RU2563796C1 - Method of treating ischemic hepatic injuries - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: hepatectomy using an intraoperative extracorporeal temporal portacaval shunt is performed in an experimental animal. On the day of the surgical intervention, the slow intravenous bolus administration of Heptral, the solution for injections, follows 1.5 hours prior to the surgical intervention in a dose of 2 mg/kg, 2 hours after the first administration - in a dose of 6 mg/kg and 8 hours after the first administration - in a dose of 4 mg/kg. What is also required is the slow intravenous bolus administration of Clarithromycin in NaCl solution 0.5 in a dose of 3 mg/kg three times a day at 7⁰⁰, 15⁰⁰ and 23⁰⁰. The postoperative period involves administering Heptral two times a day - at 9⁰⁰ in a dose of 7 mg/kg, at 16⁰⁰ in a dose of 5 mg/kg; Clarithromycin - three times a day at 7⁰⁰, 15⁰⁰ and 23⁰⁰ in a dose of 3 mg/kg. The total length of administering Heptral and Clarithromycin is 10 days.

EFFECT: method provides treating, correcting and preventing a surgical infection, ischemic and reperfusion hepatic injuries, lengthening safe periods of liver exsanguinations and avoiding major haemorrhages potentially accompanying the hepatic surgical intervention.

3 ex, 5 tbl

Description

The invention relates to medicine, namely to experimental surgery, and can be used when performing a liver resection.

The problem of intraoperative bleeding with massive blood loss during liver resections is one of the most important (Gantsev Sh. Kh. Intraoperative liver perfusion during surgical interventions on the abdominal organs. // Soviet medicine. - 1987. - No. 10. - P. 10-12.) . The most optimal and effective way to prevent this is to squeeze the hepatoduodenal ligament, which allows for temporary hemostasis and important stages of the operation with minimal blood loss (Veronsky GI Anatomical and physiological aspects of liver resection. - Novosibirsk: Nauka, 1983. - 185 s. ) However, hemodynamics are destabilized, portal hypertension is increasing, liver hypoxia and ischemia develop, which, if the threshold is exceeded for 20 minutes, can lead to irreversible morphological and functional changes in the liver, up to necrotic changes in hepatocytes (Antopolskaya E.V. Correction of ischemic liver damage during resection in conditions of bloodlessness: Abstract of thesis ... Candidate of Medical Sciences. - Kharkov, 1988. - 21 s).

To prevent and correct metabolic disorders in the cell, various drugs with an antioxidant effect are used - dibunol, sodium oxybutyrate, cytochrome C, etc. (Bilenko M.V. Theoretical and experimental justifications for the use of antioxidant therapy for the prevention of acute ischemic damage in organs. : Bioantioxidants in the regulation of metabolism in normal and pathological conditions. - M, 1982. - P. 195-213; Okovity S.V. Clinical pharmacology of antihypoxants (part II). // PHARMindeks-Practik. - 2004, 7 - P. 48- 63), but essentially their arsenal is limited, and the methods used do not yet allow a significant increase in the duration of liver anoxia.

Another direction in the fight against hepatic ischemia is the desire to protect the microvasculature of the liver through the use of drugs with different mechanisms of action. In particular, attempts are being made to influence the development of smooth muscle insufficiency of microvessels (A. P. Simonenkov. V. D. Fedorov, V. M. Klyuzhev, V. N. Ardashev. The use of adipinate serotonin to restore impaired smooth muscle function in surgical and therapeutic patients. // Bulletin of intensive care - 2005 - No. 1. - S. 1-6; Simonenkov AP, Fedorov VD On the unity of tissue hypoxia and shock. // Anest. and resuscitation. - 2000 - No. 6 . - S. 73-76; Simonenkov A.P., Fedorov V.D., Fedorov A.V. et al. Mechanism of endogenous vasomotor and smooth antiplaque failure microvasculature .// Journal of Medical Sciences -. 1994. - №6 -. pp 11-15). However, many well-known methods of influencing the microvasculature of the liver are not always able to prevent the occurrence and stop the already developed ischemic lesion of the hepatic parenchyma.

The closest is a method for the correction of ischemic damage to the liver under conditions of its bleeding, the essence of which is the intravenous administration of 5 mg of a 1% solution of serotonin-adipinate to the experimental animal before and within 30 minutes after compressing the hepatoduodenal ligament (PDS) in order to prevent the development of smooth muscle insufficiency of the microvasculature of the liver (patent No. 2134576 dated 03/11/1998). This method helps to eliminate smooth muscle insufficiency of the microvasculature, thereby improving endogenous vasomotor.

