PATHOGENETIC RATIONALE FOR THE VOLUME OF OPERATION IN PATIENTS DEPENDING ON THE CATEGORY OF NECROTIC PANCREATITIS

Over the past 20 years, the treatment of NP has changed significantly away from open surgery to minimally invasive methods, but mortality remains high and ranges from 39 to 90 % depending on the complications that develoр.

Purpose of the study: to justify the choice of the extent of surgery in patients depending on the category of necrotizing pancreatitis.

Material and methods. An analysis of the treatment of 88 patients with severe acute pancreatitis was carried out. There were 49 men (55.7 %), 39 women (44.3 %). The average age was 57.5 years. Of the total number of patients, 45 (51.1 %) had biliary pancreatitis, 31 (35.2 %) had nutritional pancreatitis, 9 (10.2 %) had posttraumatic pancreatitis, 3 (3.4 %) had postpartum pancreatitis. When treating patients, we followed a tactic based on the category of necrotizing pancreatitis, which can be parenchymal, peripancreatic, combined, sterile and infected.

Results and discussion. At the stage of pancreatogenic toxemia, 36 (40.9 %) patients were operated on according to absolute indications, including 3 women with postpartum pancreatitis, 13 (36.1 %) patients died. At the stage of pancreatogenic infiltrate, 3 (3.4 %) patients were forced to undergo surgery for the same indications and to the same extent, 1 (33.3 %) died. At the stage of purulent complications, 49 (55.7 %) patients were operated on, 20 (40.8 %) died. 30(61.2 %) patients had infected parenchymal pancreatitis, 6(20 %) died. In 19 (38.8 %) patients with peripancreatic and combined NP with the spread of phlegmon to the retroperitoneal space along the right and left lateral canals and to the mesentery of the colon, 14 (73.3 %) died. In 9 NP patients with widespread phlegmon, 8 (88.9 %) died during partial resection of the colon and proximal colostomy; out of 10, 6 (60 %) died during subtotal colectomy with ileostomy.In case of infected peripancreatic and combined necrotizing pancreatitis with the spread of phlegmon to the mesocolon, subtotal colectomy with end colostomy allows for better results than with resection of a section of the colon with end colostomy, thus reducing mortality in patients with end-stage disease.

1. Banks P. A., Freeman M. L. Practice parameters committee of the American college of gastroenterology. Practice guidelines in acute pancreatitis, Am. J. Gastroenterol. 101 (10) (2006 Oct) 2379-2400.

2. Petrov M. S., S. Shanbhag S., Chakraborty M., Phillips A. R., Windsor J. A., Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis, Gastroenterology 139 (3) (2010 Sep) 813-820, http://dx.doi.org/10.1053/j.gastro.2010.06.010. Epub 2010 Jun 9. Review.

3. Schmidt P. N., Roug S., Hansen E. F., Knudsen J. D., Novovic S., Spectrum of microorganisms in infected walled-off pancreatic necrosis e impact on organ failure and mortality, Pancreatology 14 (6) (2014 Nov-Dec) 444-449.

4. Shyu J. Y., Sainani N. I., Sahni V. A., Chick J. F., Chauhan N. R., Conwell D. L., Clancy T. E., Banks P. A., Silverman S. G. Necrotizing pancreatitis: diagnosis, imaging, and intervention, Radiographics 34 (5) (2014 Sep-Oct) 1218-1239.

5. Triantopoulou C., Delis S., Dervenis C. Imaging evaluation of post-pancreatitis infection, Infect. Disord. Drug Targets 10 (1) (2010 Feb) 15e20. Review.

6. Sharma P. K., Madan K., Garg P. K. Hemorrhage in acute pancreatitis: should gastrointestinal bleeding be considered an organ failure? Pancreas 36 (2) (2008 Mar) 141-145.

7. Andersson E., Ansari D., Andersson R. Major haemorrhagic complications of acute pancreatitis, Br. J. Surg. 97 (9) (2010 Sep) 1379-1384.

8. Werner J., Feuerbach S., Uhl W., Büchler M. W. Management of acute pancreatitis: from surgery to interventional intensive care. Gut. 2005 Mar;54(3):426-36. doi: 10.1136/gut.2003.035907. PMID: 15710995; PMCID: PMC1774421.

9. Wittau M., Scheele J., Gölz I, Henne-Bruns D., Isenmann R. Changing role of surgery in necrotizing pancreatitis: a single-center experience. Hepatogastroenterology. 2010 SepOct;57(102-103): 1300-4. PMID: 21410076.

