Surgical treatment of acute pancreatitis: indications and methods of surgical tactics

When is surgery necessary?

Inflammation of the pancreas causes severe damage to human health. Sometimes conservative treatment does not bring relief, and the disease must be treated surgically. Often surgery for pancreatitis is performed to save the patient’s life.

Indications for various forms of inflammation of the pancreas

Surgery for acute pancreatitis is performed in the following cases:

• trauma or injury to the abdominal cavity;
• obstructive jaundice caused by biliary tract infection;
• unclear diagnosis;
• pancreatic necrosis or hemorrhagic pancreatitis;
• bleeding, abscess, intestinal perforation.

Indications for surgery in chronic forms of the disease:

• virsungolithiasis (stones in the gland ducts);
• violation of the patency of the pancreatic ducts;
• chronic pancreatitis with diseases of the liver, stomach, duodenum;
• chronic pancreatitis with persistent pain;
• suspected pancreatic cancer;
• fistulas and cysts;
• duodenostasis.

Surgical treatment of chronic pancreatitis is conventionally divided into:

• pancreas surgery;
• surgery of the stomach and duodenum;
• removal of the gallbladder;
• interventions in the autonomic nervous system.

Operations, depending on the timing of execution, are:

• Early. They are carried out a week after the onset of the disease in cases of peritonitis, acute pancreatitis with destructive cholecystitis, and unsuccessful conservative treatment.
• Late. About a month after the onset of the inflammatory process, with suppuration of necrotic tissue of the pancreas, abscesses.
• Deferred. Aimed at preventing relapses, they are carried out a month or more after an attack of pancreatitis.

Dosage

In case of absolute pancreatic insufficiency, the daily requirement for lipase is 400,000 units. This situation occurs extremely rarely, so the correct dosage is selected individually. Start with a minimum dose - 1 tablet for each meal. An adult is allowed to take 18 pieces per day. Without consulting a specialist, you can take no more than 4 tablets per day. The duration of therapy depends on the severity of the disease, the minimum course is 7 days, the average is a month.

What types of operations are performed?

Of the several existing types of operations for chronic pancreatitis, the following are used in practice:

1. Longitudinal anastomosis of the pancreatic duct (pancreatojejunal anastomosis). This type of surgical intervention is chosen when the diameter of the pancreatic duct is from 8 mm, which happens with extensive damage to the main duct of the gland.
2. Pancreatic resection:

• Left-sided caudal . In case of damage to the distal pancreas while maintaining patency of the duct, this type of surgical intervention is performed, combining it with splenectomy (removal of the spleen). If the patency of the Wirsung duct is impaired, the operation is supplemented with internal drainage of the ductal system.
• Subtotal. Carry out for chronic pancreatitis affecting the tail, body and part of the head. Almost the entire gland along with the spleen is removed, leaving a small part near the duodenum.
• Pancreatoduodenal. This type of operation is performed when the head of the gland and the common bile duct are affected. The advantage of this type of operation is that it preserves the ability of the gland to produce insulin. A V-shaped dissection is made in the anterior part of the gland body until the end of the duct. A loop is created from the small intestine, through which pancreatic enzymes will be delivered to the duodenum. The operation relieves pain in most patients undergoing surgery.
• Total duodenopancreatectomy . The operation is indicated for persons with extensive necrotic lesions of the parenchyma and associated necrosis of the duodenal wall. This is usually the second operation in patients with diffuse chronic pancreatitis. Surgery for pancreatic necrosis has a very difficult postoperative period, resulting in many deaths.

Compared to resection, pancreaticojejunostomy is easier to perform , does not impair the functioning of the organ, causes fewer postoperative complications, and has low mortality.

Attention! Surgery for alcoholic pancreatitis does not restore the gland and its functioning. The main goal of the operation in this case is to eliminate pain.

Complications

The drug is well tolerated and does not cause side effects when used correctly. Adverse effects occur with uncontrolled use of the drug, or overdose. The first sign that you need to stop treatment is diarrhea, an exacerbation of symptoms of pancreatitis. In addition, long-term use of the medication can lead to:

• Skin rashes;
• Increased uric acid in urine;
• Narrowing of the small intestine;
• Obstruction;
• The appearance of ulcers, erosions;
• Irritable bowel syndrome.

