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Murodov Alijon Salimovich, Assistant of the Department GP surgery, Tashkent Medical Academy
Teshaev Oktyabr Ruhullaevich, Sadykov Rasul Rustamovich, E-mail: [email protected]
Improved results of treatment purulent destructive diseases of soft tissues using laser treatments
Abstract: The aim of research was to study the effectiveness of photodynamic treatment and CO2 laser destructive purulent wounds of soft tissues. The use of CO2 laser has allowed for the possibility of early and bloodless nekroektomii, improve wound repair, and reduces microbial contamination of purulent wounds. Method has photo coagulating and sterilizing properties effects on the tissue.
Photodynamic therapy is a very effective non-invasive and gentle treatment of purulent wounds and serve as justification for the use of the method of photodynamic therapy in clinical practice for the treatment of acute local inflammatory processes combined with CO2 laser and traditional treatments.
Keywords: Photodynamic therapy, photosensitizer, methylene blue, purulent wound, microbe, CO2 laser, laser surgery, planimetry.
Introduction
The questions about surgical infection now remain one of the priority tasks in clinical medicine and this is connected both to high morbidity rate and significant difficulties in treatment. According to the data of the literature, the quantity of the patients with acute purulent diseases of soft tissues accounts 30-60 % among all surgical patients (Svetukhin A. M. et al, 2002; Gorunov S. V., 2004; Abaev Yu. K. [1]). Thus till 70-80 % of them admit to the hospital due to urgent events. In the structure of postoperative complications the surgical infection shares from 32 up to 75 % (Efimenko N. A., 2005). More than 30 % lf all lethal outcomes in the postoperative period is connected with various purulent — inflammatory processes (Novojilov A. A., 2006).
In spite of the fact that the history of the question of treatment of these pathologies accounts not one decade, and to the present time the plenty of various techniques being proposed, the problem of efficiency and quickness of the results obtaining remains not resolved up to the end Baranov E. V. [5]. The use of laser methods of treatment appeared to be one of perspective directions in the modern medicine for solution of this problem. For today the antibacterial photodynamic therapy associated with CO2 laser in the treatment of purulent wounds is the most effective method. CO2 laser have photocoagulating properties and sterilizing action on the tissues. Thereof the section of tissues is carried out without blood loss and the surface of wound section remains to be absolutely sterile.
The photodynamic therapy (PDT) represents a rather new method of treatments based on application of medicinal preparations — Photosensitizer (of substances, sensitive to light) and laser radiation with certain length of a wave appropriate to peak of absorption of photosensitizer (Ischuk, 2009).
The purpose of research: To improve results of treatment of the patients with purulent — inflammatory diseases of the soft tissues with complex application of C02 laser and FDT.
Materials and methods
For the solution of the tasks determined it was performed examination and treatment of 327 patients with purulent wounds of soft tissues of various etiology and location of age from 16 till 82 years, treated in the department of purulent surgery of the 1st Clinical hospital on the basis of the Chair of the GP surgery of Tashkent Medical Academy during 2010-2015. Depending on the treatment performed the patients were divided into 3 groups: Group 1 (control) included 109 patients being treated by the common traditional methods; group 2 (main group I) consisted of111 patients, who received in a complex of traditional methods of treatment with FDT together with 0.05 % buffer solution of methylene blue. Group 3 (main group II) comprised 107 patients who received complex of traditional methods of treatment with CO2 laser and FDT. Among the studied patients there were 97 (57.8 %) men, and 71 (42.2 %) women at the age from 16 till 85 years. According to nosological forms at the patients there were prevailed erysipelatous inflammation in 38 patients (22.6 %) and phlegmons ofvarious localization in 22 (13 %) patients.
