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Хирургическое лечение больных острым панкреатитом

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В обзоре представлен анализ результатов последних исследований, посвященных различным аспектам хирургического лечения больных острым панкреатитом, исключая билиарный. Рассмотрены показания к вмешательствам в стерильной фазе, которые ограничены и включают ферментативный перитонит, абдоминальный компартмент-синдром при неэффективности консервативных мероприятий, панкреатогенные скопления с болевым синдромом, угрозой прорыва в брюшную полость, компрессией соседних органов в контексте синдрома нарушения целостности протока поджелудочной железы. Инфицированный некроз является основным показанием к операции при остром панкреатите. Дренирование предпочтительно позднее 4 нед от начала заболевания путем этапного подхода (step-up). Выбор способа дренирования основывают на локализации некроза, отграничивающей стенке, опыте хирурга, технических возможностях. Секвестрэктомия может быть выполнена из мини-доступа в проекции чрескожного дренажа с применением видеоэндоскопических технологий или через покрытый металлический стент. При раннем инфицировании, распространенном поражении забрюшинной клетчатки целесообразно сочетать чрескожные и эндоскопические методы, применять чреспросветное дренирование из одного или нескольких доступов несколькими дренажами.

Ключевые слова:
поджелудочная железа, панкреонекроз, стерильный некроз, инфицированный некроз, компартмент-синдром, этапное лечение, step-up, pancreas, pancreatic necrosis, sterile necrosis, infected necrosis, compartment syndrome, staged treatment, “step-up” approach

Литература:
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Surgical treatment of patients with acute pancreatitis

The paper presents an analysis of the recent studies on the various aspects of surgical management of acute (excluding biliary) pancreatitis. It evaluates the suggestion of interventions in the sterile phase, which are limited to and include enzymatic peritonitis and abdominal compartment syndrome. Surgery is suggested when conservative treatment is ineffective, pain is present, which is associated with pancreatic fluid accumulation, there is a risk of the pancreatic fluid leaking into the abdominal cavity, or compression of the adjacent organs develops due to the disconnected pancre-atic duct syndrome. Infected necrosis is the main indication for surgical intervention in acute pancreatitis. The drainage is preferably delayed for at least 4 weeks following the onset of the disease, and is gradually performed (in a “step-up” manner). The choice of drainage technique is based on the necrosis localization, delimiting wall, surgeon’s expertise, and technical capabilities. Sequestrectomy can be performed starting from mini-invasive percutaneous drainage under endoscopic guidance, or using a covered metal stent. In the cases of early infection or advanced injury of retroperitoneal tissue, it is advisable to combine percutaneous and endoscopic methods, and use multiple transluminal gateway techniques with several draining tracts installed from single or multiple points of access.

Keywords:
поджелудочная железа, панкреонекроз, стерильный некроз, инфицированный некроз, компартмент-синдром, этапное лечение, step-up, pancreas, pancreatic necrosis, sterile necrosis, infected necrosis, compartment syndrome, staged treatment, “step-up” approach