Postoperative pancreatitis is one of the most serious complications that occur after various surgeries on the abdominal organs. Its frequency varies from 0.36 to 17.2%, mortality reaches 50% V.I. Filin, 1982, V.V. Vinogradov, 1983, A.E. Lee and V.F. Tskhay, 1991, L.E. Hollander et al., 1977, with progressive forms - 60% A.F. Chernousoye and V.Yu. Mishin, 1985, SL. Kulošenkov et al., 1994, Baccini et al., 1980, and with destructive forms it ranges from 50 to 100% VA. Utkin et al., 1980, AB Lee and V.F. Tskhay, 1991.
Etiology and pathogenesis. Most often this complication occurs after surgery on the stomach (6.8-7.7% of cases), gallstones (0.2-4%), Vater papilla and RV (2.5-13.3)%), especially when technically difficult interventions on the stomach and duodenum, after surgery for a long-existing cholecystitis and choledocholithiasis.
The main cause of postoperative pancreatitis is trauma to the pancreas, which often becomes unavoidable, especially when the duodenal ulcers penetrate the gland or during the combined operation of resection of the pancreas body and tail due to germination of a stomach tumor in its tissue. The leading risk factor for the development of postoperative pancreatitis is the state of the parenchyma and the diameter of the ductal gland S.L. Shalimov et al., 1983. Postoperative pancreatitis develops if intervention is performed on the distal choledochus and is associated with an injury of the pancreas head BL. Polyansky et al., 1987. During surgical interventions on the organs of the periamular zone, as well as the pancreas, this complication is observed in 0.5-30% of the total number of operations of explosives. Vinogradov et al., 1972, AB Lee and V.F. Tskhay, 1991.
Among the causes of death, postoperative pancreatitis is the second after the failure of the sutures of the duodenal stump and anastomoses during gastrectomy and AF gastroectomy. Chernousoye and V.Yu. Mishin, 1985.
In the etiology plays a major role duodenostasis KD Toskin et al., 1975, impaired microcirculation and transcapillary metabolism V.I. Lupaltsev et al., 1981, autoimmune processes V.I. Owl, 1982, increased pressure in the bile and pancreatic ducts, RV injury.
Postoperative pancreatitis occurs more frequently on days 2–4 after operations and very rarely on days 1 and 9 of the day AF Chernousoye and V.Yu. Mishin, 1985, A.B. Lee and V.F. Tskhay, 1991. According to the mechanism of development, traumatic and non-traumatic postoperative pancreatitis are distinguished.
The injury of the parenchyma of the pancreas is applied during surgery or intraoperative examination, especially when removing the wedged stones of the distal part of the OGP, examination with a probe, and surgery on the papilla.
Marked CA. Kulechenkov et al., 1994, that for any type of pancreas injury, an OP of varying degrees of severity develops, so traumatic operations and contact with the pancreas should foresee the development of postoperative pancreatitis. On the other hand, it should be noted that not every postoperative pancreatitis can be explained by an operative trauma and not always its trauma leads to the development of OP. However, this certainly does not mean denying the need for the most careful treatment of the pancreas during the AF operation. Chernousoy et al., 1985, OB Milonov et al. 1990.
As already noted, in most cases, postoperative pancreatitis develops after operations on the biliary tract, during which instrumental examination of the bile ducts or direct intervention on the BDS is performed. In the first case, after deep sensing or the introduction of undiluted cold contrast solutions, which leads to spasm of the sphincter apparatus and prolonged reflux of the contrast agent into the pancreatic ducts, BDS edema occurs, and later develop stasis in the duct system of the pancreas and acute interstitial or infiltrative necrotic pancreatitis .B. Milonov et al. 1990.
Postoperative pancreatitis can also develop when performing papillotomy or papillosphincroplasty as a result of damage to the mouth of the GPP during a papillotomy incision V.V. Vinogradov et al., 1974, M. Rawa et al., 1972, and others. The pancreatitis developing in this case is characterized by a severe clinical course.
According to the authors, a similar picture can be observed when using transpapillary drainage, which often block the mouth of the GPP, which causes surgeons to abandon this type of drainage. Such complications can be easily avoided if you correctly carry out interventions on MDP and apply sparing methods of papillosphincterotomy Milonov et al., 1990, if necessary, the simultaneous imposition of biliodigestive and pancreatodigestive anastomosis.
Other causes of postoperative pancreatitis can be damage during the operation of vessels supplying the pancreas, its ducts or the parenchyma of the gland itself, as well as combinations of all these injuries during gastrectomy or extirpation of the stomach and splenectomy. More often, postoperative pancreatitis occurs after operations performed on low ulcers of the duodenal bulb and ulcers penetrating into the pancreas, which is usually associated with ligation of the pancreatic-duodenal artery or damage to the accessory (santorinev) pancreatic duct N.F. Sibul and RA. Truve, 1978.
Postoperative pancreatitis can also develop after splenectomy due to injury of the tail of the pancreas during ligation and crossing vessels of the splenic pedicle, as well as ligation of the splenic artery for if this manipulation is performed roughly without mobilizing the splenic artery from surrounding tissue and with insufficient development of the vascular arch passing on the lower edge of the pancreas OB Milonov et al., 1990.
In addition to trauma, postoperative pancreatitis can also develop as a result of prostate biopsy.
