RU2312663C1 - Method for treatment of acute destructive pancreatitis - Google Patents

Abstract

FIELD: medicine, surgery gastroenterology, intensive therapy.

SUBSTANCE: on background of conventional intensive therapy of pancreatitis and before surgery operation method involves carrying out intramuscular administration of galavite. In stage of enzyme toxemia galavite is administrated in the dose 200 mg, 1-2 times per 24 h. Then in the first 24 h after surgery operation - in the single dose 300 mg per 24 h. In the following days - in the dose 100 mg per a day up to disappearance of symptoms of inflammatory response and normalizing level of blood cytokines. Then treatment is continued by administration of galavite in the dose 100 mg, once per 72 h. Method provides effective treatment, reducing amount of complications, lethality, number of repeated sanitations, decreasing number of repeated operations and decreasing hospitalization period of patients based on correction of processes SIRS and CAPS in this group of patients. Invention can be used in treatment of patients with acute destructive pancreatitis.

EFFECT: enhanced effectiveness of treatment.

7 tbl, 5 dwg, 2 ex

Description

The invention relates to medicine, in particular to surgical gastroenterology and intensive care, and is associated with the treatment of acute destructive pancreatitis (PDP) and pancreatic necrosis as its clinical manifestation.

Acute pancreatitis (OP) has been consistently ranked second for several years, and in some regions, first place in the structure of emergency surgical pathology, ahead of acute appendicitis and acute cholecystitis. The most common cause of the disease is alcohol abuse and gallstone disease; in 10-30% of patients, the etiology of acute pancreatitis remains unclear. Pancreatic necrosis is accompanied by a high incidence of shock in the early stages of the disease, multiple organ failure and purulent necrotic complications. Pancreatic tissue necrosis and secondary infection of destruction foci cause systemic inflammatory response syndrome (SIRS), which determines the severity and prognosis of the disease. The leading role in the development of purulent-septic complications and generalization of infection, according to some authors, is secondary immunodeficiency. The causes of immunosuppression in destructive pancreatitis are various, a number of authors indicate that pancreatogenic toxins, impaired humoral regulation of the immune system and the resulting compensatory anti-inflammatory response syndrome (CAPS) [Pancreatonecrosis and pancreatogenic sepsis are directly involved in this process. State of the Problem / B.C. Saveliev, M.I. Filimonov, B.R. Gelfand, S.Z. Burnevich // Annals of Surgery. - 2003. - No. 1. - S.12-19, or Sinovets O.A. Modulation of the cytokine cascade as one of the pathogenetic mechanisms of the formation of acute experimental pancreatitis / O.A.Synovets // Ros.zhurn. gastroenterology, hepatology, coloproctology. - 2000. - K6. - S. 37-41., Or Bone R.C. Sepsis, SIRS and CARS / R.C. Bone // Crit. Care Med. - 1996. - V.24. - P.1125-1129].

Thus, immunological disorders occupy one of the leading places in the pathogenesis of pancreatitis. However, to date, no immunocorrection pathway has been developed for this disease.

The closest analogue of the proposed method can be considered a modern traditional treatment complex, including surgery, correction of hemodynamic, water-electrolyte disturbances, antispasmodic, antisecretory, cytostatic and antibiotic therapy (see, for example, Treatment of acute pancreatitis at an early stage of the disease: Textbook / C. St. Petersburg Research Institute of Ambulance named after II Dzhanelidze / S.F. Bagnenko, N.V. Rukhlyada, A.D. Tolstoy and others - St. Petersburg, 2002 - 24 p., Or Pancreatic necrosis and pancreatogenic sepsis. problems / BC Saveliev, M. I.Filimonov, B.R. Gelfand, S.Z. Burnevich // Annals of Surgery. - 2003. - No. 1. - S.12-19., Or Watanabe S. Acute pancreatitis: overview of medical aspects / S. Watanabe // Pancreas. - 1998. - V.16, No. 3. - P.307-311.). At the same time, these complex treatment methods do not take into account the role of SIRS and CAPS in the development of the disease, which often leads to adverse treatment outcomes.

