Variants of Drainage Surgery in Pancreatic Necrosis

The dissertation is devoted to the surgical treatment of acute destructive pancreatitis (pancreatic necrosis), a disease characterized by high morbidity and mortality reaching, according to literature data, 25–70%. Based on clinical material, the author analyzes the regularities of the spread of the destructive process in the pancreas and retroperitoneal cellular tissue depending on the scale of the lesion, and compares the capabilities of conservative therapy, diagnostic and therapeutic laparoscopy, minimally invasive interventions, as well as "closed" and "open" drainage operations. Particular attention is paid to the differentiated choice of the drainage method taking into account the clinical-morphological form and the volume of necrosis, to the optimal timing and regimes of sanation of purulent-necrotic foci, and to the improvement of the technique of forming a bursoomentostomy in total-subtotal pancreatic necrosis. The practical significance of the work is determined by the proposed diagnostic and therapeutic algorithm that allows, within 24 hours, establishing the extent and form of pancreatic necrosis, and by the substantiation of indications for various variants of drainage operations, which, according to the author's data, made it possible to reduce mortality from 25.0 to 9.8%, from 23.9 to 11.4%, and from 70 to 34.4% in the corresponding groups of patients.

Relevance of the topic.

The major medical-biological and socio-economic problem of acute pancreatitis is caused by the continuing growth of morbidity, which today in the Russian Federation amounts to 38 cases per 100,000 population. Patients with acute pancreatitis constitute 5–10% of the total number of surgical profile patients, yielding in frequency only to acute appendicitis and acute cholecystitis (Vashetko R.V. et al., 2000; Savel'ev V.S. et al., 1999, 2001; Nesterenko Yu.A. et al., 2002; Buchler M.W. et al., 2000; Powell J.J. et al., 2000; O'Reilly D.A., Kingsnorth A.N., 2007; Neoptolemos J.P. et al., 2008).

In 15–25% of cases, acute pancreatitis has a severe destructive character and is accompanied by various complications, which are the main cause of death. Mortality in pancreatic necrosis remains extremely high and, according to various authors, ranges from 25 to 70%. In 80–90% of patients it is caused by infection of foci of destruction. It is precisely the category of patients with purulent-septic complications of pancreatic necrosis that presents the greatest problems from the diagnostic, therapeutic, and economic standpoints (Filin V.I., 1994; Filimonov M.I., Burnevich S.Z., 1999; Vashetko R.V. et al., 2000; Savel'ev V.S. et al., 1999, 2001; Lysenko M.V., 2007; Bradley E.L., 1996; Beger H.G. et al., 2003; Flint R., Windsor J.A., 2004; Swaroop V.S. et al., 2007; Lohmann A. et al., 2008).

The discussion on the tactics of treatment of acute destructive pancreatitis has not led to the formation of a generally accepted algorithm of diagnostic and therapeutic measures. The questions about the criteria of effectiveness of conservative therapy, the timing and extent of surgical intervention remain controversial to this day (Savel'ev V.S. et al., 2001; Bradley E.L., 1999; Uhl W. et al., 2002; Steinberg W., 2005; Runzi M. et al., 2006).

According to the opinion of the majority of specialists dealing with the problem of diagnosis and treatment of acute pancreatitis, conservative therapy is effective in 75–85% of cases. In the remaining patients, intensive therapy does not arrest the development of the destructive process in the pancreas, surrounding organs, and tissues, which requires the application of surgical methods of treatment. Performing early operations at the height of intoxication and pancreatogenic shock leads to death in the immediate postoperative period. At the same time, an unjustifiably long delay of surgical aid contributes to the development of purulent complications, progression of pancreatic necrosis, intoxication, and multiple organ failure (Vashetko R.V. et al., 2000; Ursov S.V., 2003; Lysenko M.V., 2007; Bradley E.L., 1996; Gloor B. et al., 2001, 2005; Bassi C. et al., 2003; Werner J. et al., 2007).

Over the past 15 years, considerable progress has been made in understanding the pathogenesis of acute pancreatitis, and the capabilities of intensive therapy have changed qualitatively. At the same time, visualization of the pancreas (ultrasound examination, computed tomography, laparoscopy) has reached a qualitatively new level, thanks to which it has become possible to determine the severity of the disease and to evaluate the course of acute pancreatitis in real time (Balthazar E.J. et al., 1994; Bradley E.L., 1999; Isenmann R. et al., 1999; Gloor B. et al., 2001; Uhl W. et al., 1999, 2002; O'Reilly D.A., Kingsnorth A.N., 2007).

Thus, the growth of morbidity of acute pancreatitis, especially its destructive forms, the high mortality, and the disputability of issues of therapeutic tactics determine the necessity of further improvement of methods of diagnosis and treatment of this pathology.

Aim of the study.

Determination of the most effective variants of drainage operations in pancreatic necrosis aimed at reducing the number of complications, decreasing mortality, and improving the outcomes of the disease.

Objectives of the study.

1. To study the regularities of the spread of destructive processes in the pancreas and surrounding cellular tissue in various forms of pancreatic necrosis.

2. To evaluate the possibilities and effectiveness of minimally invasive high-technology interventions with subsequent "closed" drainage in purulent-necrotic complications of pancreatic necrosis.