Improved results of treatment purulent destructive diseases of soft tissues using laser treatments
Table 1. - Structure of the patients with purulent - destructive diseases of the soft tissues in groups
№ Nosology Control group Main group I Main group II Totally
1. Erysipelatous inflammation 24 25 24 72
2. Postinjection abscess 11 9 13 33
3. Phlegmon 8 9 7 25
4. Purulent hematoma 5 4 5 14
5. Infected wounds 14 16 12 42
6. Acute purulent mastitis 4 3 6 13
7. Carbuncle 9 7 7 23
8 Abscessing furuncle 6 5 3 17
9. Acute paraproctitis 3 5 4 12
10. Hydradenitis 7 6 6 19
11 Purulent dermoid cyst 8 7 6 21
12. Abscess 8 6 6 20
13. Postoperative wound suppuration 5 4 7 16
Totally 109 111 107 327
The characteristic of the device
The C02-laser. Length of a wave of the laser: 10.6. Target power: 1 ~ 15 w. A mode of beginning: Focusing, defocusing.
For photodynamic therapy there was used light irradiator with length of a wave 600-640 nm. with density ofpower 200 mWt/cm2. Distance from the lateral side of the radiator to the damaged surface was 2-3 cm. at absence of the thermal discomfort in the patient. The total time of irradiation depended on the area of the damaged surface and accounted from 15 up to 30 minutes.
Technique of CO2 séances and photodynamic therapy
In the complex of traditional methods the treatment was added by CO2 laser and photodynamic therapy. The application of the C02 laser has allowed early and bloodless necroectomy as well as increased efficiency of photodynamic therapy (because at presence of necrotic masses and purulent films effect of FDT is sharply reduced). On dependence of the patient's health state the quantity of séances fluctuated from 3 to 7 séances. After 2-3 séances in a zone of the purulent center there was observed significant reduction of necrotic detritus and characteristic smell. During treatment of the patients with purulent — inflammatory diseases of the soft tissues There were used the following parameters of the device "JZ-3A" at evaporation of pathologically changed tissues it is recommended to apply impulse-periodic regimen: power
15 Wt.; a diameter of a light spot 0.5 mm. duration of a pulse from 0.5 up to 1 sec.; duration of a pause between pulses 0.05 sec. (Sco-belkin O. K. et al., 1996).
The method was applied more often at superficially located purulent — inflammatory diseases of the skin and soft tissues. After surgical debridement of the purulent focus the common treatment was added with photodynamic therapy. On the wound, after standard surgical debridement and drying there was applied photosensi-tizer. As a photosensitizer there was used 0.05 % buffer solution (or ointment) of methylene blue with exposition of 30 min. Then there was carried out an irradiation of wound surface with light irradiator for photodynamic therapy. The length of a wave was 630-650 nm. with density of power 200 mWt/cm2. The distance from the buttend of the irradiator to wound surface was 10 cm. at absence of thermal discomfort in the patient. The duration of treatment was 15-30 min. depending on the area of wound surface. After irradiation of wound surface the photosensitizer becomes colorless, because the photodynamic reaction begins. The number of procedures was 3-6 séances in relation to clinical diagnosis.
In the patients from control group the temperature of body was normalized, on the average, on the 3rd day, the use of C02 laser and photodynamic therapy resulted in faster normalization of temperature of a body, on the average, on the 2nd day.
Table 2. - Dynamics of the cardiac rate and temperature of body
Parameter Before treatment After treatment
Main group I Main group II Control group Main group I Main group II Control group
Heart rate (min.) 88.3 ± 2.1 88.1 ± 1.9 87.9 ± 2.3 75.4 ± 1.3 74.0 ± 1.0 79.5 ± 1.8
Body temperature, °C 38.8 ± 0.08 38.2 ± 0.06 38.6 ± 0.05 36.9 ± 0.07 36.7 ± 0.05 37.8 ± 0.09
At hospitalization all patients had signs of intoxication of various severity degree of expressions, which were confirmed by changes of blood leucocytic formula: leucocytosis, increase in number of juvenile neutrophils, appearance of plasmatic cells, decrease in quantity of monocytes and lymphocytes, as well as rise in parameter LII (up to 6 -8 standard units). The increase in number of the juvenile neutrophils indicated about tension of compensatory mechanisms, providing for toxins inactivation. The decrease in quantity of monocytes and lymphocytes testified about inhibition of immunologic defensive system of the body. In 3 days after performance the of surgical debridement of the purulent center and realizations of complex traditional therapy in the patients there was noted decrease in parameters of LII to 2.7 Units, at additional effect of PDT on the wounds there was occurred decrease in parameter LII — to 1.95 Un.
