Introducere: Deși cu incidențã rarã, pseudoanevrismul pancreatic hemoragic(PPH) este încã o complicație potențial letalã.
Mortalitatea poate atinge 40%, dependentã de statutul pacientului, morfopatologia leziunii hemoragice æi de procedeele chirurgicale
utilizate [1]. Tratamentul optimal al PPH asociat cu pancreatitã cronicã rãmâne controversat, studiile preventive confirmând
eficacitatea arterioembiolizãrii sau intervenåiilor clasice ca metode de control a hemoragiei [2,3,4]. Din cauza seriilor limitate de
bolnavi raportate încã nu existã careva ghiduri care ar standardiza modalitãåile de rezolvare a PPH. Acest studiu descrie experienåa
clinicii în tratamentul pacienåilor cu PPH pe o perioadã de 6 ani.
Material æi metode: În perioada 2014-2020 6 pacienåi au fost trataåi pentru hemoragie din PPH trataåi în clinica de Chirurgie nr.1
„Nicolae Anestiadi” (baza clinicã IMU, Chiæinãu): toåi(100%) fiind bãrbați; vârsta – 41±7,6 ani. Pacienåii au prezentat: HDS –
4(66,67%), peritonitã – 1(16,67%), HDI – 1(16,67%), hepatitã toxicã în asociere cu icter mecanic – 1(16,67%), hemoperitoneum
– 1(16,67%), masã palpabilã în epigastru – 3(50%) etc. Ca æi factori predispozanåi ai pancreatitei cronice au fost: abuzul de
alcool(6), HDS repetate (3), hepatitã (4), inclusiv antecedente narcologice(1), litiaza biliarã(1).
Rezultate: Pseudoanevrismul pancreatic a fost stabilit preoperator doar la 2(33,33%) pacienåi în baza AngioCT, în 2 cazuri
endoscopic s-a suspectat cancer gastric cu recidivã a hemoragiei, diagnosticul definitiv fiind precizat intraoperator. Toåi pacienåii au
fost supuæi tratamentului chirurgical: de urgenåã imediatã – 4(66,67%) pentru recidivã hemoragicã incontrolabilã din ulcer-cancer
gastroduodenal sau peritonitã, de urgenåã amânatã – 2(33,33%) dupã tentativa de a confirma angiografic sursa hemoragicã æi
intenåie de embolizare æi pregãtire preoperatorie. Intervenåiile chirurgicale: duodenopancreatectomie cefalicã (1), gastrectomie
paråialã (2), rezecåia paråialã a pseudoanevrismului, splenectomie æi drenarea externã a pseudochistului (2), pancreatectomie
caudalã, splenectomie æi rezecåia unghiului lienal al colonului (1). Ca æi hemostazã în toate cazurile s-a practicat sutura fistulei
vasculare (6) cu originea din: trunchiul celiac (1), a.pancreatoduodenalã (2), a.lienalã (2), a.mesenterica superioarã (1). Angiografia
a fost utilizatã doar într-un caz pentru confirmarea diagnosticului, dar nu a avut final în hemostazã din cauza lipsei experienåei în
embolizarea fistulei vasculare cu origine din a.mezentericã superioarã. Perioada postoperatorie a evoluat grav, dar favorabil în toate
cazurile, fãrã cazuri de deces.
Concluzii: Gestionarea pseudoaneurismelor pancreatice hemoragice rãmâne o provocare pentru clinicieni. Angiografia este
valoroasã în localizarea acestora æi obåinerea hemostazei prin embolizare. În aceastã serie limitatã, pacienåii cu pseudoaneurism
hemoragic asociat cu pancreatitã cronicã trataåi prin intervenåie chirurgicalã par sã obåinã rezultate bune. Cu toate riscurile procedeul
chirurgical de elecåie trebuie sã fie unul agresiv în asigurarea hemostazei definitive æi soluåionarea patologiei de bazã, iar chirurgul
în urgenåe sã dispunã de suficientã experienåã pentru a asigura amploarea intervenåiei chirurgicale.