The objective of the invention: to propose pathogenetically based immunocorrection of systemic disorders in patients with ADP using the domestic drug "Galavit".

For this, against the background of the traditional treatment, intramuscular administration of galavit was used, the dose and regimen of which was determined depending on the stage of the disease and the stages of treatment. At the stage of enzymatic toxemia in a dose of 200 mg 1-2 times a day. On the first day after surgery, 300 mg once. In the following days - 100 mg per day until the symptoms of a systemic inflammatory reaction (hyperthermia, tachycardia, tachypnea) disappear and the blood cytokines normalize, after which administration of 100 mg is continued once every 72 hours.

The work was clinical in nature, was performed at the Department of General Surgery of the Krasnoyarsk State Medical Academy, located at the center of surgical pancreatology in Krasnoyarsk, and included the results of studies conducted in 52 patients with pancreatic necrosis, 32 of them men (61.5%) and 20 women ( 38.5%). The age of patients ranged from 30 to 58 years.

In 39 patients (75%) at the time of admission, signs of a systemic inflammatory response syndrome were revealed according to the sign scale R. Bone (1991). In 13 patients (25%), clinical manifestations of SIRS developed in the surgical department.

Depending on the objectives of the study, the patients were divided into two groups, equivalent in gender, age, age of onset, etiology, clinical and morphological forms of the disease and the severity of the patients. The distribution of patients into groups is presented in table 1.

In most patients, the average severity of the disease prevailed (76.9%), a severe degree was recorded in 23.1%. The comparison group consisted of 22 patients with destructive pancreatitis who received traditional therapy, including the correction of hemodynamic, water-electrolyte disturbances, antispasmodic, antisecretory, cytostatic therapy, H ₂ receptor blockers, antibiotic therapy. If necessary, inotropic stimulation and hardware support of respiratory activity were performed.

The volume and composition of infusion therapy depended on the initial state of central and peripheral hemodynamics, the degree of disturbance of the water-electrolyte balance and the compensatory capabilities of the myocardium. On average, with moderate severity, the infusion volume was 50 ml / kg, with severe pancreatitis reached 70 ml / kg.

All patients underwent surgical treatment. The timing of early operations ranged from 12 to 72 hours from the moment of admission to the hospital, late surgical interventions were performed on 10-14 days. Indications for surgery in the early stages of the disease were the ineffectiveness of conservative therapy during the first 3 days after hospitalization, manifested in the progression of the severity of the disease, the appearance of symptoms of peritonitis, a combination of pancreatitis and destructive cholecystitis, increasing obstructive jaundice without the possibility of resolving biliary tract decompression by endoscopic methods. In the case of successful conservative therapy, it was possible to achieve stabilization of the patients' condition, localize the focus of inflammation and perform surgical treatment in the delayed period due to purulent complications.

In the first group of patients with pancreatic necrosis, against the background of traditional intensive care and surgical intervention, changes in indicators of the immune status, cytokine spectrum, nitric oxide level and activity of apoptosis of immunocompetent cells were studied.

In patients of the second group, a complex of traditional infusion therapy included immunomodulating therapy with the drug galavit. The drug was administered intramuscularly, the dose was selected individually, based on the severity of immune disorders. 200 mg of the drug was injected 1-2 times a day into the stage of enzymatic toxemia; on the first day after the operation, the dose was increased to 300 mg once. On the remaining days, galavit was administered at 100 mg per day until the level of cytokines was normalized, after which administration was continued once every 72 hours at 100 mg.

The distribution of patients into groups is presented in table 1.

All patients underwent surgical treatment. The choice of method and timing of surgical intervention depended on the nature of the pathological process (Table 2).

