Stage approach in the treatment of patients with acute pancreatitis

Abstract

Leading place among the diseases of the pancreas is acute pancreatitis. A feature of the course of pancreatitis in young people is the high risk of complications, mortality in which reaches 5.5%, and in severe acute pancreatitis - varies between 40-70% [1]. In addition, this course of acute pancreatitis is the most dangerous in the case of open surgery, as mortality ranges from 12% to 56% [2]. In view of this, there have been recent studies of the step-up approach to treatment [3]. The purpose of this work is to improve the results of surgical treatment of patients with acute pancreatitis. Materials and methods. The results of treatment of 112 patients with acute pancreatitis, who were hospitalized in the procedure of ambulance in the Department of Surgery №2 of the Bogomolets National Medical University at the worshiper in the period 2009–2022. Severe disease was observed in 83 (74.1%) patients, moderate in 29 (25.9%) patients. In the early phase of the disease, endoscopic operations were performed in 44 (39.3%) patients, and laparotomy was performed in 12 (10.7%) patients with widespread peritonitis. In the late phase - 15 (13.4%) patients underwent laparotomy, necrsequestrectomy, abdominization pancreas, drainage of the abdominal cavity and retroperitoneal space, 36 (32.1%) patients were treated with ultrasound-guided puncture treatments. In the case of progression of the disease and ineffective drainage under ultrasound control, 5 (4.5%) patients were treated with retroperitoneoscopically assisted necrsequestrectomy, combined laparoscopic and retroperitoneoscopically assisted necrsequestrectomy in 3 (2.7%) patients, and in 2 (1.8%) patients, laparotomy, abdominization, necrsequestrectomy, drainage of the abdominal cavity and retroperitoneal space were detected. The surgical intervention in the late phase of the disease was 21±4.2 days from the onset of the disease. A stege approach in the treatment of acute pancreatitis was applied to 80 (71.4%) patients in the main group. The comparison group consisted of 32 (28.6%) patients who underwent laparotomy and laparoscopic interventions in the early and late periods of the disease without prior use of endoscopic interventions or drainage operations under ultrasound control. Results. In the main group the length of stay in the hospital was 21,3±4,2 days, respectively, in the comparison group – 48,2±5,3 days. In 42 (95.5%) patients who underwent endoscopic surgery, a positive clinical effect, rapid regression of symptoms of acute pancreatitis was achieved. In two (4.5%) patients who underwent endoscopic interventions, the disease progressed with the development of an abscess of the omental pouch, they underwent puncture drainage under ultrasound control. When using puncture drainage operations under ultrasound control in 26 (72.2%) patients achieved a positive result, the abscess cavity decreased by 63±6.2% within 7 days. In 10 (27.8%) patients, due to the progression of the disease, the following stage of treatment was performed: retroperitoneoscopically assisted necrsequestrectomy (5 (13.9%) patients), combined laparoscopic and retroperitoneoscopically assisted necrsequestrectomy (3 (8.3%) patients), and open laparotomy, abdominization, necrosequestrectomy, drainage of the abdominal cavity and retroperitoneal space (2 (5.6%) patients). Complications in the main group occurred in two (2.5%) patients, the mortality rate was 2.5% (two patients). In the comparison group, complication occurred in 8 (25%) patients, the mortality rate was 18.8% (6 patients). Conclusions. The use of minimally invasive endoscopic interventions, draining surgeries under ultrasound control, followed by combined laparoscopic and retroperitoneoscopically assisted necrsequestrectomy or open laparotomy, reduces the length of hospital stay of patients from 48.2±5.3 days (comparison group) to 21.3±4.2 days (main group) (p<0.0001, t=28.346) and the number of complications by 22.5% (p=0.0002, χ2=14.104, DI 9.2333-39.7022). The use of a stage approach in the surgical treatment of acute pancreatitis reduces mortality by 16.3% (p=0.0026, χ2=9.058, DI 4.6571-32.9639). References: 1. Kolosovych IV, Hanol IV, Cherepenko IV, Lebedieva KO, Korolova KO. INTRABDOMINAL PRESSURE AND ITS CORRECTION IN ACUTE SURGICAL PATHOLOGY. Wiad Lek. 2022;75(2):372-376. PMID: 35307661. 2. Goltsov VR, Savello VE, Bakunov AM, Dymnikov DA, Kurochkin DM, Batig EV. [Purulent-Necrotic Parapancreatitis: the Evolution of Views on Treatment]. Annaly khirurgicheskoy gepatologii = Annals of HPB Surgery. 2015;20(3):75-83. Russian. doi: 10.16931/1995-5464.2015375-83. 3. Kolosovych IV, Hanol IV, Cherepenko IV. Enteral tube feeding in acute pancreatitis and its complications. 2021;4 (78): 75-9. DOI 10.26724/2079-8334-2021-4-78-75-79.