the changes revealed indicated about activation of nonspecific body resistance and intoxication decrease. Ten days after operation in the complex treatment of purulent wounds with use of CO2 laser and PDT the value of LII correlated to the norm — 1.6 ± 0.4 Un., while in the patients of control group it remained to be increased — 1.82 ± 0.14 Un. The parameters of LII in the main group reduced faster due to decrease in neurtophil change and increase in quantity of monocytes, lymphocyte and eosinophils.
The analysis of dynamics of clinical manifestations shown, that the treatment of purulent wounds with use laser FDT results in fast reduction of perifocal inflammatory events. Hyperemia of the tissues surrounding the wound was solved during 1-2 days, there was noted marked decrease in local edema, on the average, on the 2-3 day, infiltration in the wound margins preserved for 3-4 days.
Table 3. - Blood parameters in the patients with purulent - inflammatory diseases of f soft tissues
Parameter Before treatment After treatment
Main group I Main group II Control group Main group I Main group II Control group
Leucocytes, G/l 9.8 ± 1.1 9.6 ± 1.0 9.7 ± 1.7 8.4 ± 1.0 7.9 ± 1.0 8.6 ± 1.9
Eosinophils, % 2.6 ± 0.3 2.6 ± 0.5 2.5 ± 0.6 2.1 ± 0.4 2.0 ± 0.2 2.3 ± 0.7
Stab neutrophils, % 2.2 ± 0.31 2.1 ± 0.4 2.2 ± 0.4 1.8 ± 0.2 1.6 ± 0.5 1.9 ± 0.35
Segmented neutrophils, % 36.5 ± 1.5 36.0 ± 1.0 37.0 ± 1.2 43.2 ± 1.1 40.5 ± 1.5 41.2 ± 1.3
Lymphocytis, % 48.2 ± 1.4 48.9 ± 1.5 48.6 ± 1.6 43.0 ± 1.5 41.0 ± 1.5 45.3 ± 1.2
ESR, mm/h 16.9 ± 0.5 16.0 ± 0.5 17.0 ± 0.7 9.4 ± 0.5 8.4 ± 0.5 11.0 ± 0.6
Table 4. - Dynamics of the wound process depending on the treatment performed
Methods of Treatment Quantity of patients Average Terms (days)
Wound debridement Granulation appearance Onset of marginal epithelization
Maim group I 111 4.2 ± 0.7 3.6 ± 0.6 5.1 ± 0.4
Main group II 107 3.8 ± 0.5 3.5 ± 0.6 4.9 ± 0.4
Control group 109 7.1 ± 0.5 6.9 ± 0.6 8.0 ± 0.7
Analyzing on the whole the clinical events of the wound process it is important to note that after performance of PFT there were shortened terms of wound cleaning from purulent detritus and fibrinous mass, as well as term of granulations appearance and onset of epithelization particularly of the main group II (Table 4). On the average, debridement of wound from purulent detritus and fibrinous mass developed on 3.8 ± 0.5 day, and granulation appearance was revealed on 3.5 ± 0.6 days. The onset of margin epithelization was noted on the 4.9 ± 0,4 day, that reliably was better than at traditional treatment.
In the patients of group of comparison receiving traditional treatment, in 4 patients on 3-4 day there was registered formation of secondary necrosis with following performance of necrectomies, that was not found in the main group of the patients.
Objectively to evaluate dynamics of healing of purulent wounds may be possible on the basis of planimetric examinations. They showed that in group of patients where photodynamic therapy
with methylene blue was used for treatment the area of purulent wounds decreased faster than in control group (Table 5). Thus, in the studied group the area of purulent wounds shortened to the 10 day by 75 %, at the same time at the common treatment the area of purulent wound decreased by 56 % (p < 0.05).
