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INVENTION
Patent of the Russian Federation RU2186587
METHOD FOR RECONSTRUCTION OF ENGINE AND EVACUATOR FUNCTION OF THE INTESTINE AFTER OPERATIONS ON ORGANS OF THE ABDOMINAL CAVITY AND DEVICE FOR ITS IMPLEMENTATION
The name of the inventor: Kulikov LK; Turushev A.M. Shalashov SV; Usoltsev Yu.K.
The name of the patent holder: Irkutsk State Institute for Advanced Training of Physicians; Kulikov Leonid Konstantinovich; Turushev Andrey Mikhailovich
Address for correspondence: 664079 , Irkutsk, micro district "Yubileiny, d.100, GIDUV, patch department
Date of commencement of the patent: 1999.06.11
The invention relates to the field of medicine, namely surgical gastroenterology and medical technology, and is intended for early recovery of motor-evacuation function of the intestine in the immediate postoperative period after operations on the abdominal organs, including peritonitis, acute pancreatitis, acute intestinal obstruction, and And after operations on the small and large intestine. The method and the device allow to increase the efficiency of recovery of motor-evacuator function of the intestine after operations on the abdominal cavity organs in the early postoperative period and simplify the stimulation procedure. The method includes intraoperative insertion of a probe with electrodes for the entire length of the small intestine followed by electrostimulation against a background of constant aspiration of intestinal contents. Both multipolar electrodes are installed intraluminally in the initial section of the duodenum. Electrostimulation is performed by a series of monopolar pulses of low frequency at a pulse frequency of 12 1 min for 15-30 min. Conducting electrical stimulation with a frequency of 1 series at 15, 30 and 60 seconds. The device contains a naso-intrinsic probe and electrodes. The electrode with negative polarity is located 12-14 cm after the first perforation of the probe. The electrode with positive polarity is distal to the negative one by 12-15 cm. The surgeon makes intubation of the small intestine with a naso-intestinal probe of at least 200 cm long with electrodes placed on it. The probe is held up to the ileocecal angle. Both electrodes pass through the gatekeeper and are located in the initial section of the duodenum, where the main drivers of the intestinal peristalsis rhythm are located. Stimulation is carried out by a current strength corresponding to the threshold of bowel excitability, which averages 3.5-5 mA.
DESCRIPTION OF THE INVENTION
The invention relates to the field of medicine, namely to surgical gastroenterology and medical technology, and is intended for early recovery of motor-evacuator function of the intestine in the immediate postoperative period after operations on the abdominal organs, including peritonitis, acute pancreatitis, acute intestinal obstruction, and After operations on the small and large intestine.
The main task is the following:
Develop the most effective way to restore the motor-evacuator function of the intestine after operations on the abdominal organs and the device for its implementation.
It is known that after operations on the organs of the abdominal cavity, in the overwhelming majority of cases, disorders of motor-evacuation function of the intestine of different degree of severity develop. To restore peristalsis in medical practice, various types of medicamental and physiotherapeutic methods of treatment are used. Nevertheless, the effectiveness of the methods used to restore the motor-evacuation function of the intestine is not always unambiguous, even with their combined application. This leads to the development of new, more effective methods of treating postoperative intestinal paresis.
A method for restoring the motor-evacuation function of the intestine by percutaneous electrostimulation using standard instruments (ACM-2, ACM-3, UEI-1, Stimul-1) is known. The essence of the method is as follows. In the center of the anterior abdominal wall is placed a plate electrode (cathode) with an area of 300 cm 2 , the second (anode) - 400 cm 2 - in the upper lumbar region. Electrostimulation is performed by sinusoidal modulated currents at a pulse frequency of 20-30 Hz; Modulation manual - the duration of the parcel is 20 s, the depth of modulation is 100%, the duration of one procedure is 15 min, the strength of the current is up to the contraction of the muscles of the abdominal wall. (Handbook "Techniques and methods of physiotherapy procedures" / Edited by VM Bogolyubov, p. 104). Disadvantages of this method are:
1. relatively low therapeutic effectiveness.
2. Insufficiency of single stimulation and, as a consequence, the need for repeated electrostimulation without guaranteed recovery of motor-evacuation function of the intestine.
3. undifferentiated effect of electric current on surrounding organs and tissues.
4. impossibility of reducing intestinal pressure.
5. Impossibility of direct electrostimulation of the motor centers of the intestine.
6. Difficulties in using electrodes in the early postoperative period due to the presence of wounds on the abdominal wall.
7. This method of electrostimulation requires a large amplitude of stimulating current, exceeding the threshold of sensory sensitivity and causing unpleasant and painful sensations in patients.
