the first and third days of the postoperative period, blood was taken in a volume of 200 ml and a solution of autologous cytokines was prepared according to the method described above.

The introduction of a complex of autologous cytokines into the subcutaneous fat was carried out twice by the proposed method on the first and third days of the postoperative period, 40 ml per administration. Complications during administration were not observed.

After the operation, the general state of moderate severity, subfebrile condition in the first three days after the operation, the maximum rise in body temperature to 37.6 ° C. Hyperleukocytosis and neutrophilic stab shift in the general analysis of blood was not observed, biochemical parameters within normal limits.

The postoperative period is favorable. Drainage tubes removed on day 4. No complications from the postoperative wound were observed, wound healing by primary intention. The patient was discharged on the 6th day after surgery in a satisfactory condition.

The proposed method was used in 5 patients. There were no complications during this technique.

Thus, the use of the proposed method of local cytokine therapy as a method of preventing the development of local wound complications can significantly improve the results of treatment of patients after abdominoplasty.

Claims (1)

A method for the prevention of wound complications in abdominoplasty, including antibiotic prophylaxis, drainage, characterized in that immunotherapy is carried out, for which a patient is taken 200 ml of blood into the Gemakon system, the obtained blood is separated by centrifugation at 3700 rpm for 20 minutes at plasma, leukocyte and erythrocyte masses, erythrocyte mass and plasma are returned to the patient, 200 ml of a 0.9% NaCl solution are added to the leukocyte mass, centrifugation is repeated in the same mode in for 20 min, remove the supernatant; the platelet mass is cultured with 500,000 IU of recombinant interleukin-2 and 200 ml of 0.9% NaCl solution for 60 min at 37 ° C, then centrifuged again in the same mode with the release of a supernatant containing a complex of autologous cytokines, which is injected into the subcutaneous fat in the tissue dissection zone at the points located as follows: the first point is 5 cm up from the postoperative scar along the midline; the second point is 5 cm up from the postoperative scar along the midclavicular line on the left; the third point is 5 cm stepping up from the postoperative scar along the midclavicular line to the right; the fourth point in the middle of the segment connecting the xiphoid process and the umbilicus, the solution is injected at the first point parallel to the direction of the postoperative scar to the right and left, 5 ml each on the needle, the solution is injected at the second and third points parallel to the postoperative scar in the lateral direction and perpendicular to the postoperative scar in the direction from a scar of 5 ml per needle extraction, at the fourth point the solution is injected along the midline towards the scar and from a scar of 5 ml per needle extraction on the 1st, 3rd day after surgery.

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