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9MODIFICATED METHOD OF PLASMOPHERESIS IN THE TREATMENT PATIENTS WITH PURULENT
CHOLANGITIS Nazarov Z.N.1, Isakov A.M.2, Sayinaev F.K.3, Yuldashov P.A.4
Ibragimov Sh.U.5
1Nazarov Zokir Norjigitovich - Assistant, DEPARTMENT OF SURGICAL DISEASES № 1;
Isakov Abdurauf Mamadiyarovich - PhD, Associate Professor, DEPARTMENT OF PEDIATRIC SURGERY;
Sayinaev Farrukh Karamatovich - Assistant;
4Yuldashov Parda Arzikulovich - Assistant;
5Ibragimov Sherzod Umidovich - Student, DEPARTMENT OF SURGICAL DISEASES № 1, SAMARKAND STATE MEDICAL INSTITUTE, SAMARKAND, REPUBLIC OF UZBEKISTAN
Abstract: it is noted that during 2 recent decades in Uzbekistan as well as in many countries of the world the number ofpatients with bile - excreting tracts diseases increases. The aim of investigation: improvement of surgical treatment of intraoperative magisterial bile ducts injuries. The results of surgical treatment of 103 patients with intraoperative magisterial bile ducts injuries during the period of 2000 - 2010 have been analyzed. In intraoperative revealing of bile ducts injuries of 28 patients, 18 patients had complete duct transaction, 10 -marginal injury. In 25 patients the operations for rehabilitation of bile ducts anatomy were performed at once and in 3 patients during two stages. In transaction and excision of the duct hepaticojejunoanastomosis according to Roux was performed in 5 patients, of them in 3 patients on transhepatic carcass drainage and in 2 without carcass drainage. The cause of failure in treatment of intraoperative magisterial bile ducts injuries are unpunctual diagnosis and performance of inadequate in volume operations directed to restoration of bile outflow by formation of biliobiliary and bilioduodenal anastomoses. Keywords: magisterial bile ducts, postoperative complications.
Relevance. Cholangitis Charkot was first described in 1977 as a triad of clinical signs of pain in the right upper quadrant, fever, jaundice. Rogers in 1903, the link between suppurative cholangitis, obstruction of the bile ducts and liver abscess in a patient who died after an unsuccessful attempt to resolve cholestasis. Reynolds and Dargan (1959) added to the triad Charkot shock dizziness and lethargy, which develop as a consequence of the accumulation of pus in the bile duct bile under increasing pressure with complete obstruction of the terminal part of the common bile duct [1, 3, 8]. Suppurative cholangitis - is one of the most frequent and severe complications of benign and malignant diseases of the biliary tract. Manifested complex organic and functional, general and local pathological changes in the body as a result of infection in the bile duct and occurs when a violation of their terrain and is observed in 17-83% of patients with choledocholithiasis, stenosis of the major duodenal papilla, Mirizi syndrome [1, 4, 7]. In patients with post-traumatic biliary strictures and scar contractions biliodigestive derivations cholangitis revealed more than 80% [1, 3, 8]. It is believed that without surgery acute suppurative cholangitis leads to death in 100% of cases [4, 8].
In the surgical treatment of cholangitis, significant progress related to the implementation of modern minimally invasive procedures, but there are a number of unresolved issues. One of them is holemic endotoxicosis accompanied by increases in plasma levels of metabolites (bilirubin, urea, creatinine, residual nitrogen, enzymes, average molecular weight oligopeptides (AMWO), etc.) [2, 5, 6, 9]. Postoperative mortality varies widely, ranging from 8 to 27% [3, 4, 8]. Based on the fact that the main cause of mortality is endotoxemia, the question naturally arises of detoxification.
Objective: To improve treatment outcomes in patients with suppurative cholangitis and biliary sepsis, using an improved method for plasmapheresis.
Materials and methods. The study was conducted in the clinic Samarkand Medical Institute. The basis of the study were 217 patients with obstructive jaundice complicated genesis of benign
suppurative cholangitis. In 53 patients with holemic endotoxicosis grade III - IV classification Bagnenko S.F. (2009) employed plasmapheresis, after preliminary minimally invasive decompression of the biliary tract. After the improvement of the patients and normalization of peripheral blood counts made operative treatment.