Non-traumatic postoperative pancreatitis is caused, firstly, by a sharp increase in pressure in the bile and pancreatic ducts, resulting from functional (spasm BDS, duodenostasis, paresis of the digestive tract) or organic (blood clots, cholera, pancreatolithiasis, cicatricial BDS strictures, etc.) obstacles the outflow of bile and PS, secondly, circulatory disorder of the pancreas due to neuroreflex or mechanical (ligation, compression of blood vessels, thrombosis) factors accompanying the operation, thirdly, the possibility of infection of the gland tissue pancreatic tissue.
Prerequisites for the development of this complication after surgery are previously transferred inflammation of the pancreas, CP, "diseases of the pancreatobiliary zone" in history. The cause of increased pressure in the bile and pancreatic ducts can also be duodenal hypertension, occurring in the postoperative period K. D. Toskin, 1966.1967. The development of duodenal hypertension is explained by stagnation in the cult of the duodenum after resection of the stomach according to the method of Billroth-N I.P. Tomashuk, 1972, M. Rawa et al., 1968.
In this regard, it is recommended to accurately follow such technical requirements as treatment of the duodenal stump, selection of the afferent loop length, hemming of the aforementioned loop to the lesser curvature to create a spur, correct positioning of the intestinal loop in order to avoid bends, lerekrut and others. Duodenal hypertension and pancreatitis may be due to postoperative gastrointestinal paresis.
In addition to the above etiological factors that play a role in the development of postoperative pancreatitis, the initial state of the pancreatic parenchyma and its functional state at the time of performing AA surgery are of great importance. Shalimov et al., 1983.
Thus, for the development of postoperative pancreatitis, a combination of many causal factors is necessary, among which an important role is played by changes in capillary blood flow, transcapillary metabolism and hemorheology, arising in response to coarse manitulation in the pancreas and the output sections of the bile and pancreatic ducts, as well as inhibition of the body’s immunological reactivity early postoperative period VI Lupaltsev, 1982.
The pathogenetic essence of the development of postoperative pancreatitis is reduced to the damage of pancreatocytes and the creation of conditions for interstitial activation and self-activation of the enzyme systems of the pancreas, as occurs during the primary OP.
The nature and extent of disorders developing in postoperative pancreatitis depend on the severity of the disease, the aggressiveness of pancreatic enzymes in the bloodstream, toxins, biogenic amines, and the body's defenses, as well as on the functional state of vital organs and systems.
As noted in the section on EP, the clinical severity of organ and systemic damage is not the same for all organs due to their different roles as target organs and specific tolerance to damage. These disorders develop against the background of ongoing severe toxemia, hypovolemia, and systemic disorders characteristic of OP. The main systems that determine the severity and outcome of the disease are circulatory, respiratory, detoxification, excretion, and other organs. B.C. Saveliev et al., 1990.
Clinic and diagnosis. The clinic of postoperative pancreatitis is extremely variable. She has no pathognomonic symptoms. V.V. Utkin et al., 1980J. The clinic of this complication is characterized by scarcity and inconstancy of symptoms. It flows erased, unnoticed. Symptoms of lesions of the pancreas are masked by narcotic drugs, active antibacterial therapy and body reactions in response to an operative trauma. The dominant trait is increasing intoxication with the breakdown products of proteins and enzymes. The nature of the clinical manifestation is due to the peculiarities of the early postoperative period and the possible combination with the symptoms of other complications.
There are several types of complications:
1) pronounced symptoms of its failure,
2) the phenomenon of pronounced gastrointestinal paresis
3) the prevalence of symptoms of peritonitis,
4) signs of intoxication psychosis V.I. Owl, 1982.
There are five stages of postoperative pancreatitis:
1) enzyme and hemodynamic disorders,
2) functional NC,
3) enzymatic peritonitis,
4) purulent complications,
5) terminal stage, characterized by an increase in intoxication, severe microcirculation disorders, acidosis, and symptoms of multiorgan failure.
According to the combination of leading signs, the sequence of development of pathophysiological changes in the course of the progress of the disease here is also clinically characterized by three periods:
1) the period of hemodynamic disorders and pancreatic shock,
2) the period of functional insufficiency of parenchymal organs,
3) the period of postnecrotic degenerative and suppurative complications V.S. Saveliev, 1986.
In contrast to the primary in postoperative pancreatitis, abdominal pain is not acute, localized mainly in the epigastric region and often have a surrounding character. At the same time with pains, there are often prolonged hiccups, nausea, vomiting with admixture of gastric and duodenal contents. Characterized by paralytic NC - stagnation in the stomach, the absence of intestinal noise, bloating and gas retention, "causeless meteorism", persistent intestinal paresis, difficult to respond or not at all amenable to treatment.
Characterized by changes in the skin: they can be hyperemic, pale, cyanotnichnymi, and often icteric. Cyanosis is one of the indicators of the serious condition of patients with postoperative pancreatitis, and the icteric nature of the sclera and skin occurs as a result of compression of the distal OBD by an enlarged pancreas head. Body temperature in mild forms of complications is usually subfebrile, with more severe, it can reach up to 40 ° C. The clinical picture of this complication is dominated by general intoxication, manifested by tachycardia, pulse, reaching 100-120 beats / min, lethargy, severe weakness, a decrease in blood pressure in the range of 100 / 70-70 / 50 mm Hg. Art.
