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In recent years in domestic and in foreign literature there were messages on increase in frequency of developing of acute pancreatitis in the postoperative period (V. I. Sokolov, P. L. Dubrovsky, 1967; V. S. Shapkin et al., 1970).
According to our data, acute pancreatitis complicates operative measures on abdominal organs at 0,98% of patients, giving a lethality of 6,35%. From 5100 operated this complication it is noted at 4 patients (0,08%). Smaller significance, than is attached earlier to gland injury as a direct etiological factor of this complication. Among origins of an autolysis call hit in blood of large amounts of fabric enzymes at operative measures, neuro and reflex influences from an operational zone, atherosclerosis of vessels, action of an anesthesia, sharp change of a feeding schedule that involves pancreas dysfunction.
I. S. Savoshchenko (1965) connects development of pancreatitis with deficit of protein therefore anti-proteolytic properties of serum decrease.
Increase of level of a diastase in the postoperative period does not mean development in sick pancreatitis yet. As S. I. Rybakov (1967) notes, after appendectomy concerning an acute appendicitis increase of proteolytic activity of enzymes and emergence of a diastasuria is possible. According to our data, at 9 of 84 inspected patients with an acute appendicitis the diastasuria in the early postoperative period is noted. Only at 4 of them postoperative pancreatitis, at 1 — a combination of an acute appendicitis and acute pancreatitis is diagnosed.
Complication can develop in various terms after intervention, but is more often — in the early postoperative period. According to our data, pancreatitis arose in the first 48 hours after operation more often.
Recognition presents it certain difficulties in connection with weight of the general background caused by an operational illness. Diagnosis is complicated by the fact that new qualitative changes in an organism of the patient are veiled by pathological symptoms.
In clinical development of this complication it is difficult to establish pathognomonic signs. Deterioration in the general condition of patients and discrepancy of its weight to the carried-out operative measure and terms of the postoperative period attracts attention. At most of patients the severe pains in epigastric area which are poorly stopped by drugs are noted, but also bezbolevy forms are possible.
Intensity of a pain syndrome changes in development of a disease. At development of a necrosis of gland intensity of pains decreases, in a clinical picture other symptoms prevail: circulator frustration, intestines paresis.
With a big frequency disturbance of motornoevakuatorny function of a digestive tract was noted. The symptomatology of these frustration is rather difficult regulated as practically each intervention on bodies of a digestive tract is followed by his paresis. In this regard speak only about aggravation of these frustration which are shown strengthening of vomiting, increase in a staz in a stomach, a meteorism.
Sick B., 19 years, came to clinic 10/03 1971 with complaints to pains on all stomach, nausea, vomiting, an indisposition. Pulse 92 blows 1 minute, temperature 37,5 °, a leukocytosis — 9600, a diastase of 4 pieces. In 1 hour after receipt of pain moved to the right ileal area.
Diagnosis: acute appendicitis. Urgent appendectomy. The changed worm-shaped shoot is removed flegmonozno.
12/03 1971 a condition of the patient worsened. There were severe pains in epigastric area, abdominal distention, a delay of gases and a calla. Language is dryish, the stomach is blown up, soft, at a palpation painful in epigastric area. There are no symptoms of irritation of a peritoneum. Pulse of 88 blows 1 minute, soft. Diastase of 1024 pieces. For 3 days the phenomena of dynamic intestinal impassability expressed in sharp abdominal distention, a delay of gases and a calla, oppression of a vermicular movement were the main clinical syndrome of complication. Under the influence of conservative therapy (intravenous administration of Trasylolum to 50 000 units, aminocapronic acid, spasmolysants, evacuations of gastric contents, diuresis forcing) a condition of the patient diastase level improved gradually, normalized. Recovery.
Degree of manifestation of these frustration happens considerable that demands carrying out from a number of patients of differential diagnosis with acute mechanical intestinal impassability.
All specified signs are not strictly pathognomonic for establishment of an actual reason of an aggravation of symptoms of the operated patients. The brightest of them — an acute disorder of a hemodynamics in the form of a cardiovascular collapse. On sharp falling of cardiovascular activity without acute abdominal pains as on the most characteristic symptom of acute postoperative pancreatitis, specify Massaioli (1967), Andre and others (1967). In these cases at rather successfully proceeding postoperative period suddenly there are a sharp weakness, an asthma, cyanosis, tachycardia to 120 blows 1 minute, lowering of arterial pressure to the minimum figures (60 — 40 mm of mercury.) . Intravenous administration of antishock means: hemotransfusion, Polyglucinum, purpose of cardiacs (Cordiaminum, strophanthin) have weak and short-term effect. More effective in these cases is introduction of high doses of a hydrocortisone. Clinical trial of blood does not give essential changes at early stages of a disease, the diastasuria and a hyperglycemia often are absent.
The second important symptom of pancreatitis characterizing the accruing intoxication is change of the mental status of patients. Quite often they note crazy states, an inadequate assessment of the events around, unmotivated actions, sharp motive excitement and aggression — all that keeps within concept of "postoperative psychosis". Emergence of all these changes even without the objective signs testimonial of emergence of accident in an abdominal cavity, has to guard the doctor and aim it at carrying out a number of additional researches and the corresponding therapy.
Complexity of clinical diagnosis of postoperative pancreatitis induces to systematic laboratory control externally - and intra secretory function of a pancreas in all cases where danger of development of this complication is supposed.
Treatment of postoperative pancreatitis began with conservative actions: purpose of inhibitors (Trasylolum is more often) in doses to 150 000 units a day, antibiotics (penicillin and streptomycin), and at small efficiency of antibiotics of a reserve (Sigmamycinum, Kanamycinum) etc.
Infusional therapy is regulated by indicators of a water and electrolytic exchange, the maintenance of uniform elements of blood, level of hemoglobin, proteins. Most often there is a need for compensation of a potassium exchange in connection with the found hypopotassemia. Administration of alkaline solutions is recommended to be done according to acid-base equilibrium indicators. From other infusional environments applied solutions of aminocapronic acid in the first 2 days from the beginning of emergence of complications and glucocorticoids. Decrease in daily amount of urine demands purpose of diuretics. In our clinic with success use the Hungarian drug "Uregitum".
We included systematic gastric lavages in a complex of medical actions by cold solution of soda (2 — 3 times a day), enteroclyses in the form of siphon enemas. Perinephric novocainic and lumbar blockade (a zone of an abdominal brain) are useful.
Thus, acute postoperative pancreatitis is among the heaviest complications giving high percent of a lethality and presenting considerable difficulties in recognition and treatment. Important symptoms of a disease are frustration of a hemodynamics (a cardiovascular collapse), strengthening of pains in epigastric area, disturbance motor evakuatornoy functions of a stomach and intestines, change of mentality of patients.
These data are useful in comparison to the laboratory diagnosis which is carried out in dynamics. At early identification of complication its treatment rather effective.