Возникновение острого билиарного панкреатита обусловлено микролитиазом, миграцией или вклинением камня в большой дуоденальный сосочек и, как следствие, развитием панкреатической гипертензии и аутолиза ткани поджелудочной железы. Цель исследования-разработка рациональной хирургической тактики ведения больных острым билиарным панкреатитом и его осложнениями. За 10 лет наблюдали 378 больных острым билиарным панкреатитом, из них у 304 (80%) степень тяжести болезни была легкой, у 74 (20%)-средней и тяжелой. Практически все больные с легким течением острого билиарного панкреатита оперированы в течение 3-7 сут после разрешения атаки. У больных с тяжелой степенью билиарного панкреатита отмечены общие и местные осложнения, требовавшие дифференцированной лечебной тактики. Выводы. 1. Вклинение камня в большой дуоденальный сосочек предполагает экстренную эндоскопическую папиллотомию. 2. Холедохолитиаз, холангит и механическая желтуха при остром билиарном панкреатите является показанием эндоскопической папиллотомии. 3. Холецистэктомию при билиарном панкреатите тяжелого течения следует выполнять после разрешения воспалительных изменений желчного пузыря и поджелудочной железы. Ключевые слова: желчнокаменная болезнь, микролитиаз, острый билиарный панкреатит, эндоскопическая папиллосфинктеротомия, панкреатические скопления, инфицированный панкреонекроз.
In this reviewing article there are discussed such topics as modern classification of acute pancreatitis, indications for surgical treatment of severe and, first of all, infected pancreatic necrosis, modern tendencies in this problem and controversial issues of it. The analysis of two different methods of surgeries («closed» and «open») for drainage of retroperitoneal space depending on the scale of necrotic lesion has been carried out. The perspective use of the natural transluminal endoscopic surgery (ENOTES) in the treatment of acute pancreatitis, complicated by abdominal compartment syndrome, is shown. The frequency of intraoperative and early complications after «closed» and «open» surgical interventions for severe acute pancreatitis has been reviewed; also recognition of the complications, the prevention of their occurrence and the choice of surgical or conservative methods of treating the complications.
The aim of the study. Assessment of markers of early complications in patients with acute pancreatitis. Materials and methods. Observation was carried out for 151 patients who were in the clinic from 2011 to 2019, with a diagnosis of acute pancreatitis (OP). The average age of patients (47.8±1.5) years. The patients were divided into 2 groups: group I -78 patients with developing pancreatic pseudocyst (PP) and group II -73 patients with free fl uid accumulations (FFA) of the abdominal cavity. All patients underwent comprehensive examinations, including histology of emerging cysts, clinical and biochemical blood tests, sonography and computed tomography, bacteriological and enzyme immunoassays with assessment of the level of endogenous intoxication, procalcitonin, microbial contamination and cytokines.Results. In comparison with group I patients with developing PP, the observed group II patients with FFA showed a significant increase in the degree of endogenous intoxication. A 3.0-fold increase in the level of procalcitonin in 26.8% of group I patients and in 67.1% of group II patients (p<0.05) with a directly proportional dependence of this indicator on the level of bacterial contamination (r=+0.51; p<0.05) indicated the activation of infection processes in general and, to a greater extent, in group II patients. At the same time, the condition of their last worsened due to the transition of the infl ammatory process to the parapancreatic region and into the retroperitoneal space. The high level of proinfl ammatory cytokines IL-6, TNF-α in patients of group II compared with group I, an imbalance and a decrease in the activity of the anti-infl ammatory mediator IL-10 determined a signifi cantly greater (p<0.05) activity of the infl ammatory process in patients with SFS, and were associated with an unfavorable prognosis. Conclusion.The formation of a PP is a relatively favorable outcome of acute pancreatitis, accompanied by signifi cantly less pronounced toxemia and infection rate in comparison with patients with free fl uid accumulations of the abdominal cavity.
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