RU2559921C2 - Method of restoring small intestine integrity - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to experimental surgery. A defect of the small intestine is closed by hermetic sewing of an implant from a biodegradable silk fibroin. A thread is passed in the depth of the small intestine, without damaging the mucous membrane. The implant is preliminarily soaked in the homogenate of the allogeneic or autologous bone marrow for 30 minutes.

EFFECT: method makes it possible to restore the integrity of the intestinal wall and a layer-by-layer structure of the small intestine in the area of implantation.

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Description

Technical field

The invention relates to medicine and biotechnology, namely to gastroenterology, surgery and medical biotechnology.

State of the art

According to general estimates, injuries of the small intestine account for up to 36% of all injuries of the internal organs. Damage to the small intestine occurs not only as a result of injuries, but also as complications of a number of clinical conditions (peptic ulcer, oncology). The need to restore the integrity of the intestinal wall arises as a result of surgical interventions on the small intestine. In most cases, this is achieved by applying a manual or mechanical staple seam.

When using a manual suture, there is a risk of insufficient tightness and hemostasis, the development of regional necrosis, healing by secondary intention with the formation of strictures (Buyanov V.M., Egiev V.N., Udotov O.A., Surgical suture. M .: Rapid-print, 1993. S. 101).

A mechanical stitch seam applied with staplers makes the operation technique much easier. Modern staplers allow you to control the degree of tissue compression and their comparison (Egiev V.N., The magical world of staplers. M: Center, 1995. P.176). Along with the indisputable advantages of a mechanical suture, its drawbacks are bleeding from the suture line, the presence of a foreign body between the connected tissues (tantalum staples), healing by secondary intention, infection of the abdominal cavity due to through stitching, and the apparatus is expensive. Research in this area shows that both methods (manual seam and mechanical seam) are almost equal in quality, and the final choice depends on the personal preferences of the surgeon.

But existing methods do not solve the problems of leakage of sutures and, mainly, the development of contractions, strictures of the digestive tube. Therefore, today there is a need to create new methods of treating injuries of the gastrointestinal tract (GIT).

The aim of the invention, which coincides with its technical result, is to develop a method of structural and functional restoration of the small intestine after violation of its integrity of various etiologies.

The authors drew attention to one of the most dynamically developing areas of modern biomedical science - regenerative medicine, which allows finding fundamentally new ways to solve the above problem.

Regenerative medicine makes it possible to create, on the basis of nano- and microstructured biocompatible materials, artificial analogues of organs and tissues, which are able to temporarily replace the lost functions of natural organs and tissues and contribute to their full recovery. Systems containing organs and tissues from biocompatible materials are called bioartificial or hybrid and are a combination of a biostable or biodegradable matrix (scaffold, carrier) based on materials of various nature and functioning cells of various organs and tissues. One of the elements of the technology for creating bio-artificial organs is the formation of a three-dimensional framework of biocompatible materials that mimic the structure of healthy tissue. Such three-dimensional frameworks are called matrices or matrices. Artificial matrices determine the mechanical properties, the shape of the implant, form a substrate for cell adhesion. Such matrices are used to correct extensive defects of the gastrointestinal tract, performing the barrier function at the initial stages, and subsequently ensuring full restoration of all layers of the damaged wall without the formation of stenosis and narrowing of the digestive tube.

The use of artificial biodegradable materials for surgical treatment of abdominal organs is an actual area of biomedical research. So, for the prevention of adhesion formation, membranes made of sodium hyaluronate and carboxymethyl cellulose (Seprafilm®, Genzyme Corp., Cambridge, MA) (Moreira H. Jr., Wexner SD, Yamaguchi T. et al. Use of bioresorbable membrane (sodium hyaluronate + carboxymethylcellulose) ) after controlled bowel injuries in a rabbit model // Dis Colon Rectum. 2000 Feb; V.43 (2). P.182-7). To correct more severe disorders - perforations of the stomach - allo and xenogenic submucosa of the small intestine or pig omentum (de la Fuente SG, Gottfried MR, Lawson DC et al. Evaluation of porcine-derived small intestine submucosa as a biodegradable graft for gastrointestinal healing. J Gastrointest Surg (2003) V.7. P.96-101; Siu WT, Chau CH, Law BK et al. Routine use of laparoscopic repair for perforated peptic ulcer. Br J Surg (2004) V.91. P .481-484; Ueno T., Oga A., Takahashi T., Pappas TN Small intestinal submucosa (SIS) in the repair of a cecal wound in unprepared bowel in rats. J Gastrointest Surg 2007). Studies in humans using polygactin or prolene plugs + fibrin glue or cyanoacrylate sealants have been successful (Truong S., Bohm G., Klinge U., Stumpf M., Schumpelick V. Results after endoscopic treatment of postoperative upper gastrointestinal fistulas and leaks using combined Vicryl plug and fibrin glue. Surg Endosc (2004) V.1811. P.05-1108; Disibeyaz S, Parlak E., Koksal AS et al. Endoscopic treatment of a large upper gastrointestinal anastomotic leak using a prolene plug and cyanoacrylate. Endoscopy (2005) V.37. P.1032-1033). Gore Bioabsorbable Hernia Plug (Cios TJ, Reavis KM, Renton DR, Hazey JW, Mikami DJ, Narula VK, Allemang MT, Davis SS, Melvin WS Gastrotomy closure using bioabsorbable plugs in a canine model / showed good results in dog experiments / Surg Endosc. 2008 V.22 (4). P.961-6).

