Distal Pancreatic Resection Research Articles

HPB O04 - Human Splenic Ex-Vivo Perfusion Model: A Platform for Translational Basic Science Research

Abstract Background The function of the spleen has always been shrouded in mystery and since the Renaissance leading figures have attempted to understand its function. Vesalius questioned Galen and Marcello Malpighi (1628-1694) gave the first accurate description of the histology and the physiology. The spleen still poses unique challenges as invasive approaches may produce intraperitoneal bleeding, differences between human and animal spleens complicates comparative studies, and post-mortem examinations reveal only late-stage disease manifestations and functional studies are impossible. This study describes a human splenic ex-vivo perfusion model for translational research, using microbiological studies as markers of splenic physiological function. Method Patients with left-sided pancreatic cancers scheduled for distal pancreatic and splenic resection were identified from the Hepato-Pancreatic and Biliary MDT at the University Hospitals of Leicester NHS Trust. Patients were informed, consented, and the surgical approach remained standard, with splenic artery ligation deferred until specimen extraction. The artery was cannulated, and residual blood clots were cleared with Custodiol® HTK solution. The perfusion technique employs an extracorporeal circuit incorporateing anoxygenator and a heated water chamber maintaining a 37°C perfusate. The perfused spleen was infected with Streptococcus Pneumoniae strains, with regular biopsies and perfusate gas analysis performed. Results Since February 2023, nine spleens have been successfully perfused, with an average weight of 169.5 grams, cold ischemic time of 116 minutes, and warm ischemic time of 12.2 minutes. Pressure was maintained at 80 mmHg and hourly perfusate gas analysis demonstrated a mean pH of 7.1 and a gradual increase in lactate. Histopathological examination revealed clear distinctions between the lymphoid tissue and splenic red pulp, with intact central arterioles and healthy cell morphology at time 0 and after 6 hours of perfusion. Additionally, the perfused spleens cleared S. pneumoniae strains to below-detection levels. Conclusion Our work demonstrates that a stable human splenic ex-vivoperfusion model which maintains structural and physiological integrity can be achieved from tissue that would otherwise be discarded. The continued physiological function is confirmed by the clearance of S. pneumoniae. While currently employed for microbiological studies, this model has the potential to facilitate a wide range of different translational science studieswhile reducing the need for animal experimentation. The perfusion times employed for the present study were sufficient to demonstrate bacterial clearance which was the aim but there is capacity in the system to significantly prolong the duration.

Risk factors of pancreatic fistula after distal pancreas resections: an observational retrospective study

BACKGROUND: The main complication of surgical pancreas interventions is the pancreatic fistula (PF) — abnormal secretion of pancreatic secretions into the abdominal cavity, which can lead to more severe complications. At the same time, some predictors of PF remain poorly understood. AIM: To investigate the risk factors for the development of PF after distal pancreatic resection. MATERIALS AND METHODS: The study included 40 patients who underwent distal resection. The influence of various clinical parameters on the development of PF after surgery was evaluated. Methods of mathematical modeling and correlation analysis were used. Mathematical modeling was carried out using the Random forest machine learning algorithm, and the indicator of the relative importance of the “importance” parameters was evaluated. RESULTS: According to the Random forest model, on day 1 after surgery, the most significant predictors of the development of PF were: the volume of neoplasm, age and stage of the oncological process, for which “importance” was 53.2, 13.7 and 12.5 (AUC ROC=62%); on day 3–5, “importance” was 61.7, 11.5 and 5.2 (AUC ROC=79%). An increase in the concentration of pancreatic amylase in blood plasma for 2–3 and 3–5 days correlated with its increase in the drainage discharge for 5-7 days after the intervention (r=0.48 and 0.76; p 0.05). A correlation was found between the level of amylase in the drainage discharge on 3–5 days after the intervention and the level of leukocytes according to the general blood test (r=0.62, p 0.05). CONCLUSION: An increase in plasma amylase levels is the main risk factor for the development of PF. An increase in the concentration of amylase in the drainage discharge can be considered as a potential risk factor for the development of pancreatic fistulas with clinical manifestations in the following days. The stage of the oncological process, the size of the neoplasm and the age of the patient are also risk factors.

