Ozone Therapy in the Surgery

The use of ozone therapy in the complex treatment of different forms of peritonitis is based on the double mechanism of pathogenetic action of ozone. Firstly, its local effect through the disinfectant activity versus bacteria, viruses and fungi resulted from disturbance of their membrane due to oxidation of phospholipids and lipoproteins, breakdown of polypeptide chains and proteins. And secondly, its systemic metabolic effect towards the protein-lipid complexes of plasma and cell membranes leading to an increase in pO₂ and elimination of hypoxia on the cellular level, transformation and synthesis of biologically active substances, elimination of toxemia, activation of immunocompetent cells, improvement of rheology and oxygen-transport function of blood, decrease in the intensity of lipid peroxidation processes and activation of the organism's antioxidant defense.

The treatment schema with ozone depends on the form, extension and phase of peritonitis that defines the dose and method of ozone therapy.

All variants of therapy suggested by different doctors for treatment of peritonitis are based on the combined use of local and systemic methods of ozone therapy in the complex with traditional therapy.

S.V.Semenov, A.S.Snigorenko, B.P.Kudryavtsev suggested the optimal schema of using an ozone/oxygen gas mixture in peritonitis patients by considering the associated syndrome of polyorganic insufficiency.

The local use of ozone and ozone-containing preparations: during the surgery, after elimination of peritonitis source, the abdominal cavity is rinsed with physiological saline, then filled for 10-15 min with ozonated saline solution and cooled up to 10-12^oC. The repeated revisions and sanations of the abdominal cavity are performed daily up to remission of intra-abdominal infection, for this purpose the cavity is first rinsed with 3-4 L of physiological saline and then filled with cooled ozonated saline solution for a certain time.

The parenteral use of ozonated saline solution: intravenous infusions of 400 ml of cooled ozonated saline solution are to be started in the preoperative period and then continued daily for 5-10 days.

The enteral use of ozonated saline solution: this procedure is performed for detoxication purpose during the first 3-4 days, 800 ml of cooled ozonated saline solution is introduced through a nasogastrointestinal probe.

Reflex puncture therapy with ozone: on the 2nd-3rd day after the surgery for stimulation of intestinal motility the complex of therapeutic modalities also includes reflex puncture therapy with ozone - introduction of gaseous ozone to the biologically active points according to the physician's direction.

In case of generalized purulent peritonitis, in the toxic and reactive phases, the therapy used should include peritoneal lavage of abdominal cavity with ozonated saline solution 2-3 times a day for 3-4 days after the surgery, with passive flow-out of washing liquids.

In case of great number of injured and wounded people, particularly in conditions of military surgery, the parenteral use of ozonated saline solution is replaced by major haemotherapy of autologous or donor's blood. In case of indications for blood transfusion, major haemotherapy is carried out with donor's blood.

Rectal ozone insufflations: for elimination of toxemia and stimulation of intestinal motility on the 2nd-3rd day it is recommended to start rectal ozone insufflations for 5-8 days.

As criteria for efficiency of the given treatment schema are considered the clinical picture, indices defining the severity of endotoxicosis, the data of biochemical and immunological investigations, the bacteriological results, the state of microcirculation in the intestinal wall, the end results of treatment.

The performed investigations have shown that on the 5th day of treatment with ozone it comes to a decrease in the lipid peroxidation products and moderate activation of the antioxidant system. The indices of leukocytosis, leukocyte index of intoxication, middle mass molecules approximate to norm on the 4th-5th day, there is a positive dynamics of the rheological indices of blood (A.I.Korabelnikov, E.A.Apsatarov, 2000).

The tactics of ozone therapy in peritonitis should be determined considering some important aspects. Knowing the destructive effect of high doses of ozone on the cell membranes, the daily dose of ozone may not exceed 6000-8000 mcg (A.S.Snigorenko, S.V.Semenov, 2000).

The dose of ozone has a direct relationship to the patient's age: the younger organisms - the smaller dose of ozone, and on the contrary, the dosages for elderly patients should be higher and determined individually for each patient. In case of combination of ozone with other methods having a similar effect of realization (laser therapy, ultraviolet blood irradiation, hyperbaric oxygenation) the choice of methods, dosage and duration of ozone therapy should be performed under the control of the lipid peroxidation level and activity of the antioxidant system.

