Surgical Approach in Patientsw with Acute Non-biliary Aseptic Pancreatitis, Depending on Size of Pancreatic Lesions
The literature suggests that the results of treatment of acute necrotizing pancreatitis is dependent on many factors: the patient’s age, terms of disease, the initial state of the patient, severity of disease, complications. However, the severity of the disease and the development of complications are directly dependent on the volume of the affected pancreatic tissue.
In this regard, the purpose of this survey was to study frequency of complications of the necrotizing pancreatitis and development surgical treatment tactic, depending on affected area volume.
Material and Methods. Results of treatment of 195 patients operated on for acute aseptic non-biliary necrotizing pancreatitis aged 21 to 84 years. There were 111 men (56.9 %), women — 84 (43.1 %). With disease duration up to 24 hours was observed 92 (47.2 %) patients, 25 to 72 h — 41 (21 %), more than 72 hours — in 62 (31.8 %). In 122 (62.6 %) patients, the acute necrotizing pancreatitis was a monotonous diet (too much fatty food), and in 73 (37.4 %) — alcohol intake or its surrogates. Less than 30 % of affected pancreatic tissue detected in 43 (22.1 %) patients, from 30 to 50 % — in 138 (70.8 %), and 50 % — in 14 (7.1 %).
Results and Discussion. Analysis of the data indicates that in patients with acute aseptic necrotizing pancreatitis most frequently damaged from 30 to 50 % of the pancreatic parenchyma, it was observed in 70.8 % of patients. In 22.1 % of patients showed loss of less than 30 % of the pancreas, and at 7.1 % — more than 50 %. Among the complications of acute necrotizing pancreatitis with limited and extensive necrosis of pancreas most frequently observed acute aseptic parapancreatic fluid accumulation in the Willis’s pouch and enzymatic peritonitis, and a subtotal-total — acute aseptic parapancreatic fluid accumulation in the retroperitoneum.
Acute aseptic parapancreatic liquid accumulation in the Willis’s pouch, are more or less delimited accumulation of free fluid, and in the retroperitoneum, especially in case of advanced and subtotally-total necrotizing pancreatitis — in the form of widespread infiltration parapancreatic, paracolon and sometimes in pelvic space. In this regard, the choice of method and volume of surgical intervention in acute aseptic parapancreatic fluid accumulations in the Willis’s pouch and/or retroperitoneum accumulation of a free liquid should be preferred puncture-draining operations under ultrasound and acute aseptic liquid accumulations in parapancreatic retroperitoneal fat in the form of widespread infiltration parapancreatic and paracolon space — drainage by lumbar (extraperitoneal) access.
The enzymatic peritonitis should be preferred laparoscopy/paracentesis and drainage of the abdominal cavity, which in most cases with conducting intensive infusion drug therapy prevents development of other complications of acute necrotizing pancreatitis and avoid performing more traumatic surgery.
In aseptic necrotizing pancreatitis small sizes sequesters are lysed or organization and therefore do not require surgical treatment. Aseptic and infected sequesters, that large enough, in the body and tail of the pancreas, should be removed from the mini accesses extraperitoneal (by lumbotomy), and the localized in the pancreatic head — using laparotomy, necrosectomy, omentobursostomy.
The outcome of patients with acute aseptic necrotizing pancreatitis is directly dependent on the amount of destruction of the pancreas. The worst results were obtained in the treatment of patients with subtotal-total pancreatic necrosis. Purulent complications (retroperitoneal fat cellulitis) occurred in 71.4 % of patients, and the mortality rate was 42.9 %. In case of common pancreatic necrosis, the figures were — 2.2 % and 0.7 %. Only in case of limited pancreatic necrosis was no septic complications or deaths.
In general, patients with acute aseptic necrotizing pancreatitis purulent complications occurred in 13 (6.7 %) patients: omental abscess — at 4, and the retroperitoneum abscess — in 9.7 patients died, mortality was 3.6 %. The causes of death were sepsis and multiple organ failure — in 3 patients, endotoxin shock — in 3, and pulmonary embolism — in 1.
Conclusions. The development of complications of acute aseptic necrotic pancreatitis, depends on the extent of necrosis of the pancreatical tissue, which should be considered when selecting the method and volume of surgical intervention.
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