Laparoscopic distal pancreatectomy for pancreatic cancer: an overview of evaluation and treatment strategies.

Laparoscopic distal pancreatectomies (LDP) confer benefits over open distal pancreatectomies (ODP). These benefits extend to patients with known malignancies. Despite being a common procedure for pancreatic surgeons, widespread adoption of minimally invasive approaches is still not universal. Improved understanding of the benefits of LDP as well as operative steps can help further spread the use of minimally invasive techniques. The authors present their approach to LDP with an emphasis on anatomy, intraoperative technique, and pearls/pitfalls. A brief historical overview of the development of LDP and landmark studies is also included. Review of milestones along the evolution of LDP are presented, showcasing the controversies and advantages that are associated with the procedure. Current perspectives and society recommendations are also discussed. Operative steps of LDP are described via the "clockwise technique". This technique outlines a step-wise method that includes wide mobilization for adequate exposure, slow compression of pancreatic parenchyma, and other important pearls such as patient positioning and operative planning. Proper understanding of LDP is crucial to maximizing positive outcomes from the operation. Further education on technical pearls can help increase use of minimally invasive approaches to distal pancreatic resection for cancer.

Comparative Analysis of Complications Following Distal Resections for Neuroendocrine Tumors and Adenocarcinoma: Unveiling the Differences.

BACKGROUND Adenocarcinomas and pancreatic neuroendocrine tumors (pNETs) display some similarities and differences. The aim of this study was to compare preoperative data and morphological parameters, and to assess postoperative complications after resection. MATERIAL AND METHODS Data of 162 patients who underwent distal pancreatic resection for neuroendocrine or adenocarcinoma tumor were retrospectively analyzed. After applying inclusion and exclusion criteria, 131 patients were included in the study. The preoperative data analyzed included age, sex, and ASA-PS (American Society of Anesthesiologists Physical Status) grade. The diameter of the pancreatic duct and the texture of the pancreas were analyzed. Postoperative data included grading (G1-G3), the presence of PanIN (pancreatic intraepithelial neoplasia), infiltration of structures, and postoperative complications. RESULTS Patients with adenocarcinoma were statistically older and had a higher ASA-PS class than patients with NET (P<0.001). Statistically significantly more patients with adenocarcinoma had a histopathological diagnosis of G3 (p<0.001). In patients with adenocarcinomas infiltration of structures occurred more frequently. Pancreatic duct diameter ≥3 mm was more common in patients with adenocarcinoma (P=0.045). Clinically significant pancreatic fistulas were more frequent in patients with neuroendocrine tumors (P=0.044). CONCLUSIONS Adenocarcinomas in the pancreatic body and tail are more aggressive, they cause more frequent infiltration of structures, and more often metastasize to lymph nodes compared to NETs. NETs tend to have softer pancreatic texture and higher incidence of clinically significant pancreatic fistulas, but postoperative complications of Clavien-Dindo grade ≥III occur at a similar rate in both groups.

Artificial intelligence for screening and early diagnosis of pancreatic neoplasms in the context of centralization of the laboratory service in the region.

Objective. Determination of the optimal machine learning model for the creation of software for screening and early diagnosis of pancreatic neoplasms in the context of centralization of the laboratory service in the region. Material and Methods. The clinical material was based on 1254 patients who were examined in the centralized laboratory of the Volgograd Consultative and Diagnostic Polyclinic No. 2. Of these, 139 were subsequently operated on at the Volgograd Regional Clinical Oncology Dispensary for pancreatic malignancies. In 65 (46.7 %) cases, distal pancreatic resection was performed, and in 74 (53.3 %) cases, pancreaticoduodenectomy was performed. In 28 (20.1 %) cases, at the time of tumor detection, patients did not have clinical symptoms. Statistical processing of the data was carried out using the Python programming language. Five different classifiers were used for machine learning. Results. In the course of factor analysis, 11 parameters were selected from 62 laboratory blood parameters, the dynamics of changes in which should be specifically assessed at the stages of screening and early diagnosis of pancreatic neoplasms. A comparative assessment of machine learning techniques showed that the best option for creating the appropriate software was Hist Gradient Boosting (diagnostic accuracy 0.909, sensitivity 0.642, specificity 0.965, negative predictability 0.928, positive predictability 0.794, F1 0.828, logistic regression loss function 0.352, area under the ROC curve 0.89). Conclusion. The creation of software based on the selected algorithm will make it possible to clarify the real effectiveness of machine learning on a larger population of patients with pancreatic neoplasms.