The parameters of postoperative bed-day in groups differed considerably. If at traditional treatment of the patients with purulent wounds the average bed-day coefficient was 10 days, then at the patients of the basic group I, having complex treatment in the postoperative period with use of laser photodynamic therapy, the duration of hospital staying accounted 7 days, while in the main group II this index was 5 day (p < 0.05).
During observation over the patients from the main group within one year there were not found formation of keloid or rough hypertrophy scars in any patient. The cicatrical tissue did not overhang the skin level, was smooth, did not deform the skin and subcutaneous fat and was not adhered with sublaying tissues.
Analyzing on the whole the clinical events of the wound process it is important to note that after performance of PFT there were shortened terms of wound cleaning from purulent detritus and fibrinous mass, as well as term of granulations appearance and onset of epithelization particularly of the main group II (Table 4). On the average, debridement of wound from purulent detritus and fibrinous mass developed on 3.8 ± 0.5 day, and granulation appearance was revealed on 3.5 ± 0.6 days. The onset of margin epithelization was noted on the 4.9 ± 0,4 day, that reliably was better than at traditional treatment.
In the patients of group of comparison receiving traditional treatment, in 4 patients on 3-4 day there was registered formation of secondary necrosis with following performance of necrectomies, that was not found in the main group of the patients.
Objectively to evaluate dynamics of healing of purulent wounds may be possible on the basis of planimetric examinations. They showed that in group of patients where photodynamic therapy
with methylene blue was used for treatment the area of purulent wounds decreased faster than in control group (Table 5). Thus, in the studied group the area of purulent wounds shortened to the 10 day by 75 %, at the same time at the common treatment the area of purulent wound decreased by 56 % (p < 0.05).
The parameters of postoperative bed-day in groups differed considerably. If at traditional treatment of the patients with purulent wounds the average bed-day coefficient was 10 days, then at the patients of the basic group I, having complex treatment in the postoperative period with use of laser photodynamic therapy, the duration of hospital staying accounted 7 days, while in the main group II this index was 5 day (p < 0.05).
During observation over the patients from the main group within one year there were not found formation of keloid or rough hypertrophy scars in any patient. The cicatrical tissue did not overhang the skin level, was smooth, did not deform the skin and subcutaneous fat and was not adhered with sublaying tissues.
Table 5. - Planymetry in dynamics
Group of patients Wound area (cm 2)
1 day 3 day 7 day 10 day
Main group I 93 ± 7 74 ± 4 45 ± 3 23 ± 1
Main group II 88 ± 5 72 ± 5 41 ± 4 19 ± 1
Control group 85 ± 8 68 ± 5 52 ± 3 34 ± 3
The microbiological analysis of the pathological discharges from purulent focuses showed that leading place both in the monoculture and in the associations were occupied by St. aureus (84.9 % and 80.4 %, respectively); Str. Pyogenus was isolated in the monoculture in 5.7 % and in association in 5.8 % of cases; anaerobes in 5.7 % and in 4.7 % of cases, respectively.
At quantitative microbiological examination there was established, that before treatment in the patients of both groups there was determined a high level ofcontamination ofthe wound tissues, in 1 g. ofwound tissue there were contained, on the average, 10 6-9 COE. Immediately after performance of CO2 laser and PDT the microbe contamination of the wound tissue was not changed, and one day after the contamination of the wound tissue by microbe flora decreased to 10 6-7 COE/g, during PDT and traditional treatment in 1 day the contamination of the wound tissue by microbe flora decreased to 10 7-8 COE/g. At traditional treatment these parameters did not change and account 10 7-9 COE/g. On the third day in patients of the main group II the content of microbe in 1 g of tissue accounted 103-5 COE/g, on the 7 day after performance of PDT in the granulated wounds this indicator reduced to 10 2-4 COE/g. In the patients of the
main group I in the same period of microbe contamination of the wound tissue was 10 5-6 COE/g, and in patients receiving traditional treatment in the same period the parameter of microbe contamination of the wound tissue accounted 10 6-7 COE/g, which differed by various representations. The results obtained showed that use of CO2 laser and PDT with photosensitizer methylene blue reduced more effectively bacterial contamination of the wound tissue, than traditional treatment.
