Plasmopheresis in the treatment of cholemic endotoxicosis

Samarkand SMI, Uzbekistan

The Republican Specialized Center of Surgery named after

Acad. V.V. Vahidov, Uzbekistan

In abstructive jaundice severe cholemic endotoxicosis associated with increased level of metabolites (bilirubin, urea, creatinine, residual nitrogen, enzimesoligopeptides of average molecular weight, etc.) develops and it requires an active detoxication of the body.

One of effective methods of active detoxication is plasmopheresis, which has detoxifying and immunocorrecting effect. This method of detoxication is just as effective in its detoxication property as hemosorption but it does not produce such threatening complications as impairment of hemodynamics and anemia. However, in plas-mopheresis toxic substances are only removed with plasma, even though they are found not only in plasma but also on the membrane of erythrocytes as well. Besides there is loss of plasma proteins in plasmopheresis up to 40%, which requires additional introduction of the donor protein preparations.

The aim of the study. To improve the results of surgical treatment of patients with cholemic endotoxicosis by an improved method of discrete plasmopheresis using NaClO and ozonation. In order to find effective methods of detoxication we used the improved method of plas-mopheresis in SamSMI since 2001 in treatment of cholem-ic endotoxicosis. NaClO in therapeutic doses oxidize such substances as bilirubin, urea, creatinine, ammonia, acetone, oligopeptides of average molecular weight and other toxins.

We have applied a new method of autoplasm recovery using the improved method of discrete plasmopheresis. This method is carried out as follows: taking exfusioned plasma, addition of sodium hydrochlorite solution by concentration of 1200 mg/l in a volume ratio of 10:1, the exposure of the mixture at 6-8 оС, suction removal of sediment and reinfusion of autoplasma. After adding of sodium gypochlorite solution in the plasma, the resulting mixture is ozonized by barbotaging ozone-oxygen gas mixture for 10 minutes, after which the mixture is incubated for 3-4 hours. Being convinced of its sufficient detoxication we solved the question of the possibility of reinfusion of autoplasma as plasmo-substituting medium during a subsequent session of programmed plasmopheresis. Marked detoxicating effect, manifested in significant reduction in the levels of toxic metabolites has been established: bilirubin at 5470% urea at 50-60%, creatinine at 60-80%, almost complete inactivation of transaminases.

Material and methods. Basis of clinical studies were 106 patients with abstructive jaundice of bening origin and with various malignant tumours of hepatopan-creatoduodenal zone. All patients underwent surgical interventions with the goal of elimination of obstructive jaundice and its complications.

The major indication for use of the improved method of discrete plasmopheresis was cholemic endotoxicosis of II – III degree with concentration of serum bilirubin levels above 200 mmol/l, leucocytic index of intoxication (LII) – 45 units and molecules of the average growth (MAG) – 0.46 units.

The results of the study. After the first session of the improved method of discrete plasmopheresis decrease of bilirubin levels to 10-12% was noted in most patients in the preoperative period. MAG and LII indicators decreased to 29-31%, 42-45% respectively. After the third session these figures decreased at 45-65%. It should be noted that after removing the course of obstructive jaundice, these figures on the background of the improved method of discrete plasmopheresis normalized by 3-4 days after surgery in most patients.

Conclusions. Thus, an improved method of discrete plasmopheresis in combined treatment of cholemic endotoxicosis in patients with obstructive jaundice at the stages of surgical treatment appeared to be effective and having good prospects, that allows to perform surgical interventions in optimal conditions, to accelerate the restoration of oxidative liver function, reduce the need for donor protein preparations, reduce the risk of possible immune reactions and the risk to be infected with viruses of hepatitis B and C, human immunodeficiency virus, cytomegalovirus, herpes virus.