Could EPI Be Causing Your GI Symptoms?

If you’re plagued by mysterious gas, bloating, and diarrhea, you might have exocrine pancreatic insufficiency (EPI). EPI occurs when the pancreas lacks the enzymes to help your body properly digest the food you eat. You’re more at risk of EPI if you have certain health conditions, including chronic pancreatitis, celiac disease, diabetes, cystic fibrosis, or pancreatic cancer, says Steven Gillon, DO, a specialist in digestive diseases at Holy Name Medical Center in Teaneck, New Jersey.

Another risk factor is pancreatic surgery: According to a review published in April 2020 in the World Journal of Gastrointestinal Pathophysiology, EPI is a common complication following pancreatic surgery and is often underdiagnosed and undertreated. People who have a history of alcohol abuse are also at higher risk of EPI.

Doctors likely don’t think of EPI as often as they should, according to Dr. Gillon. Because the symptoms of EPI can be the same as some other digestive conditions, it can be tricky to diagnose. But getting the correct diagnosis is important. EPI can cause symptoms that can have a negative impact on a person’s quality of life and lead to potentially life-threatening complications such as malnutrition and cardiovascular disease, according to a study published in March 2019 in the journal Clinical and Experimental Gastroenterology.

If your doctor suspects you may have EPI, they will likely take blood and stool samples and order tests to see if you have this condition, according to the World Journal of Gastrointestinal Pathophysiology review.

The good news is that the condition is treatable with pancreatic enzyme replacement therapy (PERT) or vitamin supplements, so it’s important to stay aware of common EPI symptoms.

Diarrhea

Diarrhea can be a symptom of many ailments, but if you find yourself chronically experiencing this problem along with sudden, unexplained weight loss and an overall change in bowel habits, that should raise your suspicions, says Benjamin Lebwohl, MD, a gastroenterologist and assistant professor of medicine at Columbia University Medical Center in New York City.

Steatorrhea

Something else to watch for is steatorrhea, which is foul-smelling oily stools (which float, stick to the sides of the toilet bowl, and are hard to flush) that can be especially worse after eating fatty foods. This is a specific sign of EPI, and you should notify your doctor if you experience it, says Khalid Khan, MD, a gastroenterologist and medical director of the Islet Cell Transplant Program at the MedStar Georgetown Transplant Institute in Washington, D.C.

Abdominal Pain

Abdominal pain is another symptom of many GI problems. Yet with EPI, you’ll feel that pain more when you eat, especially with fatty meals, Dr. Lebwohl says. You may also feel bloating in the abdominal area. The symptoms of diarrhea and stomach pain are also associated with irritable bowel syndrome (IBS), a more common condition than EPI. In younger people, these symptoms are more likely to be IBS, Dr. Khan says, but in people in their sixties or older who may also have diabetes, EPI is a greater possibility.

Unexplained Weight Loss and Fatigue

If you find yourself losing pounds and you’re not sure why — and you have stomach pain along with fatigue — discuss the possibility of EPI with your doctor, Gillon says. EPI prevents your body from being able to properly digest the food you eat, so people with EPI typically need a nutrient-rich diet as part of their treatment, along with enzyme replacement therapy, according to The National Pancreas Foundation (NPF).

Vitamin Deficiency

If you have EPI, your body doesn’t properly digest food, so you’ll have trouble absorbing certain nutrients, including the key vitamins A, D, E, and K, Gillon says. That’s why some people with EPI experience bone loss (osteoporosis) and other health issues related to a lack of these vitamins, according to a study published in September 2019 in the journal Pancreas. In fact, many people with EPI need supplements to help maintain appropriate levels of these vitamins, says the NPF.

When to Call a Doctor

If you’re experiencing a combination of the common symptoms of EPI, call your doctor. Before your appointment, track your symptoms — when they occur and if they’ve changed over time. Remember that fat in your stools is the classic symptom of EPI, as opposed to other digestive conditions. “It’s important to be mindful of your symptoms and not ignore or minimize them if there’s a significant change,” Lebwohl says. “If a person is at increased risk of EPI, diagnosis and treatment can result in a major improvement in quality of life.” In addition to treatment with PERT and vitamin supplements, your doctor can also help you make healthier lifestyle choices, such as improving your diet, avoiding alcohol, and not smoking.

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Chronic pancreatitis: Treatments, symptoms, and causes

Chronic pancreatitis is a long-term progressive inflammatory disease of the pancreas. Alcohol use, chemotherapy, and some autoimmune conditions can cause it.

