1. Relevance

Acute biliary pancreatitis (ABP) is a common disease, occurring in 25-30% of the total number of sick acute pancreatitis and in 15-25% it occurs in a severe form. Its main causes are the existence of gallstone disease, anatomical relationships of the general bile and main and pancreatic ducts and embryonic development between them of the “common channel”, microlithiasis, wedging and migration of stones through the major duodenal papilla [1,4].

Currently active promotion is being promoted surgical tactics for the treatment of cholelithiasis, widespread introduction of laparoscopic cholecystectomy and endoscopic retrograde pancreato- and cholangiography with the possibility of performing papillotomy and stone extraction. However, the results of surgical treatment of patients with AP leave much to be desired, since in severe forms of this disease the mortality rate reaches 15-30%. Therefore, general and local complications of AP that arise during the long course of the disease dictate the need to develop reasoned recommendations for achieving the main goal – saving the patient’s life [3,6]. In particular, it is important to promptly recognize specific laboratory and special research data characteristic of acute pancreatitis. A well-founded choice species surgical benefits, minimal invasive or "open", depending on the predominance of certain changes in the gallbladder, bile ducts, pancreas, parapancreatic and retroperitoneal space. The question of the effectiveness and at the same time the danger of endoscopic papillotomy awaits a final decision in conditions of complicated course. No less important is the determination of the timing of cholecystectomy, as well as the possibility of its implementation during a single hospitalization after the relief of acute pancreatitis of varying severity [2,5].

2. Objective of the Study

To determine the choice of the method of surgical correction of acute biliary pancreatitis in order to eliminate pancreatic and biliary hypertension.

3. Material and Methods of the Study

The article presents an analysis of the treatment of patients with acute biliary pancreatitis with moderate and severe course – 79 (30.3%) patients.

Biliary pancreatitis was more common in women, with a ratio of 1:1.5 in favor of women. The age of patients varied widely from 18 to 90 years, the average age of patients was 52.5 ± 2.0 years.

To assess the severity of the infectious process, signs of a systemic inflammatory response (SIRR) were identified. To establish signs and manifestations of multiple organ failure, the main indicators of laboratory and instrumental studies were used. Computer versions of calculation algorithms in the APACHE II scale were also used.

Ultrasound allowed us to detect not only free fluid in the abdominal cavity and swelling of the pancreas, but also the phenomena of acute calculous cholecystitis and choledocholithiasis (Fig. 1).

The most informative was magnetic resonance cholangiopancreatography for identifying the state of extrahepatic bile ducts, cholangioectasia, microlithiasis and sludge. gall bladder and bile ducts (Fig. 2).

Figure 1. Ultrasound, multiple gallbladder stones up to 0.5 cm with acoustic shadow, thickening of the gallbladder wall up to 0.6-0.7 cm

Figure 2. MRI cholangiography. Choledocholithiasis

Figure 3. Magnetic resonance cholangiopancreaticogram. Common bile duct and main pancreatic duct stones

Among patients with acute biliary pancreatitis with moderate and severe course of the disease, 6 had impaction of a stone in the major duodenal papilla (MDP), 10 had destruction of the gallbladder and sterile accumulation of the pancreas, 10 had destruction of the gallbladder and infected accumulation, and 23 had choledocholithiasis. cholangitis, mechanical jaundice, in 30 cases – infected pancreatic necrosis without a tendency to delimitation (Fig. 4).

Figure 4. Distribution of patients with moderate and severe acute biliary pancreatitis

4. Results and Their Discussion

Surgical treatment of acute biliary pancreatitis had its own characteristics associated with the need to correct cholelithiasis.

6 patients with impaction of a stone in the major duodenal papilla, as our observations showed, required elimination of the pathological condition in the nearest time after detection. These patients underwent endoscopic papillotomy performed in the first hours after admission. It is the performance of endoscopic papillotomy in an emergency manner allowed to avoid the progression of acute pancreatitis, to stop it. And after the resolution of the edema of the pancreas, to perform laparoscopic cholecystectomy.

23 patients with severe acute biliary pancreatitis, against the background of acute calculous cholecystitis, choledocholithiasis, mechanical jaundice and cholangitis, also underwent EPST. This manipulation was performed in the first 24 hours from the moment of admission.

Figure 5. Endoscopic papillotomy. Extraction of a common bile duct stone

Of these 23 patients, 14 underwent cholecystectomy within 2-3 weeks after resolution of acute pancreatitis, jaundice and cholangitis, with conversion and "open" cholecystectomy performed in 3 cases. Another 5 patients were also operated on using the "open" method due to the development of acute cholecystitis 3 days after endoscopic papillotomy. The other 3 patients were operated on 4-7 days after endoscopic papillotomy. due to the development of not only acute cholecystitis, but also the migration of stones from the gallbladder into the bile ducts with the development of jaundice. An "open" cholecystectomy, choledocholithotomy was performed and T-drainage of bile ducts. Another observed patient was operated on 2 months after endoscopic papillotomy.