Effect of laparoscopic and open distal pancreatectomy on postoperative wound complications in patients with pancreatic cancer: A meta-analysis.

At present, it is regarded as a safe and efficient operation to treat terminal pancreatic disease. In this paper, we present a summary of the results of the clinical trials that have been conducted to evaluate the efficacy of laparoscopic and open-access pancreatic resection for pancreatic carcinoma of the end of the pancreas. Systematic review of the comparison between laparoscopy and open-access pancreatic resection was conducted. Comparative studies published before October 2023 were included. The selection of the studies was done according to a particular classification and exclusion criterion. A few of our results, which were post-surgery, were associated with injury, were compared. Where appropriate, the reliability of the data has been corroborated by a sensitive analysis. Six trials of 2075 patients with pancreatic cancer who underwent distal pancreatic resection to be included in the definitive data analysis. Among them, 447 were treated with open-access surgery and 296 were treated with laparoscope. Six trials showed that there was no statistically significant difference in the risk of postoperative wound infection in patients with pancreas cancer who received a distal pancreatectomy between laparoscopy and open surgery(OR, 1.66; 95% CI, 0.76-3.61 p = 0.20). Four trials did not reveal any statistically significant differences in the risk of postoperative haemorrhage among patients with pancreas cancer who received a distal pancreatectomy between laparoscopy and open surgery (OR, 1.84; 95% CI, 0.54-6.26 p = 0.33). Both trials did not reveal any statistically significant difference in the duration of operation for patients with pancreas cancer who received a distal pancreatectomy between laparoscopy and open surgery (MD, 13.58; 95% CI, -7.31-34.46 p = 0.2). Based on these meta-analyses, the use of laparoscopy or open surgery was not associated with an increase in the risk of postoperative infection or haemorrhage. Furthermore, the duration of the two operations did not differ significantly. These two procedures appear to be a safe and viable choice in the treatment of pancreatic carcinoma. Nevertheless, a randomized, controlled study should be performed to verify the validity of this observation.

Initial Experience of Laparoscopic Distal Pancreatic Resections: A Single Institution Study with Fifteen Consecutive Cases

Objective: To review the initial experience of outcomes of a consecutive series of laparoscopic distal pancreatic resections are performed at a dedicated cancer hospital. Study Design: Case series. Place and Duration of Study: Department of Surgical Oncology at Tertiary Care Hospital, from Mar 2013 to Feb 2021. Methodology: A retrospective review of consecutive series of patients in which distal laparoscopic pancreatic resections were performed. Data was collected through the Hospital information system (HIS), an electronic hospital database. All patients were discussed in a multidisciplinary team prior to surgery. Results: Fifteen patients, including 4(26.6%) males with a mean age of 49.27±15.2, were planned for laparoscopic distal pancreatectomy. Pathologically, 12(80%) tumours were malignant, while three were benign. The procedure was converted to open in 3 patients. The mean operating time was 4.6±0.57 hours, with an estimated blood loss of around 183±28. 8mls.Mean hospital stay was 5.3±1.5 days. One patient developed a Grade A pancreatic fistula. Recurrence in the liver occurred in two patients, which was managed by systemic adjuvant therapy. However, one of them died later on because of sepsis. Conclusion: A laparoscopic distal pancreatectomy is a safe approach for distal pancreatic tumours, with minimal complications and fast recovery in appropriate cases.

Is it worth to Operate Patients with a Metastatic Pancreas Carcinoma? Case Report of a Long-Term Survivor after Liver and Lung Metastases Resection

Background: We present a case report of a successful and unexpected 9 years long survival (the patient is still alive without tumor recurrence) of a pancreas adenosquamous carcinoma with liver and lung metastasis after distal pancreatic resection with lymphadenectomy, splenectomy, with surgical and radiotherapeutical treatment of metastasis and additional chemotherapy, and chemo- and radiotherapy (Remove yellow part). The standard five-year survival for such cases is normally very poor and at rates of 0-9%.

