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II. ХИРУРГИЯ
YAK 616.37- 001- 0.89
ABOUT THE AUTHORS
Ibadildin Amangeldi Seitkazievich - doctor of medical sciences, professor, the head of the Department of *Surgical diseases №2», KazNMU n/a S.D. Asfendiyarov;
Kravtcov Valery Ivanovich - the head of operational department of the Military clinical hospital of Defense Ministry of Kazakhstan Republic;
Paltushev Abduvaly Abdumukhametovich - medical service major, the head of the Department of purulent surgery of the Military clinical hospital of Defense Ministry of Kazakhstan Republic, pal2sheff@gmail. com;
Ibadildina Saule Amangeldyevna - candidate of medical sciences, senior lecturer in *Sports Medicine" Academy of Sports and Tourism.
Keywords:
pancreatic trauma, post-traumatic pancreatitis, pancreatic necrosis.
¥йкы 6e3i жаракатыньщ ашык жэне эндоскопиялык тэсшмен емдеудщ нэтижелер1
Ибадильдин A.C., Кравцов В.И., Ибадильдина С.А., Палтушев A.A.
С.Д. Асфендияров атындаш казак улттык медицина университет!, Алматы к. К,Р К,К Эскери клиникалык госпиталь, Алматы к. Казак Спорт жэне Туризм Академиясы, Алматы к.
Ацдатпа
Авторлардьщ емдеу тэж1рибес1 бойынша уйкы безi жаракатымен 115 зардап шегушшер айкындалеан. Зардап шегушлердщ 63,5% отадан кейшп кезенде птравматикальщ панкреатит дамыса, ал 21,7% -да панкреонекроз. Тутас eлiм-жiтiм 25,4 курады. Tiкелей уйкы безiнiн жаракаты бойынша eлiм-жiтiм 9,6%, ал программаланеан сана-циялаулы видеобурсооментоскопия бойынша eлiм-жiтiм саны 5,8% еа дейiн темендедi.
Авторлардын пк'р бойынша, абдоминизация жэнепрограммаланеан санациялаулы видеобурсооментоскопия колданеан жаедайда уйкы безiнiн жаракатымен зардап шеккендердiн елiм-жiтiм саны азайып, жаксы нэтиже берелн ед'!.
Результаты открытых и эндоскопических методов лечения травм поджелудочной железы
Ибадильдин A.C.1, Кравцов В.И.2, Палтушев A.A.2, Ибадильдина С.А.3
'Казахский Национальный медицинский университет им.С.Д.Асфендиярова, г.Алматы, Казахстан; 2Военный клинический госпиталь Министерства обороны Республики Казахстан, г. Алматы, Казахстан. 3Казахская Академия Спорта и Туризма, г. Алматы, Казахстан.
Аннотация
Авторы располагают опытом лечения 115 пострадавших с травмой поджелудочной железы. В послеоперационном периоде у 63,5% пострадавших развился травматический панкреатит, причём у 21,7% панкреонекроз. Общая летальность составила 25,4%. Летальность непосредственно связанная с травмой поджелудочной железы составила 9,6%, а при выполнении программированной санационной видеобурсооментоскопии снизилась до 5,8%.
Авторы считают, что использование абдоминизации и программированной санационной видеобурсооменто-скопии позволяет улучшить результаты лечения и снизить летальность у пострадавших с травмой поджелудочной железы.
RESULTS OF OPEN AND ENDOSCOPIC METHODS OF TREATMENT OF PANCREATIC INJURY
Ibadildin A.S.1, Kravtcov V.I.2, Paltushev A.A.2, Ibadildina S.A.3
1Kazakh National Medical University named after S.D. Asfendiyarov, Almaty, Kazakhstan. 2Military clinical hospital of Defense Ministry of Kazakhstan Republic, Almaty, Kazakhstan. 3Kazakh Academy of Sport and Tourism, Almaty, Kazakhstan.
Summary
The authors have experience in treatment of 115 patients with pancreatic trauma. The postoperative period was complicated with traumatic pancreatitis in 63.5% and pancreatonecrosis in 21.7% of injured. Common mortality was 25.4%. The mortality level of directly related pancreatic injury was 9.6%, and in case of programmed sanation video bursoomentoskopy implementation decreased to 5.8%.
