Improvement of methods of sanitation of foci of infected necrosis in acute destructive pancreatitis

The dissertation is devoted to the improvement of methods of sanitation of foci of infected necrosis in acute destructive pancreatitis. It examines the assessment of severity and prediction of the course of pancreatic necrosis, the characteristics of the microflora in infected pancreatic necrosis, as well as modern approaches to the surgical and conservative treatment of the disease, including antibacterial therapy, selective decontamination of the gastrointestinal tract, and the use of bacteriophages. Based on clinical material, the results of the use of minimally invasive interventions, staged endoscopic sanitation, and hydropressive technologies in combination with a complex pyobacteriophage are analyzed, together with the dynamics of the microbial landscape and immunological parameters in patients with severe forms of infected pancreatic necrosis.

The practical significance of the work is associated with the development of a differentiated treatment tactic aimed at reducing the frequency of complications and mortality in extensive forms of acute destructive pancreatitis complicated by infected pancreatic necrosis.

Relevance of the topic

The incidence of acute pancreatitis has been steadily increasing year by year and, according to global statistical data, ranges from 200 to 800 patients per 1 million per year (C.H. Jonson, 1999). According to Russo et al. (2004), approximately 21,000 patients with acute pancreatitis are hospitalized annually in the United States. According to V.S. Savel'yev et al. (2000), in the Russian Federation acute pancreatitis accounts for 5–10% of admissions to surgical hospitals. In 15–20% of patients, acute pancreatitis develops a destructive, necrotic character. It is this category of patients with severe acute pancreatitis that presents the greatest problems in the diagnostic, therapeutic, and economic aspects (C.H. Jonson, 1999; E.I. Gal'perin, T.G. Dyuzheva, 2003).

Infected necrosis (IN) is the earliest clinical and morphological form of pancreatogenic infection in terms of the time of its occurrence (E.P. Dellinger, 2003). The highest mortality, from 40 to 70%, has been recorded after the first week from the onset of the disease, mainly due to the development of infected pancreatic necrosis (R.V. Vashetko, 2000; S. Tenner, P. Banks, 1997).

In acute destructive pancreatitis, life-threatening complications develop: retroperitoneal phlegmon, abscesses of the omental bursa, arrosive bleeding, multiple organ failure, sepsis, and others. Mortality in these complications reaches 60–80% (V.S. Savel'yev et al., 1999; E.M. Kon, 2001; M.I. Prudkov, 2005; Rermer I.G., 1985; H.G. Beger et al., 1986; B.J. Ammori, 1998; D.W. Rattner et al., 1999; C.J. McKay, 2003; Isaji S., 2006). Only in a few clinics today is the mortality in destructive forms of pancreatitis less than 25% (S.F. Bagnenko, 2005; B.S. Briskin, 2005; A.I. Lobakov, 2005).

The problem of acute destructive pancreatitis (ADP) has become especially relevant over the past decades, due to the sharply increased frequency and severity of the disease (I.G. Burnyshev, 2004; G.S. Rybakov, 2005; A. Camovale, 2005; J. Werner, 2005). The main causes of unfavorable outcomes of pancreatic necrosis (PN) are the untimely detection of severe (extensive and infected) forms of the disease and the absence of a unified approach to an objective assessment of the severity of the patient's condition (D.A. Aleksandrov, 2004; V.S. Savel'yev, 2005). The obvious successes today of intensive therapy and the improvement of treatment outcomes in patients with pancreatic necrosis in the phase of pancreatogenic shock and hemodynamic disturbances have led to the situation in which, compared with the previous decade, surgeons have more frequently encountered post-necrotic purulent-degenerative complications of pancreatic necrosis, varied in character and extent. In other words, a relatively large number of patients survive pancreatogenic shock, but the course of pancreatic necrosis becomes complicated by purulent processes (A.M. Lishchenko, 1994; Nesterenko Yu.A. et al., 1995; I.I. Zatevakhin et al., 2000; R.V. Seregin, 2004). Rehabilitation of surviving patients is extremely difficult, and the rate of disability is high (M.I. Filimonov, 2004; B. Gloor et al., 2001). Expenditures on the treatment of surgical infections currently occupy first place among the costs of treating other diseases in general hospitals in Russia. This is due, first of all, to the severity of the course of the infectious process. At the same time, the diversity of clinical and topographic-anatomical forms of the disease, and the varying levels of equipment and therapeutic capacity of institutions create a situation in which the interpretation of the obtained data is variable and ambiguous. For these reasons, at present there exist several different classifications of acute pancreatitis and numerous programs of conservative and surgical treatment, the comparative effectiveness of which is difficult to assess objectively (S.A. Shalimov et al., 1990; Yu.A. Nesterenko et al., 1994; A.L. Kostyuchenko, V.I. Filin, 2000; A.V. Pugaev et al., 2000; E.L. Bradley, 1992; D.W. Rattner et al., 1999; C.H. Jonson et al., 1999).