According to the research data, 10 patients were found to have acute calculous cholecystitis and sterile fluid accumulations in the pancreas. glands. As a rule, this was an enlargement of the gallbladder, thickening of its wall to 5-6 mm without perifocal inflammation and effusion around the gallbladder. There were accumulations of pancreatic fluid with a diameter of 5-7 cm, which were monitored using dynamic computed tomography or ultrasound. Moreover, in 5 patients it was possible to limit ourselves to a single aspiration of fluid and in 5 patients drainage of accumulations was performed. In all these cases, bacterial seeding was not detected and after resolution of the inflammation of the gallbladder and accumulations of the pancreas, the patients underwent laparoscopic cholecystectomy.

Complex situations arose when infected accumulations of pancreas were detected. glands. There are no such observations there were also 10. The reasons for their occurrence were late hospitalization of patients, long-term ineffective conservative treatment. When single infected accumulations of up to 100.0 ml of pus were detected in 7 patients, we managed to cope with puncture-catheterization method. However, in 3 observations, multiple infected clusters were diagnosed not only in the parapancreatic and retroperitoneal space, but also in the mesentery of the small intestine. Attempts to resolve them with minimally invasive This method proved unsuccessful and the patients were operated on using an “open” abdomen and the patients recovered.

In 23 cases, the “open” abdomen method was used, cholecystectomy and choledocholithotomy were performed. and T-drainage of the bile ducts. In another 7 cases, an "open" abdomen was also used, but it was impossible to perform cholecystectomy and intervention on the bile ducts due to the severity of infiltrative changes, and cholecystostomy was forced to be used.

According to the results of our study, cholecystectomy for mild biliary pancreatitis should be performed after the resolution of pancreatitis, usually within 3 to 7 days. Cholecystectomy for severe biliary pancreatitis should be performed after the resolution of infiltrative changes in the gallbladder and pancreas glands.

An important condition for the success of endoscopic papillotomy is the experience of its implementation: - its duration should not exceed 30 min.; - after endoscopic papillotomy, patient monitoring with mandatory prophylaxis of pancreatitis and infection is necessary; - cholecystectomy in mild biliary pancreatitis should be performed after resolution of pancreatitis, most often within 3 to 7 days; - cholecystectomy in severe biliary pancreatitis should be performed after resolution of infiltrative changes in the gallbladder and pancreas glands.

Thus, optimization of the tactical and technical aspects of surgical treatment of acute biliary pancreatitis with substantiated indications for various types of surgical intervention made it possible to individualize surgical tactics and avoid fatal outcomes in all cases except acute biliary pancreatitis complicated by unilateral or bilateral phlegmon of the retroperitoneal space.

5. Conclusions

1. The leading criterion in choosing the optimal treatment tactics for acute biliary pancreatitis is the detection of stones in the biliary tract, the severity of the clinical course of the disease and the involvement of the retroperitoneal space in the inflammatory process. These criteria allow us to establish indications for EPST, lithoextraction, minimally invasive puncture methods for draining fluid accumulations or "open" operations.

2. EPST effectively resolves obstruction of the bile and pancreatic ducts in acute biliary pancreatitis and eliminates ductal hypertension, which are the main cause of purulent cholangitis and pancreatic necrosis.

3. Cholecystectomy, mainly laparoscopic, is advisable to perform after conservative resolution of mild biliary pancreatitis in the next 24 hours after the attack due to the risk of relapse of the disease. After performing EPST, cholecystectomy is also justified without discharge from the hospital if papillotomy is performed without complications. In acute biliary pancreatitis complicated by sterile or infected fluid accumulations, cholecystectomy should be postponed until their complete resolution and elimination of systemic inflammatory reactions.

4. The proposed algorithm for examination and treatment of biliary pancreatitis, as well as substantiated indications for various types of surgical intervention, made it possible to individualize surgical tactics and avoid fatal outcomes in all cases except acute biliary pancreatitis complicated by unilateral or bilateral phlegmon of the retroperitoneal space.

5. Long-term, over 4 weeks, course of acute biliary pancreatitis, late admission of the patient to a specialized department and ineffective surgical intervention lead to changes in the pancreas, parapancreatic and retroperitoneal spaces, similar to those in acute alcoholic pancreatitis, which was observed in 30 patients with a mortality rate of 23.3%. The most effective surgical intervention in these observations is the use of the "open" method. "belly".