Morphological investigations showed that before surgical debridement in the histological assays the wall and bottom of the wound were presented by destructive necrotic tissues, intensively infiltrated by polymorphonuclear leucocytes, the tissues are edematous, there was noted venous and capillary plethora, stases, perivascular diapedesis and focal hemorrhages.
At traditional treatment by the data of histological and cytologi-cal studies the wound process is slowed down, the microcirculatory disorders preserve more long, there is found edema, neutrophil infiltration, focuses of necroses of the tissues. Thus inflammatory expressions prevail over reparative, macrophage reaction is slowed, macrophage-fibroblast interaction is damaged, there is found growth
The advantages of modern methods of diagnosis and intraoperative neuromonitoring during removal of intracerebral brain tumors
and maturation of granulated tissue, fibroblast proliferation and epithelization.
At цитологическом research in 3 day after СО2 laser and photodynamic effect there is noted significant reduction of microflora in the smears-prints. The contents of neutrophils reduced from 91.0 % up to 75.0 % from the total number of cellular elements. The high number of degenerative forms of neutrophils is noted (57.63 ± 4.8 %), connected with their destruction under photodynamic exposure. The increase in quantity of macrophages and monocytes with phagocytosis of bacteria, tissue and cellular detritus is found. There is occurred small quantity of fibroblasts, predominantly of juvenile forms, considerably exceeding their quantity in control group (8.7 % in comparison with the basic group I - 3.1 %, basic group II - 2.2 %, respectively). The marked changes indicated about activation of regenerative processes and corresponded inflammatory-regenerative type of cytogram.
On the 5 th day after СО2 laser and photodynamic therapy microflora was not found practically. The quantity of neutrophils decreased considerably (to 63.0 ± 3.5 %). There is met a great number of macrophages and fibroblasts (15.0 ± 2.9 % and 14.2 %,
respectively), that indicated about the further activation of repara-tive processes.
By the 7 th day macrophages and fibroblasts appeared to be prevalent cellular elements (15.8 % and 19.3 %, respectively), the young epithelial cells are found, that allows suggestion about regenerative type of cytogram.
Thus, the presented data confirm reliably high clinical efficacy of antibacterial therapy, based on СО2 laser and photodynamic effects, induced by simultaneous effect on the pathogenic microflora by physical and chemical factor.
The use of СО2 laser allowed possibility for early and bloodless necroectomy, improvement of wound reparation as well as reduction of microbe contamination of the purulent wound. The method has photocoagulating properties and sterilization effect on the tissues.
The data obtained showed that the photodynamic therapy is effective enough noninvasive and safety method for the treatment of purulent wounds and serves as basis for use of the method of photodynamic therapy in the clinical practice for treatment of local acute purulent-inflammatory processe CO2 laser and traditional methods of treatment.
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Murodova Dilorom Subhonovna, Republican Scientific Center of Neurosurgery, the Ministry of Health of Uzbekistan, Senior Researcher E-mail: [email protected]
The advantages of modern methods of diagnosis and intraoperative neuromonitoring during removal of intracerebral brain tumors
Abstract: The results of a survey of surgical treatment and observation of 66 patients with intracerebralbrain tumors of supratentorial localization. Data analysis MR-tractography allowed to choose an optimal surgical approach to tumors, to identify areas available for disposal and perform resection in an adequate amount of conservation white matter pathways of the brain, thus minimizing surgical trauma, reduced risk, and worsening of neurological deficit that determines the efficiency of operations and quality of life of patients.
Keywords: DT-tractography, white matter tracts, brain, tumor, life quality.
