Pancreatodigestive Anastomosis Research Articles

Analysis of complications of surgical treatment of patients diagnosed with pancreatic cancer.

The main treatment for pancreatic cancer (PPC) is surgery. The topography of the pancreas, its direct contact with the aorta, portal vein, inferior vena cava is a risk factor for the prevalence of the process, even with relatively small tumor sizes. Often, invasion into neighboring anatomical structures requires reconstructive intervention on adjacent vessels, aggravating the complexity of surgical intervention and its outcomes. The operation of choice for cancer of the head of the pancreas is gastropacreatoduodenal resection, and for a malignant tumor of the tail, distal resection of the pancreas with splenectomy. These operations, especially GPDR, are characterized by a high level of complications and mortality. Complications such as destructive pancreatitis (DP) and failure of the pancreatodigestive anastomosis remain the main cause of death. In our article, we will analyze the various complications that we encountered in our practice.

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.

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.

Functional outcomes of pancreaticoduodenoctomy

At present, pancreaticoduodenoctomy causes the high incidence of complications. However, it is associated with an acceptable level of postoperative mortality. With this regard and taking into consideration a significant increase in survival in pancreatic cancer, it is highly relevant to study the negative functional outcomes of surgery and develop methods for their surgical prevention. The bibliographic review focuses on the features of three main postsurgical syndromes: gastric stasis, pancreatic exocrine and endocrine insufficiency. The study shows the dependence of these syndromes on pathomorphological characteristics of pancreatic stump, preservation of the pyloric, the variant of pancreatodigestive anastomosis and other features of reconstructive stage of the surgery.

Pancreatodigestive anastomosis: the key to a favorable outcome of pancreaticoduodenal resection

The paper presents the results of various studies and meta-analyses which focus on assessing the frequency of formation of clinically significant pancreatic fistulas in various types of pancreatic-digestive anastomoses. Pancreatodigestive anastomosis is not an independent predictive factor of pancreatic complications. None of the modern types of pancreatodigestive anastomosis has proved its superiority. The choice of the pancreatodigestive anastomosis method is based on the correct selection of the organ with which the pancreatic stump is connected and the surgeon’s experience and skill in forming the anastomosis.

Differentiated approach to radical surgical treatment of elderly patients with tumor diseases of the pancreatoduodenal zone

BACKGROUND: In recent years, there has been a widespread increase in the incidence of tumors of the pancreatoduodenal zone, especially noticeable in the older age group. A decrease in the incidence of postoperative complications and mortality after pancreatoduodenal resection made it possible to expand the indications for surgical treatment of elderly and senile patients.
 AIM: Improvement of the immediate results of pancreatoduodenal resection in the treatment of elderly and senile patients suffering from tumor diseases of the pancreatoduodenal zone.
 MATERIALS AND METHODS: Pancreatoduodenal resection was performed in 61 elderly and senile patients with tumors of the pancreatoduodenal zone. The main group consisted of 32 patients, whose treatment was carried out in accordance with the developed algorithm for choosing a method for forming a pancreatodigestive anastomosis based on a scale for assessing the risk of developing pancreatic fistulas. The comparison group consisted of 29 patients in whom the method of forming a pancreatodigestive anastomosis was carried out in accordance with the preferences of the operator without taking into account the risk of developing a pancreatic fistula.
 RESULTS: In the main group, compared with the control group, pylorus-saving interventions were performed significantly more often 27 (84.4%) and 14 (48.3%) (p 0.01). There was also a decrease in the frequency of performing pancreaticojejunostomy 16 (50%) and 22 (75.9%) (p 0.05), due to the use of reservoir terminolateral pancreatojejunostomy 8 (25%) and 0, respectively (p 0.01). Postoperative complications were observed in 14 (43.8%) of the study group and in 21 (72.4%) patients of the comparison group (p 0.05). There was also a decrease in the incidence of postoperative pancreatic fistulas from 8 (27.6%) to 2 (6.2%) (p 0.05) in the study group. Repeated surgery was required in 5 (15.6%) patients of the main group and 11 (37.9%) in the comparison group (p 0.05). The lethal outcome was recorded in 3 (9.4%) patients of the main group and in 7 (24.1%) in the comparison group (p 0.05).
 CONCLUSIONS: The results of performing pancreatoduodenal resection in the treatment of elderly and senile patients can be comparable with the results of treatment of the general population. The use of the developed algorithm made it possible to reliably reduce the incidence of complications from 72.4 to 43.8% (p 0.05), postoperative pancreatic fistulas from 27.6 to 6.2% (p 0.05), as well as the frequency of repeated interventions. from 37.9 to 15.6 % (p 0.05). In addition, a downward trend in mortality was achieved from 24.1% to 9.4%.

