Conventional and Ultrasound-Assisted Focused Open Necrosectomy in the Treatment of Necrotizing Pancreatitis. Summary of the Doctoral Thesis

Abstract

Morbidity in acute necrotic pancreatitis is increasing in general in Latvia, Europe, and America. This disease is associated with a very serious course, as well as a large number of complications and mortality. In spite of the development of new technologies and the application of various minimally invasive surgical treatments, radical improvement in the results of acute necrotic pancreatitis treatment is lacking. To date, a conventional, open operation is considered a standard for surgical treatment, although the results of this surgery cannot be described as satisfactory. A team of the Surgery Clinic of the Riga East University Hospital “Gailezers” under the leadership of Professor G. Pupelis has developed an original minimally invasive, focused open method for surgical treatment of acute necrotic pancreatitis. This method has been successfully approbated and introduced in everyday practice. Given the novelty of the method, there is a need to compare the new treatment options with conventionally accepted methods. The study included 182 patients with severe acute necrotic pancreatitis, who had been subject to conservative treatment at an early stage of the disease and surgical treatment (necrosectomy) at a late stage of treatment. All patients were treated at the Surgery Department No. 10 and No. 13 of the Riga East University Hospital “Gailezers” from 2004 to 2017. All patients included in the study were divided into two major groups: a control group and a study group. In the study group, surgical tactics were applied, respecting the principles of focused open surgery, and focused open necrosectomy performed. In the control group, conventional surgical tactics were applied and an open operation performed. The hypothesis of the thesis: the application of the ultrasound-assisted FON approach improves the accuracy of perioperative diagnostics, reduces the risk of operation, enables the use of the step-up approach in high-risk patients with severe sepsis, thus reducing the duration of treatment in the intensive care unit, the total number of complications, and mortality. Scope of the Research – conduct a comparative study of the focused open necrosectomy (FON) approach, evaluating the efficacy, safety and compliance of sepsis control with the principles of modern minimally invasive surgery in the treatment of acute necrotic pancreatitis. Objectives of the Research – conduct a comparative study of the innovative FON approach and the conventional open surgical approach according to the following criteria: • Analysis of the inflammatory response dynamics; • Duration of surgery; • Duration of hospitalization; • Need for reoperation; • Number of repetitive operations; • Duration of treatment in the intensive care unit; • Complication rate; • Mortality in patient groups that underwent surgery. Conclusions: by using focused open necrosectomy, tissue trauma and the duration of surgery were reduced significantly. Focused open necrosectomy is fully consistent with the main task of surgical treatment, that is, to perform necrosectomy, as well as adequate rehabilitation and drainage of the infected focus, which triggers infection-caused systemic inflammatory responses defined as sepsis control, and patient recovery. In the postoperative period, the inflammatory response in patients decreased significantly; the time that the patients stayed in the hospital, the number of days spent in the intensive care unit, the incidence of complications, and mortality were all reduced. The operations performed at the early stage aggravated the results of treatment greatly, regardless of the surgical procedure used. Focused open necrosectomy is an efficient method; it fully complies with the patient’s safety and the principles of modern surgery in the treatment of acute necrotic pancreatitis.