The immunomodulator "Galavit" manufactured by ZAO "TsSM" Medicor ", Moscow, is a 5-amino-1,2,3,4-tetrahydrophthalazine-1,4-dione sodium salt. The drug has the ability to restore the effector mechanisms of immunity due to the indirect action through the presentative function of macrophages, regulation of the synthesis of IL-1, IL-6, tumor necrosis factor, IL-2, natural killer cells (NK cells) by reversibly inhibiting the synthesis of hyperactive macrophages of RNA and DNA pro-inflammatory cytokines for 6-8 hours or stimulating them with initial failure. At the same time, galavit is able to restore the inhibited phagocytic function of macrophages and neutrophils and, therefore, anti-infection protection. There are also reports of the detoxifying effect of the drug.

The results of the use of immunocorrective therapy with galavitis in patients with pancreatic necrosis.

As a rule, infection of foci of pancreatic tissue necrobiosis is secondary, develops at 2-3 weeks of illness and is caused mainly by opportunistic pathogens, which is possible only in an immunocompromised body. In case of infection caused by opportunistic pathogens, the immune recognition of the pathogen and its eradication is carried out with the participation of the cellular component of immunity. It has been proven that the main cause of secondary infection is the translocation of bacteria from the intestinal lumen and the anergy of cellular effectors, therefore, recovery processes depend on the activation of these effectors.

Changes in the immune system recorded in patients of group 1 who received traditional therapy prove the inability of the immune system to resist microbial attack in the early stages of pancreatic necrosis (Tables 3, 4). Under the stress of biological adaptation systems, in response to the effects of infectious agents, the synthesis of cytokines is activated, which causes a temporary or permanent violation of the regulation of the production of certain cytokines, in particular IL-2, IL-6, and tumor necrosis factor.

Currently, there are no studies on the effectiveness of galavit in the treatment of patients with acute pancreatitis. There are no standardized schemes for its use at various stages of the development of acute destructive pancreatitis, its effect on the production of pro-inflammatory cytokines, the severity of the systemic inflammatory response, and the development of secondary immunodeficiency in pancreatic necrosis have not been studied.

The effectiveness of galavit was studied in 30 patients with acute destructive pancreatitis, who constituted the 2nd group. All patients of the study group at the time of admission showed signs of a systemic inflammatory reaction, in 73.3% of patients the condition corresponded to moderate severity, and 26.7% to severe.

All patients of the 2nd group were subjected to surgical treatment, indications for surgery and implementation procedures were similar to the first group. In the early stages after hospitalization, operations from laparotomic access were performed in 12 patients (40%), 10 (33.3%) patients were operated using the laparoscopic method. Ten patients were operated on at the stage of purulent complications formation, eight of them were operated using the Mini-Assistant kit, two were operated in the traditional way due to diffuse purulent peritonitis due to opening the abscess of the omental bursa in the abdominal cavity.

The study of the immune status of patients who underwent immunocorrection with galavitis showed that, as in the comparison group, patients of the 2nd group on the first day after the operation did not have significant violations of the main indicators of the immunogram. On the 7th day of observation, there was a significant increase in the percentage of the CD2 ⁺ fraction (64.5 ± 3.7%) compared with the initial values. Throughout the entire period of the study, the phagocytic index increased, reaching normal values on day 14, while in patients of the 1st group, the indicator indicated during these periods remained low (Table 5).

On the 14th day of treatment, in patients of the 2nd group, the values of the percentage and absolute contents of the total number of blood lymphocytes, fractions CD2 ⁺ , CD4 ⁺ and immunoregulatory index were restored. The concentration of Ig A, Ig G, Ig M immunoglobulins was normal and significantly different from the initial values. There was a more significant decrease, relative to the initial figures, of the level of circulating immune complexes (26.4 ± 1.7 cu), while in the group of patients receiving conventional therapy, a significant increase in CEC occurred.

In favor of the effectiveness of the proposed scheme of immunocorrective therapy with the use of the drug galavit, the normalization of the ABOK level on the 14th day of observation in patients of the study group indicates.

The study of cytokine regulation during galavit therapy revealed fundamental differences in the dynamics of changes in the main indicators compared with the data of group 1 (table 6).

