Method of predicting severity of postoperative period course in patients with calculous cholecystitis

FIELD: medicine.

SUBSTANCE: in order to predict severity of postoperative period course in patients with calculous cholecystitis level of hormone grelin is determined in patients' blood serum before operation. If value of grelin level is 0.8-1.5 ng/ml mild course of postoperative period is predicted, if value of grelin level is >1.5-10.0 ng/ml course of medium severity is predicted. And if grelin level in blood serum increases to >10.0 ng/ml, severe course of postoperative period is predicted.

EFFECT: method makes it possible to increase accuracy of prediction of postoperative period course severity in patients with calculous cholecyctitis in cholecystectomy in order to perform treatment correction.

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The invention relates to medicine, in particular to surgery, and for forecasting the severity of the postoperative period in patients with calculous cholecystitis during cholecystectomy.

Known methods of predicting the severity of the postoperative period in patients with calculous cholecystitis during cholecystectomy - neutrophilic leukocytosis with shift, accelerated erythrocyte sedimentation rate, hyperthermia. However, temperature increase, the increase in the number of leukocytes, accelerated erythrocyte sedimentation rate may be logged in the absence of systemic inflammation that prevents the use of data from clinical and laboratory characteristics for predicting the severity of the postoperative period in patients with calculous cholecystitis (Ilchenko A.A. Cholelithiasis. M: Anarcharsis, 2004 - 200 C.). Widespread integral scale (APACHE II and others) have low specificity in terms of individual prediction.

The closest analogue of the proposed method is the determination of C-reactive protein - PSA in the blood (Warworth et al. Clin. Chim. Acta. - 1984 - Vol.138. - P.69-71).

The disadvantage of this method is that the increase in the level of PSA in the blood is not specific, may be due to atherosclerosis, inflammation, necrosis, i.e. does not always provide objective information about the severity of the postoperative period. Furthermore, it is not the strict compliance to the severity of the inflammatory process and the level of PSA (Byszewski A.Ş, Arsenev O.A. Biochemistry for the doctor. Ekaterinburg, Ural worker", 1994 - S-332).

Effect: improve the accuracy of predicting the severity of the postoperative period in patients with calculous cholecystitis during cholecystectomy for correction treatment.

The result is achieved by defining in the serum of patients with calculous cholecystitis before cholecystectomy levels of the hormone ghrelin. Ghrelin is secreted by the endocrine cells of the stomach, hypothalamus and other organs. To date, proved the breadth of his actions. It has powerful anti-inflammatory effect through the inhibition of production of Pro-inflammatory cytokines, increase the percentage of activated T-helper cells, enhances apoptosis of lymphocytes and exerts immunomodulatory, anti-inflammatory, regenerative action (Kojima m, Hosoda h, Date y et al. Ghrelin is a growth-hormone-releasing airport ACY-lated peptide from stomach. // Nature. - 1999. - Vol.402. - P.656-660. Wasseem T., Duxbury M, Ito H, Ashley SW, Robinson MK Exogenous ghrelin modulates the release of proinflammatory and anti-inflammatory cytokines in LPS-stimulated macrophages through distinct signaling pathways. // Surgery 2008 - Vol.143. - P.334-342). Proven involvement of this hormone in the regulation of energy, carbohydrate, fat, lipid metabolism. Ghrelin stimulates the secretion of hormones by the pituitary gland, mainly, somatotropic, thereby improving the processes of regeneration. His role in the rehabilitation of the sick is x after surgical stress is high. In the available literature there is no work about the use of ghrelin to predict the severity paleodrainage period in patients with calculous cholecystitis during cholecystectomy.

The method is as follows. Before surgery in patients with calculous cholecystitis collect blood using venipuncture, blood is centrifuged, get the serum and in serum by ELISA to determine the levels of ghrelin (J. Fuglsang, Skjaebaek C., Espelund U, Frystyk J, Fisker S, Flyvbjerg A, Ovesen P: Ghrelin and its relationship to growth hormones during normal pregnancy. // Clin Endocrinol (Oxf) 2005, Vol.62, No. 5. - P.554-559). Normal level fluctuations in healthy minor: 0.5 to 0.7 ng/ml, because it is involved in maintaining homeostasis.