Of these, 27 patients with a combination of indirect electrochemical detoxication plasma sodium hypochlorite at 26 with additional plasma ozonation and subsequent reinfusion detoxify plasma. Types and characteristics of different methods plasmapheresis are presented in table 1.
Table 1. Performance indicators indirect combined digitally
plasmapheresis
IEDP
FIGURES additional ozonation IEDP
reduction of urea 78,1% 75,4%
decrease in creatinine 69,9% 67,6%
reduction
total bilirubin: 90,4% 85,4%
direct 93,8% 92,6%
indirect 86,9% 78,2%
decrease in total protein 2,8% 4%
reduced albumin 3,0% 3,2%
increase in the transport function of albumin 132 123
decreased concentration (AMWO) 45,1% 43,9%
reduction (LII) 63,9% 60,2%
Processing time 2-3 h 4-16 h
The number of sessions of plasmapheresis from 1 to 3 (of 103 sessions). Rejection of plasma reinfusion due to lack of detoxification - 3 cases (methodological and laboratory error). Otherwise reinfusion provided 85-90% of circulating plasma total replenishment autobelkovymi components in small volumes (600800 ml) of plasmapheresis. Additionally with transfuzirovali fresh frozen plasma (1doza single donor) and albumin 10% 100-150 ml, and the solution Infukoll 6% - 500.0 and crystalloids.
110
Complications of holding sessions of plasmapheresis were observed in 7 cases and cropped adequate therapy. Contraindications for transfusion to adequately detoxify autoplasma unknown. Criteria detoksitsirovannosti plasma is presented in table 2.
Table 2. Criteria detoksicated of plasma, making it possible
reinfusion
Plasma parameters criteria reinfusion
Level AMWO < 0,21 conv.u
HT < 27 u/ml.
Total bilirubin < 32 mmol/l.
Creatinine < 0,2 mg/l
Urea < 8 mmol/l
The total concentration of albumin (TCA) > 35 g/l.
The effective concentration of albumin (ECA) > 30 g/l.
The binding capacity of albumin (BCA) > 0,86.
Reserve albumin binding (RAB) > 10 g/l.
If the final control and laboratory research and detoxify through IEDP and IEDP additional ozonation plasma revealed a significant increase in endotoxemia (see above criteria in the table), the reinfusion of this plasma is not recommended. Extracorporeal technique IEDP and IEDP additional ozonation plasma (holemic endotoxicosis III - IV degree) with a programmed plasmapheresis provides:
• Adequate detoxification eksfuzed of blood plasma of patients holemic endotoxicosis grade III - IV, making it suitable for autoretransfuziology;
• Reducing the need for donor plasma and albumin on average by 85%;
• The minimum likelihood of immunokonflikt characteristic volume fresh frozen plasma (FFP) transfusions from different donors;
• Improve the transport function of albumin binding sites by deblokady of hydrophobic toxic components;
• The absence of side effects;
• Cost-benefits by reducing the cost of medical plasmapheresis. Conclusions. Thus, extracorporeal IEDP and our proposed method is highly effective preoperative preparation of patients with severe holemic endotoxemia against jaundice, helps stabilize the activity of cytolytic and cholestatic process, improves the protein-synthetic function of the liver, as well as allowing to eliminate the major clinical manifestations in this heavy contingent of patients, thus greatly expand the indications for surgical treatment.
Additional ozonation eksfuzed of plasma after adding to it a solution of sodium hypochlorite can increase detoxicant effect, reduce the toxicity of the plasma and red blood cells and prevent the side effects of sodium hypochlorite. Ozone has a biological, metabolic activity with respect to organic substrates - proteins, lipids, carbohydrates, shows them the high rate constants. In addition, the additional impact of ozone can reduce the exposure to 4-16 up to 3-4 hours. In general, the method is cheap and effective, can detoxify the plasma of patients, to minimize the need for donor protein preparations, reduce the risk of possible immune reactions, the risk of patient infection hepatitis B and C, human immunodeficiency virus, cytomegalovirus, herpes.
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