THE KURSK STATE MEDICAL UNIVERSITY
DEPARTMENT OF SURGICAL DISEASES № 1
BENING PANCRESTIC DISEASE
Information for self-training of English-speaking students
The chair of surgical diseases N 1 (Chair-head - prof. S.V.Ivanov)
BY PROFESSOR O.I. OCHOTNICKOV
KURSK-2010
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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
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 Immune and allergical factors
 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
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lead to papilla Vatery spasm, and bile is pouring into pancreatic ducts. Then more big
stone leads to impassability of papilla Vatery.
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.
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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.
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.
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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.
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
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 Probably, preservation of pancreatic function
Of cause, surgical procedures cann’t cure the disease, but they are stopping their
development.
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,
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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.
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
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method has very strict indications. The most important condition for it - severe fibrose
transformation of the pancreas.
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
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 Retention of pancreatic juice with intraductal pressure increase due to protein
precipitation in it.
 Spastic influence to pancreatic vessels @
 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
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9. Instrumental diagnose of chronic pancreatitis includes the following most valuable
methods:
 US- scanning @
 CT-scanning @
 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 @
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 Probably, preservation of pancreatic function @
14. Direct radical surgical procedures on the pancreas are following, except
 pancreatic resection
 cryodestroying of the pancreas @
 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
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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.
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.
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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.
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:
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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 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.
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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.
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.
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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
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 @
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 Idiopathic
 Dermoidal cysts@
2. Pseudocysts of the pancreas are charactezised first of all by
 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 @
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7. The most valuable direct diagnostic information in patients with pancreatic cysts can be reached
by following methods, except
 US- scanning @
 RPCG
 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
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 pancreatic pseudocysts of 1-2 stage formation