Mankhwala othandizira pachimake kapamba

Chithandizo cha opaleshoni yamapapo pancreatitis imagwiritsidwa ntchito pokhapokha akuwonetsa: kusowa kwa mphamvu ya chithandizo chamankhwala, kuwonjezeka kwa zizindikiro za kuledzera ndi peritonitis, kuzindikira kwa zizindikiritso za pancreatic kapena kuchuluka kwa mafinya mu omentum, kuphatikiza kwa kapamba ndi mawonekedwe owononga a pachimake cholecystitis.

Mitundu yotsatirayi yopangira ma opaleshoni apakhungu ya pancreatitis ndi iyi: kupondaponda ndi kukoka kwa kamtanda kakang'ono kamene sikanatsutsana ndi gawo la pateni, tamponade ndi kukhetsa kwa mbali yam'maso ndikutulutsa kwa peritoneum yomwe imaphimba zikondamoyo, resection ya necrotic yasintha zikondamoyo, zikondamoyo zazikulu kuphatikiza kwa mitundu itatu yoyambirira yogwira ntchito ndikulowerera ndulu, ndulu ya chiwopsezo cha bile.

Pali intra- komanso extraperitoneal yomwe imalowa ku kapamba. Chodziwika kwambiri ndi lapanotomy yapakatikati. Kupeza bwino kumapereka njira yowonjezera yophatikizira khoma lam'mimba, makamaka ngati munthawi ya opaleshoni pakufunika kukonzanso thirakiti la biliary.

Kulowerera mkati mwa kapamba kumatha kukwaniritsidwa imodzi mwanjira zinayi. 1. Kudzera m'matumbo am'mimba. Kupeza kumeneku ndikosavuta kwambiri chifukwa kumakupatsani mwayi wofufuzira kwambiri mutu, thupi ndi mchira wa kapamba. Kuphatikiza apo, zimapangitsa kuti pakhale nthawi yodzipatula thumba la chofukizira kuchokera kumimba yonse yam'mimba. 2. Kudzera mu hepatic-gastric ligament. Kupeza kumeneku ndikosavuta ndipo ndikofunika kugwiritsa ntchito kokha gastroptosis. 3. Kudzera m'maso mwa gulu lolowera. Kuthekera kochepa kofufuza zikondamoyo zonse, zovuta za kukoka kwamkati mwazoyambira zazing'ono zimazindikira kugwiritsidwa ntchito kosowa kwa izi. 4. Mwa kusokosera kwa duodenum (T. Kocher) motero kuwulula mutu wa kapamba. Kulowa kwa kapamba kumangokhala kuwonjezera kwa zomwe zidapita.

Pazinthu zakunja zomwe zimafikira kapamba, ndizofunikira ziwiri zokha: 1) lumbotomy yamanja (pansi pa nthiti ya XII ndikufanana nayo), ndikulola kuwulula mutu wa kapamba, ndi 2) mbali yakumanzere yolumikizana ndi thupi ndi mchira wa kapamba. Njira izi zimawonetsedwa makamaka potulutsa zithupsa ndi phlegmon ya malo obwezeretsanso ndipo itha kugwiritsidwa ntchito ngati yowonjezera kwa intraperitoneal.

Kuchepetsa komanso kukoka kwa maimidwe obisalira popanda chotchinga cha peritoneum chovundikira sichimapereka kutulutsa kwa poizoni wokhala ndi ma enzymes ndi ma pancreatic minyewa. Chifukwa chake, ntchito yomwe idafalikira kwambiri inali kugawa kwam'mphepete mwa England, ndikutsatiridwa ndi tamponade ndi ngalande yamadzi yonyansa. B. A. Petrov ndi S. V. Lobachev amalimbikitsa kutulutsa kacherekedwe ka tinthu tating'onoting'ono tokhala ngati minyewa yayitali (2-5). V. A. Ivanov ndi M. V. Molodenkov kuwonjezera (makamaka ndi pancreatitis yowonongeka) amachotsa mbali pang'onopang'ono ndikuwonetsa pang'onopang'ono, kumtunda, ndi malo otsika a kutikisiko, pomwe magawo a necrosis ali olekanitsidwa kapena olekanitsa.