In most cases, the condition normalizes gradually after discontinuation of the drug; sometimes special treatment, even surgery, is required. Pancreatin itself is not dangerous to the body. Its metabolites quickly leave the body without disrupting the functions of systems and organs. Improper use of the medication can lead to dangerous consequences.

Surgical treatment of acute pancreatitis

Acute pancreatitis of the pancreas is treated surgically in cases of the following complications of pancreatic necrosis:

• peritonitis;
• abscess;
• cholangitis, blockage of the duodenal papilla with a calculus;
• bleeding in areas of necrosis;
• obstruction of the small intestine.

The following types of operations are practiced:

• Diagnostic laparoscopy. Several small incisions are made on the anterior abdominal wall to insert instruments and a probe. The stomach is filled with carbon dioxide. Removal of dead areas of parenchyma and abdominization are carried out. A large dose of antibiotic is administered to reduce the risk of postoperative infection. The wounds are sutured and treated with an antiseptic. If it is impossible to do the necessary work during the procedure, a laparotomy is performed immediately.
• Laparocentesis. Performed for ascites to remove contents under the supervision of an ultrasound machine. An incision is made along the abdominal line 2-3 cm from the navel, the skin, subcutaneous fat and abdominal muscles are dissected. The final puncture is carried out with a trocar, and it is inserted into the abdominal cavity with a rotational movement. The liquid flows out slowly, approximately 1 liter per 5 minutes. Afterwards, a tight bandage is applied to the puncture, and the abdomen is tightened with a gauze bandage to maintain pressure.
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• Laparotomy. Abdominal surgery is performed with a transverse incision or an incision is made in the right hypochondrium. The omental bursa is opened and access to the pancreas is provided. The gastrocolic ligament is dissected, and hooks are inserted to examine the anterior surface of the gland. Dead areas are removed by excision or removed with fingers. During the day, continuous lavage of the omental bursa is carried out, for which 2 afferent and outlet drains are inserted. The omental bursa is closed with separate sutures and the gastrocolic ligament is reconstructed to provide a closed irrigation system.
• Lumbotomy. Performed for phlegmon of parapancreatic tissue under general anesthesia. An incision is made parallel to the ribs along the posterior axillary line down to the muscles 5-7 cm long. The muscles are moved apart, the phlegmon is opened and silicone drainage tubes with a diameter of 1.5 cm are inserted and the purulent contents are removed. The drainage is fixed. Sanitation of the cavity is carried out every other day.

Instructions

The tablets should be drunk whole without chewing. It is forbidden to divide or break. Otherwise, efficiency decreases. Useful components will be neutralized by an acidic environment. Take with plenty of liquid. It is best to use non-carbonated mineral water. Consume during meals or immediately after a meal. Pancreatin is combined with other medications for the treatment of pancreatitis, folk remedies.

Pancreatin in acute form

Experts prescribe the drug when digestive functions are impaired. As for contraindications, one should take into account the fact that the clinical picture during an exacerbation can be different. If debilitating vomiting or severe diarrhea is observed, you should immediately contact a specialist. In this case, droppers of different mechanisms of action, drugs to reduce acidity, and many other medications are prescribed. In the first days, complete fasting is indicated, so there is simply no point in taking Pancreatin.

If the exacerbation is more like the subside of the acute form - nausea without vomiting, bloating, flatulence, heaviness in the stomach, heartburn, belching, drinking Pancreatin is allowed, but in acceptable doses - an average of 4 tablets per day. In this case, the duration of treatment will be no more than a month. At the same time, you should adhere to a diet and a proper lifestyle.

Difficulties in pancreas surgery

Surgery on the pancreas for pancreatitis is performed if the safety of the patient’s life depends on it. Surgery is used for pancreatitis in 6 to 12% of patients.

The pancreas is a very unpredictable organ that requires careful and even gentle handling. It is impossible to say with certainty how it will behave during the operation; moreover, the inconvenient location makes the operation difficult.

