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Transcript of Volgograd State Medical University Volgograd, Russia Experimental and clinical study of local...
Volgograd State Medical UniversityVolgograd State Medical UniversityVolgograd, RussiaVolgograd, Russia
Experimental and clinical study of local cryoapplication in treatment of pancreatonecrosis
S. Maskin, L. Igolkina, V. Aleksandrov, S. Petrenko, A. Ntire, N. Ermolaeva, S. Кungurtsev, N. Loktev
Faculty of hospital surgery
Background:
local cryoapplication (LC) promotes primary interruption
of the pathological biochemical and morphological
changes cascade in the pancreas (P) and retroperitoneal
tissue, that leads to changes in the pathological process.
Objective:
is to asseses the results of applying of LC to P in different
forms of PN in experimental and clinical study.
Results of the experimental study
An experimental study was executed with Wistar rats.
The model PN was created by introduction of bile of 0,5 ml into P
All rats (157) were randomized in 2 groups
After CAn = 93
Without CAn = 64
Morphological and histological studies
were performed in 1-3, 5-7, 10-14 days
after first operation
Mortality in rats in both groups
Days after operation
aftercryoapplication
(n=93)
withoutcryoapplication
(n=64) p
n % n %
1-3 25 26,9 + 2,8 30 46,9 + 5,8 <0,001
5-7 2 2,2 + 0,2 11 17,2 + 2,1 <0,001
10-14 - - - - >0,05
Commonmortality
27 29,0 + 3,0 41 64,1 + 8,0 <0,001
p <0,001 <0,001
The mortality was statistically higher in the group WCA - 64% vs 29% in the group ACA.
These parities of parameters of mortality were registered in 1-3 and 5-7 days.
In the period over 10 days the mortality was absent in both groups
Behavioural actions in rats in both groups after operations
Behavioural actions
After cryoapplication (n=93)
Without cryoapplication (n=64) #
Days after operation Days after operation
1-3(n=93)
5-7(n=60)
10-12(n=8)
1-3(n=64)
5-7(n=34)
10-12(n=10)
no dynamics, weak mobility
9096,8+10,0
2135,0+4,4p1<0,001
112,5+4,6p1<0,001P5<0,001
64100
2779,4+13,6
*
330,0+9,8p1<0,001P5<0,05
refusal of food, weak reaction on food
8995,7+9,9
1830,0+3,8p1<0,001
-p1<0,001p5<0,001
64100
2676,5+13,1
*
220,0+6,5
*p1<0,05P5<0,05
decrease in reaction on painful irritation
8591,4+9,5
1321,7+2,7p1<0,001
-p1<0,001p5<0,001
5789,1+11,1
2058,8+10,1
*p1<0,05
220,0+6,5
*p1<0,001P5<0,01
* - p<0,01 - between groups # - p>0,05 - other parameters between groups
In the group WCA the dynamics of the recovery of the basic physiological actions was significantly slower. Positive dynamics were reliably defined only by 10th day. As for the other group, ACA the expressed positive dynamics were already confirmed by 5th-7th day, and by 10th day the complete recovery was acknowledged for almost all survived rats.
Моrphological and histological parameters in autopsy in rats of both groups (n / %)
* - p<0,01 - between groups ** - p<0,05 - between groups # - p>0,05 - other parameters between groups
Morphologicalparameters
After cryoapplication (n=93) #
Without cryoapplication (n=64)
Days after operation Days after operation
1-3(n=25)
5-7(n=60)
10-12(n=8)
1-3(n=30)
5-7(n=24)
10-12(n=10)
degree of collicvationnecroses of pancreas
1766,7+13,5
1423,3+2,9p1<0,001
- p1<0,001P5<0,001
2790,0+16,6
1145,8+9,4
**p1<0,05
220,0+6,5
**p1<0,001P5<0,05
pathomorphological variations in other organs (heart, luhgs, liver, intestines)
25100
2541,7+5,3p1<0,001
225,0+9,4p1<0,001P5<0,001
30100
1458,3+12,1
p1<0,05
550,0+16,5
p1<0,05P5>0,05
Activity of regeneration7
28,0+5,6
5185,0+10,8p1<0,001
787,5+33,5
p1>0,05p5>0,05
-*
520,8+4,2
*p1<0,001
660,0+19,8
p1<0,05P5<0,05
Total necrosis: kariolisis, citolisis, membranolisis
Local necrosis:
Day 2-3
x 64 x 160
x 64 x 160
without cryoapplication
Day 2-3
after cryoapplication
Day 5
x 64 x 64
x 64 x 160
without cryoapplication
Day 5
after cryoapplication
Subtotal diffuse necrosis
Local necrosis and normal pancreas:
Day 10-14
x 64 x 160
x 64 x 160
without cryoapplication
Day 10-14 after cryoapplication
diffuse necrosis
normal pancreas:
Conclusion of the experimental study
Local CA on a pancreas in PN
- leads to the fast regressing of the autolitic processes
- and to the early beginning of regenerative processes
in a pancreas,
- that allows to avoid the development of infected PN,
- To reduce the mortality - from 64 to 29 %
- and to accelerate restoration and clinical recover.