Tamponade imachitika ndi wamba gauze kapena mphira-gauze tampons. Monga lamulo, amabweretsedwa ku thupi ndi mchira wa kapamba ndi kumtunda kwa patsekeke la omentum yaying'ono. Popeza disgment ya pancreatic kapisozi ndi tamponade yotsatira sikuti nthawi zonse kumalepheretsa kupitilira kwa njirayi ndikusungunuka kwa minyewa ya gland komanso mapangidwe a retoperitoneal abscesses, olemba angapo (A.N. Bakulev, V.V. Vinogradov, S.G. Rukosuev, etc.) akufuna kupanga kupanga resection wa zikondamoyo zomwe zakhudzidwa. Komabe, kugwiritsa ntchito ntchitoyi kumachepetsedwa ndi kusowa kwa mzere wowoneka bwino wa kugonjetsedwa, kuthekera kwa kupitiriza kwa necrosis. Mikhaylants akufuna kuchepetsa kulowererapo kwa pancreatic necrosis kokha kwachilembedwe ka kapamba (wamkulu omentum), potengera udindo wa bactericidal ndi pulasitiki wa omentum.

Pa opaleshoni chifukwa cha pachimake kapamba, novocaine blockade ya kapamba, mesentery muzu ndi omentum yaying'ono imachitidwa. 100-200 ml ya yankho la 0,25% ya novocaine amawonjezeredwa ndi kuwonjezera kwa maantibayotiki (penicillin - 200,000-300,000 DB, streptomycin - mayunitsi a 150,000-200,000).

Olembapo angapo amati, atatha kuzindikira pepala lakumapeto kwa peritoneum ndikuwonetsa pancreas, dzaza malo ake ndi plasma (100-150 g), chinkhupule chachikulu, maselo ofiira amwazi ndi kuphatikiza mankhwala. Cholinga cha kupakidwa ntchito kwauma kwa mapuloteni owuma ndikuti athetse michere ya pancreatic madzi kulowa m'mimba. Pambuyo pake, jakisoni watsiku ndi tsiku amakonzekera mapuloteniwa mu boma la mushy, komanso inhibitor ya trasylol, kudzera mu chubu lamadzi amalimbikitsidwa. Kuphatikiza apo, imapitilirabe kupatsidwa ndi kukoka kudzera m'mitsempha mpaka mkodzo umayamba kuchepa mpaka kuchuluka.

Ntchito mankhwalawa pachimake kapamba, monga lamulo, kuyendera dongosolo la biliary ndikofunikira. Ndi gallbladder yoyaka kwambiri, cholecystostomy imasonyezedwa. Pankhani ya mawonekedwe owononga a cholecystitis, cholecystectomy ndi kukhetsa kwa bile (wamba bile duct) ndikofunikira. Nthawi zina, akagwira opaleshoni, kupendekera kwa gawo la ndulu ya bile kumapezeka, kwasonyezedwa choledochoduodenostomy (onani chikhodzodzo cha Gall, opaleshoni). Kuchita kwa sphincterotomy mu milandu sikunapeze ntchito yayikulu muchipatala chifukwa cha zovuta zomwe zimachitika nthawi ya postoperative.

Pambuyo pa opareshoni, ndikofunikira kuchita zochitika zothandizira kuthana ndi kuledzera, matumbo paresis, kusokonezeka kwa mtima ndi kupuma.

