Is it possible to minimize the risk of immediate complications of pancreatoduodenal resection in patients with pathology of the pancreatic head, complicated with the syndrome of obstructive jaundice?

Abstract

Background. The issues of predicting and finding ways to avoid the origin of intraand early postoperative complications in patients with focal diseases of the biopancreatoduodenal area complicated by mechanical jaundice, reducing perioperative mortality in this challenging category of patients remain very relevant. The purpose of the work is to determine the optimal measures of the immediate results of pancreatoduodenal resection improving in patients with focal diseases of the biliopancreatoduodenal area complicated by mechanical jaundice. Materials and methods. The study reveals the analysis of the results of surgical treatment of 272 patients with focal pathology of the biliopancreatoduodenal area complicated by mechanical jaundice syndrome. Oncopathology of the biliopancreatoduodenal zone was diagnosed in 101 (90.2 %) patients of the main group and 117 (73.1 %) patients of the comparison group. Chronic pseudotumoral pancreatitis was detected in 11 (9.8 %) patients of the main and 43 (26.9 %) patients of the comparison group. The first (main group) included 112 patients who underwent risk modelling and preoperative preparation according to the original algorithm by performing mathematical modelling and genetic analysis involving conservative measures of detoxification and decompression of the biliary tract. The comparison group is represented by 160 patients prepared only by conservative therapy, and decompression of biliary hypertension was not performed. Results. Assessing the quality of preoperative care was guided by the dynamics of changes in the mental status of patients, indicators of cytolytic and cholestatic syndromes. According to the original algorithm, more significant positive changes were achieved in the main group than the comparison group due to the preoperative preparation. The number of points on the MoCA scale before surgery in the main and comparison groups was 24.9 ± 3.2 and 22.8 ± 2.4, respectively. According to the results of the DSST test, patients were distributed as follows – 40.2 ± 3.8 and 23.6 ± 2.6 points in the main and comparison groups (p < 0.05). We compared the dynamics of the level of total bilirubin. Significant differences began to be observed from the third day – 185.1 ± 2.4 μmol/l against 258.4 ± 2.9 μmol/l, on the fifth day – 163.2 ± 2.6 μmol/l against 222.2 ± 3.8 μmol/l, and finally on the eve of surgery – 112.3 ± 2.7 μmol/l against 198.3 ± 3.3 μmol/l in patients of the main group and the comparison group, respectively (p < 0.05). We assessed the dynamics of ALT activity under conditions of different types of preoperative care. We found that on the seventh day the differences persisted, gained reliability and amounted to 119 ± 12 U/l and 157 ± 14 U/l in the main group and in the comparison group, respectively (p < 0.05). The difference in the levels of AST activity between the compared groups became significant and began to gain reliability from the 5th day 124 ± 13 U/l against 150 ± 11 U/l in the main and comparison groups, respectively (p < 0.05). On the eve of surgery (PDR), the difference between the indicators of ASTactivity was also significant – 81 ± 7 U/l against 114 ± 7 U/l in the main group and the comparison group, respectively (p < 0,05). Regarding AP levels, on the 3rd day of observation its content in both groups decreased to 440.9 ± 2.1 and 550.7 ± 1.4 U/l (p < 0.05). On the 5th day of observation, the values of the indicator were even smaller, and in the main group there was a more significant decrease in the activity of AP (up to 223.2 ± 2.7 U/l) compared with the comparison group (up to 350.3 ± 1.1 U/l) (p < 0.05). Finally, on the eve of PDR, the activity of AP was 104.8 ± 1.3 U/l in the main group, and 270.8 ± 1.9 U/l in the comparison group (p < 0.05). The differences in GGT activity became more significant on the 5th day – 403 ± 29 U/l against 446 ± 35, and gained reliability on the 7th day – 304 ± 21 U/l against 374 ± 26 U/l in the main group and the comparison group, respectively. (p < 0.05). On the eve of the PDR, a further decrease in the indicator retained its reliability of 271 ± 29 U/l in the main group against 348 ± 33 U/l in the comparison group (p < 0.05). The number of life-threatening postoperative complications in the main group was 42 (37.5 %) cases, and in the comparison group – 102 (63.8 %) cases. Thus, in terms of the frequency of postoperative complications, the comparison group was significantly ahead of the main one (c2 = 18.22 df = 1 p < 0.0001). Postoperative mortality in the main group was 6.3 %, and in the comparison group – 11.9 %. Conclusions. One of the main ways to prevent postoperative complications is a clear stratification of risk factors taking into account the main parameters of the pathological condition of patients with mechanical jaundice in the preoperative stage, which is possible through the combined use of mathematical modelling and unique laboratory and instrumental methods – genetic analysis and ultrasound elastography.