Vacuum-assisted laparostomy for peritonitis-complicated destructive pancreatitis

Abstract

INTRODUCTION. Infection of pancreatic and peripancreatic necrotic tissues and fluid collections occurs in less than 10% of patients with acute pancreatitis. However, it still causes high mortality, ranging from 20% to 40% according to recent reports. A multidisciplinary team (radiologists, gastroenterologists, anesthesiologists-resuscitators) is often involved in the complex management of this severe pathology. In this interdisciplinary context, the concept of "source control" is summarized as a four-step algorithm: elimination of the cause of infection, elimination of the infected substrate, support of the body's reactive mechanisms against infection and timely diagnosisand management of complications.
Generalization of the process with subsequent acute peritonitis and paralytic ileus is an indication for performing a laparotomy with debridement of the necrotic tissues, lavage and drainage, using either the ‘closed’ or ‘open’ abdomen method. The use of intra-abdominal vacuum therapy in the setting of laparostomy in the early 72-96 hours postoperatively has advantages in terms of the possibility of guided revisions and secondary debridement with lavage, prevention of abdominal compartment syndrome (ACS), adequate drainage of the exudate from the entire abdominal cavity and reduced time for definitive closure of the abdominal wall.
MATERIAL AND METHODS. A retrospective comparative cohort study including patients with destructive pancreatitis and emergency/delayed emergency laparotomy performed was conducted in the Department of Surgery at the University Hospital Alexandrovska for the period from 2010 to 2022. In both groups, operative intervention included exposure of bursa omentalis, instrumental/ digital necrectomy/debridement, profuse lavage (warmed saline solution alone, or followed by antiseptic solution), cholecystectomy and transcystic drainage (in a large percentage of cases), and divided depending on the subsequent behavior: group A – primary closure of the abdominal wall after implantation of a "bouquet" of drains and group B – leaving a laparostomy with implantation of a set for negative therapy for 72-96 hours with subsequent closure of the abdominal wall using different methods. Primary endpoints examined were early postoperative mortality (up to 30 days from the initial surgical intervention) and postoperative early surgical/non-surgical complications. Secondary endpoints studied are length of stay in the ICU, total hospital stay and treatment costs. Statistical data processing was performed with SPSS.20. RESULTS. For the period 2010-2022 a total of 31 patients with acute destructive (hemorrhagicnecrotizing) pancreatitis underwent surgical treatment. 67% of patients are male and 33% - women.
In group A there are 26 patients (83.9%) and in group B – 5 patients (16.9%). Early postoperative mortality was reported in 46.2% (12 patients) in group A and 20% (1 patient) in group B. Reported postoperative early surgical and non-surgical complications were a total of 53.8% in group A and 40% (2 out of 5) in group B. The average hospital stay of the patients from group A in the ICU was 13 days and in group B – 9 days. A crude cost determination demonstrates an approximately 30% lower cost in group B supposedly due to the lower rate of postoperative complications and shorter ICU stay.
DISCUSSION. Hemorrhagic-necrotizing pancreatitis continues to be one of the most important causes of severe diffuse peritonitis. The development of infected pancreatic necrosis (IPN) and infected peripancreatic fluid collections still represents a relevant event in the natural course of severe acute destructive pancreatitis. Since the first clinical case of negative pressure wound treatment (NPWT) was reported in 1989, numerous publications have followed, demonstrating the promoting role of this method in faster wound control and healing through several mechanisms: reduction of bacterial contamination, improvement of local microperfusion and stimulation of reparative process es at cellular and tissue level. Initial use of laparostomy in combination with negative pressure in abdominal trauma was subsequently adapted in the treatment of severe abdominal sepsis with associated benefits: elimination of exudate and adjuvants; prevention of ACS, contamination prevention of the laparostomy from the environment, preparation of the abdominal cavity and wall for subsequent definitive closure.
CONCLUSION. The combined therapy with negative pressure gives the opportunity for more adequate patient management – source control of the primary pathology and reduced complication rate. It clearly improves the treatment outcomes of patients, reduces the time for abdominal cavity closure, reduces the total hospital stay and especially the stay in the intensive care units, thereby reducing total costs.