Surgery: surgical treatment of acute pancreatitis. Surgical treatment of pancreatitis The benefits of massage for the human body

Surgical treatment of acute pancreatitis is used only for special indications: lack of effect from conservative therapy, an increase in symptoms of intoxication and peritonitis; identification of symptoms indicating a pancreatic abscess or accumulation of pus in the cavity of the lesser omentum; combination of pancreatitis with a destructive form of acute cholecystitis.

There are the following types of surgical interventions for acute pancreatitis: tamponade and drainage of the lesser omental sac without dissection of the peritoneum over the pancreas; tamponade and drainage of the omental bag with a dissection of the peritoneum covering the pancreas; resection of necrotically altered parts of the pancreas; biological tamponade of the greater omentum of the pancreas; a combination of the first three types of operations with interventions on the gallbladder, extrahepatic bile ducts and the nipple of Vater.

There are intra- and extraperitoneal accesses to the pancreas. The most common is the upper midline laparotomy. A good access is additionally provided by a transverse incision of the abdominal wall, especially in those cases when, during the operation, there is a need for revision of the biliary tract.

Intraperitoneal access to the pancreas can be achieved in one of four ways. 1. Through the gastrocolic ligament. This access is most convenient because it allows you to examine most of the head, body and tail of the pancreas. In addition, it creates the best conditions for isolating the stuffing bag from the rest of the abdominal cavity. 2. Through the hepatogastric ligament. This access is less convenient and it is advisable to use it only for gastroptosis. 3. Through the mesentery of the transverse colon. The limited possibilities of examining the entire pancreas, the difficulties of subsequent drainage of the cavity of the lesser omentum determine the rare use of this access. 4. By mobilizing the duodenum (T. Kocher) and thus exposing the head of the pancreas. This access to the pancreas can only be an addition to the previous ones.

Of the extraperitoneal approaches to the pancreas, only two are important: 1) right-sided lumbotomy (below the XII rib and parallel to it), which allows to expose the head of the pancreas, and 2) left-sided lumbotomy to approach the body and tail of the pancreas. These accesses are especially indicated for drainage of abscesses and phlegmons of the retroperitoneal space and can be used as an additional to the intraperitoneal one.

Tamponade and drainage of the omental sac without dissection of the peritoneum covering the gland do not provide an outflow of toxic substances containing activated enzymes and molten pancreatic tissues. Therefore, the most widespread operation with a dissection of the peritoneum over the gland, followed by tamponade and drainage of the omental sac. B. A. Petrov and S. V. Lobachev recommend dissecting the peritoneum above the gland with 2-4 longitudinal incisions running from the head to the tail of the gland. V. A. Ivanov and M. V. Molodenkov additionally (especially with destructive pancreatitis) exfoliate the peritoneum and expose the anterior, upper and lower surfaces of the gland, while the areas of necrosis are dissected or excised.

Tamponade is carried out with ordinary gauze or rubber-gauze tampons. As a rule, they are brought to the body and tail of the pancreas and to the upper part of the cavity of the lesser omentum. Since dissection of the pancreatic capsule with subsequent tamponade does not always prevent the progression of the process with subsequent melting of the gland tissue and the formation of abscesses of the retroperitoneal tissue, a number of authors (A. N. Bakulev, V. V. Vinogradov, S. G. Rukosuev, etc.) propose to produce resection of the affected area of the pancreas. However, the use of this operation is limited by the lack of a clear demarcation line of the lesion, the possibility of subsequent continuation of necrosis. Mikhailyants suggested limiting surgery for pancreatic necrosis to only biological tamponade of the pancreatic region (greater omentum), based on the clinically established bactericidal and plastic role of the omentum.

During an operation for acute pancreatitis, novocaine blockade of the pancreas, mesenteric root and lesser omentum is performed. Enter 100-200 ml of a 0.25% solution of novocaine with the addition of antibiotics (penicillin - 200,000-300,000 BD, streptomycin - 150,000-200,000 IU).

A number of authors suggest that after dissection of the posterior peritoneum and exposure of the pancreas, its surface should be covered with dry plasma (100-150 g), a hemostatic sponge, dry erythrocytes with the addition of antibiotics. The purpose of the topical application of dry protein preparations is to neutralize the pancreatic juice enzymes entering the abdominal cavity. Subsequently, daily administrations through the drainage tube into the cavity of the lesser omentum of these protein preparations in a mushy state, as well as the trasylol inhibitor, are recommended. In addition, it continues to be administered by drip intravenously until the diastase in the urine decreases to normal numbers.

In operations for acute pancreatitis, as a rule, revision of the biliary tract is necessary. With a catarrhal inflamed gallbladder, cholecystostomy is indicated. In cases of detection of a destructive form of cholecystitis, cholecystectomy with drainage of the bile (common bile) duct is necessary. In some cases, when a narrowing of the outlet section of the bile duct is detected during the operation, choledochoduodenostomy is indicated (see Gallbladder, operations). The operation of sphincterotomy in these cases has not found wide application in clinical practice due to frequent complications in the postoperative period.

After the operation, it is necessary to carry out measures aimed at combating intoxication, intestinal paresis, disorders of the cardiovascular system and respiration.

The pancreas is one of the most important organs of the digestive system. It is responsible for the synthesis of insulin and the production of many enzymes involved in metabolism. In cases where the gland becomes inflamed, it is customary to talk about the occurrence of a disease such as pancreatitis. It can be in the chronic stage or acute.

The acute phase of pancreatitis develops due to the fact that cellular digestive enzymes, which are usually in a passive state, are activated under the influence of various factors. This starts the process of digestion of the gland's own tissue. In this case, one can clearly see an increase in the size of the internal organ, cell necrosis with the formation of destruction sites.

Clinical picture of acute pancreatitis

The symptoms that patients describe depend on many factors - the form of pancreatitis, the period of its development. Usually, the disease is manifested by severe pain in the abdomen, which radiate to the back. In this case, quite frequent and repeated nausea and vomiting can occur. If the disease is caused by excessive drinking, pain may appear some time after intoxication. With cholecystopancreatitis, pain may appear after eating. Acute pancreatitis can occur without pain, but there is a pronounced systemic reaction syndrome.

The condition of a patient with pancreatitis can be worsened by its complications:

Retroperitoneal phlegmon;
Diffuse peritonitis;
Cysts, pseudocysts of the pancreas;
an abscess;
diabetes mellitus;
Thrombosis of the vessels of the abdominal cavity;
Calculous cholecystitis.

As a rule, treatment for acute pancreatitis takes place in conditions of mandatory hospitalization. Since the disease is quite dangerous, it is impossible to delay in contacting a doctor.

Treatment of pancreatitis

Sugar level

Treatment of patients with acute pancreatitis must be selected by a doctor, taking into account the indicators of the clinical and pathomorphological form of the disease, the stage of development of the process, and the severity of the patient's condition.