According to clinical manifestations, cardiovascular, abdominal, hepatic-renal, cerebral, and other postoperative pancreatitis syndromes are distinguished. Cardiovascular syndrome is manifested by tachycardia, hypotension, microcirculation disorder (pallor, decrease in skin temperature, cold sweat). Abdominal syndrome is manifested by dynamic NK (nausea, vomiting, paresis), abdominal pain, abdominal wall defiance. Hepatic-renal syndrome is manifested by increasing jaundice, pathological changes in the urine, decreased diuresis, azotemia, etc.
Recognition of postoperative pancreatitis is very difficult, so it is diagnosed relatively later. The reason is the absence of typical clinical manifestations and sufficiently reliable laboratory tests.
Among the signs of circulatory insufficiency, we note tachycardia ahead of body temperature, changes in CVP, signs of ARF, manifested by shortness of breath (more than 26 breaths per minute), intoxication psychosis caused by severe eczemic intoxication, which is sometimes mistakenly interpreted. On palpation of the abdomen there is pain in the upper sections, muscle tension. The same symptoms are characteristic of acute primary pancreatitis and cannot be used to diagnose postoperative pancreatitis, especially if surgery is performed on organs located in the upper floor of the abdominal cavity. The Blumberg-Shchetkin symptom is often observed. However, we note that the symptoms of peritoneal irritation may be absent even with destructive pancreatitis.
Summarizing the above, it should be said that it is impossible to isolate the typical clinical symptoms of postoperative pancreatitis, however, if there are such major clinical signs as psychosis, deterioration in the general condition of patients without visible reasons, girdle pain in the upper abdomen without visible reasons, hiccups , nausea, vomiting, hyperthermia, pallor, breast, lethargy, tachycardia, lowering blood pressure, abdominal distension, lack of motility (paralytic NC), vomiting congestive contents, muscle tension in the epigastric Noah areas symptoms of intoxication, cardiovascular disorders and symptoms of acute PPN VK Gostishchev, NE Zolit, 1983, and the exclusion of other complications (inconsistency of stitches of the duodenal stump and anastomoses, abscess of the abdominal cavity, myocardial infarction, pneumonia), should consider the development of postoperative pancreatitis and carry out targeted diagnostic and therapeutic measures.
It should be noted that in 60% of patients in the clinical picture of postoperative pancreatitis mental disorders predominate: delirium, prolonged prostration, delirious state, inadequate behavior. In some patients with the progression of endotoxemia, severe dysfunctions of the central nervous system are observed, which are mistakenly regarded as cerebral disorders, which can also make it difficult to diagnose OP.
Mental disorders and cerebral phenomena with OP occur quite often.
Perhaps none of the known complications and diseases of the abdominal organs needs to confirm the results of LI as well as postoperative pancreatitis. General clinical analysis of blood in such patients is characterized by an increased number of leukocytes (up to 20 thousand), a shift of the leukocyte formula to the left, the toxic granularity of leukocytes, the appearance of young forms, high ESR.There is a decrease in the level of total protein and albumin in the serum.
For laboratory diagnosis of postoperative pancreatitis, many tests have been proposed that have different values: determination of serum sialic acid levels, calcium content, transaminase, methemalbumin, heminic compounds. The attention of researchers is attracted by specific pancreatic enzymes (a-amylase, lipase, trypsin), the increased content of which is considered a classic sign of OP.
The greatest diagnostic value is an increase in the level of a-amylase in peritoneal exudate in patients in the early postoperative period. Vinogradov, 1983.
For pancreatic necrosis is characterized by a sharp drop in the level of diastase from high to low. There is an increase in bilirubin, mainly due to the direct fraction, transamine blood.
In postoperative pancreatitis, significant changes occur in the coagulation and anticoagulation systems of the blood: a decrease in clotting time, an increase in plasma tolerance to heparin, an increase in fibrinogen concentration, a decrease in fibrinolytic activity, an increase in viscosity and an increase in the adhesion-aggregation capacity of erythrocytes, a change in their electrical potential N.P. Alexandrova et al., 1979.
The resulting cellular aggregates, clogging the blood vessels of organs and tissues (sludge-syndrome), become centers of reproduction of microorganisms in them. Increased blood clotting activity and inhibition of fibrinolysis in this case lead to thromboembolic complications from the vital organs.
Along with a thrombotic no less serious complication is the opposite state - pathological bleeding (gito-coagulation), which develops simultaneously with vascular thrombosis or after it E.E. Bazhenov, 1970.
In the diagnosis of postoperative pancreatitis, it is advisable to carry out RI. At the same time, functional changes in the stomach and duodenum, moderate paresis of TC loops (symptom of the “duty loop”), isolated lateral swelling (W (Gautier symptom), increased peristalsis, signs of duodenostasis (pendulum movements of barium sulfate in the duodenum and swelling of its CO) can be detected Dysfunction of the diaphragm may be the first indirect signs of a process developing in the pancreas: restriction of the mobility of its domes, relaxation on the affected side. In later periods there are discal atelectases in the basal regions easy x and fluid in the pleural sinuses (reactive pleurisy).
Recently, new, fairly reliable and practically safe methods that facilitate the diagnosis of postoperative pancreatitis and monitor the treatment of patients with this disease are being introduced into clinical practice. These include ultrasound and CT, as well as digital computerized angiography and nuclear magnetic resonance. Ultrasound allows to clarify the presence of pancreatitis, identify the prevalence of the process in the pancreas and promptly diagnose purulent complications. With the help of CT, it is possible to determine the volume of the lesion of the gland, to detect the accumulation of fluid in different parts of the abdominal cavity and the stuffing box, to reveal a picture of the focus of necrosis in the gland.