Zizindikiro zochizira opaleshoni

Chizindikiro chokwanira cha opaleshoni ndimatenda a pancreatic necrosis(wamba pancreatic necrosis, pancreatogenic abscess, kachilombo ka madzi kapangidwe, retoperitoneal necrotic phlegmon, purulent peritonitis, kachilombo pseudocyst. Mu septic gawo la matendawa, kusankha kwa njira yopangira opaleshoni kumatsimikiziridwa ndi mawonekedwe a matenda ndi pathomorphological a pancreatic necrosis komanso kuopsa kwa mkhalidwe wa wodwalayo. Ndi aseptic chikhalidwe cha pancreatic necrosis, kugwiritsa ntchito kwa laparotomic sikuwonetsedwa chifukwa cha chiwopsezo chachikulu cha matenda opatsirana osachepera necrotic komanso kukula kwa magazi okhudzana ndi intraperitoneal, kuwonongeka kwa iatrogenic pamimba. Opaleshoni ya Laparotomic yomwe imagwiritsidwa ntchito mkati mwa aseptic gawo lowononga kapamba liyenera kuvomerezedwa. Zowonetsera za:

kusungidwa kapena kupitilira kwa ziwalo zingapo zolimbana ndi maziko a chisamaliro chokwanira chokhazikika komanso kugwiritsa ntchito njira zowonjezera zachipatala,

kufala kofupikira

kulephera kupatula kwathunthu kachilombo ka necrotic ndondomeko kapena matenda ena othandizira opaleshoni yodzidzimutsa.

Kuchita opaleshoni yotseguka kumatengedwa mwachangu kwa enzymatic peritonitis mu gawo loyambirira la matendawa chifukwa cha zolakwika mosiyanitsa ndi matenda ena ofulumira pamimba, popanda chisamaliro champhamvu, ndi njira yolakwika komanso yolakwika yothandizira. Ultrasound owongoleredwa puncture-kukhetsa kulowerera

Kutha kuchitira zolimbana ndi matenda ozungulira (kupumira ndi ma catheter) kumatsimikizira kusunthika kwa njira ya ultrasound popereka chidziwitso chokwanira pamagawo onse azithandizo za odwala omwe ali ndi pancreatic necrosis. Kugwiritsa ntchito kwa ma percutaneous drainage ntchito kwatsegula mwayi wina wazotheka odwala omwe ali ndi mitundu yochepa ya pancreatic necrosis. Zizindikiro za kupuma-pang'onopang'ono pokoka molamulidwa ndi ultrasound ya pancreatic necrosis ndi kukhalapo kwa mapangidwe amadzimadzi am'mimbamu pamimba ndi kubwezeretsa malo. Kuchita opaleshoni yoyendetsedwa pansi pa kayendetsedwe ka ultrasound, zinthu zotsatirazi ndizofunikira: kuyang'ana kwamkati bwino, kukhalapo kwa malo otetezedwa otetezedwa, ndi kuthekera kochita opaleshoni ngati mukukumana ndi zovuta. Kusankhidwa kwa njira yochititsira kulowerera kwa pancreatogenic fluid kumatsimikiziridwa, mbali imodzi, mwa njira yotetezedwa yopulumutsira, komanso, mwa kukula, mawonekedwe ndi mawonekedwe a zomwe zilimo. Mkhalidwe waukulu wa kulowerera koyenera umaganiziridwa kuti ndi kukhalapo kwa "zenera la echo" - mwayi wamayimbidwe wofikira pachinthucho. Makonda amaperekedwa kwa trajectory akudutsa omentum yaying'ono, m'mimba ndi m'mimba, kunja kwa makoma a ziwalo zopanda pake ndi mitsempha yamitsempha, zomwe zimatengera topography ndi kutengera kwa chotupa. Contraindication chifukwa cholowetsa

kusapezeka kwa madzi a chigawo chowonongeka,

kupezeka pa njira kukoka kwa ziwalo zam'mimba thirakiti, kwamikodzo dongosolo, mtima dongosolo,

kuvutika kwamphamvu kwa dongosolo la magazi.

Mndandanda wa zoperekera opaleshoni pansi paulamuliro wa ultrasound umaphatikizapo kuboola singano imodzi ndikuchotsa kwake (ndi wosabala volumetric madzimadzi) kapena ngalande zawo (mapangidwe ophatikizika amadzimadzi am'madzi). Ndi kusakwanira kwa njira zopumira, amayamba ntchito zonyamula zachikhalidwe. Drainage iwonetsetse kutuluka konsekwere, kukonza bwino kwa catheter mu lumen ya patsekeke ndi pakhungu, kuyika kosavuta, kuchotsa ndi kukonza dongosolo.

