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12Received by the Editor 02.11.2020
IRSTI 76.29.39
THE USE OF MEDIATORS IN THE COMPLEX TREATMENT OF PURULENT-SEPTIC WOUNDS
A. Shakenov, S. Saparbayev, V. Absatirova, A. Ismatov, S. Kozhahmetov, O. Akyshev, R. Chekaev
NcJSC "Astana Medical University", Nur-Sultan city, Kazakhstan
The choice of treatment tactics for patients with purulent-septic wounds has always been not an easy one for a surgeon. It is necessary to take into account the morphological, pathophysiological and biochemical aspects of the course and its outcome is determined by the mechanisms of tissue damage, the existence of an inflammatory process, the level of protective properties of the organism, the reactivity of the immune system and the initial state of the patient, etc.
This review reflects the most commonly used methods of treating infected wounds, their advantages and disadvantages. Moreover, the article represents the topicality in proceeding the study of the given issue.
Key words: infected wound, purulent surgery, wound immunology, regeneration, wound process, cell therapy, wound repair, cell mediators, cytokines, immunocorrection wound, purulent intoxication.
ИСПОЛЬЗОВАНИЕ МЕДИАТОРОВ В КОМПЛЕКСНОМ ЛЕЧЕНИИ ГНОЙНО-СЕПТИЧЕСКИХ РАН
А.Д. Шакенов, С.С. Сапарбаев, В.К. Абсатирова, А.Ю. Исматов, С.К. Кожахметов, О.К. Акышев, Р.А. Чекаев
НАО «Медицинский университет Астана», Нур-Султан, Казахстан
Выбор тактики лечения больных гнойно-септическими ранами всегда был для хирурга непростой задачей. Необходимо учитывать морфологические, патофизиологические и биохимические аспекты течения, а его исход определяется механизмами поражения тканей, наличием воспалительного процесса, уровнем защитных свойств организма, реактивностью иммунной системы и исходным состоянием пациента.
В этом обзоре отражены наиболее часто используемые методы лечения инфицированных ран, их преимущества и недостатки. Статья представляет актуальность в продолжении исследования данной проблемы.
Ключевые слова: инфицированная рана, гнойная хирургия, иммунология раны, регенерация, раневой процесс, клеточная терапия, заживление раны, клеточные медиаторы, цитокины, гнойная интоксикация.
1Р1-СЕПТИКАЛЫ ЖАРАЛАРДЫ КЕШЕНД1 ЕМДЕУДЕ МЕДИАТОРЛАРДЫ ПАЙДАЛАНУ
А.Д. Шакенов, С.С. Сапарбаев, В.К. Абсатирова, А.Ю. Исматов, С.^. ^ожахметов, О.К. Акышев, Р.А. Чекаев
«Астана медицина университета КеАК, Н^р-С^лтан к;., ^азакстан
1рвдьсептикалык жаралармен ауыратын наукастарды емдеу тактикасын тацдау хирург Yшiн эрдайым киын мэселе болып келген. Курстыц морфологиялык, патофизиологиялык жэне биохимиялык аспектшерш ескеру кажет, ал оныц нэтижеа тщдердщ закымдану механизмдерiмен, кабыну процесшщ болуымен, организмнiц корганыш касиеттержц децгейiмен, иммундык жYЙенiц реактивтiлiгiмен жэне наукастыц бастапкы кYЙiмен аныкталады.
Б^л шолуда ж^ктырган жараларды емдеудiц жш колданылатын тэсiлдерi, олардыц артыкшылыктары мен кемшiлiктерi кврсетiлген. Макалада осы проблеманы зерттеудi жалгастырудагы взектiлiк кврсетiлген.
ТYЙiндi свздер: ж^ктырган жара, iрiндi хирургия, жараныц иммунологиясы, регенерация, жара процеа, жасуша терапиясы, жараны емдеу, жасуша медиаторлары, цитокиндер, iрiндi интоксикация.
Introduction
The problem of treating infected wounds of various origins belongs to one of the most investigating branches of medicine, which is still under the study and extremely topical for a long time. Despite the widespread use of antibiotic therapy, the main problem is the persistent prevention of infectious complications. Furthermore, under the influence of the widespread use of antibiotics, the nature of the infectious process has changed, resistant and antibiotic-independent forms have emerged inside and outside hospital strains. In addition, there are frequent cases of allergic complications, dysbacteriosis, superinfection, decreased immunological resistance of the organism and other complications [2-7].
