THE KURSK STATE MEDICAL UNIVERSITYDEPARTMENT OF SURGICAL DISEASES № 1

BENING PANCRESTIC DISEASE

Information for self-training of English-speaking studentsThe chair of surgical diseases N 1 (Chair-head - prof. S.V.Ivanov)

BY PROFESSOR O.I. OCHOTNICKOV

KURSK-2010 CHRONIC PANCREATITIS

Chronic pancreatitis isn’t independent disease, it’s the phase condition, continue and

result of acute pancreatitis. Besides, attacks of acute pancreatitis may be considered as

episode in chronic pancreatitis development. This phase is characterized by oedema of

pancreatic tissue, seldom by necrosis and hemorrhage. It leads to fibrose or calcinosis of

the pancreas.

So, chronic pancreatitis is chronic relapsing process, which includes in itself episodes

of acute oedema and necrosis of the pancreas, outside of it development of pancreatic

sclerosis and parenchyma atrophy are presented.

The most important link in chronic pancreatitis development acute attack is. Total

necrotic pancreatitis leads usually to patient death, large focal necrosis is being finished

by secvestration with subsequent connective tissue transformation or pseudocyst

formation. Oedema form of acute pancreatitis is being finished by progressive fibrose of

the pancreas with extra- and intrasecretory insufficiency.

It is known, that with presence of common symptoms of chronic pancreatitis

pathogenesis, which are characterized by tendency to atrophy of glandular elements and

its connective tissue transformation, there are peculiarities of disease development, which

are determinated by its etiological factors. For example, in the base of alcohol pancreatitis

some lesions of protein precipitation is. In the base of chronic bile pancreatitis intermittent

papilla Vatery impassability lies.

As etiological classification of chronic pancreatitis the following can be used /Hollender/

1. Main factors

Gallstone disease

Alcoholism

Postoperative pancreatitis

Endoscopical procedures on bile and pancreatic ducts

Abdominal trauma

2. Seldom factors

Endocrinal diseases

Pregnancy

Drugs pancreatitis

Immune and allergical factors

2

Neurogenic pancreatitis

Congenital pancreatitis

Viral and parasitogenic pancreatitis

3. Shock and acidosis caused pancreatitis

One of the most important etiological factor of pancreatitis gallstone disease is.

Frequence of pancreatitis is known to be depending on duration of gallstone disease. In

cases of more then 5-years disease presence, chronic pancreatitis can be found in 35%

of patients.

The possibility of necrotic pancreatitis appearance due to bile reflux into the main

pancreatic duct was proved by Opie in 1901. This observation has been lied into the base

of “common canal theory” According it, there are so anatomical conditions, then,

combined opening of the common bile duct and the main pancreatic duct into the

duodenum gives possibility for bile pouring into pancreatic ducts due to papilla Vatery

obstruction.

By researches of a lot of authors the anatomical conditions for “common canal“ are

established to be found in 65-80% of patients. But incarcerated stones of papilla Vatery

are found in 3-5% of patients only. Bile stones are known can lead to intermittent

impassability of distal part of the common bile duct due to not direct stone obstruction of

papilla Vatery, but long time spasm of hepato-pancreatic sfincter.

Among factors, promoting to realize this mechanism, are divided following: plural bile

stones, wide cystic duct, that gives some possibilities for migration into the common bile

duct.

Last time much attention is payed to microcholedocholitiasis in pathogenesis of

papillospasm, papillostenosis and secondary pancreatitis. This microstones cann’t be

found by traditional instrumental methods, such as US-examination or X-Ray

cholangiography. It may be verify by coprological examination after attack of acute

pancreatitis.

Neoptolenus in 1989 has formulated the theory of “persisting choledocholitiasis”. The

author divides two phases of pancreatitis development. In first stage some small stones

lead to papilla Vatery spasm, and bile is pouring into pancreatic ducts. Then more big

stone leads to impassability of papilla Vatery.