Minimally invasive approaches in pancreatic cancer surgery

SummaryThis literature review reflects the present evidence on minimally invasive pancreatic surgery, differentiating between distal pancreatic resection and pancreatoduodenectomy for pancreatic cancer. The review analyzed studies comparing minimally invasive and open pancreatic surgery in PubMed, the Cochrane Library, and the WHO Trial Register according to the following MeSH search strategy: MeSH items: pancreatic surgery, minimally invasive surgery, robotic surgery, laparoscopic surgery, pancreatoduodenectomy, and distal pancreatic resection. In systematic reviews and meta-analysis, minimally invasive distal pancreatectomy (MI-DP) has been shown to result in shorter hospital stays, less blood loss, and better quality of life than open distal resection (ODP) with similar morbidity and mortality. Meta-analyses have suggested similar oncological outcomes between the two approaches. Minimally invasive pancreatoduodenectomy (MI-PD) has been shown to offer advantages over open surgery, including shorter length of stay and less blood loss, by expert surgeons in several studies. However, these studies also reported longer operative times. As the procedure is technically demanding, only highly experienced pancreatic surgeons have performed MI-PD in most studies, so far limiting widespread recommendations. In addition, selection of cases for minimally invasive operations might currently influence the results. Registry studies from dedicated groups such as the European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS) and randomized controlled trials currently recruiting (DIPLOMA‑1 and 2, DISPACT-2) will bring more reliable data in the coming years. In conclusion, both MI-DP and MI-PD have shown some advantages over open surgery in terms of shorter hospital stays and reduced blood loss, but their effectiveness in terms of oncological outcomes is uncertain due to limited evidence. The study highlights the need for further randomized controlled trials with larger sample sizes and registry studies to further evaluate the safety, efficacy, and oncological outcomes of minimally invasive pancreatic resections.

Early vs late drain removal after pancreatic resection-a systematic review and meta-analysis.

Reducing clinically relevant post-operative pancreatic fistula (CR-POPF) incidence after pancreatic resections has been a topic of great academic interest. Optimizing post-operative drain management is a potential strategy in reducing this major complication. Studies involving pancreatic resections, including both pancreaticoduodenectomy (PD) and distal pancreatic resections (DP), with intra-operative drain placement were screened. Early drain removal was defined as removal before or on the 3rd post-operative day (POD) while late drain removal was defined as after the 3rd POD. The primary outcome was CR-POPF, International Study Group of Pancreatic Surgery (ISGPS) Grade B and above. Secondary outcomes were all complications, severe complications, post-operative haemorrhage, intra-abdominal infections, delayed gastric emptying, reoperation, length of stay, readmission, and mortality. Nine studies met the inclusion criteria and were included for analysis. The studies had a total of 8574 patients, comprising 1946 in the early removal group and 6628 in the late removal group. Early drain removal was associated with a significantly lower risk of CR-POPF (OR: 0.24, p < 0.01). Significant reduction in risk of post-operative haemorrhage (OR: 0.55, p < 0.01), intra-abdominal infection (OR: 0.35, p < 0.01), re-admission (OR: 0.63, p < 0.01), re-operation (OR: 0.70, p = 0.03), presence of any complications (OR: 0.46, p < 0.01), and reduced length of stay (SMD: -0.75, p < 0.01) in the early removal group was also observed. Early drain removal is associated with significant reductions in incidence of CR-POPF and other post-operative complications. Further prospective randomised trials in this area are recommended to validate these findings.

