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UDC 616.37-002-08
ARTERIAL INFUSION IN THE TREATMENT OF PATIENTS WITH ACUTE PANCREATITIS
1 Altai State Medical University, Barnaul
2 Regional Clinical Hospital, Barnaul
G.A. Arutyunyan1, A.R. Aliyev1, K.E. Vlasov2, D.D. Arzamastsev2, V.G. Petrenko2
The article presents the results of application of regional intravascular therapy in patients with acute pancreatitis with drugs that cause "deblocking" of microcirculation. Clinically, there were examined 125 patients with acute pancreatitis, who were divided into two groups. The first group included 65 patients with traditional methods of treatment. The second group consisted of 60 patients who, in order to improve blood circulation in the pancreas and to open the microcirculatory bed in complex treatment, were exposed to long-term regional arterial infusion (LAI) in the celiac trunk, gastroduodenal artery (GDA) of alprostadil, disaggregants and antibiotics. The use of local management of alprostadil and disaggregants leads to an improvement in blood circulation in the parenchyma of the pancreas with stimulation of the processes of delimitation, in the form of formation of early fluid clusters with a decrease in the infiltration of retroperitoneal tissue and its infection. Key words: pancreas, acute pancreatitis, microcirculation, prolonged arterial infusion, alprostadil.
In recent years, acute pancreatitis (AP) has been occupying a leading position among urgent surgical diseases [1, 2, 3]. It is known that the tissue of the pancreatic gland (PG) is sensitive to ischemia. The appearance of free radicals during its development leads to endothelial dysfunction, increased permeability for active proteases affecting intracellular homeostasis, followed by activation of polymorphonuclear leukocytes. All these factors can participate in the pathogenesis of acute pancreatitis [4, 5, 6]. The blockage of microcirculation causes the prevalence and depth of necrosis in the pancreas, being an important factor in the occurrence of subsequent infection [7, 8, 9].
The intravenous method of drug administration is not always effective due to their low concentration [8, 10, 11]. The depletion of microcirculation in the pancreas in the early phase of acute pancreatitis can play a key role in the progression of this disease [8, 10, 12]. Increased level of intravascular coagulation and angiospasm complement micro-circulatory disorders in pancreatic tissue, resulting in necrotic changes in its parenchyma [8, 9, 13]. The area of damage to the prostate tissue depends on the level of intra-organ hemoperfusion disorders [5, 11, 14]. Thus, local application of an angi-oprotective agent to influence the microcirculatory bed of the pancreas in the treatment of acute pancreatitis seems appropriate.
The aim of the study was to improve the results of the complex treatment of acute pancreatitis by local correction of circulatory disorders in the pancreas.
Materials and methods
A total of 125 patients with acute pancreatitis were examined, of which the majority (p <0.001) were men - 87 (69.6 ± 4.1%), women - 38 (30.4 ± 4.1%) (Table 1). The age varied from 17 to 76 years.
Patients were divided into two groups, depending on the method of treatment. The first group (comparison) included 65 (52 ± 4.5%) patients who entered the clinic late in the period from the onset of the disease, after the standard systemic infusion therapy, which was carried out earlier in the city and district hospitals, with the inclusion of antibiotics and protease inhibitors. The second group (primary) included 60 (48 ± 4,4%) patients with acute pancreatitis, in the complex treatment of which there was applied local intra-arterial rheo-logical therapy to the celiac, gastroduodenal artery and in some cases to the splenic artery. The treatment was aimed at opening the pancreatic vascula-ture with subsequent administration of antibiotics in order to suppress microflora and prevent local infection. Patients of the second group were divided into two subgroups. The first subgroup comprised 27 patients (21.6%), in the complex treatment of which prolonged arterial infusion into the celiac trunk (CT) of the drug mixture, including disaggre-gant (pentoxifylline), heparin was used. Infusion was carried out in a continuous mode after cath-eterization of the orifice of the celiac trunk according to Seldinger's method. The infusate included: pentoxifylline 10.0 ml, heparin 10 thousand units, and octreotide 0.3 ^g, followed by the introduction of cephalosporins of III or IV generation, or carbap-enems (daily dose 3-4 g). The second subgroup - 33 (26.4%) patients, DAI was performed locally, depending on the zone of vascular lesion. In this subgroup, the gastroduodenal artery was catheterized in 12 (36.4%) patients, the orifice of the trunk in 16 (48.6%) patients, the total hepatic artery (OPA) in 3 (9%) patients, and in 2 (6%), the catheter was inserted into the splenic artery. Prior to the initiation of prolonged intra-arterial infusion, the patients were stabilized by carrying out a number of necessary diagnostic and therapeutic measures. First
of all, it was video laparoscopic abdominal drainage performed in 21 (16.8%) patients. To ensure a permanent drug effect on the tissue level, the DAI was carried out in a continuous mode with the help of an infusion pump for six days.