Chithandizo cha Conservative

Yofunika yokonza chithandizo cha pachimake kapamba zikuphatikizapo:

kukakamiza kubisika kwa kapamba, m'mimba ndi duodenum,
Kupha kwa hypovolemia, madzi-electrolyte ndi zovuta zama metabolic,
kuchepa kwa ntchito ya enzyme,
Kutha kwa matenda oopsa munthawi zopumira komanso pancreatic,
kusintha kwa magazi acheological ndi magazi ndi kuchepetsa matenda am'magazi,
kupewa ndi kuchiza kwa magwiridwe antchito amalephera kwamatumbo,
kupewa ndi kuchiza mavuto a septic,
kukhalabe ndi mpweya wabwino mthupi la wodwalayo mochokera pansi pamtima komanso popuma,
mpumulo wa zowawa.

Chithandizo chimayamba ndikukonza madzi osankhidwa mwa electrolyte, kuphatikizapo kuthana ndi mayankho amtundu wa isotonic ndi kukonzekera kwa potaziyamu wa kloramu ndi hypokalemia. Pofuna kusiya kuchita kulowetsedwa mankhwala mu boma la kukakamiza diuresis. Popeza pancreatic necrosis ikuperewera chifukwa cha kuchepa kwa gawo lamwazi m'madzi, ndikofunikira kukhazikitsa mapuloteni amtundu wathu (plasma yatsopano yozizira, makonzedwe a albin yaumunthu). Chitsimikizo chokwanira cha kulowererapo kwa media ndikuyambiranso kwa BCC, hematocrit, normalization wa CVP. Kubwezeretsanso kwa ma microcirculation komanso zigawo za magazi m'magazi zimatheka mwa kukhazikitsidwa kwa dextran ndi pentoxifylline.

Mofananamo, chithandizo chimachitidwa chofuna kupondaponda ntchito za kapamba, zomwe zimapangidwa makamaka ndikupanga "kupuma kwakuthupi" poletsa kudya kwa masiku 5. Kuchepetsa kofunikira kwa katulutsidwe katumba kamachitika chifukwa cha chidwi cha chapamimba kudzera mu chubu la nasogastric ndi chiphalaphala cha m'mimba ndi madzi ozizira (hypothermia yam'deralo). Kuchepetsa acidity ya chapamimba katulutsidwe, zamchere kumwa, proton pampu zoletsa (omeprazole) zotchulidwa. Poletsa ntchito zachinsinsi za gastropancreatoduodenal zone, analogue yopanga ya somatostatin imagwiritsidwa ntchito - octreotide pa mlingo wa 300-600 mcg / tsiku ndi magawo atatu a subcutaneous kapena intravenous. Mankhwalawa ndi zoletsa za basal komanso zolimbikitsidwa zamkati, m'mimba ndi matumbo aang'ono. Kutalika kwa mankhwalawa ndi masiku 5-7, omwe amafanana ndi nthawi yogwira hyperenzymemia.

Ndi pancreatic necrosis, chifukwa cha kupatsika kwadongosolo, ndikofunika kugwiritsa ntchito njira zakunja: ultrafiltration, plasmapheresis.

Kuchita mwanzeru antibacterial prophylaxis ndi mankhwala a matenda a pancreatogenic ndikutitsogolera kwa pathogenetic. Ndi interstitial (edematous mawonekedwe) kapamba, antibacterial prophylaxis sichinatchulidwe. Kuzindikiritsa kwa pancreatic necrosis kumafuna kuikidwa kwa antibacterial mankhwala omwe amachititsa kuti pakhale vuto lothandizira la bactericidal m'dera lomwe lakhudzidwa ndikuwonetsa zochita zonse zokhudzana ndi tizilombo toyambitsa matenda. Mankhwala osankhidwa a prophylactic ndi achire amagwiritsidwa ntchito ndi carbapenems, 3nd ndi 4th cephalosporins osakanikirana ndi metronidazole, fluoroquinolones kuphatikiza ndi metronidazole.

