Intra-arterial therapy in the combination therapy of acute pancreatitis

The article discusses the results of endovascular therapy (ET) in 92 patients with various forms of acute pancreatitis. ET was conducted without operative treatment, in preparation for operation, and in the postoperative period. Ten patients were subjected to direct hypothermia by intraarterial infusion of cooled solutions. Bi-arterial catheterization of the aortic branches was performed for higher efficacy of the management of acute pancreatitis and prevention of its complications. The inclusion of ET in the complex of therapeutic measures for acute pancreatitis led to a fall of pancreonecrosis lethality from 54% to 25%.     

Differential treatment of acute pancreatitis

Results of examination and treatment of 194 patients with acute pancreatitis were analyzed. It is revealed that the diagnosis of an etiopathogenetic form of acute pancreatitis is a key moment in the choice of the treatment. Patients with acute biliary pancreatitis and alimentary pancreonecrosis with pancreatogenic peritonitis require urgent surgical treatment at early stages of the disease. Laparoscopic cholecystectomy and Haulstad's drainage of the common bile duct are the procedures of choice in acute biliary pancreatitis. Alimentary pancreonecrosis with pancreatogenic peritonitis is the indication for videolaparoscopic drainage procedure and peritoneal dialysis as soon as possible after the disease beginning. This approach decreased lethality, number of complication and hospital stay.     

Fundamentals of complex treatment of acute destructive pancreatitis]

Results of treatment of 240 patients with an acute pancreatitis were analyzed. There were assigned two groups taking into account stage of severity of pancreonecrosis and stage of polyorganic insufficiency. In 147 patients with mild stage and moderate stage conservative treatment was undertaken, in 93 patients with severe course different operative interventions were performed in urgent and emergent order and in period of postnecrotic complications occurrence. Application of such an approach have permitted to lower the postoperative complications frequency in 1.9 the value. Mortality had constituted 22.6%.     

Early diagnosis and surgical tactics at acute destructive pancreatitis

Based on retrospective analysis of 292 case histories of patients with acute pancreatitis the computed model permitted to differentiate destructive and hydropic pancreatitis and to predict clinical course of pancreonecrosis has been constructed. Algorithm of treatment tactics depending on this analysis has been developed. Use of laparoscopy in early period with results of computed prognosis permitted to decrease the rate of diagnostic mistakes at pancreonecrosis from 59.2 to 39.5%. Algorithm of surgical tactics permitted to reduce lethality at small- and medium-focal pancreonecrosis from 51.7 to 5.1%, and the rate of purulent complication--from 23.8 to 2.5%.     

Results of application of synthetic antioxidants in treatment of patients with destructive pancreatitis

Results of examination and treatment of 103 patients with pancreonecrosis are presented. Influence of antioxidant mexidol on acute pancreatitis (AP) was studied. It is demonstrated that mexidol in AP permits to slow down destructive processes in the pancreas, promotes localization of inflammation and normalization of clinical and laboratory picture of the disease that permits to decrease significantly number of severe complications of AP and reduce lethality.     

Surgical treatment of acute destructive pancreatitis with low frequency ultrasound

Energy of low-frequency ultrasound was used for removal of necrotic foci in the pancreas and parapancreatic tissue before septic complications. Studies of the pancreas of patients who had died of pancreonecrosis permitted to select optimum configuration of working butt of wave-wire. Experimental studies (22 dogs) demonstrated high efficacy of this method: necrotic foci were removed completely with little capillary bleeding; microscopic study showed that wound process had reparative character with minimum inflammation. Clinical study was carried out in 172 patients with acute destructive pancreatitis. In 139 patients traditional methods were used: left-sided resection of the pancreas, abdominization of the pancreas, staged sequestrectomies. Lethality in this group was 46.7%. Thirty-three patients underwent ultrasonic necrosequestrectomy, lethality was 30.3%.     

