Ọgwụ ịwa ahụ nke nnukwu pancreatitis

A na-eji ọgwụgwọ ịwa ahụ nke nnukwu pancreatitis mee ihe naanị iji gosipụta ọpụrụiche: enweghị mmetụta nke ọgwụgwọ Conservative, mmụba nke mgbaàmà nke mmenaanya na peritonitis, njirimara nke ihe mgbaàmà na-egosi ọpụpụ akwara ma ọ bụ mmụba nke ọrịre ahụ, ngwakọta nke pancreatitis nwere ụdị mbibi nnukwu cholecystitis.

Typesdị ụdị ịwa ahụ a na - eme maka nnukwu ọrịa a na - ahụkarị: tamponade na mwepu nke obere omental bursa na - enweghị dissection nke peritoneum n'elu pancreas, tamponade na drainage nke bred na peritoneum na - ekpuchi pancreas, resection nke necrotic gbanwere pancreas, pancreas buru ibu. ọnya nke ụdị ọrụ atọ izizi ndị a na-etinye aka na gallbladder, extrahepatic bile ducts na ara Vater.

Enwere ụzọ intra- na extraperitoneal na pancreas. Ihe a na-ahụkarị bụ laparotomy median nke dị elu. Ohere dị mma na-enyekwu akụkụ nje akụkụ nke afọ, tumadi ebe enwere oge ịwa ahụ na-achọgharị ntụgharị nke biliary.

Enwere ike mejuputa nnweta intraperitoneal n’otu n’ime ụzọ anọ. 1. Site na akwara afọ. Nnweta a dabara adaba n'ihi na ọ na-enye gị ohere inyocha ọtụtụ isi, ahụ na ọdụ nke pancreas. Na mgbakwunye, ọ na -emepụta ọnọdụ ka mma maka ikewapụ akpa nri n’akụkụ oghere ime ahụ. 2. Site na akwara ịba ọcha n'anya. Nnweta a adịghị nfe ma ọ ga-adaba adaba iji ya naanị gastroptosis. 3. Site na ngagharị nke eriri transhịlị. Ohere nwere ike ịtụle akwara niile, ihe isi ike nke mmiri na-esochi na obere mkpesa na-ekpebi nnweta a na-adịghị ahụkebe. 4. Site na nchikota nke duodenum (T. Kocher) ma si otu a na - ekpughe isi nke pancreas. Ntinye aka a na pancreas nwere ike ịbụ naanị mgbakwunye na nke mbụ.

N’ime ụzọ a ga-esi banye n’akpịrị, naanị abụọ bụ ihe dị mkpa: 1) lumbotomy n’akụkụ aka nri (n’okpuru ọgịrịga nke XII na ihe yiri ya), na-enye ohere igosipụta isi akwara, na mmadụ abụọ n’akụkụ aka ekpe nke na-abịa nso n’ahụ na ọdụ nke pancreas. A na-egosikarị usoro ndị a maka mmebi nke oghere na phlegmon nke oghere retroperitoneal ma enwere ike iji ya dị ka ndị ọzọ na intraperitoneal.

Tamponade na mpe mpe akwa nke bursa na-enweghị dissection nke peritoneum nke na-ekpuchi gland adịghị enye oke ihe na-egbu egbu nke nwere enzymes na-arụ ọrụ na akwara anụ ahụ. Ya mere, ọrụ kachasị gbasaa bụ ntụpọ nke peritoneum karịa gland, yana tamponade na drainage nke roment bursa. B. A. Petrov na S. V. Lobachev na-atụ aro ka a na-ejikọta oghere ahụ na gland site na ntụgharị ihu ogologo 2-4 site na isi ruo na ọdụ nke gland. V. A. Ivanov na M. V. Molodenkov na mgbakwunye (ọkachasị na pancreatitis na-emebi ihe) na-ekpughere peritoneum ma gosipụta ihu, elu na ala nke gland, ebe akụkụ ma ọ bụ na-ekesa akụkụ nke necrosis.