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But, sometimes, may be found some forms of pancreatitis against background of

gallstone disease, but without any lesions of bile ducts and papilla Vatery. In this kind of

pancreatitis, which can be named as cholecystopancreatitis, there are no enough causes

to say about any important role of bile-pancreatic reflux. Cholecystectomy in this condition

usually doesn’t cure this pancreatitis. It is foundation to think, that in some cases of

accompanying presence of bile stone disease and pancreatitis is explained by the

presence of same common etiological factors for gallstone disease and pancreatitis, for

example, chronic duodenal impassability, duodenal diverticulums. In this cases the

resolving of secondary changes in bile duct cann’t give any possibilities for pancreatitis

cure.

Alcohol pancreatitis

For pancreatitis due to alcohol the most severe morphological changes are

characterized. Alcohol influence to the pancreas can be explained by direct and mediate

damages of acinar cells.

In pathogenesis of alcohol chronic pancreatitis main significance belongs to following:

1. Hyperstimulation of external secretory function of the pancreas

2. Retention of pancreatic duct with intraductal pressure increase due to protein

precipitation in it.

Alcohol has a stimulative effect to the pancreas. This influence is realized by neurological

and hymoral agents. Besides, alcohol has some spastic influence for papilla Vatery so

does morfinum.

Pathological morphology of chronic pancreatitis

Acute and chronic pancreatitis are characterized by necrosis of acinar cells with

appearance of inflammatory reaction and its late transformation into connective tissue. By

macroscopical view the gland more often has increase size, fibrose capsule is sclerotic

changed. There are some focuses of old necrosis with yellow color. In hystological

examination the gland has a lot of fibrose fields with leukocytes inflammation.In pancreatic

tissue false cysts can be found. The main pancreatic duct is twist with small stones.

Nerves trunks, which are following in connective tissue become hypertrophycal with

inflammatory infiltration. Nerves nodes are changed too. By Mallet-Guy this changes can

explain constant pain syndrome in cases of chronic pancreatitis.

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In general, all pathological changes of the pancreas may be characterized as:

chronic indurative pancreatitis

chronic pseudocyst pancreatitis

chronic pseudocalculose pancreatitis

Clinical picture

There are several clinical forms of chronic pancreatitis. They are following:

1. Chronic relapsing pancreatitis. It is the most spreading clinical form. It can be

consequence of acute pancreatitis. Intermittent acute attacks are characterized for this

clinical form. The attack is described as pain crisis. The crisis is accompanying by

increase level of pancreatic enzymes in the blood and the urine, sometimes - jaundice.

During acute attack not only pancreas oedema develops, but necrotic pancreatitis can

be too. Though in patients with long time anamnesis of chronic pancreatitis necrotic

changes are rare. It is explained by atrophy of functional active gland cells and their

transformation into fibrose tissue.

2. Chronic painful pancreatitis. In this cases pain syndrome is constant. The pain is dull

ache, gnawing. In anamnesis of the patients quite often pancreonecrosis occurs.

Besides pain syndrome there are weithloss and dyspeptical complaints.

3. Latent pancreatitis. This variant of chronic pancreatitis, sometimes, is being described

as painless. But it isn’t true, because some pain takes place in it too. But on first line in

the cases functional lesions of the pancreas going out.

4. Pseudotumorose pancreatitis. Stable obstructive jaundice is the most important clinical

sign of this form. So, the clinical picture of this form is meeting often in cases of

pancreatic cancer. But in patients with chronic pancreatitis the jaundice is

accompanying by some pain syndrome and manifestations of extra- and intrasecretory

pancreatic insufficiency. Correct diagnosis in this cases is quite difficult not only before

surgical procedure, but during it too. Often, only long time medical supervision gives

possibility for determination of correct diagnosis.

5. Some researches describe the 5-th form of chronic pancreatitis - chronic

cholecystopancreatitis. But independently on presence or absence gallstone disease,

pancreatitis may be relapse, painful or latent.

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The base point in diagnosis formation in cases of chronic pancreatitis pain syndrome

is. Pain syndrome absence in this disease is very rare. Determination of extrasecretory

functional lesions of the pancreas may be consider as corroboration of chronic

pancreatitis. They are: progressive weithloss in accompanied of safe appetite, abundant,

fast stool with notdigestive food remainders.

The diagnosis of chronic pancreatitis is corroborated by addition of diabetes mellitus

or, rare, hypoglycemical conditions.