The pancreas is a gland in the upper abdomen, behind the stomach and below the ribcage. It produces important enzymes and hormones that help break down and digest food. It also makes insulin to moderate the levels of sugar in the blood.

The most common cause of chronic pancreatitis is long-term alcohol use disorder, which causes 40–70% of all cases. Autoimmune conditions, blockages of the ducts, vitamin deficiencies, chemotherapy, and some other factors may also cause chronic pancreatitis.

Chronic pancreatitis sometimes begins with acute pancreatitis, which is a sudden and severe type of the condition. It can persist after the acute phase passes, causing progressive and permanent damage to the pancreas.

Keep reading to learn more about chronic pancreatitis, including treatment, symptoms, and causes.

Common signs and symptoms of chronic pancreatitis include severe upper abdominal pain that can sometimes travel along the back and is more intense following a meal, as well as nausea and vomiting, more commonly occurring during episodes of pain.

As the condition progresses, the episodes of pain become more frequent and severe. Some individuals will experience constant abdominal pain.

As chronic pancreatitis progresses, and the ability of the pancreas to produce digestive juices deteriorates, the following symptoms may appear:

• smelly, greasy stools
• bloating
• abdominal cramps
• flatulence

Eventually, the pancreas may not be able to produce insulin at all, leading to type 1 diabetes, which can produce the following symptoms:

• thirst
• frequent urination
• intense hunger
• unintentional weight loss
• tiredness
• blurred vision

Treatment focuses on alleviating symptoms, slowing or stopping damage to the pancreas, and managing health problems stemming from chronic pancreatitis.

Lifestyle changes

People with chronic pancreatitis may need to make some lifestyle changes, including:

• Avoiding alcohol consumption, if applicable: Stopping consuming alcohol will help prevent further damage to the pancreas. It will also help relieve the pain. Some people may need professional help to give up alcohol. Continuing to drink increases the risk of death.
• Stopping tobacco use, if applicable: Smoking is not a cause of pancreatitis, but it can accelerate the progression of the disease.
• Making dietary changes: Eating small low fat meals more frequently may help ease symptoms.
• Taking vitamins and enzymes: A person may need to replace pancreatic enzymes in their diet or take fat-soluble vitamins to ensure proper nourishment.

Pain management

Doctors may recommend pain relievers, starting with over-the-counter options. If these do not work, a doctor may recommend stronger pain-relieving medication, including:

• nonsteroidal anti-inflammatory drugs, such as ibuprofen or naproxen
• pregabalin
• opioids, if other pain treatments prove ineffective

Living in pain can lead to depression, which may increase the perception of pain. A doctor may prescribe antidepressants to ease both emotional and physical pain.

Insulin

The pancreas may stop producing insulin if the damage is extensive. This can cause diabetes. In one study involving people with genetic pancreatitis, 48% of the participants eventually developed diabetes.

A person may need regular insulin therapy if the pancreas no longer produces this hormone.

Surgery

Sometimes, severe chronic pain does not respond to pain relievers. The ducts in the pancreas may have a blockage. This can cause an accumulation of digestive juices, causing intense pain.

Another cause of chronic intense pain could be inflammation of the head of the pancreas.

Several forms of surgery may treat more severe cases.

Endoscopic surgery

A surgeon inserts a narrow, hollow, flexible tube called an endoscope into the digestive system, guided by ultrasound. This allows them to thread a tiny deflated balloon through the endoscope and into the duct. Inflating the balloon widens the duct so that the surgeon can place a stent to keep it open.

Surgery relieves symptoms in approximately 60% of people who choose this option.

Pancreas resection

Pancreas resection is the removal of part of the pancreas. This relieves the pain caused by inflammation irritating the nerve endings, and it also reduces pressure on the ducts.

Three main techniques are used for pancreas resection:

• The Beger procedure: This involves resection of the inflamed pancreatic head with careful sparing of the duodenum. Then, a surgeon attaches the rest of the pancreas to the intestines.
• The Frey procedure: A doctor may recommend this when inflammation at the head of the pancreas and blocked ducts together cause pain. The Frey procedure adds a longitudinal duct decompression to the pancreatic head resection. The surgeon removes the head of the pancreas and compresses the ducts by connecting them to the intestines.
• Pylorus-sparing pancreaticoduodenectomy: A surgeon removes the gallbladder, the ducts, and the head of the pancreas. Doctors typically only recommend this in very severe cases of intense chronic pain when the head of the pancreas is inflamed and the ducts are also blocked. This is the most effective procedure for reducing pain and conserving pancreas function. However, it has the highest risk of infection and internal bleeding.