A na-eji tamponade ahụ na-eji akwa gauze nkịtị ma ọ bụ akwa a na-eji rọba. Dị ka a na-achị, a na-ebute ha na ahụ na ọdụ nke pancreas na akụkụ nke elu nke oghere obere mmanụ ahụ. Ebe ọ bụ na dissection nke pancreatic capsule na tamponade na-esote anaghị egbochi ọganiru nke usoro ahụ na ntinye agba gland na ntinye nke retroperitoneal abịaghị, ọtụtụ ndị edemede (A.N. Bakulev, V.V. Vinogradov, S.G. Rukosuev, wdg) na-atụ aro imepụta Yabụ nke pancreas metụtara. Agbanyeghị, iji ọrụ a amachibidoghị usoro ngbanwe doro anya na mmerụ ahụ, enwere ike ọ ga - eso nke necrosis. Mikhaylants tụrụ aro ka amachie ihe ịwa ahụ maka ọrịa akwara na-egbochi naanị ọgwụ nje nke pancreas (nnukwu mmanye), dabere na ọgwụ nje guzobere ọgwụ na ọrụ robaiki ahụ.

N'oge a na-awa ahụ maka nnukwu ọrịa akwara, mgbochi novocaine nke pancreas, a na-eme mkpọrọgwụ mgbọrọgwụ na obere omentum. A na-agbakwunye 100-200 ml nke 0.25% nke novocaine na mgbakwunye nke ọgwụ nje (penicillin - 200,000-300,000 DB, streptomycin - 150,000-200,000 nkeji).

Ọtụtụ ndị dere na-atụ aro, mgbe ha gbasasịrị mpempe akwụkwọ nke peritoneum ma kpughee pancreas, jupụta elu mmiri ya na plasma akọrọ (100-150 g), mkpụrụ osisi dị oke egwu, mkpụrụ ndụ ọbara uhie na mgbakwunye nke ọgwụ nje. Ebumnuche nke usoro nke usoro protin protin na-ewepụ mmiri bụ ịkwụsịlata enzymes ihe ọ pancụ pancụ nke pancreatic. Mgbe nke ahụ gasịrị, a na-atụ aro inpa kwa ụbọchị nke usoro protein ndị a na ọnọdụ adịghị ala ala, yana onye na-egbochi trasylol, site na ọkpọkọ mmiri mmiri. Na mgbakwunye, ọ na-aga n'ihu na-ahụ ya site na iji mmiri na-agbawa intravenously ruo mgbe diastase na mmamịrị na-ebelata ka ọnụọgụ nkịtị.

N'ime arụmọrụ nke nnukwu pancreatitis, dịka iwu, nyocha nke traktị biliary dị mkpa. Site na ọnya ọgbụgba na-egbu egbu na - egosi cholecystostomy. N'ihe banyere nchọpụta nke cholecystitis, cholecystectomy na mmiri nke bile (otu ihe nwere otu ọzọ) dị mkpa. N'ọnọdụ ụfọdụ, mgbe ịwa ahụ, a na-achọpụta ụzọ dị warara nke ihe mmịpụta ọ bụla, a na - egosi choledochoduodenostomy (leekwa akpa ume, ịwa ahụ). Ofrụ ọrụ nke sphincterotomy n'ọnọdụ ndị a achọtaghị nnukwu ọrụ na usoro ọgwụgwọ n'ihi ọtụtụ nsogbu na-esote oge ọmụmụ.

Mgbe ọ rụsịrị ọrụ ahụ, ọ dị mkpa iji mepụta ihe ndị dị na ya iji lụsoo mmamịrị, paresis eriri afọ, nsogbu nke usoro akwara umeji na iku ume.