Certain information about the status of the pancreas can be obtained with the help of angiography. However, with the introduction of a contrast agent under high pressure, there is a danger of increasing the destructive process in the gland, and therefore, following the study, it is necessary to conduct intraarterial drug therapy V.M. Laschevker, 1982, OB Milonov et al., 1990.
In recent years, in order to diagnose postoperative pancreatitis, they began to apply the method of liquid crystal thermography and direct thermometry of the pancreas. However, to apply the above-mentioned highly informative methods, special equipment and personnel are required. A more accessible and relatively safe method is the control-dynamic laparoscopy V.M. Buyanov et al., 1980.
During laparoscopy, hemorrhagic or greenish-yellow exudate containing pancreatic enzymes and foci of steatonecrosis are characteristic of hemorrhagic, fatty and mixed pancreatic necrosis. Of the likely signs of pancreatic necrosis, a serous and hemorrhagic imbibition of the omentum, gastrocolic ligament, mesentery root of the transverse OK, retroperitoneal tissue is revealed.
Such laparoscopy allows you to establish the diagnosis of postoperative pancreatitis as early as possible and promptly prescribe therapy, relying on a favorable outcome of the disease in a large number of patients.
Finishing the section on the clinic and the diagnosis of postoperative pancreatitis, we conclude that each of the above clinical symptoms in itself could be explained by another postoperative complication, therefore the difficulty of differential diagnosis of postoperative pancreatitis is understandable.
However, dynamic control of a-amylase, total proteolytic and lipolytic activity of blood serum and other biochemical media, taking into account the clinic, as well as the results of laparoscopy, ultrasound, CT, angiographic methods of research and the appearance of pus-nosed amylase from the drainages in it helps to timely identify This is a serious complication.
Prevention and treatment. Prevention of postoperative pancreatitis should be ensured by strict adherence to operative techniques, more nagging surgical intervention, intraoperative preventive administration of protease inhibitors and the mandatory inclusion of cytostatics in the complex VD intensive therapy. Sheiko, 1983.
Preventive measures to eliminate the factors contributing to the development of complications include:
1) careful handling in the BDS area when removing stones from the OZhP, careful attitude to the pancreas tissue,
2) compulsory completion of the operation by external drainage of the biliary tract and Novocainic blockade of the round ligament of the liver in patients with the possibility of pancreatic paired hypertension, especially in patients with signs of CP and intraoperative trauma, and the appointment in the first days of prophylactic doses of anti-enzymes,
3) complete nasogastric aspiration of gastric and duodenal contents through a thin probe, as well as adequate drainage of the gastric stump in order to avoid duodenostasis after stomach operations,
4) complex conservative and infusion therapy, corrective disorders of homeostasis in the postoperative period M.G. Sachek and V.V. Anichkin, 1986.
The data of intraoperative cholangiography are also taken into account. If a reflux of a contrast agent into the pancreatic duct is noted, it is recommended that these patients in the postoperative period be kept under close dynamic observation or they must be administered 5-fluorouracil for 3 days after surgery. However, all these measures do not always guarantee success, so the main thing is the timely diagnosis of this complication.
After intervention on the BDS and the pancreas with the opening of the main duct in the presence of other aggravating factors, external drainage of the pancreatic duct of the SA is recommended. Shalimov, 1984.
Adhering to the conservative tactics in treatment, we consider it necessary to note that the delay with surgical intervention in postoperative pancreatitis is fraught with serious consequences, up to an unfavorable outcome. The reason for this outcome is mainly progressive pancreatic necrosis with symptoms of secondary purulent infection, severe intoxication.
Treatment of postoperative pancreatitis begins immediately after diagnosis. It should be comprehensive and pathogenetically justified. Therapeutic measures are aimed at eliminating pain syndrome and neuroreflex disorders, eliminating hypertension in the common bile and pancreatic ducts, arresting processes in the pancreas with shock doses of protease inhibitors, suppressing secretory activity and creating “functional rest” of the pancreas, fighting vascular and metabolic disorders, reducing enzymatic activity and other origin of endotoxemia by binding and removing toxins, as well as preventing the occurrence of purulent and other complications of SA. Nesterenko et al, I988.
From the moment of detection of postoperative pancreatitis during the acute period, patients should be on parenteral nutrition. For the relief of pain, narcotic and non-narcotic analgesics are prescribed, perirenal or sacrospinal blockages are administered (60-100 ml each of a 0.25% novocaine solution under the fascia of the sacrospinous bone 2 cm to the right and left of the spinous process line). The blockade of the round ligament of the liver and retroperitoneal space is also used. The administration of morphine in the treatment of postoperative pancreatitis is not recommended, as it causes spasm of the sphincter of Oddi and an increase in pressure in the pancreatic ducts.