Unconventional Technique of Terminolateral Pancreatojejunostomy 
 Formation

Backgraund. Pancreatoduodenal resection (PDR) is the only radical treatment for malignant tumors of the periampullary zone. The development of postoperative pancreatic fistula (POPF) is the most common complication of PDR. The main risk factors for the development of POPF are the narrow main pancreatic duct and the soft, "juicy" pancreatic parenchyma. Thus, it is the stage of formation of a pancretodigestive anastomosis that is of decisive importance for the course of the postoperative period.The aim of the study was to improve immediate surgical treatment outcomes of patients suffering from oncological diseases of the periampullary zone with a soft pancreas and a narrow pancreatic duct.Methods. A novel method to form terminolateral reservoir invagination pancreatojejunostomy has been developed and introduced into clinical practice. The results of treatment of 94 patients with tumors of the periampullary zone were analyzed. Based on preoperative radiological diagnosis and intraoperative findings, such factors of a high risk of POPF development as a soft pancreas and a narrow major pancreatic duct ( 3 mm) were detected in 23 patients (24.4%). In 11 patients who were treated in 2018-2019, a novel method of pancreato-jejunoanastomosis formation was applied. The comparison group consisted of 12 patients who received treatment in 2014-2017; a differentiated approach to the formation of a pancreatodigestive anastomosis was not applied.Results. In patients of the main group, there was a tendency to an increase in the proportion of pylorus-saving PDRs. The only statistically significant difference was the use of reservoir terminolateral pancreatojejunostomy at the reconstructive stage of surgery. Complicated postoperative course was observed in 7 (63.6%) patients of the main group and in all patients of the comparison group (p 0.05). There was also a decrease in the incidence of postoperative pancreatic fistulas from 66.6 to 18.2% (p 0.05) in the study group. Repeated surgery was required in 3 (27.2%) patients of the main group and 7 (58.3%) patients in the comparison group (p 0.05). The lethal outcome was recorded in 2 (18.2%) patients of the main group and in 3 (25%) in the comparison group (p 0.05).Conclusion. A soft, loose pancreas and a narrow main pancreatic duct are the most significant risk factors for complications in the postoperative period. Management of this condition requires a differentiated approach to the treatment option of pancreatodigestive anastomosis formation, depending on the characteristics of the pancreas of an individual patient. The proposed technique for the reservoir terminolateral pancreatojejunoanastomosis formation allowed statistically significantly reducing the incidence of complications from 100 to 63.6% and the incidence of postoperative pancreatic fistulas from 66.6 to 18.2% in high-risk patients..

Pancreatodigestive anastomosis: from history to modernity

This review is devoted to history of pancreatodigestive anastomoses (PDA), technique of the most popular PDA, causes of pancreatic fistula and its prevention. Contradictory data were obtained in randomized trials and meta-analyses devoted to pancreatic anastomoses. There is no optimal anastomosis excluding clinically significant postoperative pancreatic fistula. Therefore, further studies should be aimed at new approaches reducing the incidence of clinically significant postoperative pancreatic fistula.

WAYS TO PREVENT COMPLICATIONS AFTER PANCREATODUODENECTOMY

Pancreatoduodenectomy (Whipple procedure or Kausch-Whipple procedure) is the most radical surgery for oncological diseases of the periampular zone. The level of complications after it remains high even in large specialized centers. The presented research analyzes the immediate and remote results after Whipple’s procedures. These operations were conducted in the Surgical Clinic № 2, on the basis of the Dnepropetrovsk Mechnikov Regional Hospital. All operations were performed at the period from 2008 to 2019. 120 Whipple’s procedures were included to the study including 102 cases when pancreatojejunostomy was applied at the reconstructive stage, and in 18 cases pancreaticogastrostomy was performed. The choice of the pancreatojejunostomy method depended on the transverse size of the isthmus and the body of the pancreas, the diameter of the Wirsung duct. Early postoperative complications were presented by pancreatic fistulas, gastrostasis, pancreatic stump necrosis, internal bleeding from the anastomosis zone, intraperitoneal bleeding, acute early adhesive intestinal obstruction, failure of hepaticojejunostomy. Among them pancreatic fistulas were most often detected - in 25 (20.8 %) patients. Type A was detected in 9 (7.5 %) cases, type B – in 11 (9.2 %) cases, type C – in 5 (4.1 %) cases. The total number of complications after pancreatojejunostomy was 35.3%, after pancreaticogastrostomy – 22.2 %. Late postoperative complications were presented by peptic ulcer after gastroenteroanastomosis and postoperative ventral hernias. Mortality after Whipple’s procedure was 7.5 %. The reduction of the total number of complications and mortality rate after Whipple’s procedure is associated with the state of pancreatic parenchyma, the choice of the pancreatodigestive anastomosis and the accumulation of clinical experience.

Experiments and strategy for treatment of stenotic pancreatodigestive anastomosis after pancreatoduodenectomy

Experiments and strategy for treatment of stenotic pancreatodigestive anastomosis after pancreatoduodenectomy

Pancreatojejunostomy with modified purse-string suture technique.