Ọgwụ ịwa ahụ Mkpesa maka ịwa ahụ

Ihe ngosiputa zuru oke maka ogwugwo bu oria a na-egbu nekariza(necrosis na-efe efe, panreatogenic abscess, nje mmiri nwere nje, retroperitoneal necrotic phlegmon, purulent peritonitis, pseudocyst nje). N’oge ọgbụgba nke ọrịa ahụ, a na-ekpebi nhọrọ nke usoro ịwa ahụ ọgwụ site n’ịwa ụlọ na pathomorphological ụdị ọrịa akwara ọria na ogo nke ọnọdụ onye ọrịa. Site na ọdịdị aseptic nke necrosis pancreatic, ekwesighi iji ọgwụ mgbochi laparotomic n'ihi nnukwu ihe ize ndụ nke ibute ọrịa nke necrotic sterile na mmepe nke ọbara ọgbụgba intraperitoneal, mmebi iatrogenic na eriri afọ. Ekwesịrị ịwa ahụ maka ọrịa Laparotomic n'oge usoro ọgbụgba na-emebi ihe. Ihe na-egosi na o nwere ike ịbụ:

ichebe ma ọ bụ inwe mmerụ ahụ ọtụtụ akụrụngwa megide nlekọta nke nlekọta ahụike na-aga n'ihu na ojiji nke obere ịwa ahụ na-emetụta obere oge.

mgbu mgbu azụ

enweghi ike ịdabere na ya wezuga oria necrotic ma obu oria ndi ozo choro ogwugwo mberede.

Ihe ogwugwo oghe na-emeghe ngwa ngwa maka enzymatic peritonitis na usoro mbufe nke ọrịa ahụ n'ihi njehie nchọpụta dị iche na ọrịa ndị ọzọ ngwa ngwa nke akụkụ ahụ, na-enweghị nlekọta ahụike, bụ usoro ọgwụgwọ na-enweghị ezi uche na nke ezighi ezi. Ultrasound duziri ndumodu-adọta adọ

Ikike ime nyocha nke achọrọ (puncture na catheter) na-ekpebi nnabata nke usoro ultrasound n'inye ozi buru ibu na ọkwa niile nke ọgwụgwọ nke ndị ọrịa nwere ọrịa akwara. Ojiji nke ọgbụgba mmiri na-emebi emebi emeghewo ohere ndị ọzọ n'ọgwụgwọ ndị ọrịa nwere ụdị ọrịa akwara dị ntakịrị. Ihe na - egosiputa ntughari site na nchịkwa nke ultrasound maka obon necrosis bu ọnụnọ nke nnukwu mmiri na - eme n'ime oghere na oghere oghere. Iji rụọ ọrụ ịwa ahụ n'okpuru nchịkwa ultrasound, ọnọdụ ndị a dị mkpa: ọhụụ dị mma banyere oghere ahụ, ọnụnọ nke nchekwa dị mma maka mmiri mmiri, yana enwere ike ịwa ahụ ma ọ bụrụ na enwere nsogbu. A na-ekpebi nhọrọ nke usoro maka iwepụta ihe ọgbụgba maka ọgịrịga maka nkụchi pancreatogenic, n'otu aka ahụ, site na ụzọ ọgbụgba dị mma, na nke ọzọ, site nha, udi na ọdịdị nke ihe ahụ. A na-ahụta ọnọdụ maka isi ihe na-ezughị ezu dị ka ọnụnọ nke "windo nkuzi" - nnweta ikuku na-enweghị nsogbu na ihe ahụ. Enyere ntụnye uche na-agafe na obere mkpụkọ ọgbụgba, eriri afọ na eriri afọ, n'azụ mgbidi akụkụ ahụ na akwara, nke dabere na mbido akwụkwọ ahụ na ịkọwa ọnya ọnya. Contraindications maka itinye aka na ntanetị:

enweghị nke mmiri mmiri mebiri emebi nke saịtị mbibi ahụ,

ọnụnọ n'okporo ntụpọ nke akụkụ nke eriri afọ, usoro urinary, akwara vaskụla,

nnukwu nsogbu nke sisọmu ọbara.

Ọkwa ịwa ahụ n’okpuru nchịkwa ultrasound gụnyere otu agịga ọ bụla na mwepụ ya na-esote ya (ya na ụdị nsị nke volumetric). N'adịghị arụ ọrụ nke itinye aka na ntanetị, ha na-ebido arụmọrụ ọdịnala. Mpepu kwesịrị ịgbapụta ihe ndị dị n’ime, ezigbo idobe nke catheter ahụ n’akpụkpọ ahụ na n’ahụ, nrụnye dị mfe, mwepụ na mmezi nke usoro nsị.

