Pancreaticoduodenal Resection Research Articles

Challenges during pancreatoduodenectomy and ways to overcome them

Background. Pancreaticoduodenal resection (PDR) is the surgical procedure for cancer of the head of the pancreas, distal common bile duct, duodenum and ampulla of Vater. This surgery is associated with a high risk of complications, the development of which can be influenced by various factors. since pancreatic fistula is a key complication of PDR, the choice of the method for pancreatic anastomosis becomes especially important. Material and methods. The search for publications was carried out using the PubMed and Elibrary systems from January 1980 to January 2024. of the 2,300 sources found, 69 were used to write the review. We included data from both retrospective and prospective clinical trials that were devoted to pancreatoduodenectomy for malignant neoplasms, the difficulties encountered in performing this surgery and ways to solve them. Results. Currently, there are more than 60 types of pancreatico-digestive anastomosis, which indirectly indicates the absence of a universal one that ensures the prevention of pancreatic fistula. The treatment outcomes may be influenced by the nature of neoadjuvant treatment, concomitant diseases, anatomical features, presence of obstructive jaundice and methods of its relief. The main mechanisms of influence of negative factors on the development of complications are considered. an individual approach to the patient, taking into account all factors, can significantly reduce the risk of complications.

Vascular Complications of Pancreaticoduodenal Resection: Prevention and Treatment

Vascular Complications of Pancreaticoduodenal Resection: Prevention and Treatment

Assessment of quality of life in patients after surgery for pancreatic and periampullary malignancies. Systematic review

Aim. To analyze the current methods of life quality assessment in patients undergoing surgical treatment for pancreatic and periampullary cancer, to study the influence of surgical treatment and postoperative complications on the quality of life. Materials and methods. The study involves a systematic review of the literature available in MEDLINE, Embase and e-Library electronic databases for 2015–2022. The methodology of the systematic review is reflected in the study protocol, designed according to PRISMA guidelines. Results. The systematic review embraces 26 studies including 4937 patients met the inclusion criteria. The present study examines design and objectives, survey forms, methods of surgical interventions and drug treatment, survey frequency and data collection methodology, risk of systematic error, etc. Conclusion. When choosing a survey form, most authors favored EORTC QLQ-C30 and EORTC QLQ-PAN26. Even the most complex surgeries such as pancreaticoduodenal resection and pancreatectomy can provide a satisfactory quality of life. Many current studies appear methodologically-challenged thereby increasing the risk of systematic error and reducing the reliability of the data. The quality of life of patients in this category is to be further investigated, the optimal principles and methodology of such studies are to be standardized, in particular, in Russian healthcare system.

Pancreaticoduodenal resection with marginal resection of the portal vein: case study

Pancreatic cancer (PC) represents a challenging manifestation of a gastrointestinal tumour, which poses a formidable impediment for healthcare professionals and patients alike. The prognosis for this condition is often discouraging, particularly following a pancreatectomy, which has a poor five-year survival rate. The sole practical cure for PC is surgical resection, despite the negative outcomes. The standard surgical procedure for pancreatic head cancer is pancreaticoduodenectomy (PD). Although PD has been associated with higher morbidity and mortality rates, recent advancements have reduced the risks associated with this operation. When it comes to PC surgery, one promising approach is the resection of the portal vein. This technique has been shown to improve the ability to remove the cancerous tissue (resectability) and to remove it completely (radicality). This study was carried out at the department of pancreatology hepatology and transplantation of organs and tissues, Grodno regional clinical hospital in Grodno, Belarus. Our team treated a patient with pancreatic adenocarcinoma, who underwent a pancreaticoduodenal resection and marginal resection of the portal vein as part of their treatment plan. PD with marginal resection of the portal vein reduces risks and improves patient outcomes, as confirmed by CT and ultrasound data. Further research is needed to expand its efficacy and improve patients' recovery and quality of life post-surgery.