Pancreatitis can be treated conservatively and surgically.

With conservative treatment, which most often begins a complex of therapeutic measures, first of all, the water and electrolyte balance is adjusted.

This includes the transfusion of isotonic solutions and potassium chloride preparations with a reduced content in the patient's blood.

In addition, the basic conservative treatment of pancreatitis includes:

Tactical suppression of the secretion of juices of some organs of the digestive system;
Decreased enzyme activity;
Elimination of high blood pressure in the biliary and pancreatic tract;
Improving the rheological properties of blood and eliminating circulatory disorders;
Prevention and treatment of functional insufficiency of the gastrointestinal tract, as well as complications caused by sepsis;
Maintaining the optimal level of oxygen in the patient's body through the use of cardiotonic and respiratory therapy;
Providing assistance to the patient by relieving him of pain.

If hypermetabolic reactions develop, they resort to the use of this type of nutrition, in which nutrients are introduced into the patient's body using intravenous injections.

When restoring the function of the digestive system, it is necessary to prescribe enteral nutrition, in which the patient receives food through a special probe.

Surgical treatment of acute pancreatitis is used only in cases of special indications:

The use of conservative medical methods did not bring positive results;
Deterioration of the patient's condition due to an increase in symptoms of general intoxication of the body
The appearance of symptoms that indicate the presence of a pancreatic abscess;
The combination of pancreatitis with a destructive form of acute cholecystitis.

About 15% of patients in whom acute pancreatitis has passed into the stage of purulent complications require surgical treatment. This procedure is performed under general anesthesia with lung intubation, areas of necrosis (dead tissue) are removed from the pancreas.

Surgical intervention for acute pancreatitis is carried out in two versions:

Laparotomy, in which the doctor gets access to the pancreas through incisions in the abdominal wall and in the lumbar region. Many doctors agree that such an operation, performed in the aseptic phase of destructive pancreatitis, should be strictly justified and used only for indications, which can be:

Preservation and increase of disorders that continue to progress against the background of ongoing complex intensive care and the use of minimally invasive surgical interventions;
Widespread and widespread defeat of the retroperitoneal space;
The inability to reliably and completely exclude the infected nature of the necrotic process or other surgical disease requiring emergency surgical intervention.

Most doctors agree that an open surgical intervention undertaken on an emergency basis for enzymatic peritonitis in the pre-infectious phase of the disease due to incorrect diagnostic data with other diseases of the peritoneal organs, without prior intensive therapy, is an unreasonable and incorrect measure.

Minimally invasive methods (, puncture-draining interventions), which are performed through punctures in the patient's abdominal wall. This option solves not only therapeutic, but also diagnostic problems, thanks to which it is possible to obtain material for bacteriological, cytological and biochemical studies, which makes it possible to best differentiate the aseptic or infected nature of pancreatic necrosis.

Indications for puncture-draining interventions under ultrasound control in pancreatic necrosis is the appearance of fluid in the abdominal cavity and retroperitoneal space.

Contraindications for puncture-draining intervention are the absence of a liquid component, the presence of gastrointestinal tract, urinary system, vascular formations on the puncture path, and pronounced disorders of the blood coagulation system.

Under ultrasound control, a single needle puncture is performed, followed by its removal (with sterile volumetric liquid formations) or their drainage (infected volumetric liquid formations). This should ensure the outflow of the contents, sufficient fixation of the catheter in the lumen of the cavity and on the skin.

In some cases, drainage does not give the desired effect. You can talk about this in the presence of pronounced inflammatory reactions, multiple organ failure, all kinds of inclusions in the focus of destruction.

If the results of studies have established that the necrotic component of the focus significantly predominates over its liquid element and the patient's condition does not improve, the use of such drainage methods is inappropriate.

Surgical interventions for acute pancreatitis

Distal resection of the pancreas. It is carried out in cases where the organ is partially damaged. In this case, the tail and body of the pancreas of different volumes are removed.
Subtotal resection is permissible only when the gland is completely affected. It consists in removing the tail, body and most of the head of the pancreas. At the same time, only small portions of it adjacent to the duodenum remain. There is no complete recovery of organ functions after the operation. This can only be achieved through a pancreas transplant.
Necrosequestrectomy is performed under the control of ultrasound and fluoroscopy. The revealed liquid formations of the pancreas are removed with the help of drainage tubes. Further, drainages of a larger caliber are introduced into the cavity and washing is carried out. At the final stage of treatment, large-caliber drainages are replaced with small-caliber ones, which ensures gradual healing of the cavity and postoperative wound while maintaining the outflow of fluid from it.

Preparing the patient for pancreatic surgery

Diet after surgery

The first time, which is usually 2 days, the patient does not take any food and is on a starvation diet. On the 3rd day, gradually, in small doses, tea, pureed soups cooked without meat, protein omelet, steamed, crackers, cottage cheese are introduced into the diet. Doctors give recommendations to stick to such a diet for about a week. All foods that are allowed to patients with diseases of the digestive system are gradually introduced into the diet. The possibility of physical activity is determined by the volume of the operation and the individual characteristics of the body.

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“Like a crouching panther, she laid her head on the bend of the duodenum, spread her thin body on the aorta, lulling her with measured movements, and nonchalantly deflected her tail into the gate of the spleen. Just as this beautiful, shy predator can unexpectedly do irreparable harm, so does the pancreas. Beautiful, like an angel of heaven, like a demon, insidious and evil” - prof. Golubev.
Anatomy and physiology. Pan- whole, creas- meat (all meat). The pancreas (PG) develops from three primordia: two ventral and one dorsal. At 4-5 weeks of intrauterine development, a close relationship with duodenum and choledochus is already traced. Lies behind the stomach at the level of L1 - L2. Length 15-23 cm, height - 3-6 cm, weight 70-150 g. There is a head with an uncinate process, a neck (narrowed part at the passage of the vessels), a body and a tail. There is no clear capsule.
Clinical significance of anatomical features:

close embryologically determined connection of the head and duodenum;
part of the common bile duct passes into the head of the pancreas (jaundice);
retroperitoneal location (always retroperitoneal reaction up to phlegmon);
behind the solar plexus (irradiation posteriorly and relief in the position on all fours);
in contact with the largest branches of the aorta and tributaries of the portal vein (arrosive bleeding);
with pathology of the tail - splenomegaly;
between the prerenal fascia and the fascia of the pancreas, a layer of loose fiber (the body and tail are easily mobilized);
the root of the mesocolon lies on the anterior surface of the pancreas (from the very beginning of the onset of panreatitis, paresis of the colon occurs).