Ọgwụ nchekwa

Usoro nlekọta nke nnukwu ọrịa ọrịa pancreatitis gụnyere:

imechi ọnya nke pancreas, afọ na duodenum,
mkpochapu nke hypovolemia, mmiri-electrolyte na nsogbu nke metabolic,
ibelata ọrụ enzyme,
mkpochapu ọbara mgbali elu n'usoro biliary na pancreatic,
mmelite nke rheological Njirimara nke ọbara na Mbelata microcirculatory ọrịa.
mgbochi na ọgwụgwọ nke arụmọrụ nke eriri afọ,
mgbochi na ọgwụgwọ nke nsogbu septic,
na-ebute nnyefe oxygen dị mma n'ahụ ahụ onye ọrịa ya na cardiotonizing na ọgwụgwọ iku ume,
nnwere onwe mgbu.

Ọgwụgwọ na-amalite site na mgbazi nke mmiri-electrolyte, gụnyere mmịnye nke ihe isotonic na nkwadebe potassium chloride na hypokalemia. Iji detoxify mepụta ọgwụ infusion na usoro nke mmanye diuresis. Ebe ọ bụ na a na - enwe ọria ụsọ nke bcc n'ihi mwepu nke plasma nke ọbara, ọ dị mkpa iwebata protein ndị ala (plasma na-adị ọhụrụ, nkwadebe nke albumin mmadụ). Ihe nchoputa maka otutu uzo mgbasa ozi okpukpu a bu iju mmeghachi omume nke BCC, hematocrit, dika iwu nke CVP. A na - eweghachi nkwụghachi nke microcirculation na ihe ọmụmụ nke ọbara site na nhọpụta nke dextran nwere pentoxifylline.

N’akụkụ ahụ, a na-eme ọgwụgwọ maka igbochi ọrụ nke pancreas, bụ nke a na-enweta site n’ịmepụta “izu ike anụ ahụ” site na ịmachibido iri nri nri ruo ụbọchị ise. A na - enweta mmachi nke ọma na mmiri pịrị apị site na ichere nke ihe ndị dị n'ime afọ site na nsị nasogastric na oghere gastric na mmiri oyi (hypothermia mpaghara). Iji belata acidity nke eriri afọ, a na-enye alkaline ọ drinkụ ,ụ, proton pump inhibitors (omeprazole). Iji gbochie ọrụ nzuzo nke eriri afọ, a na-eji ntụpọ nke somatostatin eme ihe - octreotide na nha 300-600 mcg / ụbọchị yana nchịkwa subcutaneous atọ. Ọgwụ a bụ ihe na - egbochi basal na - akpali akpalire nke pancreas, afọ na obere eriri afọ. Ogologo oge ọgwụgwọ bụ ụbọchị 5-7, nke kwekọrọ na oge hyperenzymemia na-arụ ọrụ.

Na necrosis pancreatic, maka ebumnuche nke sistemu, ọ bụ ihe amamihe dị na ya iji usoro extracorporeal: ultrafiltration, plasmapheresis.

Ductme prophylaxis antibacterial ezi uche na ọgwụgwọ nke ọrịa ọrịa pancreatogenic bụ ihe na-eduga n'ọrịa pathogenetic. Site na usoro mbu (edematous form) pancreatitis, egosighi nje ihe na - egbochi nje. Nchoputa nke akwara obara bu nchoputa nke ogwu nje ihe na emeputa ihe nlebara anya nke oma n’ile anya na mpaghara emetụtara ya dika ihe nlere di iche-iche di ka ihe omumu nile. Ọgwụ nke nhọrọ maka prophylactic na iji ọgwụgwọ bụ carbapenems, cephalosporins ọgbọ nke anọ na nke anọ yana metronidazole, fluoroquinolones na njikọ metronidazole.

