Kharkov National Medical University,

Kharkov, Ukraine

In the structure of modern polytraumatism the pancreatic injuries constitute 45-54 % of the cases of concomitant injury [5, 11]. After pancreatic injuries the disability achieves 30-40 %, mortality – 9-34 % in the different cases [7, 10]. Early mortality often presents the consequences of uncontrolled bleeding, but later one – sepsis and concurrent multiple organ failure. At the same time, pancreatic injury-associated mortality is 2-17 % [4, 12].

There is no uniform accepted surgical tactics for pancreatic ruptures at the present time. Before 1980s surgical intervention included necessary suturing for locations of disruption with following packing and draining of an injury site. At that, the frequency of posttraumatic pancreatitis achieved 67 %, and mortality – 21 % [1, 5].

During the last decade it is not advisable to suture rupture locations in the case of absent bleeding. It is considered that wound closure does not favor primary degeneration of a defect, and it increases local disorders in circulation, promotes pancreatic necrosis, posttraumatic pancreatitis, pancreatic fistula and other pancreatogenic complications. Pancreatic tissue suturing is performed only in individual cases for hemostasis [12].

In the conditions of high risk of postsurgical complications the alternative choice for pancreatic disruption suture can be connecting soft tissues with high frequency current – electro-welding.

Formation of welded joint is based on the effect of electrothermic denaturation of protein molecules [9]. Electric current of low voltage partially disrupts cellular membranes. As a result, protein fluid releases. By means of protein coagulation the tissues slick together – “weld together”. After a given period the morphologic structure of tissues restores, resulting in absence of a scar in usual understanding of this word. The temperature in the welding region is 60-70° C [8].

Compared to the traditional methods of surgical treatment, electro-welding allows reducing time of surgery and blood loss. Welding seams heal easier, and it promotes decreasing costs for drugs, particularly for narcotic ones [8].

The objective of the study was assessment of efficiency of electro-welding method for treatment of pancreatic disruptions in patients with polytrauma.

MATERIALS AND METHODS

The study was performed at the basis of the department of polytrauma and anesthesiology in Kharkov City Clinical Hospital of Emergency Medical Aid by the Name of A.I. Meshchaninov. 27 cases of pancreatic injuries were analyzed during 2000-2012. The main criterion of inclusion into the study was pancreatic disruption. The conditions of patient selection for the study were historical absence of chronic pathology of pancreatic duodenal biliary zone, blood diseases, burdened heredity, cardiovascular disease at the stage of decompensation. For evaluating injury severity ISS (Injury severity score) was used [2]. The control group included 15 patients with standard treatment techniques. The main group included 12 patients with the new surgical technique.

All patients gave the written consent for participation in the study. The performed studies corresponded to the ethical standards by the commission of Kharkov National Medical University which were developed in concordance with Helsinki declaration of World Association “The ethical principles of conduction of scientific medical studies with human participation”, with amendments from 2000 and with the standard terms for the issues of ethics of Ukraine Ministry of Health #690 from 23.09.2009.

For all patients with pancreatic injuries cholecystostomy, bursa omentalis and abdominal cavity draining and intestinal intubation were performed. For all control patients the pancreatic sutures were applied only in case of unstable hemostasis; atraumatic materials were used. For the patients of the main group hemostasis and restoration of pancreatic anatomical integrity were achieved with the high frequency electrocoagulator EK 300M1 produced by the Institute of Electric Welding by the name of E.O. Paton (Fig.).

Figure

Electric coagulator ÅÊ 300Ì1

The main stages could be described schematically as indicated below. The injured sites of the pancreas or blood vessels are compressed with their superficial layers using welding instruments. Then a surgeon compresses the location of welding with use of electrodes and turns the device in the automatic mode “WELDING”. The welding process and exposition of exhibit passage of current are installed by the automatic control system. After power cutoff the captured tissue is released.    

The principle of action of welding is based on the effect of structural connection of molecules under the influence of electric thermal mechanic influence. For rapid and non-complicated restoration of physiologic function of a destructed organ the program assigns minimal thermal factor needed for tissue connection.

Use of EK 300M1 device is without suturing material. It allows significant reduction and simplification of surgical intervention for pancreatic disruption and decreasing risk of postsurgical complications [3].

The efficiency of the offered method was assessed according to its influence on the rates of complications and mortality in patients with pancreatic injuries.