Differentiated surgical policy in destructive pancreatitis

A total of 4522 patients with acute pancreatitis (AP), 1142 from them with pancreonecrosis (PN), were treated in surgical clinics of Saratov Military Medical Institute in 1990-2002. Intervention was made in 381 patients. Is shown, that the introduction of modern methods of treatment new operative receptions, change of the indications for "open" drainage operations, use of original policy-surgical classification has allowed to lower a mortality from AP from 12 to 8.25%, and postoperative lethality from 38.1 up to 19.5%. At the analysis of results of work the doubtless positive effect of application Sandostatin fixed at treatment.     

Use of calcium channel blockers for prophylaxis of multiple organ failure in acute destructive pancreatitis

The purpose of this study was to investigate effectiveness of the usage of calcium channels blockers and plasmaleukopheresis in prophylaxis of the syndrome of polyorganic insufficiency (SPI) in patients with acute destructive pancreatitis. 30 patients operated on for pancreonecrosis were divided into 2 groups: study group (13 patients) and control one (17 patients) matched for sex, age, extent and character of changes in the pancreas. Taking into account a substantial role of hyperactive neutrophils in pathogenesis of SPI, Verapamil (dose of 0.5 mg/kg/day) and discrete plasmaleukopheresis were included in the complex of treatment for patients of the study group. Effectiveness of the treatment was assessed according to the quantity of complications, lethality values of leukocytosis and leukocyte index of intoxication (LII) as well as by the scale of the severity of sepsis (SSS). Complicated postoperative course was seen in 41.18% of cases in the control group and 23.07%--in the study one. Lethality in the control group made up 11.8% (2 patients); there were no lethal outcomes in the study group. Anearlier decrease in leukocytes count, LII and SSS in the study group was significant. The conclusion is made on effectiveness of the use of calcium channels blockers and discrete plasmaleukopheresis for prophylaxis of SPI in acute destructive pancreatitis.     

Magnetic resonance imaging in the diagnosis of acute pancreatitis

Overall 52 patients with acute pancreatitis were examined with MRI and spiral CT. The examination was performed during 24 hours from admission time. Results of examination were assessed confidentially by 3 experts with 5-scores scale. Non-parametric chi-square criterion was used for significances detection. MRI demonstrated advantages over spiral CT in diagnosis of fat necrosis, sequestration and hemorrhages. MRI compares well with contrast CT in diagnosis of pancreonecrosis. MRI permits to diagnose destructive lesions in pancreas without contrast agent, and accordingly without additional effect on pancreas and kidneys. It is concluded that MRI is high informative method in diagnosis of acute pancreatitis and its complications.     

The postoperative pancreatitis after the pancreatic surgery

The results of 302 operations on the pancreas were analyzed: of them 107 were pancreatoduodenal resections; 67 were distal resections of the pancreas; 74 were various resections of the head of the pancreas and middle resections and 54 other operations. The postoperative pancreatitis was registered in 178 patients. The preventive use of the octreotide intraoperatively and in early postoperative period showed no influence on the frequency and severity of the postoperative pancreatitis. The ultrasound was the optimal screening diagnostig method, whereas the computed tomography was the best in pancreonecrosis diagnostics and the volume of the pancreatic tissue damaged. Of 178 patients with the postoperative pancreatitis 17 died, the lethality rate was 9.5%.     

Pancreatitis predominantly affecting the caudal part of the pancreas

The characteristics of specific features of acute and chronic processes in the caudal pancreatis and surrounding retroperitoneal fat is given on the basis of an analysis of 273 cases of pancreatitis with the predominant lesion of this portion. It was established that acute caudal pancreonecrosis at an early period had atypical symptoms and more favourable course than that of the proximal parts of the pancreas. Later periods of the development of this variant of the disease are characterized by great frequency and spread of pyo-necrotic lesion of the retroperitoneal fat. Specific features of the clinical course, diagnosis and treatment were formulated and their being taken into account allowed to reduce lethality of patients with caudal pancreatitis from 39.0% to 25.0%.     