While treatment can work well, it is also very risky, with a death rate as high as 10%.

Total pancreatectomy

This involves the surgical removal of the whole pancreas. It is very effective in dealing with the pain.

However, a person who has had a total pancreatectomy will be dependent on treatment for some of the vital functions of the pancreas, such as the release of insulin.

Autologous pancreatic islet cell transplantation

During the total pancreatectomy procedure, a suspension of isolated islet cells is created from the surgically removed pancreas and injected into the portal vein of the liver. The islet cells will function as a free graft in the liver and produce insulin.

Alternative and complementary remedies will not cure chronic pancreatitis, but they may help ease symptoms.

Combining alternative remedies with standard treatments may help get better results. Replacing standard treatments with alternative ones may allow the disease to progress more rapidly, causing more symptoms.

Some options include:

• Yoga: Yoga may help a person relax, easing pain, anxiety, and depression.
• Massage: Massage can improve circulation and may help with relaxation and pain.
• Acupuncture: Acupuncture is a traditional Chinese medicine technique for realigning the body’s energy. Some people anecdotally report that it helps them.
• Meditation: Meditation can help ease the stress of living with a chronic condition and may help some individuals better manage their pain.
• Exercise: Exercise can help a person reach or maintain a moderate body weight and may reduce the side effects of other conditions, potentially also reducing inflammation. Moreover, regular exercise may improve mood and alleviate pain.

Taking dietary measures is vital to reduce the effects of pancreatitis.

The pancreas is involved in digestion, and pancreatitis can impair this function. This means that people with the condition will have difficulty digesting many foods.

Rather than three large meals per day, people with pancreatitis will be advised instead to consume six small meals. It is also better to follow a low fat diet.

Managing the diet during pancreatitis aims to achieve four outcomes:

• reducing the risk of malnutrition and shortages of certain nutrients
• avoiding high or low blood sugar
• managing or preventing diabetes, kidney disease, and other complications
• decreasing the likelihood of an acute flare-up of pancreatitis

A diet plan will be drawn up by a doctor, or the person may be referred to a qualified dietitian. The plan is based on the person’s current levels of nutrients in the blood shown in diagnostic testing.

Meal plans will generally involve food sources that are high in protein and have dense nutritional content. These are likely to include whole grains, vegetables, fruits, low fat dairy products, and lean protein sources, such as boneless chicken and fish.

Fatty, oily, or greasy foods should be avoided, as these can trigger the pancreas to release more enzymes than usual. As a primary cause of chronic pancreatitis, alcohol is also best avoided while on a pancreatitis-friendly diet.

Depending on the extent of the damage, individuals may also have to take artificial versions of some enzymes to aid digestion. These will ease bloating, make their feces less greasy and foul-smelling, and help any abdominal cramps.

Chronic pancreatitis is usually a complication of recurrent episodes of acute pancreatitis. These can lead to permanent damage in the pancreas.

Acute pancreatitis occurs when trypsin becomes activated within the pancreas. Trypsin is an enzyme that is produced in the pancreas and released into the intestines, where it breaks down proteins as part of digestion.

Trypsin is inactive until it has reached the intestines. If trypsin becomes activated inside the pancreas, it will start to digest the pancreas itself, leading to irritation and inflammation of the pancreas. This becomes acute pancreatitis.

Alcohol misuse

Consuming alcohol can cause a process that triggers the activation of trypsin inside the pancreas, as can gallstones.

People who misuse alcohol and develop acute pancreatitis tend to have repeated episodes and eventually develop chronic pancreatitis.

Repeated bouts of acute pancreatitis eventually cause permanent damage to the pancreas, leading to chronic pancreatitis.

This is also known as alcohol-related chronic pancreatitis.

Idiopathic chronic pancreatitis

When a condition is idiopathic, it has no known cause. Idiopathic chronic pancreatitis accounts for most of the remaining cases.

Most cases of idiopathic chronic pancreatitis develop in people aged 10–20 years and those aged over 50 years.

Experts do not exactly know why other age groups are rarely affected. The SPINK-1 and the CFTR genes, types of mutated genes, exist in about 50% of people with idiopathic chronic pancreatitis. These genetic mutations may undermine the functions of the pancreas.

