IMPROVEMENT OF SURGICAL TREATMENT OF ACUTE BILIARY PANCREATITIS.

Abstract

Purpose of the study: improving the surgical treatment of biliary pancreatitis by using a universal retractor and improved methods of omentobursostomy with drainage of the omental bursa.

Study design: Non-randomized controlled clinical trial Material and methods: This study included thirty-nine patients who underwent surgical procedures between October 2022 and September 2023 in Semey, located in the Abay region. The study examined the general characteristics of surgical interventions performed for acute biliary pancreatitis using our proposed treatment methods and devices to improve the outcomes of acute biliary pancreatitis. Open surgery was indicated when simultaneous surgical intervention on the gallbladder, bile ducts, pancreas, and retroperitoneal space was necessary.

Results: The study included 39 participants (100%), with 26 women (66.7%) and 13 men (33.3%). The average age of the participants was 48.6±1.2 years. The most common clinical manifestations of acute biliary pancreatitis observed in the study were abdominal pain (100%), fever (46.1%), and chills (41%). Dyspeptic symptoms such as nausea and vomiting were present in 48.7% of participants, while symptoms of cholestasis and skin itching were observed in 23%. All 39 patients (100%) experienced pain, with 13 (33.4%) experiencing girdle pain and 12 (30.7%) experiencing epigastric pain. The most common location of pain was under the right hypochondrium in 14 (35.9%) patients. The most frequent surgical intervention was cholecystectomy with drainage of the common bile duct (CBD) performed in 43.5% (n=17) of cases. Other surgical interventions included choledochoduodenostomy (CDD) according to the Yurash-Vinogradov method in 18% (n=7), hepaticojejunostomy according to Roux-en-Y in 7.7% (n=3), and laparotomy with dissection of the pancreatic capsule with abdominalization in 7.7% (n=3). A developed method was applied in 5.1% (n=2) cases, where acute biliary pancreatitis was complicated by infected pancreatic necrosis, requiring urgent necrectomy, sanitation of the omental bursa and parapancreatic tissue. In these cases, laparotomy with cholecystectomy + drainage of the CBD with omentobursostomy and retroperitonealostomy was performed. Endoscopic interventions were used in 18% (n=7) cases.

Conclusions: Thus, complications after surgical treatment of biliary pancreatitis occurred in 17.9% (n=7) of patients, including bile leakage at the site of the drainage tube placement 2.6% (n=1), biliodigestive anastomosis failure 2.6% (n=1), scar stenosis of the terminal part of the common bile duct after drainage 5.1% (n=2), increased severity of acute pancreatitis 5.1% (n=2) after endoscopic lithotripsy, fluid accumulation in the subcutaneous tissue (seroma) 5.1% (n=2). There were 5.1% (n=2) deaths. The causes of death were recurrent erosive bleeding with total pancreatic necrosis and septic shock with the development of multi-organ dysfunction. In complicated cases of acute biliary pancreatitis, when there was a need for simultaneous surgical intervention on the gallbladder, bile ducts, pancreas, and retroperitoneal space, we used our developed universal wound expander (EAPO No. 038346 dated 12.08.2021). The wound expander allows for better visibility of the surgical field and significantly facilitates the surgeon's work during the surgical procedure. The double-lumen spiral drain (No. 7691 dated 13.10.2023) provides adequate drainage and continuous flushing, as well as irrigation with medications to prevent further destruction of the pancreatic parenchyma and the development of purulent-septic complications. To monitor the dynamics of treatment for pancreatic necrosis during subsequent sanations, we also used the method of omentobursoscopy (No. 36736 dated 02.08.2024) in the postoperative period, which allowed for controlled manipulations in the omental bursa and retroperitoneal space, creating conditions for higher quality and safer work for the surgeon in the treatment of acute purulent pancreatitis.