Urgent total pancreatoduodenectomy for profuse gastro-intestinal bleeding caused by renal cancer metastases to the pancreas

Urgent total pancreatoduodenectomy for profuse gastro-intestinal bleeding caused by renal cancer metastases to the pancreas

Experience of implementing enhanced recovery program in pancreatic surgery

Aim. To assess the feasibility of enhanced recovery program for patients undergoing pancreatic surgery. Materials and methods. Between January 2019 and May 2022, 47 patients with various pancreatic diseases underwent surgery at the University Clinic of A.I. Evdokimov Moscow State University of Medicine and Dentistry and FMBA of Russia. Male patients comprised 24 (51%), female – 23 (49%); the age of patients was 22 to 78 years (mean age 43.5 years). Pancreaticoduodenal resection was performed in 30 patients, distal pancreatic resection in 17 patients. All patients received some elements of the enhanced recovery program. Results. An uneventful postoperative period was observed in 36 patients (76.6%). Gastric stasis developed in 4 cases (8.5%), pancreatic fistulas in 4 (8.5%), postoperative pancreatitis in 3 (6,4%). A reoperation was performed in 1 case (2.1%) with intra-abdominal bleeding. The average length of stay in the intensive care unit comprised 1.8 days. Conclusion. The use of Fast Track in pancreatic surgery does not significantly increase the incidence of early postoperative complications, meanwhile it reduces the length of hospital stay after surgery and provides more cost- effective results. However, the development of a clear protocol for the management of patients requires further research and accumulation of data.

Anatomical venous landmarks for division of the distal pancreas: Implications for pancreatic resection

IntroductionResection of the pancreas is done for benign and malignant diseases. Distal pancreatectomy (DP) is defined as a resection of the body and tail of the pancreas which lie to the left of the superior mesenteric vein (SMV). The inferior mesenteric vein (IMV) is traditionally described to be draining into the splenic vein. This study aimed to determine the relationship of the IMV with respect to the distal pancreas to illustrate how it can be implemented as a landmark, especially to define the tail of the pancreas for parenchyma-sparing distal pancreatic resection. MethodsThis study included the dissection of 50 cadavers, which were obtained from the Department of Clinical Anatomy at a higher education institution in South Africa. The sex of the cadavers and the drainage pattern of the IMV were documented, along with the distance from the confluence of the SMV and splenic vein. Descriptive statistics were used to summarise the results. [Ethical Approval Number: BE465/18]. ResultsWide variation in the drainage patterns of the IMV was noted, with overall 48% draining into the SMV, 36% in the splenic vein and the rest at the confluence of the SMV and splenic vein. The preferential pattern of the IMV draining into the SMV was more prominent in males, with females having been evenly distributed between the SMV and splenic vein. The distances measured were not statistically significant owing to the restricted sample size and outliers noted during data collection. ConclusionThis study confirmed the wide variation in drainage patterns of the IMV. Literature regarding limited pancreatic resections and the rate of pancreatic endocrine failure is increasing. The measured distances show some promise in using the IMV as a landmark for dividing the pancreas when it is draining directly into the splenic vein. However, larger cohort studies are required to validate this hypothesis.

Current standards of surgical management of gastric cancer: an appraisal.

Gastric cancer (GC) is the fifth most common malignancy worldwide and portends a grim prognosis due to a lack of appreciable improvement in 5-year survival. We aimed to analyze the available literature and summarize the current standards of surgical care for curative and palliative intent treatment of GC. We conducted a systematic search on the PubMed database for studies on the management of GC. Endoscopic resection is an acceptable treatment option for T1a tumors. The role of optimal resection margin for GC remains unclear. D2 lymph node dissection remains the standard of care with splenectomy needed selectively for splenic hilum involvement. A distal pancreatic resection should be avoided. The advantage of bursectomy and omentectomy in GC surgery is not clear. Multi-visceral resection may be considered for locally advanced GC in carefully selected patients. Minimally invasive approaches are non-inferior to open surgery. Surgery should be abandoned prior even in metastatic GC within the frame of multimodal therapy approach. Various trials have conclusively shown improved patient outcomes when well-established surgical standards are followed.