Despite many efforts, pancreatic fistula remains the most troublesome complication following pancreatic resections, especially in case of anastomosis made with soft pancreatic tissue. The purpose of the authors was to show their modification of purse-string pancreatodigestive anastomosis and the results obtained. Between January 2013 and June 2015, the technique was applied in 49 patients; one purse-string suture and two U-shaped mattress sutures were used to create the pancreatojejunal anastomosis. In case of soft pancreatic parenchyma, an external stent was temporarily left in the main pancreatic duct. The most frequent pathology was pancreatic cancer, and a pylorus-preserving Whipple procedure was mostly done. Postoperative early morbidity rate was 35%. There were two fistulas, one grade A fistula from a fibrotic pancreas (4.2%) and one grade B in case of a soft pancreas (4%). However, there was no reoperation and mortality. According to favorable results, the modification of the purse-string suture technique makes this method even safer.

Differentiating type 2 DM and true type 3c DM in patients who have survived severe acute pancreatitis

took place in the duodenum, which contributed to the full duodenal digestion. All patients stopped pain. For 5 years after the operation indicators of exo-, endocrine functions of the pancreas have stabilized and are consistent with the values âVhâVhbefore surgery. Quality of life score was much better than before procedure. Conclusion: analysis of long-term results showed that organ-preserving (not resection) type of operation and creating pancreatodigestive anastomosis with the inclusion of duodenal in the digestive is an alternative intervention to resection surgery in patients with CP.

Comparative evaluation and technical aspects of pancreatodigestive anastomoses during parenchyma-preserving operations in patients with chronic pancreatitis with ductal hypertension

Actuality. The paper presents a new type of pancreatodigestive anastomosis in the form of isolated pancreaticojejunoduodenoanastomosis as the final stage of parenchyma-preserving operation – total longitudinal pancreatowirsungoduodenopapillotomy. Aim . In order to implement the isolated pancreatodigestive anastomosis in clinical practice we performed the parenchyma-preserving surgery in 71 patients with chronic pancreatitis with ductal hypertension. Methods and results. It has been studied that patients with this disease need physiological drainage of pancreatic juice and bile into the duodenum for duodenal phase of digestion. It was found that these requirements are met by developed and implemented in practice isolated pancreaticojejunoduodenostomy with evacuation of pancreatic juice and bile into the duodenum. Conclusion . This indicates that this type of surgery is an alternative to pancreatodigestive anastomosis according to Roux, for which the low drainage of pancreatic juice into jejunum bypassing the duodenum is typical.

Endoscopic ultrasonography‐guided pancreatic duct drainage after failed endoscopic retrograde cholangiopancreatography in patients with malignant and benign pancreatic duct obstructions

Endoscopic ultrasonography (EUS)-guided pancreatic drainage has been advocated as a rescue treatment for management of patients in whom retrograde access to the pancreatic duct (PD) is technically unsuccessful. The aim of the present study was to evaluate the feasibility and efficacy of EUS-guided drainage for failed endoscopic retrograde cholangiopancreatography. A total of 17 EUS-guided PD drainage (EUS-PD) procedures were carried out in 14 patients (age: mean 64.6 years, range 54-81 years, eight men). The rendezvous technique was successful in 11 of 17 procedures (64.7%). Three of five patients with an unsuccessful rendezvous technique successfully underwent EUS-PD stenting (7-Fr plastic stent [two cases], 5-Fr endoscopic nasobiliary drainage [one case]). In the two remaining patients, puncture and pancreatography were successful; however, antegrade passage of the guidewire failed. EUS-guided decompression of PD is a feasible and effective treatment for the management of symptomatic high-pressure PD due to stricture of the PD and/or stenotic pancreatodigestive anastomosis. However, this procedure is technically challenging, has a high rate of complications, and should be done only at tertiary-care centers.

Pancreatobiliary drainage using the EUS-FNA technique: EUS-BD and EUS-PD

The recent progression of endoscopic ultrasonography (EUS) enables EUS-guided transmural drainage based on the EUS-guided fine-needle aspiration biopsy technique. Prior to the development of EUS-guided drainage procedures, the options for treating obstruction of the pancreatobiliary system included surgical drainage, percutaneous drainage using ultrasound and radiological guidance, and endoscopic (non EUS-guidance) transmural drainage. Today, using EUS guidance and dedicated accessories, it is possible to create bilio- or pancreato-digestive anastomosis, EUS-guided biliary drainage (EUS-BD), and EUS-guided pancreatic drainage (EUS-PD). The recent literature describes that EUS-BD and EUS-PD have acceptable success and complication rates. These procedures are anticipated for use as alternatives to surgery or percutaneous drainage when endoscopic transpapillary procedures fail.

Analysis of elastase 1 for evaluation of excretory function of the pancreas after gastropancreatoduodenal resection.

The level of elastase 1 in feces was markedly decreased in all patients with tumors of the pancreatic head or its involvement before and after gastropancreatoduodenal resection and was close to normal in patients with retroperitoneal tumors not invading the pancreas. Serum elastase 1 concentrations were virtually the same in patients, normal subjects, and patients without signs of pancreatic involvement. The presence of elastase 1 in feces reflects adequate function of the pancreato-digestive anastomosis, while low concentrations of the enzyme indicate impaired function of the pancreas, presumably because of operation trauma and tumor process. Measurement of elastase 1 in feces is a highly informative and specific test for evaluation of pancreatic function in patients with pancreatic tumors, which can be used in clinical practice.