Роль и место люмботомии в хирургическом лечении острого небилиарного инфицированного некротического панкреатита

Abstract

Material and Methods. Treatment results of 104 patients with рostnecrotic parapancreatic infected fluid accumulations in the retroperitoneal fat (retroperitoneal fat (adipose tissue) phlegmon) who were treated at the clinic from 2000 to 2013 were analyzed. The age of patients ranged from 22 to 80 years, including patients aged 50 years who comprised 60.5 %. The men was 71 (68.3 %), women — 33 (31.7 %). Duration of the disease up to 24 hours was noted in 32 (30.8 %) patients. The period of the disease up to 25 to 72 hours was observed in 23 (22.1 %) patients. Duration of the disease more than 72 hours was marked in 49 (47.1 %) patients. Local pancreatic necrosis (less than 30 % necrosis of pancreatic parenchyma) was identified in 6 (5.8 %) patients, extensive type (from 30 to 50 % necrosis of pancreatic parenchyma) was noted in 57 (54.8 %) patients, subtotal total pancreatic necrosis (more than 50 % necrosis of pancreatic parenchyma) was determined in 41 (39.4 %). The retroperitoneal fat phlegmon with involvement of the parietal peritoneum in inflammation with diffuse purulent peritonitis was detected in 7 (6.7 %) patients, the retroperitoneal fat phlegmon without peritonitis — in 80 (76.9 %), combination the phlegmon on retroperitoneal fat аnd pancreatic and/or was revealed in 17 (16.4 %). Results and Discussion. It was established that left-sided retroperitoneal fat phlegmon often develops in acute infected necrotizing pancreatitis in 64.4 % of patients. Right-sided retroperitoneal adipose tissue phlegmon was detected in 25 % of patients and bilateral — in 10.6 %. The highest mortality was observed in bilateral retroperitoneal fat phlegmon in 63.6 % of cases, it reached the level of 26.9 % in left-sided phlegmon, and 7.7 %. Also the highest mortality was observed in combination phlegmon of retroperitoneal fat аnd pancreatic and/or omental abscess in 41.2 % of cases. The mortality comprised 28.6 % in retroperitoneal fat phlegmon with diffuse purulent peritonitis and it reached the level of 22.5 % in retroperitoneal fat phlegmon without peritonitis.Results of various surgical interventions application in retroperitoneal fat phlegmon indicated that the application of laparotomy was accompanied with the highest mortality (34.9 %). Slightly better results were obtained by the application of puncture — drainage operations under ultrasound (PDO-US) — 16.7 %. However, according to our data, they were effective in 28.6 % of patients with retroperitoneal fat phlegmon in the form of free fluid accumulation. Mortality after lumbotomy amounted 13.3 %. This operation was performed in 71.4 % of patients with retroperitoneal fat phlegmon in the form of «purulent honeycomb», including 21.4 % of patients for whom PDO-US was ineffective. Thus, the operations on the retroperitoneal fat from minimal accesses (lumbotomy, sequestrectomy, drainage of retroperitoneal fat) are the most popular surgical interventions for retroperitoneal fat phlegmon. However, our experience has shown that one dissection on the retroperitoneal fat is not enough. The absolute majority of patients needed staged sanations of retroperitoneal fat (staged sequestrectomy).Conclusion. In the postnecrotic infected pancreatic and/or parapancreatic fluid accumulations in the retroperitoneal fat (retroperitoneal fat phlegmon) as purulent impregnation cellular spaces in the form of «honeycomb» operation of choice is direct surgical interventions on the pancreas and retroperitoneal fat from the minimal accesses (extraperitoneal access — lumbotomy) with subsequent staged sequestrectomy. Operation of choice for phlegmon of retroperitoneal fat and diffuse purulent peritonitis with involvement of the parietal peritoneum in inflammatory process is laparotomy, sanation and drainage of abdominal cavity, dissection of extraperitoneal phlegmon, drainage of retroperitoneal fat with subsequent programmed abdominal cavity and retroperitoneal fat sanation. Puncture — draining surgical interventions under ultrasound should be used with pancreatic and/or omental abscesses and phlegmon of retroperitoneal fat in the form of free fluid accumulation, and laparotomy, sequestrectomy, omentobursostomy to remove large enough sequesters located in the head and body of the pancreas.