MIL-therapy / Method of treatment / 7.1. Surgical disorders.
7.1. Surgical disorders.
The structural basis of MLT stimulating effect on wound healing process lies in microvessels changes, dilatation and increased neovascularization because of the intensification of endothelial cells proliferative activity . Under MIL-treatment the basis for connective tissue is formed: first of all, fibrocytes, barrier-protective and regulative function of macro- and microphages, plasma cells, eosinophils and especially mast cells. MLT reduces the duration of all healing phases without any qualitative changes in the wound process.
Timely and correctly performed MIL-therapy improves the results of treatment in patients with peritonitis, decreases mortality and the rate of complications, reduces terms of hospitalisation.
A marked therapeutical effect is achieved after the application of combined treatment : antibiotic lavage of the abdominal cavity and MIL-therapy in post-operative period.
In localised form of peritonitis 4 zones (Fig.2 A, zones 1, 2, 3,4) on the abdominal wall along the wound margins are irradiated for 2 min on each zone. Impulse frequency is 50 Hz at the first 3 procedures, further - 50 Hz; LED radiation power is 40 mWt. After that the projection of crural vessels (Fig.2 A, zones 5, 6) is irradiated. The course of treatment consists of 3-7 procedures.
Histamine and serotonin levels decrease after the first MIL-therapy procedure while in the control group their normalisation takes place only on the 3th-5th day after the operation. After 3-5 procedures we observe rapid decrease of inflammative process in the peritoneum, intensification of reparative processes with the reconstruction of the mesothelial layer, rapid POL decrease, normalisation of endorphin level.
Diffused forms of peritonitis
MIL-therapy is performed in the combination with traditional medicamentous therapy as prescribed below: 1 procedure - SLRB on the area of crural vessels (Fig.2 B, zones 3, 4) with exposure time 5 min on every side of the body (frequency 10 Hz, LED radiation power 40 mWt). Afterwards, the upper third of the sternum with exposure and the left subclavicular vascular bundle are irradiated for 2 min each (Fig.2 B, zones 2 and 1, respectively).
2 procedure is performed 4-6 hours after: the irradiation of the abdominal cavity at 6 points (iliac area, right and left subcostal areas, along the surgical wound in two zones) with exposure for 2 min on each zone (Fig.2 B, zones 7, 8, 9, 10, 5, 6). The treatment by this scheme is performed for two days. After that MIL-therapy is performed once a day on zones 7, 8, 9, 10, 5, 6 (Fig.2 B) for 2 min on every zone (frequency 80 Hz, LED radiation power 50 mWt) during 5-7 days.
MIL-treatment results in the elevation of relative and absolute number of lymphocytes, but the discharge of functionally inadequate macrophages is absent; antioxidant system is activated thus leading to the utilisation of POL products in the exchange processes and to the reduction of endogenous intoxication. Reduction of biogen amines level up to normal limits within 5-7 procedure confirms a marked anti-inflammatory MIL-effect. The rate of post-operative complications, duration of treatment, mortality rate decrease in the average by 1,5-2 times.
A combination of hemosorption and extra-corporal MIL-impact to the blood has proven to be very effective. The maximal effect is observed after 2-4 hemosorption procedures (if necessary - with the administration of immune stimulators: Na nucleates, T- activin, etc.) under the reduction of marked endotoxicosis. 250 ml of blood are irradiated for 4-5 min (LED radiation power 60 mWt, laser radiation impulse frequency 50 Hz). Radiation sessions are performed every other day between hemosorption operations; later, every day ( the course of treatment - 8-10 procedures and more). Control of the immune status of the organism is an important moment so as it helps to define the optimal amount and repetition factor of procedures necessary for receiving the maximal stimulating effect. Increase of macrophages functional activity at first LT sessions is a favorable prognostic sign.
Diagnostics and prognosis in peritonitis are significantly simplified with biophotometry. Low values of the reflection coefficient (RC) indicate unfavorable course. In uncomplicated peritonitis RC normalisation occurs on the 8-9 day ( see Article 8).
Fig.2. MIL-therapy in localised (A) and diffused (B) forms of peritonitis.
Clean wounds and fresh post-operative scars
MIL-therapy of clean wounds and fresh post-operative scars ( as prophylactics of suppuration) is performed on the second day (after a trauma, surgery) and then every day in the morning during first several days; after that every other day depending on the course of wound process. The curative terminal is placed 3-5 mm above the wound surface covering its periphery ( the wound of 10 cm2 is irradiated for 2 min; during one session 2-4 zones are irradiated depending on wound dimensions)
(Fig .3). Frequency is 5 Hz during first 3 days, 50 and 80 Hz - later. LED radiation power is 30 mWt. There are 7-8 sessions in one course.
Reparative processes are more active comparing to patients who did not received MIL-therapy; it is obvious after the second procedure, maximum - after the 6th ( intensity of granular tissue growth increases, DNA and RNA synthesis is activated, the amount of acid mucopolysakharids which are mediators of fibroblast proliferation is increased). The healing has the primary tension without rough scarring.
Fig.3. MIL-therapy of wounds
MIL-therapy is the same as in clean wounds. After the second procedure hyperemia on the skin, edema around the wound, perifocal inflammation and pain decrease. By the 7-8 procedures pain disappears, wound defect is filled with the granular tissue; after that epithelisation develops starting from the wound edges; the wound is reduced by two times in comparison to the controls; afterwards epithelisation slows down. Healing (complete epithelization) takes place, in the average, by the 22nd day (in the control group - by the 29th day) with good cosmetic and functional results.
