ENZYMATIC PERITONITIS IN PATIENTS WITH ACUTE ASEPTIC NON-BILIARY NECROTIZING PANCREATITIS

I.N. Djansyz

Abstract


Material and methods. The results of treatment in 81 patients with enzymatic peritonitis caused by acute non-biliary aseptic necrotizing pancreatitis. They were hospitalized at the clinic from 2006 to 2012. Within 24 hours after the first signs of the disease, 38 (46.9 %) patients were admitted to hospital, 25 to 72 hours — 18 (22.2 %), later that 72 hours — 25 (30.9 %). Unilateral feeding (excess absorption of predominantly fatty foods) was the cause of acute pancreatitis in 51 (63 %) patients, and alcohol intake (excess alcohol) or its surrogates — in 30 (37 %). According to sonography data, less than 30 % of necrosis of the pancreas was detected in 18 (22.2 %) patients, from 30 to 50 % — in 59 (72.8 %), over 50 % — in 4 (4.9 %).
Results and discussion. Drainage of the abdominal cavity using laparoscopy or paracentesis has been carried out in 81 patients with enzymatic peritonitis within 1–2 days of hospitalization. In 66 (81.5 %) patients laparoscopy or paracentesis in combination with the drainage of the abdominal cavity were the ultimate way of surgical treatment of acute non-biliary aseptic necrotizing pancreatitis. After surgery, 3 patients died, mortality was 4.5 %. In the remaining patients a comprehensive conservative therapy enabled to achieve regression of inflammatory changes both in the pancreas and in parapancreatic tissue.
The second group consisted of 15 (18.2 %) patients, who along with enzymatic peritonitis had other complications of acute pancreatitis: aseptic parapancreatic fluid accumulation in omental bursa was detected in 11 (73.3 %) patients, and in retroperitoneal fat — in 4 (26.7 %).
Puncture drainage intervention under ultrasound performed in 13 patients: 11 — for acute aseptic parapancreatic liquid accumulations in omental bursa and 2 — for acute aseptic parapancreatic liquid accumulations in the retroperitoneal fat. Suppurative complications occurred in 2 (15.4 %) patients: 1 (9.1 %) — omental abscess and 1 (25 %) — retroperitoneal fat abscess. For acute aseptic parapancreatic liquid accumulations in the retroperitoneal fat in the form of widespread infiltration of parapancreatic and retroperitoneal fat, 2 patients underwent lumbotomy and drainage of retroperitoneal fat. In general, in this group of patients, deaths weren’t detected. The incidence of suppurative complications was 13.3 %.
Analysis of the findings suggests that enzymatic peritonitis has been observed in 41.1 % of patients with acute non-biliary aseptic necrotizing pancreatitis. While only in 18.2 % of patients it is combined with the formation of acute aseptic parapancreatic liquid accumulations in omental bursa and/or retroperitoneal fat. And in most of them (in 73.3 %) acute aseptic parapancreatic liquid accumulations were located in omental bursa and only in 26.7 % — in the retroperitoneal fat.
Mortality in patients with enzymatic peritonitis was 3.7 %. Moreover, if in patients with enzymatic peritonitis the leading causes of death were endotoxin shock and multiple organ failure, then at later stages of treatment the most frequent cause of death was sepsis.
In 63 (77.8 %) patients development of enzymatic peritonitis was the only manifestation of acute necrotizing pancreatitis, which enabled to carry out only drainage of the abdomen using laparoscopy or laparocentesis along with carrying out complex conservative therapy. Other complications of acute necrotizing pancreatitis in these patients have not been observed, indicating a more favorable course of disease in patients with enzymatic peritonitis.
Contamination of acute aseptic parapancreatic liquid accumulations in omental bursa and/or retroperitoneal fat was observed in 13.3 % of patients with enzymatic peritonitis, while in patients without enzymatic peritonitis, the figure was 9.5 %.
Conclusions. In enzymatic peritonitis caused by acute non-biliary aseptic necrotizing pancreatitis, preference should be given to laparoscopic drainage of abdominal cavity or to laparocentesis. Duration of drainage standing in the abdominal cavity was defined by the presence of secretion (usually no more than 2–4 days). In its absence, the drains must be removed from the abdominal cavity. In the presence of acute aseptic parapancreatic liquid accumulations more than 50 ml in omental bursa and more then in 100 ml in retroperitoneal fat, puncture drainage surgery under ultrasound shoul be carried out. In acute aseptic parapancreatic liquid clusters in the retroperitoneal fat in the form of widespread infiltration of parapancreatic and retroperitoneal fat, the preference should be given to lancing and drainage of infiltration by cross (extraperitoneal) access.

Keywords


acute non-biliary aseptic necrotizing pancreatitis, enzymatic peritonitis

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DOI: https://doi.org/10.22141/1997-2938.4.23.2013.86906

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