НАРУШЕНИЯ УГЛЕВОДНОГО ОБМЕНА У БОЛЬНЫХ РАКОМ БОЛЬШОГО СОСОЧКА ДВЕНАДЦАТИПЕРСТНОЙ КИШКИ ДО И ПОСЛЕ ПАНКРЕАТОДУОДЕНАЛЬНЫХ РЕЗЕКЦИЙ

56 patients with cancer of major duodenal papilla were examined before and after pylorus-saving pancreaticoduodenal resection. Carbohydrate metabolism was estimated before and after the operation, impact of the operation on diabetes mellitus progression was detected. If there were no carbohydrate metabolism abnormalities in 75% before the operation, then there were 55% of such patients after the operation. After the pylorus-saving pancreaticoduodenal resection the impaired glucose tolerance was detected in 4 (7%) of patients whose carbohydrate metabolism had corresponded to norms before the operation. 7 (13%) Of 17 (31%) patients had diabetes mellitus of mild severity after the pylorus-saving pancreaticoduodenal resection, the rest 10 (18%) had diabetes mellitus of moderate severity. In 7 (13%) patients after the pylorus-saving pancreaticoduodenal resection the diabetes mellitus of moderate severity was detected for the first time, at that in 4 patients diabetes mellitus of mild severity was detected, and in 3 patients — diabetes mellitus of moderate severity (everyone received insulin therapy in the long-term postoperative period) was detected. Checking protocol of the patients’ carbohydrate metabolism in the perioperative period was described in detail. The possibility of prognostication of carbohydrate metabolism abnormalities in the long-term postoperative period by indications of carbohydrate metabolism before the operation and in early postoperative period was studied. Middle blood glucose level in early postoperative period is an informative indication for prognostication of carbohydrate metabolism state in the long-term postoperative period. An algorithm of patients’ examination with cancer of major duodenal papilla before the operation and after it was offered; also checking protocol of carbohydrate metabolism indices and correction of the detected abnormalities in the early postoperative period were offered. Обследовано 56 больных раком большого сосочка двенадцатиперстной кишки до и после пилоросохраняющей панкреатодуоденальной резекции. Произведена оценка углеводного обмена до и после операции, установлено влияние оперативного вмешательства на развитие сахарного диабета. Если до операции нарушений углеводного обмена не наблюдалось у 75% пациентов, то после нее таких больных осталось 55%. После пилоросохраняющей панкреатодуоденальной резекции нарушенная толерантность к глюкозе обнаружена у 4 (7%) пациентов, у которых до операции углеводный обмен соответствовал норме. Сахарный диабет легкого течения после пилоросохраняющей панкреатодуоденальной резекции имели 7(13%) из 17 (31%) пациентов, у остальных 10 (18%) диагностировали сахарный диабет средней степени тяжести. У 7 (13%) пациентов после пилоросохраняющей панкреатодуоденальной резекции был впервые выявлен сахарный диабет специфического типа, причем у 4 из них диагностировали легкую форму сахарного диабета, у 3 — диабет средней степени тяжести (все получали инсулинотерапию в отдаленном послеоперационном периоде). Изучена возможность прогнозирования нарушений углеводного обмена в отдаленном послеоперационном периоде по показателям углеводного обмена до операции и в раннем послеоперационном периоде. Показатель среднего уровня глюкозы в крови в раннем послеоперационном периоде является информативным критерием для прогнозирования состояния углеводного обмена в отдаленном послеоперационном периоде. Разработан алгоритм обследования больных раком большого дуоденального сосочка до и после операции, а также предложены протокол контроля показателей углеводного обмена и вариант коррекции установленных нарушений в раннем послеоперационном периоде.

Extirpation of distal part of the pacreas in the severe erosive intraperitoneal bleeding caused by postoperative necrotic acute pancreatitis

Institutul de chirurgie „A.V. Vishnevskii”, Moscova, Rusia, Al XII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova cu participare internațională 23-25 septembrie 2015Introducere: Pancreatita acută postoperatorie (PAP) reprezintă o complicație gravă ce apare după o intervenție chirurgicală pe pancreas (P). Incidența ei poate atinge 58,9%, în timp ce formele severe se întîlnesc în 24,2% cazuri (Kubyshkin V.A.). O trăsătură distinctivă este apariția pe fonul acesteia a dehiscenței anastomotice, fistulelor pancreatice (FP) și hemoragiilor erozive (HE). Scopul lucrării: De a aprecia eficacitatea rezecției bontului pancreatic în caz de HE postoperatorie. Material și metode: La 17 pacienți sursa de HE a fost vena lienală și mezenterică superioară, artera hepatică și mezenterică superioară. Toți pacienții au fost distribuiți în 2 grupuri. În primul grup (5 pacienți) intervenția chirurgicală s-a finisat cu suturarea și ligaturarea vaselor, în cel de-al doilea – extirparea bontului pancreatic. HE a apărut în 8-15 zile după operația inițială, în timp ce FP a fost obsevată în toate cazurile. Rezultate: Toți pacienții au suportat intervenție chirurgicală de urgență. Suturarea vasului sîngerînd s-a efectuat în 5 cazuri, dintre care în 3 au fost relevate hemoragii repetate (toți 5 pacienți au decedat). Extirparea bontului distal pancreatic a fost efectuată la 12 pacienți, dintre care 8 au supraviețuit, iar 4 au decedat. În toate cazurile de deces operația a fost efectuată în condiții de anemie posthemoragică severă. Concluzii: Suturarea și ligaturarea vasului sîngerînd în cazul PAP necrotice deseori este neefectivă și se soldează cu decesul pacientului. Profilaxia apariției și tratamentul adecvat al PAP permite prevenirea formării FP și reduce riscul apariției HE. Extirparea bontului distal pancreatic în cazul PAP severe, deși este o intervenție de disperare, poate fi recomandată cu scop curativ.Introduction: Postoperative acute pancreatitis (PAP) is a serious complication that occurs after surgery on the pancreas (P). The incidence can reach 58.9%, while severe forms are encountered in 24.2% cases (Kubyshkin VA). Its distinctive feature is the occurence of anastomotic dehiscence, pancreatic fistulas (PF) and erosive hemorrhage (EH). The aim: To assess the effectiveness of distal pancreatic resection in cases of postoperative EH. Material and methods: In 17 patients the source of EH was superior mesenteric and splenic vein, hepatic and superior mesenteric artery. All patients were divided into 2 groups. In the first group (5 patients) surgery ended with suturing and ligation of vessels in the second group – distal pancreatic resection was performed. EH appeared in 8-15 days after the initial surgery. PF was mentioned in all cases. Results: All patients have undergone emergency surgery. The suture of the bleeding vessel was performed in 5 cases, including 3 cases of repeated bleeding (all 5 patients died). Distal pancreatic resection was performed in 12 patients: 8 pat ients have survived, 4 – died. In all cases of death, the surgery was performed in patients with posthaemorrhagic severe anemia. Conclusions: Suturing and ligation of bleeding vessels in necrotic PAP is inefficient and often leads to death of the patient. The prevention of occurrence and adequate treatment of PAP allows to prevent the PF formation and reduces the risk of EH. Extirpation of distal part of the pancreas cause a severe PAP, though is an desperate operation, but may be recommended for therapeutic purposes