The pancreas is located very close to several important “positions” at the same time:

• Abdominal aorta.
• Common bile duct.
• Kidneys.
• Superior and inferior hollow arteries.
• Superior mesenteric vein and arteries.

Important! The pancreas communicates with the duodenum through the general blood flow, which complicates the operation. Pancreatic tissue is not resistant to damage; after operations on the pancreas, fistulas often form and bleeding occurs.

Surgeries on the pancreas are complex and the mortality rate is very high. The most disappointing prognosis after surgery for pancreatic necrosis. Of course, a lot depends on the timeliness of the operation, the general health of the patient, and his age.

Poor prognosis after surgery for malignancy. Such patients are at high risk of disease recurrence. With a responsible attitude towards health, following doctor’s orders, and following a diet, the prognosis is more optimistic.

Patient reviews

Ekaterina, 27 years old: I took Pancreatin to normalize digestion after overeating fatty and fried foods. A very good remedy. Within three days, the abdominal pain, flatulence, and bloating disappeared. I was also prescribed this drug to prevent damage to the pancreas as part of serious antibiotic treatment.

Oleg, 39 years old: I have chronic pancreatic insufficiency, so I constantly need to take enzyme medications. I have been taking Pancreatin for about a year now with breaks every 2 weeks. It really helps to compensate for the deficiency of your own enzymes and maintain digestion at the desired level.

Elena, 34 years old: I had part of my pancreas removed. I also take Pancreatin. Periodically, the doctor replaces it with Creon or Mezim. During breaks in taking enzymes, you must follow a strict diet and completely avoid fats.

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Postoperative pancreatitis

The pancreas is an organ that is extremely sensitive to mechanical damage. Unfortunately, surgical interventions on the pancreas, stomach, and papilla of Vater can initiate postoperative pancreatitis. Often a complication occurs during difficult operations on the stomach and duodenum.

Important! Pancreatitis after surgery often occurs with a long course of cholecystitis, cholangitis and choledocholithiasis. The disease is diagnosed as edematous or destructive pancreatitis. Mortality is very high - approximately half of cases of postoperative pancreatitis end in the death of the patient.

Reviews from patients who have undergone pancreatic surgery indicate the importance of following diet and medical prescriptions.

Action

The active substances are not absorbed by the intestines and are excreted unchanged from the body in feces. They begin to act within a few minutes, maximum activity is observed after 45 minutes. Enzymes break down fats, starch, and proteins, speeding up the digestion of food. Thanks to the normal functioning of the digestive tract, heaviness, bloating, nausea, heartburn, belching, and flatulence disappear.

In severe cases of pancreatitis, the drug is taken every time after meals, since the pancreas cannot produce the necessary enzymes. With a moderate clinical picture, to prevent exacerbations, drink the drug 1-2 times a day. The therapeutic effect occurs almost immediately, but it is necessary to achieve stable remission and restoration of pancreatic function. A course of at least 2 weeks is required.

Analogs

The pharmacy can offer a wide selection of analogues with the same active ingredient or similar effect.

Enteric-soluble tablets with the active ingredient pancreatin. Take 2 pcs during, after, and before meals. The daily dose reaches 18 pieces, selected individually. Among the main contraindications, manufacturers indicate individual intolerance, acute pancreatitis.

It is produced in the form of capsules with different dosages of the active substance. The upper shell protects enzymes from the influence of an acidic environment. Not absorbed by the intestines, excreted in feces. It works on the basis of pancreatin hydrochloride. Indications and contraindications are similar.

The active substances of the enzyme medicine are protease, amylase, lipase. Breaks down fats, carbohydrates, proteins, helps digest food. Drink during or after meals. The dose is selected individually. Prescribed with caution to pregnant and lactating women. A direct contraindication is individual intolerance to the components.

In general, all analogs have an identical mechanism of action and contain the same active substances.

Other analogues:

The price of analogues is from 50 rubles. Up to 1000 rub. Available without a prescription, but consultation with a specialist is advisable.