Even having achieved a certain success in the treatment of infected wounds, there is no particular tendency to reduce suppurative diseases and infectious complications. Many authors believe that the reason is the insensitivity of pathogens to antibiotics and secondary immunodeficiency [4, 7-9]. Taking into consideration the statistics of deaths associated with an infected wound in surgical clinics, it will be equal to approximately 42% of mortality [4,5].
It is apparent, the wound repair is a rather complex, morphological, pathophysiological and biochemical process. Factors directly related to tissue damage as the primary or secondary wound infection; the existence of an inflammatory process, often with suppuration preventing natural healing; the level of reserve capabilities of the body; reactivity and their initial state of the patient can influence the process and the result of wound repair [3,4,6]. It should be realized that new factors emerge having a crucial influence on the disease process in general and purulent-inflammatory processes in particular. As a result, it is the poor ecology of the environment, socio-economic factors, drug abuse, etc. The influence of these factors on the clinics of the pyoinflammatory process and the peculiarities of the therapy of an infected wound are not widely investigated [4,6,10,11]. At the same time, conventional methods of therapy are often ineffective and it is necessary to introduce new approaches in therapy, to develop new protocols and tools using the latest scientific and technical advances [3-6,10,12].
Nowadays, the amount of information about new methods to improve the results of treatment of purulent wounds is increasing, however, a completely satisfactory method for surgeons has not been developed and the fact of a large number of proposed methods indicates their low efficiency and lack of consensus on this issue. On this topic, S. S. Girgolav wrote in his study: "It is unlikely that for any other purpose in medical practice, a greater number of both individual means and its combinations (recipes) and the whole methods and systems were proposed than for treatment of wounds" [13].
The significance of treating the infectious course of purulent wounds is the timely opening of abscesses with subsequent rational drainage, which reduces the absorption of the decay products of bacteria and tissues, toxins, limiting the wound process and the formation of a necrotic mass with subsequent separation through draining incisions. At the same time, it is not always possible to stop and limit the inflammatory process only by opening and draining the purulent cavity [3,12,14].
Timeous tissue necrotomy has always been the main principle of the surgeon in the treatment of infected wounds. This tactic of therapeutic measures has a physiological rationale, in natural conditions, necrolysis improves reparative regeneration of wounds and it is impossible to heal completely. Herewith, the standard methods of local wound therapy restrict the inflammatory process, preventing septic complications and improving conditions for repair in the affected tissue. Therefore, the means and preparations used for the local treatment of wounds, primarily, should have antiseptic properties, stimulate the development of granulation tissue and epithelialization of the wound, as well as increase the protective properties of tissues. Naturally, general and local treatment of wounds should be implemented taking into account the infectious agent and its sensitivity to antibiotics, with considering the general state of the patient, assessing the reserve capacity of the body and the degree of the clinical course of the wound process in order to prevent complications [3,6- 8,14,15].
However, in 1990. M.I. Kuzin and B. M. Kostyuchenok [3] noted in their studies that standard protocols suitable for wound therapy at all stages of healing have not been worked out yet because
the tasks of the therapeutic effect on the infected wound are too different in all phases of inflammation, regeneration and epithelialization. Consequently, the requirements for the local medical treatment of wounds are as follows: firstly, the therapy of infected wounds should be carried out in strict accordance with the phase of inflammation where the wound is located, passingin different phases of the wound process. Secondly, in some cases, drug therapy does not provide a fully effective stimulation for the wound process. Thirdly, nowadays there are no drugs that simultaneously provide a fast combined and complete rejection of necrotic masses from the wound wherein suppressing the growth of wound infection and stimulating effectively wound healing.
If all the objectives of treating infected wounds aggregate, then in the first phase of the wound inflammation process they are limited to rapid drainage and wound purification, creating conditions for unobstructed drainage and suppressing wound infection. Moreover, in the second phase - by stimulating wound healing processes.
Nowadays, in the local treatment of wounds, more than 100 antiseptic agents and preparations are successfully used, differing in their origin and mechanism of process [2,3,4].
A major breakthrough in the therapy of infected wounds is associated with the creation of multicomponent water-soluble liniment and immobilized lysing enzymes [2,3,4,6,14]. Protein-degrading enzymes, which are secreted during tissue necrosis, as well as produced by immune cells, are the most important for the inflammatory process during the period of wound cleaning. They activate the release of cytokines for neutrophils and mononuclear cells from the bloodstream into the inflammatory process, phagocytosis of bacteria and tissue breakdown products, which is due to their mediated antibacterial effect. A variety of applied enzymes is obtained from animal pancreas (trypsin, chymotrypsin, pancreatic ribonuclease and deoxyribonuclease) or from bacterial types of breeding -streptokinase, strepdornase, collagenase, alpha-amylase.
