OPTIUNI CHIRURGICALE IN TRATAMENTUL PANCREATITELOR ACUTE

Studiu retrospectiv-2000-2006

SPITALUL CLINIC JUDETEAN ORADEACHIRURGIE II

Autori: Parascovia Pop Axentii, Mariana Ungur, N. Babǎu, M. Pop, R. Rogia, R.German, O. Şimon, M. Florea, M. Zdrâncǎ, R. Dima, D. Dejeu, L. Borza, Ramona Marţi, M. German, C. Ţirtea, Larisa Gherciu, Carolina Cazan

PREZENTARE POSTER

Introducere

Pancreatita acuta reprezinta o entitate patologica care ridica numeroase probleme de diagnostic si de tratament, datorita etiologiei vaste, uneori neelucidata, fiziopatologiei complexe, diagnosticului dificil precum si datorita tratamentului chirurgical atat de controversat.Deasemenea o problema-cheie in tratamentul pancreatitelor acute reprezinta alegerea momentului optim pentru interventia chirurgicala.Tehnicile imagistice si interventionale tot mai moderne si mai sofisticate au schimbat modalitatile de abordare diagnostica precum si strategia terapeutica in afectiunile pancreatice..

Abordarea chirurgicala moderna in pancreatita acuta se bazeaza tot mai mult pe diagnosticul imagistic. Acuratetea diagnostica a tomografiei computerizate si rezonantei magnetice nucleare, punctia transcutana ghidata echografic reduce considerabil necesitatea interventiilor chirurgicale in pancreatita acuta. Aceste tehnici moderne imagistice stabilesc exact momentul optim de interventie chirurgicala.

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Utilizarea tomografiei computerizate dinamice si asocierea sa cu punctia aspirativa a permis diagnosticul necrozei pancreatice infectate care reprezinta indicatie chirurgicala absoluta.Exista controverse asupra indicatiilor operatorii in necrozele neinfectate, la pacientii cu evolutie clinica agravata si fara aspect tomodensitometric de necroza pancreatica si la cei cu necroza pancreatica severa, dar neinfectata in evolutia precoce. Tratamentul general nespecific de terapie intensiva, de suport al diverselor sisteme si organe cu scopul prevenirii insuficientei pluriviscerale, precum si antibioprofilaxia precoce pentru prevenirea infectiei necrozei pancreatice si antibioterapia curativa a scazut semnificativ mortalitatea din primele zile de evolutie a pancreatitelor acute. Tratamentul complicatiilor locale s-a efectuat prin abord chirurgical, practicandu-se pe scara larga necrozectomii.

Material si metoda

S-a efectuat un studiu retrospectiv pe perioada anilor 2000-2006, in sectia clinica CHIRURGIE II al Spitalulul Clinic Judetean Oradea analizandu-se abordarea chirurgicala in pancreatita acuta.S-au studiat foile de observatie clinica, cercetarea vizand in special atitudinea chirurgicala si evolutia postoperatorie.S-a studiat un lot de 140 de cazuri cu pancreatita acuta..

Rezultatele studiului, interpretare, discutii.

Dintre acestea 91 de cazuri avand o pondere de 65%, au fost reprezentate de pancreatite acute edematoase si 49 de cazuri reprezentand un procentaj de 35% - pancreatite acute citosteatonecrotice si necroticohemoragice.

Repartitia cazurilor de pancreatita acuta in functie de morfopatologie.

Nr.total de cazuri pancreatite acute

Pancreatiteacute edematoase

Pancreatite citosteatonecrotice

Pancreatite necroticohemoragice

140 91 31 18

% 65% 22,15% 12,85%

Pancreatitele acute necrotico-hemoragice au fost reprezentate de 18 cazuri cu o pondere de 36,73%. Pancreatitele citosteatonecrotice s-au evidentiat in 31 de cazuri reprezentand 63,27% din totalul cazurilor studiate.Repartitia pe sexe a fost urmatoarea: 76 de cazuri sexul masculin (54,29%) si 64 de cazuri apartin sexului feminin cu o pondere de 45,71 % din totalul cazurilor .