One of the manifestations of chronic pancreatitis some specific complications are

The presence of pancreatolitiasis

The exposure of intrapancreatic part of the common bile duct

The presence of enzymaemia against background of pain attacks.

Considerable lesions of extrasecretory function of the pancreas

Expose of cyst after pain attack.

Accompanying plural fluid with considerable maintenance of pancreatic enzymes

Instrumental diagnose of chronic pancreatitis

US-examination. The method gives possibility to expose one of the three variants of

chronic pancreatitis:

1. secondary, accompanying with bile stone disease

2. pancreatitis, complicated by cysts

3. primary pancreatitis without pancreatic cysts

Valuable diagnostic information may be received by X-Ray examination. In cases of

stones pancreatitis, they may be found. Besides, X-Ray examination gives possibility to

expose the increase of pancreatic masses.

Often it is necessary to use RPCG, sometimes - CT-scanning.

Surgical treatment of chronic pancreatitis

Today, surgical correction of chronic pancreatitis should pursue following aims:

Pain syndrome resolving

Management of pancreatic complications

Probably, preservation of pancreatic function

Of cause, surgical procedures cann’t cure the disease, but they are stopping their

development.

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In cases of secondary cholangyogenic pancreatitis it’s necessary to resolve etiological

factors of the disease. It creates conditions for prophylaxy of some complications and

accompanied lesions of pancreato-bile system. But in cases of primary pancreatitis and in

some forms of secondary pancreatitis etiotropical treatment is impossible.

Among different clinical syndromes of chronic pancreatitis pain once is one of the most

important, first of all from the positions of indications for surgical management. In 1/3 of

patients with chronic pancreatitis indications for surgical treatment are connected with

sings of pancreatogenic stenosis of the common bile duct and the duodenum or

segmental portal hypertension.

Among complications of chronic pancreatitis indications for surgical corrections are

being appeared in cases of presence of pseudocysts, pancreatic fistulas, late suppurative

complications.

All operations in cases of chronic pancreatitis are divided into 5 groups. They are:

1. Operations on adjoining organs

operations on bile ducts and papilla Vatery

operations on digestive organs

2. Direct surgical procedures on the pancreas

pancreatic resection

internal drain procedures of pancreatic ducts and cysts

pancreatic duct occlusion

external drain procedure of pancreatic ducts and cysts

3. Palliative operations

surgical procedures on nerve system

cryodestroying of the pancreas

4. Endoscopic procedures on the pancreas and its ducts

5. “Closed” surgical operations are creating under US- and CT-control

The indications for surgical operations on bile ducts are appearing in two forms of chronic

pancreatitis. At first - cholangiogenic pancreatitis, in which the lesions of gallbladder,

common bile duct and papilla Vatery are the causes of secondary changes of the

pancreas. At second - primary pancreatitis alcohol etiology with development of tubular

stenosis of intrapancreatic part of the common bile duct.

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In some cases chronic pancreatitis is occurring due to chronic duodenal impassability.

It can has been corrected by two main surgical modes.

with keeping of duodenal passage

with switch off duodenal passage.

Among this operations the most wellknown the following are: the dissection of Treic

ligament, duodenointestinal anastomosis, antrumectomy with vagotomy.

Among direct surgical procedures on the pancreas different kinds of pancreatic

resection are using. They are:

distal resection

near-total pancreatectomy

sectoral pancreatectomy

pancreato-duodenal resection /Wipple procedure/

total pancreatoduodenectomy

For today the most spread operation in cases of chronic pancreatitis some internal

drain procedures are. Main pancreatic duct hypertension is known to be the cause of pain

syndrome and one of important factor of chronic pancreatitis development. This condition,

besides, can lead to appearance of some disease complications, such as pseudocysts,

external pancreatic fistulas. So, it is obviously, that internal pancreatic duct drainage is

expedient. But, it’s known from literature, that internal drainage procedures don’t

influence on reversible development of atrophy and fibrose changes of the pancreas.

The main conditions for successful internal drain procedures the proved occlusion or

stenosis of proximal part of the main pancreatic duct are. Internal drain procedures may

by realized as:

1. Dissection and plastic of main pancreatic duct opening

2. Longitudinal pancreatointestinostomy by Puestou I, II or terminal

pancreatointestinostomy by Du Vale

Among other surgical modes different sorts of main pancreatic duct occlusion are

used. Exception of exsocrinal pancreatic secretion function leads to pain disappearance.

