Diagnosis and Surgical Treatment of False Pancreatic Cysts

The dissertation is devoted to the diagnosis and surgical treatment of false cysts of the pancreas, one of the relevant problems of abdominal surgery. The work analyzes clinical material from 1998–2004, develops an algorithm for diagnosing complicated forms of false cysts, and compares various methods of surgical treatment. Special attention is given to the development of a temporary shunt for cystogastrostomy and combined drainage of the common bile duct and the subhepatic space, aimed at reducing recurrence rates and improving the outcomes of operative treatment.

ACTUALITY OF THE PROBLEM. Diagnosis and surgical treatment of false cysts of the pancreas continue to remain one of the most complex and relevant problems in abdominal surgery. The number of patients with pancreatic cysts in surgical wards is steadily growing, increasing in parallel with the growth in the number of acute and chronic pancreatitis cases, as well as pancreatic injuries. The main cause of false cyst development is acute destructive pancreatitis (Gostischev V.K., Afanasyev A.N., Ustimenko A.V., Pulatov O.Kh., 2006; Voytkovsky A.E., Botasheva V.S., Nemchinov A.O., 2006). The stable increase in morbidity, high mortality, and significant economic costs of treatment have moved the problem of acute pancreatitis and its complications far beyond purely medical concerns (Galeev M.A., Kononov V.S., Doroev V.D., Zavarukhin V.A., 2006). Despite the improvement of surgical tactics, as well as intensive therapy methods, depending on the severity of the disease course, mortality amounts to 5.1% (Voytkovsky A.E., Botasheva V.S., Nemchinov A.O., 2006) and can reach 50% (Lombardo G., 1991, Grace R.A., 1993). False cysts of the pancreas are an absolute indication for surgical treatment (Gataullin N.G., Titov R.I., Titov A.R., 1998). The treatment strategy for patients with false cysts of the pancreas must be strictly individual and depend on the stage of the disease, the localization of the pathological process, and the presence of complications (Babenkov G.D., Olshantsky A.A., Kirichenko B.B., Usov S.N., Kravchenko A.V., 2001). Each method of operative treatment of this disease has both its disadvantages and advantages. The disadvantages of resection methods include their technical complexity, trauma, high mortality, and persistent disability of patients due to disruption of the normal physiological process of digestion with malabsorption and development of diabetes mellitus (Kurygin A.A., Nechaev E.A., Smirnov A.D., 1996). A negative aspect of external drainage of false cysts of the pancreas is the palliative nature of the operation, recurrence of cysts and their suppuration, as well as the formation of long-existing external pancreatic fistulas that do not respond to conservative therapy and require repeated technically complex, traumatic surgical interventions (Danilov M.V., Fedorov V.D., 2003, Martov Yu.B., Kirkovsky V.V., Martov V.Yu., 2001, Yatsky N.A., Sedov V.M., Sopiya R.A., 2003). Internal cyst drainage is considered the most effective; however, its disadvantage is the obliteration of cysto-digestive anastomoses and infection of pancreatic cysts (Danilov M.V., Fedorov V.D., 2003, Kaltaev K.K., 1998). According to data from various authors (Bradley E.L., 1981, Howard J.M., 1982, Huizinga W.K., 1992), the recurrence of this disease after operative treatment averages 11–20%. The frequency of recurrence of pancreatic cysts depends not only on complications but also on the type of operative intervention. After external drainage, the complication rate is 18%, after internal drainage — 8%, and after radical cyst removal — 4.3% (Adams D.B., 1992). Cysts with communication with the main pancreatic duct recur more frequently (M. Barthet, M. Bugallo, L.S. Moreira, 1993). Moreover, there is no unified tactic in determining indications and choosing the optimal variant of surgical intervention for false cysts of the pancreas (Nesterenko Yu.A., 1997, Mishin M.Yu., Kezorova A.P., 2000). These very questions are devoted to this work.

GOAL OF THE RESEARCH. The goal of this work is to improve the results of surgical treatment and reduce the recurrence rate of the disease in patients with false cysts of the pancreas.

TASKS OF THE RESEARCH. 1. To study the main causes of development and recurrence frequency of false cysts of the pancreas based on data from surgical departments of city clinical hospitals of Ufa for 1998–2004.

2. To conduct a comparative evaluation of various methods of surgical treatment of false cysts of the pancreas.

3. To develop an algorithm for diagnosis of complicated forms of false cysts of the pancreas.

4. To develop and apply a temporary shunt in surgical treatment of false cysts of the pancreas.

5. To analyze the structure of mortality in false cysts of the pancreas based on data from pathological anatomy departments of Ufa for 1998–2004.

SCIENTIFIC NOVELTY. An algorithm for diagnosis of complicated forms of false cysts of the pancreas has been proposed.

Optimal variants of operative interventions for this pathology have been determined.

A temporary shunt has been developed and introduced into practice for surgical treatment of false cysts of the pancreas (Patent of the Russian Federation for Utility Model No. 52711 dated 27.07.2006.), used when performing cystogastrostomy.

A combined drainage of the common bile duct and the subhepatic space has been developed and applied (Patent of the Russian Federation for Utility Model No. 51503 dated 27.02.2006), which was used in the complication of false cyst of the pancreas by mechanical jaundice, when revision and drainage of the common bile duct become necessary.

PRACTICAL SIGNIFICANCE. The conducted analysis of the results of surgical treatment of false cysts of the pancreas made it possible to trace the early and late results of operative interventions for this pathology.

The proposed algorithm facilitates timely diagnosis of complicated forms of false cysts of the pancreas.

The developed and used temporary shunt during cystogastrostomy prevents early scarring of the anastomosis and recurrence of the cyst, thereby allowing improvement of the results of surgical treatment of patients with this pathology.

The developed combined drainage allows simultaneous drainage of the common bile duct, the ampulla of Vater, and the subhepatic space and improves the efficiency of treatment.

IMPLEMENTATION OF THE RESULTS. The results of the work have been implemented in the surgical department of City Clinical Hospital No. 18 of Ufa.

VALIDATION OF THE WORK. The materials of the dissertation were reported and discussed at the general hospital conference of surgeons of City Clinical Hospital No. 18 of Ufa (2004), at a meeting of the Association of Surgeons of the Republic of Bashkortostan (2004), and at the plenary sessions of the problem commissions "Emergency Surgery" and "Infection in Surgery" of the Interdepartmental Scientific Council on Surgery of RAMN and at the Russian Scientific and Practical Conference "Actual Problems of Emergency Surgery (Acute Pancreatitis, Pyoseptic Complications of Acute Pancreatitis)" in the city of Stavropol (2006).

PUBLICATION OF RESEARCH MATERIALS.

The main provisions of the dissertation work are set out in six publications. Two patents of the Russian Federation for Utility Model have been obtained (No. 52711 dated 27.07.2006 "Temporary Shunt in Cystogastrostomies" and No. 51503 dated 27.02.2006 "Combined Drainage of the Common Bile Duct and the Subhepatic Space") published in the VAK Bulletin "Utility Models".

STRUCTURE AND VOLUME OF THE DISSERTATION. The dissertation is presented on 140 pages of typed text and consists of an introduction, a literature review, four chapters of own research, a conclusion, conclusions, practical recommendations, illustrated with 32 figures and 16 tables. The list of references includes 85 domestic and 66 foreign authors.