Ghrelin levels in serum from 0.8 to 1.5 ng/ml in patients with calculous cholecystitis before surgery suggests that postoperative period after cholecystectomy will have have a mild case, without complications. Ghrelin levels in serum >of 1.5 to 10.0 ng/ml in patients with calculous cholecystitis before surgery suggests that postoperative period after cholecystectomy will be moderate. Ghrelin levels in serum >of 10.0 and higher in patients with calculous cholecystitis before surgery suggests that postoperative period after cholecystectomy will have heavy during the s and should conduct timely adjustment of drug therapy. The study of ghrelin levels in serum of patients with calculous cholecystitis allows us to predict the severity of the postoperative period after cholecystectomy.

Examples of specific performance

Example 1. Patient H., 62 years old, suffering from cholelithiasis within three years. Bothered by frequent pain in the right hypochondrium. Hospitalized in an emergency in connection with the attack "biliary colic" after 9 hours from the beginning of the attack. A state of moderate severity. Skin subcarina. Tongue coated white bloom. The abdomen is not swollen, in the act of breathing is involved. Palpation of severe pain and a small defense in right hypochondrium. The gall bladder is not palpated. Ghrelin levels in the blood - to 20.6 ng/ml (normal 0.5-0.7 ng/ml), leukocytes of 8.90×109l, PSA 0,96 mg/l (normal 0-4,0 mg/l). Operated in an emergency after 3.5 hours from receipt due to the ineffectiveness of conservative therapy. On the basis of high hyperprolinemia predicted severe postoperative period, and therefore before the operation started antibiotics (Cefotaxime intravenously) and detoxication therapy (isotonic sodium chloride 500 ml potassium chloride 10% 5 ml magnesium sulfate 25% 5 ml intravenous drip. When laparoscopy: the liver is enlarged, the capsule uneven, dull. In the region of the STI gallbladder dense infiltrate. Gall bladder large, tense, partly situated intrahepatic. Wall thick, swollen, slimy in places black. When the puncture produced thick bile and pus. Performed cholecystectomy. In the neck of the bladder two stones up to 6 mm, obtenerse cystic duct. Histological examination in the mucosa of the gallbladder cholesterosis, leukocytic infiltration, foci of necrosis and hemorrhage in the wall. Conclusion: acute phlegmons-gangrenous cholecystitis. The patient was transferred to the intensive care unit. Postoperative period was hard: within four days of continued fever up to 38°C, unstable hemodynamics: fluctuations AD from 100/60 to 180/100 mm Hg; appeared polytopia arrythmia. Alat increased to 68 IU/l (normal range 0-35 IU/l)AST to 71 IU/l (normal up to 45 IU/l). Conducted antibacterial therapy - Cefotaxime 1,0/day intravenously for 5 days. Conducted infusion therapy. For prevention of thromboembolic complications immediately after surgery was used heparin subcutaneously to 4 days. Wound healing by primary intention. The patient was discharged on the 9th day.

Example 2. Patient P., aged 57, began to notice pain in the right hypochondrium in the month. Sonography revealed multiple gallstones, thickened walls. Blood tests: erythrocyte sedimentation rate 5 mm/h, lake. 8×109l, PSA 0,85 mg/who Made planned laparoscopic cholecystectomy. Diagnosis after surgery: cholelithiasis, chronic calculous cholecystitis. Histologically, the wall of the gallbladder lymphoid infiltration, fibrosis. Histopathological conclusion: chronic cholecystitis. Ghrelin levels before surgery: 0.9 ng/ml, i.e. has a favorable prognosis of postoperative period. Conducted antibiotic prophylaxis with Ceftriaxone 1.0/2 times - before and after surgery. Histology: lymphoid infiltration of the gallbladder wall. The postoperative period was uneventful. Temperature is normal. Leukocytes of 8.90×109l, Alat before and after surgery, respectively 20 IU/l, 22 IU/l, AST - 19 IU/l and 23 IU/L. Healing by primary intention. Discharged on day 6.