But this method has very strict indications. The most important condition for it - severe

fibrose transformation of the pancreas.

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Good results after surgical correction of chronic pancreatitis due to distal

pancreatectomy or Wipple procedure are being reached in 60-80%, after Puestou

procedure - in 65-85% and in 40-60% after transduodenal plastic of main pancreatic duct

opening. Surgical procedures on vegetative nerve system lead to positive results less then

50% with relapse in a 2-6 months.

TEST - QUESTIONS

1. Etiological classification of chronic pancreatitis includes following, except

Main factors

Seldom factors

Parasitogenic pancreatitis @

Shock and acidosis caused pancreatitis

2. Main etiological factors of chronic pancreatitis includes following, except

Endocrinal diseases @

Pregnancy @

Gallstone disease

Alcoholism

Postoperative pancreatitis

Endoscopical procedures on bile and pancreatic ducts

Abdominal trauma

Immune and allergical factors @

3. Microcholedocholitiasis can be found by:

US-examination

X-Ray cholangiography

Coprological examination @

4. In pathogenesis of alcohol chronic pancreatitis main significance belongs to following,

except

Hyperstimulation of external secretory function of the pancreas

Retention of pancreatic juice with intraductal pressure increase due to protein

precipitation in it.

Spastic influence to pancreatic vessels @

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Direct lesions of acinar cells

5. In general, all pathological changes of the pancreas may be characterized as:

chronic indurative pancreatitis @

chronic cholecystopancreatitis

chronic fibrose pancreatitis

chronic pseudocyst pancreatitis @

chronic pseudocalculose pancreatitis @

6. The main clinical forms of chronic pancreatitis are following, except

Chronic relapsing pancreatitis.

Chronic painful pancreatitis.

Latent pancreatitis.

Chronic pseudocyst pancreatitis @

Pseudotumorose pancreatitis.

7. Obstructive jaundice is more characterized for:

Chronic relapsing pancreatitis.

Chronic painful pancreatitis.

Latent pancreatitis

Pseudotumorose pancreatitis.@

8. One of the manifestations of chronic pancreatitis some specific complications are,

except

The presence of pancreatolitiasis

Aneurism of celiac trunk @

The exposure of intrapancreatic part of the common bile duct

The presence of enzymemia on background of pain attacks.

Considerable lesions of extrasecretory function of the pancreas

Expose of cyst after pain attack.

Accompanying plural fluid with considerable maintenance of pancreatic enzymes

9. Instrumental diagnose of chronic pancreatitis includes the following most valuable

methods:

US- scanning @

CT-scanning @

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FGDS

ERCP @

X-Ray examination @

Vena Cava Graphya

10. US-examination gives possibility to expose one of the three variants of chronic

pancreatitis,except

primary pancreatitis without pancreatic cysts

secondary, accompanying with bile stone disease

indurative pancreatitis @

pancreatitis, complicated by cysts

pseudotumorose pancreatitis @

11. The most important indication for surgical management in patients with chronic

pancreatitis is

pain syndrome @

exsocrinal insufficiency

danger of complications

12. Among complications of chronic pancreatitis indications for surgical corrections are

being appeared in cases of presence of

pseudocysts @

pancreatic fistulas @

exsocrinal insufficiency

late suppurative complications @

pancreatic calculuses

13. Today, surgical correction of chronic pancreatitis should pursue following aims,

Pain syndrome resolving @

Management of pancreatic complications @

Probably, preservation of pancreatic function @

14. Direct radical surgical procedures on the pancreas are following, except

pancreatic resection

cryodestroying of the pancreas @

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internal drain procedures of pancreatic ducts and cysts

surgical procedures on nerve system @

external drain procedure of pancreatic ducts and cysts

pancreatic duct occlusion

15. Among direct surgical procedures on the pancreas different kinds of pancreatic

resection are using. They are following, except

distal resection

near-total pancreatectomy

Puestou - I @

sectoral pancreatectomy

pancreatoduodenal resection /Wipple procedure/

total pancreatoduodenectomy

16. Internal drain procedures may by realized as following, except

1. Dissection and plastic of the main pancreatic duct openning

2. Puestou I, II procedures

3. Wipple procedura @

4. Du Vale procedure

PANCREATIC CYSTS Cystic formations of the pancreas are of the main objects of different diagnosis between them

and other focal diseases of digestive organs on upper level of the abdominal cavity and the

retroperitoneal spatium.