Minimally invasive technologies in diagnosis and treatment of local purulent complications of destructive pancreatitis

Sixty patients with local purulent complications of destructive pancreatitis were treated. Interventional procedures under visual control were performed in 38 patients: in 26 (68.4%) -- under control of computed tomography and in 12 (31.6%) -- ultrasound-assisted procedures. Traditional surgeries were performed in 22 patients. Complete recovery was seen in 23 (60,6%) of 38 patients of the first group, all these patients have solitary, one-chamber and non-sequestered purulent cavities which are formed in 82.6% cases due to microfocal pancreonecrosis. Transcutaneous drainage was ineffective in 14 (36.8%) patients that required conversion to laparotomy. It is demonstrated that treatment policy in purulent-necrotic complication of pancreonecrosis must be individual. Adequate method of local treatment must be determined by size and localization of purulent and necrotic lesions, presence of sequesters and septa.     

Continuous retroperitoneal infusion of a novocaine cocktail in the combined treatment of severe forms of acute pancreatitis

Severe forms of acute pancreatitis were treated in 53 patients (25 with a destructive form, 28 with an edematous form) with using permanent infusions of a novocaine cocktail into the retroperitoneal space. General lethality was reduced to 5.7%. In the group of patients with a destructive form of acute pancreatitis lethality was 12%. Nobody died in the group of patients with the edematous form. No complications were noted resulting from the method.     

Change of external and internal secretory pancreatic function in pancreatitis

In 49 patients with an acute pancreatitis and 91 - with chronic pancreatitis were studied external and internal secretory pancreatic function in remote terms after the treatment. In 48 (52.7%) patients, suffering chronic pancreatitis, the investigated indexes were studied in dynamic before and after the operation. There was established the disorders of external secretory pancreatic function in an acute pancreatitis of severe stage and noninfected pancreonecrosis in patients, to whom direct operative pancreatic interventions were not performed. Indications for conduction of internal drainage of the pancreatic ducts, taking into account data of preoperative instrumental examination and initial activity of fecal elastase-1, were substantiated. The advantages of Beger and Frey operations, in comparison with resecting procedures, were proved because of lesser occurrence of the pancreatic functions disorders.     

Pathogenetic approach to diagnosis and treatment of acute pancreatitis

Results of examination and treatment of 958 patients with acute pancreatitis are analyzed. The study group consisted of 372 patients treated in accordance with special clinical protocols (2001-2004). The control group consisted of 586 patients treated before these protocols extensive use (1995-2001). The two groups were similar by the main clinical characteristics. It was demonstrated that the treatment according standard protocols permitted to reduce general lethality from 3.9% (control group) to 2.7% (study group), postoperative lethality - from 14.3 to 11.5%. General lethality at severe acute pancreatitis decreased from 18.5 to 12.7%, postoperative lethality - from 26 to 19%.     

Acute pancreatitis after resection of stomach for low duodenal ulcer

Results of the treatment of 71 patients with postbulbar ulcer of the duodenum are presented. Stomach resection by Bilrot-II was performed in 22 (30.9%) patients, by Bilrot-I--in 2 (2.8%), by Roux with plastic reconstruction of duodenal stump with intestinal tube--in 16 (22.5%) patients. Precardial proximal vagotomy with drainage operation was performed in 31 (43.6%) patients with massive periulcerous infiltration. Acute postoperative pancreatitis (APP) was seen in 29 (40.8%) patients chiefly after resection of stomach, 6 (8.4%) of them had pancreonecrosis. Postoperative lethality in the group of patients with APP was 12.6%. Ultrasonic examination of the pancreas and its vascular structures is the main method for diagnosis of postoperative pancreatitis. The cause of APP is the mechanic deformation and spasm of major duodenal papilla (MDP) that may be associated with cholinergic denervation and edema of MDP after resection and trauma of tissues. The removal of MDP spasm is an effective prophylactic measure for elimination of pancreatic hypertension. One of the methods of removal of MDP spasm is periarterial sympathectomy of gastroduodenal artery and prolonged drug blockade of celiac plexus in addition to stomach resection.     