The disadvantage of this method is that the authors limited themselves to the use of a drug that regulates microcirculation, without correction of other inevitably occurring disorders caused by the effects of ischemia, such as activation of lipid peroxidation processes and structural and functional changes of varying severity (Bezugly V.P. Hypoxia and its role in liver pathology // Advances in Hepatology. - Riga, 1971. - Issue 3. - P. 94-110 .; AO Bueverov. Oxidative stress and its role in liver damage // Russian Journal of Gastroent rheology, hepatology, coloproctology. - 2002. - T. XII. - No. 4. - P. 21-25 .; Merzhinsky V.E., Konvay V.D. Effect of stopping regional blood flow in the liver on the state of lipid peroxidation // Violation of regulatory mechanisms in extreme and terminal conditions. - Omsk, 1991. - P. 57-61.), And a double administration of the drug only on the day of surgery is not enough for the treatment and prevention of hypoxic and reperfusion injuries of the liver tissue. In addition, the use of this method does not exclude the possibility of joining a surgical infection and does not prevent its development in the area of surgical intervention, which increases the risk of the formation of abscesses, phlegmon, the development of peritonitis and other purulent complications. The disadvantages of this method can also include the refusal to use extracorporeal portocaval bypass surgery, which, with portal hyperthesis, which inevitably develops after blockade of the hepatoduodenal ligament, effectively contributes to decompression of the portal system (A. Yeramishantsev, Past and present surgery of portal hypertension: a look at the problem. // Russian Journal of Gastroenterology, Hepatology, Coloproctology - 2001. - T. 11, No. 4. - P. 75-77; Yeramishantsev AK Development of the problem of surgical treatment of blood of varicose veins of the esophagus and stomach. // Annals of surgical hepatology. - 2007. - Volume 12, No. 2. - P. 8-15; Patios MD Surgery of portal hypertension. - Tashkent: Medicine, 1984. - 319 s; Uglov F.G., Koryakina T.O. Surgical treatment of portal hypertension. - L .: Medicine, 1964. - 220 s). To prevent the deposition of blood in the portal vein system and the correction of hemodynamic disorders, the use of temporary extracorporeal portocaval shunts of various modifications is applied (Zatolokin V.D., Perkov A.A. et al. Actual issues of surgical gastroenterology. Kursk, 1994).

Under the influence of ischemia in the liver, interconnected and interdependent processes occur. After the cessation of blood flow to the organ, intrahepatic cholestasis occurs, cellular intoxication and dystrophic phenomena in the organ increase, negative morphofunctional changes in the liver occur, smooth muscle insufficiency of the microvasculature of the liver develops, the energy-synthesizing function of the respiratory chain of mitochondria is disrupted due to the limitation of aerobic energy production, progressive oxygen deficiency progresses, and active oxygen deficiency progresses forms of oxygen with the formation of free radicals are depleted reserves of endogenous antioxidants and lipid peroxidation (LP) processes are activated with the accumulation of their products, which ultimately leads to damage and destruction of organ cells (Bilenko M.V. Ischemic and reperfusion damage to organs (molecular mechanisms, ways of prevention and treatment) .- M. Medicine, 1989. - 368 p .; Simonenkov AP, Fedorov VD Prevention and treatment of serotonin deficiency in surgical patients. // Surgery. Journal of them. N.I. Pirogov. - 2003. - No. 3. - S. 76-80 .; Shnevays V.B., Levin G.S. The role of free radical oxidation in the pathogenesis of acute liver necrosis in visceral ischemic shock. // Patol. physiology and experiment. therapy. - 1996. - No. 2. - S. 39-43 .; Yakovenko E.P., Grigoriev P.Ya., Agafonova N.A. et al. Intrahepatic cholestasis - from pathogenesis to treatment // Practicing physician. 1998. No. 13 (2). - S. 20-24). In addition, when performing surgical interventions, and especially such as resection of the liver, favorable conditions arise (bleeding, bile leakage, necrosis and sequestration of the parenchyma, etc.) for joining and developing a surgical infection in the surgical area, which increases the risk of phlegmon, abscesses, the development of peritonitis and other purulent complications, and thereby may complicate the postoperative period. Therefore, both prophylaxis and the fight against such a negative factor, which is a surgical infection, are required. Considering the above, we consider the simultaneous impact of several key pathological processes to be relevant and promising.

The technical result of the invention is the treatment, correction and prevention of the development of surgical infections, ischemic and reperfusion injuries of the liver that occur during resection of the body under conditions of temporary shutdown from the blood circulation, prolongation of the safe time for bleeding the liver, and as a result, the prevention of massive bleeding during operations on it.

The technical result is ensured by the fact that the animal undergoes a liver resection with intraoperative use of temporary extracorporeal portocaval bypass grafting, on the day of the operation heptral in the form of an injection solution is injected intravenously slowly 1.5 hours before the operation at a dose of 2 mg / kg, 2 hours after the first administration at a dose of 6 mg / kg and 8 hours after the first administration at a dose of 4 mg / kg; in addition, clarithromycin is slowly injected intravenously in a 5.0 mg isotonic NaCl solution at a dose of 3 mg / kg three times a day at ^7:00 , ^15:00 , at ^23:00 ; in the postoperative period, enter: heptral - twice a day - at 9 ⁰⁰ at a dose of 7 mg / kg, at 16 ⁰⁰ at a dose of 5 mg / kg; clarithromycin - three times a day - at 7 ⁰⁰ , at 15 ⁰⁰ , at 23 ⁰⁰ at a dose of 3 mg / kg; the total duration of the introduction of heptral and clarithromycin is 10 days.

The pharmacological effect of heptral is due to the fact that it makes up for the deficiency of ademethionine and stimulates its production in the body, primarily in the liver and brain; it participates in biological transmethylation reactions - it provides the redox mechanism of cellular detoxification, increases the solubility of bile acids and their removal from hepatocytes, protects the membranes of liver cells from toxic effects; improves the metabolism of indolamines (serotonin, etc.), which contribute to the relief of smooth muscle insufficiency of the microvasculature of the liver, thereby normalizing endogenous vasomotor, reducing local hypoxia of internal organs and improving metabolism in problem areas. Heptral acts as a stimulator of cell regeneration and hepatocyte proliferation, normalizes metabolic reactions in the liver, has a choleretic effect due to increased mobility and polarization of hepatocyte membranes, and helps to restore the synthesis and flow of bile. As a result of heptral exposure, liver functions are restored with an improvement in the metabolic and microsomal oxidation processes occurring in it, and suppression of the formation of fibrous tissue. The wide spectrum of action of this drug is manifested by its hepatoprotective, choleretic, cholekinetic, neuroprotective, antioxidant, detoxification, regenerating and anti-fibrosing properties. After iv administration of heptral, the pharmacokinetic profile of ademetionine is biexpotential with a rapid distribution phase in the tissues and clearance with T1 / 2 of about 1.5 hours; absorption with i / m administration - 96%, Cmax are achieved 45 minutes after application; plasma concentrations decrease to their initial values within 24 hours (Vidal Handbook. Medicinal Products in Russia. - M.: AstraFarmService, 2004. - S. B-350 - B-351.).

