Aim. To evaluate an effectiveness of various surgical methods for pancreatic pseudocysts complicated by bleeding.

Material and Methods. The results of surgical treatment of 31 patients with pancreatic pseudocysts complicated by bleeding (false aneurysm type I) were presented. Patients were divided into two groups depending on surgical treatment: group 1 (15 patients) – laparotomy, intraoperative hemostasis and external drainage of pancreatic pseudocyst; group 2 (16 patients) – selective angiography with vascular embolization followed by US-assisted external percutaneous drainage of pancreatic pseudocyst.

Results. An effectiveness of various surgical techniques was assessed by the incidence of severe sepsis and mortality rate. There were no cases of severe sepsis and lethal outcomes after minimally invasive treatment while in the 1st group severe sepsis developed in 33,3% (5 patients), mortality was 20,0% (3 patients).

Conclusion. Minimally invasive measures are optimal for pancreatic pseudocysts complicated by bleeding. Laparotomy is advisable if minimally invasive interventions are impossible due to various reasons. 

Aim. To analyze the causes of bleeding in chronic pancreatitis patients and efficacy of different hemostatic techniques.

Material and Methods. The study included 632 patients with chronic pancreatitis operated in 1981–2016. Pancreatic pseudocysts were observed in 404 cases (63.9%), bleeding – in 70 cases (17.3%). Conventional surgical treatment was applied in 49 cases (group 1), endovascular approach was used for 21 patients and 10 of them underwent additional surgery in the future (group 2). Bleeding into cyst’s cavity was in 22 patients (31.4%); cyst wall rupture followed by bleeding into gastrointestinal tract – in 30 (42.8%), into abdominal cavity – in 10 (14.3%), into retroperitoneal space – in 6 (8.6%), into pleural cavity – in 2 (2.8%) cases.

Results. In group 1 18 (36.8%) patients underwent conventional surgical ligation of the vessels, drainage and tamponade of the pseudocyst; 8 (17.0%) patients – external drainage of pancreatic duct; 7 (14.5%) – vessel ligation followed by longitudinal pancreatojejunostomy; 8 (15.5%) – distal pancreatectomy; 2 (4.1%) – pancreatoduodenectomy; 2 (4.1%) – middle pancreatectomy; 4 (8.1%) – splenic artery ligation, splenectomy and external drainage of the pseudocyst. 4 patients with severe bleeding died in this group. Endovascular approach was applied in 21 cases of the 2nd group: embolization of splenic artery – in 11 (52.4%) cases, gastroduodenal artery – in 7 (33.3%) cases, gastroduodenal arch – in 3 (14.3%) cases. In 11 (52.4%) cases isolated false aneurysm embolization was performed. In another 10 (47.6%) cases endovascular approach was combined with open surgery. 1 (4.7%) patient died from severe posthemorrhagic complications and delayed endovascular treatment. Overall mortality due to hemorrhagic complications was 7.1%.

Conclusion. Hemorrhagic complications developed in view of exacerbation of chronic pancreatitis. Surgical tactics was aimed at hemostasis, elimination of ductal hypertension and drainage of pseudocyst. Endovascular treatment is the most reliable that however does not exclude subsequent open pancreatic surgery. Minimally invasive drainage of ducts and pseudocysts was also useds.

Methods. The results of endovascular hemostasis in 42 patients with pancreatic bleeding are presented. The causes of bleeding were complications after pancreatic surgery in 8 patients, acute pancreatitis in 6 patients, chronic pancreatitis in 27 patients and pancreatic tumor in 1 case. 19 patients had gastrointestinal bleeding including hemorrhage into postnecrotic cyst in 7 patients, retroperitoneum – in 2 cases, abdominal cavity – in 6 patients, postoperative wound – in 2 cases. 6 patients had combined variants of bleeding.

Results. Bleeding source was detected by computed tomography and angiography in all patients. Technical success was achieved in 42 patients. 2 patients had recurrent bleeding in remote period due to vascular arrosion distal to covered stent with preserved collateral blood flow. Repeated embolization had stopped the bleeding in both cases.

Conclusion. Endovascular embolization is effective treatment of pancreatic bleeding. Proper organization of the treatment requires hospitalization into specialized centers.

Aim. To analyze incidence, diagnosis and treatment of postpancreatectomy hemorrhage (PPH).