To assess the degree of severity of AP, a prognostic chart was developed at the St. Petersburg Research Institute of Emergency Care, which
is convenient for clinical use and has high specificity and prognostic significance. As can be seen from the table (Table 2), the predominant form at admission was a moderate degree of AP, which was 89 (71.2%) patients, severe pancreatitis was in 36 (28.8%) patients. The study groups of patients were comparable in severity of acute pancreatitis (Table 1).
Table 1
Distribution of patients in groups according to the degree of severity of AP
Number of patients
AP degrees Main group Comparison group Total
n % n % n %
Slight - - -
Moderate 43 71,7 46 70,8 89 71,2
Severe 17 28,3 19 29,2 36 28,8
Total 60 100 65 100 125 100
Note: p>0,05
Evaluation of the effectiveness of arterial infusion was carried out according to the dynamics of the clinical course of the disease and changes in laboratory parameters, as well as ultrasound, MSCT of the abdominal cavity.
Results and methods
In the comparison group, upon admission there was recorded peripancreatic infiltrate in 41 (63.1%) patients, on the background of treatment - in 45 (69.2%). In the main group, peripancreatic infiltrate decreased during treatment in 34 (56.6%) patients (p <0.05). Sterile pseudocyst on the background of treatment was detected in 25 (41.7%) patients in the main group, which is considered a favorable outcome in the treatment of acute pancreatitis. In the comparison group, it appeared only in 11 (16.9%) patients (p <0.05). In patients of the main group during the treatment period, the infection rate of AP was 11.7%, and in the comparison group - 32.3%, which is by 20.6% more than in the main group (p <0.05). Against the background of local infusion therapy in the main group, the inflammatory process in the retroperitoneal tissue was previously stopped. Only in two cases (3.3%), sterile retroperitoneonecrosis progressed to infected ret-roperitoneonekrosis (retroperitoneal phlegmon). Whereas in the comparison group, it was detected in 11 (16.9%) patients (p <0.05). The incidence of infection and the spread of the purulent process beyond peripancreatic fiber was less in the main group than in the comparison group (Table 2). Thus, local antibiotic therapy in the orifice of the ce-liac trunk after the restoration of blood circulation reduces the frequency of purulent complications.
In the main group, there was no arrosive bleeding from the vessels of retroperitoneal tissue. In the comparison group, in 2 (3.1%) patients they
led to a lethal outcome. The development of the fistulas of the gastrointestinal tract during treatment was detected in 5 (7.7%) the patients in the comparison group, only one (1.7%) case of fistula was registered in the main group (p <0.05). Pancreatic fistula as a result of treatment developed in 1 (1.7%) of the patient of the main group, and in the comparison group - in 3 (4.6%) patients as a result of frequent sanations with the implementation of necrosequestrectomies. The course of acute pancreatitis in the comparison group was more severe than in the main group, and almost half had several intraperitoneal complications. High lethality - 10.7% - in the comparison group was the result of a high incidence of purulent-septic complications. Death in most patients is associated with the development of multiple organ failure due to an extensive purulent-necrotic process in the prostate and retroperitoneal tissue. Mortality in the main group was 5.0%, which is significantly less than the compared values (p <0.05) (Table 3).