However, all of the above methods relate to point perforations. There is no evidence that the materials used in these works can be used to correct more severe (extensive) gastrointestinal injuries.

The essence of the claimed method consists in introducing an implant from a biodegradable material into the region of the small intestine defect, which is kept for 30 minutes in a homogenate of autologous or allogeneic bone marrow tissue, subsequent fixation of the implant by tightly sewing with nodal sutures to restore the structural and histological integrity of the small intestine wall.

The biodegradable material of this invention is silk fibroin, which is by far one of the most promising biodegradable materials. The most important advantage of silk fibroin matrices is the high adhesion of cells responsible for regeneration to them. During implantation, these constructs are not rejected by the immune system, but are replaced by surrounding tissue with the participation of immunocompetent cells. The products of their biodegradation are non-toxic (Konkov AS, Pustovalova OL, Agapov II. Biocompatible materials from regenerated silk for tissue engineering and drug therapy // Biotechnology, 2010, No. 1. P.9-16).

A promising approach is the vitalization of matrices from biodegradable materials by cellular compositions. The greatest biomedical safety, compliance with existing and developing legal standards is carried out by the methods of vitalization, consisting in keeping the object in the homogenate of autologous or syngeneic bone marrow cells with minimal extracorporeal exposure. The use of autologous and syngeneic material, the absence of a stage of its cultivation, technical accessibility and safety determine the possibility of using these techniques also for the needs of extreme medicine.

The use of the above techniques for suturing when embedding an implant made of biodegradable material, silk fibroin in a damaged area of the small intestine, which has been maintained in a homogenate of autologous, syngeneic or allogeneic bone marrow cells, allows creating an effective way to restore the integrity and structure of the small intestine in case of injuries of varying severity.

Experimental studies have shown that the best results can be obtained by fixing the implant around the perimeter with a nodal suture.

The claimed method is illustrated by the following example.

Example 1. Implants are obtained by longitudinal dissection into two parts of silk fibroin tubes. As a result, the implant is a rectangle with dimensions: 0.9 × 0.7 cm.

Before transplantation, the implants are washed in physiological saline (0.9% NaCl), then they are kept in the allogeneic bone marrow (CM) homogenate for 30 minutes: male Wistar rats are donors, CMs are isolated from the femur; 0.3 ml of CM are homogenized in 4.5 ml of physiological saline.

Two days before the surgical intervention of animals (recipients of male rat Wistar, weight 280-320 g) deprived of solid food. Animals receive a 10% glucose solution without restriction (per os). The operation is performed under general anesthesia (Zoletil + Xylazine), premedication - atropine sulfate at a dose of 0.04 mg / kg, subcutaneously 15 minutes before the intervention. Animals are fixed in position on the back. The surgical field is limited to sterile gauze wipes, a laparotomy is performed. A section of the jejunum 7 cm distal to the stomach is removed into the surgical wound, after which an oval-shaped section of the intestinal wall 0.8 × 0.6 cm is excised from the mesenteric edge of the intestine. Next, from the side of the serous membrane of the intestine, 5-6 nodal sutures are applied around the perimeter, hermetically fix the implant to the wall, creating a kind of “patch” from the implant in the affected area. The thread is carried out in the thickness of the intestinal wall without damaging the mucous membrane (Fig. 1).

The intestine is placed in the abdominal cavity, after which layer-by-layer suturing of the cavity is performed tightly. At the beginning of the operation, ceftriaxone is administered intramuscularly at the rate of 100 mg / kg body weight, then daily injections of ceftriaxone are performed for 4 days at the rate of 50 mg / kg body weight.

In the postoperative period, animals receive a 10% glucose solution for 2 days, after which they are transferred to a standard diet.

For histological evaluation of the results of the operation at periods of 1-2-3 weeks, animals are euthanized. The layers of the anterior abdominal wall are dissected in layers, the jejunum is removed and the intestine of interest is circularly resected, the length of the resected area is: implant length + 4 mm.

With a macroscopic examination, 1 and 2 weeks after surgery, the implant is visualized in the thickness of the soft tissues of the intestinal wall; after 3 weeks, the implant is not visualized, restoration of the intestinal wall is noted. During histological examination, by the 3rd week after implantation, restoration of all layers of the intestinal wall is observed, the implant is not registered.

The above example confirms that the use of the presented method for restoring the integrity of the small intestine allows not only to directly close the defect by sewing a patch from the vitalized biodegradable material by the specified method, but also completely restore the histological structure of the wall of the small intestine at the fixation site of the implant.

Claims (1)

A method of restoring the integrity and structure of the small intestine, which consists in introducing an implant of biodegradable material into the region of the small intestine defect, which is kept for 30 minutes in the homogenate of autologous or allogeneic bone marrow tissue, and subsequent fixation of the implant by tightly sewing with nodal sutures around the implant from the side serous membrane of the intestine to restore the structural and histological integrity of the wall of the small intestine, using biodegradable fiber material Ina silk.

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