Against the background of the therapy, an increase in IL-2 concentration to normal values (148.3 ± 5.4 pg / ml) was already observed on the 3rd day. The upward trend continued until 7 days of observation; during these periods, the maximum concentration of IL-2 was recorded (172.1 ± 2.6 pg / ml). On the next day, the indicator decreased and until the end of the observation, the values of the indicated cytokine were within normal limits.

In the comparison group, the level of IL-2, after reaching normal values by 5 days, progressively decreased to critically low numbers (figure 1). This fact confirms the advisability of the early use of immunocorrective therapy for the treatment of patients with pancreatic necrosis.

The use of galavit in combination with basic traditional therapy in patients of the 2nd group made it possible to reduce the concentration of IL-6 by 1.9 times already on the third day, and on the 5th day this indicator reached normal values (286.7 ± 8.2 pg / ml ) Further, after a moderate increase in the concentration of the studied cytokine on day 7 (397.4 ± 4.5 pg / ml), the level of IL-6 fluctuated within the normal range until the end of the observation, unlike the 1st group, in which the level of IL-6 was increased throughout the observation period, and starting from the second week of the disease, tended to increase (figure 2).

On the 7th day of observation, the concentration of IL-2 and IL-6 in patients of the study group exceeded normal values by 31.9% and 31.1%, respectively, which indicates the positive effect of the treatment method used on the development of an adequate immune response in the stage of formation of peripancreatic infiltrate and to a certain extent, helps to prevent the development of infection of foci of inflammation.

Upon admission, the concentration of TNF-α in patients of the 2nd group, as in the comparison group, was several times higher than normal values. On the third day, the level of TNF-α in patients of the study group was significantly lower than in the comparison group, on the 5th day it reached the upper limit of the norm (9.3 ± 2.2 pg / ml), but it did not significantly differ from similar indicators of the group comparisons. On the 7th day, the concentration of TNF-α again increased and approached the initial level (14.7 ± 1.6 pg / ml), after this, during the rest of the observation period, a stable tendency to a decrease in the level of tumor necrosis factor was observed in patients of the 2nd group, whereas in the comparison group, an increase in the indicator was noted (Fig. 3).

Initially, the concentration of nitric oxide in patients of the 2nd group was 27.6 ± 1.3 μmol / ml and did not significantly differ from the parameters of the comparison group (Fig. 4).

On the third day, a significant decrease in the indicator to 23.1 ± 1.4 μmol / ml was recorded, in contrast to patients of the 1st group, in which a significant increase in the level of nitric oxide was observed during this period. On the 7th day, the content of nitric oxide in patients of the study group increased to the maximum level (45.8 ± 2.6 μmol / ml), but already on the 10th day the indicator decreased to the lower limit of the norm and remained in these limits until the end of the observation.

Noteworthy is the significant difference in the level of nitric oxide in the early stages of pancreatic necrosis between patients of the comparison group of the study group. It was found that an excessive increase in the concentration of nitric oxide in the first few days of the disease increases the risk of purulent necrotic complications at 2-3 weeks of observation.

In patients of the 2nd group, due to the positive effect of galavit on metabolic and immunoregulatory processes, there was no critical increase in the concentration of NO on the third day of observation. Probably, stabilization of the concentration of nitric oxide at an early stage of the disease helps to reduce the induction of the synthesis of pro-inflammatory cytokines, thereby preventing the excessive release of anti-inflammatory cytokines and, consequently, the development of depletion and decompensation of the body's immune system.

Activation of the nitroxidergic system on day 7 is the result of the directed action of pro-inflammatory cytokines to provide adequate antimicrobial protection. A decrease in the concentration of nitric oxide during these periods in patients of the 1st group indicates a decrease in the body's ability to withstand microbial aggression.

It should be noted that the maximum values of the level of nitric oxide and TNF-α were observed at the same time, which is probably due to the stimulating effect of immunomodulating galavit therapy on antimicrobial defense mechanisms and the cellular immunity in response to a microbial attack. Clinically, in the second week, the secondary infection joins and the formation of infected pancreatic necrosis occurs.