The pancreas is a gland of mixed secretion: the endocrine section includes the islets of Langerhans, the exocrine section consists of pancreatocytes combined into acini.
Exocrine functions: ecbolic (water up to 1-4 l/day); production of 20 enzymes and proenzymes; secretion of electrolytes (neutralization of gastric juice and the creation of an alkaline environment).
Endocrine functions: amylolysis (a-amylase - polysaccharides); proteolysis (trypsinogen is converted into duodenum to trypsin); lipolysis; nucleolysis (ribonuclease, deoxyribonuclease).
After eating, secretion lasts 3 hours. Hard, thick and fatty foods are retained longer and the panrceas secrete longer.
Acute pancreatitis - aseptic inflammation of the pancreas of the demarcation type, which is based on necrobiosis of pancreatocytes and enzymatic autoaggression, followed by necrosis and dystophia of the gland and the addition of a secondary purulent infection (V. S. Saveliev, 1986).
For 25 years, the incidence has increased 40 times. Age 30-50 years. Postoperative mortality 30-60%. Mortality in patients with acute necrotizing pancreatitis is from 20 to 70%.
Etiopathogenesis. Acute pancreatitis is a polyetiological disease, but monopathogenetic. The bottom line is the depressurization of the ductal system, caused by intraductal hypertension and direct trauma to pancreatocytes, which leads to premature activation of enzymes in the gland. In the experiment, ruptures of the epithelium in the area of ductoacinar junctions occur already at 40 cm of the water column.
1. Mechanical factors (mechanical damage to various anatomical structures):

trauma to pancreatocytes due to intraductal hypertension (stone, obstructive stenosis, polyps, ERCP, papillary diverticulitis);
refluxes (biliary pancreatic, duodeno pancreatic with duodenal hypertension);
direct trauma (mechanical, chemical, intraoperative).

Logical, although difficult to prove, in patients is the theory of microcholedocholithiasis (infringement of small stones in the OBD).
2. Neurohumoral factors: stress, hormone therapy, nutritional disorders (obesity!), pregnancy, hypercalcemia, hypertriglyceridemia.
3. Toxic-allergic factors : infection (virus), allergy, drugs, alcohol and surrogates, poisoning, endogenous intoxication.
Although it starts suddenly, but there is a background - Mondor. Practically two reasons: cholelithiasis and alcohol intake.
The factor directly provoking an attack is everything that causes the production of pancreatic juice: a plentiful meal (fatty, fried), drug stimulation of pancreatic secretion (prozerin, pilocarpine, secretin, pancreazimin).
Theory of pathogenesis is based on three provisions (V. S. Savelyev, 1986):
1. The leading role of biochemical disorders of lipolysis and proteolysis (with intraacinar activation of enzymes under the influence of cytokinase).
2. Foci of necrosis are primarily aseptic.
3. Pancreatogenic toxemia leads to profound disorders of central and peripheral hemodynamics and multiple organ failure.
Genesis of intoxication.
Primary factors of aggression - entry into the blood of activated pancreatic enzymes.
Secondary factors of aggression - activation with the participation of trypsin of the kallikrein-kinin system of the blood and tissues, the release of free kinins (bradykinin, histamine, serotonin). It is manifested by a characteristic pain syndrome, an increase in vascular permeability. Activation of lipid peroxidation with a decrease in tissue antioxidant protection.
Tertiary factors of aggression - ischemic toxins (myocardial depression factor).
Aggression factors and toxins enter through the portal vein and thoracic lymphatic duct. First target organs: liver, lungs, then heart, central nervous system, kidneys. The syndrome of multiple organ failure is formed.
The route by which the infection is transmitted to sterile pancreatic necrosis is the translocation of intestinal bacteria.
Periods of morphogenesis:
The period of alteration and the formation of necrosis (in addition to damage to pancreatocytes, there is intense exudation into the retroperitoneal space and the peritoneal cavity).
The period of perifocal inflammation is first aseptic, then septic (from the intestines and during surgery).
The period of restitution (often incomplete with partial restoration of exo- and endocrine functions).
Classification(clinical and morphological):
Forms: edematous pancreatitis (abortive pancreatic necrosis),
fatty pancreonecrosis,
hemorrhagic pancreatic necrosis (generalization of the process due to damage to the protein structures of the stroma by activated proteolytic enzymes).
Acute pancreatitis is a staging disease:

stage of pancreatic colic and shock;
stage of early endogenous intoxication;
stage of general inflammatory changes;
stage of local purulent-inflammatory changes.

At a conference in Atlanta (1992), four main forms of acute pancreatitis were identified, which are a priority in use today, as they determine modern tactics:

edematous interstitial pancreatitis (75 - 80%: of these, 30% have gallstones, 50% have alcohol);
acute necrotic (necrotizing) pancreatitis - 20%;
pancreatic abscess (distinguish from infected necrosis);
subacute pancreatic pseudocyst develops at 3-5 weeks.