Site na mmepe nke ọrịa metabolism na-arịa, mmeghachi omume hypermetabolic, a na-enye nri nri parenteral zuru ezu (ngwọta nke glucose, amino acid). Mgbe ị na-eweghachi ọrụ nke eriri afọ n'ime ndị ọrịa nwere ọrịa akwara ọsịsa, ọ bụ ihe amamihe dị na ya ịkọpụta nri nri (nri agwakọta), nke a na-eme site na nyocha nke nasojunal arụnyere na nsoro nke Treitz ligament endoscopically, ma ọ bụ n'oge ịwa ahụ.

Ihe ngosi maka ogwugwo

Ihe ngosiputa zuru oke maka ogwugwo bu oria a na-egbu nekariza (necrosis na-efe efe, panreatogenic abscess, nje mmiri nwere nje, retroperitoneal necrotic phlegmon, purulent peritonitis, pseudocyst nje). N’oge ọgbụgba nke ọrịa ahụ, a na-ekpebi nhọrọ nke usoro ịwa ahụ ọgwụ site n’ịwa ụlọ na pathomorphological ụdị ọrịa akwara ọria na ogo nke ọnọdụ onye ọrịa. Site na ọdịdị aseptic nke necrosis pancreatic, ekwesighi iji ọgwụ mgbochi laparotomic n'ihi nnukwu ihe ize ndụ nke ibute ọrịa nke necrotic sterile na mmepe nke ọbara ọgbụgba intraperitoneal, mmebi iatrogenic na eriri afọ.

Dị ọnya na - egbochi necrosis - Ngosiputa maka ojiji nke isi teknụzụ pere mpe mpe nke ọrịa ịwa ahụ: ọgbụgba laparoscopic na mwepu nke oghere dị na ọnụnọ nke enzymatic peritonitis na / ma ọ bụ usoro ọgbụgba (ọgbụgba) n'oge a na --emepụta nnukwu ọmụmụ mmiri na - adịghachi na oghere retroperitoneal. Wa ahụ site na nnweta laparotomic, nke a na-eme na onye ọrịa nwere necrosis na-enweghị nsogbu, ga-abụ ọkwa dị mkpa ma na-ezo aka "arụmọrụ obi nkoropụ".

Ekwesịrị ịwa ahụ maka ọrịa Laparotomic n'oge usoro ọgbụgba na-emebi ihe.
Ihe na-egosi na o nwere ike ịbụ:

ichebe ma ọ bụ inwe mmerụ ahụ ọtụtụ akụrụngwa megide nlekọta nke nlekọta ahụike na-aga n'ihu na ojiji nke obere ịwa ahụ na-emetụta obere oge.
mgbu mgbu azụ
enweghi ike ịdabere na ya wezuga oria necrotic ma obu oria ndi ozo choro ogwugwo mberede.

Ultrasound duziri ndumodu-adọta adọ

Ihe mgbochi ị na-anyụ nsị n'okpuru nchịkwa ultrasound na-edozi nyocha na ọrụ ọgwụgwọ. Diagnostic ọrụ a bụ inweta ihe maka ọmụmụ ihe na-akpata ọrịa, cytological na biochemical, nke na-enye ohere ka ọdịiche dị mma nke usoro ase ma ọ bụ akparamagwa nke pancreatic necrosis. Ahụike ọrụ bụ ịchụpụ ihe ndị mejupụtara nje ahụ na mmezigharị ya ma ọ bụrụ na achọpụta ihe ịrịba ama nke ọrịa.

Ihe na - egosiputa ntughari site na nchịkwa nke ultrasound maka obon necrosis bu ọnụnọ nke nnukwu mmiri na - eme n'ime oghere na oghere oghere.

Iji rụọ ọrụ ịwa ahụ n'okpuru nchịkwa ultrasound, ọnọdụ ndị a dị mkpa: ọhụụ dị mma banyere oghere ahụ, ọnụnọ nke nchekwa dị mma maka mmiri mmiri, yana enwere ike ịwa ahụ ma ọ bụrụ na enwere nsogbu. A na-ekpebi nhọrọ nke usoro maka iwepụta ihe ọgbụgba maka ọgịrịga maka nkụchi pancreatogenic, n'otu aka ahụ, site na ụzọ ọgbụgba dị mma, na nke ọzọ, site nha, udi na ọdịdị nke ihe ahụ. A na-ahụta ọnọdụ maka isi ihe na-ezughị ezu dị ka ọnụnọ nke "windo nkuzi" - nnweta ikuku na-enweghị nsogbu na ihe ahụ. Enyere ntụnye uche na-agafe na obere mkpụkọ ọgbụgba, eriri afọ na eriri afọ, n'azụ mgbidi akụkụ ahụ na akwara, nke dabere na mbido akwụkwọ ahụ na ịkọwa ọnya ọnya.