Clarithromycin, a 14-membered macrolide antibiotic, has a number of properties that are required for liver resections. It is characterized by pronounced antimicrobial activity, which also acquires special significance under the conditions of exposure to ischemia, is active against many microorganisms, including intracellular. Like all macrolides, clarithromycin has not only anti-inflammatory, but also immunomodulatory effects. After intravenous administration, clarithromycin is rapidly distributed throughout all tissues and body fluids and penetrates well into them, creating concentrations several times higher than the level in blood plasma. When used in our dosage of T1 / 2, clarithromycin is from 5-7 hours to 7-9 hours (Russian Medicines Register of the Radar 2011 - M., 2010, - P. 412-419). The use of macrolide antibiotics, in particular clarithromycin, has a pronounced endothelio- and cardioprotective effect, helps to reduce the level of malondialdehyde, ketodienes, diene conjugates, which are markers of the LPO intensity in the blood (Chernomortseva ES, A.S. 2226101 RU C2, A61K 31/7048 A method for limiting the necrosis zone when modeling coronary occlusal myocardial infarction in animals with a reduced antioxidant background. Kursk State Medical University No. 2002104522; Bull. 9. - 30 p.). They are distinguished by their ability to inhibit the initiation stage of free radical reactions of lipid peroxidation, preventing a whole cascade of negative oxidative reactions leading to a violation of the integrity of cell membranes, which is associated with their own antioxidant properties of drugs (Chernomortseva E.S. Effect of macrolides on the functional capabilities of the endothelium and myocardium in experimental modeling of l-name-induced endothelial dysfunction // Kursk scientific and practical bulletin "Man and his health." - 2010, No. 1. - P. 30-33.).

Given the pharmacological effects of heptral and clarithromycin, it is obvious that when used in combination, these drugs complement each other, while simultaneously affecting the main links of pathological processes in liver ischemia.

The method is as follows.

On the day of surgery, an experimental animal (rabbit) is injected slowly clarithromycin in 5.0 isotonic NaCl solution at a dose of 3 mg / kg at ^7:00 in the marginal vein of the ear; heptral is slowly injected in a jet form as an injection for 1.5 hours before surgery at a dose of 2 mg / kg, 2 hours after the first administration, heptral is administered at a dose of 6 mg / kg. After processing the surgical field with a 1% solution of chlorhexidine bigluconate under intravenous hexenal anesthesia (0.03 g / kg), a laparotomy is performed. One of the loops of the small intestine is brought out into the wound (initial section), and one of the small intestine veins of large diameter, which are located near the duodenum-small intestine ligament, is isolated as having the largest diameter and denser wall (portal pool vein). Three ligatures are brought under the selected vein: proximal, middle, distal. The peripheral ligature serves to fix the silicone cannula (then it ligates the distal end of the vein). The lumen of the vein is opened between the two master ligatures in an oblique direction, and one end of the shunt from the silicone tube is inserted into it, which is fixed with a middle ligature on the vein. The other end of the shunt is inserted into a vein on the anterior extremity of the animal (the superior vena cava system), for which a 1.5–2 cm long skin incision is made on the inner surface of the animal’s extremities, the vein is carefully dissected stupidly and sharply, three ligatures are placed under it (similar to ligatures in the small intestine vein). Before work, the shunt is filled with 5% glucose solution with heparin to reduce the likelihood of thrombosis of the small intestine vein and shunt device, heparin is administered at a rate of 120 U / kg of animal weight. Following this, the hepatoduodenal ligament is infiltrated with 4.0 ml of a 0.25% solution of novocaine and clamped with an elastic intestinal clamp for 30 minutes. Then, a resection of the left external lobe of the liver is performed. After the blockage of the hepatoduodenal ligament is removed, the applied shunt is removed, the cannulated veins are ligated with proximal and distal ligatures, the abdominal cavity is drained, hemostasis is monitored, and the wounds of the anterior abdominal wall and anterior extremity of the animal are sutured tightly. On the same day, clarithromycin is injected slowly into the marginal ear vein of the animal at 15 ⁰⁰ with a 5.0 mg isotonic NaCl solution at a dose of 3 mg / kg; heptral 8 hours after the first injection is administered at a dose of 4 mg / kg; at 23 ⁰⁰ , clarithromycin is again administered at a dose of 3 mg / kg. In the postoperative period, enter: heptral - twice a day - at 9 ⁰⁰ at a dose of 7 mg / kg, at 16 ⁰⁰ at a dose of 5 mg / kg; clarithromycin - three times a day - at 7 ⁰⁰ , at 15 ⁰⁰ , at 23 ⁰⁰ at a dose of 3 mg / kg; the total duration of the introduction of heptral and clarithromycin is 10 days.