Determination of the optimal reconstruction for pancreaticoduodenal resection based on modified scintigraphy of gastrointestinal motility

Aim. To improve the outcomes of pancreaticoduodenal resection by determining the optimal reconstruction based on objective assessment of the functional state of the upper gastrointestinal tract using a modified “double” scintigraphic study.Materials and methods. 147 pancreaticoduodenal resections were performed in the period of 2016–2022. Patients underwent “double” scintigraphic study on days 30 and 90 after surgery. The mean age of the patients was 59.6 years (23–83); the male to female ratio was 1.27:1. All patients underwent gastropancreatoduodenal resection or pancreatoduodenal resection with pylorus preservation. The patients were divided into 3 groups according to the variant of the reconstructive stage of surgery. Group 1 underwent reconstruction according to Child, group 2 – Child reconstruction and interintestinal anastomosis formation according to Brown, the reconstructive stage in group 3 involved Roux-en-Y isolation of the small intestine (Roux-en-Y reconstruction).Results. “Double” scintigraphic study revealed that the best result on the 30th and 90th postoperative days was observed in patients who underwent pancreaticoduodenal resection with pylorus preservation, reconstructive stage according to Child and formation of interintestinal anastomosis after Brown.Conclusion. “Double” scintigraphy is an effective procedure to determine the motility of the stomach, biliodigestive anastomosis and motility of the small intestine. As a result, the optimal reconstruction after pancreaticoduodenal resection was determined in patients with neoplasms of the pancreatic head or the periampullary region and chronic pancreatitis.

Superelastic titanium nickelide stents with memory form prevent the development of cicatricial lesions of the extrahepatic bile ducts in the location of pancreatoand biliodigestive anastomoses

Surgical interventions for benign lesions of the extrahepatic bile ducts in 15-25% of cases end with the creation of bypass biliodigestive anastomoses. After pancreaticoduodenal resection, every 6 patients have failure of biliodigestive anastomoses and the formation of an external biliary fistula. During the same operation, failure of the pancreatodigestive anastomosis develops in about 15-40%, leading to high mortality. The use of traditional technologies in the surgical treatment of pancreatic pseudocysts is accompanied by the development of early complications and leads to relapses. In connection with this, interest arose in the use, for the treatment and prevention of these complications accompanying operations on the bile ducts and pancreas, of a new generation of implant materials with shape memory. From 1990 to 2021, we performed 183 stenting operations for pancreato- and biliodigestive anastomoses with titanium nickelide stents. In the comparison group of 56 patients with cicatricial lesions of the extrahepatic biliary tract, who used STPD and precision suture, good results were achieved in 58.5%, satisfactory in 22%, unsatisfactory in 19.5%. In the second comparison group of patients with this pathology, who underwent X-ray endobiliary stenitization with nitinol stents with a round thread section, good results were obtained in 41.8% of patients, satisfactory - in 58.2%. The average duration of stent functioning in this group of patients was 38.2±2.3 months. The results of treatment and prevention of the development of cicatricial lesions of the extrahepatic bile ducts of pancreato- and biliodigestive anastomoses using superelastic stents made of titanium nickelide with shape memory indicate the effectiveness and prospects of this direction both in open and laparoscopic operations.

Pancreatic Trauma

Traumatic pancreatic injuries are associated with significant morbidity and mortality. The review analyses recent studies on epidemiology, classification, diagnosis and treatment of patients with pancreatic injury. Pancreatic injury in abdominal trauma is observed from 3% to 12% of cases, the overall mortality ranges from 0% to 31% and is largely determined by damage to other organs. The most widely accepted grading system for defining categories of pancreatic injuries is Organ Injury Scaling developed by the American Association for the Surgery of Trauma. A high index of suspicion is necessary for early diagnosis, since in the first hours after the injury clinical manifestations and laboratory parameters are not specific, and changes in the CT picture do not correlate to the severity of the injury in 20-40% of cases. Contrast-enhanced CT is the first-line diagnostic tool in hemodynamically stable patients. MRI with MRCP and ERCP is used to evaluate the integrity of the pancreatic duct. Nonoperative management is recommended for hemodynamically stable grade I and grade II pancreatic injuries. Patients with pancreatic duct injury require predominantly surgical treatment. The preferred type of surgery for grade III and more severe injuries (distal resection, drainage of the damaged area combined with endoscopic drainage and stenting, or organ-preserving surgery in the form of pancreaticojejunostomy, pancreaticogastrostomy) remains controversial. In case of pancreatic injury proximal to the venous confluence, drainage of the damaged area is the only fairly safe option for the patient, indications for pancreaticoduodenal resection are limited to concomitant injury of the bile duct, duodenum with involvement of the major duodenal papilla, massive bleeding from crushed tissues of the pancreatic head. Larger prospective studies are warranted for better management of patients with pancreatic trauma.

