[Surgical resolutions determining outcomes of infected pancreatic necrosis]

AIM

To evaluate technology, indications and time of minimally invasive semi-closed and laparotomic sanations for infected pancreatic necrosis (IP).

MATERIAL AND METHODS

Initially it was used sonography-assisted minimally invasive semi-closed drainage of IP with gradual augmentation of catheters' diameter. In 462 patients with IP liquid pus prevailed over sequesters in epigastric localized pancreatonecrotic phlegmon (ELPF) and pancreatonecrotic abscesses. So, minimally invasive approach may be definitive. Epigastric advanced pancreatonecrotic phlegmon with predominant sequesters is often followed by conversion to transverse omentobursopancreatostomy (OBPS) to open all purulent accumulations.

RESULTS

Surgical treatment immediately after parapancreatic infiltrate suppuration (i.e. within 3-4 weeks after onset of the disease) is associated with reduced mortality. Absent result of minimally invasive drainage is followed by mortality from the 11^th day and maximum in 14 days after treatment onset. Therefore, focal IP resistant to minimally invasive drainage requires conversion to transverse OBPS or video-assisted sequestrectomy after 10-13 days. The lowest mortality (14.8±2.5%) was observed in patients who underwent minimally invasive drainage or transverse OBPS within 10-13 days. Ineffective prolonged minimally invasive drainage was accompanied by high mortality rate (60.7±3.2%, p<0.001).

CONCLUSION

Conversion to transverse OBPS or video-assisted sequestrectomy are required if minimally invasive drainage of IP is ineffective after 10-13 days. Clear understanding of indications for closed and open drainage of PI helps to avoid tactical and technological errors.

[Laparotomy closure in advanced peritonitis]

AIM

to improve the results of advanced peritonitis management.

MATERIAL AND METHODS

743 patients with advanced peritonitis were studied. Patients were divided into 2 groups depending on treatment strategy.

RESULTS

Programmed relaparotomy combined with removable draining musculoaponeurotic seams during laparotomy closure decreased mortality from 47.8±2.7% to 24.1±2.3% (p<0.001) and provided 4-fold reduction of postoperative suppuration incidence (p<0.001). Refusal from removable draining musculoaponeurotic seams and use of only cutaneous seams in persistent abdominal hypertension were associated with further decrease of mortality to 15.8±2.7% (p<0.05).

CONCLUSION

Programmed relaparotomy combined with removable draining musculoaponeurotic seams are advisable for advanced peritonitis management. Laparotomy closure with only cutaneous seams is indicated in case of persistent abdominal hypertension. Large eventration always requires abdominal wall repair. APACHE-III scale scores have significant prognostic value in patients with advanced peritonitis.

[The choice of tactical decisions in surgical treatment of massive infected pancreonecrosis]

Treatment results of 368 patients with infected pancreonecrosis were analyzed. Overall lethality was 29.6 ± 3.4%. Maximal lethality was among patients with phlegmona - 43.6 ± 5%, minimal (12.9 ± 3.8%) among patients with abscess. Spread phlegmonas, when closed sequestrectomy was impossible, were treated by transversal omentobursopancreatostomy. When the closed drainage of infected pancreonecrosis areas was not effective after 10-13 days, conversion to the omentobursopancreatostomy was performed. Lethality among patients with non-alternative closed drainage was 50.0 ± 4.5%. Lethality after omentobursopancreatostomy was 19.0 ± 4.2%.