In addition, the process is differentiated by localization and flow.
By localization: capitate, caudal, total.
Downstream: 1) abortive (interstitial or edematous); 2) slowly progressing (fatty panreonecrosis); 3) rapidly progressive (hemorrhagic pancreatic necrosis); 4) lightning fast.
Clinic. Pain - permanent symptom. Starts suddenly with pancreatic colic. From the very first moment it is extremely intense, scary, cruel. Moderate pain in only 6%. In 10%, pain leads to collapse. Posterior irradiation in 65%. Almost does not increase with coughing and deep inspiration.
Vomit - constantly. Multiple. It does not alleviate the condition, but even increases the pain (due to increased pressure in the ductal system due to increased intra-abdominal pressure). With the addition of erosive gastritis - vomiting of coffee grounds.
Other mechanisms of vomiting: progressive intestinal paresis (at 5-7 days) and the presence of high intestinal obstruction (after 8-12 days) due to compression of the duodenum by the infiltrate of the pancreas head. The peculiarity of such vomiting is the absence of preliminary nausea.
Signs of pancreatogenic toxemia: shock, fright, change in facial features, shortness of breath, tachycardia, collapse, dry tongue. A change in the color of the skin is characteristic (pallor, jaundice, cyanosis, vascular spots, marbling, acrocyanosis). Arise and reach the greatest expressiveness in the first 5 days from the beginning.
objective data late due to the deep location of the gland.
Bloating due to paresis of the predominantly transverse colon. Painful tension in the epigastrium. Pain in the left or right lumbocostal angle (Mayo-Robson symptom). With fatty pancreatic necrosis, a painful infiltrate can be palpated in the epigastrium and left hypochondrium (3-5 days from the onset). Cyanotic spots on the skin of the abdomen and extremities (Mondor's symptom), petechiae around the navel, on the buttocks due to damage to peripheral vessels (Grunwald's symptom).
Patients afraid of palpation, Mondor. "Rubber" abdomen due to isolated swelling of the transverse colon.
Causes of jaundice: 1) choledochal stones, 2) swelling of the pancreas head, 3) toxic hepatitis.
The phenomena of insufficiency of the cardiovascular, respiratory, hepatic-renal and endocrine systems develop very quickly.
For acute pancreatitis are so characteristic psychotic disorders due to intoxication of the brain, which can be considered its typical symptom. Delirious syndrome predominates, which consists in a disorder of consciousness, impaired orientation in time and place. Sharp motor and speech excitement, fear, anxiety, hallucinations. Recovery may be simultaneous with somatic disorders, but may be delayed. The severity of mental disorders does not always correspond to the degree of destruction of the gland. They are aggravated by the background, more often by initial cerebrovascular insufficiency.
Thrombohemorrhagic syndrome - the main clinical and laboratory effect of pancreatic aggression in acute pancreatitis. Reasons: evasion of pancreatic enzymes into the blood, deep microcirculation disorders, hypoxia and acidosis, immune aggression in the form of complement activation, increased formation of immune complexes, the appearance of a significant number of T-killer lymphocytes.
Characterized by severity from the very first hours. The bottom line is diffuse hypercoagulability and fibrin formation. Microcirculation disorders are aggravated, cell exchange becomes more difficult. Very quickly, the pool of coagulants and antiplasmins is depleted and the stage of hypercoagulability turns into consumption coagulopathy with the development of thrombocytopenia. As a result, intravascular coagulation inhibits hemostasis. In parallel, proteases, acting on the proteins of the basement membrane of the vascular wall, significantly increase its permeability - common hemorrhages of a universal nature.
Clinic of thrombohemorrhagic syndrome: increased vascular thrombosis at the puncture sites, hemorrhages at the puncture site due to the subsequent development of consumption coagulopathy.
Treatment of thrombohemorrhagic syndrome: Prophylactic use of rheomodifiers (rheopolyglucin, neorondex) and antiplatelet agents (dipyridamole), drugs affecting microcirculation (trental, agapurin, heparin in prophylactic doses). Low molecular weight heparins are promising.
At the stage of hypercoagulation with damage to the lungs, liver, brain - therapeutic doses of heparin with fibrinolysis activators (theonicol, complamin, nicotinic acid).
In the stage of coagulopathy of consumption, transfusion of coagulants (native plasma, cryoprecipitate, fibrinogen), platelet mass, etamsylate up to 1.5 g / day.
Criteria that aggravate the prognosis of the course of pancreatitis.
Clinical: absence or atypical localization of pain, fever up to 38 and above, the presence of epigastric infiltrate, cyanosis, dry skin, swelling of the lower extremities, complications (peritonitis, bleeding, obstruction, encephalopathy, coma, cardiovascular failure), presence chronic diseases (diabetes mellitus, hypertension, ischemic disease, chronic pneumonia, chronic pyelonephritis, collagenosis, hepatitis, liver cirrhosis).
Laboratory: leukocytosis 15 109 / l and above, a sharp decrease in urinary diastase, hyperglycemia 12 mmol / l and above, hypoproteinemia 60 g / l, residual nitrogen 42.8 mmol / l and above, hyperbilirubinemia more than 30 μmol / l; increase in ALT and AST more than 1.0, ALT activity more than 6 times, serum LDH activity 4 times, blood urea level more than 17 mmol / l, calcium below 1.75 mmol / l - indications for surgery (if below 1, 5 mmol / l - absolutely unfavorable prognosis).
Diagnostics.
Diagnostic tasks: 1) establishment of pancreatitis; 2) identification of patients with developing pancreatic necrosis; 3) determination of infection of pancreatic necrosis.
Clinical diagnosis is a priority. Pain in the epigastric region, aggravated by palpation, with posterior and girdle irradiation, vomiting that does not bring relief, reliably determine the diagnosis. Confirm amylasemia and amylasuria. Modern biochemical markers: CPR (more than 120 mgdl), LDH (more than 270 U), PMN-elastase (more than 15 U).
The criteria for necrotizing pancreatic necrosis are the severity of the intoxication syndrome, as well as symptoms from the abdominal cavity: swelling of the upper sections with symptoms of intestinal paresis.
Infection is established by fixing the clinical and paraclinical indicators of the septic process.
Ultrasound diagnostics. Direct signs of acute pancreatitis: an increase in all sizes of the gland, fuzzy contours, heterogeneity of the parenchyma, a decrease in echo density, diagnosis of biliary tract pathology, effusion in the omental bag. Indirect signs: the presence of effusion in the abdominal cavity, an increase in the retrogastric space, ectasia of the bile ducts, paresis of the gastrointestinal tract.
Signs of destruction: heterogeneity of the echostructure and the presence of silent areas, blurring of the contours, an increasing increase in contours in dynamics, the presence of effusion in the abdominal cavity.
In the later stages, ultrasound diagnostics of the emerging cyst is relevant.
CT (including spiral) evaluates necrosis of the gland and peripancreatic tissue with an accuracy of 85-90%. The presence and magnitude of necrosis in 90% determines CT with contrast.
Fine needle biopsy under ultrasound reveals infection of necrosis (100% specificity ) - the main indication for surgery.
Pancreatography and papillotomy. Modern studies have shown that the removal of bile duct stones by papillotomy has a beneficial effect on the course of biliary pancreatitis. Pancreatography may be done within 6 to 12 hours of symptom onset to look for duct changes or outflow obstruction in the dorsal duct system. Stents are recommended to protect against edema. It is not required for clearly alcoholic pancreatitis and the absence of bile duct stones.
Laparoscopy reveals:

plaques of steatonecrosis on the peritoneum;
serous infiltration (“glass edema”) of tissues adjacent to the gland, greater and lesser omentum;
the nature of the peritoneal exudate (serous or hemorrhagic) and its transparency (transparency changes from the end of 1 week);
pushing the stomach and bulging of the gastrocolic ligament;
enlarged, tense gallbladder.