Ndi kukula kwa kagayidwe kachakudya kagayidwe kachakudya matenda, hypermetabolic zimachitikira, kholo lathunthu zakudya limayikidwa (zothetsera shuga, amino acid). Mukamabwezeretsa ntchito yam'mimba m'matumbo mwa odwala omwe ali ndi pancreatic necrosis, ndikofunikira kuperekera zakudya zamagulu (zosakaniza zamankhwala), zomwe zimachitika pogwiritsa ntchito projigal probe yomwe imayikidwa kutali ndi Treitz ligament endoscopically, kapena pa opaleshoni.

Zizindikiro zakuchita opareshoni

Chizindikiro chokwanira cha opaleshoni ndimatenda a pancreatic necrosis (wamba pancreatic necrosis, pancreatogenic abscess, kachilombo ka madzi kapangidwe, retoperitoneal necrotic phlegmon, purulent peritonitis, kachilombo pseudocyst. Mu septic gawo la matendawa, kusankha kwa njira yopangira opaleshoni kumatsimikiziridwa ndi mawonekedwe a matenda ndi pathomorphological a pancreatic necrosis komanso kuopsa kwa mkhalidwe wa wodwalayo. Ndi aseptic chikhalidwe cha pancreatic necrosis, kugwiritsa ntchito kwa laparotomic sikuwonetsedwa chifukwa cha chiwopsezo chachikulu cha matenda opatsirana osachepera necrotic komanso kukula kwa magazi okhudzana ndi intraperitoneal, kuwonongeka kwa iatrogenic pamimba.

Osauka mitundu ya pancreatic necrosis - Chizindikiro chogwiritsa ntchito makamaka matekinoloje osagwira a opereshoni: laparoscopic debridement ndi draina wamatumbo pamaso pa enzymatic peritonitis ndi / kapena puncutaneous punigation (drainage) panthawi yopanga mawonekedwe amadzimadzi amadzimadzi mu malo obwezeretsanso. Kuchita opaleshoni mwa kupezeka kwa laparotomic, kochitidwa mwa wodwala wosakhazikika pancreatic necrosis, kumakhala kofunikira nthawi zonse ndipo kumatanthauza "ntchito zotaya mtima".

Opaleshoni ya Laparotomic yomwe imagwiritsidwa ntchito mkati mwa aseptic gawo lowononga kapamba iyenera kuvomerezeka.
Zowonetsera za:

kusungidwa kapena kupitilira kwa ziwalo zingapo zolimbana ndi maziko a chisamaliro chokwanira chokhazikika komanso kugwiritsa ntchito njira zowonjezera zachipatala,
kufala kofupikira
kulephera kupatula kwathunthu kachilombo ka necrotic ndondomeko kapena matenda ena othandizira opaleshoni yodzidzimutsa.

Ultrasound owongoleredwa puncture-kukhetsa kulowerera

Kuchepetsa ma phukusi pogwiritsa ntchito njira yoyendetsera pansi pa ultrasound kumathetsa vuto la kuzindikira ndi kuchiritsa. Kuzindikira ntchitoyi ndikupeza zinthu zofunikira pophunzira mabacteriaological, cytological and biochemical maphunziro, omwe amalola kusiyanitsa bwino kwa aseptic kapena kachilombo ka pancreatic necrosis. Zachipatala ntchito ndikuchotsa zomwe zili m'matumbo ndikupanga kukonzanso kwake kuti mupeze zizindikiro za matenda.

Zizindikiro za kupuma-pang'onopang'ono pokoka molamulidwa ndi ultrasound ya pancreatic necrosis ndi kukhalapo kwa mapangidwe amadzimadzi am'mimbamu pamimba ndi kubwezeretsa malo.