Different forms are being complicated by pancreatic cysts in average 5 %. In patients with

chronic pancreatitis the cysts are being found in 25%, and indications for surgical management

appear in 37% of them. At last, most often the pancreatic cysts are exposing in patients with most

severe necrotic pancreatitis. It is about 50%.

As a con sequel of pancreatic injury the cysts appear in 20-30%. Besides, among different cystic

formations of the pancreas about 15% are constituted by cavity forms of tumors -

cystadenocarcinoma and cystadenoma.

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The Howard classification of pancreatic cysts is the most spreaded in practice:

1. The true cysts /with mucous epithelium/

A/ Congenital

the single or plural cysts in the pancreas only

the pancreatic cysts in accompany with cyst formations in another organs /Landau

disease/

the fibrocystose of the pancreas

dermoid cysts

B/ Acquired cysts

retentional cysts /cyst dilation of the pancreatic ducts/

parasitogenic cysts

tumorous cysts

-malignant

-benign

2. Pseudocysts /without mucous epithelium/

A/ Inflammatory /due to acute or chronic pancreatitis/

B/ Post traumatic

due to accident

due to any surgical procedures

C/ Unknown genesis.

But, for today, the subdivision of pancreatic cysts into true and false is conditional. It has

become known, that the primary retentional true cysts can have received some signs of pseudocysts

due to necrotic or inflammatory changes. From another side, the wall of post necrotic acquired

pancreatic cysts can be being covered by epithelium. Besides, it was proved the possibility of the

presence both epithelium and scary changes on cystic wall at the same time. So, the separation of

false and true pancreatic cysts isn’t so strict.

For every day practice it is more important to know only the main types of pancreatic cysts with

their etiological peculiarities and morphological differences. So, you should pay attention at

following subdivision.

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1. Extra pancreatic pseudocysts. They are post necrotic big size cysts. They can be post traumatic

too. Their walls aren’t formed and they be considered as parapancreatic leaks or suppurative fluid.

They may occupy a lot of room.

2. Intrpancreatic pseudocysts. They have been formed due to attack of relapse pancreatitis. The

cysts haven’t big sizes, usually connect with the pancreatic ducts and localize in the head of the

pancreas.

3. The cyst dilation of the pancreatic ducts /hydrops/. Most often it is meeting in cases of alcohol

pancreatitis.

4. Retentional cysts - the most rare sort of pancreas cyst lesions. They localize in distal part of the

pancreas, have thick walls. Usually they appear due to chronic pancreatitis, thought, another parts

of the pancreas haven’t severe changes.

5. The plural thick wall cysts. They can be isolated or in accompany with same once in other

organs. Usually, there are no doubts in congenital genesis of the disease.

6. The cystic tumors of the pancreas.

In one patient different types of the cysts can be met at the same time. In cases of chronic

relapse pancreatitis it’s passable to find at the same time extra- and intrapancreatic pseudocysts,

cystic dilation of the pancreatic ducts in different combinations. Spontaneous disappearance of

pancreatic cysts is very rare, and the cysts with sizes more then 6 cm never have resolved in once

own.

In 15-20% the pancreatic cysts are being complicated by suppurative inflammation, perforation,

acute bleeding into the cyst cavity or digestive tract with severe mortality. Top urgent surgical

management of the cysts due to their complications is accompanied by serious difficulties, first of

all , because these procedures, usually, aren’t radical. At last, pancreatic cyst can mask cavity forms

of some malignant tumors. So, the pancreatic cyst diagnosis creation is the obligate indication for

surgical treatment. But the questions are following: the mode of surgical management, the time of it

and allowed volume.

Clinical diagnosis.