To treat purulent wounds the course of MIL-therapy may be enlarged up to 13 procedures. Frequency is 50 Hz at the first 3 sessions, after that - 80 Hz, LED radiation power is 50 mWt. Exposure time is about 10 min. Before laser session the treated wound has to be clarified from debris and drugs (pus secretion absorbs up to 90% of laser radiation). Sometimes it is better to perform MIL-irradiation through a sterile gauze bandage. It is very important to keep to the rules of sterilisation while sterilising the terminal surface (wiping with 96% ethyl alcohol and fixing a protective sterile membrane on the terminal). After MIL-therapy the wound is treated in the usual surgical way.
Two MIL- procedures are enough to control signs of inflammation ( in the controls after 5-6 days); normal granular tissue is developing on the 4th-5th day in the wound. Terms of invalidity are reduced by 1,5-2 times in comparison to the traditional treatment.
Purulent disorders of soft tissues
To treat purulent processes in soft tissues (abscesses, phlegmons, mastitis, whitlows, furuncles, carbuncles, inflammative infiltrates), when purulent abscess is formed, a surgical intervention, a flowing-puncture lavage, drainage or other surgical manipulations are performed depending on the location of purulent focus. MIL-therapy is performed in combination with medicamentous treatment at 2-4 zones around the focus (Fig.5), exposure 2 min on each zone with LED radiation power of 50 mWt. Every subsequent procedure is performed with a new frequency value in the following order: 5, 10, 50, 80, 150, 600, 1500 Hz (every course consists of 5-7 daily procedures).
Slowly healing and non-healing wounds, trophic ulcers.
Before laser treatment slowly healing and non-healing wounds, trophic ulcers are cleaned by hydrogen peroxide or other solutions commonly used in surgical practice for removing purulent-necrotic debris. MIL-therapy is started only after the examination of the lesion for possible malignization. A laser terminal is put directly on the ulcer margins and newly-formed granular tissue at zones 2-4 (Fig.4) either on the protective membrane or on one- layer sterile gauze in a contact way. In large ulcers MIL-irradiation is performed by moving the terminal slowly from ulcer periphery to its center. Impulse frequency is 50 Hz, LED radiation power is 60 mWt, exposure is up to 5 min. After that MIL-irradiation is done on the thymus projection (zone 1) and on the projection of left subclavicular vascular bundle (zone 2) for 2 min. The course of treatment - 7-8 procedures. The repeated course with frequency 80 Hz and LED radiation power 40 mWt is performed 6-7 days after. Exposure on the ulcer is 4-6 min, after that the popliteal fossa (zone 3) and the inguinal vascular bundle (zone 4) on the diseased extremity ( exposure for 2 min each) are irradiated.
Laser effectiveness for treating purulent wounds and trophic ulcers is increased when proteolithic enzymes immobilized on synthetic bandage materials are added.
Fig. 4. MIL-therapy in slowly healing and non-healing wounds
MIL-therapy is performed together with desintoxicative and antibiotic therapy twice a day (Fig. 5): SLBR on the vascular bundle above the effected zone (zone 1), frequency 5 Hz, exposure 7 min., LED radiation power 40 mWt. Then the pathologic focus is irradiated (frequency 1500 Hz, exposure 5 min) contactly at several zones or distantly with the labile method; LED radiation power is 30 mWt.
If patients have Erysipelatous inflammation on the face, MIL-irradiation is performed on the carotid area (zone 2) at both sides (2 min each), frequency 5 Hz. After that irradiation is done parasternally to the right and to the left at the II-III intercostal region (zones 3) for 2 min on each zone (frequency 5 Hz) and on the inflammation ( frequency 50 Hz, exposure 2 min). LED radiation power is 40 mWt.
The course of treatment consists of 7-8 sessions. MIL-therapy course is repeated in 3 weeks, but sessions are performed once a day.
Fig. 5. MIL-therapy in Erysipelatous inflammations
MIL-therapy is indicated in the syndrome of marked excudative changes in superficial burns; for the prophylactics of burn deepening and for the stimulation of reparative processes in subdermal burns; for improving blood and lymph circulation in the paranecrotic zone and for the stimulation of patent granular layer in pre-operative period in case of deep burns as well as and in post-operative period - for the stimulation of regenerative processes; for prophylactics and treatment of pneumonia and for controlling secondary immune deficiency. Strategy and tactics for MIL-therapy in policlinics, hospital and specialised medical institutions are chosen depending on the prognosis which is given to a burnt patient.
MIL-therapy is contraindicated: for patients with extended deep burns and unfavorable or doubtful prognosis when patient is in burn shock; for burnt patients with acute respiratory insufficiency, acute renal-liver failure; acute stroke; non-compensated Diabetes mellitus, acute alcohol delirium, epilepsy.
MIL-therapy is performed at the early stages after trauma on the opened wound surfaces (distantly at a distance of 5-6 mm from the wound surface) or through bandages. Frequency is 80 Hz, LED radiation power is 20 mWt, exposure to one zone is 8 sec. till necrotic masses are rejected and 4 sec. after the removal of necrotic debris. 3-4 zones on 1% of the injured area are irradiated, duration of MIL-therapy session is 3-5 min ( up to 35 zones). Simultaneous application of two terminals makes the procedure much more effective if the injured area is large. The course of treatment in case of necrosis and in pre-operative period ( on the opened wound) is 5 procedures; in the post-operative period (at dressings through the bandage) - as it is prescribed, but not more than 5 procedures.
Under MIL-therapy wound healing process is usually more smooth. It also reduces terms of pre-operative preparation by 4 days on the average. The graft taking increases up to 95-100% (85-90% in the control). Terms of hospitalisation for burns of II-IIIA stages are reduced to 2-2,5 weeks on the average (the same index without MIL-therapy is 3-4 weeks).