Method of predicting probability of unfavourable outcome of pancreonecrosis in post-operation period

FIELD: medicine.

SUBSTANCE: invention relates to medicine, can be used in surgery, resuscitation science. In patients with pancreonecrosis parametres of peroxide resistance of erythrocytes are evaluated and if decrease of erythrocyte chemiluminescence intensity to 61.3±9.4 and lower at the background of increase of light sum to 814.6±53.8 mV*sec and higher is registered by the third day of post-operation period, unfavourable outcome is predicted.

EFFECT: method ensures increase of accuracy, simplification and reduction of time for prediction of probability of unfavourable outcome of pancreonecrosis in post-operation period, as well as rapidity (reaction time 30-60 seconds), which allows to use it for early diagnostics of fatal complications and timely correction of intensive therapy scheme.

4 tbl, 1 ex

 

The invention relates to medicine, can be used in surgery, intensive care.

Known way to predict the outcome of destructive pancreatitis (RF Patent No. 2153676, G01N0 33/68, G01N 033/483, publ. 27.07.2000 g)providing a biopsy of the pancreas with the definition in biopsy samples of the concentration of malondialdehyde. The method has several disadvantages: invasiveness, technical complexity, high risk of developing complications such as parenchymal bleeding, lack of precision associated with different content of malondialdehyde in different parts of the gland with Subtotal and krupnooptovyh forms of pancreatic necrosis.

There are a predictor of complications and fatal outcome in patients with acute pancreatitis (RF Patent No. 2161804, G01N 33/84, publ. 10.01.2001, by definition acidosis in arterial blood. The method is also vysokointensivnymi, requires specially trained personnel and equipment.

Known methods for predicting outcome of acute alcohol (Patent RF №2312348, G01N 33/50, C12Q 1/68, publ. 10.12.2007,) and idiopathic pancreatitis (RF Patent No. 2310848, G01N 33/48, C12Q 1/68, publ. 20.11.2007,), consisting in the study of the genotype of the patient by polymerase chain reaction and detection of mutations in SPINK1 genes, GSTM1, GSTT1, PRSS1 and CFTR predict the development of severe pancrease the rose and the adverse outcome of the disease. These methods are costly and do not reflect the changes the severity of the patient in the dynamics of the disease.

Closest to the present invention is a method for predicting the postoperative period in surgical patients (Patent RF №2067768, G01N 33/68, publ. 10.10.1996,), consisting in a laboratory blood test in pre - and postoperative period by determining the concentration of myoglobin. When increasing concentrations of myoglobin in the postoperative period predict progressive postoperative complications with adverse outcome. The method does not take into account the specifics of complications and pathogenesis of destructive pancreatitis associated with hyperactively free-radical oxidation.

It is known that the main causes of postoperative mortality when pancreatic necrosis in the early stages is multiorgan failure in late - abdominal sepsis (Aphogee, AIA. Acute pancreatitis. - M.: Profile, 2007. - 336 S.; Vstavali, Migranov, Bergeland, Clavulanic and other Acute pancreatitis as a problem of emergency surgery and intensive care // Consilium medicum. - 2000. No. 9. - C.14-17). It is proved that the severity of multiple organ failure in acute destructive pancreatitis correlates with the level of oxidative damage to protein and lipids (Inpsect. Oxidative stress and the critical state in surgical patients // journal of intensive care. - 2004. No. 3. - 27-30). The development of abdominal sepsis according to the modern view is also accompanied by significant changes in lipid metabolism and imbalance in the system of free-radical oxidation - antioxidant protection (science Department Chairman, Vasudev, Slaman, Gdimagecopy. The state of free-radical oxidation of lipids and antioxidant defenses in sepsis from the positions of the severity of systemic inflammatory response // Intensive therapy. - 2005. No. 3. - P.32-34).

The objective of the invention: improved accuracy, simplifying and reducing the time for prediction of probability of an unfavourable outcome of pancreatic necrosis in the postoperative period.

The task to solve due to the fact that in patients with pancreatic necrosis estimate the parameters of the peroxide resistance of erythrocytes and upon registration of the decrease in the intensity of chemiluminescence of erythrocytes to 61.3±9,4 and less on the background of the increasing setosum to 814,6±53,8 mV·sec or more to the third day of the postoperative period predict adverse outcome.