Treatment.
Most patients suffer from mild to moderate disease and usually recover. Pancreatic necrosis is complicated by 20-30% of cases. Drug prevention of pancreatic necrosis is not yet possible. “The pancreas is an organ that cannot be relied upon” - Zollinger.
As early as 1894, Korte suggested the priority of surgery in the treatment of pancreatitis. But, perhaps, there were no such frequent changes in the opposite strategies of surgical treatment in any emergency disease.
Considering the surgical treatment of pancreatitis, and we should only talk about necrotizing pancreatitis, it is important to keep in mind that open classical interventions and drainage with tampons inevitably lead to infection of the abdominal cavity and retroperitoneal space with a severe nosocomial infection (this problem is exacerbated in Russian hospitals). At the same time, the zone of infection as a result of operations inevitably expands. As a result, the detoxifying effect of the operation is quickly replaced by the generalization of the infectious process. Further, in the early period of the disease, the patient experiences a state of endotoxic shock and is more vulnerable to operational aggression.
At present, an active conservative strategy with delayed operations should be recognized as a priority for mass use. It is based on powerful intensive therapy, including detoxification at the level of the circulatory and lymphatic systems, antibiotic therapy, treatment of intestinal insufficiency syndrome to stop the translocation of the intestinal flora, and correction of organ and system insufficiency. Surgical treatment with this variant of the strategy is maximally delayed for a remote period. Such intensive therapy often avoids local and systemic complications. Organizationally, patients should be treated immediately upon admission by resuscitation intensive care specialists under the dynamic supervision of a surgeon.
Conservative treatment:

restoration of the BCC. With an edematous form, 2-4 liters per day is enough, with severe ones - 6-10 liters. In the latter case, an additional 500-1000 ml of 5% albumin or plasma is important due to the significant loss of protein;
hunger;
parenteral nutrition after 24 hours if long-term treatment is expected. Enteral nutrition begins gradually with a low-fat meal;
relief of pain. Mild complaints are relieved by a combination of antispasmodics with peripheral analgesics. In case of insufficiency, analgesics of central action (tramal) are connected. In the third stage, drugs are prescribed. With prolonged severe pain - epidural anesthesia.

Glucosone-vocaine mixture (25 ml of 2% novocaine solution in 400 ml of 5% glucose solution), novocaine blockades.
Relief of spasm to relieve intraductal hypertension and vasoconstriction: nitroglycerin, platifillin, noshpa.
Antiemetics: dimetpramide, torecan, methaclopramide (cerucal, raglan), a permanent probe into the stomach.
A probe into the stomach in severe forms with a clear dysmotility. Gastric lavage to eliminate the source of humoral stimulation of the pancreas (water +4-+6°C for 2-4 hours 2 times a day).
Intestinal stimulation (do not use prozerin!): novocaine 0.25% 100-200 ml + sorbitol 20% 100-200 ml IV.
Protease inhibitors: = counterkal after 4 hours (40-60 thousand units per day for mild form, 100 thousand units for severe),
= E-ACC - 150 ml of a 5% solution after 4-6 hours,
= 5 FU - 15% mg / kg of body weight per day (3-4 ampoules 750 - 1000 mg IV - 3 days).
The appointment of protease inhibitors and drug inhibition of pancreatic secretion in the course of international clinical trials was found to be ineffective. Attempts to “calm down” the gland with drugs (glucagon, somatostatin, atropine, calcitonin, carbonic anhydrase inhibitors, drug blockade of gastric juice secretion, removal of gastric contents through a tube) were unsuccessful, since secretion is already inhibited in acute inflammation.
The experiment showed that the introduction of antitrypsin is only favorable if it is carried out prophylactically before the development of pancreatitis. In practice, antienzymes are prescribed when the activation of trypsin during the cascade activation of other enzymes (elastase and phospholipase) has ended.
Infusion detoxification, elimination of hypovolemia and dehydration (colloids + crystalloids 3000-4000 ml per day) under the control of BCC, CVP, blood pressure and heart rate. Correction of protein disorders. Intensive treatment also includes artificial respiration, hemofiltration up to hemodialysis.
Improvement of microcirculation. New work suggests the use of isovolemic hemodilution and plasmapheresis.
Antibacterial therapy. The appearance of high temperature and other septic phenomena requires its immediate appointment. More often, there are two types of flora: opportunistic flora of the gastrointestinal tract (before surgery) and nosocomial infection (after surgery). Early therapy reduces secondary infection. It is advisable to prescribe antibiotics that obviously cover the corresponding spectrum of pathogens. IMIPENEM and gyrase inhibitors (CIPROFLOXACIN, OFLOXACIN) are preferred. It is promising to detect pathogens during pancreatic puncture under ultrasound.
Intraluminal destruction of aerobic gram-negative microorganisms in the intestinal tract prevents infection of the pancreas. For example, colistin sulfate 200 mg, amphotericin 500 mg, and norfloxacin 50 mg orally every 6 hours.
Treatment of disseminated intravascular coagulation syndrome. To prevent thrombosis, it is advisable to prescribe heparin in prophylactic doses.
Immunocorrection, vitamin therapy.

Surgery. Until 1985, patients were more likely to die from toxic shock at an early stage.
Patients with limited and aseptic necrosis should be treated conservatively (mortality is two times less). The overall percentage of infection of pancreatic necrosis is 40-60%, which occurs after about 2 weeks from the onset.
Indications for surgery (infection of pancreatic necrosis): 1) failure of intensive care for more than 3-4 days; 2) progressive multiple organ failure (lungs, kidneys); 3) shock; 4) sepsis; 5) severe peritonitis; 6) infected pancreatic necrosis (the presence of pathogens in necrosis of the gland); 7) massive necrosis (more than 50% on contrast CT); 8) massive blood loss; 9) an increase in obstructive jaundice, obstruction of the common bile duct and duodenum; 10) false cysts; 11) acute obstructive cholecystitis.
Early interventions are carried out with total or subtotal infected necrosis. Further operations are performed during the period of melting and sequestration (on days 7-10-14) - a phased necrosequestrectomy.
Both options provide detoxification. So, peritoneal exudation in hemorrhagic pancreatic necrosis gives a maximum of intoxication in the first 4-6 hours and lasts 24-48 hours. After removal of the peritoneal effusion, the intensity of peritoneal exudation decreases by 10-12 times.
Early intervention objectives (not urgent!):

removal of increased interstitial pressure in the gland itself and parapancreatic (retroperitoneal) tissues;
removal of hypertension in the biliary tract and pancreatic ducts;
elimination of peritonitis;
relief of retroperitoneal phlegmon (often enzymatic);
blockade of the root of the mesentery, parapancreatic and retroduodenal tissue.

Operations with classical open access for edematous pancreatitis should be considered a mistake due to the inevitable infection of the gland.
Modern technology - careful sparing necrectomy (mainly digitally) with intraoperative and staged lavage, followed by open management and multiple sanitation. The volume of the washing liquid in the first days after the operation is 24-48 liters. The criterion for the effectiveness of washing can be the presence and level of enzymes and microbiological analysis of the washing liquid.
Operation progress:

upper median laparotomy;
aspiration of peritoneal effusion;
examination of the omentum (purulent omentitis), mesocolon, mesentery of the small intestine, gallbladder, choledochus, duodenum;
wide dissection of the gastrocolic ligament;
wide opening of the omental bag (mobilization of the splenic angle of the colon;
with pronounced parapancreatic changes, the retroperitoneal space is widely opened by dissecting the parietal peritoneum along the perimeter of the pancreas, as well as along the outer edge of the duodenum (according to Kocher), the ascending and descending sections of the colon;
parapancreatic injection (novocaine 1/4% - up to 200 ml + counterkal 20-40 thousand units + penicillin 2 million units + hydrocortisone 125 mg);
omentopancreatopexy;
drainage of the stuffing bag through the left hypochondrium;
cholecystectomy with choledochostomy (according to Pikovsky) for acute and chronic calculous cholecystitis or cholecystostomy;
sequestrectomy, necrectomy (not earlier than 10 days from onset) or distal resection of the pancreas with splenectomy (3-5 days from onset with damage to the tail, when there is a border, thrombosis of the veins of the spleen, infarction of the spleen);
flow lavage of the stuffing bag 2-3 liters with outflow of dialysate through the lumbar incision;
drainage of flanks and small pelvis;
drainage of the retroperitoneal space from the lumbar region;
duodenpancreatsplenectomy with necrosis of the duodenum.