The study was performed on 22 rabbits of both sexes of the Chinchilla breed weighing from 2.5 to 3 kg. Experimental animals were observed up to 30 days, including blood sampling from the marginal ear vein for biochemical studies and a liver biopsy to determine the content of lipid peroxidation products (LPO) in the liver tissue homogenate. The determination of the level of transaminases - the activity of alanine aminotransferase (ALT) and aspartate aminotransferase (ACT) in the blood serum - was carried out according to the Reitman-Frenkel method, lactate dehydrogenase (LDH) - according to Savel, the concentration of bilirubin - according to the method of Endrashik, cholesterol according to Ilkueta, β-lipop urea - diacetylmonoxime method. In addition, the levels of alkaline phosphatase (ALP), total protein, prothrombin index (PTI), fibrinogen were determined by conventional methods, and a thymol test was performed. Indicators of cytolysis syndrome were the activity of ALT, ACT, and LDH. Indicators of cholestasis syndrome are alkaline phosphatase activity, the concentration of bilirubin, cholesterol and β-lipoproteins. Indicators of hepatosuppressive syndrome were the concentration of total protein, fibrinogen content and prothrombin index; mesenchymal-inflammatory syndrome - thymol test. The content of lipid peroxidation products - diene conjugates (DC) and malondialdehyde (MDA) - was determined by the method of I.D. Steel et al. (1977). Before all experiments, all animals were sampled from the marginal ear vein for biochemical studies (control). Heptral and clarithromycin were injected into 18 animals throughout the study according to the scheme we proposed; temporary portocaval bypass grafting was performed intraoperatively. The surgical field was treated with a 1% solution of chlorhexidine bigluconate, under intravenous hexenal anesthesia (0.03 g / kg), an upper middle laparotomy was performed, a temporary portocaval shunt was applied, a hepatoduodenal ligament of 4 ml of 0.25% novocaine solution and infused were infiltrated elastic intestinal clamp for 30 minutes. Then the elements of the glisson and caval systems of the left external lobe of the liver were bandaged. Following this, a resection of the left external lobe of the liver was performed with its blunt and sharp separation along the interlobar sulcus, imposition of liver sutures on the organ stump and plastic wound surface with a lock of a large omentum on the leg. After removing the clamp from the hepatoduodenal ligament, a portocaval shunt was removed, hemostasis was monitored, and the wound of the anterior abdominal wall was sutured in layers tightly. Four rabbits underwent clamping of the hepatoduodenal ligament for 30 minutes and resection of the left external lobe of the liver without administration of the studied drugs.

The animals that were injected with heptral and clarithromycin well underwent surgery, the postoperative period was satisfactory, without complications, the survival rate of the animals was 100%. With a 30-minute liver ischemia without pharmacological protection in the postoperative period, animals showed adynamia, lethargy, and lack of appetite, which indicated the severity of changes in the rabbit's body. Two animals died on the 2nd day after surgery, two rabbits survived up to 3 days.

A morphological study of liver tissue after exposure to it for 30 minutes of ischemic anoxia without heptral and clarithromycin showed that in the first two days of the experiment, hemodynamic disorders were aggravated, interstitial edema was increased, plethora of triads and central veins was determined, and the area of hepatic parenchyma with dystrophic and necrobic tissue increased changes. In the zone of triads and in the central zones of the hepatic lobules, widespread stasis was observed in the portal and central veins, ruptures of their walls against the background of increasing discomplexation of the lobules themselves. The cytoplasm of hepatocytes was swollen, separate foci of plasmorrhagia were observed. Lipoidosis was combined with granular and hydropic dystrophies with a predominance of the latter. By the 3rd day, discirculatory disorders were growing in the liver tissue - dilatation and plethora of blood vessels, cells with signs of coagulation necrosis were visualized, leukocyte infiltration was observed between the liver lobules and beams, and there was practically no glycogen in hepatocytes.

Against the background of heptral and clarithromycin administration with a 30-minute liver ischemia, the recovery period was significantly shorter than without the studied drugs. Throughout its course, positive changes have occurred. A morphological study of the liver parenchyma in the group of animals using the studied drugs after 30 minutes of reperfusion revealed a weakly expressed plethora of the central veins with single zones of granular dystrophy around them. In the zone of triads, single round-cell infiltrates appeared, phagocytic particles were found in the cytoplasm of macrophages from the composition of infiltrates, and in some cases, whole red blood cells, there were no necrotic changes in hepatocytes. The glycogen content in the cytoplasm of hepatocytes on the first day after the operation decreased moderately, which was manifested by a slight decrease in the number of large granules of SHIK-positive substances. During the first three days, the expansion of the central veins in the liver was stopped, there were no zones of vacuole dystrophy, there were fewer areas of granular dystrophy, SHIK-positive substances accumulated faster, only single round-cell infiltrates were found in the triad zone, there were no necrotic changes in hepatocytes. The preservation of glycogen granules in the cells was higher, its reserves were restored faster. A week after the start of the experiment, the glycogen content in hepatocytes was already quite high, the number of SIC-positive substances increased rapidly; plethora of vessels, which was previously insignificant, was no longer noted. In the middle of the observation period in the experiment, the state of the liver tissue was already comparable to the initial one. Thus, although moderate morphological changes were noted in the liver parenchyma, nevertheless, the recovery period was rather short, during which pronounced positive changes took place, characterized, in particular, by the significant preservation of glycogen granules in the cells and accelerated restoration of its stores.

After 30-minute liver ischemia with clarithromycin and heptral, the maximum activity of the enzymes ACT and ALT (table 1; units: ALT and ACT - mmol / (h · l)) occurs on the 3rd day of the postoperative period.

Compared with the control, ALT and ACT increased 3.28 and 3.37 times, respectively; however, the values obtained with 30-minute liver ischemia without clarithromycin and heptral administration increased significantly: ALT - by 7.52 times, ACT - by 7.46 times. By 14 days, against the background of anti-ischemic protection, a 2.12- and 1.77-fold decrease in serum ALT and ACT was observed in comparison with the peak of enzyme activity with complete normalization of these parameters by the 30th day of the experiment.