The method is as follows. In patients with pancreatic necrosis in the preoperative period and on the first, third, seventh, 14 day post-operative period from the cubital is ENES take 3 ml of blood in a test tube with 80 UNITS of heparin. The test tube is centrifuged at 2000 rpm for 15 minutes, then drained the plasma. RBC mass twice washed in physiological solution of sodium chloride with subsequent centrifugation for 5 minutes at 2000 rpm after the third centrifugation, the supernatant was removed and the remaining cells are diluted five times with a physiological solution of sodium chloride and used for research. In a measuring cell of biochemiluminescence contribute 0.1 ml of washed erythrocytes; 0.4 ml of phosphate buffer (KH2PO4- 0,272 g/100 ml KCl - 0,780 g/100 ml, pH 7.5), 0.4 ml of a solution of ferric sulfate (0.01 mm to 0.14 g/50 ml), 0.2 ml lyuminola (cooked in 1 n KOH). Initiation of free-radical oxidation is performed by infusion of 0.1 ml of 2% hydrogen peroxide. Time recording is 30-60 seconds.

In the postoperative period in patients with pancreatic necrosis estimate the parameters of the peroxide resistance of erythrocytes and upon registration of the decrease in the intensity of chemiluminescence of erythrocytes to 61.3±9,4 and less on the background of the increasing setosum to 814,6±53,8 mV·sec or more to the third day of the postoperative period predict adverse outcome.

Among surveyed were persons of both sexes aged 20 to 75 years (table 1). Causes of acute pancreatitis was alcohol (46,3%), diseases of the VC is evistaa system (44,4%), and injuries of the pancreas (3,7%).

The diagnosis of pancreatic necrosis was established on the basis of the anamnesis, the clinical picture of the disease, laboratory tests, ultrasound examination of abdominal cavity and retroperitoneal space, esophagogastroduodenoscopy, according to testimony emergency diagnostic laparoscopy, CT. Verification forms of pancreatic necrosis was carried out on the basis of bacteriological examination of peritoneal exudates and content stuffing bags obtained intraoperatively during laparoscopy or laparotomy.

Table 1
Characteristics of the patients by age, gender, etiology and clinical form of acute pancreatitis
The average age46,86±3,3 (20-75)
Gender (male/female)35 (64,8%)/19 (35,2%)
Edematous pancreatitis26 (48.1 percent)
Sterile pancreatic necrosis13 (24.1 per cent)
Infected pancreatic necrosis15 (27.8 per cent)
B is learny 24 (44.4 per cent)
Alcoholic25 (46,3%)
Traumatic2 (3,7%)
Idiopathic3 (5,6%)

The Department conducted a comprehensive intensive infusion therapy with the use of antispasmodics, analgesics, drugs octreotide, antimetabolites, blockers H2-receptors, blood detoxification and hemodynamic series aimed at suppressing the exocrine functions of the pancreas and the decline of pancreatic taxinomie. The indication for surgery was considered progressive intoxication and multiple organ failure, in spite of complex conservative therapy within 12-24 hours or the lack of positive effects from the intensive care period longer than 72 hours from the beginning of complex conservative therapy increase clinic peritonitis, cholangitis, progressive jaundice.

All patients with pancreatic necrosis operated. Patients with sterile pancreatic necrosis (SF) was performed with video-assisted laparascopic interventions aimed at evacuation content and drainage stuffing bags and abdomen, according to testimony - cholecystectomy or x is lesistosti. In patients with infected pancreatic necrosis (IIT), as well as the development of purulent complications SF missions from mini-access with limited lesions of the gland and operation of verhnesadovogo laparotomic access abdominale pancreas, flow-proryvnym drainage and marsupialization stuffing bags, nasointestinal drainage.

The analysis of indicators peroxide resistance of erythrocytes revealed the following patterns (table 2):

Table 2
Parameters peroxide resistance of erythrocytes in patients with edematous pancreatitis in the dynamics of the disease
IndexThe length of hospitalization (days), number of patients (N)
The first (N=26)The third (N-26)Fifth (N=22)Eighth (N=21)
The maximum chemiluminescence intensity, mV210,8±19,4*231,2±20,6*184,9±17,9*141,7±12,1
Sutasoma, mV·sec 443,4±26,2*591,2±30,1*479,9±24,3*402,16±25,2
* The significance of differences compared with normal values at P<0,05.