Curative-tactical approaches in patients with pancreatic pseudocyst

Experience of treatment in the clinic of 162 patients with pancreatic pseudocyst was analyzed. Modern principles of diagnosis and treatment of patients were adduced. Operation before the cyst capsule formation is compulsory, caused by the complications occurrence and the pancreonecrosis progression. External drainage of an acute pancreatic pseudocyst was performed in 61 patients, internal drainage--in 72. After external drainage the cyst recurrence was noted in 17, the pancreatic fistula formation--in 7 patients. The poorest results were noted in patients with infected pancreonecrosis and in pseudocyst formation.     

The role of immune disorders in formation of local and systemic complications of severe acute pancreatitis

There were studied the factors, which initiate the immune response in severe acute pancreatitis, in 57 patients of both gender ageing from 16 to 66 years, in whom the acute pancreatitis severity had constituted 3 marks and more (according to the Ranson criterions). In majority of the patients the combined type of the immune disorders had prevailed. The first stage of the disease was characteristic for metabolic hyperactivity occurrence with raising of HLA-DR+ level as well as of immunoregulating coefficient at the expense of the T-helpers quantity increase. In 47.1% of the patients with aseptic pancreonecrosis also the HLA-DR1 leukocytic antigens were revealed in combination with normal phagocytic activity of neutrophils present in 85.3% of them. In these patients also most frequently were revealed such antigens as HLA-A1 (in 20.6% of observations), HLA-A9 (in 29.4%), HLA-B13 (in 30.4%), HLA-B16 (in 20.6%). In 51.2% of patients, suffering infectionized pancreonecrosis, there was revealed HLA-DR2 lymphocytic phenotype. In them there were noted high suppressive activity of T-lymphocytes, lowering of phagocytic activity of neutrophils, activation of the aberrant adhesion molecules (ICAM-1, ICAM-3) on the background of higher concentration of interleukin-8 present in the blood serum in comparison with such in patients, suffering aseptic pancreatic necrosis.     

Diagnosis and surgical treatment of pancreonecrosis

Actual problems of diagnosis and treatment of pancreonecrosis (PN) are discussed. Results of treatment of 154 patients hospitalized with sterile necrosis SN (n = 133) and infected PN (n = 21) were analyzed. SN became infected in 49 patients. The diagnostic methods were as follows: USE, CT, biochemical examinations of blood, urine and exudate. Percutaneous puncture contrast retroperitoneography (PPCR) was developed. It is demonstrated that modern diagnostic methods and PPCR permit one to diagnose PN, detect location, zone of retroperitoneal fat's necrosis and characterize its infection. The size of lesion of retroperitoneal fat in patients with sterile PN (n = 133) does not determine severity of the patients' condition and early lethality, but increases the risk of infection and makes worse prognosis of the disease. In laparoscopic sanation of the abdominal cavity for fermentative peritonitis, compared with laparotomic one, infection developed less rarely (10.2 and 40%, p < 0.01) and lethality decreased. Lethality in repeated mini-invasive surgeries through burso- and retroperitoneostomas performed in 34 patients with infected pancreonecrosis was 17.6% that is lower than one in repeated relaparotomies (n = 21, lethality 47.8%).     

Surgical treatment of patients with acute pancreatitis]

Since 1963 to 1973 in the clinic 1449 patients were treated for acute pancreatitis and cholecystopancreatitis. A considerable increase in the number of these patients was observed during recent 8 years, mainly on account of destructive forms. 92 patients were operated upon (6.3%), including 9 subjects with pancreatic edema, 39--with hemorrhagic pancreatitis, 36--with pancreonecrosis, 8--with purulent pancreatitis. Indications to surgical therapy are considered to be as follows: the presence of initial signs of diffuse peritonitis or prounced signs of limited peritonitis, if the conservative therapy during 8-10 hours was a failure.