Other, much rarer causes include:

• autoimmune chronic pancreatitis, wherein the person’s immune system attacks the pancreas
• hereditary pancreatitis, wherein a person has a genetic condition and is born with a pancreas that is not working effectively
• cystic fibrosis, another genetic condition that damages various organs, including the pancreas

While chronic pancreatitis can develop in anyone, certain factors increase the risk, including:

• chronic alcohol misuse
• autoimmune conditions
• chronic inflammation, often due to an autoimmune condition
• chemotherapy
• genetic mutations that may run in families
• nutritional deficiencies

There are no reliable tests to diagnose chronic pancreatitis. A doctor may suspect the condition because of the person’s symptoms, history of repeated acute pancreatitis flare-ups, or alcohol misuse.

Blood tests may be useful in checking the blood glucose levels, which may be elevated.

Blood tests for elevated levels of amylase and lipase are not reliable at this stage. Amylase and lipase blood levels rise during the first couple of days of pancreatitis and then settle back to normal after 5–7 days. An individual with chronic pancreatitis would have had the condition for much longer.

Doctors need to have a good look at the pancreas in order to diagnose the condition properly. This will most likely involve:

• An ultrasound scan: High frequency sound waves create an image of the pancreas and its surroundings on a monitor.
• A CT scan: X-rays are used to take many pictures of the same area from several angles, which are then placed together to produce a 3D image. The scan will reveal changes of chronic pancreatitis.
• Magnetic resonance cholangiopancreatography scan: This scan shows the bile and pancreatic ducts more clearly than a CT scan.
• An endoscopic ultrasound: An endoscope is inserted into the digestive system. The doctor uses ultrasound to guide the endoscope through.

People with chronic pancreatitis have a greater risk of developing pancreatic cancer. If symptoms worsen, especially the narrowing of the pancreatic duct, doctors may suspect cancer. If so, they will order a CT scan, an MRI scan, or an endoscopic study.

There are several ways in which chronic pancreatitis can develop and become more harmful to a person’s well-being.

Stress, anxiety, and depression

The condition may have an effect on a person’s psychological and emotional well-being. Constant or recurring pain that is often severe may cause distress, anxiety, irritability, stress, and depression.

It is important for a person to tell a doctor if they feel depressed, anxious, or very unhappy. A support group can help them learn coping skills and feel less isolated.

Pseudocyst

This is a collection of tissue, fluid, debris, pancreatic enzymes, and blood in the abdomen, caused by leakage of digestive fluids escaping from a pancreatic duct that is not working effectively.

Pseudocysts do not usually cause any health problems. However, sometimes they can become infected, cause blockage to part of the intestine, or rupture and cause internal bleeding. If this happens, the cyst will have to be surgically drained.

Pancreatic cancer

Pancreatic cancer is more common in people with chronic pancreatitis. Although the relative risk increases, the absolute risk remains low.

Avoiding alcohol consumption significantly reduces the risk of developing chronic pancreatitis in people with acute pancreatitis. This is especially the case for individuals who drink large amounts of alcohol regularly.

Refraining from drinking excessive amounts of alcohol may prevent pancreatitis. It is also important to manage chronic medical conditions to reduce the risk of inflammation, which damages the pancreas.

Chronic pancreatitis is a serious condition that can undermine a person’s overall health and shorten their life span. It can lead to pancreatic cancer, diabetes, and other chronic conditions.

Several medical conditions increase the risk of pancreatitis. This means many people with this diagnosis also have other serious health issues.

Early diagnosis and treatment are critical for prolonging a person’s life and easing their pain. The right treatment can slow or stop damage to the pancreas.

Individuals with abdominal pain or other pancreatitis symptoms should contact a doctor to discuss treatment options.

Emphysematous pancreatitis

Oleg Kruglov

Illustrations Contents

Emphysematous pancreatitis is a rare complication of acute pancreatitis resulting from an infection causing necrosis of the pancreas. The addition of gas-producing flora results in the characteristic presence of gas in the parenchyma and around the pancreas.

Pathology

Infectious process caused by gas producing bacteria such as Escherichia coli , Clostridium perfrigens , Staphylococcus sp , Streptococcus sp , Klebsiella sp and Pseudomonas sp . The gas formed as a result of vital activity is carbon dioxide and nitrogen resulting from the fermentation of glucose by some bacteria.