The authors considers that applying of abdominization and periodical video assisted sanitation of the omental bursa can improve treatment outcomes and reduce mortality in patients with pancreatic trauma.
АВТОРЛАР ТУРАЛЫ
Ибадильдин Амангельды Сейтказиевич
- м.е.д., профессор, «№2хирургиялык аурулар»кафедрасынын менгеруш1с1, С.Д. Асфендияров атындаеы казак улттык медицина университет, Алматы к.
Кравцов Валерий Иванович -КК Эскери клиникалык госпитал1н1н операциялар бел1м1н1н бастыеы, Алматы к.
Палтушев Абдували Абдумухаметович
- медицина кызметшщ майоры, Эскери клиникалык госпиталшщ i:рШi хирургия бел1м1нщ бастыеы, Алматы к. [email protected].
Ибадильдина Сауле Амангельдиевна -м.е.к., спорт жэне туризм Академиясынын «Спорт медицинасы»кафедрасынын аеа окытушысы.
Туйш сездер
уйкы безшщ жаракаты, жаракаттанудан кей1нг1 панкреатит, панкреонекроз, программаланеан санациялаулы видеобурсооментоскопия.
ОБ АВТОРАХ
Ибадильдин Амангельды Сейтказиевич -д.м.н., профессор, заведующий кафедрой «Хирургические болезни №2», Казахский Национальный медицинский университет им. С.Д. Асфендиярова, г. Алматы;
Кравцов Валерий Иванович - заведующий операционным отделением Военного клинического госпиталя МО РК, г. Алматы;
Палтушев Абдували Абдумухаметович -майор медицинской службы, начальник отделения гнойной хирургии Военного клинического госпиталя МО РК, г. Алматы.
Ибадильдина Сауле Амангельдыевна -к.м.н., старший преподаватель кафедры «Спортивная медицина»Академии спорта и туризма, г.Алматы.
Ключевые слова:
травма поджелудочной железы, посттравматический панкреатит, панкреонекроз, программированная санационная видеобурсооментоскопия.
Relevance of topic
Treatment of pancreatic injury is an actual problem in surgery, both in peacetime and in wartime. This is due not only to the growth of injuries, but also the difficulty of the treatment of injured, a lot of complications and high mortality as well.
Anatomical features and physiological significance of pancreas determine the complexity of trauma diagnosis, the severity of the pathological process and the choice of therapeutic tactics when it is wounded.
Pancreatic injuries are among the relatively infrequent, but usually difficult to diagnose and severe injuries. They are found in 1-8% of patients with abdominal trauma, usually in combination with damage to other organs and make up 15-20% among damages of abdominal organs [1, 7, 10].
The most important complication of severe pancreatic injury is traumatic pancreatitis. According to the literature review during pancreatic injury it develops in 28-100% of cases [1, 2] has different morphological forms of aseptic to infected pancreatic necrosis and accompanied by lesions of the retroperitoneal fat. Mortality in the isolated pancreatic injury is from 17.5 to 32.3%, and in complex injuries, it reaches 40-57%. When the head of a gland is injured mortality is 2 times higher than in cases when the body and tail are [1, 2, 7]. The main reasons are arrosive hemorrhage and multiple organ failure associated with inflammatory conditions of retroperitoneal space and sepsis [1, 3]. Increasing number of patients with severe pancreatic injury, high mortality rate and the lack of standardization in the treatment of this category of patients is an urgent problem nowadays.
The purpose and objectives of the study
To summarize clinical experience in applying bursoomentostomi and periodical video assisted sanitation of the omental bursa in the treatment of pancreatic injuries.
Materials and methods
There were 115 patients on treatment with pancreatic injury in our clinic since 1986 to 2016, which is 7.3% of all hospitalized with abdominal trauma. There were 89 (77.4%) men, 26 (22.6%) women. The age of patients was from 32 to 57 years. 49injured were impaired by alcohol, which made 43% of all patients with pancreatic injury. During the 1st day 100 (87%) injured were accepted in the clinic where during the first 2 hours arrived - 64 (64.2%) and after 1 day or more - 15 (13%) patients. Patients of all groups dominated
by the trauma of criminal character 72 patients (62.4%), 37 (32%) patients received injuries in car accidents, 6 (5.6%) patients - work injury. Isolated pancreatic damage was observed in 33 (29%), multiple - 52 (45%), complex - 30 (26%) patients. Non-penetrating abdominal trauma was the cause of damage to the pancreas in - 62 (53.7%) of patients, with penetrating stab wounds - in 50 (43.5%) patients, gunshot wounds - in 3 (2.8%) patients. Liver injury (21%), spleen (14.1%), large vessels (12%), colon (12%), stomach (10.5%) were frequently observed in cases with multiple lesions.
