Stage approach in surgical treatment of acute pancreatitis.

Abstract

The article deals with the problem of diagnosis and treatment of acute pancreatitis, which remains one of the most common surgical diseases of the abdominal cavity with a high risk of complications, the mortality rate of which reaches 5.5%, and in acute pancreatitis it varies within 40-70%. The purpose of this work is to improve the results of surgical treatment of patients with acute pancreatitis. The results of treatment of 112 patients with acute pancreatitis, who were hospitalized in the procedure of ambulance in the Department of Surgery No. 2 of the Bogomolets National Medical University in 2009-2019 period are analyzed. Severe disease course was observed in 83 (74.1%) patients, moderate – in 29 (25.9%) patients. In the early phase of the disease, endoscopic operations were performed in 44 (39.3%) patients, and laparotomy was performed in 12 (10.7%) patients with advanced purulent peritonitis. In the late phase 15 (13.4%) patients underwent laparotomy, necrsequestrectomy, abdominization of the pancreas, drainage of the abdominal cavity and retroperitoneal space, 36 (32.1%) patients were treated with ultrasound-guided puncture treatments. In the case of progression of the disease and ineffective drainage under ultrasound control, 5 (4.5%) patients were treated with retroperitoneoscopically assisted necrsequestrectomy, combined laparoscopic and retroperitoneoscopically assisted necrsequestrectomy was performed in 3 (2.7%) patients, and in 2 (1.8%) patients – open laparotomy, abdominization, necrsequestrectomy, drainage of the abdominal cavity and retroperitoneal space. The surgical intervention in the late phase of the disease was 21±4.2 days from the onset of the disease. A stage approach in the treatment of acute pancreatitis was applied to 80 (71.4%) patients in the main group. The comparison group consisted of 32 (28.6%) patients who underwent laparotomy and laparoscopic interventions in the early and late periods of the disease without prior use of endoscopic interventions or drainage operations under ultrasound control. In the main group the length of stay in the hospital was 21,3±4,2 days, in the comparison group – 48.2±5.3 days respectively. In 42 (95.5%) patients who underwent endoscopic surgery, a positive clinical effect, rapid regression of symptoms of acute pancreatitis was achieved. In two (4.5%) patients who underwent endoscopic interventions, the disease progressed with the development of an abscess of the omental pouch, they underwent puncture drainage under ultrasound control. When using puncture drainage operations under ultrasound control in 26 (72.2%) patients, a positive result was achieved, the abscess cavity decreased by 63±6.2% within 7 days. In 10 (27.8%) patients due to the progression of the disease, the following stage of treatment was performed: retroperitoneoscopically assisted necrsequestrectomy (5 (13.9%) patients), combined laparoscopic and retroperitoneoscopically assisted necrsequestrectomy (3 (8.3%) patients), and open laparotomy, abdominization, necrosequestrectomy, drainage of the abdominal cavity and retroperitoneal space (2 (5.6%) patients). Complications in the main group developed in two (2.5%) patients, the mortality rate was 2.5% (two patients). In the comparison group, complications developed in 8 (25%) patients, the mortality rate was 18.8% (6 patients). The use of minimally invasive endoscopic interventions, draining surgeries under ultrasound control followed by combined laparoscopic and retroperitoneoscopically assisted necrsequestrectomy or open laparotomy reduces the length of hospital stay of patients from 48.2±5.3 days (comparison group) to 21.3±4.2 days (main group) (p<0.0001, t=28.346) and the number of complications by 22.5% (p=0.0002, χ²=14.104, CI 9.2333-39.7022). The use of a stage approach in the surgical treatment of acute pancreatitis reduces mortality by 16.3% (p=0.0026, χ² =9.058, CI 4.6571-32.9639).