Intravenous administration of 0.5% novocaine in the amount of 20-40 ml is recommended. This is justified by the fact that Novocain has the ability to inhibit kallikrein, relieve spasm. In order to relieve sphincter spasm Some use different antispasmodics (papaverine, but-went, platifillin, aminophylline, diafillin, nitroglycerin). The gag reflex is removed by the introduction of cercula (raglan). The functional peace of the pancreas is provided by fasting for 3-5 days (only 200 ml of alkaline drink per day is allowed). They use drugs that block the secretion of pancreatic enzymes and inhibit the stimulating effect of hydrochloric acid (atropine, diamax, throwing, cimetidine, almagel), derivatives of pyrimidine bases (methyluracil, pentoxyl), cytostatics (5% solution of 5-fluorouracil 10 ml intravenously, calculating 15 mg / kg for 1-3 days, ftorafur 10 ml of 4% solution 1-2 times a day) D.I. Dalgat, 1989.
In order to inactivate KKS, reduce hypertrilinemia, antienzyme drugs are used. Often used gordox or contrykal (100 thousand. IU intravenous I rae / day), tras il ol (200-300 thousand. IU intravenously 1 time / day). The duration of the course of these drugs is 5 days. It is very important to start anti-enzyme therapy in a timely manner, and the administration of drugs is fractional with an interval of 3-4 hours, as they are rapidly excreted by the kidneys (B.C. Savelyev, 1985, Warbe, 1968). For normalization and stabilization of biosynthetic processes in the pancreas with OP, ribonuclease is used (2-3 mg per 1 kg of patient's body weight), and in severe cases and again with an interval of 24 hours.
Atropine is not recommended to be prescribed for a long time, as it may contribute to the enhancement of intoxication psychosis and an increase in the viscosity of the KDP B.C. Saveliev et al., 1969. Pancreatic enzyme blockade cytostatic preparations are also prescribed, since allergic factors play a role in the pathogenesis of OP, therefore antihistamine and desensitizing drugs are prescribed (diphenhydramine, suprastin, pipolfen).
To improve the rheological properties of blood, perfusion of organs, as well as the prevention of intravascular thrombus formation, it is advisable to administer rsopoliglukina, hemodez, use heparin 5–10 thousand. IU under the skin of the abdomen 4 times / day for 4–5 days. Heparin in this dosage is able to quickly interrupt the chain reaction of blood coagulation, block thromboplastin and thrombus formation and thereby prevent intravascular coagulation of blood and its consequences. Pavlovsky et al., 1984.
To improve microcirculation and tissue perfusion, heparin should be combined with rsoligluglukin, komplamin, acetylsalicylic acid and other antiplatelet agents. In severe forms of PP, alkylating compounds (cyclophosphamide, cyclophosphamide) are used. The therapeutic effect of these drugs is largely due to the inhibition of protein synthesis in the pancreas and the inhibition of the synthesis of zymogen, therefore, the inhibition of self-activation of pancreatic cells and the production of pancreatic enzymes of SAA. Nesterenko et al., 1979.
Antihistamines, corticosteroids (prednisone, hydrocortisone), epsilon-aminocaproic acid, and large doses of vitamin C are used to eliminate vascular disorders and reduce the permeability of the vascular wall. It is considered necessary to install a stomach probe for permanent evacuation of gastric contents. To suppress the hyperacid state of the CO of the stomach, it is advisable to prescribe gastrocepin.
Pathogenetically sound method of treatment of postoperative pancreatitis is considered local cooling of the pancreas. With a decrease in temperature of 5-10 ° C, the rate of metabolic processes and enzymatic catalysis in the BC of Peny is significantly reduced, H.H. Korpan, 1985. In order to create a therapeutic concentration of inhibitors in the pancreas, the method of intra-arterial regional infusion through the celiac trunk or the pancreatic-epiploic artery has recently been applied.
For intra-arterial infusions, a variety of mixtures are used, including protease inhibitors, shggostatics, antispasmodics, peripheral vasodilators, antihistamines, antibiotics, heparin, aminophylline, nicotinic acid, reopolyglukine, hemodez, albumin solutions, glucose, polyionic fluids.
In recent years, there have been reports of the effectiveness of endolymphatic administration of protease inhibitors. The effectiveness of the action of inhibitors is largely dependent on the time elapsed from the onset of the disease to their use. Being suppressors of glandular protease production, eliminating the effects of enzymatic intoxication, stabilizing the action of quinines on the cardiovascular system, giving anesthetic effect, reducing swelling of the pancreas, antienzymes do not hinder the destruction of the gland parenchyma and the development of purulent complications.
In case of progressive necrosis and irreversible circulatory disorders in the pancreas, none of the drugs administered in the traditional way have a therapeutic effect. Milonov et al., 1990. They can only help to limit necrosis due to improved regional blood circulation and the relief of peripheral perifocal inflammatory response. The most effective inhibitors in the early period of the disease - in the first 3-6 hours. This is due to the fact that during the use of protease inhibitors there is no local suppression of the activation of pancreatic enzymes Yua Nesterenko et al., 1981.
Of the activities that affect the local inflammatory process in the pancreas, HBO should be noted, which improves metabolism and microcirculatory processes in tissues, and also, normalizing the oxygen balance, eliminates arterial hypoxia, improving the oxygen-binding functions of hemoglobin B.V. Petrovsky et al., 1983. With HBO, a good analgesic effect is observed in most patients, the duration of enzyme toxemia is reduced, hemodynamic disorders are quickly eliminated, helping to eliminate intestinal paresis, the disappearance of peritoneal phenomena, a decrease in the number of purulent complications, especially in the presence of non-clostridial anaerobic events, especially in case of non-clostridial anaerobic flies,
One of the main tasks in the treatment of postoperative pancreatitis is detoxification. Of the methods of detoxification therapy, forced diuresis is the most simple and effective. Kovalchuk, 1982.It provides a preliminary liquid load of Ringer-Locke solution (1500-2000 ml), the introduction of a diuretic (15% solution of mannitol at the rate of 1-1.5 g per 1 kg of body weight) and solution of aminophylline (20 ml of 2.4% - th solution), and then electrolyte solutions (3 g of potassium chloride, 5 g of sodium chloride and 3 g of calcium chloride) and protein preparations (plasma, albumin, protein, gelatinol).