The modern version is the closure of the abdominal cavity with retroperitoneal drainage with tampons for 48 hours. Subsequent change to drains. The average duration of retroperitoneal lavage is 22 days.
Interventions more than 10 days from the beginning (including repeated ones). The goal is the timely removal of dead tissues of the pancreas and retroperitoneal tissue. There may be several interventions, since necrotization in different areas varies in time and necrectomy at one time is often not successful. Indications for repetition of interventions:
1) clinic of abscessing pancreas (increase in intoxication syndrome, despite detoxification);
2) arrosive bleeding;
3) clinic of ongoing peritonitis.
Improvements in minimally invasive surgical techniques in recent years have brought forward an alternative strategy, providing a return to the idea of early intervention. The latter has the grounds that early relief of the focus of intoxication directly in the gland, removal of enzymatic effusion from the peritoneal cavity and retroperitoneal space, organization of closed drainage with minimal surgical trauma, and visual control of the pancreas with the possibility of repetition are logical and effective. Its implementation became possible with the use of laparoscopic (V. S. Savelyev et al. 1992; V. P. Sazhin et al., 1999) and mini-accessible - interventions for sanitation and drainage of the lesser omentum cavity, abdominal cavity and retroperitoneal space (M. And Prudkov et al., 1999; V. A. Kozlov et al., 1999).
The prospect of surgical treatment of pancreatic necrosis today is seen in the combination of intensive treatment, starting from the first minutes of the patient's visit to the clinic, and the use of minimally invasive surgical technologies to organize effective drainage of the destruction zone and purulent inflammation of the gland, abdominal cavity and retroperitoneal space. Useful repeated sanitation of the abdominal cavity and retroperitoneal space. The latter is the testing ground on which the purulent-necrotic drama is played out, since the pancreas - it is a retroperitoneal organ.
LATE OPERATIONS are performed when acute inflammatory processes subside (not earlier than 2-3 weeks after the onset of the disease): with subacute pseudocysts, cicatricial strictures of the pancreatic duct.
False cysts, as a result of the development of pancreatitis, may disappear on their own. Cysts can first be punctured under ultrasound or CT. If, after multiple punctures, the cyst is filled to a value of more than 5-6 cm, catheterization is indicated under ultrasound guidance. If unsuccessful, surgery.

Therapeutic tactics in acute pancreatitis.

Patients with suspected acute pancreatitis should be on an emergency basis hospitalized to the surgical hospital. Patients with a destructive form of acute pancreatitis need treatment in the intensive care unit.

The main objectives of the treatment of acute pancreatitis are:

1. Suppression of autoenzymatic aggression and inflammation in the pancreatic tissue.

2. Prevention and treatment of pancreatogenic toxemia, complications and disorders of all types of metabolism.

3. Prevention and treatment of peritonitis and parapancreatitis.

4. Prevention and treatment of postnecrotic complications.

The main directions and methods of complex therapy for destructive pancreatitis include:

1. Intensive corrective therapy (maintaining the optimal level of oxygen delivery with the help of infusion, cardiotonic and respiratory therapy).

2. Methods of extracorporeal detoxification (hemo- and lymphosorption, hemo- and plasma filtration, plasmapheresis) and enterosorption. However, at present, the algorithm for extracorporeal and enteral detoxification has not been finally developed, which requires further evidence-based research.

3. Blockade of the secretory function of the pancreas and mediatosis. For this purpose, it is first of all advisable to use somatostatin/octreotide preparations. In the absence of these agents, it is possible to use antimetabolites (5-fluorouracil). Lack of evidence for effectiveness protease inhibitors in pancreatic necrosis does not allow us to recommend their further clinical use at the present time.

4. Antibacterial prophylaxis and therapy.

The data of microbiological studies are the basis for the choice of antibacterial drugs for pancreatic necrosis, the spectrum of action of which should cover gram-negative and gram-positive aerobic and anaerobic microorganisms - the causative agents of pancreatogenic infection. This corresponds to the choice of an empirical regimen of antibacterial prophylaxis and therapy for pancreatic necrosis.

The most important determinant of the effectiveness of antibiotics is their ability to selectively penetrate into the tissues of the pancreas through the hemato-pancreatic barrier.

Depending on the different penetrating ability in the pancreatic tissue, three groups of antibacterial drugs are distinguished:

GroupI. The concentration of aminoglycosides, aminopenicillins and first-generation cephalosporins after intravenous administration does not reach the minimum inhibitory concentration (MIC) in the tissues of the pancreas for most bacteria.

GroupII represented by antibacterial drugs, the concentration of which, after intravenous administration, exceeds the MIC, which is effective in suppressing the vital activity of some, but not all, microorganisms frequently encountered in pancreatic infection - protected broad-spectrum penicillins: piperacillin / tazobactam and ticarcillin / clavulanate; III generation cephalosporins: cefoperazone and cefotaxime; IV generation cephalosporins (cefepime).

IIIgroup are fluoroquinolones (piprofloxacin, ofloxacin, and especially pefloxacin) and carbapenems (meropenem, imipenem / cilastatin), which create maximum concentrations in pancreatic tissues, exceeding the MIC, for most infectious agents in pancreatic necrosis. Metronidazole also reaches bactericidal concentration in the tissues of the pancreas for anaerobic bacteria, so it can be used as a component of combined antibiotic therapy (cephalosporin + metronidazole).

With edematous pancreatitis, antibacterial prophylaxis is not indicated.

The diagnosis of pancreatic necrosis is an absolute indication for the appointment of antibacterial drugs (groups II and III), which create an effective bactericidal concentration in the affected area with a spectrum of action relative to all etiologically significant pathogens.

It is extremely difficult to differentiate immediately the purpose of prescribing antibiotics for pancreatic necrosis - preventive or therapeutic - in many cases, given the high risk of infection of the necrotic pancreas and the complexity of its documentation by clinical, laboratory and instrumental methods in real time.

The development of often fatal sepsis in pancreatic necrosis requires the immediate appointment of antibacterial agents with maximum effect and minimal side effects.

The efficiency factor should dominate in relation to the factor

cost.