Досвід виконання розширених панкреатодуоденальних резекцій у хворих на злоякісні новоутворення панкреатобіліарної зони, ускладнені синдромом механічної жовтяниці

Despite the results of randomized trials, mortality and survival rates, clinical aspects of extended pancreaticoduodenal resection remain a subject of debate. Purpose - to determine the effect of the pancreaticoduodenal resection volume expanding on the results of surgical intervention. Materials and methods. The results of surgical treatment of 101 patients with malignant neoplasms of the pancreatobiliary zone, complicated by mechanical jaundice syndrome, were analyzed. Depending on the volume of lymph node dissection, patients were randomized into two cohorts. The main group included 33 (32.7%) patients who underwent an extended version of pancreatoduodenal resection; the comparison group included 68 (67.3%) patients who underwent standard pancreaticoduodenal resection. Results. Intraoperative blood loss in extended interventions somewhat exaggerated the volume of blood loss in standard ones, however, there was no statistically significant advantage (522±165) ml versus (468±124) ml (p>0.05). In patients after extended surgical interventions, the average debit of lymph through the drains was (512±26) ml/day, which was almost 46.2% higher than the average amount of lymph outflow through the drains in patients after standard ((236 ± 31) ml/day) and was statistically confirmed (p<0.05). Secretory diarrhea lasting more than 2 weeks, as a complication of extended pancreatoduodenal resection, occurred in 7 (21.2%) patients, and after the standard one - only in 3 (4.4%) (p<0.05). A life-threatening postoperative complication as failure of the pancreatodigestive anastomosis due to pancreatic necrosis of the pancreatic stump complicated the course of the postoperative period in 9 (13.2%) patients after standard interventions, while after extended interventions it was diagnosed in 4 (12.1%) patients. Mortality after standard pancreatoduodenal resection was 7.4% (5 patients), after extended resections - 6.1% (2 patients). Conclusions. On the one hand, the obtained results demonstrate more difficult conditions of extended pancreaticoduodenal resection performing, and, on the other hand, the absence of statistically significant differences with standard intervention in terms of the frequency of complications. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of the participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

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.

Pancreaticoduodenal resection for primary unresectable pancreatic head cancer after neoadjuvant chemotherapy

The paper describes a clinical case of successful combined modality treatment of a patient with pancreatic ductal adenocarcinoma with extension to the superior mesenteric artery and vein. The examination revealed an unresectable tumor. Twelve courses of FOLFIRINOX therapy showed good results, upon which the treatment plan was changed and a typical pancreaticoduodenal resection was performed. Pathological examination revealed ductal adenocarcinoma urT1N0M0R0, TRG 2. The postoperative period was uneventful. The efficacy of drug treatment for ductal adenocarcinoma has increased markedly in recent years. Neoadjuvant chemotherapy can be considered the most effective for locally advanced tumors.

A CLINICAL CASE OF LATE SEVERE BLEEDING FROM THE AREA OF PANCREATICOJEJUNOANASTOMOSIS AFTER PANCREATICODUODENAL RESECTION

Abstract. Virsungorrhagia is characterized by bleeding from the ampulla of the nipple through the pancreatic duct and occurs in 1 in 1500 patients with gastrointestinal bleeding from the upper parts of the gastrointestinal tract. It most often occurs as a result of the formation of a pseudoaneurysm due to chronic pancreatitis.
 The purpose of the work: to present a clinical case of severe bleeding from the area of pancreatico-jejunoanastomosis after pancreaticoduodenal resection.
 Materials and methods: There were 5 patients with virsungorrhagia in the Center for Gastrointestinal Bleedings of the Vinnytsia Regional Clinical Hospital named after M.I. Pyrogov from 2014 to 2023. All patients are male. Age from 45 to 67 years. Four patients had longitudinal pancreatojejunostomy in the past. One has Pancreatoduodenal resections according to Whipple. All of them had recurrent bleeding.
 Discussion: The presentation of a clinical case of late heavy bleeding from the area of pancreaticojejunal anastomosis after pancreaticoduodenal resection in a patient with complicated fibrotic-degenerative chronic pancreatitis is presented.
 Conclusions: Virsungoragia is a rather rare complication of surgical interventions on the pancreas, which is difficult to diagnose. The most effective way to stop bleeding is to stitch the bleeding vessel.

