Therapeutic Approach for Parapancreatic Infiltrate in Patients with Acute Aseptic Necrotizing Pancreatitis
Patients and Methods. We analyzed treatment outcomes for 251 patients with acute nonbiliary aseptic necrotizing pancreatitis and parapancreatic infiltrate who were treated at the clinic from 2006 to 2013. The age of the patients varied from 21 to 84 years old. 142 (56.6 %) were men, and 109 (43.4 %) were women. 120 (47.8 %) people were admitted 24 hours after the first signs of the disease, 50 (19.9 %) — after 25–72 hours and 81 (32.3 %) — after 72 hours. The cause of acute necrotic pancreatitis was unvaried nutrition (excessive intake of fat food) in 158 (62.9 %) patients, and excessive alcohol or its substitute intake in 93 (37.1 %) patients. The ultrasound was used for the acute necrotic pancreatitis and its complications examination. According to the sonography less than 30 % of pancreas necrosis was detected with 55 (21.9 %) patients, 30–50 % with 177 (70.5 %) patients and more than 50 % with 19 (7.6 %) patients.
The Results and Consideration. Analysis of the data shows that the complex intensive therapy allows 24.7 % of patients with acute necrotizing pancreatitis aseptic achieve full recourse parapancreatic infiltration without forming liquid collectors. However, when used as a starting empirical antibiotic therapy carbapenems (imipenem-cilastatin, meropenem) in combination with non-steroidal anti-inflammatory drugs (lornoxicam), the figure was 31.6 %, while the use of other non-steroidal anti-inflammatory antibiotics without drugs only 10 %.
Among the complications of acute necrotizing pancreatitis aseptic enzymatic peritonitis observed in 41.1 % of patients, acute aseptic fluid accumulation in the packing bag — 49.2 %, acute aseptic fluid accumulation in the retroperitoneal fat — in 14.8 %, and a combination of acute aseptic liquid accumulations in the packing bag and retroperitoneal fat — 1.1 %.
In 77.8 % of patients develop enzymatic peritonitis was the only manifestation of acute necrotizing pancreatitis, which will limit the drainage of the abdominal cavity by laparoscopy or laparacentesis along and conduct complex conservative therapy. Other complications of acute necrotizing pancreatitis in these patients have not been observed, indicating a more favorable course of illness in patients with enzymatic peritonitis. In 18.2 % of patients had a combination of enzymatic peritonitis with acute aseptic liquid accumulations in the packing bag and/or retroperitoneal fat, which required further perform other surgical procedures.
In acute aseptic liquid clusters in the packing bag is the use of highly puncture — draining operations. The incidence of suppurative complications was 4.4 % and the mortality rate — 1.1 %. Indication for surgery is the presence in the packing bag according liquid sonography education of more than 50 ml. In acute aseptic liquid clusters in the retroperitoneal fat puncture — drainage operations are effective only in patients with the accumulation of free fluid in the retroperitoneal fat (over 100 ml). Under aseptic liquid clusters in the retroperitoneal fat in the form of widespread infiltration parapancreatic retroperitoneal fiber and preference should be given autopsy, audit and drainage of retroperitoneal fat lumbar extraperitoneal access.
Indication for surgery are as sonography data and clinical data: Explicit infiltration and pain in the lumbar region, increase in body temperature to 38 °C or more. The necessity of the operation occurs in most cases by 4–6 days of illness. It should be noted that in most cases lumbotomy in the treatment process includes a number of landmark audits and remediation (sequestrectomy) retroperitoneal fat. Their frequency and amount determined by the state of the retroperitoneal fat, the presence of seizures and non-draining areas. According to our data, the frequency of acute aseptic parapancreatic liquid accumulations in the form of accumulation of free fluid in the retroperitoneal fat is 25 %, and in the form of widespread infiltration of parapancreatic and retroperitoneal fat — 75 %.
Use as a starting empirical antibiotic therapy carbapenems (imipenem-cilastatin, meropenem) in combination with anti-inflammatory non-steroidal drugs (lornoxicam) allowed in acute aseptic liquid clusters in the packing bag to reduce the incidence of infected pancreatitis (omental abscess) from 8.3 to 1.8 %, and the mortality rate from 2.8 to 0 %. In acute aseptic liquid clusters in the retroperitoneal fat incidence of infected pancreatitis (retroperitoneal fat phlegmon) decreased from 63.6 to 11.8 %, and the mortality rate from 18.2 to 0 %. In general, group 1 suppurative complications occurred in 3 (1.8 %) patients died — 2 (1.2 %) in group 2, these figures were — 10 (12.5 %) and 4 (5 %).
Conclusion. Improve the results of treatment of acute necrotizing pancreatitis aseptic promotes a differentiated approach to the choice of method and volume of surgical intervention, depending on the location and nature of acute aseptic liquid accumulation. Inclusion of conservative measures in acute aseptic necrotic pancreatitis as a starting antibiotic therapy carbapenems (imipenem-cilastatin and meropenem) in combination with non-steroidal anti-inflammatory drugs (lornoxicam) allows 3.2 times reduce the incidence of acute aseptic liquid accumulations in omental and retroperitoneal fat, 6.9 times — the frequency of septic complications and 4.2 times — mortality.
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