10. Mier J., León E. L, Castillo A., Robledo F., Blanco R. Early versus late necrosectomy in severe necrotizing pancreatitis. Am J Surg. 1997 Feb;173(2):71-5. doi: 10.1016/S0002-9610(96)00425-4. PMID: 9074366.

11. Raraty M. G., Halloran C. M., Dodd S., Ghaneh P., Connor S., Evans J., Sutton R., Neoptolemos J. P. Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach. Ann Surg. 2010 May;251(5):787-93. doi: 10.1097/SLA.0b013e3181d96c53. PMID: 20395850.

12. Bakker O. J., van Santvoort H. C., van Brunschot S., Geskus R. B., Besselink M. G., Bollen T. L., van Eijck C. H., Fockens P., Hazebroek E. J., Nijmeijer R. M., Poley J. W., van Ramshorst B., Vleggaar F. P., Boermeester M. A., Gooszen H. G., Weusten B. L., Timmer R.; Dutch Pancreatitis Study GrouP. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA. 2012 Mar 14;307(10):1053-61. doi: 10.1001/jama.2012.276. PMID: 22416101.

13. Kaprin I. A., El‘doradova E. E., Glabaj V. P. Hirurgicheskoe lechenie i oslozhneniya operacij pri ostrom pankreatite tyazhelogo techeniya. Issledovaniya i praktika v medicine. 2018;5(4):72-81.

14. L. W. Traverso, R. A. Kozarek, Pancreatic necrosectomy: definitions and technique, J. Gastrointest. Surg. 9 (3) (2005 Mar) 436-439.

15. M. G. Raraty, C. M. Halloran, S. Dodd, P. Ghaneh, S. Connor, J. Evans, R. Sutton, J. P. Neoptolemos, Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach, Ann. Surg. 251 (5) (2010 May) 787-793.

16. M. L. Freeman, J. Werner, H. C. van Santvoort, T. H. Baron, M. G. Besselink,

17. J. A. Windsor, K. D. Horvath, E. vanSonnenberg, T. L. Bollen, S. S. Vege, International multidisciplinary panel of speakers and moderators. Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference, Pancreas 41 (8) (2012 Nov) 1176-1194.

18. Bugiantella W., Rondelli F., Boni M., Stella P., Polistena A., Sanguinetti A., Avenia N. Necrotizing pancreatitis: A review of the interventions. Int J Surg. 2016 Apr;28 Suppl 1:S163-71. doi: 10.1016/j.ijsu.2015.12.038. Epub 2015 Dec 18. PMID: 26708848.

19. M. G. Besselink, T. J. Verwer, E. J. Schoenmaeckers, E. Buskens, B. U. Ridwan, M. R. Visser, V. B. Nieuwenhuijs, H. G. Gooszen, Timing of surgical intervention in necrotizing pancreatitis, Arch. Surg. 142 (12) (2007 Dec) 1194e1201.

20. Zatevahin I. I. Pankreonekroz: (diagnostika, prognozirovanie i lechenie) : [monografiya] / Zatevahin I. I., Ciciashvili M. S. H., Budurova M. D., Altunin A. I. – Moskva : [b. i.], 2007. – 223 s. : il., tabl.; 22 sm.; ISBN 978-5-7809-0064-1

21. Patent RU № 2320278 S1 MPK A61V 17/00 (2006.01) Rossijskaya Federaciya Sposob formirovaniya ileostomy [tekst] / Belokonev V. I., ZHitlov A. G. – № 2006122700/14, zayavl. 26.06.2006, opubl. 27.07.2008 Byul. № 9.

22. Avizhec YU. N., Majorov V. M., Dunbarov Z. A., Adamovich D. M., Lin V. V., Podol‘skij A. L. Rasprostranennyj fermentativnyj parapankreatit kak morfologicheskij kompanent pankreonekroza po dannym autopsii / Aktual’nye voprosy hirurgii. Materialy XV s’ezda hirurgov Respubliki Belarus’. – Brest «Al‘ternativa», 2014: 2016-2017.

23. Stanovenko V. V., Podolinskij S. G., Martov V. YU., Podolinskij YU. S., Kupchenko A. M. Lechenie destruktivnogo pankreatita v faze gnojno-septicheskih oslozhnenij / Aktual‘nye voprosy hirurgii. Materialy XV s»ezda hirurgov Respubliki Belarus‘. – Brest «Al‘ternativa», 2014: 282.

24. Grigor’ev E. G., Sadah M. V., Bojko T. N., Kaporskij V. I., Gel‘fand S. A., Dvoryanov YA. A., Kalinichenko A. V., Kolmakov S. A. Nekroticheskij mezoi parakolit v terminal‘noj stadii inficirovannogo pankreonekroza. Infekcii v hirurgii. 2008;(4):38-42.