In patients with edematous pancreatitis in the first days of the disease amplitude flash exceeded the normal value (136,7±10,3 MB) on average 1.55 times, sutasoma - 1.24 times (norm - 369,52±28,15 mV·sec).

On the third day of inpatient treatment there was a significant decrease in peroxide resistance, which was reflected in the excess setosum 1.56-fold compared with normal. This confirms the literature data that, in edematous pancreatitis with the rise of clinical symptoms occurs induction of peroxidation processes, content increases in the peripheral blood of toxic products and, accordingly, decreases the stability of biological membranes. In the next 5-8 days to conservative therapy indicators peroxide resistance was close to normal. This was manifested in the decrease of the maximum intensity of chemiluminescence and sutasoma that at discharge did not differ from normal values by more than 10%.

Significant differences indicators peroxide resistance of erythrocytes in sick is sterile (SF) and infected pancreatic necrosis (IDU) have been identified (table 3). The pancreatic necrosis was accompanied by persistent changes in the structure of the cell membrane, leading to more pronounced changes in the indicators peroxide resistance of erythrocytes. Unlike patients with edematous pancreatitis intensity of chemiluminescence of erythrocytes at 1.7 times, and sutasoma 2.1 times higher than the age norm. The minimum resistance of erythrocytes was observed in destructive forms of acute pancreatitis immediately after the surgical intervention. Thus, the greatest value of sutasoma coincided with the peak intensity of the chemiluminescence.

During the first weeks of the postoperative period in patients with destructive pancreatitis with a favorable course of the disease was increasing the resistance of erythrocytes, the parameters peroxidation was close to normal on the 14th day of the postoperative period.

Postoperative mortality in patients with destructive pancreatitis amounted to 32.1 per cent. Among the causes of death of three patients with sterile pancreatic necrosis, died in the early period (first five days after surgery), prevailed manifestations of multiple organ failure: cardiopulmonary and renal failure. Five patients with infected pancreatic necrosis died on the third - fourth week of the disease is t late septic multiple organ failure (3 patients) and arrozivnym bleeding (2 patients).

In the early postoperative period in patients with poor prognosis marked decrease in the intensity of chemiluminescence of red blood cells on a background of double relative to the rate of increase setosum (table 4). To the third day of the postoperative period the maximum chemiluminescence intensity of red blood cells did not exceed 61,3 MB, amounting to only 0.45 of the normal value, while sutasoma reached 814,6±53,8 mV·sec, exceeding the normal value of 2.1 times. In a further tendency to increase in peroxide resistance of erythrocytes was observed.

Table 4
Parameters peroxide resistance of erythrocytes in patients with pancreatic necrosis with fatal diseases
The follow-up periodIndex
I max, MBS, mV*sec
Before surgery228,5±21,4*721,3±56,1*
The first day after surgery174,8±19,6793,6±64,5*
The third day after surgery 61,3±9,4*814,6±53,8*
The seventh days after surgery33,6±8,4*828,5±79,0*
14th day after surgery29,8±9,4*850,4±68,3*
* The significance of differences compared with normal values at P<0,05.

Thus, the proposed method in the near term postoperative period to predict adverse outcome of pancreatic necrosis. The advantage of this method is the simplicity associated with the availability of reagents and the lack of need for specially trained personnel, and expressnet (reaction time 30 to 60 seconds), so you can use it for dynamic correction tactics intensive activities, with the threat of adverse outcome of the disease.

Example

Statement of the case history No. 6033

Patient W., 42 years old, hospitalized in Krasnoyarsk city centre surgical pancreatology 12 December 2008 with a diagnosis of pancreatic necrosis. Etiological factor was the consumption of alcohol and fatty foods. Within 8 hours under conditions of intensive therapy was conducted infusion therapy with the use of antispasmodics, analgesics, ochre the Chida, antimetabolites, H2-receptor blockers, blood detoxification and hemodynamic number. Prophylactic intravenous assigned Meronem. Despite ongoing therapy, progressed the symptoms of endogenous intoxication. Pay attention to the initial high values of the maximum intensity of chemiluminescence of erythrocytes - 240,4 mV and sutasoma - 740,6 mV·sec.