A positive effect of immunocorrective therapy was also recorded in the study of the dynamics of apoptosis of immunocompetent peripheral blood cells.

During the first 5 days, a low percentage of HSC apoptosis was observed, on the 7th day there was a moderate increase (up to 6%), after which the rate significantly decreased to 4%, then the level of HSC apoptosis tended to decrease and the minimum values were recorded by the end of the observation ( figure 5).

Thus, the proposed method for the treatment of acute destructive pancreatitis has a targeted immunoregulatory effect, preventing the excessive production of inflammatory mediators at an early stage of the disease and stimulating their synthesis in the late period. This helps to reduce the pathological effects of a systemic inflammatory reaction, eliminate the imbalance of pro-inflammatory cytokines and prevents the development of a subsequent immunosuppressive state. Normalization of the level of endogenous IL-2 contributes to the timely stimulation of the cellular component of immunity. Stabilization of the level of nitric oxide in the early stages of the development of the disease helps to reduce the incidence of both early and late complications.

Analysis of the incidence of complications in patients of the 2nd group revealed a significant decrease in the total number of both early and late complications compared with patients who received traditional therapy (Table 7).

In the comparison group, a relatively equal number of early and late complications was noted, but the numbers of early mortality prevailed. In addition, in this group, the largest number of repeated readjustments was recorded (50%). Relaparotomy was required in four cases, the same number of sanations was necessary in patients operated with the Mini-Assistant tool kit, and after laparoscopic interventions were performed in the first two days, three patients (13.6%) underwent repeated operations 10-14 days later about the ongoing pancreatic necrosis and the development of purulent complications.

In the 2nd group of patients, the applied treatment method allowed to stabilize the condition of patients at an early stage of treatment, to reduce the manifestations of SIRS, which led to a significant decrease in both early and late complications. The early stabilization of the nitroxidergic system and the level of pro-inflammatory cytokines contributed to a significant decrease in the manifestations of systemic inflammation and purulent complications compared with the comparison group, maintaining an adequate immune response at all periods, in patients of the 2nd group three times less often pancreatogenic shock developed, 30% less often - respiratory and 40% hepatic-renal failure.

During treatment in patients of the 2nd group, only in 3 cases, pancreatic necrosis was complicated by the development of retroperitoneal phlegmon, in 2 - purulent peritonitis, in 4 patients in the late postoperative period an abscess of the omental bursa was formed. Mortality in the study group was 16.7%, which is 15.1% lower than in the comparison group.

In addition to reducing the rates of complications and mortality in favor of the effectiveness of the proposed treatment method, a significant decrease in the number of repeated operations in patients of the 2nd group indicates So, out of 30 patients in this group, repeated surgical interventions were performed in 26.6%, which is 27.7% lower than similar indicators in the comparison group.

Reducing the incidence of complications in the early and late period of the disease allowed to reduce the length of stay of patients of the 2nd group in the hospital by an average of 8 days.

Clinical examples

Clinical example No. 1 (early operation)

Patient X., 56 years old, medical history number 4067, was admitted to the center of surgical pancreatology of the city of Krasnoyarsk on May 25, 2005 with a diagnosis of acute pancreatitis. Delivered by an ambulance doctor. In the emergency room examined. From the anamnesis it was found that the patient consumed alcohol substitutes at a dose of at least 500 milliliters per day for 5 days. On the 6th day after drinking alcohol, intense dull pains appeared in the epigastric region, the dynamics of pain intensified, took on a girdling character, nausea appeared, the patient vomited several times, and vomiting did not bring relief. An objective examination of the skin is pale, moist, cold to the touch, respiratory rate of 20 per minute, heart rate of 90 per minute, blood pressure 90/60 mm RT. Art. The tongue is dry, the abdomen is not swollen, the upper half lags behind in breathing, during palpation is tense, painful in the mesogastric and epigastric regions. Positive symptoms of Kerte, Chukhrienko, symptoms of peritoneal irritation are doubtful. The peristalsis is sluggish, the gases do not leave, there was no stool.