Results of the clinical study
All patients (208) were randomized in 2 groups
After CAn = 92
Without CAn = 116
Complications and mortality in the infected forms pancreatonecrosis
in both groups of patients
Formsof the
pancreato-necrosis
After cryoapplication (n=92) Without cryoapplication (n=116)
n
Complications(infected)
Mortality
n
Complications(infected)
Mortality
n % n % n % n %
Steril PN(n=17)
6 - - - - 11 645,5+14,1
**1
9,1+2,6*
Infected PN(n=197)
86 11 12,8+1,3 14 16,3+1,7 111х
(105+6)26
23,4+2,2 #
2926,1+2,5
*
Including: Infected PN with local PNPP (n=20)
14 - - - - 6 116,7+7,4
**1
16,7+7,4**
Infected PN with
total PNPP (n=177)72 11 15,3+1,8 14 19,5+2,2 105 25
23,8+2,3*
2826,7+2,6
**
In total (n=214) х 92 11 12,0+1,2 14 15,2+1,5 122х 3226,2+2,3
#30
24,6+2,2 ## - p<0,001 - between groups
* - p<0,01 - between groups** - p<0,05 - between groups
IPN - infected pancreatonecrosisPNPP – purulent necrotizing parapancreatitis
Mortality in the infected forms pancreatonecrosis
in both groups of patients
Groups of patients
After cryoapplication (n=92) Without cryoapplication (n=111)
Mortality - 14 (16,3+1,7 %) Mortality - 29 (26,1+2,5 %)
Formsof the
infectedpancreatonecrosis
IPN + local. PNPP
IPN + total. PNPP
including IPN + local. PNPP
IPN + total. PNPP
including
Initially PNPP
later
developed PNPP
Initially PNPP
later
developed PNPP
patientsабс. 14 72 61 11 6 105 79 26
% 16,3 83,7 70,9 12,8 5,4 94,6 75,2 24,8
mortality
абс. - 14 6 8 1 28 6 22
% -19,5+ 2,2
9,8+ 1,2
72,7+ 22,6
16,7+ 7,4 *
26,7+ 2,6 *
7,6+ 0,8 **
84,6+ 16,8 **
* - p<0,05 - between groups** - p>0,05 - between groups IPN - infected pancreatonecrosis
PNPP – purulent necrotizing parapancreatitis
Abdominal sepsis and mortalityin the infected forms pancreatonecrosis
in both groups of patients
Groups of patients
After cryoapplication (n=92) Without cryoapplication (n=111)
Mortality - 14 (16,3+1,7 %) Mortality - 29 (26,1+2,5 %)
Formsof the
infectedpancreatonecrosis
IPN + local. PNPP
(n= 14)
IPN + total. PNPP
(n = 72)
Including IPN + local. PNPP(n= 6)
IPN + total. PNPP
(n = 105)
Including
Initially PNPP
(n = 61)
later
developed
PNPP (n = 11)
Initially PNPP
(n = 79)
later
developed PNPP(n = 26)
sepsis
n - 10 2 8 - 25 4 21
% -13,9+ 1,6
3,3+ 0,4
72,7+ 22,6
-23,8
+ 2,3 *5,1
+ 0,5 *80,8
+ 10,1**
mortality
n - 4 - 4 - 17 - 17
% -40,0
+ 13,2-
50,0+ 19,0
-68,0
+ 13,8 **-
81,0+ 17,9**
* - p<0,001 - between groups** - p>0,05 - between groups
IPN - infected pancreatonecrosisPNPP – purulent necrotizing parapancreatitis
The number of arrosive hemorrhages
decreased due to the local CA in infected PN
- 1,1+0,6% vs 3,6+0,3% (p<0,001)
Modification of methods local cryoinfluence on a pancreas – introduction of liquid nitrogen in bursa omentalis
We carry out anatomical and experimental studies
The procedure becomes simpler, including the laparoscopyapproach.
Currently, in collaboration
with Russian Innovative company
BIOMEDSTANDART CJSC,
we are conducting works
on development and creation
of cryosurgical equipment and tools
for these purposes.
Conclusion
Performed experimental and clinical studies suggest high
efficiency of local CA for treatment of different forms of PN.
The obtained clinical data confirm pathogenetic validity of
CA for the treatment of different forms of PN,
that leads to the decrease of purulent-necrotic complications
in P and parapancreatic tissue and to the decrease
of mortality of this severe pathology.