The following can summarize the most important clinical syndromes of any lesions of the

pancreas:

1. The pain syndrome. It is connected with compression of surrounding tissues and organs by the

cyst or its distension due to inflammation, bleeding into it. Additional significance in pain

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syndrome appearance pancreatic juice hypertension has due to direct pressing of the main

pancreatic duct by the cyst, especially if it localizes in the head of the pancreas.

2. The clinical syndrome of extracrinal insufficiency. It is characterized by weightless, diarrhea.

This syndrome isn’t specific for pancreatic cysts, but it’s important in diagnose of chronic

pancreatitis, which is the background of cyst formation.

3. The syndrome of endocrinal insufficiency. Its condition is characterized for chronic pancreatitis

too and is being showed by diabetes militants or decreases the sugar tolerance test.

4. The syndrome of bile contestation. This sign appears in cases of head pancreatic cysts with

common bile duct compression.

5. The syndrome of duodenal impassibility

6. The syndrome of segmental portal hypertension.

Among instrumental diagnostic methods the following have the most valuable: US-scanning,

CT-scanning, angiography.

By ultrasound pancreatic pseudocysts are imaging as “cavity” sign. It is the lower acoustic

density zone. The “ripe” pancreatic cysts have correct round form with sharp regular borders and

homogeneous contents. The density of cyst capsule is more then surrounding tissue. In cases of

”unripe” pancreatic cysts the capsule isn’t sharp, there contents isn’t homogeneous, there are some

debrises, flakes.

US-scanning gives possibility to diagnose not only pancreatic cyst presence, but to find some

complications, first of all - obstructive jaundice. The signs of it the bile tree dilation, gallbladder

enlargement are.

In according cyst site and size it can displace surrounding organs, first of all - the stomach and

the duodenum. It can leads to acute or chronic duodenal impassibility. By ultrasound it will be

imaged by stomach distension with changed peristalsis. More rare pancreatic cysts can press the

main pancreatic duct with its dilation in distal part of the pancreas. This duct can be found

confidently by ultrasound till the cyst wall. The minimal cyst size can be found is 10-15 mm.

Difficulties can be in initial period of their formation due to the inflammatory debrises presence in

it.

There are no strict differential signs between benign and malignant pancreatic cysts, so great

importance is belonged to thin needle biopsy of the formation under US-control.

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The “cavity” is one of the most important sign in CT-scanning. CT-scanning permits not only

determinate the fact of cavity presence, but to research its localization and peculiarities of its

structure. The contents of pancreatic cysts have very low density, so CT can find them confidently.

Pancreatic cysts have stable, constant angiography picture. Large cysts lead to displace of

visceral arteries till celiac trunk. In addition, there are vasselloss areas in the pancreas. The method

can be recommended for topical diagnose of large formations, suspected going out from the

pancreas.

X-Ray examination can give only indirect signs of volume lesion of the pancreas without

different diagnose between pancreatic cyst, chronic pseudotumorose pancreatitis and tumor.

Treatment

There are no common treating tactics in cases of pancreatic cysts. It is depended on such factors,

as cyst wall condition, cyst contents, changes of other pars of the pancreas and surrounding organs.

In plan order the most important factor the cyst wall condition is. There are 4 stages of

pancreatic cyst formation.

1 stage /duration first 1,5 month - the cyst hasn’t yet formed from destructive cavity in omental

burs. There are indications for conservative therapy of acute pancreatitis only.

2 stage /2-3 months after cyst formation/ - the cyst walls are presented by friable granular tissue.

The operation isn’t indicated except cases of any complications appear. In that cases /suppurative

inflammation, pain pressing syndrome/ the external drain procedure should be used only.

3 stage /3 month - 1 year/ - the cyst wall is durable. There are possibilities for traditional

external or internal drain procedures

4 stage /later 1 year/ - in this stage there are clear borders of the cyst and surrounding tissues.

Cystectomy or some sorts of internal drainage procedure can be used.

Thus, in that way the choice of fit time for surgical management is based on balance between

the wish of radical treatment after disappearance of acute inflammatory changes in the pancreas and

aspiration procedures immediately for prophylaxis future complications. It is important, that about

30% of postnecrotic infiltration and acute postnecrotic pancreatic cysts may be cured under

influence of conservative therapy.