Material and Methods. 318 patients after pancreatectomy were analyzed. There were 223 interventions for pancreatic tumor and 95 cases of chronic pancreatitis. Perioperative care was held by ERAS protocol. PPH occurred in 32 cases (10.1%) including 24 patients with pancreatic tumor and 8 patients with chronic pancreatitis. 5 patients had early PPH, 27 – late bleeding. In 19 cases PPH was intraperitoneal, 11 – intraluminal, combined – 2. Besides clinical examination transabdominal ultrasound, computed tomography and endoscopy were used for diagnosis.

Results. Conservative haemostatic therapy was used in 6 patients. In 17 patients re-laparotomy was done, 3 of them had recurrent PPH subsequently. Endovascular treatment was carried out in 11 cases, 2 of them had previous re-laparotomy. Recurrent PPH after endovascular procedure was observed in 2 cases. 5 patients (15,6%) died.

Conclusion. PPH is the most dangerous complication after pancreatectomy. Instrumental diagnosis and treatment strategy should be used according to patient’s status and severity of PPH. Endovascular procedures are preferred. Re-laparotomy should be done for profuse PPH with hemodynamic instability and for revision after endovascular procedure for intraperitoneal PPH. 

Aim. To analyze the survival of liver cirrhosis patients and to assess the effectiveness of endoscopic interventions to prevent bleedings of portal genesis.

 Material and Мethods. The study included 449 liver cirrhotic patients with portal hypertension and bleeding from gastroesophageal varices. All patients were divided into 2 groups. The main group included 239 patients for the period 2010–2015 and the control group – 210 patients for the period 1996–2010.

 Results. There were 33 (27%) patients without recurrent variceal bleeding after endoscopic interventions in the control group and 64 (54.2%) patients in the main group. These values were 32.4% (45) and 109 (61.6%) respectively in case of staged approach including endoscopic hemostasis followed by portosystemic bypass. Long-term recurrence-free period was observed in 40.7% (33) cases of the control group and in 68.1% (64 of 94) cases of the main group after endoscopy. In case of endoscopic interventions followed by portosystemic bypass recurrence was absent in 45.9% (45 of 98 patients) and 71.2% (102 out of 153 patients) in both groups respectively. Conservative therapy alone was effective only in 3 (10.7%) cases to prevent recurrent bleeding that determines its low therapeutic ineffectiveness.

Conclusion. Modern possibilities of endoscopic technologies have significantly improved treatment and prevention of variceal bleeding. Staged application of endoscopy and portosystemic decompression improves 1-year survival from 80% to 88% and 3-year survival from 42% to 64%. 

Aim. To evaluate safety of perioperative regional chemotherapy in combined treatment of ductal adenocarcinoma of the pancreatic head.

 Material and Methods. 53 patients underwent neoadjuvant regional chemotherapy, R0-surgery and adjuvant regional chemotherapy courses. Regional chemotherapy was performed by administration of gemcitabine in a suspension of lipiodol into gastroduodenal artery that was supplemented by oxaliplatine infusion. After that complete blood cell count, biochemical and coagulation examination were made. Toxicity evaluation was conducted according to Common Toxicity Criteria. Postoperative complications, hospital-stay in groups of combined therapy (group A) and isolated surgery (group B) were compared.

Results. There were no complications after angiography and catheterization. Postembolization syndrome arose in 10 (18.8%) patients, hematologic toxicity – in 13 (24.5%) cases (Common Toxicity Criteria score 1–2). Anemia was observed in 5 (9%) patients, neutropenia – in 2 (4%) and trombocytopeniya in 1 case. Nausea appeared in 11 (20.7%) patients, vomiting – in 10 (18.8%) cases. Postoperative complications in group A occurred in 20 (38%) cases, in group B – in 20 (37%) cases. Incidence of postoperative complications was similar in both groups. Mean hospital-stay was 18 days in group A and 16 days in group B. At the stage of adjuvant chemotherapy toxic effects were rare and did not require reducing the dose or abrogation of the drug.

 Conclusion. Regional chemotherapy with gemcitabine and oxaliplatin may be considered safe stage in combined treatment of pancreatic head adenocarcinoma. Further investigations are necessary to assess an effectiveness of treatment.

Aim. To determine surgical tactics and principles of preferential surgical intervention for chronic calculous pancreatitis based on assessment of results of various approaches and methods of surgical correction.

