TREATMENT OF PATIENTS WITH EXTERNAL PANCREATIC FISTULAS AFTER PERCUTANEOUS DRAINAGE INTERVENTIONS OF PANCREATIC PSEUDOCYSTS

Introduction. External pancreatic fistulas are developed up to 45 % during the postoperative period after the percutaneous drainage of pancreatic pseudocysts. According to some authors this fact is the main contraindication for using of transcutaneous method in  treatment of these patients.

The objective is to optimize the tactics of treatment for minimizing the possible development of external pancreatic fistulas

Materials and methods. Puncture-draining operations were performed in 164 patients with chronic pancreatic pseudocysts. Puncture operations with ultrasound control were primarily performed in 54 patients (32.9 %), they were effective for 29 patients (53.7 %). Traditional surgical interventions were performed in 7 patients (12.9 %) from this group. Percutaneous drainage of pseudocyst was secondary used in 18 patients (33.4 %). Percutaneous drainage of pseudocysts was primarily used in other group consisting of 110 (67.1 %) patients. During the postoperative period, external pancreatic fistula formed in 36 (32.7 %) patients from this group. The fistulas were eliminated by supplementing the transcutaneous interventions with endoscopic methods.

Results. Endoscopic papillosphincterotomy was performed in 36 patients. Pancreatic fistulas were closed after the operation in 12 patients (33.3 %). Endoscopic formation cystogastro-, cystoduodenoanastomosis on «lost drainage» were performed in 9 patients (25 %). Temporary decompression transpapillary stenting of the MPD was performed in 15 patients (41.7 %), endoscopic retrograde stenting was performed in 5 of them. Antegrade stenting of the MPD was transcutaneously performed in 10 patients. There were no lethal outcomes. Fistulas regressed in all patients. Recurrence of cyst formation, pancreatic hypertension were not be to dynamic examinations. Algorithm of treatment was formed and based on the results of a retrospective analysis to treatment of pancreatic cysts in general surgical clinic of «Pavlov First Saint Petersburg State Medical University».

Conclusions. Coherent combining of minimally invasive technologies in the treatment of patients with chronic pancreatic pseudocysts leads to good results: absolute cystic regression and elimination of pancreatic fistulas as appropriate.

1. M. Larsen, R. Kozarek. Management of pancreatic ductal leaks and fistulae. Journal of Gastroenterology and Hepatology 29 (2014) 1361–1370, DOI:10.1111/jgh.12574

2. A. Tyberg, K. Karia, M.Gabr, A.Desai. Management of pancreatic fluid collections: A comprehensive review of the literature. World J Gastroenterol2016 February 21; 22(7): 2256-2270, DOI: 10.3748/wjg.v22.i7.2256

3. E. Zerem, G. Hauser, S. Loga-Zec, S. Kunosić, P. Jovanović, D. Crnkić. Minimally invasive treatment of pancreatic pseudocysts World J Gastroenterol2015 June 14; 21(22): 6850-6860, DOI: 10.3748/wjg.v21.i22.6850

4. M.M. Lerch, A. Stier, U. Wahnschaffe, J. Mayerle. Pancreatic Pseudocysts: Observation, Endoscopic Drainage, or Resection? Dtsch Arztebl Int 2009; 106(38): 614–621, DOI: 10.3238/arztebl.2009.0614

5. Q.Guo, A. Li, W. Hu. Predictive factors for successful ultrasound-guided percutaneous drainage in necrotizing pancreatitis, SurgEndosc, Publ. online, Oct. 2015, DOI 10.1007/s00464-015-4579-x

6. Timoshin A.D., Shestakov A.L., Jurasov A.V. Maloinvazivnye vmeshatel’stva v abdominal’noj hirurgii [Minimally invasive interventions in abdominal surgery] Moscow: TriadaH, 2003. 216p.

7. Grishin I.N., Gric V.N., Lagodich S.N. Kisty, svishhipodz heludochnojzhelezyiihoslozhnenija [Cysts, fistulas of pancreas and their complications] Minsk: High school, 2009. 272 p.

8. Rebrov A.A., Semenov D.YU., Vasil’ev V.V., Gunya Z.A., Mel’nikov V.V., Vaganov A.A. Chreskozhnye vmeshatel’stva v lechenii bol’nyh psevdokistami podzheludochnoj zhelezy [Percutaneus interventions in patients patients with pancreatic pseudocyst]. Annaly hirurgicheskojgepatologii. 2017; 22 (1): 49-55

9. S. Tenner , J. Baillie, J. DeWitt , S. Swaroop Vege, American College of Gastroenterology Guideline: Management of Acute Pancreatitis. Am J Gastroenteroladvance online publication, 30 July 2013; DOI: 10.1038/ajg.2013.218