BLEEDING INTO THE CAVITY OF POST-NECROTIC PSEUDOCYSTS IN CHRONIC PANCREATITIS: DIAGNOSIS AND SURGICAL TREATMENT OPTIONS

Abstract

Вackground. Postnecrotic pancreatic pseudocysts (PPP) occur in the range of 20–60% as a complication of chronic pancreatitis (CP). One of their rare complications is bleeding into PPP cavity (6–17%). Objective. To analyze various methods for diagnosing bleeding into PPP cavity as well as to assess immediate and long-term outcomes of a personalized surgical approach to its treatment. Material and methods. 44 patients were operated on for bleeding into PPP cavity in the surgical department (hepatology) of the Emergency Hospital in Minsk from 01.01.2010 to 31.12.2019. The pre-operative assessment protocol included: ultrasound, endoscopy with examination of the Vater papilla area, Multislice Computed Tomography Angiography (MSCTA). The outcomes of surgical interventions have been evaluated during the immediate (30 days) and follow-up (3 years) periods. Results. The incidence of bleeding into PPP cavity among 218 CP patients operated on for PPP amounted to 20.18% (44 cases). Transabdominal ultrasound and MSCTA of the abdominal cavity were successively performed for correct clinical picture assessment. We performed proximal resection of the pancreatic head in 27 patients with pseudoaneurysms of the branches of pancreatoduodenal arteries or veins. 5 patients (P% (95% CI)=11.4 (1.8-33.1)) underwent pylorus-preserving pancreaticoduodenal resection, or local resection of the pancreatic head according to C.F. Frey – 16 (P% (95% CI)=36.4 (17.2-57.2)) and 6 patients (P% (95% CI)=13.6 (8.1-34.3)) underwent local resection of the head and isthmus of the pancreas – using our own surgical technique (pat. 22555, Republic of Belarus). In case of pseudoaneurysms of the branches of the splenic artery or vein, there were detected bleedings into PPP cavity, the PPPs being located in the area of the body and/or tail of the pancreas. In 11 cases (P% (95% CI)=5.0 (15.4-36.6)) the bleedings were detected and resolved during pancreatocystojejunostoanastomosis using "Roux-en-Y" jejunal loop. In 2 cases the patients underwent longitudinal pancreaticojejunostomy according to Partington-Rochelle for arterial bleeding accompanied by recurrent virsungorrhagia. (P% (95% CI)=4.54 (3.0-20.9)). Complications were observed in 17 (38.6%) cases (P% (95% CI)=39.8 (17.2-47.2)), there being 2 (5.26%) fatal outcomes (P% (95% CI)=4.7 (0.2-24.9)). Conclusion. Diagnosis of bleeding into PPP cavity should be based on comprehensive medical examination assessment including findings from ultrasound, endoscopy with examination of the Vater papilla area, MSCTA. Surgical treatment outcomes confirm the value of a personalized surgical approach for the management of bleeding into the cavity of pancreatic pseudocysts in CP.