The highest serum bilirubin level was observed on the 3rd day of observation, with respect to the control, the increase was 1.84 times (table 2; units: bilirubin - mmol / l, alkaline phosphatase - mmol / (h · l), cholesterol - mmol / L, β-lipoproteins - g / L; p <0.05; n = 22). Then, by the 14th day, a marked decrease of 1.65 times relative to the maximum 3-day values occurred. By the end of the experiment, the numerical values corresponded to the initial ones.

Significant changes in cholesterol, β-lipoproteins, alkaline phosphatase and thymol samples at all observation times were not observed (tables 2, 4). In this case, there was a slight decrease in fibrinogen, PTI and total protein during the first 7 days after surgery (table 3; units: fibrinogen - mg / L, PTI -%, total protein - g / L).

The serum urea level in the group of experiments with clarithromycin and heptral was increased on day 3 1.26 times from the original with a gradual decrease to the initial values by the end of the second week of observation (table 4; units: urea - mmol / l; thymol sample - units; p <0.05; n = 22).

Thus, all the considered indicators, starting from the seventh day, tended to complete normalization of their values and by the 30th day of observation corresponded to the initial ones.

The introduction of clarithromycin and heptral in experiments with 30-minute liver ischemia contributed to a less pronounced LPO process, the intensity of which throughout the entire observation period was significantly lower compared to data obtained without drug administration (table 5; units: DC and MDA - mmol / g; p <0.05; n = 22). The increase in the content of DC and MDA in the liver tissue 30 minutes after the removal of the blockade of the PDS was 1.28 and 1.34 times, respectively. The greatest increase in the content of lipid peroxidation products in the liver tissue homogenate was observed on the 3rd day: DC - 1.69 times; MDA - 1.84 times, while their values were 1.66 and 1.89 times less, respectively, compared with the group without anti-ischemic protection.

When studying the obtained data, one can note a steady tendency towards normalization of the studied parameters starting from the 7th day: the decrease in DC and MDA on the 7th day of observation was 1.29 and 1.27 times, and on the 14th day - 1.51 and 1 , 35 times, respectively, compared with the maximum values achieved on the 3rd day. By the end of the experiment, the levels of DC and MDA corresponded to the initial. Thus, the administration of clarithromycin and heptral with a 30-minute liver ischemia significantly reduced the intensity of lipid peroxidation processes and contributed to their normalization.

It becomes apparent that the administration of clarithromycin and heptral with 30-minute liver ischemia helps to reduce the severity of cytolytic, hepatosuppressive and cholestatic syndromes, correct biochemical parameters and return them to their original level by the 30th day after surgery.

Thus, when the liver was exposed to 30 minutes of anoxia during administration of clarithromycin and heptral, the intensity of pathological processes was significantly reduced, which prevented and retarded the development of ischemic changes in the organ. And since there were no pronounced morphological and functional changes in the liver tissue in the postoperative period, the period of convalescence was not prolonged, we can conclude that the administration of clarithromycin and heptral when compressing the PDS for 30 minutes was effective.

Examples of specific application.

Example No. 1. Rabbit N 4. Operation 24.07.2014

After treating the surgical field with a 1% solution of chlorhexidine bigluconate under intravenous hexenal anesthesia (0.03 g / kg), an upper middle laparotomy was performed, the hepatoduodenal ligament was visualized and infiltrated with 4.0 ml of a 0.25% novocaine solution, squeezed by its elastic intestinal clamp for 30 minutes. Then, the elements of the glisson and caval systems of the left external lobe of the liver were ligated. Following this, a resection of the left external lobe of the liver was performed with its blunt and sharp separation along the interlobar sulcus, imposition of liver sutures on the organ stump. After removing the clamp from the hepatoduodenal ligament, hemostasis was controlled and the wound of the anterior abdominal wall was sutured in layers tightly.

Results of biochemical studies:

07/24/2014 - before the operation: ALT - 0.77 mmol / (h · l); AST - 0.44 mmol / (h · l); LDH - 1.40 mmol / (h · l); bilirubin - 13.48 μmol / l; Alkaline phosphatase - 2.33 mmol / (h · l); cholesterol - 3.79 mmol / l; β-lipoproteins - 0.27 g / l; fibrinogen - 3.93 mg / l; IPT - 83.2%; total protein 71.4 g / l; urea - 3.61 mmol / l; thymol test - 1.37 units; DK - 0.92 mmol / g; MDA - 0.065 mmol / g.

07.24.2014, after 30 minutes of reperfusion: ALT - 1.59 mmol / (h · l); AST - 1.20 mmol / (h · l); LDH - 1.85 mmol / (h · l); bilirubin - 18.58 μmol / l; Alkaline phosphatase - 3.01 mmol / (h · l); cholesterol - 3.96 mmol / l; β-lipoproteins - 0.53 g / l; fibrinogen - 3.06 mg / l; IPT - 79.4%; total protein - 57.8 g / l; urea - 4.13 mmol / l; thymol test - 1.43 units; DK - 1.39 mmol / g; MDA - 0.128 mmol / g.

07/25/2014: ALT - 3.05 mmol / (h · l); AST - 1.81 mmol / (h · l); LDH - 2.59 mmol / (h · l); bilirubin - 26.72 μmol / l; Alkaline phosphatase - 3.21 mmol / (h · l); cholesterol - 3.88 mmol / l; β-lipoproteins - 0.51 g / l; fibrinogen - 3.04 mg / l; IPT - 62.6%; total protein - 59.8 g / l; urea - 4.75 mmol / l; thymol test - 1.51 units; DK - 1.71 mmol / g; MDA - 0.178 mmol / g.