Distal pancreatic resection: A novel technique for closure of bulky firm pancreas

Distal pancreatic resection: A novel technique for closure of bulky firm pancreas

ODP051 Presymptomatic Genetic Screening Leading to the Diagnosis of Paraganglioma Associated with Duodenal and Pancreatic Neuroendocrine Tumours in a Carrier of a Pathogenic MAX Variant

Abstract Introduction MAXpathogenic variants have been found to predispose to pheochromocytomas and paragangliomas (PPGLs) and more recently to pituitary tumors 1. Clinical Case A 30 yo man presented to the emergency department for diplopia and high blood pressure (200/100mmHg). His workup showed elevated plasmatic normetanephrines (9. 01nmol/L; N &amp;lt;0.92) and a 3.7cm right adrenal mass with a density of 30HU. The patient underwent right laparoscopic adrenalectomy and the pathologist reported a 4.5cm pheochromocytoma with a PASS score of 4 and a Ki-67 of 2-4%. The patient was screened with a panel of 14 susceptibility genes for PPGLs (INVITAE, CA, USA) that revealed a pathogenic germline nonsense heterozygous MAX mutation (c.223C&amp;gt;Tp. Arg75*). This mutation was previously described in a family where four members suffered from bilateral PHEOs at a young age (28-35 yo) 2 . Following the identification of the pathogenic variant of MAX gene, the patient's father (61 yo) underwent genetic counselling and was found to carry the same germline mutation. His past medical history included long-standing hypertension with hypertensive cardiomyopathy and diabetes. His blood work showed a mildly elevated plasmatic normetanephrine (1.41nmol/L; N &amp;lt;1.2) with normal metanephrine. An abdominal CT-scan showed a 1.5cm precaval nodularity. On a complementary 18 F-FDG PET/CT, the precaval mass had a 3.5 SUVMax and a second mass was identified in the duodenum (D3) with an uptake of 4.9 SUVMax. The 68 GaDOTATE PET/CT confirmed the precaval (SUVMax36.3) and duodenal (SUVMax51.6) lesion and in addition, revealed a pancreatic mass (SUVMax9.3). The patient underwent a distal pancreatic, duodenal and precaval node resection. The pathology report showed a 1.7cm G1 pancreatic neuroendocrine tumor (NET) (Ki-67 &amp;lt;3%) and a 2.3cmG1 duodenal NET (Ki-67 &amp;lt;3%). The precaval node was a paraganglioma (PGL) with a preserved SDHB staining, negative cytokeratine 8/18 and a Ki-67 of 1.65%. The son had normal imaging of his pancreas. To our knowledge we report the second case of association of MAXmutation with gastrointestinal TNE. Conclusion This case presents the rare association of a familial MAX mutation presenting with a pheochromocytoma in the index case and a presymptomatic discovery of a PGL and multiple NETs in the father. This supports the hypothesis that MAXmutations might be associated with multiendocrinetumors 3.

Endoscopic management of complications in the hepatobiliary and pancreatic system and the tracheobronchial tree

Endoscopic methods are nowadays apriceless tool for the treatment of postoperative complications after hepatobiliary, pancreatic and thoracic surgery. Endoscopic decompression of the biliary tract is the treatment of choice for biliary duct leakage after cholecystectomy, hepatic resection or liver transplantation. Postoperative biliary duct stenosis can also be successfully treated by endoscopic balloon dilatation and implantation of various endoprostheses in most of the patients. In the case of pancreatic fistulas, especially those occurring after central or distal pancreatic resections, endoscopic decompression of the pancreatic duct can significantly contribute to rapid healing. Additionally, interventional endosonography provides avaluable treatment option for transgastric drainage of postoperative fluid collections, which often accompany a pancreatic fistula. Various treatment alternatives have been described for the bronchoscopic treatment of bronchopleural and tracheoesophageal fistulas, which often lead to the rapid alleviation of symptoms and often to the definitive closure of the fistula.

