Diagnostic Significance of Intra-Abdominal Pressure in the Treatment of Patients with Pancreatic Necrosis

The dissertation is devoted to the diagnostic significance of intra-abdominal pressure in the treatment of patients with pancreatic necrosis. Acute destructive pancreatitis is characterized by high mortality and frequent development of multiple organ failure, one of the causes of which is considered to be intra-abdominal hypertension. The work is aimed at determining the clinical and prognostic significance of elevated intra-abdominal pressure in patients with pancreatic necrosis.

During the study, the dynamics of intra-abdominal pressure changes were investigated, their pathogenetic relationship with the development of complications was established, the optimal method of pressure measurement was selected, and a diagnostic and treatment program was developed. It has been demonstrated that dynamic measurement of intra-abdominal pressure is a highly informative diagnostic test that allows assessment of the degree of pancreatic destruction and prediction of complication development. Prolonged elevation of intra-abdominal pressure in pancreatic necrosis requires open drainage surgery. The results have been implemented in the clinical practice of the Department of Military Field (Naval) Surgery of the State Institute for Improvement of Physicians of the Ministry of Defense of the Russian Federation.

Essence of the Topic.

The necessity of improving methods of treatment for patients with acute destructive pancreatitis is due to a significant increase in morbidity, unresolved issues regarding the choice of surgical tactics and methods of conservative treatment, and the highest mortality rate of up to 85% among patients with urgent surgical pathology (19, 42, 52, 56, 76, 78, 89, 92, 121, 153, 215).

In many regions of the Russian Federation, acute pancreatitis has risen to third place in the structure of emergency surgical pathology and has become a kind of marker of social and economic well-being as a whole (8, 1, 24, 26, 29, 42, 56, 65, 73, 78, 83, 121, 214).

A critically important aspect in the development of acute pancreatitis is the extremely short period during which the pathological process is localized only in the pancreas and does not affect the body as a whole. The frequency of extra-organ complications in pancreatic necrosis ranges from 60.8% to 96.5% (21, 24, 47, 52, 79, 184, 208). Infection of necrotic foci occurs in 40–70% of patients with pancreatic necrosis. This category of patients presents the greatest problem in diagnostic, therapeutic, and economic aspects (11, 15, 89, 154, 162, 189, 208, 225).

Mortality from acute pancreatitis in Russia in recent years has been 22.7–23.6%, while in Moscow in 2005 it was 26.3–28.3% (4, 56, 63, 78, 83). In pancreatic necrosis, mortality ranges from 20–85% (8, 11, 20, 29, 56, 78, 83, 153, 157, 162, 169, 191, 222).

Pancreatic necrosis is generally accompanied by the development of various complications, including multiple organ failure, which in 95–97% of cases is the primary cause of fatal outcomes (3, 8, 36, 42, 65, 76, 79, 83, 89, 93, 153, 169, 191, 205, 210).

One of the causes of the development of multiple organ failure syndrome in critically ill patients is considered to be intra-abdominal hypertension (17, 32, 34, 72, 131, 147, 156, 163, 203, 224).

The study of elevated intra-abdominal pressure in various pathological conditions has received considerable attention over the past two decades. However, accurate data on the frequency of its development and prognostic value in patients with pancreatic necrosis are still lacking (17, 34, 58, 139, 163, 165, 215), which determines the need for further study of this problem.

In light of the above, the goal and objectives of the research have been determined.

Goal of the study: to determine the clinical and prognostic significance of elevated intra-abdominal pressure in patients with pancreatic necrosis.

Research objectives:

1. To investigate the dynamics of intra-abdominal pressure changes in patients with pancreatic necrosis.

2. To determine the pathogenetic relationship between intra-abdominal pressure dynamics and the development of complications in patients with pancreatic necrosis.

3. To study the currently used methods of measuring intra-abdominal pressure and select the optimal one for patients with pancreatic necrosis.

4. Based on the obtained data, to develop and substantiate a diagnostic and therapeutic program for the treatment of pancreatic necrosis.

Scientific novelty of the research.

For the first time, a comparative analysis of the diagnostic significance of methods of measuring intra-abdominal pressure in patients with destructive pancreatitis has been conducted in this work.

A dependence between the level of intra-abdominal pressure and the extent of pancreatogenic inflammatory process in the abdominal cavity and retroperitoneal space has been established.

Based on the analysis of intra-abdominal pressure measurement results in patients with pancreatic necrosis, an algorithm of diagnostic and therapeutic measures has been compiled, allowing assessment of changes in the pancreas and adjacent anatomical areas in a short time.

Practical significance.

Measurement of intra-abdominal pressure in destructive pancreatitis makes it possible not only to assess the degree of pancreatic destruction but also to detect the development of complications of destructive pancreatitis.

The pattern of intra-abdominal pressure changes in pancreatic necrosis provides insight into the features of its course and factors influencing the disease prognosis, and is of great importance for the choice of surgical treatment tactics.

Main provisions of the dissertation to be defended.

1. Dynamic measurement of intra-abdominal pressure is a highly informative diagnostic test in the comprehensive treatment of patients with pancreatic necrosis.

2. The study of intra-abdominal pressure dynamics in patients with pancreatic necrosis, taking into account clinical data and results of instrumental investigations, makes it possible to clarify the severity of pancreatitis and predict the development of its possible complications.

3. The magnitude of intra-abdominal pressure is determined by the scale and degree of inflammatory-destructive changes in the pancreas, retroperitoneal tissue, and adjacent anatomical areas.

4. Prolonged elevation of intra-abdominal pressure in pancreatic necrosis requires open drainage surgery.

Implementation of research results.

The developed method for diagnosing and correcting intra-abdominal pressure levels, and the algorithm for diagnosing and managing patients with pancreatic necrosis, have been implemented in the clinical practice of the clinical bases of the Department of Military Field (Naval) Surgery of the State Institute for Improvement of Physicians of the Ministry of Defense of the Russian Federation (City Clinical Hospital No. 29 of Moscow, 32 Central Naval Clinical Hospital of the Ministry of Defense of the Russian Federation). The results are used in the educational process at the Department of Military Field (Naval) Surgery of the State Institute for Improvement of Physicians of the Ministry of Defense of the Russian Federation.

Defense of research results.

The materials of the dissertation research were reported and discussed at the XI Symposium with international participation "Modern Methods of Instrumental Diagnostics" (Moscow, 2006), the 14th All-Russian Scientific and Practical Conference "Achievements of Modern Gastroenterology" (Tomsk, 2006), the 137th Session of the Section of Military Field Surgery of the Moscow Surgical Society (Moscow, 2006), the Scientific and Practical Conference "Prospects for Improving Specialized Medical Care at the 32 Central Naval Clinical Hospital of the Ministry of Defense of the Russian Federation" (Moscow, 2006).

Publications.

Nineteen printed works have been published on the dissertation topic, of which ten are in central press.

Volume and structure of the dissertation.

The dissertation is presented in 125 pages of typescript and consists of an introduction, a literature review, three chapters of original research, a discussion of the results, a conclusion, findings, practical recommendations, and a reference list of 227 sources (98 domestic and 129 foreign authors). The work is illustrated with 18 tables and 24 figures.