07/27/2014: ALT - 3.43 mmol / (h · l); AST - 2.39 mmol / (h · l); LDH - 3.26 mmol / (h · l); bilirubin - 30.85 μmol / l; Alkaline phosphatase - 3.29 mmol / (h · l); cholesterol - 3.75 mmol / l; β-lipoproteins - 0.48 g / l; fibrinogen - 2.83 mg / l; IPT - 61.2%; total protein - 59.7 g / l; urea - 5.62 mmol / l; thymol test - 1.50 units; DK - 2.11 mmol / g; MDA - 0.183 mmol / g.

By the end of the third day of observation, the animal died.

Example N 2. Rabbit N 9. On the day of the operation, August 6, 2014, a rabbit was slowly injected clarithromycin into the marginal ear vein into a rabbit 5.0 ml of isotonic NaCl at a dose of 3 mg / kg at 7 ⁰⁰ ; heptral was slowly injected in a jet form in the form of an injection for 1.5 hours before surgery at a dose of 2 mg / kg, 2 hours after the first administration, heptral was administered at a dose of 6 mg / kg. After treating the surgical field with a 1% solution of chlorhexidine bigluconate under intravenous hexenal anesthesia (0.03 g / kg), a laparotomy was performed. One of the loops of the small intestine (initial section) was brought into the wound, and one of the small intestinal veins of large diameter (vein of the portal pool) was isolated. Three ligatures were brought under the isolated vein: proximal, middle, distal. The lumen of the vein was opened between the two master ligatures in an oblique direction and one end of the silicone tube shunt was inserted into it, which was fixed with a middle ligature on the vein. The other end of the shunt was inserted into a vein on the anterior limb of the animal (the superior vena cava system), for which a 1.5-2 cm long skin incision was made on the inner surface of the animal's limb, the vein was carefully dissected bluntly and sharply, three ligatures were placed under it (similar to ligatures in the small intestine vein). Before work, the shunt was filled with 5% glucose solution with heparin to reduce the likelihood of thrombosis of the small intestine vein and shunt device, heparin was administered at a rate of 120 U / kg of animal weight. Following this, hepatoduodenal ligament was infiltrated with 4.0 ml of a 0.25% solution of novocaine and squeezed with an elastic intestinal clamp for 30 minutes. Then, the elements of the glisson and caval systems of the left external lobe of the liver were ligated. Following this, a resection of the left external lobe of the liver was performed with its blunt and sharp separation along the interlobar sulcus, imposition of liver sutures on the organ stump. After the blockage of the hepatoduodenal ligament was removed, the applied shunt was removed, the cannulated veins were ligated with proximal and distal ligatures, the abdominal cavity was drained, hemostasis and wounds of the anterior abdominal wall were controlled, and the anterior extremity was sutured layer by layer. On the same day, clarithromycin was injected slowly into the marginal vein of the ear at 15 ⁰⁰ with a 5.0 mg isotonic NaCl solution at a dose of 3 mg / kg; heptral 8 hours after the first administration was administered at a dose of 4 mg / kg; at 23 ⁰⁰ , clarithromycin was again administered at a dose of 3 mg / kg. In the postoperative period were administered: heptral - twice a day - at 9 ⁰⁰ at a dose of 7 mg / kg, at 16 ⁰⁰ at a dose of 5 mg / kg; clarithromycin - three times a day - at 7 ⁰⁰ , at 15 ⁰⁰ , at 23 ⁰⁰ at a dose of 3 mg / kg; the total duration of administration of heptral and clarithromycin was 10 days.

Results of biochemical studies:

08/06/2014 - before the operation: ALT - 0.78 mmol / (h · l); AST - 0.45 mmol / (h · l); LDH - 1.36 mmol / (h · l); bilirubin - 13.44 μmol / l; Alkaline phosphatase - 2.49 mmol / (h · l); cholesterol - 3.91 mmol / l; β-lipoproteins - 0.35 g / l; fibrinogen - 3.89 mg / l; IPT - 81.2%; total protein 71.1 g / l; urea - 3.79 mmol / l; thymol test - 1.43 units; DK - 0.92 mmol / g; MDA - 0.071 mmol / g.

08/06/2014, after 30 minutes of reperfusion: ALT - 0.98 mmol / (h · l); AST - 0.66 mmol / (h · l); LDH - 1.41 mmol / (h · l); bilirubin - 13.72 μmol / l; Alkaline phosphatase - 2.58 mmol / (h · l); cholesterol - 3.89 mmol / l; β-lipoproteins - 0.35 g / l; fibrinogen - 3.82 mg / l; IPT - 80.9%; total protein - 69.2 g / l; urea - 3.74 mmol / l; thymol test - 1.39 units; DK - 0.92 mmol / g; MDA - 0.087 mmol / g.

08/07/2014: ALT - 1.31 mmol / (h · l); AST - 0.72 mmol / (h · l); LDH - 1.58 mmol / (h · l); bilirubin - 15.04 μmol / l; Alkaline phosphatase - 2.77 mmol / (h · l); cholesterol - 3.87 mmol / l; β-lipoproteins - 0.35 g / l; fibrinogen - 3.71 mg / l; IPT - 80.6%; total protein - 69.1 g / l; urea - 3.87 mmol / l; thymol test - 1.38 units; DK - 1.05 mmol / g; MDA - 0.093 mmol / g.