Example 3. Patient B., 52 years old, was hospitalized in the emergency order after 5 hours from the beginning of the attack of biliary colic with complaints of pain in the right hypochondrium, nausea, retching and vomiting, weakness. Sonography during preventive examination a year ago were found gallstones. Pain in hypochondrium didn't bother. When receiving a satisfactory condition. Tongue moist, coated with white bloom. The abdomen is not swollen, soft, painful to palpation in the right upper quadrant. The gall bladder is not palpated. The liver is not enlarged. Leukocytes of 7.6×109/l; ESR 25 mm/hour, Alat 24,0 IU/l, AST 15.0 M is/l; PSA 2.0 mg/l ghrelin Levels 9.0 ng/ml. Operated in an emergency. Gallbladder in inflammatory growths. In the gallbladder thick bile and stone with a diameter of 10 mm Cystic duct tortuous lumen to 3 mm Pathomorphological moderate sclerosis of the gallbladder wall, cholesterosis its walls and lymphoid and neutrophilic infiltration. Conclusion: acute exacerbation of chronic cholecystitis. Given the moderate increase in the concentration of ghrelin in serum, predicted postoperative period after cholecystectomy moderate, and that was confirmed. Temperature rose to 37.5°C, held for three days. Was expressed pain syndrome. The ECG recorded ventricular premature beats. Showed cytolytic syndrome: ALT 53,7 IU/l, ACT 47,9 IU/L. Held antibiotic cephalosporins. Introduced Ketonal 2 ml 2 times a day - two days. Introduced drip polarizing a mixture of glucose, insulin, potassium and saline, potassium chloride, sulphate of magnesia. Postoperative wound healing by primary intention. Discharged on day 7.

Example 4. Patient B., aged 45, is delivered to the surgical Department with complaints of pain in the right hypochondrium, nausea, weakness. The patient considers himself about two years, when there were recurrent pain in the right hypochondrium. Lately there is dust pains became more frequent. Made an ultrasound of the liver, gallbladder, pancreas and diagnosed with calculous cholecystitis. Yesterday after eating fatty and spicy foods pain in the right hypochondrium became intense. The condition is satisfactory. High power. The skin is clean, normal color. In pulmonary pathology. Heart sounds clean, rhythmic. HELL 120/80 mm Hg white furred Tongue, wet. The abdomen is not swollen, painful in the right hypochondrium. The gall bladder is not palpated. Border of the liver in norm. ESR 26 mm/hour, leukocytosis of 5.1×109/l; p 6%, S. 37%, l 50%m 7%. ALT 25 IU/l, ACT 27 IU/l Fibrinogen 2,63 g/l (normal range 2,0-4,0 g/l), prothrombin time of 11.8 seconds (normal 11-16 sec). Ghrelin levels were 1.5 ng/ml Given a slight increase in blood levels of ghrelin, predicted a slight postoperative period after cholecystectomy. So I spent the antibiotic Cefotaxime 1,0 intravenously before and after surgery. The postoperative course was easy. There were no complications. Subfebrile temperature was in the first day, then normal. From analgesics (ketonala) the patient refused. Postoperative wound healing by primary intention. Discharged on the 6th day in good condition. Pathomorphological - in the wall of lymphoid infiltration, fibrosis and in some places boundary distance of leukocytes in the blood vessels. Conclusion: the exacerbation of XP the technical cholecystitis.

Prediction of the severity of the postoperative period after cholecystectomy was performed in 25 patients with calculous cholecystitis. Controlled health patients operated, temperature, laboratory tests of inflammation, wound healing, hemodynamics, the presence of complications of the operation, the occurrence of cytolytic syndrome, signs of acute Bilyasuvarskogo pancreatitis. Ghrelin levels up to 1.5 ng/ml indicates that the post-operative period will leak easily, >1,5-10,0 ng/ml will be moderate, >of 10.0 ng/ml postoperative period heavy.

The value of the proposed method is that it allows us to predict the postoperative period in patients with calculous cholecystitis before cholecystectomy, to prepare for possible complications, to solve practical problems will require antibiotic therapy, or can be limited to the antibiotic, plan detoxication therapy, prevention of DIC, time to adjust therapy.

A method for predicting the severity of the postoperative period in patients with calculous cholecystitis by examining the blood, characterized in that before surgery in patients taken from a vein blood and serum to determine the levels of the hormone ghrelin, and at the value level, the ghrelin of 0.8-1.5 ng/ml predicts a slight postoperative period, when the value of the level of ghrelin >1,5-10,0 ng/ml predicted for moderate, with an increase of ghrelin levels in serum >of 10.0 ng/ml predict a severe course of the postoperative period.



 

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