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The surgical diagnosis and management of pancreatic pseudochist


Author: Carmen Neamţu
Degree:doctor of medicine
Speciality: 14.00.27 - Surgery
Year:2006
Scientific adviser: Vladimir Hotineanu
doctor habilitat, professor, State University of Medicine and Pharmacy "Nicolae Testemitanu"
Institution:
Scientific council:

Status

The thesis was presented on the 15 February, 2006
Approved by NCAA on the 27 April, 2006

Abstract

Adobe PDF document16.00 Mb / in romanian

Thesis

CZU 616.37-006.03-07-089

Adobe PDF document 3.39 Mb / in romanian
183 pages


Keywords

pancreatic pseudochist, mature, during maturation, optimal surgical moment, chistopancreatojejunoanastomosys on isolated Roux anse

Summary

In this thesis are described the results of the complex treatment of 121 patients with pancreatic pseudochist, comunicating or not with pancreatic duct, and wirsungian hypertension, operated in Surgical Clinic No. 2 in period of 1994-2005.

The purpose of this study was to optimise the diagnosis methods and to elaborate a rational surgical management of the pancreatic pseudochist treatment, through the correlation of surgical techniques with the optimal surgical moment, given by the maturation degree of pseudochistic wall, thus the complications and recidives rates to be minimum.

From the total number of patients with pancreatic pseudochist included, 92 (76%) were men and 29 (24%) were women. The age varied between 27 and 78 years, with an average of 45,78.

The study propose a contemporary diagnosis algorithm, which includes clinical and laboratory dates and imagistic explorations (echography, simple abdominal radiography, gastro and duodenography, retrograd endoscopic colecistopancreatography, computer tomography, MRI, wirsungography and intraoperative echography).

The surgical indication was done by mature pancreatic pseudochist in 45 (37,2%) cases, by pancreatic pseudochist during maturation (less than 6 month from debut) in 17 (14%) cases, and by pancreatic pseudochist with postoperative complications in 59 (48,8%) cases, facts which bring to the elaboration of a self surgical management.

Chistopancreatojejunostomy on isolated Roux anse, was made in 50 (41,3%) cases – 16 (29,7%) lot I, 34 (49,55%) lot II. External drainage was made in 49(40,5%) cases. Miniinvazive operations was made in 5 (4,1%) cases. Retrograd endoscopic colangiopancreatography with papilosfincterotomy was made in 2 (1,65%) cases. In 4 (3,3 %) cases was applied chistopancreato-jejunoanastomosys on Omega anse. In 5(4,1%) cases was made chistopancreato-jejunoanastomosys with colecisto-jejunoanastomosys, respectively coledoco-jejunoanastomosys at patients with pancreatic pseudochist complicated with mechanical icter. In one case (0,83 %) was made colecistectomy with chistopancreatojejunoanastomosys on isolated Roux anse. In one case (0,83 %) with pyloric stenosis was made chistopancreato-jejunoanastomosys associated with coledocojejunoanastomosys, gastro-enteroanastomosys and colecistectomy. In one case (0,83%) was made chistopancreatojejunoanastomosys with colecisto-jejunoanastomosys on Omega anse, and 2 cases (1,65%) had benefit from another types of anastomosys. Caudal pancreatic resection with pancreatico-jejunal derivation and splenectomy was made to 1 patient (0,83 %).

The postoperative complications rate was 26 (21,48%) cases -lot I -16 (29,62%), lot II -10 (14,92%), precocious 21(17,35%) cases -lot I -14 (25,92%), lot II -7 (10,44%) with an average of hospitalizing days of 15,73 days – lot I (21,11 days), lot II (11,40 days) tardily 5 (4,1%) - lot I – 2 (1,65%), lot II – 3 (2,5%). These difficulties in postoperative evolution necessitated urgent conservative therapeutic maneuvers and just in 5 (23,80%) cases -lot I -3 (21,42%) cases, lot II - 2 (28,57%) cases, clinical situation determinate surgical reintervention.

It was necessary a surgical reintervention of internal derivation at distance to 25,51% cases. From a total of 25 reinterventions: 12% – all from lot I – had benefit of external drainage, 4% – from lot I - of miniinvasive drainage, and the rest of 84% had benefit of chistojejunoanastomosys on isolated Roux anse in “Y”. It has to be mentioned that any of chistojejunoanastomosys on isolated Roux anse (50 made as first surgical step and 21 as reintervention) had not developed postoperative fistulas and had proved permeable at ERCP and MRI control.

At 1 year from surgical intervention, 71 (72,45%) patients - lot I – 29 (76,3%), lot II -42 (48,33%), took back their previous activities, having an active job. 19 (19,2%) patients - lot I -7 (26,92%), lot II -12 (20,0%), renounced to some activities which necessitated intense physical effort, and 5 (5,1%) patients - lot I -2 (2,63%), lot II -3 (6,67%), renounced completely to all previous activities.

From 13 (10,75%) - lot I - 6 (15,8%), lot II -7 (11,66%) persons with handicap, preoperatively integrated in invalidation financial help, postoperatively just 5 (5%) persons -lot I -2 (25%), lot II -3 (5%) mentained this state, 3 (3%) - lot I -2 (5,26%), lot II -1 (1,66%) having a relatively normal life, and 5 (5%) - lot I – 2 (5,26%), lot II – 3 (5%) lost this state, regaining their work capacity, being not invalid anymore.

Satisfaction was reached in 94,9% patients, just 1,02% patients being unsatisfied with their actual state. Postoperative mortality reported on a period of 12 month was 3,3%.

The analysis of precocious and tardily results after interventions of chisto-jejunal decompression derivation, made us to consider these operations being elective in the decompression of pancreatic pseudochist and in the reestabilish of pancreatic juice flux in digestiv tract, allowing a good socio-professional reintegration, but with an attentive monitorise of the patients.