The cause of death in two patients in the main group was multi-organ failure due to the development of extensive purulent necrotic damage to ret-roperitoneal tissue, and in one, it was associated with the appearance of a high intestinal fistula. Lethal outcomes occurred only in patients with severe forms of acute pancreatitis and accounted for 17.6% in the main group and 36.8% in the comparison group. Using the technology of intraar-terial local rheological therapy with alprostadil and disaggregants in combination with antibiotics can reduce the frequency of purulent-destructive complications. This led to a reduction in the number of open surgeries and sanation relaparotomies with the reduction of the length of stay of patients in the hospital.
Table 2
Intraabdominal complications in patients with acute pancreatitis at the time of admission and on the background of ongoing treatment
Comparison group Main group
(n=65) (n=60)
Complications Before Treatment Before Treatment
treatment outcomes treatment outcomes
n % n % n % n %
Sterile forms 53 81,5 32 49,2 51 85 44 73,3*
Infected forms 12 18,5 33 50,8 9 15,0 16 26,7*
Aseptic destructive complications:
Peripancreatic infiltrate 41 63,1 45 69,2 43 71,6 34 56,6*
Sterile pseudocyst 0 0 11 16,9 0 0 25 41,7*
Sterile retroperitoneonecrosis (changes in 35 retroperitoneal tissue) 53,9 24 36,9 32 53,3 30 51,2*
Purulent-destructive complications:
Infected retroperitoneonecrosis (retroperitoneal phlegmon) 9 13,8 20 30,7 7 11,7 9 15,0*
Infected pseudocyst (abscess) 0 0 8 12,3 0 0 5 10,0
Fistulas of the digestive tract 0 0 5 7,7 0 0 1 1,7*
Arrosive bleeding 0 0 2 3,1 0 0 0 0
Pancreatic fistula 0 0 3 4,6 0 0 1 1,7
Peritonitis 3 4,6 6 9,2 2 3,3 4 6,6
Sepsis 4 6,1 9 13,8 3 5,0 5 8,3
Note: * - significant differences between the indicators (p <0.05)
Results of treatment of patients in groups with acute pancreatitis Table 3
Indices Comparison group Main group N=60
Subgroup 2А Subgroup 2B
M±m M±m M±m
Number of patients (n) 65 27 33
Number of abdominal sanitations 2,8±0,1 1,7±0,2 1,3±0,1
Р1-2 <0,05 Р1-3<0,05 Р2-3>0,05
Inpatient days 35,8±2,1 27,8±3,2 23,6±2,8
Р1-2 <0,05 Р1-3<0,05 Р2-3>0,05
Lethality, n (%) 7 (10,7%) 3 (5,0%)*
Note: * - significant differences between the indicators (p <0.05)
Conclusions:
1. The technology of conducting local rheologi-cal therapy includes superselective catheterization of the gastroduodenal artery or catheter placement in the orifice of the celiac trunk using alprostadil, disaggregants for opening the pancreatic vascula-ture, followed by regional antibiotic therapy.
2. The use of local rheological therapy in patients of the main group at the early stages of treatment of acute pancreatitis of moderate and severe degree makes it possible to reduce the frequency of puru-
lent-destructive complications to 20.6%, the number of open surgeries and sanitations of the abdominal cavity to 1.5 ± 0.2, duration of treatment in a hospital up to 25.3 ± 2.4 days and reduce lethality.
References
1. B.S. Briskin, O.Kh. Khalidov, Yu.R. Aliyarov, A.E. Shebzukhov, E.A. Dobryakova, A.A. Landi-shevro View evolution in acute destructive pancre-
atitis surgical treatment. Annals of surgical hepatolo-gy. 2009; 3: 63-68.
2. Vinnik Yu.S., Cherdantsev DV, Pervova OV, Lopatin D.Yu., Miller S.V. Acute pancreatitis. A modern view of the problem. Krasnoyarsk; 2007: 52.
3. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Working Group IAP/APA (International Association of Pancreatology/American Pancreatic Association) Acute Pancreatitis Guidelines. Pancreatology. 2013; 13: 1-15.