8. The design features of the above instruments require specially trained personnel.
The closest to the proposed (prototype) is the method for restoring the motor-evacuation function of the intestine, which includes intraoperative nasointestinal intubation of the small intestine with a probe with unipolar electrodes placed on it, followed by electrostimulation in the early postoperative period using an inert plate-shaped cutaneous electrode. A standard naso-intestinal probe intended for intubation of the small intestine, 1.6 m long with perforations for aspiration of the contents, is used. The electrodes are located 20 cm apart and are six hollow steel cylinders connected by an insulated conductor. During the operation, the small intestine is intubated for its entire length. In the postoperative period, electrostimulation is performed with a current strength of 8-10 mA, a series of monopolar pulses of rectangular shape with a pulse duration of 5 m / s, a pulse cycle time of 2 s, a repetition rate of 50 Hz (autorid No. 1560231 A1, USSR, April 30, G.). In this case, the electrode with the reverse polarity is located on the skin. However, given this method of electrostimulation, taking into account the low electrical conductivity of the skin, it is necessary to increase the current supplied to the electrodes, which is much higher than the threshold of excitability of the intestine, which can lead to an exorbitant inhibition of nerve endings due to their overexcitation. In turn, an increase in the applied current may have a negative effect on the intestinal wall contacting the electrodes, but also cause an incidental pain effect. In addition, electrodes located along the length of the probe create an extensive electric field that can adversely affect the surrounding organs and tissues, in particular their hydroionic composition. Despite the certain effectiveness of this method of electrostimulation of the intestine, there is often a need for repeated electrostimulation. The design features of the devices used for this method of electrostimulation (Endoton, Gastroemma, Stimul-1, etc.), do not allow setting the parameters of the "maintenance stimulation" regime.
The aim of the proposed invention is to increase the recovery efficiency of motor-evacuator function of the intestine after operations on the abdominal cavity organs in the early postoperative period and simplify the procedure of electrostimulation.
To restore intestinal function in the immediate postoperative period, we use a device containing a naso-testine probe 1 with positive 2 and negative 3 electrodes located on it. During surgery on the abdominal organs after elimination of the cause of the disease, we make intubation of the small intestine with a nasointestinal probe with a length of at least 200 cm with electrodes placed on it. In this case, the surgeon conducts the probe to the ileocecal angle and makes sure that both electrodes pass the gatekeeper and are located in the initial section of the duodenum, where the main drivers of the intestinal motility rhythm are located. In the near postoperative period, against the background of a decrease in intestinal pressure due to active and passive aspiration of intestinal contents, the pacemaker zone of the intestine (pacemaker) is electrostimulated by current strength corresponding to the threshold of bowel excitability, which averages 3.5-5 mA, a series of monopolar pulses of rectangular shape With a pulse duration of 5-7 ms. The pulse pulse time is 0.5 s. The frequency of the series of pulses is 12 in 1 min, which corresponds to the physiological rhythm of the intestinal motility. The stimulation frequency is 50 Hz. Active stimulation is carried out for 15-30 minutes before the appearance of peristalsis, and then the device is transferred to the regime of electrostimulation supporting the motility of the intestine by rare series (1 series / 15, 30, 60 s) of pulses, depending on the intensity of peristaltic waves. Removal of the probe is performed with stable peristalsis on the inserted probe without electrostimulation in the presence of an independent stool.
With pronounced changes in the intestinal wall, for example, with slowly regressing peritonitis, when your own energy resources of the intestine are not sufficient to maintain peristalsis, a second phase of electrical stimulation ("supporting" electrical stimulation) can be performed for a long time. In this case, the therapeutic effect consists in the elimination of microcirculatory stasis, the improvement of regional hemodynamics, and consequently in the correction of metabolic disorders.
Comparative analysis with the prototype showed that the proposed method differs from the known one in that:
1. There is no external electrode (both electrodes, both positive and negative are cavitary).
2. The electrode with negative polarity is located 12-14 cm after the first perforation of the naso-intestinal probe, the second electrode with positive polarity distal to the first one by 12-15 cm. The electrode with negative polarity is installed in the pylorobulbar zone.
3. The electrostimulation is carried out in a rhythm corresponding to the physiological rhythm of the peristalsis of the small intestine - 12 series of pulses per minute.
4. Supportive stimulation is used - one series of pulses at 15, 30 and 60 seconds.
Thus, this technical solution corresponds to the criterion of the invention "novelty".