Damage to the head of the pancreas occurred in 27 (23.5%) patients, to the body - in 59 (51.3%), to the tail - in 29 (25.2%) of patients.
Diagnosis of pancreatic injury was based on clinical symptoms, results of laboratory and instrumental ultrasound and CT studies. Primary surgical treatment was performed with knifewounds and gunshot wounds, and in penetrating wounds laparotomy was performed. In cases when there was closed abdominal injury as an indication for surgery was a presence of peritonitis or intra-ab-dominal bleeding. Paracentesiswas performed to all patients with closed abdominal injury. Informative diagnostic accuracy of abdominal paracentesis was 92%.
To the patients with abdominal injuries the laparotomy was performed from medial access under endotracheal anesthesia that provides a complete revision of the abdominal cavity and retroperitoneal space.
The indications for pancreas exploration were the wounds directed toward the pancreas and penetrating into the packing bag, the presence of blood in it, hematoma in the pancreas and retro-peritoneum. For the operative exploration of pancreatic gland gastrocolic ligament was opened in the middle third in the region with the lowest number of vessels, which allowed to make a full exploration of all segments of the pancreas and parapancreatic zone. Further surgical approach depended on the damage level to the prostate and surrounding organs. The classification of the American Association of Trauma Surgeons (AAST) was used to determine the degree of anatomical destruction of the pancreas [www.aast. org/Library/TraumaTools/InjuryScoringScales. aspx#pancreas].
77 (67%) of patients had a pancreas contus-sion, subcapsular hematoma, small non-bleeding visible wounds (grade I acc.to AAST).
In 25 (21.7%) cases, the injured were with deep wounds of the pancreas with heavy bleeding without damaging Wirsung's duct (grade II acc.to AAST).
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ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 1-2017
The trauma of the pancreas with a full cross-break and Wirsung duct injury occurs in 8 (7%) patients (grade III acc.to AAST).3 (2.6%) patients had damage to the proximal segments of pancreas with a Vater nipple damage (grade IV acc.to AAST).
2 (1.7%) patients were with massive destruction of the pancreatic head with damage to 12 duodenum and the common bile duct (grade V acc.to AAST)
Small non-bleeding visible pancreatic injuries (grade I acc.to AAST) were not sutured. Bur-soomentostomi was formed, through which the omental and retroperitoneal fat was sanitized.
With deep wounds of the pancreas (grade II acc. to AAST) with heavy bleeding, bleeding vessel was pierced with minimum damage gland tissue. Fabric gland and organ of the capsule is not sutured, which contributed to the drainage of pancreatic juice and wound content of the pancreas. The operation ends with bursoomentostomi overlay and drainage of the abdominal cavity.
Distal resection bursoomentostomi, abdominal drainage was fulfilled in cases when tears and wounds were larger than half the diameter of the full transverse rupture of pancreas and with injury of Wirsung duct (grade III acc.to AAST).
A careful hemostasis gland injury site with bandaging and stitching blood vessels has been made in cases when there were lesions proximal pancreatic involving the major duodenal papilla (grade IV acc.to AAST) . If it is impossible to carry out a reliable hemostasis the bleeding zone was swabbed. The operation was completed through the drainage of omentalbursoomentostomi, drainage of retroperitoneal fat behind the head of the pancreas through counteropening on the right side of the abdomen. In all cases, biliary tree ducts and the abdominal cavity were drained.
In cases with the massive destruction of the pancreatic head with simultaneous damage to the duodenum, the common bile duct (grade V acc. to AAST) the minimum amount of the operation to save the life of the injured had been carried out. Hemostasis was conducted by stitching or plugging bleeding sites. The duodenum wound was sutured excluding the gut of the passage of food. When impossible to take in the gut wound duode-nostomi formed. The operation was completed with bursoomentostomi drainage of the bile ducts, retroperitoneal fat, the abdominal cavity. With damages of grade II-V abdominization of the gland had been carried out.