One of the modern modes for surgical correction of postnecrotic pancreatic cysts the transskinal

diapeutic method is. It includes the transskinal puncture of the cyst under US-or CT-control with

cytological, biochemical, microbiological examination of the aspirate. Then, transskinal external

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drainage procedure of the cyst can be used. In cases of absence the communications between the

cyst and the main pancreatic duct sclerosing therapy of the cyst can be realized. Sometimes it is

possible to create the transskinal cystogastro- or cystoduodenal anastomoses under US and

endoscopic control.

The principles of surgical correction

In cases of pancreatic pseudocysts important role belongs to forced palliative surgical

procedures of external cyst drainage. This mode is the only in patients with complicated

development of pseudocysts. It can be realized by traditional way or by noninvasive techniques

under US and CT control.

In cases of large intrapancreatic pseudocysts in proximal part of the pancreas with stomach

union it is more expediency to create internal drainage by gastrocystostomy.

The more universal operation the cystointestinal anastomoses are. They are indicated in cases of

“ripe” extra- or intrapancreatic pancreatic cysts with proximal localization.

In cases of pancreatic cysts accompanied with the main pancreatic duct dilation it is more

expediency the creation of longitudinal pancreaticocystointestinal anatomy.

In cases of distal pancreatic pseudocysts it is more effective to use the distal partial pancreas

resection, which can be aided by pancreatointestinal stomy if there is intraductal hypertension.

The resection of the pancreas is the choice-operation in cases of unsuccessful of primary

palliative or radical operation.

In cases of retentional pancreatic cysts the primary external cyst drainage can lead to stable

pancreatic fistula formation. So, different modes of internal drainage are indicated.

TEST QUESTIONS

1. According Howard classification there are following types of pseudocysts of the pancreas except

Inflammatory

Posttraumatic

tumorous cysts @

Idiopathic

Dermoidal cysts@

2. Pseudocysts of the pancreas are charactezised first of all by

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epithelium mucose absence @

presence of some complications

large size

3. More often pancreatic pseudocysts can be complicated by

perforation into abdominal cavity @

bleeding into it @

malignant transformation

suppuration @

4. Enough indication for surgical management in cases of pancreatic cysts is

pancreatic cyst presence @

presence of some complications

cyst size more then 4 cm

5. Clinical picture of pancreatic cysts includes following syndromes except

The pain syndrome.

The clinical syndrome of extracrinal insufficiency.

The syndrome of endogenic intoxication @

The syndrome of endocrinal insufficiency.

The syndrome of bile congestition.

The syndrome of duodenal impassibility

Angina abdominal @

The syndrome of segmental portal hypertension.

6. The syndrome of endocrinal insufficiency in patients with pancreatic pseudocysts is

characterized by following

diabetes millitens @

hypergastrinemia

hyperaldosteronism

decrease the sugar tolerance test @

7. The most valuable direct diagnostic information in patients with pancreatic cysts can be reached

by following methods, except

US- scanning @

RPCG

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X-Ray examination

CT-scanning @

Angiography @

Laparoscopy

8. Some sorts of cystointestinal anastomoses are indicated in

1 stage of pancreatic cyst formation

2 stage of pancreatic cyst formation

3 stage of pancreatic cyst formation @

4 stage of pancreatic cyst formation @

9. Temporary external pancreatic cyst drainage is indicated in

never

all cases of suppurative cyst complications @

3 stage of uncomplicated pancreatic cyst formation

4 stage of uncomplicated pancreatic cyst formation

10. Some possibilities for traditional surgical internal drainage procedures in patients with

panceatic pseudocysts at first are appearing in

1 stage of pancreatic cyst formation

2 stage of pancreatic cyst formation

3 stage of pancreatic cyst formation @

4 stage of pancreatic cyst formation

11. Correct the following expression “The more universal treating mode in patients suffered from

pancreatic pseudocysts the cystointestinal anastomoses are. They are indicated in cases of “unripe”

extra- or intrapancreatic pancreatic cysts with proximal localization.”

12. The partial resection of the pancreas is indicated in

pancreatic pseudocysts of proximal localization

pancreatic pseudocysts of distal localization @

pancreatic pseudocysts with size more then 4 cm

pancreatic pseudocysts of 1-2 stage formation

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