The results of laboratory tests - in the general analysis of blood HB 160 g / l, leukocytes 12.6 × 10 ⁹ / l, bilirubin 35.0 μmol / l, amylase 92 g / h · l, urea 8.7 mmol / l. IL-2 98.3 pg / ml, IL-6 512.1 pg / ml, TNF-α 8.4 pg / ml, nitric oxide concentration 46.7 μmol / ml. Urinalysis - without features.

The results of instrumental examination methods - ECG-metabolic changes in the myocardium. According to ultrasound, the pancreas is enlarged, the structure is hypoechoic, in the cavity of the omental bursa up to 200 milliliters of fluid. Conclusion - acute pancreatitis, omenobursitis. On FGS - in the lumen there is a large amount of mucus, bile, in the antrum - a mass of acute flat erosion.

On the basis of the data obtained, a diagnosis was established - severe acute pancreatitis of alcoholic etiology, omentobursitis.

The patient was prescribed conservative treatment - intravenous infusion of saline solutions, glucosonocaine mixture with antispasmodics in a total volume of 2500 milliliters per day. Sandostatin 100 milligrams 2 times a day subcutaneously. Ciprofloxacin 1 gram 2 times a day intravenously. Galavit 200 milligrams 2 times a day intramuscularly.

Despite the treatment, the patient's condition worsened, symptoms of peritonitis appeared. A decision was made to perform surgery from video laparoscopic access. An operation was performed under endotracheal anesthesia. During surgery, up to 3 liters of hemorrhagic effusion were removed from the abdominal cavity, and plaques of steatonecrosis were found on the parietal peritoneum. The gastrocolic ligament was dissected, up to 300 milliliters of effusion in the stuffing bag, drained. The body and head of the gland are dark cherry in color with subcapsular hemorrhages, parapancreatic fiber is imbibed with exudate. The pancreatic abdomination, debridement, drainage of the omental bursa and the free abdominal cavity were performed. The postoperative diagnosis is subtotal alcoholic hemorrhagic pancreatic necrosis, parapancreatitis, omentobursitis, diffuse enzymatic peritonitis.

In the postoperative period was treated in the intensive care unit. Received infusion therapy, secretolytics, antibiotics, symptomatic treatment. For anti-inflammatory and immunomodulating purposes, 300 milligrams of galavit was once administered on the first day after surgery. Then, until the symptoms of the systemic inflammatory reaction disappear and the level of pro-inflammatory cytokines and nitric oxide are normalized, 100 milligrams of galavit per day, and then 100 milligrams of galavit once every three days.

The postoperative period was smooth. Infection of foci of pancreatic necrosis and retroperitoneal tissue did not occur. Drainage from the abdominal cavity was removed on the 5th day after the operation, from the stuffing bag - on the 10th day after the operation. Repeated surgical interventions were not required. Healing of postoperative sutures by primary intention was discharged in satisfactory condition 15 days after surgery.

Clinical example No. 2 (late operation)

Patient R., 50 years old, medical history number 3123, was admitted to the Center for Surgical Pancreatology of the city of Krasnoyarsk on February 22, 2005 with a diagnosis of postcholecystectomy syndrome, acute pancreatitis. Delivered by an ambulance doctor. In the emergency room examined. From the anamnesis it was found out that the pain appeared after eating fatty foods. In the dynamics of the pain intensified, took on herpes zoster, independently took antispasmodics - without effect. From the anamnesis it was found out that in 2000 she was operated on for cholelithiasis, a cholecystectomy was made from mini-access. After the operation, at least 2 times a year, intense abdominal pain appears, which is why it is treated in a hospital. An objective examination of the skin is warm, moist, respiratory rate of 16 per minute, heart rate of 80 per minute, blood pressure 120/80 mm RT. Art. The tongue is dry, the abdomen does not swell, the upper half lags behind in breathing, during palpation is tense, painful in the mesogastric and epigastric regions. Positive symptoms of Kerte, Chukhrienko, there are no symptoms of peritoneal irritation. Peristalsis is heard, the gases go away, there was no stool.