Staging

Emphysematous pancreatitis falls under the characteristics of necrotizing pancreatitis on the Balthazar scale and, accordingly, it has the highest score on the CT severity scale.

Diagnostic

Computed tomography is the modality of choice because it has the highest sensitivity and specificity for visualization and detection of gas inclusions.

Course and prognosis

This complication is characterized by a high mortality rate. Percutaneous drainage of fluid collections is used and, in the absence of a clinical response, surgical resection of necrotic tissue is considered.

Differential diagnosis

• atmospheric gas introduced during instrumental examinations or as a result of surgical intervention (e.g. condition after ERCP)
• small bowel fistula formation with reflux from an adjacent hollow organ

Literature

1. Dr Daniel J Bell and Dr Bruno Di Muzio et al. emphysematous pancreatitis. Radiopedia

2. Kvinlaug K, Kriegler S, Moser M. Emphysematous pancreatitis: a less aggressive form of infected pancreatic necrosis?. (2009) Pancreas. 38(6): 667-71. doi:10.1097/MPA.0b013e3181a9f12a – Pubmed

3. Wig JD, Kochhar R, Bharathy KG, Kudari AK, Doley RP, Yadav TD, Kalra N. Emphysematous pancreatitis. Radiological curiosity or a cause for concern?. (2008) JOP : Journal of the pancreas. 9(2): 160-6. Pubmed

Pancreas

• Anatomy
  • Pancreas (anatomy, embryology)
• Anomalies of development
  • Pancreas doubling
  • Annular pancreas
• Pancreatitis
  • Revised Atlanta Classification of Acute Pancreatitis
    • Acute peripancreatic fluid accumulation
    • Acute necrotic accumulation
      • Delimited pancreatic necrosis
  • Complications of pancreatitis
    • Emphysematous pancreatitis
  • CT severity index of acute pancreatitis according to the Balthazar score
• Tumors of the pancreas
  • Pancreatic endocrine tumors
    • insulinoma
    • gastrinoma
    • vipoma
• Trauma of the pancreas
  • Injury of the pancreas: AAST classification

Postoperative pancreatitis in pancreatic surgery

Introduction

Postoperative pancreatitis (PP) is one of the most severe postoperative complications, which is observed not only after abdominal operations, but also after interventions on the chest organs, peripheral vessels [4, 12, 14, 18]. Most often, PP occurs after operations on the pancreas (PZ). The incidence of PP in these situations, according to different authors, ranges from 1.9up to 50% [4, 16]. A distinctive feature of PP after pancreatic surgery is the severe course of this complication, the occurrence of anastomotic suture failure, arrosive intra-abdominal bleeding, and, in a later period, pancreatic fistulas [12, 15, 20, 21]. At the same time, in recent publications devoted to the surgical treatment of pancreatic diseases, PP is not considered among the complications, only its consequences are taken into account: pancreatic fistulas, abdominal abscesses [20, 23].

Surgical treatment of patients with benign and malignant diseases of the pancreas is one of the priorities of the Department of Abdominal Surgery of the Institute of Surgery. A.V. Vishnevsky. Unfortunately, it is not possible to avoid the occurrence of PP, despite the observance of the necessary precautions. We set out to find out the causes of PP, its early clinical, biochemical manifestations, as well as the signs detected by radiological diagnostic methods, and the principles of treatment of complications.

Material and methods

This report analyzes the results of surgical treatment of 302 patients with malignant and benign tumors of the pancreas (166 patients) and chronic pancreatitis (136), operated in 2007-2009. Two patients underwent robot-assisted interventions: distal resection of the pancreas (ductal adenocarcinoma) and resection of its head (solid pseudopapillary tumor). The study did not include patients who underwent palliative surgery that was not associated with intervention on the pancreas. PP occurred in 178 (58.9%) of patients, including the edematous form of PP was in 105, pancreatic necrosis – in 73 patients. The nature of the operations performed and the frequency of occurrence of PP are reflected in Table. 1.

During the operation, the initial state of the pancreatic parenchyma and the main pancreatic duct (MPD) was assessed – the manifestation of atrophy and sclerosis, the presence of pancreatic hypertension, calculosis. Subsequently, the presence of fibrosis and atrophy of the pancreatic tissue was controlled by morphological examination.