Contraindications maka itinye aka na ntanetị:

enweghị nke mmiri mmiri mebiri emebi nke saịtị mbibi ahụ,
ọnụnọ n'okporo ntụpọ nke akụkụ nke eriri afọ, usoro urinary, akwara vaskụla,
nnukwu nsogbu nke sisọmu ọbara.

Isi ihe kpatara adịghị ala mmiri nke purulent-necrotic foci na pancreatic necrosis bụ usoro buru ibu na-emegide ihe ndabere nke iji sistemụ na-eji obere dayameta eme ihe, nke chọrọ ntinye nke drains ọzọ ma ọ bụ dochie ya nwere nnukwu ngbanye dayameta. N'ọnọdụ dị otu a, nke mbụ, mmadụ kwesịrị iburu nsonaazụ nke CT, nke na-enye ohere nyocha ebumnuche nke anụ ahụ na akụkụ mmiri nke mbibi retroperitoneal, yana njikọta nke ọnọdụ onye ọrịa yana ogo mmeghachi omume sistem. Na enweghị ọtụtụ nsị anụ ahụ na onye ọrịa nwere ọrịa akwara ọwụwa, mmezi nke ọnọdụ onye ọrịa, mkparị nke nnwale na nyocha ụlọ nyocha nke mmeghachi omume mkpali n’ime ụbọchị 3 mgbe ịba ọchasị nke saịtị mbibi megidere usoro nhụchalụ akwara pere mpe, na-eme ịwụnye ọtụtụ mmiri mmiri na-ahụ anya nke nwere ọnya ọnya na ọnya na belata echogenesis. N'ime oge ọmụmụ, ọ dị mkpa iji hụ na usoro mmiri ọgwụ mgbochi ga-asachapụ akụkụ mbibi ahụ (ma ọ bụ akụkụ pere mpe).

A na - egosi nhụjuanya nke mkpokọ mmiri na - eme ọsịsa, nke a na - eme n'okpuru nchịkwa nke ultrasound na onye nwere ọrịa pancreatic necrosis, na - egosi site na syndromes nke mmeghachi omume sistemu na - akpata nkwụsi ike ma ọ bụ na - aga n'ihu na - agbasa ọtụtụ akụkụ ahụ, ọnụnọ nke hyperechoic, nsonaazụ nke incomogeneous na saịtị mbibi ahụ.

N’ọnọdụ nsogbu necrosis nke ọrịa akwara na-efe efe, mgbe dị ka nsonaazụ nke ultrasound na CT a chọpụtara na akụkụ necrotic nke ọnya ahụ na-enwe mmụba ya n’arụ mmiri (ma ọ bụ nke ikpeazu adịrị n’otu ọkwa nke ọgbụgba na-emebi emebi), na njikọta nke ọnọdụ onye ọrịa anaghị adị ka ọ dịwanye mma, iji ihe na-emebi emebi. zọ mgbapụta adịghị arụ ọrụ.

Ihe ogwugwo na obere oge ịwa ahụ na-enwe uru doro anya na ịkpụzi ụdị omimi mmiri n'ụdị dị iche iche mgbe arụchara laparotomic, ọkachasị mgbe usoro mmebi emebi ugboro ugboro. Agaghị eji ụzọ ọgbụgba mmiri dị ka ụzọ a ga - esi gwọ ụdị ọrịa akwara a ga - enwe mgbe a ga - agbaso usoro dị ogologo. N'ọnọdụ ndị dị otú ahụ, iji nweta ọgwụgwọ ọgwụgwọ, mmadụ kwesịrị ịdabere na nkwado nke ntinye ọrịa laparotomy.