Results of surgical treatment of chronic pancreatitis and cysts of the pancreas in view of their morphological condition during surgery

Abstract

Background. To date, reasonable indications and contraindications have not yet been developed for the implementation of draining, resection-draining and resection procedures with preoperative consideration of risk factors of their performance, there are no modern diagnostic and treatment algorithms for the treatment of patients with complications of chronic pancreatitis and pancreatic pseudocysts. Therefore, a retrospective analysis of failures during the surgical interventions on the pancreas would contribute to the creation of diagnostic and therapeutic algorithm with maximum consideration of the risk factors that would enable the individualization of treatment program and provide a long therapeutic effect to the patient with minimal risk of disease recurrence and minimal surgical trauma. This is an actual problem of modern surgery. The aim of the study was to define principal causes, which resulted in failures at surgical treatment for complications of chronic pancreatitis and cysts of the pancreas. Materials and methods. There was performed the retrospective analysis of 108 follow-up cards of patients operated for complications of chronic pancreatitis (n = 66) and pseudocysts of the pancreas (n = 42) with application of draining, resection-draining and resection surgical interventions. During the retrospective analysis, we took into account the morphological state of pancreatic parenchyma and presence of pseudocysts of the pancreas at the time of operation, blood loss during the surgery, the incidence and nature of intra- and postoperative complications depending on the type of surgical interventions, extent and adequacy of the operation, lethality. Results. The nature of the complications of chronic pancreatitis and pancreatic pseudocysts: a constant or recurrent pain, dilatation of pancreatic duct, calculus of pancreatic duct, calcifications of the parenchyma of the pancreas, stenosis of the intrapancreatic part of the common bile duct, biliary hypertension, obstructive jaundice, duodenal obstruction, segmental suprahepatic or subhepatic portal hypertension, ascites, abscess of the pancreas, external pancreatic fistula, fistula choledochoduodenalis. Failures during the surgical treatment for complications of chronic pancreatitis and pseudocysts of the pancreas were detected in 57 (57.0 %) cases, including 33 (57.9 %) cases in the treatment for complications of chronic pancreatitis and in 24 (42.1 %) cases during the treatment of pseudocysts of the pancreas. Lethal cases were registered in 4 (3.7 %) patients at the implementation of draining (longitudinal pancreatojejunostomy, cystopancreatojejunostomy) and resection surgical interventions (pancreatoduodenal resection). The nature of failures in most cases (64.9 %) was presented by impossibility of performing adequate surgical intervention (n = 21), insufficiency of seams of anastomosis (n = 6), postoperative bleeding (n = 5) and significant blood loss during the surgery (n = 5). Most of the major causes of failure of surgical treatment for complications of chronic pancreatitis and pancreatic pseudocysts were related to the morphological state of the pancreas and pancreatic pseudocysts during the operation: active inflammation and its combination with varying degrees of fibrosis of pancreatic parenchyma (n = 47); early fibrosis of pancreatic parenchyma (n = 15), immature pancreatic pseudocyst (n = 5), as well as soft “juicy” pancreas (lipomatosis on the background of active inflammation of the pancreatic parenchyma) (n = 8). Conclusions. Basic factors, which determine the risks and failures of surgical treatment for complications of chronic pancreatitis and pseudocysts of the pancreas, are: a) activity of inflammation, degree of fibrosis of pancreatic parenchyma at the time of surgery; b) maturity of the wall of pancreatic pseudocysts, its connection with pancreatic duct, localization, size and nature of complications of pseudocysts of the pancreas; c) inadequately chosen term and type of surgical intervention; d) inadequate performance of surgical intervention.