As an intraoperative prophylaxis of PP in 229(73.1%) of patients with resection or transection of the pancreas used octreotide. The use of the drug was the same in all patients and consisted in the introduction of a synthetic octapeptide, a derivative of sonatostatin, 0.1 mg before mobilization of the pancreas and before cutting/dissecting its parenchyma. They refused preventive administration of the drug in 73 patients with severe sclerotic and atrophic changes in the parenchyma of the organ. In the postoperative period, all operated patients received the drug at a dose of 0.1 mg 3-4 times a day for 3-4 days. During the operation, the reaction of the pancreas to the surgical trauma was recorded – the appearance of “subcapsular” edema, plaques of steatonecrosis.

From the first hours after the operation, the condition of the patients was taken into account. The clinical manifestations of PP were considered to be confusion, stupor, lethargy; inefficiency of spontaneous breathing or the inability to “remove the patient” from apparatus breathing; persistent tachycardia, unstable hemodynamics, despite adequate anesthesia and infusion therapy; pain in the upper abdomen of a girdle character or in the lumbar region; the release of stagnant gastric contents through a nasogastric tube, the lack of restoration of peristaltic activity of the intestine; discharge through the drainage of the abdominal cavity (stuffing bag) of the separated color of tea or “meat slops”.

Laboratory diagnostic criteria included monitoring of the level of blood leukocytes, blood amylase and drainage discharge on days 1-5 of the postoperative period. In all patients, the level of amylase was determined according to the method of B. Smith and I. Roe in the modification of A.M. Ugolev.

Ultrasound of the abdominal organs in dynamics was performed in 302 (100%) patients on the first postoperative day using Voluson 730 pro V devices from General Electric (USA), Sonoline Elegra, Sonoline Sienna from Siemens (Germany) with multifrequency sensors at the frequency 3.5 MHz. In the future, ultrasound diagnostics was used for atypical postoperative course.

The study assessed the degree of heterogeneity of the pancreatic parenchyma, its swelling, the presence of fluid accumulations in the operation area and the free abdominal cavity. In the presence of fluid, a diagnostic puncture was performed, and the level of amylase in it was determined. Ultrasound monitoring of the condition of the pancreatic tissue was performed for the first time 12-16 hours after the operation in all patients, and subsequently, as needed.

Computed tomography (CT) was performed in 27 patients on Secura and Tomoskan SR 7000 (Germany), Brilliance (Holland) CT scanners in the presence of clinical, laboratory and ultrasound manifestations of PP. CT results were assessed using the Balthazar CT Severity Index (1994), ranking it by degree from A to E using a scoring scale from 0 to 4. The scores obtained were summed up with scores reflecting the magnitude of pancreatic necrosis [9-11, 19].

Treatment of PP included intensive infusion and antispasmodic therapy, preventive administration of antibacterial drugs, and stimulation of intestinal motility. With the threat of developing multiple organ failure, extracorporeal detoxification methods (plasmapheresis, ultrahemofiltration) were used. In the event of arrosive bleeding, postoperative peritonitis, an emergency operation was performed.

The severity of complications that occurred was assessed according to the classification of D. Dindo et al. [23].

Results and discussion

During the intraoperative and subsequent morphological assessment of the state of the pancreatic tissue, it was found that out of 302 patients operated on for pancreatic tumors and chronic pancreatitis, in 217 (71. 8%) it was little changed, the diameter of the MP did not exceed 4-5 mm; among these patients, PP occurred in 168 (77.4%). Pronounced sclerotic and atrophic changes in the tissue and expansion of the MPD by about 10 mm were noted in 85 patients, among whom PP occurred only in 10 (11.8%).

By the end of the operation, 7 patients had subcapsular edema, and 1 patient even had single plaques of steatonecrosis. In the postoperative period, all these patients inevitably developed severe PP, which corresponded to pancreatic necrosis.

Out of 178 patients with PP, a synthetic octapeptide derivative of sonatostatin was intraoperatively used preventively in 137, while in all these patients the gland parenchyma was assessed as little changed.

In the first hours (up to 18 hours) after the operation, when mechanical ventilation was performed, 26 patients had persistent tachycardia of 120-130 beats per 1 min, not associated with hypovolemia and the adequacy of anesthesia; cold sweat and acrocyanosis; failure of attempts to transfer to spontaneous breathing or rapid exhaustion during spontaneous breathing. All these patients subsequently developed a detailed clinical picture of severe PP (pancreatic necrosis).

Discharge through the abdominal cavity drainage at that time always had a hemorrhagic character, its amount varied from 50 to 650 ml. Amylase activity in the fluid released through the drains was increased in 198 patients and averaged 1137 ± 1.96 units, in 104 patients with severe atrophy of the pancreatic tissue, the amylase level did not exceed normal values.