An effective method of detoxification is drainage of the thoracic lymphatic duct. It contributes to the removal of toxic metabolites from the body, reduction of pancreatic edema, removal of PG and normalization of metabolic processes in the liver V.S. Saveliev et al., 1983.
The most effective methods of sorption detoxification are hemo- and lympho-sorption using coal or ion-exchange sorbents. Laptev et al., 1985, I.I. Shimanko et al., 1986.
Plasmapheresis based on the complete removal of the patient's plasma with the replacement of it with an adequate amount of fresh donor plasma deserves attention. L.А. Ender et al., 1985. To normalize EBV, CBS, and protein metabolism, active infusion therapy is performed using Ringer-Locke, acesol, lactasol, sodium bicarbonate, potassium chloride, and other electrolyte solutions.
To replenish energy costs used 10-20% glucose solution with insulin. Protein losses are compensated for using plasma, albumin, protein, amino acid mixtures (aminokrovin, aminosol, polyamine, moriamin, amikin, “New” alvezin), which are good plastic materials. Along with energy and plastic preparations, it is necessary to use B vitamins, ascorbic acid, anabolic hormones (nerobol, retabolil).
In connection with severe disorders of microcirculation, in order to prevent DIC, intravenous administration of nicotinic acid is recommended at the rate of 3 mg / kg, reopolyglukine 1S ml / kg, contractile 100 TUE / kg, heparin 500 U / kg / day B.C. Saveliev et al., 1983.
Importance should be given to antibiotic therapy as a measure of the prevention of purulent complications M.I. Kuzin et al., 1985. Of the antibiotics, more commonly used drugs (intravenously) are broad-spectrum drugs, taking into account their pharmacokinetics and preferential accumulation in the pancreatic tissue (ampicillin, ceporine, cefamisin, kefzol, tetracycline, erythromycin, gentamicin, rifamycin, sizomitsin, et al., Etc.). sulfa drugs are also prescribed. In order to prevent the development of non-clodridial anaerobic microflora, a 0.5% solution of metronidazole (100 mg) is injected intravenously, and before the operation it is recommended to administer trichopolum (0.5 g 3 times a day).
An important therapeutic and preventive measure is immunotherapy. For this purpose, globulin, antistaphylococcal plasma, prodigiosan, levamisole are used, direct blood transfusions are made, etc.
Quantum hemotherapy, ultraviolet irradiation of autologous blood, and the use of intravascular laser irradiation give a good therapeutic effect. Zemskov et al., 1994.
It should be noted that with PP, the destruction of the gland develops relatively quickly, and the pancreonecroe often leads to insolvency of the stitches of the duodenal stump and anastomosis. These two facts speak in favor of reducing the time of conservative treatment for this complication.
The progression of the phenomena of peritonitis, the increase in intoxication, the lack of effect from the conservative treatment of postoperative pancreatitis, carried out in full within 20 hours after the development of the complication, serve as an indication for X-ray. During the operation, the cause contributing to the development of postoperative pancreatitis or hypertension in the duct is established and eliminated: OZHP, duodenostasis is drained, the abdominal cavity, the omental bag are sanitized, inflammatory exudate is removed from the abdominal cavity, necrotic tissue and RV sequestra.
Novocainic blockade of larapankreatic fiber is produced with the addition of antibiotic and antienzyme preparations. When edema of the retroperitoneal tissue is drained by its multi-perforated tube, which is led to the pancreas bed through the opened sheet of peritoneum along the lower edge of the latter. The operation is completed with drainage of the stuffing box and abdominal cavity with siliconized, multi-pleated tubes. One of the drainage tubes is used to introduce inhibitors of pancreatic enzymes and antibiotics.
In the later periods with purulent postoperative pancreatitis, the optimal measure is a wide opening and revision of the stuffing pouch in order to detect and open foci of parapancreatic fiber, after opening they are well drained. In case of late X-ray, necrsequestrectomy, sanitation and drainage of septic foci, as a rule, are performed, conditions for reinfusion into the bile intestine are created, a cholecystostomy discharge or external drainage of obstructive ulcers are imposed.
Elimination of the cause of postoperative pancreatitis, adequate drainage of the omental bursa and parapancreatic fiber in combination with a comprehensive, targeted conservative therapy is the main condition for the successful treatment of this heavy group of patients. With this complication, there is still a high mortality rate, mainly due to late recognition and untimely intervention. Unfortunately, RL in such patients is often unsuccessful.
With pancreatic necrosis with abscess formation, necrequestrectomy, pancreatectomy are performed, and after that sanation and drainage of the stuffing box and retroperitoneal space is performed.