The rational use of ozone therapy allows considerably decreasing the symptoms of endotoxicosis, complications and lethality due to peritonitis and speed up the recovery.

The effect of medical ozone on the infected wound surface is achieved through the combined therapy.

The local ozone therapy leads to elimination of regional hypoxia in the purulent focus through stimulation of activity of the respiratory enzymes succinodehydrogenase and cytochrome oxidase. This takes place along with an increase in partial oxygen tension in the wound by 10-16% in comparison with the initial level (Yu.N.Belokurov, V.M.Molodkin, 1995) and maintenance of the increased level of tissue oxygenation in the period after the performed treatment. Normalization of tissue metabolism is associated with elimination of acidosis, improvement of microcirculation and trophism of tissues modified by inflammation, normalization of reparative processes and acceleration of epithelization.

Ozone in gaseous phase and contained in solutions of crystalloids is able to suppress the growth of bacterial flora: staphylococcia, Proteus, colibacillus, Klebsiella, fungi, anaerobic flora. Through ozone it comes to an increase in the sensitivity of microbes to antibiotics that reduces their dose and exposition time. It comes to fast bacterial decontamination of wounds, cleaning of their surface from necrotic masses, appearance of granulations and edge epithelization. Through ozone therapy on the 3rd-4th day it comes to disappearance of pain syndrome

The parenteral use of ozone produces a detoxication effect on the organism, speeds up correction of the free-radical processes, activates the endogenous defense enzymes, improves the rheology of blood, leads to mobilization of the humoral and cellular immunity.

After the surgical treatment of purulent focus the wound surface is exposed to irrigations with an ozone/oxygen gas mixture by means of plastic frame-chambers (the wound has been previously moistened). Ozone concentration and exposition time depends on the area of affection, causative factor, severity grade of purulent-inflammatory process.

As soon as it comes to cleaning of pathological focus from necrotic masses and appearance of granulations, higher ozone concentrations should be gradually decreased for stimulation of regeneration and completion of epithelization. The frequency of treatments and duration of treatment course of local ozone therapy should be determined individually.

For acceleration of cleaning of wound surface from necrosis and pus it is possible before the irrigation with an ozone/oxygen gas mixture to use "mini"-baths with cooled ozonated distilled water.

For local sanation it is also possible to use ozonated saline solution in the form of flowing irrigations of pathological surfaces.

After the local treatment of inflammation focus it is a time for applications with ozonated solutions or ozonized olive oil. S.N.Gorbunov suggests for the first 2-3 days to cover the wound with sorbent treated with ozonated 10% sodium chloride solution.

It is necessary to perform daily intravenous drop-by-drop infusions of ozonated physiological saline at a volume of 400 ml for 10 days. In case of severe endotoxicosis ozonated saline solution can be introduced twice a day or in combination with major autohaemotherapy with ozone twice a week.

Owing to suppression of the organism's compensatory-adaptive mechanisms the combined therapy should include the use of antioxidants.

The combination of local and systemic methods of ozone therapy in the treatment of purulent wounds allows shortening treatment duration, repeated operations, and lethality.

In the treatment of this pathology the use of ozone is based on its main properties: bactericidal, analgesic effects, improvement of the rheological properties of blood in the microcirculatory zone, activation of the oxygen-dependent extra- and intracellular processes, intensification of activity of immunocompetent cells and regeneration.

The treatment includes several methods of ozone therapy: local - ozone gas irrigations of focal processes by means of plastic chamber, subcutaneous ozone injections around the place of ulceration, applications with ozonized olive oil; systemic - parenteral infusions of ozonated saline solution. The treatment schema for each patient is determined individually depending on the character and ulcer size, its genesis.

After 2-3 procedures of ozone therapy the patients report about remission of pain, decrease in the feeling of heaviness in the damaged limb, burning sensation and itch, regress of local appearances of inflammation. After 6-8 procedures it comes to active cleaning of ulcer, appearance of granulations, gradual process of focal and edge epithelization. It comes to general improvement of the patient's condition, stabilization of the picture of lipid profile, activation of the antioxidant enzymatic system.