First experience of using augmented reality technology in liver and pancreas laparoscopy

Aim. To describe the experience of using augmented reality system in abdominal surgery at one clinical center.Materials and methods. In 2021–2022, five patients underwent laparoscopy with augmented reality technology. The interventions included echinococcectomy with resection of IV, V, VI liver segments, pancreaticoduodenal resection for pancreatic head cancer, excision of mesostenium cyst, resection of pancreas body and tail for neuroendocrine tumor.Results. Application of 3D models requires putting on glasses, scaling and setting a model on the screen image, which sometimes prolonged surgery time to 25 minutes. In a number of operations the use of augmented reality navigated the surgeon when working near vascular structures. After looking through the AR model, a surgeon felt more confident in terms of individual anatomy.Conclusion. Augmented reality can become a reliable and promising tool in abdominal surgery. However, further technological development in augmented reality systems is needed to increase their performance.

Severe hemobilia after pancreaticoduodenal resection, caused by false aneurysm of right branch of a. hepatica propria as a complication of transcutaneous transhepatic cholangiostomy

Severe hemobilia after pancreaticoduodenal resection, caused by false aneurysm of right branch of a. hepatica propria as a complication of transcutaneous transhepatic cholangiostomy

Role of bacteriocholia in development of infectious complications of pancreaticoduodenal resection

The incidence of infectious complications after pancreaticoduodenal resection remains significant. High frequency of bacteriocholia in this category of patients is a result of preoperative biliary drainage. The role of bacteriocholia in the development of surgical site infection and the methods of exposure to it are yet to be studied. The authors presented the analysis of Russian and foreign literature and considered the role of bacteriocholia in the development of surgical site infection after pancreaticoduodenal resection. Bacteriocholia appears to be one of the most significant factors in the surgical site infection after this kind of resection. Bacterial cultures in the intraoperative bile sample and the surgical microbiome are represented by pathogens resistant to standard drugs used for perioperative antibiotic prophylaxis. In order to decrease the incidence of surgical site infections after the pancreaticoduodenal resection it is essential to continue searching for the methods of exposure to bacteriocholia including revision of the approaches to perioperative administration of antibacterial agents.

Gastric stasis following pancreatoduodenal resection: terminology and prevention issues

Gastric stasis constitutes a common complication of pancreaticoduodenal resection, which is insufficiently covered in Russian literature. The paper considers issues pertaining to terminology and the current classification of gastric stasis. The possibilities of preventing this complication are discussed from the perspective of evidence-based medicine.

Difficulties in diagnosing pancreatoblastoma

Clinical observation of surgical treatment received by a patient with pancreatoblastoma is described. In the preoperative period, specialists had difficulties in determining the nature of the neoplasm, which led to some tactical complications. The patient underwent pancreaticoduodenal resection that involved resection of the pancreatic body, as well as the confluence of the superior mesenteric and splenic veins. The histologic and immunohistochemical studies confirmed the diagnosis of pancreatoblastoma. Therefore, the patient was referred for chemotherapeutic treatment.

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.

Modification of prophylactic anticoagulation regimen reduces the incidence of thrombotic complications after venous reconstruction.