08/09/2014 g .: ALT - 1.33 mmol / (h · l); AST - 0.93 mmol / (h · l); LDH - 1.76 mmol / (h · l); bilirubin - 16.01 μmol / l; Alkaline phosphatase - 2.83 mmol / (h · l); cholesterol - 3.84 mmol / l; β-lipoproteins - 0.37 g / l; fibrinogen - 3.62 mg / l; IPT - 80.2%; total protein - 67.5 g / l; urea - 3.91 mmol / l; thymol test - 1.42 units; DK - 1.14 mmol / g; MDA - 0.106 mmol / g.

08/13/2014 g .: ALT - 1.12 mmol / (h · l); AST - 0.75 mmol / (h · l); LDH - 1.53 mmol / (h · l); bilirubin - 13.55 μmol / l; Alkaline phosphatase - 2.51 mmol / (h · l); cholesterol - 3.88 mmol / l; β-lipoproteins - 0.32 g / l; fibrinogen - 3.75 mg / l; IPT - 81.4%; total protein - 69.1 g / l; urea - 3.84 mmol / l; thymol test - 1.42 units; DK - 1.08 mmol / g; MDA - 0.092 mmol / g.

08/20/2014: ALT - 0.79 mmol / (h · l); AST - 0.48 mmol / (h · l); LDH - 1.44 mmol / (h · l); bilirubin - 13.51 μmol / l; Alkaline phosphatase - 2.49 mmol / (h · l); cholesterol - 3.91 mmol / l; β-lipoproteins - 0.31 g / l; fibrinogen - 3.80 mg / l; IPT - 81.6%; total protein - 70.4 g / l; urea - 3.83 mmol / l; thymol test - 1.44 units; DK - 0.87 mmol / g; MDA - 0.089 mmol / g.

09/08/2014: ALT - 0.74 mmol / (h · l); AST - 0.46 mmol / (h · l); LDH - 1.33 mmol / (h · l); bilirubin - 13.42 μmol / l; Alkaline phosphatase - 2.49 mmol / (h · l); cholesterol - 3.91 mmol / l; β-lipoproteins - 0.29 g / l; fibrinogen - 3.86 mg / l; IPT - 81.7%; total protein 71.8 g / l; urea - 3.79 mmol / l; thymol test - 1.42 units; DK - 0.86 mmol / g; MDA - 0.075 mmol / g.

The postoperative period was satisfactory.

Example No. 3. Rabbit N17. On the day of surgery, 08/20/2014, a rabbit was injected slowly into the marginal ear vein with clarithromycin in a 5.0 mg isotonic NaCl solution at a dose of 3 mg / kg at 7 ⁰⁰ ; heptral was slowly injected in a jet form in the form of an injection for 1.5 hours before surgery at a dose of 2 mg / kg, 2 hours after the first administration, heptral was administered at a dose of 6 mg / kg. After treating the surgical field with a 1% solution of chlorhexidine bigluconate under intravenous hexenal anesthesia (0.03 g / kg), a laparotomy was performed. One of the loops of the small intestine (initial section) was brought into the wound, and one of the small intestinal veins of large diameter (vein of the portal pool) was isolated. Three ligatures were brought under the isolated vein: proximal, middle, distal. The lumen of the vein was opened between the two master ligatures in an oblique direction and one end of the silicone tube shunt was inserted into it, which was fixed with a middle ligature on the vein. The other end of the shunt was inserted into a vein on the anterior limb of the animal (the superior vena cava system), for which a 1.5-2 cm long skin incision was made on the inner surface of the animal's limb, the vein was carefully dissected bluntly and sharply, three ligatures were placed under it (similar to ligatures in the small intestine vein). Before work, the shunt was filled with 5% glucose solution with heparin to reduce the likelihood of thrombosis of the small intestine vein and shunt device, heparin was administered at a rate of 120 U / kg of animal weight. Following this, hepatoduodenal ligament was infiltrated with 4.0 ml of a 0.25% solution of novocaine and squeezed with an elastic intestinal clamp for 30 minutes. Then, the elements of the glisson and caval systems of the left external lobe of the liver were ligated. Following this, a resection of the left external lobe of the liver was performed with its blunt and sharp separation along the interlobar sulcus, imposition of liver sutures on the organ stump. After the blockage of the hepatoduodenal ligament was removed, the superficial shunt was removed, the cannulated veins were ligated with proximal and distal ligatures, the abdominal cavity was drained, hemostasis was controlled, and the wounds of the anterior abdominal wall and anterior extremity of the animal were sutured tightly layer by layer. On the same day, an animal was injected slowly into the marginal vein of the ear with clarithromycin 15 in a 5.0 mg isotonic NaCl solution at a dose of 3 mg / kg; heptral 8 hours after the first administration was administered at a dose of 4 mg / kg; at 23 ⁰⁰ , clarithromycin was again administered at a dose of 3 mg / kg. In the postoperative period were administered: heptral - twice a day - at 9 ⁰⁰ at a dose of 7 mg / kg, at 16 ⁰⁰ at a dose of 5 mg / kg; clarithromycin - three times a day - at 7 ⁰⁰ , at 15 ⁰⁰ , at 23 ⁰⁰ at a dose of 3 mg / kg; the total duration of administration of heptral and clarithromycin was 10 days.

Results of biochemical studies:

08/20/2014 - before the operation: ALT - 0.76 mmol / (h · l); AST - 0.45 mmol / (h · l); LDH - 1.38 mmol / (h · l); bilirubin - 13.32 μmol / l; Alkaline phosphatase - 2.41 mmol / (h · l); cholesterol - 3.89 mmol / l; β-lipoproteins - 0.31 g / l; fibrinogen - 3.83 mg / l; IPT - 82.5%; total protein - 72.2 g / l; urea - 3.86 mmol / l; thymol test - 1.40 units; DK - 0.87 mmol / g; MDA - 0.075 mmol / g.

