Surgical Tactics in Acute Necrotizing Pancreatitis

P.G. Kondratenko, M.V. Konkova, A.A. Vasiliev, A.A. Yepifantsev, I.N. Djansiz, I.V. Shirshov, A.A. Yudin

Abstract


The objective of the study — to improve the indications for the choice of the method and the amount of surgery and terms of its performance in patients with acute necrotizing pancreatitis.
Material and Methods. We have analyzed the outcomes of treatment of 7984 patients with acute pancreatitis at the age of 18 to 89 years who were treated in the clinic from 1979 to 2012. Disease duration up to 24 h was observed in 2124 (26.6 %) patients, from 25 to 72 h — in 5053 (63.3 %), more than 72 h — in 807 (10.1 %). 6970 (87.3 %) patients were treated conservatively, 1014 (12.7 %) patients were operated.
Results and Discussion. In 217 patients (1st group — 1979–1998) the main surgical procedure was laparotomy, including the early one and in the development of septic complications. The mortality rate was 39.2 %.
In 84 patients (2nd group — 1999–2001) we withdrew from carrying out early interventions, laparotomy was performed only in the development of purulent complications. The mortality rate was 27.4 %.
In 246 patients (3rd group — 2002–2005) we mainly used puncture-draining operations under ultrasound (PDO-US) control and lumbotomy in septic complications, as well as endoscopic surgical transpapillary interventions (ESTI) in biliary pancreatitis. The mortality rate was 13.4 %: in nonbiliary pancreatitis — 15.8 %, in biliary — 2.3 %.
In 467 patients (4th group — 2006–2012) indications for surgery, the terms of its timing of its implementation, the choice of the method and volume of the procedure, as well as staging of their application depended on the phase of the disease and developed complications. PDO-US lumbotomy, especially in aseptic pancreonecrosis were more widely used, and ESTI in biliary pancreatitis significantly reduced the number of suppurative complications of the disease and postoperative mortality.
Postoperative mortality was 6 %: in nonbiliary pancreatitis — 7.5 %, in biliary — 2.2 %. Inclusion in comprehensive critical care of broad-spectrum antibiotics, especially carbapenems (imipenem-cilastatin, meropenem), in aseptic pancreonecrosis made it possible to avoid in 94.5 % the development of septic complications: in the localization of acute aseptic liquid accumulations in the omental bursa — in 98.5 % of the patients, and in retroperitoneal fat — in 81.3 %. Similar rates when using cephalosporins of 3rd generation (ceftriaxone, cefoperazone) and fluoroquinolones (moxifloxacin, gatifloxacin) were, respectively, 84.6; 90 and 66.7 %.
And in parapancreatic infiltrate inclusion in a comprehensive conservative treatment of antibiotics from the group of carbapenems enabled to avoid in 32.4 % of patients acute aseptic parapancreatic liquid clusters, as well as surgery. In the application of cephalosporins of 3rd generation and fluoroquinolones, this index was only 13.3 %. Postoperative mortality in aseptic pancreonecrosis was 4.5 %, and in infected necrotizing pancreatitis — 10.7 %.
Conclusion. Surgical approach in acute necrotizing pancreatitis should take into account the form and phase of the disease, and provide: the rejection of earlier abdominal operations in any form of the disease; active prevention of infectious complications in aseptic pancreonecrosis, including by removing the substrate for suppuration, extensive use of minimally invasive surgery (laparoscopy, endoscopic papillosphincterotomy, puncture-draining interventions under ultrasound control) as well as the immediate surgery on the pancreas from minimal access (lumbotomy).


Keywords


acute necrotizing pancreatitis; surgical approach

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DOI: https://doi.org/10.22141/1997-2938.3.22.2013.87422

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