Improvement of endoscopic methods of treatment of patients with acute biliary pancreatitis

Abstract

Modern approaches to the choice of treatment tactics for acute pancreatitis (AP) are quite diverse, but the main trend is the superiority of complex conservative therapy over early surgical intervention [1]. It is quite clear that the decision regarding the treatment plan for AP depends on a number of reasons: the etiology and clinical picture of the disease, methods of diagnosis and forecasting the development of complications, the chosen tactics of patient management [2]. With regard to the tactics of AP of biliary etiology, at the moment a consensus has been reached among surgeons ‒ the treatment of patients should be minimally invasive, aimed at restoring the patency of the pancreatico-biliary duct system, reducing the risk of complications and recurrence of the disease. However, despite the relative safety of endoscopic interventions compared to traditional methods and their important role in many clinical situations, the frequency of postoperative complications can reach 20.6%, and the mortality rate is 3% [3]. The purpose of the study was to improve the results of surgical treatment of patients with acute biliary pancreatitis through the development and implementation of advanced endoscopic techniques aimed at restoring the patency of the pancreatic-biliary duct system. Materials and methods of research. The study was based on the results of the examination of 100 patients with acute biliary pancreatitis, who were divided into two groups: a comparison group - patients who used traditional methods of examination and treatment (n=48) and the main group - patients who used improved surgical tactics (n=52). Indications for endoscopic operations were: mechanical jaundice, choledocholithiasis, including complicated by acute cholangitis, stenotic papillitis, dilation of the common bile duct (regardless of the presence of calculi in it according to ultrasound). To assess the effectiveness of surgical tactics in the studied groups, a comparative analysis of the applied methods, the frequency of postoperative complications and mortality was carried out. Results of the research. Endoscopic interventions to restore the passage of bile and pancreatic juice in cases of biliary etiology of AP were performed in 75% (39/52) of the main group, in 77.1% (37/48) of the patients in the comparison group (χ2=0.06, 95% CI -14.66-18.42, p=0.8). Thus, among patients in the comparison group, endoscopic papillosphincterotomy (EPST) was used in 21 (43.8%) patients, balloon dilatation of the sphincter of Oddi in 12 (25%) patients, balloon dilatation and choledochal stenting in 4 (4%) patients. In turn, among the patients of the main group, EPST was performed in 7 (13.5%) patients, including one (1.9%) patient with choledochal stenting, EPST under the control of choledochoscopy according to our own method (Ukraine utility model patent No. 135693 «Method of surgical treatment of biliary pancreatitis») ‒ in 9 (17.3%) patients, installation of a nasobiliary stent and lavage of the pancreatico-biliary duct system according to our own method (Ukraine utility model patent No. 139587 «Method of surgical treatment of acute pancreatitis») – in 23 (44.2%) patients. In the postoperative period, in the comparison group, complications occurred in 21.6% (8/37) of patients, namely, hemorrhagic complications in 10.8% (4/37) cases (in two (5.4%) patients, they occurred immediately after EPST), purulent-septic ‒ in 10.8% (4/37) cases, postoperative mortality was 2.7% (1/37). In the main group, hemorrhagic complications in the postoperative period were observed in one (2.6%) patient and were associated with the progression of the disease, while there were no purulent-septic complications and deaths. Conclusion. The introduction of improved endoscopic methods of treatment of acute biliary pancreatitis aimed at restoring the patency of the pancreatico-biliary duct system made it possible to reliably reduce the frequency of postoperative complications in patients of the main group by 19% (χ2=6.47, 95% CI 4.24-34.71, p=0.01), a trend towards a decrease in mortality by 2.7% was also observed (χ2=1.05, 95% CI -6.53-13.82, p=0.3). References: 1. Baron, T. H., DiMaio, C. J., Wang, A. Y., & Morgan, K. A. (2020). American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis. Gastroenterology, 158(1), 67–75.e1. https://doi.org/10.1053/j.gastro.2019.07.064 2. Kolosovych, I. V., Bezrodnyi, B. H., Hanol, I. V., & Cherepenko, I. V. (2020). Stage approach in surgical treatment of acute pancreatitis. Medicni Perspektivi, 25(2), 124–129. https://doi.org/10.26641/2307-0404.2020.2.206384 3. Cahyadi, O., Tehami, N., de-Madaria, E., & Siau, K. (2022). Post-ERCP Pancreatitis: Prevention, Diagnosis and Management. Medicina (Kaunas, Lithuania), 58(9), 1261. https://doi.org/10.3390/medicina58091261