The results of laboratory tests - in the general analysis of blood HB 125 g / l, leukocytes 10.6 × 10 ⁹ / l, bilirubin 25.0 μmol / l, amylase 43 g / h · l, urea 5.6 mmol / l. IL-2 135.2 pg / ml, IL-6 217.1 pg / ml, TNF-α 4.2 pg / ml, nitric oxide concentration 21.4 μmol / ml. Urinalysis - without features.

The results of instrumental examination methods - ECG - signs of left ventricular hypertrophy. According to ultrasound, the pancreas is of normal size, the echostructure is heterogeneous. Conclusion - diffuse changes in the pancreas. At FGS - atrophic gastritis.

On the basis of the obtained data, the diagnosis was established - postcholecystectomy syndrome, acute pancreatitis of mild severity.

The patient was prescribed conservative treatment - intravenous infusion of a glucosonocaine mixture with antispasmodics in a total volume of 800 milliliters per day. Sandostatin 100 mg once daily subcutaneously.

On the second day of hospitalization, retrograde cholangiopancreatography was performed, the diagnosis was made - stenotic papillitis, endoscopic papillosphincterotomy was performed.

After the operation, the patient's condition deteriorated sharply. The pain intensified, nausea appeared, and vomited several times. Shortness of breath occurred, heart rate increased, blood pressure decreased. The patient was transferred to the intensive care unit. Conservative treatment has been strengthened, with immunomodulating and anti-inflammatory goals, galavit has been prescribed. During the first 2 days of being in the intensive care unit, 200 milligrams of galavit was administered once a day intramuscularly. Then, 100 milligrams once a day for 7 days.

After 7 days, computed tomography of the abdominal organs was performed. The presence of fluid formation in paracolic fiber on the right is established. The cavity is punctured under the control of ultrasound, pus is obtained from the cavity. It was decided to perform operations from mini-access.

Seven days later, the patient was operated on for subtotal pancreatic necrosis, phlegmon retroduodenal and paracolic tissue on the right. The pancreas was abdominated, omentobursostomy, lumboretroperitoneostomy, ileoretroperitoneostomy, and oral drainage of the omental bursa and retroperitoneal fiber.

In the first day after the operation, in addition to traditional therapy, 300 milligrams of galavit was administered intramuscularly once, then until the cytokines normalized and the symptoms of the systemic inflammatory reaction disappeared - 100 milligrams of galavit intramuscularly once a day, then 100 milligrams of galavit once every three days.

The postoperative period was smooth. Against the background of the use of galavit, the cavities quickly cleared, repeated operations were not required. Replacement of drainages with thinner ones was performed 7 days after the operation, and drainage was removed 14 days after the operation. Repeated surgical interventions were not required. Discharged in satisfactory condition 20 days after the operation.

Thus, the lowest rates of complications, mortality, the number of reorganizations and the length of hospital stay were recorded in the group of patients who received immunocorrective therapy using galavit. This allows us to conclude that it is advisable to include targeted immunotherapy in the complex of therapeutic measures for patients with pancreatic necrosis to stop the SIRS and CAPS processes. Moreover, according to studies, immunocorrection with galavitis must begin in the early stages of the development of the disease.

Claims (1)

A method of treating acute destructive pancreatitis, including surgery and traditional intensive therapy of pancreatitis, characterized in that they additionally administer galavit intramuscularly, while in the stage of enzymatic toxemia, galavit is administered 200 mg 1-2 times a day, then on the first day after surgery - 300 mg per day once, and on subsequent days - 100 mg per day until the symptoms of the systemic inflammatory reaction disappear and the level of cytokines in the blood normalizes, after which treatment is continued ction galavita 1 time in 72 h, 100 mg.

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