Material and Methods. Since January 1989 till March 2016 475 patients were treated. There were 234 draining, 15 resection-draining operations and 14 resections. In 174 patients (36.6%) 2 or more operations were executed due to ineffective primary intervention.

Results. Two patients died after draining operations. After draining operations the incidence of early and long-term postoperative complications was 10.3% and 23.9% respectively, after resection-draining operations – 6.7% and 13.3%; after resections – 21.4% and 78.6%. Obstructive jaundice was not observed after resection-draining operations. One patient had pancreatic diabetes and recurrent abdominal pain. Topographic and anatomical features of calculous pancreatic changes were established. Ductal hypertension is accompanied by its enlargement in 75.9% of patients. Pancreatic stones are predominantly localized in glandular head along anterior surface. Virsungolithiasis was noted in 20–25% of patients.

Conclusion. Parenchyma-sparing interventions are more effective compared with resections. In our opinion, the most advisable surgery for chronic calculous pancreatitis are resection-draining operations including longitudinal pancreaticocystojejunostomy by Frey’s procedure type supplemented by contact ultrasound lithotripsy. It is suggested clinical classification of chronic calculous pancreatitis that should be kept in mind to determine surgical tactics. 

Aim. To study pancreatic changes in acute pancreatitis with internal pancreatic fistula and to assess the results of retroperitoneoscopic sanations for this pathology.

 Material and Methods. Contrast-enhanced CT was made in 30 patients. Localization and depth of necrosis were evaluated in sagittal, axial and coronal sections. Swelling and infiltration of retroperitoneal fat up to pelvic floor aperture were the criteria for evaluating severity of retroperitoneal fat lesion. All patients were divided into two groups. The first group included 15 patients with pancreatic head or isthmus necrosis and viable parenchyma of body and tail who underwent retroperitoneoscopic drainage of retroperitoneal fat in 4–5 hours after disease onset. The second group consisted of 15 patients with various forms of pancreatic necrosis who were operated only at the stage of infected pancreatic necrosis.

 Results. In the first group hospital-stay was 45 ± 5.3 days. External pancreatic fistula was observed in all patients that was closed within 4.8 ± 1.1 months after surgery. Deaths were absent. Postoperative ventral hernia was not observed. Pancreatic pseudocysts occurred in 3 (20%) patients. Mean hospital-stay in the second group was 80 ± 5.3 days, mortality rate – 33.3%. External pancreatic fistula formed in 2 (13%) patients, postoperative ventral hernia – in 3 (20%) cases, pancreatic pseudocyst – in 3 (20%) cases.

Conclusion. Contrast-enhanced computed tomography visualizes internal pancreatic fistula and gives information for differentiated surgical approach in acute pancreatitis patients. External drainage of retroperitoneal fat is pathogenetically proved treatment of patients with internal pancreatic fistula and acute severe pancreatitis. 

Aim. To identify the major risk factors of acute postoperative pancreatitis, to determine optimal volume of drug prevention, to study the possibility of intravenous administration of octreotide 600 mcg/ml in transpapillary endoscopic interventions.

Material and Methods. In group I (72 patients) prevention of acute post-manipulation pancreatitis prior to endoscopic transpapillary interventions included intravenous administration of octreotide 600 mcg diluted in 60 ml 0.9% sodium chloride solution (NaCl). On the day of endoscopic intervention octreotide was administered fractionally 200 mcg 3 times per day. In group II (78 patients) acute pancreatitis was prevented by subcutaneous injection of octreotide 100 mcg before endoscopic intervention and subsequent 3-fold subcutaneous injection of 100 mcg on the day of surgery.

Results. Risk factors of acute pancreatitis are young age, difficult cannulation of major duodenal papilla, atypical papillosphincterotomy, contrast injection into pancreatic duct. It is proved that intravenous administration of octreotide 600 mcg/ml reduces the risk of acute pancreatitis and transient hyperamylasemia from 16.7% and 19.2% to 11.1% and 16.7% respectively compared with conventional subcutaneous injection (100 mcg). Thus, it reduces the duration (p < 0.016) and severity of hyperamylasemia (p < 0.005).

Conclusion. Intravenous administration of octreotide 600 mcg/day is more effective and convenient compared with conventional scheme to prevent acute postmanipulation pancreatitis.

Aim. Systematization of experience and improvement of outcomes of minimally invasive biliary drainage surgery for obstructive jaundice.