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Repartitia cazurilor de pancreatita acuta in functie de sex.

Din studiul acestor 140 de cazuri s-a evidentiat etiologia pancreatitelor acute.Principala cauza generatoare de pancreatita acuta este cea biliara, urmata de cea etanolica, dismetabolica si posttraumatica, mai rar. Ca si factori etiologici dismetabolici declansatori ai pancreatitei acute am evidentiat in studiul de referinta - hiperlipidemia si hipercalcemia. Etiologia posttraumatica, desi mai rar intalnita a fost reprezentata in acest studiu de 2 cazuri: o contuzie abdominala la care se constata intraoperator pancreatita necrotico-hemoragica posttraumatica abcedata care a necesitat lavaj si drenaj multiplu; un alt caz studiat –traumatism cu fractura de pancreas - intraoperator se constata ruptura de pancreas cefalo-corporeala, hematom al lojii pancreatice, pancreatita necrotico-hemoragica postraumatica; se practica splenopancreatectomie corporeo-caudala si drenaje multiple: subfrenic stang, subhepatic si in fundul de sac posterior Douglas.Atitudinea chirurgicala abordata in cele 91 de cazuri de pancreatite acute adematoase studiate a fost colecistectomia retrograda si colecistectomia anterograda.. In 67 de cazuri (73,62%), interventia chirurgicala efectuata a fost colecistectomia retrograda. si in 24 de cazuri (26,38%) colecistectomia anterograda. La 25 de cazuri din totalul celor 91 de cazuri de pancreatite acute edematoase cu o pondere de 27,47% din total s-a practicat drenaj transcistic.

Conduita chirurgicala in pancreatita acuta edematoasa.

In celelalte 49 de cazuri reprezentate de pancreatite acute citosteatonecrotice si necroticohemoragice se abordeaza calea biliara principala cu drenaj Kehr, drenaj al lojei pancreatice , drenaj al bursei omentale si drenaj transmezentericDin totalul acestor 49 de cazuri, evolutia nefavorabila postoperatorie a necesitat efectuarea a 6 reinterventii chirurgicale (12,24%) pentru hemoragii in loja pancreatica si necroze infectate. In 2 cazuri studiate de pancreatita acuta citosteatonecrotica, la reinterventia chirurgicala s-a constatat prezenta de tesuturi necrotice localizate extrapancreatic, la nivelul spatiului retroperitoneal. Atitudinea chirurgicala abordata in acest caz a reprezentat necrozectomia asociata cu drenaje multiple retroperitoneale. In alte 2 cazuri de pancreatita acuta necrotico-hemoragica asociate cu abces pancreatic cu sechestru pancreatic s-a practicat evacuarea abcesului, lavaj, drenaj.Intr-un alt caz de pancreatita acuta necrotico-hemoragica asociata cu un ulcer duodenal hemoragic s-a practicat necrozectomie in prima interventie chirurgicala. La cea de a 2 a reinterventie s-au efectuat necrozectomii extinse cu drenaj Pezzer (colecistostomie pe sonda Pezzer) si drenaj transgastric pe sonda Foley pentru un abces fistulizat in stomac. Din studiul

Nr.total cazuri de pancreatite acute

Sexul masculin

Sexul feminin

140 76 64 % 54,29% 45,71%

Interventia chirurgicala

Colecistectomie retrograda 67 cazuri(73,62%)

Colecistectomie anterograda 24 cazuri(26,38%)

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efectuat s-a evidentiat un caz clinic particular grevat de multitudinea complicatiilor care au necesitat efectuarea a 2 reinterventii chirurgicale. Un pacient a prezentat posttraumatic o pancreatita acuta necrotico-hemoragica..S-a efectuat prima interventie chirurgicala pentru un fuzeu pancreatic suprainfectat parieto-colic drept. Primul gest chirurgical a constat in efectuarea debridarii fuzeului pancreatic, lavaj, drenaj al lojei pancreatice prin ligamentul gastro-colic, drenaj parieto-colic. S-a reintervenit pentru o fistula biliara externa pentru care s-a efectuat drenaj biliar tip Kehr. A treia abordare chirurgicala a constat in necrozectomii peripancreatice extinse, lavaj, drenaj multiplu.Indicatiile tratamentului chirurgical in pancreatita acuta sunt reprezentate de :

