Поздние осложнения острого панкреатита: диагностика и лечение

• Автор: Тадепалли, Роу Нареш
• Шифр специальности: 14.00.27
• Научная степень: Кандидатская
• Год защиты: 2002
• Место защиты: Москва
• Количество страниц: 143 с.

INDEX
PAGE
INTRODUCTION
CHAPTER 1 : LATE COMPLICATIONS OF ACUTE
PANCREATITIS: DIAGNOSIS AND
MANAGEMENT (REVIEW OF LITRATURE).
CHAPTER 2: MATERIAL AND METHODS
2.1 SELECTION OF PATIENTS.
2.2 INVESTIGATIVE MODALITIES.
CHAPTER 3: OBSERVATIONS
3.1 CLINICAL MANIFESTATIONS.
3.2 INVESTIGATIONS.
3.3 MANAGEMENT.
3.4 COMPLICATION.
3.5 MORTALITY AND MORBIDITY.
CHAPTER 4: DISCUSSION
ALGORITHM
SUMMERY
CONCLUSION
PRACTICAL RECOMMENDATIONS
REFERANCES

INTRODUCTION:
Pancreatic necrosis is associated with high mortality and morbidity world
over.
The different mortalities of operative procedure have been found to be as
follows:
Banks (1971) 54%
Warshaw (1974) 34%
Camer (1975) 28%
Jones et al (1975) 11%
Ranson and Spencer (1977) 26%
Frey etal (1979) 37%
Saxon et al (1981) 5%
Bardley and Fuleninder (1984) 30.5%
Warshaw and Jin (1985) 5%
Hollenderetal (1987) 25%
Beger (1989) 10%
Saw etal (1991) 17%
Reberetal (1991) 20%
Rattner et al (1992) 25%
A large amount of research has been done to understand the process of pancreatic necrosis , its diagnosis and management.
Different studies have had different observations and given different conclusions.
Blazer, in 1879, made the first recorded observation of pancreatitis with fat necrosis , Reginald Fitz (1889) was the first person to give accurate description and classification of acute pancreatic disease, in which he distinguished three types of inflammation; - haemorrhagic; gangrenous and suppurative pancreatitis, with the different symptoms accompanying each.
Inl925, Lord Moynihan further delineated the surgical approach to pancreatitis, Wherein he out lined the principles of lesser sac drainage and debridment, and these are very nearly followed till date.
The reported incidence of pancreatic necrosis in acute pancreatitis varies from: 1-9%, as evaluated by various authors such as Altemerier(1963); Far-
ringer( 1966-67); Lukash(1967); Evans(1969); Cogbill(1970); and Grace(1976).
E.C.P.Shi et al and Warsaw (1984) reported an incidence of about 4% in cases of acute pancreatitis
Yeo and Cameron(1990) reported an incidence of pancreatic necrosis to be 5% as a complication of acute pancreatitis.
Bardley(1982) reported an incidence of 8.5% in his series.
As per H.G.Beger(1989), necrotising course of acute pancreatitis develops in 8-15% of patients.
E.L.Bradley III (1997), reports an incidence of 19.5%, of pancreo-necrosis, from a prospective study of 194 patients presenting with acute pancreatitis, using dynamic pancreatography as a standard for detection.
Buchler et al, (1999) in a retrospective study have reported to have an incidence of 20% of pancreatic necrosis, in patients admitted for acute pancreatitis.
CT-scan offers better visualization of the retroperitoneal structures and better overall visualisation of the pancreas: according to Mender (1980) and Silver-stein (1981). In contrast, Danmann (1980) observed that CT changes do not always correlate with disease severity.
Siler and Wulsin in 1950, pointed out that for pancreatic collection, operation should be sufficient to ensure adequate drainage, but extensive exploration should be avoided.
As stated by Blumenthal et al (1959), while the treatment of acute pancre-atits is largely medical, the treatment of its complications and squeal are largely surgical.
Bradley (1987), in his series of 28 patients managed the infected pancreatic necrosis by extensive de-roofing of the superior retro peritoneum, blunt pancreatic

Some of the results are as follov :
Authors Procedures performed Survivors/Total
l.Chau et al (1959) Subtotal pancreatectomy (40%) 1/1
2.Khedroo &Casella (1966) Subtotal pancreatectomy (2/3rd) 2/2
3. Waterman (1968) Sump drainage of pancreas 9/10
4.Lawson et al (1970) Triple-ostomy with drainage 7/11
5.Warshaw et al (1974) Triple-ostomy with drainage: 5-abscess 1-pseudocyst
2-pancreatic debridment 12/18
6.Hubbard et al (1972) Debridment & drainage 3/3
7.Jordan et al (1972) Drainage of pancreas 9/21
8.Nortan & Eiseman (1974) 2-drainage of pancreas & biliary de
compression 4-subtotal pancreatectomy & sple- 0/2
nectomy 3/4
9.Dritsas (1976) Near total pancreatectomy ;gastro
duodenectomy, hemicolectomy 1/1
lO.Langerbeam (1976) 4-drainage 4/4
2-debridment & marsupalisation 1/2
3-sub total resection (75-90%) 3/3
11 .White/Heimbach (1976) All had drainage of pancreas, triple
osteomy 24/30
12.Ranson (1979) 4-drainage & triple ostomy 4/4
5-distal sub-total resection 0/5
13.Rosato (1981) Debridment & drainage 9/9
14.McCarthy & Drainage 12/29
Dickerman (1982) Debridment 9 6/9
Indication of Surgery in acute pancreatitis:
1 .Uncertain diagnosis. In certain situations it may be difficult to reliably exclude peritonitis or intestinal strangulation from acute pancreatitis, necessitating an exploration. Rarely acute pancreatitis and other intra-abdominal problems may coexist.