4. Bromberg B.B., Maistrenko N.A., Shanin Yu.N. et al. The significance of platelet abnormalities in the prognosis of the outcome of acute pancreatitis. Regional blood circulation and microcirculation. 2013; 3(47): 4-10.
5. Cherdantsev D.V. Some features of the pathogenesis of the syndrome of systemic inflammatory response in patients with acute pancreatitis. Herald of the Clinical Hospital №51. 2009; 5: 19-25.
6. Liu LR, Xia SH. Role of platelet-activating factor in the pathogenesis acute pancreatitis. World J Gastroenterol. 2006;12(4): 539-545.
7. Grigoryev E.G., Molchanova O.V., Sada-kh M.V. Assessment of the state and viability of the pancreas in pancreatic necrosis according to intraoperative ultrasound. Infections in surgery. 2012; 10(4): 33-37.
8. Dibirov M.D., Larichev D.V., Yuanov A.A. Violation of central and peripheral hemodynamics in acute pancreatitis. Infections in surgery. 2010;8(2): 7-11.
9. Nesterenko Yu.A., Polyansky V.A., Lish-chenko A.N. Endovascular therapy in preventing purulent complications of destructive pancreatitis.
Kubanskii nauchnyi meditsinskii vestnik. 1995; 2-3: 39-40.
10. Ganaha F, Yamada T, Yorozu N. Vascular access system for continuous arterial infusion of a protease inhibitor in acute necrotizing pancreatitis. Cardiovasc Intervent Radiol. 1999; 22(5): 436-438.
11. Hackert T, Hartwig W, Frite S, et al. Ischemic acute pancreatitis: Clinical features of 11 patients and review of the literature. Am J Surg. 2009; 197: 450-454.
12. Khudaiberdiev R.I., Khidoyatov B.A., Yu-nukhojaev P.Yu. Microvascular bed of the pancreas. Morphology. 1994; 1(3): 115-124.
13. Shoikhet Ya.N., Dederer Yu.M., Roshchev
I.P. The importance of eliminating microcirculato-ry disorders in the area of the inflammatory focus in the treatment of sepsis. Surgery. 1989; 6: 58-61.
14. Pokrovsky K.A., Zubritsky V.F., Zabelin M.V., Bragin A.G. Effectiveness of regional intraarterial therapy in the complex treatment of patients with pancreatic necrosis. Moscow Surgical Journal. 2009; 5(9): 38-41.
Contacts
Corresponding author: Arutyunyan Genri Alek-sandrovich, assistant of the Department of Faculty Surgery named after Professor I.I. Neimark, hospital surgery with course of FVE of the Altai State Medical University, Barnaul. 656056, Barnaul, ul. Lyapidevskogo 1. Tel.: (3852) 689674. Email: genriaurum@ya.ru
Aliyev Aleksandr Rushtievich, Candidate of Medical Sciences, Associate Professor of the Department of Faculty Surgery named after Professor I.I. Neimark, hospital surgery with course of FVE of the Altai State Medical University, Barnaul. 656056, Barnaul, ul. Lyapidevskogo 1. Tel.: (3852) 689674. Email: science@agmu.ru
Vlasov Konstantin Evgenievich, Head of the Department of purulent surgery of the Regional Clinical Hospital, Barnaul. 656056, Barnaul, ul. Lyapidevskogo 1. Tel.: (3852) 689674. Email: science@agmu.ru
Arzamastsev Denis Dmitrievich, Candidate
of Medical Sciences, Head of the Department
of X-ray endovascular surgery of the Regional
Clinical Hospital, Barnaul.
656056, Barnaul, ul. Lyapidevskogo 1.
Tel.: (3852) 689674.
Email: science@agmu.ru
Petrenko Vasily Gennadievich, physician of the Radiation Diagnostics Department of the Regional Clinical Hospital, Barnaul. 656056, Barnaul, ul. Lyapidevskogo 1. Tel.: (3852) 689674. Email: science@agmu.ru