In some cases epithelization of ulcerous surfaces comes after the second course of complex ozone therapy, when the interval between them is 2-3 weeks. If plastic surgery is necessary, the use of ozone for sanation leads to complete transplantability. Recidivation of ulcer is considerably reduced, hospitalization time of this group of patients is decreased.

The use of ozone in the treatment of decubitis is the most suitable variant both for the patient and doctor among the numerous methods of traditional treatment. It does not cause any trouble to the patient. It leads to fast disappearance of necrosis and unpleasant smell.

Recommended methods of ozone therapy:

• Ozone/oxygen gas irrigation under "suction cup" in low-pressure conditions;
• Major autohaemotherapy with ozone.

In case of strongly contaminated or necrotized tissues associated with suppuration for bactericidal purpose it is necessary to perform ozone irrigations at higher ozone concentrations for 20-40 min depending on the tolerance. In case of tendency towards healing ozone concentration used should be gradually decreased, otherwise there is a risk of repeated opening of wound. Treatment duration and frequency of procedures is determined individually. Along with local ozone therapy it is necessary to perform major autohaemotherapy with ozone for stimulation of oxygen-dependent processes, metabolism, defense systems of the organism, elimination of tissue hypoxia.

Ozone is used against the major mechanism of tissue damage - oxidative stress that develops as from the first days of burn shock due to sharp intensification of the oxidative processes and insufficiency of the antioxidant defense system.

The administration of therapeutically dosed active oxygen facilitates restoration of dynamical balance between lipid peroxidation and antioxidant enzymes. It comes to a considerable decrease in the level of endotoxemia that results in the better-manifested correction of immunological status, increase in the activity of phagocytosis. Ozone ensures optimization of the respiratory, cardiovascular, secretory systems.

It actively participates in the correction of practically all pathological processes encouraging the syndrome of polyorganic insufficiency in burn disease. All the above-mentioned allow considering ozone therapy as a method of endogenous detoxication.

Recommended methods of ozone therapy:

• Intravenous drop-by-drop infusions of ozonated saline solution or major autohaemotherapy with ozone for systemic effects;
• Ozone gas irrigations by means of plastic chambers for local effects.

The local treatment of burn wounds in the form of ozone gas irrigation by means of plastic chambers facilitates elimination of pathogenic flora and inflammation inside and outside the wound, formation of bright fine-grain granulations, reduction of time required for wound healing, improvement of autotransplantation in deep burns

Ozone gas irrigation of burn surfaces is performed at higher ozone concentration in case of their contamination, then in case of wound cleaning and beginning of focal or edge epithelization ozone concentration should be decreased. Duration and frequency of local ozone therapy is individual.

For surgical treatment of burn surfaces ozonated saline solution (at high ozone concentrations) is widely used as a bactericidal agent. At the stage of epithelization of skin defects it is possible to use applications with ozonized olive oil.

During the ozone therapy it comes to a considerable increase in pO2, decrease in the blood level of glucose and underoxidated products, fast dynamics of decrease in the markers of endogenous intoxication, improvement of the rheological properties of blood, normalization of the antioxidant defense activity, elimination of dysphagocytosis, normalization in the indices of T-lymphocytes, IgM, IgG, IgA.

The clinical efficiency of ozone in the complex of infusion-transfusion therapy in burn disease allows using it at a full range.

Ozone therapy is included into the treatment complex of purulent-inflammatory diseases of pleura and lung in order to overcome bacteriemy, endogenous intoxication through the powerful oxidative potential of ozone, for stimulation of the organism's protective and compensative systems, correction of energy metabolism, stabilization of the antioxidant defense. Ozone therapy decreases insufficiency of tissue drainage system, intensifies the processes of microcirculation improving peripheral supply with oxygen.

The oxidative therapy is performed as a combination of intravenous infusions and rinsing of empyema cavity by means of ozonated saline solution.

The local ozone therapy in pyothoraxes and pyopneumothoraxes is performed as punctions of pleural cavity and its rinsing through the drainage by means of ozonated saline solution. These procedures are performed daily for 5-8 days depending on the severity of the process. Ozonated saline solution is also introduced intravenously for 4-5 days (R.B.Mumladze etc, 1998) within the complex of infusion treatment program.