Recently, the method of abdominalization of the gland is used in order to stop the enzymatic autolysis of the pancreas and cryodestruction. When cryodestruction does not only suppress the excretory activity of the gland, but also inactivates the enzymes, stops their entry into the blood, and therefore does not develop pronounced enzyme toxemia, as with other methods. The advantage of cryodestruction is the low invasiveness of the reoperation, its short duration is A.B. Lee and V.F. Tskhay, 1991.
Improving the results of treatment of PP due primarily to their early diagnosis. The latter is mainly based not on searching for and waiting for specific and laboratory manifestations of RV inflammation, but on carefully identifying signs of an adverse postoperative course and excluding its other complications.
Thus, the timely diagnosis of postoperative pancreatitis and targeted, pathogenetically substantiated intensive therapy can give a certain therapeutic effect. With the help of such therapy, it is possible to avoid repeated surgical intervention in many cases. With the ineffectiveness of conservative therapy, worsening of the condition, the appearance of signs of peritonitis, an increase in the effects of intoxication, they resort to RL.
Treatment for acute pancreatitis in adults and children should be carried out only in a hospital. Therapy of any form of acute pancreatitis is always started with conservative methods, but under the supervision of a surgeon and resuscitator, as the patient's condition often deteriorates rapidly. He may need emergency care.
The treatment regimen for acute pancreatitis involves the use of drugs from different pharmacological groups. It is necessary to conduct anesthetic and anti-shock therapy, as well as the introduction of drugs that remove enzymatic aggression.
Preparations for the treatment of acute pancreatitis are selected by a doctor. The choice depends on the severity of the condition, the presence of comorbidities and the individual characteristics of the patient. Read more about what drugs can be prescribed for acute pancreatitis →
Fluids to restore the water-salt balance of the body
The inflammatory process leads to the development of intoxication: fever appears, the heart rate and respiratory movements increase, persistent painful vomiting, diarrhea, profuse sweating develops. As a result of these processes, a person loses a lot of fluid, the volume of circulating blood decreases, the amount of electrolytes in the blood decreases.
Therefore, the treatment of acute pancreatitis in the hospital necessarily includes infusion and detoxification therapy, which performs the following functions:
- fighting shock and collapse
- restoring water balance
- normalization of the electrolyte composition of blood,
- prevention of thrombosis, including pancreatic vessels,
- improvement of metabolism.
Intravenous drip is administered Reopoliglyukin, which lowers blood viscosity, improves microcirculation, reduces inflammatory swelling of the pancreas. Hemodez is also used, it quickly binds toxins and removes them with urine, promoting detoxification.
To restore the water-salt balance, additional saline solutions are injected intravenously, including such preparations:
- isotonic solutions of sodium chloride, potassium, polarizing mixture,
- 5% glucose solution with insulin is effective for stopping the fatty destruction of gland tissue,
- Acesol, Trisamin,
- gluconate calcium jet.
The inflammatory process contributes to the shift of the internal environment of the body to the acidic side. Therefore, to normalize the acid-base balance, sodium bicarbonate solution is injected intravenously.
After recovery of circulating blood volume and water-electrolyte metabolism, intravenous administration of solutions of albumin, polyglucin, blood plasma is necessary. They improve the nutrition of tissues, support the immune system, compensate for the lack of protein absorption against the background of pancreatitis. Their introduction also has anti-shock effect, helps to increase blood pressure, improve the general condition of the patient. For parenteral nutrition in the acute period of the disease, fatty emulsions administered intravenously are used.
To reduce the release of digestive enzymes and limit the areas of necrosis of pancreatic tissue, resulting from autolysis, the following drugs are used:
- Protease inhibitors (Contrycal, Trasilol, Gordox). They are administered intravenously several times a day at a dose, depending on the severity of the condition. These drugs inhibit the activity of trypsin and other digestive enzymes, forming with them inactive complexes that are rapidly eliminated from the body. But these funds are effective only at the initial stage of acute pancreatitis.
- Cytostatics (5-fluorouracil) also have anti-inflammatory, desensitizing effects and inhibit the synthesis of proteolytic enzymes. But these are toxic drugs, so the expediency of their appointment is always decided individually.
- Synthetic neuropeptides (Dalargin).
Hydrochloric acid produced by the gastric mucosa stimulates the secretory function of the pancreas. Therefore, drug treatment of acute pancreatitis includes drugs that reduce the secretory activity of the stomach. Most often, Kvamatel, Almagel and other antacids are prescribed. Atropine injections are effective. Cimetidine is intravenously administered.
Treatment for acute pancreatitis with anti-enzyme drugs should be started immediately after the patient enters the hospital. They are administered shock doses several times a day to sustained improvement.
- Attach a cold heating pad on the left hypochondrium.
- Eliminate ingestion through the mouth.
- Aspirate the contents of the stomach with a nasogastric tube, especially with nausea and frequent vomiting. Antacids can also be injected directly into the stomach using a probe.
- To carry out intragastric hypothermia.
Detoxification methods such as lymphosorption and plasmapheresis contribute to the accelerated elimination from the body of excess digestive enzymes, toxins and products of cellular degradation.
Plasmapheresis is called blood purification. In this procedure, a certain amount of blood is removed from the body, cleaned of toxins and injected back into the patient’s vascular system. This manipulation is carried out according to the following indications: signs of pancreatic necrosis, the development of peritonitis, the preoperative period in which the procedure improves the prognosis of surgical intervention. Disadvantages are: complexity, duration of the manipulation, its high cost.