However, the given enzymes are not always available for the use in everyday practice. This prevents its scarcity and high cost, short duration of exposure, destructive effect on granulation tissue, the possibility of increasing general intoxication during active processes of necrolysis. Furthermore, allergic reactions and intolerance to water-soluble ointments can occur, but with their prolonged use, microorganisms become resistant to antibacterial substances contained in their composition.
Nowadays, there is a narrow spectrum of targeted processes and the high cost of drugs, when all new strains of microorganisms emerge, stimulate the search for new methods of the most effective local impact on the wound process. Here, liquor electrolysis deserve special attention, namely sodium hypochlorite [16-19], this liquor has an obvious antimicrobial effect against both gram-positive and gram-negative bacteria, and even antibiotic-resistant flora. However, the information about the use of sodium hypochlorite is found as well, the reparative processes in the wound proceed much slower, and in some sources it is even mentioned that tissue healing is inhibited [16,18,19].
More and more information is discovered in the literature on the successful use of electrochemically activated liquids of neutral anolyte and catholyte in the treatment of purulent-inflammatory diseases and wounds [12,17,20]. Various tissue and protein preparations are used increasingly in biological stimulants of the wound process. This group includes extracts from various organs and tissues, preparations from canned dermis and other protein preparations [2,3,4,14,21,22 ]. In addition to the above mentioned drugs, blood components in the form of a bacteriostatic hemobandage or hematopast, also called hemosyntolysin, are successfully used [23].
The human placenta, which is known to be rich in active hormones and hormone-like mediators, neuropeptides, various growth factors, enzymes, amino acids, signaling molecules and many other biologically active substances, is of particular interest as a biological stimulator of the process of tissue regeneration and repair [24]. It has already been proven that the tissue of the human placenta renders an evident wound healing, regenerating, hemostatic, anti-inflammatory activity, as well as stimulates the normalization of local immunity parameters [25,26]. The authors noted that the use of placental tissues in the treatment of purulent processes in soft tissues stimulated the effective cleaning of wounds from necrotic masses, as well as accelerated healing and epithelization. The bactericidal properties of biological coatings have not been determined, but the anti-inflammatory effect, according to the researchers, caused the protective mechanism of the wound surface from the
unfavorable effect of the environment, normalization of the pH of the wound surface and an increase of local phagocytosis.
It should be noted, that the widespread use of this method in purulent surgery is constrained by two main factors: the first one is its processing and storage; the second is the combined preparation of the wound by methods of surgical, enzymatic treatment to obtain the maximum effect.
In 1995. L.V. Kovalchuk [28] used xenogenic (porcine) cytokines in the experimental work in the treatment of infected wounds in rabbits and obtained excellent results due to early suppression of inflammation, acceleration of epithelialization, repair and analgesic impact. It was evident, that the biological complex of cytokines was involved in the wound process at all stages of inflammation. So, in the early period (up to 7 days), there was an increased migration and functional activity of neutrophils, which was reflected in the wound cleaning from the bacterial load. At the later stages (23 weeks), under the influence of a biological complex of cytokines and mediators, there was a revealing of a huge local amount of fibroblasts with the formation of collagen fibers, an increase in the marginal epithelialization of the wound. Along with fibroblastic processes, the mechanisms of suppression of the proliferation of connective tissue and the process of scarring were also included.
Later, the studies were published demonstrating the effective use of recombinant cytokines in the clinic. Thus, O.R. Ziganshin (2001) utilized successfully Roncoleukin for the treatment of chronic prostatitis in the form of urethral instillations [29], and L.F. Aznabaeva and A.S. Simbirtsev [30] proved the effectiveness of Betaleukinthrough a transnasal catheter in purulent rhinosinusitis.
Materials and Methods
Taking into account mentioned above, it can be concluded that, despite the diversity of the number of sufficiently effective methods of local therapy for infected wounds, up to date, the treatment of patients with this pathology is not an easy task. The same methods, different in their effectiveness, depending on the location and depth of the lesion, can be limited in use or not available for widespread usage. This means that the principle of therapy should be complex and contain both operational and conservative methods, and methods aimed at suppressing and eliminating the pathological pathogen, detoxification, correction of homeostasis disorders, stimulation of the body's reserve capabilities and increasing its resistance. In addition, operative and conservative therapies should be reviewed as complementary and not competing or mutually exclusive. All this makes it topical and expedient to further search for the most effective, cost-effective and readily available methods of therapy for infected wounds.