After 2-3 procedures of local ozone therapy it comes to a decrease in the number of microbial bodies in the pleural exudate or their complete disappearance. On the 2nd-3rd day from the beginning of ozone therapy it comes to improvement in the general state of patients: improvement of appetite, normalization of body temperature, stabilization of the hemodynamical indices. A decrease in the inflammatory symptoms and appearances is manifested as a decrease in the leukocyte index, decrease in the number of middle molecules, in the level of end products of lipid peroxidation, normalization of the immunological indices, the levels of urea, creatinine, bilirubin, antioxidants.

Ozone therapy intensifies the effect of antibacterial and detoxication therapies in the complex treatment, considerably stimulates the reparative processes that results in shortening of hospitalization time and decrease in the percentage of lethal outcomes.

Owing to its unique properties, ozone therapy is successfully used in the treatment of arthropathies. The result of performed therapy is based on the anti-inflammatory effect through ozone modulation of the prostaglandin system forming the intracellular antioxidant defense of the organism against the activation of free-radical reactions (Chow, 1981; Rokitansky, 1987).

The analgesic effect is achieved through penetration of ozone into the area of arthral inflammation and oxidation of pain-inducing mediators (E.Riva Sansewermo, 1989). Active oxygen improves metabolism of arthral tissues and structure of protective cartilage preventing their further destruction, restores tissue processes, microcirculation in the damaged tissues, produces a regenerative effect.

Already after the first procedures most of the patients reported about elimination of pain syndrome, increase in the range of passive and active movements in the damaged joint. The painless period after the course of ozone therapy lasts on average for 3-5 months, then the treatment course should be repeated.

It comes to an increase in the efficiency of treatment in arthropathies through a combination of oxidative therapy with other methods of treatment such as medicamentous, physiotherapeutic ones (C.Simsen, 1995).

With consideration to the above-mentioned, it is recommended after ozone to introduce into the articular cavity glucocorticoide-diprospan 1 ml once a week for a total of 3-5 procedures (V.N.Gretchko, 2000) or antihomotoxic preparation Zeel-T, 5 injections at an interval of 2-3 days (Z.S.Mironova etc, 1998; V.V.Lintyakov, L.I.Musatova, 2001). The use of this complex therapy allows the organism to maintain the structural homeostasis making the conditions for regressive vicariation.

The disturbances of arterial peripheral circulation, particularly of the lower limbs, are considered the main indication for ozone therapy at low dosages by producing effects on the different links of pathogenesis.

An increase in the peroxide resistance of the erythrocytes through the use of therapeutic doses of ozone leads to an increase in the elasticity and deformability of the erythrocytes that has a beneficial effect on the rheological properties of blood in the microcirculatory bed and oxygen-transport function of blood improving the release of oxygen in the capillary area and increasing its utilization. Thereby ozone improves the structural-functional properties of cell membranes that performs a leading role in the oxidative free-radical processes and in the synthesis of endogenous antioxidants, suppression of red blood cell aggregation.

The dysbalanse between these two processes is one of the mechanisms inducing atherosclerosis. Thanks to optimization of the peripheral circulation, ozone therapy facilitates a decrease in the tonus of arterioles and opening of non-functional capillaries as well as improvement in the function of compensative collateral anastomosis with the prolonging effect.

The successful use of ozone therapy mostly depends on the correct indication in each individual case. The experience has shown that the angiological, surgical and ozone therapeutic methods should not compete with each other, but ideally support each other.

After 4-5 procedures the patients report about a decrease in walking pain, decrease in the distance of painless walking, decrease in foot chilly sensation. After 2-3 infusions the cases of calf cramps in walking and rest have been observed rarely.

It comes to a positive change in the blood level of enzymatic antioxidants, decrease in the lipid peroxidation products, normalization of lipid exchange - total cholesterine, B-lipoproteides, triglycerides, total lipids.

The short-term character of clinical-functional improvement (5-7 months) in patients with obliterative arterial atherosclerosis of the lower limbs requires to regularly repeating the courses of ozone therapy.

Thus, medical ozone improving microcirculation and oxygenation of tissues of the whole organism, optimizes its oxygen homeostasis and causes the reorganization of compensative reactions in conditions of pathology on different levels of vascular systems that results in restoration of functions of peripheral circulation through starting the function of collaterals.

The long-lasting increased blood level of glucose in diabetes mellitus leads to irreversible changes in blood vessels, kidneys, eyes and nervous system.