Introduction: Bleeding pancreatic pseudoaneurysm(BPP) is a rare, but potentially lethal complication. Mortality rate may reach 40%
depending on the patient`s status, morphology of the lesion and surgical procedures [1]. The optimal treatment of BPP in chronic
pancreatitis remains controversial, preliminary studies confirming the efficacy of arterial embolisation or classic interventions for
bleeding control [2,3,4]. Due to limited number of reported cases there exist no guidelines for standard BPP management. This
report describes a 6 year experience of BPP patients in our clinic.
Material and methods: During 2014-2020 6 patients were treated for BPP within Clinic of Surgery nr.1 „Nicolae Anestiadi” (IMU,
Chiæinãu): all(100%) male; age – 41±7.6 years. Patients presented with: upper GI bleeding – 4(66.67%), peritonitis – 1(16.67%),
lower GI bleeding – 1(16.67%), toxic hepatitis with obstructive jaundice – 1(16.67%), hemoperitoneum – 1(16.67%), epigastric
mass – 3(50%) etc. Predisposing factors for chronic pancreatitis: alcohol abuse(6), repeated upper GI bleeding(3), hepatitis(4),
history of drug addiction(1), cholelithiasis(1).
Results: Pancreatic pseudoaneurysm was found preoperatively in 2(33.33%) cases at AngioCT, in 2 patients endoscopically gastric
cancer with rebleeding was presumed, the final diagnosis being established intraoperatively. All patients underwent surgical
treatment: immediate – 4(66.67%) for uncontrolled recurrent bleeding from gastroduodenal ulcer-cancer or peritonitis, delayed
surgery – 2(33.33%) after attempt of preoperative preparation and angiographic confirmation of the bleeding source and
embolisation. Surgical interventions: cephalic duodenopancreatectomy (1), partial gastrectomy (2), partial pseudoaneurysm
resection, splenectomy and external drainage of the pseudocyst (2), caudal pancreatectomy, splenectomy and splenic flexure colon resection (1). For hemostasis vascular fistula suture was performed(6) which originated from: celiac trunk(1), a.pancreatoduodenalis
(2), a.lienalis (2), a.mesenterica superior (1). Angiography was used in one case only for diagnosis, but didn`t end up with
hemostasis due to lack of experience of vascular fistula originating from amesenterica superior embolisation. Postoperative period
had severe evolution, but with favorable outcome, without mortality.
Conclusions: Management of bleeding pancreatic pseudoaneurysm represents a challenge for surgeons. Angiography is a valuable
tool for diagnosis and hemostasis by embolisation. In this limited case series patients with bleeding pancreatic pseudoaneurysm in
chronic pancreatitis, treated surgically seem to have good results. With all the potential risks the surgical procedure should be
aggressive for definitive hemostasis and resolution of the primary disease, while the surgeon in emergency should have enough
experience and skills in order to perform such extensive surgery.

References
1. Balachandra S, Siriwardena AK: Systemic appraisal of the management of the major vascular complications of pancreatitis. Am
J Surg. 2005, 190: 489-495. 10.1016/j.amjsurg.2005.03.009.
2. Gambiez LP, Ernst OJ, Merlier OA, Porte HL, Chambon JPM, Quandalle PA: Arterial embolization for bleeding pseudocysts complicating
chronic pancreatitis. Arch Surg. 1997, 132: 1016-1021
3. Beattie GC, Hardman JG, Redhead D, Siriwardena AK: Evidence for a central role for selective mesenteric angiography in the
management of the major vascular complications of pancreatitis. Am J Surg. 2003, 185: 96-102. 10.1016/S0002-
9610(02)01199-6
4. Bergert H, Hinterseher I, Kersting S, Leonhardt J, Bloomenthal A, Saeger HD: Management and outcome of hemorrhage due to
arterial pseudoaneurysms in pancreatitis. Surgery. 2005, 137: 323-328. 10.1016/j.surg.2004.10.009.

resection (1). For hemostasis vascular fistula suture was performed(6) which originated from: celiac trunk(1), a.pancreatoduodenalis
(2), a.lienalis (2), a.mesenterica superior (1). Angiography was used in one case only for diagnosis, but didn`t end up with
hemostasis due to lack of experience of vascular fistula originating from amesenterica superior embolisation. Postoperative period
had severe evolution, but with favorable outcome, without mortality.
Conclusions: Management of bleeding pancreatic pseudoaneurysm represents a challenge for surgeons. Angiography is a valuable
tool for diagnosis and hemostasis by embolisation. In this limited case series patients with bleeding pancreatic pseudoaneurysm in
chronic pancreatitis, treated surgically seem to have good results. With all the potential risks the surgical procedure should be
aggressive for definitive hemostasis and resolution of the primary disease, while the surgeon in emergency should have enough
experience and skills in order to perform such extensive surgery.

References
1. Balachandra S, Siriwardena AK: Systemic appraisal of the management of the major vascular complications of pancreatitis. Am
J Surg. 2005, 190: 489-495. 10.1016/j.amjsurg.2005.03.009.
2. Gambiez LP, Ernst OJ, Merlier OA, Porte HL, Chambon JPM, Quandalle PA: Arterial embolization for bleeding pseudocysts complicating
chronic pancreatitis. Arch Surg. 1997, 132: 1016-1021
3. Beattie GC, Hardman JG, Redhead D, Siriwardena AK: Evidence for a central role for selective mesenteric angiography in the
management of the major vascular complications of pancreatitis. Am J Surg. 2003, 185: 96-102. 10.1016/S0002-
9610(02)01199-6
4. Bergert H, Hinterseher I, Kersting S, Leonhardt J, Bloomenthal A, Saeger HD: Management and outcome of hemorrhage due to
arterial pseudoaneurysms in pancreatitis. Surgery. 2005, 137: 323-328. 10.1016/j.surg.2004.10.009.