Intense pains of the shingles nature, even against the background of complex and competent treatment with the use of analgesics, persist for 24 hours. This persistent nature of the pain syndrome is explained by the ongoing necrotic process in the tissues of the pancreas. Indeed, despite all the therapeutic measures, the process of autolysis cannot be stopped immediately.
To reduce the suffering of the patient, pain medications are injected intravenously. Tramadol, Baralgin, Novocain and other anesthetics are used. Subcutaneous administration of Promedol, the use of a mixture of glucose and novocaine solutions has a good effect. The effect of anesthetics is enhanced when parallel to the introduction of antispasmodics (solutions of Papaverine, Platyfillina) subcutaneously.
Their introduction will not only expand the vessels of the gland, but also relieve spasm of the sphincter of Oddi, facilitating the outflow of bile and pancreatic juice into the intestine. Intravenous administration of Atropine and Nitroglycerin also contributes to the removal of the spasm of the smooth muscles of the bile ducts.
With severe pain, blockades are indicated. Most often, bilateral perirenal or paravertebral novocainic blockade according to Vishnevsky is performed. Epidural anesthesia is also very effective. These procedures not only relieve pain and inflammation, but also reduce the external secretion of the pancreas, contribute to the flow of bile into the intestine.
Therefore, blockades are used to treat acute biliary pancreatitis, or cholecystopancreatitis, the aggravation of which is often triggered by the ingestion of large amounts of fatty or fried foods. Read more on how to eat during pancreatitis →
In this type of disease Novocain can be administered intravenously in combination with diphenhydramine and promedol. The procedure helps to relax the sphincters, normalize the secretion of bile and digestive enzymes.
To reduce pain, there must be constant aspiration of acidic gastric contents through the probe. Reduces the severity of pain and ultraviolet laser irradiation of blood. It also reduces the inflammation of the body, improves blood rheology.
For the treatment of acute pancreatitis, it is necessary to remove from the body the excess of digestive enzymes that destroy the pancreas. In addition, in most cases, the edematous form of the disease is diagnosed; therefore, the administration of diuretics significantly alleviates the condition.
They can be used intramuscularly or intravenously, depending on the severity of the patient's condition, only after the drip administration of protein or saline solutions. Such a forced diuresis helps to relieve intoxication and improve well-being. Most often for this purpose is used Lasix and Mannitol solution.
The inflammatory process in the pancreas leads to impaired digestion of food and severe intoxication. As a result, after eating nausea appears, repeated painful vomiting with an admixture of bile, after which the person does not feel relieved. This leads to loss of fluid and electrolytes, exhausting the patient. Of antiemetic drugs, Regen is usually used as an injection.
A patient with suspected acute pancreatitis should be hospitalized in the surgical department, where he immediately begins to receive intensive therapeutic care. This is due to the possibility of rapid deterioration, increased necrotic processes, the need for emergency surgery. According to statistics, surgical treatment of acute pancreatitis is performed in every fifth patient.
For surgical intervention there are special indications:
- conservative treatment of acute pancreatitis did not give positive results (according to vital indications, drainage of the abdominal cavity and removal of pancreatic necrosis are performed),
- the appearance of symptoms of peritonitis,
- the formation of an abscess or cyst in the tissues of the gland,
- suspicion of acute surgical disease of the abdominal organs,
- signs of phlegmonous or gangrenous cholecystitis.
Endoscopic methods of intervention are widely used, in particular, peritoneal lavage. With the help of a laparoscope set the drainage in the abdominal cavity, which contribute to its purification from excess enzymes and toxins.
First aid for a seizure
The first actions of the patient during exacerbation of the disease are reduced to three principles: hunger, cold and peace. With the appearance of intense pain in the abdomen, indomitable vomiting, severe intoxication, you must immediately call an ambulance.
The following steps should be taken:
- Eliminate the entry of food into the stomach.
- Put ice on the left hypochondrium area.
- Calm the person and put him in a comfortable position.
- Give antispasmodic drugs in the form of tablets or intramuscular injections. It can No-shpa, papaverine, platifillin.
- Make an intramuscular injection of Cerucul, if available in the first-aid kit.
Doctors in the hospital, having established the diagnosis, will inject painkillers: Analgin, Baralgin, etc.
Treatment of folk remedies
Acute pancreatitis is a pathology that often leads to emergency surgery. No folk remedies can not help the patient. He needs to be treated only in the hospital, and the sooner a person is taken to the hospital, the more chances to do without surgery.
Self-medication, attempts to remove the manifestations of acute pancreatitis by folk methods lead to the loss of valuable time and worsen the prognosis of the disease. No traditional method can be applied in the acute stage.
In the periods between exacerbations, the patient may take:
- Infusion and immortelle decoction (1 tablespoon of plant flowers per cup of boiling water). Drink three times a day for 1/2 cup.
- Infusion golden mustache. Crushed leaves (2 pcs.) Pour 2 cups of boiling water, boil for 20 minutes. Then the tool insist 8 hours, filter and drink 25 ml three times a day.
- Propolis in its purest form. Pieces weighing about 3 g are chewed between meals.
- Kissels from blueberries or cranberries. The recommended amount is 2-3 glasses per day.
Treatment of acute pancreatitis is a difficult task that can be managed only in stationary conditions. The patient should be under the supervision of specialists of different profiles, since the health and life of the patient is directly dependent on the timeliness and adequacy of complex therapy.