e16250 Background: Surgical treatment for pancreatic cancer (PC) with venous reconstruction is associated with a high risk of venous thrombosis. The purpose of this study was to analyze the dynamics of the blood fibrinolytic system in the postoperative period in PC patients after venous reconstruction. Methods: The study included patients with PC (T3N0-1M0), mean age 63 years. Patients of the main group (n = 11) underwent pancreaticoduodenal or corporocaudal resection with venous reconstruction (portal and superior mesenteric veins), mesenteric cross-clamping time 7-40 minutes (average 23 minutes). Patients of the control group (n = 11) received similar surgical treatment without venous resection. All patients received postoperative prophylactic anticoagulation: standard nadroparin 0.4 ml once a day in the control group and a modified regimen of nadroparin 0.1 ml per 10 kg of body weight per day in a low bleeding risk in the main group. Levels of tPA, uPA, PAI-1 and suPAR, and tPA-act, uPA-act, and PAI-1-act activity were determined in the blood plasma by ELISA (Technoclone, Austria; R&D Systems, USA) on days 1-3, 5-7 and 8-14 after surgery. Results: No thrombotic complications were registered in the main group during the 30-day observation period, while 2 patients (18.2%) in the control group were diagnosed with distal venous thrombosis on days 10-14. The frequency of hemorrhagic complications was similar in both groups (9.1% vs 9.1%). Levels of PAI-1 decreased by 2.4 times in both groups on days 1-3 after surgery, tPA increased by 1.7 times (p < 0.01), and tPA-act increased in the main group by 2.9 times. On days 5-7, no changes were registered in the control group, while patients of the main group showed decreased tPA-act by 3.2 times and elevated suPAR and PAI-1 by 2.2 times (p < 0.01) and PAI-1-act by 3.6 times. However, levels of PAI-1-act decreased by 2.2 times (p < 0.01) in the main group on days 8-14, and in control group PAI-1 increased by 2.4 times (р < 0.05). Thus, patients in the main group had 2.4 times higher levels of tPA on days 1-3, compared to the control group, and higher suPAR on days 5-7 (by 1.8 times, p < 0.01), PAI-1 and PAI-1-act by 2.0 times (p < 0.01), and higher tPA (by 4.4 times) on days 8-14. Conclusions: The proposed scheme of prophylactic anticoagulation showed its efficacy and safety. It activated fibrinolysis 1-3 days after surgery. Further on, we could observe signs of enhanced prothrombotic and pro-inflammatory state despite the ongoing anticoagulant therapy, which, however, was not manifested by thrombotic complications. Levels of tPA increased significantly by days 8-14 after venous reconstruction and intestinal ischemia, while inhibitor levels remained high, which can be considered a change in the balance towards activation of fibrinolysis and enhancement of anti-inflammatory processes.

Surgical treatment of resectable and borderline resectable pancreatic cancer in tertiary cancer center: the 6-year experience

Objective: The aim of the study is to analyze the short and long-term results of surgical treatment of resectable and borderline-resectable patients during 2015-2017 (1st period) and 2018-2021 (2nd period). Material and Methods: A retrospective analysis of patients treated with pancreatic resection with (VR) and without portal or mesenteric vein resection (standard resection, SR) for exocrine pancreatic carcinoma in National Cancer Institute, Kyiv, Ukraine in 2015-2021. Results: 188 patients underwent surgical treatment, among which 67 received concomitant portal/mesenteric vein resection. Postoperative mortality was 10.04% (14.93% and 6.61% in VR and SR group, respectively, p=0.11). Textbook outcome rate was 67.3% vs 72.7% in VR and SR groups, respectively (p=0.57). Comparing 2015-2017 and 2018-2021 time periods, TO rate did not change for VR – 67.9% vs 66.8% (p>0.99), but tended to increase in SR group – 62.2% vs 80.4% (p=0.089). Median overall survival was 17.03 month and did not differ between VR and SR. OS of all patients differed significantly between 2015-2017 and 2018-2021 – 13.8 vs 22.5 month (p=0.013). In multivariative analysis pancreatic head resection and lower tumor grade were positive prognostic factors, while age >65 and first study period – negative for OS. Conclusion: Extended due to venous resection pancreatectomies lead to comparable with standard procedures short-term and long-term results. The tumor grade G1-2, patient age less than 65, pancreaticoduodenal resection, and treatment period 2018-2021 were independent factors for better prognosis. Further prospective data is necessary to obtain representative results

Node negative duodenal adenocarcinoma is associated with long‐term patient survival following pancreaticoduodenal resection

Duodenal adenocarcinoma (DA) is a rare gastrointestinal malignancy. There is limited data reporting patient outcomes following radical pancreatic resection for DA. We assessed the disease-free (DFS) and overall survival (OS) in patients undergoing pancreaticoduodenectomy for DA in our institution. We retrospectively analysed all patients undergoing pancreatic resection of DA at our institution between January 2009 and March 2020 inclusive. Ninteen patients underwent pancreatic resection at our institution for DA during the study period. The overall postoperative morbidity and mortality was 37% and 5%, respectively. Nine patients (47%) had no nodal involvement. Median follow up was 25 months (range 1-108 months). Median DFS for our whole cohort was 17 months but was significantly higher in patients with no nodal metastasis [p< 0.001]. Median OS was 9.5 months for the whole cohort but was significantly higher in the patients with no nodal metastasis (60 months) compared to those with nodal metastasis (17.5 months) [p< 0.003]. Improved DFS and OS for patients undergoing pancreaticoduodenectomy for DAs is associated with lymph node negative disease.