Results and discussion
Before 2008, main surgical tactics to the patients with pancreatic injury was careful hemosta-
sis, drainage of omental sac, retroperitoneal fat, and abdominal cavity. The wounds of the pancreas were not sutured. If the damage to pancreas was grade III-V according to AAST the biliary tree was drained. Abdominization of pancreas and bur-soomentostoma allowed to carry out adequate drainage of parapancreatic and omental fat. Since 2008, our hospital began to carry out periodical video assisted sanitation of the omental bursa to patients with pancreatic injury. To perform it during operation two special laparoport swere sewn into the packing bag (patent №19772, 28.05.2008) periodical video assisted sanitation of the omental bursa.
In postoperative period, periodical video assisted sanitation of the omental bursa was performed at the endoscopic stand firm taking into considiration intensive care background starting from 5th day. The basic technological principle of the operation is to remove only necrotizing tissue or purulent sequesters of pancreas and peripan-creatic mass with maximum sparing to unmodified tissue,the lavage of peritoneal omental sac and evacuation of fluid. At the apparent inflammatory and necrotic changes in the pancreas and para-pancreatic tissue sanation carried out in 2 days. When pathological process decreased sanation was carried out at longer intervals. In the absence of purulent discharge, sequesters and reduce of the discharge from the peritoneal omental sac up to 20 mL and normalization of test results periodical video assisted sanitation of the omental bursa was seased. There were no omental, subhepatic and subdiaphragmatic abscesses. This method of treatment was applied to 17 patients showed high efficiency. In this group, 1patient died from arrosive hemorrhage. Mortality in this group was reduced to 5.8%.
In postoperative period, 73 (63.5%) patients developed post-traumatic pancreatitis, and in 25 (21.7%) - pancreatic necrosis. Arrosive hemorrhage occurred in 11 patients (9.6%), peritoneal omental sac abscess in 7 (6%), obstructive abscess in 5 (4.3%) patients, peritonitis was observed in 12 (10.4%) patients with damage to the intestines, stomach, liver. After partial distal resection of the pancreas in 2 cases there were formed fistulas of the gland, which were repaired after conservative therapy.
Overall mortality rates were (25.4%) that is 29 people, 18 (64%) patients died the first day because of combined injuries incompatible with life, severe shock and bleeding. 11 injured (9.6%) patients died from complications directly related to pancreatic injury: arrosive hemorrhage and septic
complications. Mortality in this group was 9.6%. And in the group of patients who underwent periodical video assisted sanitation of the omental bursa mortality was 5.8%.
Consequently, when the pancreas injury is grade II-V according to AAST it is necessary to perform an abdominization of the gland with peritoneal omental sac and the peritoneal cavity drainage. If the damage is III degree according to AAST distal pancreatectomy must be performed. In postoperative period, the use of periodical video assisted sanitation of the omental bursa can improve response to the treatment and reduce mortality.
References
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Conclusions
In cases of pancreatic injury it is optimal to use classification of AAST, allowing to unify the surgical approach.
Information and diagnostic consideration of laparocentesis during pancreatic injury 92%.
The main cause of complications and death to our patients with pancreatic trauma were arrosive hemorrhage (9.6%), peritonitis (10.4%) and septic complications such as omental abscess (6%), obstructive abscess (4.3%) .
Periodical video assisted sanitation of the omental bursa has reduced mortality to 5.8% to patients with pancreatic injury.
6. UrmanMG.Abdominal trauma// Perm: IPK "Star", -2003, - P. 259.
7. Demidov VA, ChelnokovDL. Treatment of injuries of the pancreas// Surgery,- 2009; 1: 44-48 p.
8. Panov RA. Pancreatogenicomentobursites: Author... Thesis for kand. ofmedical sciences, -SPb, 2000, -172 p.
9. Galkin RA. Damages of Pancreas// Surgery,-1978-№7- 83-87 p.
10. Vasguez IC, Coimbra R., Darid B. et al. Management of penetrating pancreatic trauma: an 11-year experience of level-1 trauma center injury// 2001;32:753-759.
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