Aspects of surgical treatment tactics in acute pancreatitis

Abstract

Introduction. Acute pancreatitis (AP) has an annual incidence of 15-36 per 100,000 general population. About 20-30% of them will develop moderate or severe AP. AP denotes mortality of 46-70% of cases in its destructive forms, raising this issue to the priority rank. Thus, multiple questions about surgical tactics remain unsolved in these patients. Aim of study. To study the incidence, etiology, clinical course, and possibilities of minimally invasive surgical methods in order to improve the treatment outcomes of patients with AP. Material and methods. The results of the medical-surgical treatment were analyzed in 97 patients with AP treated in the Municipal Hospital “Sfânta Treime” surgery clinic. The severity of AP was assessed according to the Atlanta classification. The volume of pancreatic destruction was estimated according to the Balthazar score. Patients were stratified into 4 groups: 1- focal: lesion volume <30%; 2-massive: 30- 50%; 3-subtotal: 50-80% and 4-total: >80%. The BISAP score was used to identify patients at increased risk of in-hospital mortality. Surgical treatment methods included: I - ultrasound drainage of fluid collections; II - laparoscopy, lavage and drainage of the abdominal cavity; III - laparotomy with necrosectomy and drainage. Results. The age distribution of AP showed a predominance in the groups of 30-40 years (28 patients, 28.9%) and 40-50 years (34 patients, 35.1%). Gender ratio – 76 males/21 females. Alcohol was the most common etiological cause (58 patients, 59.8%), followed by biliary pancreatitis (34 patients, 35.1%), and in 8 cases (5.1%) idiopathic AP. Of the 97 patients, severe AP form was established in 38 (39.2% of cases), of which in 4 cases (10.5%) with focal necrosis <30% and 34 (89.5%) cases with necrosis of parenchyma >30%. The BISAP score <3 was determined in 3 patients with destructive pancreatitis, in the other 35 cases being >3. Minimally invasive techniques in 43 (44.3%) cases contributed to the recovery of patients, representing the basic surgery, especially in focal or massive AP. In total and subtotal AP, these methods, combined with intensive care, represented stages of surgical treatment, contributing to the stabilization of the patient. Minimally invasive interventions led to the location of the necrotic focus and its delimitation, therefore improving the intraoperative conditions for subsequent open surgery. This tactic reduced the incidence of septic complications from 21.9 to 13.1% and diminished mortality from 26.7 to 18.3%. Conclusion. The combined minimally invasive techniques present an alternative in the treatment of destructive AP, a final treatment method for a limited pancreatic lesion or a stage of complex surgical treatment.