Nowadays, it is known that in purulent-destructive processes, intoxication syndrome is growing, which requires urgent correction of organs and systems. There are several definitions of the concepts: "Endogenous intoxication syndrome" (EIS), "Endotoxemia", "Bacterial endotoxicosis" (BET). EIS is the development of various pathological states, heterogeneous in etiology and load, but due to the accumulation in tissues and biological fluids of products formed in the body (endotoxins). Endotoxemia is the accumulation of endotoxins directly in the blood [33].
Endotoxicosis is the clinical symptoms of endogenous intoxication, a set of the heaviest state cases with precise catabolic reactions, disruption and termination of the functioning of natural detoxification systems, an intense effect on the body defense system, and on heterogeneous substances. There are famous studies where mediators of embryonic stem cells correct endogenous intoxication for increasing the reserve capabilities of the body.The primary measure in the treatment of endotoxicosis should be the prime cause sanitation and the prevention of toxin entry from the primary affect: radical surgical intervention, including adequate sanitation of the focus, its maximum possible delimitation and effective drainage [33].
The wound repair defect is possible only with a well-chosen and precise interaction of biological and molecular processes of cell migration, proliferation and restructuring of the extracellular matrix. At one of its deceleration process, healing is slowing down and the wound becomes chronic. In the process of healing, the wound passes through the following phases: coagulation, inflammation, migration-proliferation (including matrix restructuring) and remodeling. At acute wounds in each phase of inflammation, biological and cellular processes mutually complement and stimulate each other, which are not noticeable in chronic ones. Some areas of the
chronic wound surface can turn up simultaneously in different phases of repair; the processes of transition from one phase to another are separated. Even in the process of physiological healing, such complications as joining of a secondary infection, the development of local thrombosis and tissue ischemia can emerge [34]. Both in the experiment and in clinical practice, it has been shown that both acute and chronic wounds of any other genesis (bedsores, ischemic and venous ulcers) often get stuck in one or another phase, and therefore the repair process is delayed. Primarily, it occurs by the tolerance to various methods of therapy and the decline in the therapeutic prognosis. Purulent-destructive wounds are characterized by a more protracted phase of inflammation, the decrease in the activity of inflammatory cells and the deceleration of ECM restructuring. These are disorders, which contribute to the transition of the wound from acute to chronic. It is evident that the amount of collagen produced by fibroblasts is decreasing among patients leading to the deceleration in the wound surface contraction. Moreover, the disturbance of carbohydrate metabolism entails the increase in matrix metalloproteases (MMP) and the decrease in nitric oxide (NO), a transforming growth factor beta-1 (TGFpi), which is the reason of deceleration in the formation of ECM. The interaction of glycated collagen with ECM and fibroblasts or endothelial cells prevents cell adhesion, its proliferation, and wound contraction [34].
It should be noted that recombinant preparations of immunocytokines were mainly used parenterally for these purposes. For the treatment of purulent-destructive processes, it is advisable to apply the principle based on the local application of autologous and allogeneic (or heterologous) cytokines [6]. It has been proven that cytokines, as short-lived products of short-distant force, provide the desired effect at their high local concentration in the focus of inflammation [6]. The theoretical substantiation of local immune-correction in recent years was the data about cytokines as a single system of regulation in the function of body cells by polypeptide and signaling molecules that control the growth, division and functional activity of cells of various tissue including fibroblasts, osteoclasts, chondrocytes, keratinocytes, endothelial cells, nerve tissue cells [35]. A complex of cytokines excreted by macrophages, neutrophils, and monocytes plays the greatest role in the regulation of the inflammatory reaction, as well as the regulation of reparative processes in the infected wound [10]. More than a century ago, an idea of I. I. Mechnikov [8] about the main role of the mononuclear phagocytes system in the unification of all types of cells participating in the organism defense reactions is generally true till today. I. I. Mechnikov [8] stated that the reactions of inflammation are implemented by the use a living connection between connective tissue cells, endothelial elements and leukocytes, forming a chain of factors that play a major role in inflammation. Under the influence of cytokines - chemokines, cell chemotraction is implemented where virus or bacteria are penetrated, it takes place discretely for a certain type of cells. For neutrophils, as a rule, the first chemotractant in the focus of destruction is a peptide produced by macrophages - MDNCF / NAP, later called IL-8, besides IL-8, chemotactic functions are performed by a macrophage inflammatory protein (MBB-1), being not only chemotractants, but granulocyte activators as well. Chemotraction of monocytes from peripheral blood is implemented with the help of MCP (monocyte chemotractant protein 1,2,3), produced by macrophages, monocytes and other cells. The inclusion of CD4 + lymphocytes, monocytes and eosinophil into the wound is carried out by the lymphocytic chemottractive factor (LCHF), promoting the expression of IL-2 receptors on the surface of T-lymphocytes, taking part in the activation of a specific immune response to the causative agent of purulent infection.
