A MODIFIED METHOD OF PLASMAPHERESIS IN THE TREATMENT OF PATIENTS WITH PURULENT CHOLANGITIS

Davlatov S.S.*, Kasymov Sh.Z.**, Kurbaniyazov Z.B.*, Ismailov A.O.*

*The Chair of Faculty and Hospital Surgery of Samarkand State Medical Institute’s.

**The Republican Specialized Center of Surgery named after Academician V.V. Vahidov.

Introduction. The frequency of septic complications of inflammatory diseases of the biliary tract, despite the attention of researchers to this issue remains highly relevant. It is believed that without surgery acute suppurative cholangitis leads to death in 100% of cases (4,6). 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, enzimesoligopeptides of average molecular weight, etc.) (2,5). Postoperative mortality varies widely, ranging from 8 to 27% (1,3,4). Based on the fact that the main cause of mortality is endotoxemia, the question naturally arises of detoxification. Plasmapheresis, is the most extensively studied by adjuvant therapy. With convincing evidence of effectiveness of plasmapheresis in purulent cholangitis further research to improve its efficiency by reducing the amount and possible reinfusion patients treated purified plasma.

The aim of the study. Improvement of treatment results biliary sepsis and severe biliary sepsis using an improved method of plasmapheresis.

Materials and methods. The study was conducted in the clinic Samarkand medical institute. The basis of the study were 217 patients with hyperbilirubinemia, acute cholangitis, biliary sepsis and severe sepsis benign biliary origin, complicated by suppurative cholangitis. Most of the patients were women 136, men were 81. The mean age was 65,3 ± 8,7 years.

In this paper, for the diagnosis of acute cholangitis and biliary sepsis, we defined the basic laboratory findings possible to calculate the degree of organ failure on the scale of SOFA (Sepsis organ failure assessment) and the severity of the systemic inflammatory response criteria for SIRS (Systemic inflammatory response syndrome). Laboratory and Diagnostics in addition to accepted clinical blood and urine tests included the following methods. On the function of the liver was assessed by bilirubin and its fractions in the blood serum, the activity of serum transaminases, alkaline phosphatase, protein content and its fractions, cholesterol levels, prothrombin, indicators thymol and sublimate samples as well as on the content of electrolytes in the blood serum. Noninvasive preoperative diagnosis of acute cholangitis, biliary sepsis and pathology gepatopankreatoduodenal zone, against which they were spent, in addition to physical examination, including a review of X-rays of the abdomen, ultrasound, computed tomography. Endoscopic studies included holedohoskopi, fibrogastroduodenoscopy, laparoscopy, retrograde cholangiopancreatography.

The distribution of patients according to the etiological basis is presented in Picture. 1.

Picture. 1. Distribution of the patients because of obstructive jaundice.

As seen in the chart, the most common cause of cholangitis and biliary sepsis is choledocholithiasis 64%, followed by acute pancreatitis is 9.7%, the third place is a breakthrough hydatid cysts in choledoch 8.3%, the fourth and fifth accounted for stricture of the terminal and stricture of the major duodenal papilla, respectively 5.5% and 5.5%.

The results of the study. All patients were divided into four groups.

Group 1 - patients with obstructive jaundice without evidence of an inflammatory response (SIRS = 0) - 85 patients.

Group 2 - patients with obstructive jaundice and slightly pronounced inflammatory response (SIRS one characteristic) (acute cholangitis) - 79 patients.

Group 3 - patients with two or more signs of SIRS (biliary sepsis) - 40 patients.

Group 4 - patients with two or more signs of SIRS and organ dysfunction SOFA> 0 (severe biliary sepsis) - 13 patients.

In 53 patients with biliary sepsis and severe biliary sepsis used plasmapheresis, after preliminary minimally invasive decompression of the biliary tract. After the improvement of the patients and normalization of peripheral blood counts made surgery. 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 of plasma exchange are presented in table 1.

Table 1.

Performance indicators indirect combined digitally plasmapheresis.

Figures	IEDP additional ozonation	IEDP
Reduction of urea	78,1%	75,4%
Decrease in creatinine	69,9%	67,6%
Reduction Total bilirubin: Direct Indirect	90,4% 93,8% 86,9%	85,4% 92,6% 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 ranged from 1 to 3 (of 103 sessions). Rejection of plasma reinfusion due to lack of detoxification was in 3 cases (methodological and laboratory error). Otherwise reinfusion provided 85-90% of circulating plasma total replenishment autoprotein components in small volumes (600-800 ml) of plasmapheresis. Additionally with was poured fresh frozen plasma (1doza from one donor) and albumin 10% 100-150 ml, and the solution Infukoll 6% - 500.0 and crystalloids. Complications during the sessions of plasmapheresis were observed in 7 cases and were cropped adequate therapy. Contraindications for transfusion to adequately detoxify autoplasma unknown.

Detoxify plasma before transfusion were taken out of the container 10 ml plasma biochemical studies. Make sure it is sufficient detoksikated, the question of the possibility of reinfusion autoplasma as plasma-protection during a subsequent session programmed 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 (with an average of 8-12 hours) 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.

Literature

1. Akhaladze G.G. and other. Clinical stage of suppurative cholangitis. // Annals of Surgical Hepatology -1997. - № 2. – P. 103-109.

2. Halperin E.I. Akhaladze G.G. Biliary sepsis: some features of the pathogenesis // Surgery. - 1999. - № 10. - P. 16-19.

3. Davlatov S.S., Kasymov Sh.Z., Kurbaniyazov Z.B., Rakhmanov K.E., Ismailov A.O. Plasmopheresis in the treatment of cholemic endotoxicosis // Academic Journal of West Siberia № 1, 2013. P. 30-31.

4. Syusyukin A.E. Kostyuchenko A.L. Belsky A.N. etc. Modern efferent therapy in clinical toxicology // Efferent therapy-2004. № 3.-P. 69-71.

5. Shapovalyants S.G. and other endoscopic techniques in the treatment of post-surgical scar stricture of bile ducts. // Annals of surgical hepatology -2007. - № 2. – P. 70-77.

6. Kondrup J., Almdal T., Vilstrup High H. volume plasma exchange in fulminant hepatic failure (et al.) Int. J. Artif. Organs. - 1992. - N 15. - P. 669 - 676.