Kuchita opaleshoni yoyendetsedwa pansi pa kayendetsedwe ka ultrasound, zinthu zotsatirazi ndizofunikira: kuyang'ana kwamkati bwino, kukhalapo kwa malo otetezedwa otetezedwa, ndi kuthekera kochita opaleshoni ngati mukukumana ndi zovuta. Kusankhidwa kwa njira yochititsira kulowerera kwa pancreatogenic fluid kumatsimikiziridwa, mbali imodzi, mwa njira yotetezedwa yopulumutsira, komanso, mwa kukula, mawonekedwe ndi mawonekedwe a zomwe zilimo. Mkhalidwe waukulu wa kulowerera koyenera umaganiziridwa kuti ndi kukhalapo kwa "zenera la echo" - mwayi wamayimbidwe wofikira pachinthucho. Makonda amaperekedwa kwa trajectory akudutsa omentum yaying'ono, m'mimba ndi m'mimba, kunja kwa makoma a ziwalo zopanda pake ndi mitsempha yamitsempha, zomwe zimatengera topography ndi kutengera kwa chotupa.

Contraindication chifukwa cholowetsa

kusapezeka kwa madzi a chigawo chowonongeka,
kupezeka pa njira kukoka kwa ziwalo zam'mimba thirakiti, kwamikodzo dongosolo, mtima dongosolo,
kuvutika kwamphamvu kwa dongosolo la magazi.

Cholinga chachikulu cha kukoka kosagwira kwa purcin necrotic foci mu pancreatic necrosis ndikutsata kwakukulu kotsutsana ndi maziko ogwiritsa ntchito ngalande zazing'ono zamkati, komwe kumafunikira kukhazikitsa kwa zowonjezera kapena kukonzanso ndi ngalawo yokulirapo. Muzochitika zotere, choyambirira, munthu akuyenera kuwongoleredwa ndi zotsatira za CT, zomwe zimaloleza kuwunika kwa minofu ndi zinthu zamadzimadzi zowonongedwa, komanso kuphatikizika kwa mkhalidwe wa wodwalayo komanso kuopsa kwa kayendedwe ka dongosolo. Popeza pali ziwalo zambiri zosavomerezeka mu wodwala wokhudzana ndi pancreatic necrosis, kusintha kwa mkhalidwe wa wodwalayo, mawonekedwe a chipatala ndi ma labotale zizindikiro za chotupa mkati mwa masiku atatu pambuyo poti pakhale njira yotsuka ya malo owonongera motsutsana ndi maziko a pancreatic necrosis, kutengera kukhazikitsa ma drainage angapo m'mitsempha yowoneka bwino komanso zotupa. Mu nthawi yogwira ntchito, ndikofunikira kuonetsetsa kuti kuyeretsa (kapena kwaphula) kwa magawo owononga ndi njira zothetsera vuto la antiseptic.

Kusakwanira kwa kukoka kwa mapangidwe amadzi a pancreatogenic, ochitidwa motsogozedwa ndi ultrasound wodwala wokhala ndi pancreatic necrosis, akuwonetsedwa ndi ma syndromes a kutchulidwa kwamtundu wa kutupa, kulimbikira kapena kupita patsogolo kwa ziwalo zambiri, kukhalapo kwa hyperechoic, echo-inhomogeneous inclusions pamalo owonongera.

M'mikhalidwe yofala pancreatic necrosis, potsatira zotsatira za ultrasound ndi CT zimapezeka kuti gawo lachiwonetsero la chithokomiro limapambaniratu pazinthu zake zamadzimadzi (kapena chomaliziracho sichikupezeka kale pamlingo wina wamagetsi osakanikirana), komanso kuopsa kwa mkhalidwe wa wodwalayo sikufuna kusintha, kugwiritsa ntchito kupindika. Njira zamkati ndi zopanda ntchito.

Zowonjezera zowonjezera zowonjezera zomwe zili ndi maopaleshoni obisika omwe ali ndiubwino wopanga mapangidwe ochepa a madzi a volumetric nthawi zingapo pambuyo pa opaleshoni ya laparotomic, makamaka pambuyo poti abwereze. Njira zopangira madzi percutaneous sizingagwiritsidwe ntchito ngati njira yayikulu yothandizira yamankhwala amtunduwu wa pancreatic necrosis mukaganiziridwa kwa nthawi yayitali komanso mozama. Zikatero, kuti akwaniritse zochizira, munthu ayenera kutsamira laparotomy.