Results
As the result of the exposure of the mentioned proinflammatory cytokines in the capillaries, being close to the focus of inflammation, there is a marginal accumulation of granulocytes, monocytes and lymphocytes. In the attachment mechanism, adhesion molecules not only of leukocytes, but also of endothelial cells play a crucial role [28]. Thus, the expression increase of transmembrane glycoproteins ICAM-1 and VCAM-1 on the surface of endotheliocytes is accompanied by the existence of neutrophil and macrophage infiltration of tissues adjacent to the wound. Local tissue edema during inflammation is provided, to a large, extent by granulocyte cytokines IL-1 and TNF, GM-CSF and G-CSF, which cause dilation of vessels and increase their permeability. The synergism in the operation of phagocytes and endothelial cells in the focus of wound inflammation is not
completed there, it turned out that in the period of their activation, endothelial cells have the ability to produce blood coagulation factors. Moreover, at the stage of phagocytosis, macrophages are expressed on the membrane or excrete factors with procoagulant activity under the influence of cytokines (INF, IL-1 and TNF), viruses, bacterial LPS, T-lymphocytes. Thrombosis of small vessels in the wound is an evolutionary fixed event with the participation of endothelium and macrophages, supporting to restrict the spread of infection in the body and the process of destruction. As the result of phagocytes revitalization, and the operation of their products of inflammatory mediators and enzymes, the lysis occurs on the wound surface of purulent-necrotic masses, as well as the transition to the stage of regeneration with tissue restoration and scar formation. Under the influence of the complex of macrophage mediators, granulation tissue is formed. The formation of granulation tissue is the result of the operation on its cellular elements of growth factors of diverse histogenetic orientation, secreted by macrophages, lymphocytes, fibroblasts. Among the cytokines that regulate the growth and division of fibroblasts, the growth factor from platelets (BFGF, BFGF, TGF)is involved at an early stage of healing stimulating the proliferation of fibroblasts and the process of angiogenesis. TGF is involved in the formation of granulation tissue and epithelial regeneration. IL-1 regulates the growth of fibroblasts and endothelial cells as well stimulating the migration of epidermal cells in the wound, the creation of the epidermis, regeneration of nerve endings with the induction of growth factor production in the nervous system [33]. An active increase in cellular repair in the proliferative phase of regeneration is replaced by a rarefaction of the vascular network and an increase in the synthesis of the connective tissue matrix (collagen, proteinlycan, elastin, etc.).
Some cytokines (IL-1, BFGF, FAF, TGF ) induce collagen synthesis by fibroblasts, while others (INF, IL-1) at high doses, TNF inhibit collagen synthetic function and thus positively and negatively regulate wound healing [35].
At the stage of reparation and normalization of the inflammation reaction of the wound process, mechanisms for suppressing excessive proliferation of connective tissue activate, operating on the principle of self-regulation. Fragments of the connective tissue matrix (collagen, protein glycan) operate on macrophages, inducing the secretion of prostaglandin E2 and IL-1. Prostaglandin E2, in turn, stimulates the synthesis of collagenase in macrophages, being responsible for collagen degradation [35]. In human skin fibroblasts, the expression of collagenase is detected upon stimulation with interleukin-1, TNF, INF, PDGF [35]. All this prevents from the formation of rough collagen scars.
Discussion
Thus, summing up the results of this review, it can be confirmed that the outcome of the wound process depends on a set of intercellular interactions of lymphocytes, macrophages, fibroblasts, endotheliocytes, keratinocytes and other cells via direct and indirect receptor and mediator contacts according to the principle of self-regulation.
In these processes, the cytokines injected to the patient, perform more than one function. On the one hand, they initiate the migration of blood cells into the purulent process, which is confirmed by a 1.52-fold increase in the ratio of mononuclear cells and granulocytes on the 4th day after treatment. Furthermore, they stimulate oxygen metabolism and phagocytosis, lead to lysis of the wound surface from purulent-necrotic masses and the regeneration phase acceleration (provided by MYTH, LIF, INF, TNF). On the other hand, the obtained cytokines trigger a local cytokine cascade involving cells on the wound surface, stimulating the production of collagen, fibroblasts, endothelial cells, and nerve formations.
Consequently, as the result of a complex use of natural cytokines obtained in the treatment of purulent wounds, it is possible to achieve a faster phase of wound cleaning from pathogenic flora, earlier cleaning of the wound from necrotic masses, activation of healing processes and early epithelialization. This reveals the possibility for clinicians to develop new combined methods for the treatment of purulent-destructive wounds [35].
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