3. To determine indications for "closed" and "open" methods of drainage operations.

4. To develop optimal methods, regimes, and timing of drainage of purulent-necrotic foci.

5. To optimize the technique of forming a bursoomentostomy in total-subtotal pancreatic necrosis.

Main propositions put forward for defense.

1. The degree and scale of the initial lesion of the pancreas are the leading signs that determine the choice of the method of surgical treatment in various clinical-morphological forms of acute destructive pancreatitis.

2. In patients with acute pancreatitis with a necrosis scale of up to 30%, multi-target intensive therapy combined with diagnostic and therapeutic laparoscopy and intra-arterial administration of antibiotics, with subsequent "closed" drainage of the abdominal cavity and methods of minimally invasive surgery, make it possible to interrupt the development of destruction, to cause regression of degenerative and inflammatory changes in the pancreas and retroperitoneal cellular tissue.

3. In pancreatic necrosis with a scale of lesion of the pancreas up to 60%, accompanied by sequestration of extensive areas of the gland and retroperitoneal cellular tissue, diagnostic and therapeutic laparoscopy with minimally invasive interventions play an auxiliary role. Adequate sanation of foci of destruction (necros sequestrectomy) is possible only by laparotomy with subsequent "closed" drainage of the abdominal cavity, parapancreatic, and retroperitoneal cellular tissue on the 12th–14th day from the onset of the disease, before the development of purulent-septic complications.

4. Necrosis of the pancreas exceeding 60% leads to the development of extensive phlegmons of the retroperitoneal cellular tissue and pancreatogenic sepsis. Early operations involving "open" drainage of foci of necrosis 48–72 hours from the onset of the disease, combined with multi-target intensive therapy, make it possible to arrest the development of fatal complications in 65.6% of patients.

Scientific novelty.

On the basis of the results of laboratory, instrumental, radiological, and clinical studies, the regularity of the spread of destructive processes has been revealed depending on the scale of the lesion of the pancreas and retroperitoneal cellular tissue.

The expediency of diagnostic and therapeutic laparoscopy and high-technology minimally invasive methods of drainage in limited forms of pancreatic necrosis has been determined.

The criteria for the use of "closed" and "open" drainage operations in pancreatic necrosis have been optimized.

The optimal timing and methods of continuous-aspiration lavage of foci of destruction have been specified depending on the extent of pancreatic necrosis.

Practical significance of the work.

A diagnostic and therapeutic algorithm has been proposed that allows, within 24 hours, establishing the extent of pancreatic necrosis and its clinical-morphological form.

A regularity has been revealed in the development of the pathological process in the pancreas depending on the scale of the initial lesion of the gland, which allows predicting the character and timing of the occurrence of complications.

Parameters have been calculated for assessing the severity of the condition and the degree of organ dysfunction in patients with pancreatic necrosis using multifactorial scales, which make it possible to monitor the effectiveness of the therapy being carried out and to set indications for surgical treatment.

Rational standardized schemes of treatment and indications for the "closed" and "open" methods of drainage of foci of destruction have been proposed, which made it possible to reduce mortality from 25.0 to 9.8%.

It has been proved that intensive multi-target therapy combined with diagnostic and therapeutic laparoscopy and "closed" drainage of foci of destruction as the final stage of treatment of pancreatic necrosis is effective with 30% necrosis of pancreatic tissue.

It has been proved that necros sequestrectomy in patients with destruction of 30–60% of pancreatic tissue and "closed" drainage of foci of destruction, performed on the 12th–14th day from the onset of the disease, makes it possible to avoid the development of purulent complications and to reduce mortality from 23.9 to 11.4%.

It has been proved that early operations in patients with destruction of more than 60% of pancreatic tissue (48–72 hours from the onset of the disease), involving mobilization of the pancreas with subsequent "open" drainage of the abdominal cavity, omental bursa, and retroperitoneal cellular tissue, constitute the main component of anti-shock therapy and make it possible to prevent the development of extensive phlegmons of the retroperitoneal space and pancreatogenic sepsis, as well as to reduce mortality from 70 to 34.4%.

Implementation of the work.

The main results of the research carried out are applied in the diagnostic and therapeutic process in the departments of surgery and intensive care of the Burdenko Main Military Clinical Hospital, the 3rd Vishnevsky Central Military Clinical Hospital, the 6th Central Military Clinical Hospital, Moscow City Clinical Hospital No. 23, Moscow City Clinical Hospital No. 29 named after N.E. Bauman, and are also used in teaching at the departments of surgery and military field surgery of the State Institute for Advanced Medical Training of the Ministry of Defense of the Russian Federation.

Approbation of the work.

The main propositions of the dissertation were reported and discussed at a meeting of the Department of Surgery of the State Institute for Advanced Medical Training of the Ministry of Defense of the Russian Federation (2005, 2008); at the V All-Army Conference with international participation (2005); at the final scientific-practical conferences of the Burdenko Main Military Clinical Hospital named after Academician N.N. Burdenko with international participation (2006, 2007).

Publications.

On the materials of the dissertation, 14 scientific works have been published, of which 2 in central press, 1 monograph.