Ïå÷åíü è aeåë÷íûå ïóòè Цель. Определение оптимального способа и изучение результатов миниинвазивной билиарной декомпрессии при механической желтухе опухолевого генеза. Материал и методы. Билиарная декомпрессия выполнена 59 больным, рандомизированым на группы чрескожного дренирования (n = 33) и транспапиллярного стентирования (n = 26). Вторым этапом в проспективной группе больных (n = 159) применена приоритетная тактика транспапиллярной билиарной декомпрессии. Результаты. Транспапиллярное и (или) чрескожное дренирование желчных путей успешно осуществлено всем больным. Отмечена высокая эффективность купирования синдрома холестаза: уровень билирубина сыворотки крови снижался на 39,2, 53,9 и 77,0% на 3-и, 7-е и 14-е сутки после дренирования соответственно. Выявлена более низкая частота осложнений у больных с транспапиллярной декомпрессией желчных путей (7,7%) по сравнению с чрескожной (30,3%, p = 0,032), при равной клинической эффективности и летальности (p = 0,316). В проспективной группе из 159 больных транспапиллярное стентирование (63%) было неэффективным в 31 (29,9%) наблюдении, что потребовало дополнительного эндоскопического лечения либо чрескожной холангиостомии. Летальность составила 13,8% (n = 22). Заключение. Учитывая более низкую частоту осложнений при равной эффективности и летальности при механической желтухе опухолевого генеза, может быть рекомендовано эндоскопическое транспапиллярное стентирование. При невозможности его выполнения по техническим или анатомическим причинам следует выполнять чрескожное дренирование желчных путей с первичной или отсроченной реканализацией опухолевой стриктуры. Используемый алгоритм позволяет дифференцированно подходить к выбору метода билиарной декомпрессии и улучшить результаты лечения. Клю че вые сло ва: механическая желтуха, декомпрессия, транспапиллярное стентирование, чрескожная чреспеченочная холангиостомия.

Relevance. There is a discussion about the prevalence of early or late mortality and the main causes of death in different phases of acute pancreatitis. Analysis of mortality is important for the determination of ways to improve the results of treatment of pancreatic necrosis. Aim of the research is analysis of the structure, timing characteristics and causes of deaths in pancreatic necrosis, the effect of the configuration of parapancreatitis and surgical tactics on the outcome of the disease. Materials and methods. Retrospective single-center study of lethal outcomes in acute pancreatitis was performed, the structure of mortality, cases of discrepancies in diagnoses, the timing of the onset and causes of deaths of patients were studied. The lethal outcomes were compared in the operated patients, the frequency of the mesentery root involvement, the indications and the timing of the interventions were assessed. Results. The ratio of early and late mortality was 45,2% to 54,8%, respectively. The main causes of early mortality – endotoxin shock and multi-organ failure, late one – infectious complications. In 9,6% of the patients, the diagnosis was made only with an autopsy. The prognostic value of the SOFA and SAPS II scales is characterized as low. The tactics of surgical treatment has changed in favour of minimally invasive surgery. The average conversion time for ineffective percutaneous procedures was 21,4 days. The involvement of mesentery in parapancreatitis was often accompanied by a breakthrough of the abscess into the abdominal cavity. Conclusion. The surgical component of the reduction in mortality is the rejection of unreasonable surgical interventions, the earlier conversion to "traditional" operations in case of ineffective minimally invasive treatment and the allocation of "central" localization of parapancreatitis as a serious prognostic factor of the course of severe pancreatitis.

Aim of the study is to evaluate efficacy of different methods of minimally invasive treatment of pancreatic pseudocysts (PPC). Methods. A single center retrospective study of patients with pancreatic pseudocysts (n = 17): 90 males (76.9 %), 27 females (23.1 %) aged 25 to 72 years. The patients underwent external percutaneous drainage (group 1, n = 96) or internal drainage (group 2, n = 21). The diagnosis of pseudocysts included clinical, laboratory (biochemical and bacteriological) and special investigation methods: radiological, endoscopic, ultrasound examination of hepatobiliary zone, computer tomography. Results. Complications in the early postoperative period were observed in patients from both groups 1 and 2. They were related to inefficacy of cystodigestive anastomosis, which required percutaneous drainage in 2 cases (9.5 %), or to formation of pancreatic fistula. Lethal outcomes were not observed. Readmission to surgical department for removal of the drainage was required in 28 (23.9 %) patients from group 1. Internal drainage is considered more advantageous for PPC decompression compared to external one due to persistence of pancreatic fluid passage through gastrointestinal tract. External drainage is associated with frequent external pancreatic fistulae formation as well as prolonged hospital stay and treatment in an outpatient setting worsening the quality of life, but it is an intervention of choice in somatically severely ill patients, in fast growing cyst, imperfectly formed wall and threatening cyst rupture into abdominal cavity or abscess. These aspects prevent from refusal from external drainage for PPC treatment. Conclusion. When choosing the optimal time and type of surgical intervention in PPC, the surgeon should evaluate localization, sizes, maturation of PC wall and its relation to pancreatic duct, somatic state and patient’s individual features.

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