The patient underwent surgery: performed videolaparoscopy, signs of hemorrhagic pancreatic necrosis: up to two liters of dark hemorrhagic exudate, edema and hyperemia of the round ligament of the liver, severe vascular injection parietal peritoneum, swelling anterior wall of the stomach, swelling of the greater omentum, sluggish bowel movements. Fulfilled the aspiration of exudate in the subhepatic space and to the pelvis installed tubular drains. Bacteriological examination of the microflora in the exudate was not found. Postoperative diagnosis: Subtotal sterile pancreatic necrosis. Spilled enzymatic peritonitis.

In the postoperative period against the background of comprehensive intensive infusion therapy the patient's condition remained serious. When the chemiluminescent study on the first day after surgery, there was a trend to decrease the intensity of chemiluminescence of erythrocytes with granadina high values setosum. On the second day decrease in the intensity of chemiluminescence of erythrocytes was achieved 104,5 MB, coupled with a progressive increase in setosum to 870,4 mV·sec regarded as prognostic of adverse outcome of the disease.

Patient assigned additional laboratory and instrumental investigations (full blood count, examination of blood gas composition, immunological, triglycerides, x-ray examination of the chest, fibrogastroduodenoscopy). On the third day of the postoperative period according to the results of additional studies diagnosed the phenomenon of multiple organ failure with involvement in the pathological process of the lungs (the syndrome of acute lung injury ALI), the hemostatic system (consumption coagulopathy).

Inclusion in the complex of therapeutic measures oxygenotherapy, infusion of fresh frozen donor plasma contributed to the compensation function of the respiratory system and hemostasis. According to the chemiluminescent studies on the seventh day of the postoperative period there is a tendency to normalization peroxide resistance of erythrocytes: the maximum chemiluminescence intensity was increased to 115,4 MB, sutasoma decreased to 570,3 mV·sec. On the eighth day the patient was transferred to the General surgical ward. The development of the settlement of the necrotic complications were noted. At 18 days the patient was discharged in satisfactory condition.

Thus, taking into account parameters peroxide resistance in a prospective prediction of outcome of pancreatic necrosis can prevent the development of fatal complications of the disease through early detection and timely correction scheme intensive care.

Method of predicting the likelihood of adverse outcome of pancreatic necrosis in the postoperative period, including laboratory blood testing in pre - and postoperative period, characterized in that in patients with pancreatic necrosis estimate the parameters of the peroxide resistance of erythrocytes and upon registration of the decrease in the intensity of chemiluminescence of erythrocytes to 61.3±9,4 and less on the background of the increasing setosum to 814,6±53,8 MB·and more to the third day of the postoperative period predict adverse outcome.



 

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5 ex

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to gastroenterology. To assess regeneration of gastric ulcers and duodenal ulcers, morphological study is conducted. The initial stage of regeneration is determined in case of simultaneous presence in the periultserose area of fibroblasts with well-developed system of granular endoplasmic reticulum and mast cells with forming specific granules. The final stage of regeneration with formation of scar is determined at presence of reduction of the granular endoplasmic reticulum in fibroblasts and degranulation of mast cells.

EFFECT: method increases accuracy of assessment of regeneration of gastric ulcer and duodenal ulcer.

3 ex

FIELD: medicine, clinical toxicology.

SUBSTANCE: at patient's hospitalization one should gather the data of clinical and laboratory values: on the type of chemical substance, patient's age, data of clinical survey and laboratory values: body temperature, the presence or absence of dysphonia, oliguria being below 30 ml/h, hemoglobinuria, erythrocytic hemolysis, exotoxic shock, glucose level in blood, fibrinogen and creatinine concentration in blood serum, general bilirubin, prothrombin index (PTI), Ph-plasma, the state of blood clotting system. The state of every sign should be evaluated in points to be then summed up and at exceeding the sum of points being above "+20" one should predict unfavorable result. At the sum of "-13" prediction should be stated upon as favorable and at "-13" up to "+20" - prediction is considered to be doubtful.

EFFECT: higher accuracy of prediction.

2 ex, 3 tbl

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