[OPEN NECROSECTOMY IN THE COMPLEX TREATMENT OF THE SEVERE ACUTE PANCREATITIS].

The aim of the study was to determine the indication for the method of open abdomen-open necroseqtomy in the complex treatment of acute pancreatitis. 74 patients with the diagnosis of acute pancreatitis were selected for the treatment. Patients were divided by severity of disease: mild acute pancreatitis - 29 patients were treated by conservative method; moderate acute pancreatitis - 29 patients were treated by following methods: 17 patients - by conservative method; 4 patients by conservative treatment with fasciotomy; 8 patients - by open abdomen method without fasciotomy after conservative treatment. Severe acute pancreatitis - 16 patients were treated by following methods: 2 patients by open abdomen technique with single necroseqtomy and sanitation after fasciotomy, 8 patients - with the method of open abdomen from which 3 patients needed a single necroseqtomy and sanitation, 3 patients had a double necroseqtomy and sanitation and 2 patients three and four times the necreseqtomy and sanitation were used with a fastener, 6 patient were treated conservatively. We identified indication and contraindication for treatment of severe acute pancreatic necrosis by open necroseqtomy. Indications: 1) Pancreatic and/or peripancreatic necrosis (based on contrast-enhanced dynamic CT scan) complicated by documented infection (guided FNA culture or extraluminal retroperitoneal gas). 2) Sterile necrosis with progressive clinical deterioration despite maximal medical treatment. Contraindications: 1) Pancreatic and/or peripancreatic necrosis without evidence of infection or clinical deterioration. 2) Early operation (within a week from onset of acute pancreatitis) before the systemic inflammatory response syndrome (SIRS) is stopped and intensive conservative treatment is still required.

[FASCIOTOMY IN THE COMPLEX TREATMENT OF THE ABDOMINAL COMPARTMENT SYNDROME FOR PANCREATIC NECROSIS].

The long-term history of studying of a problem of acute pancreatitis in its different aspects, is fight against a pancreatic necrosis and a pancreatic infection. Technology progress in improvement of diagnostic methods and treatment of a pancreatic necrosis and its complications, changed a situation, but treatment of such patients remains the most difficult task for the doctors dealing with pancreatitis issues. The main factor of risk at a pancreatic necrosis are: gland necrosis volume, the severity of enzymatic endo intoxication, degree of intraabdominal hypertension, a translocation of microbes from intestines in the blood circulation and an abdominal cavity. The Abdominal Compartment Syndrome (ACS), at a pancreatic necrosis is connected with presence of multiorgan insufficiency, caused by intraabdominal hypertension. Definition of indications of a fasciotomy in the complex treatment of the adominal compartment for pancreatic necrosis was our research objective. Management of intraabdominal hypertension and ACS consists of a maintenance therapy and if necessary, an abdominal decompression which is considered one of treatment methods. The difficulty of a decompression of an abdominal cavity at ACS which arose on the background of a pancreatic necrosis is that laparotomy in the first phase of its treatment is extremely undesirable and even harmful manipulation which is related to infecting necrotic zones that considerably aggravates the prognosis. These requirements are met by a fasciotomy i.e. broad section of an aponeurosis on the white line of a stomach. The volume of an abdominal cavity at this manipulation increases at the expense of a diastasis of rectus muscle and stretching of skin and peritoneum, while the abdominal cavity hermetism is maintained. We have performed subcutaneous fasciotomy in 4 patients for ACS treatment. The fasciotomy is a targeted mini invasive method for the complex treatment of pancreatic necrosis. Performing fasciotomy and use of a modern complex of an intensive care will allow to achieve improvement of results in the treatment of patients with pancreatic necrosis, without performance of traumatic laparotomy and a laparastomy.

HYPOGENESIS OF RIGHT LOBE OF LIVER ACCOMPANIED BY PORTAL HYPERTENSION AND ESOPHAGOGASTRIC VARICEAL BLEEDING; A RARE ANOMALY: A CASE REPORT.

Hypo-agenesis of the right lobe of the liver is an extremely rare finding. It is defined as the complete or partial absence of liver tissue on the right side without previous disease or surgery. It is usually an incidental finding. A 32-year-old female patient came to Emergency Department of TSMU the First University Clinic 22.10.2015 with an initial diagnosis of upper gastrointestinal bleeding. Her medical history showed no previous diseases of the liver or episodes of hemorrhage. Dizziness, nausea, vomiting with red blood, melena was presented on admission. Esophagogastroduodenoscopy revealed III degree varicose of veins from middle part of the esophagus to cardiofundal part of the stomach. Hemorrhage was observed from cardial part of the stomach. Control of bleeding was not achieved endoscopically. Sengstaken-Blakemore tube was used to stop bleeding temporarily. Computed tomography with angiography was performed. Right lobe of the liver was presented with VII and VIII segments. Medial edge of the left lobe of the liver is located near the spleen. Liver parenchyma is homogenous. No thrombosis of the portal or hepatic veins was revealed. Gallbladder was dislocated laterally and cranially without pathological changes. Extra- and intrahepatic biliary ducts were not dilated. There was colonic interposition between the liver and diaphragm. Diagnosis was established - hypogenesis of right lobe of liver, atrophy-hypertrophy complex, portal hypertension, varicose of the veins of the esophagus and cardiofundal part of the stomach, hemorrhage from variceal vein of the cardial part of the stomach, acquired coagulation factors deficiency, functional hypersplenism, posthemorrhagic anemia. In our case there was congenital hypogenesis of the right lobe of the liver. Five months follow-up showed no recurrent bleeding.