The analysis of patent and specialized literature showed that the proposed method and device for its implementation differ not only from the prototype, but also from other technical solutions in this and related fields. The authors did not find ways of intestinal stimulation of the intestinal rhythm driver using only cavity electrodes located on the naso-intestinal probe in combination with aspiration of intestinal contents in the nearest postoperative period. And there were no variants of prolonged "maintenance" stimulation.
The proposed distinctive features of the design and method allow:
1. to obtain a guaranteed effect of electrostimulation without the use of medications.
2. Reduce the applied current to the threshold values of excitability of the intestine. This eliminates negative subjective effects, such as pain, a feeling of discomfort in the abdomen in response to electrical stimulation.
3. Simply simplify the procedure of electrostimulation (due to the lack of an external electrode).
4. to obtain an additional therapeutic effect against the background of prolonged supporting electrical stimulation due to correction of regional hemodynamics and, accordingly, metabolism.
Thus, the proposed technical solution meets the criteria "inventive level" and "industrial applicability".
The proposed device is a two-lobed naso-intrinsic probe with a length of at least 200 cm. The outer diameter of the probe is 0.7 cm, the inner diameter is 0.5 and 0.1 cm. Two insulated wires are lead along the thin lumen, each of which terminates in an electrode. The electrodes are two thin-walled metal cylinders with a diameter of 0.7 cm and a length of 1.5 cm, located at a distance of 12-15 cm from each other. In this case, the negative electrode is located 12-14 cm from the proximal perforation of the probe, and the positive electrode is distal.
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The proposed device is used as follows . During the surgical intervention on the abdominal organs, intubation of the small intestine is performed with a standard naso-intestinal probe of at least 200 cm length with disposed on it multi-polar (+, -) electrodes and perforations along the entire length for aspiration of intestinal contents. The electrodes are two hollow metal cylinders, tightly fixed to the outer wall of the naso-intrinsic probe and connected to the electrical connector by conductors located inside the probe wall. The first (negative) electrode is located most proximally - 12-14 cm after the first perforation of the probe. The second (positive) distal to the first by 12-15 cm. With electrostimulation, there is no significant dispersion of the electric field to surrounding organs and tissues, since most of the electric current passes through intestinal contents, which is a mixture of electrolytes, and closes in a small space. After performing the main stage of the operation on the abdominal organs to prevent development in patients in the postoperative period of dynamic intestinal obstruction (intestinal paresis), a nasointestinal intubation of the small intestine with the above-described probe is performed. The probe is carried into the small intestine up to the ileocecal angle by a manual method, "stringing" the intestinal loops onto it. In this case, the surgeon makes sure that the negative (proximal) electrode is located strictly in the pylorobulbar zone, where the main drivers of intestinal rhythm are located. In the mesentery of the small intestine, we introduce about 40 ml of 0.25% novocaine to block the sympathetic innervation of the intestine. The surgical wound is layer-by-layer. The free end of the probe is fixed to the nasal septum to prevent displacement of the probe, and accordingly the electrodes from the driver's zone of intestinal rhythm (pylorobulbar zone). |
In the near postoperative period, against the background of a decrease in intestinal pressure due to active and passive aspiration of intestinal contents, an electrostimulation of the pacemaker zone of the small intestine is performed with a current strength corresponding to the bowel excitability threshold, which averages 3.5-5.0 mA, a series of monopolar pulses of rectangular shape with Pulse duration 5-7 m / s. The stimulation frequency is 50 Hz. The pulse pulse time is 0.5 s. Pause between series of pulses 5 s. Stimulation is carried out for 15-30 minutes and then is transferred to the supporting intestinal peristalsis: interruptions between series of pulses are 15, 30 and 60 seconds, depending on the intestinal peristalsis. "Supporting" electrical stimulation can be used for a long period of time. When the persistent stimulation effect (the presence of a non-diluted stable peristalsis) is reached, the electrostimulation is stopped. Naso-intestinal probe is removed according to indications.
