Severe acute pancreatitis: risk factors of adverse outcomes and their correction

Abstract

Aim. To analyze management of severe acute destructive pancreatitis and to determine the main tactical, anatomical and pathophysiological factors determining risks of adverse outcomes. Material and methods. 3581 patients with acute pancreatitis were enrolled. Retrospectively, 239 patients were assigned to severe pancreatic necrosis; invasive surgical techniques were applied in 210 cases. Twenty-nine patients with pancreatic necrosis underwent endoscopic papillosphincterotomy with main pancreatic duct stenting. Results. Overall mortality in patients with severe pancreatic necrosis was 32.3%, in case of minimally invasive techniques – 29.6%, conventional approach – 34.1%. There were similar outcomes regardless surgical technique in patients with pancreatic necrosis (p > 0.05), although introduction of main statements of national recommendations for treatment of pancreatic necrosis (regardless severity) reduced mortality from 25.4% to 9.5% (p < 0.001). Advanced parapancreatitis was accompanied by mortality near 36.5%. Stenting of main pancreatic duct was followed by death of 3 out of 29 patients with pancreatic necrosis (10.3%). Conclusion. Indications and choice of surgical approach according to national recommendations are not accompanied by improved postoperative mortality in patients with severe pancreatic necrosis and multiple organ failure. However, according to analysis on the whole, there is reduced postoperative mortality regardless severity of disease if these recommendations are sustained. Widespread involvement of retroperitoneal structures is adverse prognostic factor. Early endoscopic intraduodenal drainage in effective to prevent parapancreatic tissues.

Use of Stents in Correction of Outflow Disorders from the Main Pancreatic Duct in Patients with Pancreonecrosis

“…The analysis of modern literature has shown that in different periods of time such methods of improving the outflow of pancreatic secretions in acute pancreatitis as EPST, removal of the pinched stone of the BDS ampoule, dissection of the cicatricial stricture of the LPD ampoule, active aspiration of pancreatic secretions, interventions for tumor strictures in the LPD area, stenting of the main pancreatic duct with short plastic stents, nasopancreatic drainage, as well as the use of intraductal administration of various drugs were used [7][8][9]. But these methods have not been widely used in practice until today [4,7].…”

“…We proceeded from the position that the restoration of the outflow from the preserved part of the pancreas by EIDC is an effective prevention of the progression of the pathological process in the gland itself and its transition to parapancreatic fiber. The possible prospects of this direction in the treatment of severe PN is confirmed by the fact that the effectiveness of stenting of the Virsung duct as a measure of prevention of postmanipulatory pancreatitis is proven [4,7].…”

“…In the structure of patients with acute abdominal surgical pathology, the proportion of patients with acute pancreatitis (AP) is currently 10-12% [1,2]. The overall mortality rate in patients with acute pancreatitis has not changed significantly over the past few decades and ranges from 5-7%, while the mortality rate among patients with pancreatic necrosis or pancreonecrosis (PN) without differentiation of the form reaches 23-26% [1][2][3][4][5][6]. From our point of view, a possible reserve for a reliable improvement in the immediate results of treatment of patients with PN is the search for diagnostic methods for early objective diagnosis of anatomical and morphological destructive changes of the pancreas and parapancreatic tissues, followed by an objective assessment of the configuration of necrosis, and based on this -in determining the optimal invasive techniques for preventing the progression of pancreatic necrosis and destructive parapancreatitis [3,5].…”

Modern Aspects of Surgical Treatment of Pancreonecrosis

“…Пoкaзaниями к хиpуpгичecкoму вмешательству в нaчaльнoй фaзe зaбoлeвaния являютcя: острый деструктивный холецистит при остром панкреатите (ОП), а также стерильный ПН с явлениями прогрессирующего синдрома полиорганной недостаточности (ПОН), рефрактерного к адекватной интенсивной комплексной консервативной терапии, что имеет место, как правило, при отграниченных жидкостных скоплениях или при «ферментативном» перитоните. При этом основными технологическими принципами операции являются эвакуация жидкости, обеспечение полноценного дренирования [5,7,8].…”

“…Использование этих методов нередко дает возможность выполнить адекватный объем необходимой хирургической коррекции ПН с наименьшим риском экзогенного инфицирования [8,11]. У больных со стерильным ПН с наличием свободной жидкости в брюшной полости наиболее оптимальным хирургическим доступом является лечебно-диагностическая лапароскопия, а при обнаружении в брюшной полости и/или забрюшинном пространстве отграниченных скоплений жидкости (ОСЖ), не содержащих секвестров, -пункция и дренирование под контролем ультразвукового исследования (УЗИ) [7,9,12]…”