Хірургічне лікування гострого біліарного панкреатиту

Abstract

Introduction. Despite the widespread of associated damage of the biliary system and the pancreas, a lot of issues of treatment tactics remain unresolved. There is no doubt that an adequate treatment of this pathology should combine the surgical and conservative components which will be determined by the peculiarities of the course of pathological processes in the bile ducts and in the pancreas.Materials and methods. A clinical examination and treatment of 126 patients with acute biliary pancreatitis have been performed. Men were 32 (25.4%), women – 94 (74.6%). There was isolated cholecystolithiasis in 65 patients with acute biliary pancreatitis (group 1). 35 patients were diagnosed small concrements in different parts of the common bile duct, which did not cause obstruction of the common bile duct (group 2). 26 patients were diagnosed obturating concretions of the common bile duct, including – impacted into a large duodenal papilla (third group).Results and their discussion. Clinical symptomatology, biochemical blood count, elevation of α-amylase, lipase, pancreatic α-amylase, and positive ACTIM Pancreatitis test allowed us to establish a preliminary diagnosis of acute pancreatitis. Ultrasound examination evaluated changes in the pancreas, but did not always fully describe the state of extrahepatic bile ducts. Magnetic resonance imaging (MRI) was used to fully characterize the pathology of the common bile duct, which made it possible to clearly identify the genesis of acute biliary pancreatitis. At the first stage of treatment, all diagnostic-therapeutic measures were performed during 24 hours. The absence of pathological inclusions in the common bile duct was determined in 80.0% of patients of group 1 using ultrasound examination. MRI was performed for 20.0% of patients. 25.7% of patients of group 2 needed MRI, and 74.3% – transpacillary endoscopic radiography. The ultrasound examination was effective only in 7.7% of patients of group 3. Other patients in this group to verify the cause of acute biliary pancreatitis required the use of other methods of radiotherapy. During 24 hours, laparoscopic cholecystectomy (LCE) was performed in 49 patients (75.4%) of group 1. Patients of groups 2 and 3 were performed endoscopic diagnostics and revision of extrahepatic biliary ducts, followed by LCE during 24 hours. 12 (9.5%) patients had complications related to the unfavorable course of the inflammatory process in the pancreas and peripanecratic tissue. The formation of false pancreatic cysts was diagnosed in 2 patients of group 1, in 3 patients – group 2 and in 2 patients – group 3. Taking into account their favourable course and the absence of laboratory and clinical data for their infection, these patients were recommended to follow dynamic observation in the outpatient settings. Abscesses of retroperitoneal space developed in 5 patients (group 2 – in 3 patients and group 3 – in 2 patients).Conclusion. Diagnostic tactics in acute biliary pancreatitis should include: determination of the activity of lipase, α- amylase, pancreatic α-amylase, ACTIM Pancreatitis test and MRI. Active surgical tactics involving LCE should be used in patients with acute biliary pancreatitis in cholecystolithiasis, and also endoscopic transpasillary decompression of the common bile duct in choledocholithiasis, within 24 hours of patient’s stay in the surgical department.