pancreatita biliara pancreatita cu necroza sterila asociata cu insuficienta pluriorganica care nu raspunde

la tratamentul conservativ instituit prompt si agresiv. infectia pancreatica cu sepsis.Este esential in tratamentul pancreatitei acute momentul optim al deciziei chirurgicale. Exista controverse. Se considera oportuna interventia chirugicala tardiva dupa 3-6 sapt de evolutie. Argumentul unei interventii chirurgicale tardive este reprezentat de o demarcatie buna a tesuturilor necrozate. Acest fapt asigura eficienta sechestrectomiilor si a drenajului abceselor. Criteriile care ne orienteaza in alegerea momentului oportun de interventie chirurgicala sunt simptomele si semnele clinice care confirma infectia necrozei pancreatice:

alterarea starii clinice a bolnavului reaparitia febrei leucocitoza diagnostic imagistic tomografic pozitiv culturi prelevate din aspiratul percutan prin tehnici interventionale (punctie

aspirativa ghidata ecografic sau computer tomografic)Evolutia postoperatorie a pancreatitelor de origine biliara este favorabila.In cazul pancreatitelor acute citosteatonecrotice si necrotico-hemoragice , evolutia este grevata de complicatiile locale.In tratamentul pancreatitelor acute un rol important il detine antibioprofilaxia si antibioterapia postoperatorie.Cercetari clinice efectuate pe trialuri randomizate au evidentiat eficacitatea unor antibiotice care realizeaza concentratii terapeutice peste concentratia minima inhibitorie in parenchimul si sucul pancreatic-cefalosporine (cefamandole, cephalotin, cefoxitin, ceftazidime, ceftizoxime), chinolone (ciprofloxacin, ofloxacin, pefloxacin), metronidazol, peniciline de ultima generatie (imipenem, tienam, meronem), aminoglicozide (gentamycin, amikacyn, clindamicyn). In studiul de fata s-au administrat peniciline de ultima generatie (meronem, imipenem si tienam), cefalosporine de generatia a III a si chinolone(ciprofloxacin) cu rezultate bune in profilaxia supuratiilor pancreatice si in tratamentul postoperator. Aceasta medicatie administrata a determinat o evolutie pozitiva a cazurilor studiate si scaderea numarului de cazuri de pancreatite acute care au necesitat reinterventii chirurgicale pentru suprimarea necrozei infectate. Din totalul celor sase cazuri in care s-au practicat reinterventii chirurgicale , un caz a avut o evolutie nefavorabila, fulminanta cu decesul bolnavului. Acest caz a fost reprezentat de o pancreatita acuta necrotico-hemoragica asociata cu un ulcer duodenal hemoragic, la care in pofida reinterventiei chirugicale , antibioterapiei postoperatorii si a tratamentului nespecific agresiv de terapie intensiva, starea clinica a pacientului se deterioreaza, prezentand disfunctii pluriorganice-ocluzie intestinala dinamica, hemoragie digestiva superioara, stare septica.In consecinta, din acest studiu retrospectiv al cazurilor de pancreatite acute abordate chirurgical rezulta o mortalitate postoperatorie de 16,66%

Concluzii

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1. Incidenta pancreatitelor acute a scazut semnificativ in ultimii anii datorita tratamentutului adecvat al bolii de baza- vizand in special rezolvarea chrurgicala a cazurilor de pancreatite acute de etiologie biliara.

2. Mortalitatea postoperatorie in pancreatitele acute a scazut deasemenea apreciabil datorita asocierii la tratamentul necrozei pancreatice infectate a tratamentului antibiotic specific- peniciline de generatie noua si cefalosporine de generatia a III a.

3. Gesturile chirurgicale complexe efectuate in momentul optim de actiune au avut ca si scop final tratamentul complicatiilor locale- suprimarea focarelor necrotice infectate.

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