Example 1 . A 62-year-old patient was taken to the hospital three days after the onset of the disease with complaints of intense pain but to the entire abdomen, nausea, repeated vomiting, fever to 38 ° C. On admission, the patient's condition is severe, the symptoms of peritoneal irritation are positive throughout the abdomen. Laparotomy was performed for emergency indications. With the revision of the abdominal cavity the diagnosis was made: "Acute gangrenous destructive appendicitis., Purulent appendicitis diffuse." Completed appendectomy, sanation and drainage of the abdominal cavity. The intubation with the proposed device was then carried out with the first (negative) electrode located 14 cm from the proximal perforation of the probe and corresponded to the pylorobulbar zone, and the positive electrode was distal 12 cm. In the first hour after the end of the operation, the pacemaker was electrostimulated Intestine (pylorobulbar department) for 15 min. To monitor the efficiency of the device and evaluate the motor activity of the intestine, myography, phonography, and ballonometry were used. 12 minutes after the initiation of electrostimulation, peristaltic activity of the small intestine appeared. The device was switched to a mode of supporting electrostimulation in the intestine motility in the 15th minute. The pulse repetition frequency is one pulse series per 30 s. In pauses between series of pulses, myography was performed. After 2.5 hours after the initiation of electrostimulation, peristaltic activity was found to be satisfactory. Stimulation stopped. The probe was removed after 28 hours. During this time period the patient's peristalsis was stable, by the end of the first day after the operation the patient had an independent chair. The postoperative period was favorable.
Example 2 . The patient S., 39 years old, was taken to the hospital two days after the onset of the disease with complaints of intense dull pain in the abdomen, repeated vomiting, fever. Lack of a chair. In the anamnesis, the patient had two operations on the abdominal organs. When entering the hospital, the patient's condition is regarded as extremely severe, the symptoms of irritation of the peritoneum along the entire abdomen, the sound of splashing is heard. Immediate laparotomy was performed, during which a massive adhesive process was identified, a ileal lap turn with necrosis last for 50 cm. Enterolysis, resection of the small intestine, entero-enteroanastomosis, sanitation and drainage of the abdominal cavity was performed. Nasointestinal intubation with a proposed probe with electrodes was performed. The probe is held manually until the ileocecal angle. The negative electrode was installed in the pylorobulbar zone and was 12 cm from the first perforation of the probe. The positive electrode was located distal to the negative perimeter of 15 cm. After the operation, against a background of constant aspiration of the intestinal contents, an electrostimulation of the driver of the rhythm of the small intestine (pylorobulbar department) Low-frequency current (stimulation frequency 50 Hz, current strength 5 mA, pulse duration 7 ms, pulse train frequency 12 / min) for 15 min. Then, against the background of a potentiated peristalsis, the device was switched to the supporting electrostimulation mode - 1 series of pulses in 60 seconds. After 16 hours the patient had a stool, gases went away. Given the stability of peristalsis, the probe was removed 1 day after the operation. The postoperative period was favorable. In a satisfactory condition on the 10th day after the operation the patient was discharged for outpatient treatment at the place of residence.
The proposed method and device were used in the treatment of 12 patients. In all cases, the effect of early intestinal electrostimulation of the pacemaker zone of the small intestine was consistent with the expected result. The efficiency of electrostimulation was 100%, no complications were observed. The effect of prolonged maintenance electrostimulation has been reliably confirmed:
1. No repeated electrostimulation procedures were required.
2. The strength of the applied current is reduced to the threshold values of excitability of the intestine.
3. Eliminated negative subjective effects, such as pain and discomfort in the abdomen, in response to electrical stimulation.
4. The rhythm of electrostimulation is as close as possible to the physiological rhythm of the peristalsis of the small intestine.
5. Only the driver zone of the rhythm of the small intestine was stimulated, which significantly reduced the effect of electric current on surrounding organs and tissues.
6. Reduced the negative effect of electrodes on the intestinal mucosa due to a decrease in the applied current.
7. There is an additional therapeutic effect due to correction of regional hemodynamics against the background of prolonged maintenance electrical stimulation.
8. Simplified procedure of electrostimulation.
9. Portability and design features of the device allow carrying out the procedure of electrostimulation in the intensive care and reanimation room and do not require the presence of specially trained personnel.
This method and device for its implementation is recommended to be used in clinical practice in the departments of emergency surgery and in surgical gastroenterology.
CLAIM
1. A method for reconstructing the motor-evacuation function of the intestine after operations on the abdominal organs, comprising the intraoperative insertion of a probe with electrodes over the entire length of the small intestine followed by electrostimulation against a background of constant aspiration of intestinal contents, characterized in that both of the different polar electrodes are set intraluminally in the initial section of the duodenum And electrostimulation is performed by a series of monopolar pulses of low frequency at a pulse frequency of 12 per minute for 15-30 minutes, and then a supporting electrostimulation is performed at a frequency of 1 series at 15, 30 and 60 seconds.
2. An apparatus for reconstructing the motor-evacuatory function of the intestine after operations on the abdominal organs, comprising a naso-intrinsic probe and electrodes, characterized in that the electrode with negative polarity is located 12-14 cm after the first perforation of the probe, and an electrode with a positive polarity distal to the negative At 12-15 cm.
print version
Date of publication 29.03.2007gg
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