The drugs of choice for both prophylactic and therapeutic use are:

carbapenems,

Fluoroquinolones (especially pefloxacin) + metronidazole,

Cephalosporins III-GU generation + metronidazole,

Protected penicillins (piperacillin/tazobactam, ticarcillin/clavulanate).

Taking into account the role of intestinal translocation of bacteria in the pathogenesis of infectious complications of pancreatic necrosis, it is advisable to include a regimen of selective intestinal decontamination in the antimicrobial therapy regimen (in particular, oral administration of fluoroquinolones (pefloxacin, ciprofloxacin)).

Pancreatic necrosis is a risk factor for the development of fungal superinfection, which determines the advisability of including antifungal agents (fluconazole) in the treatment program for patients with pancreatic necrosis.

The duration of antibiotic therapy for pancreatic necrosis is determined by the timing of the complete regression of the symptoms of a systemic inflammatory response.

Considering the dynamics of the pathological process in pancreatic necrosis from sterile to infected and the often multi-stage nature of surgical interventions for effective antibiotic therapy, it is necessary to provide for the possibility of changing several regimens.

5. Nutritional support for acute pancreatitis

Nutritional support is indicated for the severity of the patient's condition with pancreatitis on the Ranson scale > 2 points, on the APACHE II scale > 9 points, when verifying the clinical diagnosis of pancreatic necrosis and / or the presence of multiple organ failure. When verifying the edematous form of pancreatitis and the presence of positive dynamics in its complex treatment within 48-72 hours, natural nutrition is shown after 5-7 days.

The effectiveness of total parenteral nutrition in pancreatic necrosis is questionable. This is explained by the following negative effects of total parenteral nutrition: increased enterogenic translocation of bacteria, development of angiogenic infection, immunosuppression, and high cost of the method. In this regard, to date, it is more appropriate and effective for pancreatic necrosis to carry out enteral nutrition in the early stages of the disease through a nasojejunal probe installed distally to the ligament of Treitz endoscopically or during surgery. In the case of the development of tolerance to enteral nutrition (increased levels of amylase and lipasemy, persistent intestinal paresis, diarrhea, aspiration), total parenteral nutrition is indicated in patients with pancreatic necrosis.

Surgical treatment of pancreatic necrosis.

With regard to the principles of differentiated surgical treatment of pancreatic necrosis and its septic complications, there are fundamental differences. They relate to the optimal timing and modes of surgical intervention, approaches, types of operations on the pancreas, biliary system, methods of drainage operations of the retroperitoneal space and abdominal cavity.

The indication for surgery for pancreatic necrosis is:

Infected pancreatic necrosis and/or pancreatogenic abscess, septic phlegmon of retroperitoneal tissue, purulent peritonitis, regardless of the degree of multiple organ disorders.

Persistent or progressive multiple organ failure, regardless of the fact of infection, despite complex intensive conservative therapy for 1-3 days, indicating extensive necrosis of the pancreas and retroperitoneal tissue or a high risk of pancreatogenic infection.

Surgical treatment is indicated for patients in whom, according to CT angiography, the scale of necrosis exceeds 50% of the pancreatic parenchyma and/or the spread of necrosis to the retroperitoneal space is diagnosed, which corresponds to a high risk of infection and fatal systemic complications.

Pancreatogenic (enzymatic, abacterial) peritonitis is an indication for laparoscopic debridement and drainage of the abdominal cavity.

The fact of infection of necrotic tissues is an important but not the only indication for surgery, especially in the early stages of the disease.

An important role in the objectification of indications for surgery is played by the use of integral scales for assessing the severity of the patient's condition with destructive pancreatitis.

Methods of surgical treatment vary widely, which is determined by the dynamics of the pathomorphological process in the pancreas, retroperitoneal tissue and abdominal cavity. The technical solution of the necrossequestrectomy stage is the same, therefore, special importance must be attached to the choice of the method of drainage operations in the retroperitoneal space, since the drainage method chosen already at the first operation significantly determines the choice of the operational tactics mode.

There are currently three main drainage operations method with pancreatic necrosis, which provide different conditions for drainage of the retroperitoneal space and abdominal cavity, depending on the extent and nature of the lesion of the pancreas, retroperitoneal tissue and abdominal cavity.

The proposed methods of drainage operations include certain technical methods of external drainage of various sections of the retroperitoneal tissue and the abdominal cavity, which necessarily involves the choice of certain tactical modes of repeated interventions:

Programmed revisions and sanitation of all zones of necrotic destruction and infection in various parts of the retroperitoneal space ("according to the program")

Urgent and forced re-interventions ("on demand") due to existing and / or developed complications (continued sequestration, inadequate drainage, bleeding, etc.) in the dynamics of pathomorphological transformation of necrosis / infection zones in the retroperitoneal space and abdominal cavity.

Methods of drainage operations of the retroperitoneal space in pancreatic necrosis are classified as follows:

"Closed"

"Open"

"Half Open"

I. "Closed" method of drainage operations includes active drainage of the retroperitoneal tissue and the abdominal cavity under conditions of the anatomical integrity of the cavity of the omental sac and the abdominal cavity. This is achieved by implanting multi-channel, silicone drainage structures for the introduction of antiseptic solutions fractionally or incandescently into the focus of destruction (infection) with constant active aspiration. The "closed" method of drainage involves the implementation of repeated interventions only "on demand". Control over the focus of destruction/infection and the function of drainage is carried out according to the results of ultrasound, CT, video-optical equipment, fistulography.

It is advisable to use the methods of laparoscopic "closed" bursoomentoscopy and sanitation of the omental bag. Using laparoscopic technique, laparoscopy, decompression of the gallbladder, sanitation and drainage of the abdominal cavity are performed, and then using specially designed tools from the mini-laparotomic access, the pancreas is examined, necrosequestrectomy is carried out in full and pancreato-mentobursostomy is formed. Starting from 3-5 days after the operation, staged rehabilitation is performed with an interval of 1-3 days. In the interoperative period, lavage of the cavity of the stuffing bag is carried out.

Apply methods of endoscopic drainage and rehabilitation of the retroperitoneal space through the lumbar extraperitoneal access. Minimally invasive surgical methods of percutaneous puncture drainage of the parapancreatic zone and other parts of the retroperitoneal tissue, the gallbladder under ultrasound and CT control are becoming more widespread. Minimally invasive interventions are easy to perform, less traumatic and effective if there is a reasonable indication and adherence to the methodology. With the ineffectiveness of the above drainage methods for pancreatic necrosis, laparotomy is indicated.

The main indications for the "open" and "semi-open" method of drainage of the retroperitoneal space are:

Large-scale forms of pancreatic necrosis in combination with damage to the retroperitoneal tissue;

Infected pancreatic necrosis and pancreatogenic abscess in combination with large-focal forms of infected pancreatic necrosis;

Relaparotomy after ineffective "closed" or "semi-open" drainage methods.