Materials and Methods. Antegrade biliary drainage surgery was made in 1271 cases including external percutaneous transhepatic cholangiostomy in 977 patients and biliary stenting in 294 patients. 284 (96.6%) patients underwent stenting as the second stage and 10 patients as simultaneous procedure. In 924 (94.6%) patients percutaneous cholangiostomy was performed for malignant tumors, including 667 (72.2%) cases of periampullary tumors, 112 (12.1%) – liver and proximal bile ducts cancer, 135 (14.6%) – progression of other malignancies. In 745 (76.3%) patients percutaneous cholangiostomy was the first stage of treatment. Later on gastropancreaticoduodenectomy was performed in 216 patients and bypasses in 235 patients. Indications for biliary stenting were periampullary tumors in 171 (58.2%) patients, liver and proximal bile ducts cancer in 17 (5.8%) cases and other tumors in 34 (11, 6%) cases.

Results. Complications were observed in 7 (0.7%) patients including 4 cases of procedure-related events. Laparotomy was required in 2 patients. 3 patients developed gastrointestinal bleeding that was stopped conservatively in 2 of them; 1 patient died. 26 (8.8%) patients had complications after biliary stenting including acute pancreatitis in 15 cases and liver failure in 10 patients; 1 patient died from gastrointestinal bleeding. Overall postoperative mortality after percutaneous biliary drainage was 0.16%.

Conclusion. Percutaneous transhepatic biliary decompression is accompanied by comparatively low incidence of complications and mortality. In particular it is caused by improvement of special tools and the use of new materials for endobiliary catheters and stents. More effective use of such high-tech materials and tools requires a certain correction and optimization of treatment approaches

Aim. To evaluate the role of radiological methods in diagnosis and differential diagnosis of cystic transformation of bile ducts and monitoring of operated patients.

Material and Methods. The study included 38 patients with cystic transformation of bile duct aged 25–75 years (mean 41.1 ± 13.5 years). There were 6 (16%) men and 32 (84%) women. Preoperative survey included ultrasound, CT, MRI, ERCP. All patients were operated.

Results. All patients were divided into 2 groups: group 1 consisted of 17 (44.7%) patients with primary disease, group 2 – 21 (55.3%) patients with previous surgery for biliary cysts. Cystic transformation was not eradicated almost in all cases that resulted symptoms in remote period. Computed tomography was excluded from the diagnostic algorithm in view of these data. Therefore, cost and time of examination were reduced. The most effective diagnostic protocol for cystic transformation of bile duct includes ultrasound, contrast-enhanced MRI. These methods cover all necessary diagnostic spectrum and define the diagnosis in almost 98–100% of cases.

Conclusion. An assessment of cystic transformation of bile ducts should include following parameters: cyst type by T. Todani classification, state of its wall and content, relationship with surrounding organs and their structural changes. These parameters are important to choose the right surgical approach. These data should be obtained at preoperative stage. It is essential to begin a survey from non-invasive methods. High risk of long-term postoperative complications and malignant transformation indicates the need for dynamic monitoring of patient after surgery. 

It is presented clinical observation of the patient with cystic pancreatic transformation and von Hippel-Lindau syndrome. The possibilities of molecular-genetic testing for this disease are shown. The observation illustrates the need for detailed clinical examination and molecular genetic testing for cystic pancreatic transformation in young patients without chronic pancreatitis.

It is presented the case report of liver alveococcosis complicated by invasion of inferior vena cava. Right-sided hemihepatectomy with circular resection and replacement of suprarenal inferior vena cava was performed. Synthetic PTFE prosthesis reinforced by rings for better framework function and less possibility of thrombosis was used for inferior vena cava reconstruction. We applied total vascular isolation of liver. Cell Saver was obligatory for autologous blood re-infusion. The severity of post-resection liver failure, biliary complications, postoperative hemorrhage were evaluated by ISGLS criteria. There are no signs of recurrence within follow-up. 

It is presented case report of severe chronic pancreatitis caused by primary hyperparathyroidism with hypercalcemia. State of the woman was complicated by chronic renal failure, bone and nervous system lesion. Comprehensive medical and surgical treatment was made within 2 stages despite a rare combination of diseases that significantly improved patient's state. Case report demonstrates the possibilities of modern diagnosis and surgical treatment of heavy contingent of patients with rare combination of diseases.