By the end of the 1st day after the operation, when almost all patients were transferred to spontaneous breathing and became available for communication, it became possible to assess the clinical manifestations characteristic of PP. The identified symptoms in patients with PP are shown in Table. 2.

As it turned out, an indisputable manifestation of PP was a combination of an increase in the level of amylase in the blood and in the drainage discharge with a syndrome of impaired motor function of the intestine, including gastrostasis (belching, hiccups, secretion of congestive discharge through a gastric tube up to 1500 ml per day), inhibition of the peristaltic activity of the small intestine .

Isolation of dark-brown or “meat slop” effusion from the abdominal cavity one day after the operation was observed in 68 patients and was a pathognomonic sign of pancreatic necrosis.

Based on the data of clinical and instrumental methods of examination, the diagnosis of PP by the end of the 1st day after surgery was established in 178 (58.9%) patients.

On the 2nd and 3rd days after surgery, the condition of 105 (58.9%) of 178 patients with PP improved significantly, the clinical manifestations of pancreatitis regressed, which corresponded to the edematous form of acute pancreatitis.

Despite intensive conservative therapy, in 73 (41.1%) patients, clinical manifestations of PP persisted later than 3 days after surgery. The volume of secreted dark hemorrhagic or tea-colored exudate with a high content of amylase did not tend to decrease. An instrumental examination revealed changes in the pancreatic parenchyma corresponding to pancreatic necrosis.

With the rapid development of the necrotic process in the pancreas, ultrasound revealed fluid in the pleural cavities in 31 (42. 4%) patients, in the abdominal cavity and omental sac – in 71 (97.2%) patients. This picture persisted up to the 5th day of the disease in 46 (64%) patients. Zones of necrosis during ultrasound were detected only on the 5-7th day in the form of hypoechoic (51.6%) or hyperechoic (48.4%) zones.

To clarify the diagnosis, especially when ultrasound was difficult due to the presence of a large amount of gas in the intestine, 27 (8.9%) patients underwent CT scan. In the native phase of contrasting, from 2-3 days, infiltration and inhomogeneity of the pancreatic tissue with a density of 20-40 H units without a clearly differentiated structure was determined in the operation area.

In the first 5 days, the size of the pancreas increased in all patients, in some parts of the organ its external contour was indistinctly visualized (in 4 patients, the pathological process progressed in dynamics). The density of the pancreas was reduced, but with contrast enhancement, the accumulation of the drug in the parenchyma of the gland was uniform, although reduced. The size of the pancreas was significantly increased, in all patients the contours of the gland lost their clarity, while the structure of the duodenal wall was not differentiated in 4 patients. The uneven accumulation of the contrast medium due to the presence of foci of necrosis made it possible to accurately assess the extent of the organ lesion. Prostate tissue of reduced density and a zone that does not accumulate a contrast agent in 14 patients were localized in the area of ​​the tail and body of the pancreas, in 13 patients – in the area of ​​the head of the pancreas. In 2 patients, the affected area was 30%, in 14 patients – 30-50%, in 5 cases necrosis exceeded 50% according to Balthazar.

Patients received intensive conservative therapy, which gave a clear positive effect in the edematous form of PP. With PP corresponding to pancreatic necrosis, therapeutic conservative measures made it possible to achieve a decrease in endogenous intoxication, the use of extracorporeal detoxification ensured the resolution of multiple organ failure. With severe PP, patients received a balanced nutritional support using early enteral tube feeding, which effectively compensated for the body’s energy losses, especially in the case of mono- or multiple organ failure. However, none of the cases managed to avoid certain complications, which often had a multiple cascade character. As a rule, failure of the sutures of the pancreato- and/or biliodigestive anastomosis first occurred, followed by arrosive bleeding, the formation of pancreatic fistulas (Table 3).

When the sutures failed, a characteristic pathological discharge along the drains was manifested. As a rule, discharge that manifested pancreatic necrosis (brown or dirty hemorrhagic hue) changed its appearance due to the admixture of bile or pancreatic juice. Reliable delimitation from the free abdominal cavity by this time in 23 patients made it possible to avoid repeated operations, while in 12 cases additional drainage was required, which was performed under ultrasound guidance. Subsequently, 16 of 23 patients developed pancreatic fistulas.

The spread of intestinal contents in the abdominal cavity could not be avoided in 5 patients who were urgently operated on, additional drainage was performed.