II."Open" method of drainage operations in case of pancreatic necrosis, it involves the implementation of programmable revisions and sanitation of the retroperitoneal space and has two main options for technical solutions, determined by the predominant scale and nature of the lesion of the retroperitoneal space and abdominal cavity. This method includes:

Pancreatomentobursostomy + lumbotomy (Fig. 13, 14);

Pancreatomentobursostomy + laparostomy.

The indication for pancreato-mentobursostomy + lumbotomy is an infected and sterile widespread pancreatic necrosis in combination with a lesion of the parapancreatic, paracolic and pelvic tissue. Pancreatomentobursostomy is formed by suturing fragments of the gastrocolic ligament to the parietal peritoneum in the upper third of the laparotomy wound by the type of marsupialization and draining all areas of necrosis/infection with Penrose drains in combination with multi-lumen tubular structures.

Rice. 13. Drainage of the omental bag through omentopancreatobursostomy.

Rice. 14. Drainage of the parapancreatic spaces (B) through the lumbar access (A).

The Penroz drainage, referred to in the domestic literature as a "rubber-gauze swab", is impregnated with antiseptics and water-soluble ointments ("Levosin", "Levomekol"). Such a surgical tactic provides subsequent unhindered access to these areas and the performance of adequate necrosequestrectomy in a programmed mode with an interval of 48-72 hours. Staged replacement of Penrose drains allows eliminating their significant drawback associated with short-term drainage function and exogenous (re)infection. As the retroperitoneal tissue is cleared of necrosis and detritus, with the appearance of granulation tissue, a transition to a "closed" drainage method is shown.

With the development of widespread purulent peritonitis and the extreme severity of the patient's condition with widespread and / or infected pancreatic necrosis (severe sepsis, septic shock, APACHE II > 13 points, Ranson > 5 points), laparostomy is indicated. carrying out programmed sanitation of retroperitoneal tissue and abdominal cavity in 12-48 hours.

III."Semi-open" drainage method in case of pancreatic necrosis, it involves the installation of ribbed multi-lumen drainage structures in combination with Penrose drainage. Under these conditions, the laparotomic wound is sutured in layers, and the combined drainage design is removed through a wide counter-opening in the lumbosacral abdomen (lumbotomy). Such operations are called "traditional", when the change of drainage structures, as a rule, is delayed by 5-7 days. With large-scale necrosis and sequestration, complex topography of the formed channels, conditions are often created for inadequate drainage of foci of necrosis / infection, and repeated operations in 30-40% of patients are performed with a delay in time in the "on demand" mode. Therefore, to prevent these complications, the potential of drainage of retroperitoneal tissue can be increased if adequate replacement of drains is carried out in the "according to the program" mode, i.e. at least after 48-72 hours, impregnate the Penrose drainage with antiseptic solutions, combine with sorbents or ointments on a water-soluble basis ("Levosin" / "Levomekol"). The implementation of adequate surgical tactics in the conditions of the "semi-open" method of external drainage in pancreatic necrosis is achieved by performing only programmed surgical interventions. The “on demand” mode in this situation should be recognized as ineffective, having neither theoretical nor practical justification.

It should be especially noted that the presented methods of "closed" and "open" drainage of retroperitoneal tissue are not competitive, since, subject to the methodology and reasonable indications, they are designed to provide adequate and complete sanitation of all zones of necrotic destruction and pancreatogenic infection.

In conclusion, it should be noted , that further progress in improving the results of complex treatment of destructive pancreatitis is determined by the joint work of the surgical teams of the Russian Federation.

Surgery for acute pancreatitis is a necessary emergency measure if there is a widespread lesion of the pancreas or severe complications of the disease. Before performing a surgical intervention, it is necessary to determine the extent of the organ damage. The degree of pathological changes in the tissues of the pancreas plays a decisive role.

Indications for intervention

The expediency of the operation is determined by the doctor, but the main indication is pancreatic tissue necrosis, the spread of which can lead to the death of the patient. Surgical treatment is also used in the following cases:

if a purulent abscess of the organ progresses;
with pancreatitis, which is accompanied by the formation of a cyst;
if infection of the gland provokes the occurrence of peritonitis;
with complete tissue death and loss of organ functions.

With the help of the operation, it is possible to prevent dangerous consequences and save the life of the patient.

Operation types

Etiopathogenetic approaches help the doctor develop a competent algorithm of actions when there is a spreading lesion of the pancreas.

2010 03 12 Surgeon about pancreatitis

OPERATIONS ON THE PANCREAS

Hospital surgery distinguishes several methods of surgical intervention for. Frequently used methods:

Distal resection. Represents a partial deletion. In this case, only the body and tail of the organ are excised. This type of intervention is necessary in cases where infection has affected only some of the tissues in pancreatitis.
subtotal removal. With such an operative intervention, not only the body and tail are resected, but also some part of the head. Save only a small area, which is located in close proximity to the duodenum.
Necrosequestrectomy. This type of operation in acute pancreatitis is performed only under careful ultrasound control. Produce a puncture of the liquid formations of the pancreas and with the help of drains carry out the outflow of the contents.

Access to the focus is possible using laparotomic and endoscopic methods. The second approach is less invasive than the first.

Nutrition after surgery

During the postoperative therapy of pancreatitis, a cardinal revision of the diet is important. In the first 2 days, any food is completely excluded. Then, for 7-10 days, a special menu is provided with the inclusion in the diet of weakly brewed tea, pureed vegetable soups, as well as dairy-free cereals, steamed omelets, crackers and a small amount of cottage cheese.

Compensation for the lack of enzymes is carried out with the help of drugs that complement each meal. A standard diet is used for pancreatitis after a recovery period.

Possible consequences

The consequences after surgery for pancreatitis are not uncommon, especially when an infected pseudocyst is present.

With a lack of an enzymatic component, a severe violation of the digestive function occurs. In details .

Any error in the diet can provoke the death of the remaining tissue.

Postoperative complications

The most common complications after surgery for acute pancreatitis:

Purulent peritonitis. Occurs when cells become infected. The spread of purulent-necrotic masses in the retroperitoneal space can lead to death. Such a consequence is possible with the wrong approach to laparotomy.
Exacerbation of Hirschsprung's disease. With a long chronic course of pathologies of the large intestine, excision of some fragments of the pancreas leads to persistent constipation.
Pancreatic shock. An acute pathological process, accompanied by exposure to endotoxins, which lead to necrosis of the remaining part of the organ. Provokes minimization of microcirculatory properties of blood. At the same time, blood pressure drops. With the aseptic nature of pancreatic necrosis, endotoxins are the gland's own enzymes, which aggressively affect the organ, provoking the formation of a focus of inflammation.