The use of ozone in the treatment of diabetic angiopathies is based on its ability to produce a positive effect on the carbohydrate and lipid metabolism, to improve the oxygen-transport function of blood, to eliminate the microcirculatory disturbances also through its positive influence on the rheological properties of blood as well as an active effect on the process of lipid peroxidation and the system of antioxidant defense. So, it is recommended to include ozone therapy in the treatment schema of complications of diabetes mellitus that is verified from the pathogenetical point of view.

Recommended methods of ozone therapy:

• Intravenous drop-by-drop infusions of ozonated saline solution.

After the course of ozone therapy the patients report about "clearing" of eyesight, there is an objective evidence about an increase in the initially decreased sharpness of eyesight, decrease in the number of hematomas at the eye bottom, increase in the fitness for work.

It comes to changes in the kind and intensity of pain in the legs in rest and during walking, in the appearance of foot paresthesia, improvement in the skin trophism. Along with a decrease in the level of glucose, cholesterin and triglycerides, erythrocyte aggregation, it comes to normalization in the level of lipid peroxidation products and increase in the antioxidant defense activity in the blood plasma.

Owing to suppressed immunity in diabetes mellitus it comes to development of threatening complication - syndrome of diabetic foot with purulent-necrotic affection. Ozone therapy is included into the complex treatment of this severe pathological process to achieve a faster and more effective correction of disturbances of homeostasis, phagocytosis, immunity, microcirculation, activation of oxygen-dependent processes in the organism, increase in the energy substrates, elimination of endogenous intoxication. In case of purulent processes ozone is used at the local level as an etiotropic method with powerful bactericidal, virucidal and fungicidal effects.

The number of ozone treatments and intervals between them should be determined individually for each patient depending on his state and disease picture.

In case of properly chosen treatment on the 3rd-4th day it comes to a decrease in intoxication symptoms: decrease in the body's temperature, normalization of sleep, appetite, improvement in the picture of peripheral blood. After first procedures of ozone therapy it has been observed a decrease in the intensity of pain, decrease in the edema, infiltration and hyperemia round the wound.

Cleaning of wound surface from microflora and purulent-necrotic mass comes on the 5th-7th day of treatment, appearance of granulations and beginning of epithelization is observed on the 9th-12th day. It comes to an increase in the pO2 level of damaged skin; decrease in the blood level of glucose, fibrinogen, urea, creatinine, end products of lipid peroxidation, middle molecules.

Ozone therapy reduces an average treatment time, decreases the number of amputations or their volume.

The performed investigations have shown that in pancreonecrosis it comes to intensification of the free-radical lipid peroxidation processes, activation of the proteolytic processes, disturbances of hemostasis.

Owing to disturbances of secretory function of beta cells, it comes to insulin resistance, decrease in the intensity of carbohydrate metabolism, energy deficit and, as a result, insufficiency of antioxidant defense and decrease of antiproteolytic potential of plasma.

For normalization of homeostatic reactions at this metabolic orientation it is necessary to correct oxido-reduction potential that facilitates intensification of protein-synthetic function of liver, elimination of tissue hypoxia, decrease in symptoms of systemic inflammatory syndrome and endogenous intoxication, activation of the reparative-regenerative processes (S.M.Tchudnych etc, 1995).

Thus, the efficiency of ozone therapy in the complex treatment of destructive pancreatitis is pathogenetically verified.

The therapy is performed under the control of biochemical indices of blood.

The use of oxidative therapy in the complex treatment of pancreonecrosis allows to decrease the volume of antibacterial therapies, infusions solutions, immunomodulators and ensures a wide range of clinical effects: normalization of body temperature on average by 2-3 days earlier, appearance of active intestinal motility, improvement of general state, stabilization of hemodynamical indices, homeostasis and immunological status. It comes to a decrease in the frequency of polyorganic insufficiency and lethality, improvement of treatment results in patients of this category.

However, it is necessary to pay particular attention to patients, which have chronic pancreatitis in the anamnesis. In this case the use of medical ozone in the treatment of different pathological conditions can lead to sharp aggravation of pancreatitis with a severe form of course due to powerful release of proteolytic enzymes. Should such a situation occur, it is necessary to stop ozone therapy and start traditional intensive therapy.