The fight against pancreatogenic infection is currently associated with considerable difficulties, due to the wide spread of antibiotic-resistant forms of microorganisms that reduce the effectiveness of antibacterial drugs. Their frequent use without an appropriate protocol has promoted the emergence of resistant strains of microorganisms from the polymicrobial pool of intestinal bacteria (B.R. Gel'fand, 2001; S.V. Yakovlev, 2004; J.J. De Waele, 2004).

The improvement of methods of diagnosis and pathogenetic complex treatment of acute pancreatitis in recent years has made it possible to significantly improve the treatment outcomes of edematous and mild forms of acute destructive pancreatitis, whereas the issues of treatment tactics for severe, extensive forms of acute destructive pancreatitis and its post-necrotic complications still remain far from their final resolution.

Aim of the study

To improve the results of surgical treatment of patients with acute destructive pancreatitis complicated by infected pancreatic necrosis through a differentiated approach to the choice of treatment tactics and the improvement of methods of necro-sequestrectomy and sanitation of foci of infected necrosis using a complex pyobacteriophage and hydropressive technologies.

Objectives of the study

1. To investigate the dynamics of the qualitative composition of the microflora in patients with infected pancreatic necrosis.

2. To improve minimally invasive treatment procedures, in particular endoscopic sanitation, within the overall complex of treatment of patients with infected pancreatic necrosis.

3. To determine the clinical effectiveness of the use of a complex liquid pyobacteriophage in combination with hydropressive sanitation of the omental bursa cavity in patients with infected pancreatic necrosis.

4. To evaluate changes in immunological parameters in patients with severe infected pancreatic necrosis when a complex liquid pyobacteriophage is used in combination with hydropressive technology.

5. To determine the influence of methods of sanitation of the omental bursa on the quantitative composition of the microflora in infected pancreatic necrosis.

Scientific novelty

The effectiveness of the use of commercial bacteriophages — a complex liquid pyobacteriophage in combination with the use of the hydropressive device UVGS-1 in the complex treatment of patients with infected pancreatic necrosis has been established.

Practical significance

Methods of sanitation of foci of infected pancreatic necrosis have been improved with the use of commercial bacteriophages — a liquid complex pyobacteriophage and a Pseudomonas bacteriophage in combination with a hydropressive device, which makes it possible to clean the purulent cavity more rapidly, remove necrotic tissue, and reduce the percentage of complications and mortality, as well as the duration of hospitalization of patients.

Main propositions put forward for defense

1. In extensive forms of infected pancreatic necrosis, the character of operative interventions consists in performing laparotomy, extensive mobilization of the transverse colon, and the pancreas. The main stages are necrectomy, omentobursostomy or laparostomy, lumbotomy followed by staged (after 24–48 h) endoscopic sanitation using the hydropressive device UVGS-1.

2. The microbial landscape in infected pancreatic necrosis is represented by nosocomial and autochthonous flora, characterized by high antibiotic resistance.

3. The immune status is a marker of the severity of endogenous intoxication and has prognostic significance.

4. A highly effective and safe method of combating nosocomial infection is the use of commercial bacteriophages, in particular the solution of a liquid complex bacteriophage, which is a mixture of sterile filtrates of phagolysates of staphylococci, streptococci, enterococci, Proteus, Klebsiella, Pseudomonas aeruginosa, and Escherichia coli.

Implementation into practice

The results of the study have been introduced into the clinical practice of the departments of general surgery of City Clinical Hospital No. 23 named after «Medsantrud» on the basis of the Department of General Surgery of the MMA named after I.M. Sechenov.

Approval of the work took place on «30» June 2009 at a meeting of the Department of General Surgery of the MMA named after I.M. Sechenov.

Publications

Based on the materials of the dissertation, 9 works have been published. Of these: 1 article in a central publication, 8 in the proceedings of All-Russian scientific conferences. The main propositions of the dissertation were reported at the III International Surgical Congress «Scientific Research in the Implementation of the Program "Health of the Population of Russia"» (Moscow, 21–24 February 2008), and at the scientific conference with international participation «Uspenskiye Chteniya» (Tver, 2008).

Scope and structure of the work

The dissertation is set out on 132 pages of typewritten text, illustrated with 11 tables, 23 figures, and 2 clinical observations. The work consists of an introduction, a review of the literature, a description of the methods of research, a chapter devoted to the results of the author's own studies, a discussion of the results obtained, conclusions, and practical recommendations. The reference list contains 238 sources (117 domestic and 121 foreign).