For evaluation of the representativity of the main and control groups the comparison in relation to gender and pancreatic injury severity was performed with Fisher’s exact test. For comparison of the groups according to age and injury severity Student’s test was used, with data presentation as mean (M) and mean of error (m).

The statistical analysis of the results of evaluation of efficiency of the new surgical technique was performed using Fisher’s exact test. In testing statistical hypotheses the critical level of significance was 0.05 [6].

RESULTS

According to the data in the table 1 the main and the control groups did not have statistically significant differences in the main characteristics (Table 1).

Table 1
Characteristics of patient groups with pancreatic disruptions

Indicator	Main group                                                                 (n = 12)	Control group                                       (n = 15)	P
Age, years                                                                     (M ± m)	36.33 ± 3.15	33.53 ± 3.23	0.55
Male	9 (75 %)	11 (73.3 %)	1
ISS, points                                                            (M ± m)	22.50 ± 1.40	24.87 ± 1.24	0.22
Pancreas injury degree > II	5 (41.6 %)	6  (40 %)	1

The analysis of results of surgical treatment of the patients with pancreatic disruptions (Table 2) showed that pancreatogenic complications were in 20 patients (74 %), with the greatest amount (51.9 %) conditioned by posttraumatic pancreatitis, 7.5 % - pseudocysts, 3.7 % - retroperitoneal phlegmon, 11.1 % - abscesses in bursa omentalis and in subphrenic space. The mortality was 11.1 % as result of multiple organ insufficiency, without statistical differences between the groups: the main group – 8.3 % (1 patient), the controls – 13.3 % (2 patients). Use of EK 300M1 device for treatment of pancreatic disruptions favored evident decrease in posttraumatic pancreatitis compared to the control group (25 % vs. 66.6 %). The comparative analysis of other complications (pseudocyst, phlegmon, abscesses) did not show significant differences between the control and main groups (Table 2).

Table 2
Pancreatogenic complications and mortality in patients with pancreatic disruptions

Indicator	Main group                                                       (n = 12)	Control group                                                     (n = 15)	Total                                                   (n = 27)	P
Posttraumatic pancreatitis	3 (25 %)*	10 (66.6 %)	13 (48.1 %)	0.05
Pseudocyst	0	2 (13.3 %)	2 (7.4 %)	-
Retroperitoneal phlegmon	0	1 (6.7 %)	1 (3.7 %)	-
Subdiaphragmatic abscess, omental abscess	1 (8.3 %)	2 (13.3 %)	3 (11.1 %)	1
Mortality	1 (8.3 %)	2 (13.3 %)	3 (11.1 %)	1
Note: * – difference between groups is statistically-valid, P ≤ 0.05.

We give the results of the own clinical follow-up of the patient with pancreatic disruption treated with electro-welding method with EK 300 M1 device.

The patient K., age of 24, medical history #39714, was admitted in the department of polytrauma of Kharkov city hospital on 18.01.2011 with diagnosis: “Closed abdominal trauma. Ruptured spleen. Superficial disruption of the pancreas in the tail region. Hemoperitoneum of degree 2-3”. Laparotomy was performed. Revision of bursa omentalis showed superficial disruption of the pancreas without signs of injury to the main duct. There was pancreatic bleeding. During abdominal cavity revision the rupture of the spleen was identified along the visceral surface, with deepness up to 3 cm. There were splenectomy, hemostasis, welding the pancreatic disruption with EK 300M1, contact cholecystostomy, transnasal intestinal intubation, abdominal and bursa omentalis draining. Pancreatic suturing was not performed.

The postsurgical course was without serious complications. Intestinal peristalsis appeared on day 3.

The laboratory values on the first day: blood amylase – 41 mg/(s L), total bilirubin – 15.24 mcM/L, glucose – 9.7 mmol/L; day 3: blood amylase – 10.9 mg/(s L), total bilirubin – 11.26 mcM/L, glucose – 7.3 mmol/L; day 15: blood amylase – 22.1 mg/(s L), total bilirubin – 10.21 mcM/L, glucose – 6.7 mmol/L.

On day 10 the patient was transferred to the general room. Control ultrasound examination of the abdominal cavity showed satisfactory state of the pancreas, without signs of pseudocysts, infiltration and abscesses. The patient was discharged in satisfactory state on day 20.

CONCLUSION

The results of the study show that electro-welding technique for pancreatic disruption in polytrauma allows restoration of anatomic integrity, providing hemostasis with reduced time of surgical intervention and reducing risk postsurgical pancreatogenic complications, particularly, posttraumatic pancreatitis.