08/20/2014, after 30 minutes of reperfusion: ALT - 0.89 mmol / (h · l); AST - 0.54 mmol / (h · l); LDH - 1.41 mmol / (h · l); bilirubin - 13.68 μmol / l; Alkaline phosphatase - 2.63 mmol / (h · l); cholesterol - 3.92 mmol / l; β-lipoproteins - 0.33 g / l; fibrinogen - 3.81 mg / l; IPT - 81.8%; total protein - 69.7 g / l; urea - 3.85 mmol / l; thymol test - 1.36 units; DK - 0.92 mmol / g; MDA - 0.094 mmol / g.

08.21.2014: ALT - 1.32 mmol / (h · l); AST - 0.71 mmol / (h · l); LDH - 1.58 mmol / (h · l); bilirubin - 15.12 μmol / l; Alkaline phosphatase - 2.81 mmol / (h · l); cholesterol - 3.93 mmol / l; β-lipoproteins - 0.34 g / l; fibrinogen - 3.72 mg / l; IPT - 79.8%; total protein - 67.4 g / l; urea - 3.88 mmol / l; thymol test - 1.35 units; DK - 1.09 mmol / g; MDA - 0.099 mmol / g.

08/23/2014 g .: ALT - 1.28 mmol / (h · l); AST - 0.97 mmol / (h · l); LDH - 1.79 mmol / (h · l); bilirubin - 15.14 μmol / l; Alkaline phosphatase - 2.85 mmol / (h · l); cholesterol - 3.86 mmol / l; β-lipoproteins - 0.35 g / l; fibrinogen - 3.68 mg / l; IPT - 80.5%; total protein - 65.4 g / l; urea - 3.92 mmol / l; thymol test - 1.40 units; DK - 1.18 mmol / g; MDA - 0.112 mmol / g.

08/27/2014: ALT - 1.13 mmol / (h · l); AST - 0.82 mmol / (h · l); LDH - 1.61 mmol / (h · l); bilirubin - 13.67 μmol / l; Alkaline phosphatase - 2.63 mmol / (h · l); cholesterol - 3.88 mmol / l; β-lipoproteins - 0.34 g / l; fibrinogen - 3.78 mg / l; IPT - 80.8%; total protein - 67.1 g / l; urea - 3.89 mmol / l; thymol test - 1.41 units; DK - 1.09 mmol / g; MDA - 0.094 mmol / g.

09/06/2014: ALT - 0.78 mmol / (h · l); AST - 0.44 mmol / (h · l); LDH - 1.45 mmol / (h · l); bilirubin - 13.41 μmol / l; Alkaline phosphatase - 2.52 mmol / (h · l); cholesterol - 3.89 mmol / l; β-lipoproteins - 0.33 g / l; fibrinogen - 3.83 mg / l; IPT - 81.4%; total protein - 69.2 g / l; urea - 3.88 mmol / l; thymol test - 1.39 units; DK - 0.93 mmol / g; MDA - 0.088 mmol / g.

09/20/2014 g .: ALT - 0.73 mmol / (h · l); AST - 0.45 mmol / (h · l); LDH - 1.39 mmol / (h · l); bilirubin - 13.36 μmol / l; Alkaline phosphatase - 2.42 mmol / (h · l); cholesterol - 3.90 mmol / l; β-lipoproteins - 0.32 g / l; fibrinogen - 3.83 mg / l; IPT - 82.1%; total protein 71.8 g / l; urea - 3.81 mmol / l; thymol test - 1.40 units; DK - 0.91 mmol / g; MDA - 0.076 mmol / g.

The postoperative period was satisfactory. The results obtained indicate that the use of our proposed method for the prevention and treatment of the effects of ischemic effects on the liver with intravenous heptral and clarithromycin according to our scheme with a 30-minute liver ischemia reduced the intensity and contributed to the normalization of biochemical processes, prevented the violation of the structure of the liver parenchyma, development cytolytic, cholestatic and hepatosuppressive syndromes and associated expressed functional morphological FIR changes, thereby preventing development of the ischemic changes in the body, significantly reduced the severity of potential liver damage due to oxygen starvation and provides not only shielding but also a therapeutic effect.

Thus, our proposed method allows us to extend the safe period of liver bleeding up to 30 minutes, provides treatment, correction and prevention of ischemic and reperfusion injuries of the liver tissue and its microvasculature arising from the resection of this organ under conditions of temporary shutdown from blood circulation, to avoid polypharmacy, to reduce the time rehabilitation treatment, helps prevent massive bleeding during liver operations.

Claims (1)

A method of treating ischemic disorders of the liver, including temporarily shutting it off from the blood circulation and intravenous administration of a drug, characterized in that the experimental animal undergoes liver resection with intraoperative use of temporary extracorporeal portocaval bypass grafting, on the day of surgery, heptral is slowly injected intravenously in the form of an injection solution for 1 , 5 hours before surgery at a dose of 2 mg / kg, 2 hours after the first injection at a dose of 6 mg / kg and 8 hours after the first injection in d ze 4 mg / kg; in addition, clarithromycin is slowly injected intravenously in a 5.0 mg isotonic NaCl solution at a dose of 3 mg / kg three times a day at ^7:00 , ^15:00 , at ^23:00 ; in the postoperative period, enter: heptral - twice a day - at 9 ⁰⁰ at a dose of 7 mg / kg, at 16 ⁰⁰ at a dose of 5 mg / kg; clarithromycin - three times a day - at 7 ⁰⁰ , at 15 ⁰⁰ , at 23 ⁰⁰ at a dose of 3 mg / kg; the total duration of the introduction of heptral and clarithromycin is 10 days.