Bleeding from the area of ​​pancreatojejunostomy or pancreatic stump in 8 patients, which had an arrosive character, required immediate surgical treatment. Performed relaparotomy, hemostasis was provided by ligation with stitching. Subsequently, there was no recurrence of bleeding. The superior mesenteric or portal vein was the source of bleeding in 3 patients. It arose from the stump of a previously ligated inflow of the main vein, lysed with pancreatic juice. A similar mechanism of bleeding was observed in 2 cases, in which its source was the hepatic artery and the renal artery. It was impossible to perform extirpation of the pancreatic stump due to the severity of the condition of the patients, they had recurrent bleeding, both patients died.

According to the classification of D. Dindo, PP, which occurred in 302 operated patients, led to complications of I-II degree of severity in 86 (28.5%), III a-b degree in 31 (10.3%), IV degree in 1 (0 .3%), V degree of severity – in 17 (5.6%) patients.

Of the 178 patients with PP, 17 (9.5%) died. In 4 of them, PP corresponded to the edematous form, death was due to decompensation of severe concomitant diseases. Pancreatic necrosis and its complications were the cause of death in 13 cases.

Surgical interventions on the pancreas have always been and remain an area of ​​increased danger for patients. At the beginning of the development of surgical pancreatology, postoperative mortality reached 10-15% [3, 5, 6, 17], the number of patients with complications in the immediate postoperative period was 50-60% [2, 13, 16, 25, 26]. With the acquisition of experience, the development of optimal surgical tactics and operating techniques, the emergence of modern methods of surgical hemostasis, high-quality suture material in leading clinics involved in surgical pancreatology, mortality has significantly decreased and ranges from 0 to 10%. At the same time, postoperative complications are observed in 30-50% of cases [2, 22, 28].

Possessing high functional activity, the pancreas is extremely sensitive to damaging mechanical influences. Surgical interventions on the pancreas that have retained functional activity are always fraught with an increased risk of developing PP [1, 29, 31]. Even the use of minimally invasive technologies, such as robotic surgery and laparoscopy, does not guarantee the absence of PP. The term “soft gland” accepted in the literature implies the absence of pronounced sclerosis and atrophy of the pancreatic tissue [24, 30, 32, 33]. It is pink in color with preserved lobulation, the diameter of the GPP does not exceed 3-4 mm. The leaflet of the parietal peritoneum, covering the ventral surface of the pancreas, is thin, transparent; there are no adhesions with the stomach and mesentery of the transverse colon; on palpation, the tissue of the gland has a soft elastic consistency.

In our opinion, PP is initiated during the operation, while the nature of the lesion of the pancreas is initially “laid” as edematous pancreatitis or pancreatic necrosis. The effectiveness of preventive intraoperative and even more so postoperative use of octreotide is questionable [7, 27]. At the same time, the more pronounced sclerosis and atrophy of the pancreatic tissue, the wider the GLP, the less likely it is to develop PP.

An increase in the level of amylase in the discharge through the drains and in the blood plasma for 1 day after surgery without clinical manifestations of PP did not serve as an absolute sign of the occurrence of this complication, while the combination of an increase in the content of amylase in the discharge through the drains and in the plasma with persistent tachycardia , unstable blood pressure, gastrostasis and inhibition of intestinal motor activity certainly indicated the development of PP. Ultrasound and CT made it possible to clarify the diagnosis, determine the degree of damage to the pancreas, parapancreatic tissue, the presence of fluid accumulations [8, 9, eleven].

The currently widely accepted classification of complications after pancreatic surgery, proposed by D. Dindo (2004), is based on an assessment of the amount of therapeutic measures required to eliminate them, but does not reflect the nature of the complications themselves [13, 23]. According to our data, the main complication in the immediate postoperative period is PP and its consequences. At the same time, the edematous form of PP responds well to conservative therapy and does not lengthen the postoperative hospital stay. At the same time, pancreatic necrosis leads to severe, often fatal complications. Failure of pancreatojejunoanastomosis in combination with arrosive bleeding from the main vessels is the most severe complication. The only radical method to eliminate this complication is the extirpation of the pancreatic stump.

Thus, postoperative pancreatitis is a common complication after pancreatic surgery, occurring in 58.9% of cases. Its cause is intraoperative trauma of the pancreas. With a little changed pancreatic parenchyma, the probability of postoperative pancreatitis reaches 77.