Distal resection for pancreatic tumors

Aim. To study the specific features of the splenic artery architectonics and evaluate the results of distal pancreatic resection for various tumors.Materials and Methods. In the anatomical part, we examined 88 organ complexes taken from people whose death was not associated with diseases of the abdominal organs. We studied the topography of the splenic artery and the dependence of the number of its branches to the pancreas on the vessel tortuosity. The clinical part of the study presents the results of 122 distal resections performed during 2016-2021. 79 operations were carried out using the traditional method, 32 operations were robot-assisted, and 11 were performed laparoscopically.Results. The research found a relationship between the degree of the splenic artery tortuosity and the number of branches to the pancreas, which varies from three to nine. Out of the 122 operated patients, in 24 (19.7%) cases a clinically relevant (type B) pancreatic fistula that required additional treatment was formed. Intra-abdominal bleeding developed in 15 (12.3%) patients: early – in 10, late arrosive hemorrhage associated with a pancreatic fistula – in 5 cases. One (0.8%) patient died.Conclusion. It is necessary to consider the architectonics of the splenic artery during distal pancreatic resection. The frequency of pancreatic fistula formation does not depend on the method of performing the operation. Of the prognostic factors, the body mass index is statistically significant. Late arrosive bleeding develops against the background of a clinically relevant pancreatic fistula.

A study on several surgical methods of pancreas guided by main pancreatic duct treatment

With the gradual spread of laparoscopic and robotic technology, pancreatic surgery is developing toward reducing complications and preserving more pancreatic functions. The main pancreatic duct is an important outflow channel for pancreatic exocrine fluid, and precise management of the main pancreatic duct can effectively reduce the occurrence of postoperative pancreatic complications. This paper focuses on the difficulties of pancreatic-intestinal anastomosis, distal pancreatic resection, the relationship between the pancreatic pseudocyst and main pancreatic duct, and partial pancreatic resection, and introduces how to properly manage the main pancreatic duct in common pancreatic procedures under laparoscopic and robotic techniques. Besides, the "mucosa-to-mucosa six-stitch method" for mid-pancreatic resection and end-to-end anastomosis has been proposed, which can achieve the best surgical results with minimally invasive technology and benefit more patients.

Experience of using stent grafts in the treatment of patients with arrosive bleeding after pancreatic surgery

Aim. To evaluate inhospital outcomes of endovascular treatment in patients who underwent endoprosthetic replacement of the culprit vessel due to arrosive bleeding after pancreatic surgery.Material and methods. In the period 2012-2021 at the A. V. Vishnevsky National Medical Research Center of Surgery, 821 operations on the pancreas due to tumors and complicated chronic pancreatitis were performed. Seventy-five (9,1%) patients developed postoperative arrosive bleeding. Stent grafts were used to stop bleeding in 14 (18,7%) of them. There were 9 men (64,3%) and 5 women (35,7%). The median age of patients was 60 years (men — 61 years, women — 59 years). Arrosive bleeding occurred after pancreaticoduodenal resection in 13 patients, while in one case — after distal pancreatic resection. In all 14 cases, postoperative bleeding was severe and classified as grade C according to the International Study Group for Pancreatic Surgery (ISGPS) classification.Results. There were following sources of bleeding: gastroduodenal artery — 4 (28,6%) patients, proximal hepatic arteries (right/left) — in 4 (28,6%) patients, proximal superior mesenteric artery — in 2 (14,3%), dorsal pancreatic artery — in 1 (7,1%), false aneurysm of proximal splenic artery — in 1 (7,1%), proximal common hepatic artery — in 2 (14,3%). In 10 (71,4%) patients, endoprosthetic replacement of the proximal segment of culprit artery was performed, while in 4 (28,6%) patients with arrosion of short gastroduodenal artery stump and false aneurysm, endoprosthesis replacement of the common hepatic artery was performed with a transition to the proper hepatic artery. The technical success of endovascular hemostasis (absence of contrast media extravasation) was achieved in 100% of cases. Three (21,4%) of 14 patients developed rebleeding from another arterial source. Inhospital mortality was 28,6% (n=4). The cause of deaths in 3 cases was the direct complications of endovascular hemostasis, while in one patient — progressive postoperative pancreatitis with the outcome in multiple organ failure.Conclusion. Endovascular hemostasis using a stent graft is an effective surgical method for the treatment of arrosive bleeding after pancreatic surgery. The intervention is associated with possible complications, the risk of which must be taken into account before the procedure. We consider arrosive bleeding from a defect in the main vessel (common/ proper/right or left hepatic arteries, superior mesenteric artery) as an indication for performing endoprosthetic replacement.