Pancreatoduodenal Resection Research Articles

Results of extended pancreatoduodenal resections for malignant neoplasms of the pancreatobiliary zone in conditions of cholemia

Results of extended pancreatoduodenal resections for malignant neoplasms of the pancreatobiliary zone in conditions of cholemia

Optimized Drainage of Pancreatic-Digestive Anastomosis in Patients with Pancreatoduodenal Resection

Summary The study compared early post-surgical complications between two groups of patients with pancreatoduodenal resection for pancreatic head carcinoma: patients with pancreatic-gastric anastomosis with mixed drainage and controls with pancreatic jejunal anastomosis with external drainage. The present study was a cohort study. The patient group was selected prospectively, and the control group – retrospectively. Patients were randomized by sex, age, primary tumor location, pancreatic parenchyma density, clinical symptoms, tumor–node–metastasis (TNM), and grade (G). We used the IBM SPSS Statistics software with the following tests: Fisher’s exact test, Pearson’s chi-squared test, Mann–Whitney U test. The optimized reconstruction approach with mixed drainage reduced early complications: early mortality - by 2.5%, overall morbidity - by 7.5%; pancreatic-digestive anastomosis insufficiency - by 2.5%; intra-abdominal bleeding - by 2.5%; intra-abdominal infection - by 2.5%; gastroparesis - by 5.0%; wound infection - by 2.5%; biliary leakage -by 2.5%. There were no cases of clinically significant pancreatic fistula. The control group was associated with an average of 9-fold higher relative risk of early complications. The passage was restored between the 4th and 7th day. Patients had a shorter average hospital stay (11 days) compared to controls (22 days). Digestive anastomoses reconstruction on a single loop and mixed intraluminal drainage through a modified nasogastric tube led to a 7-fold reduction in early post-surgical complications and a 2-fold shorter hospital stay.

Viktor Ivanovich Bulynin - Professor, Chairman of the Voronezh Regional Society of Surgeons, Honorary Citizen of Voronezh. To the 90th of birthday

Viktor Ivanovich Bulynin - Professor, Chairman of the Voronezh Regional Society of Surgeons, Honorary Citizen of Voronezh. To the 90th of birthday

Prevention of insufficiency of pancreatojejunoanastomosis during pancreatoduodenal resection using falciform ligament of the liver

Prevention of insufficiency of pancreatojejunoanastomosis during pancreatoduodenal resection using falciform ligament of the liver

Decompression of the bile and pancreatic ducts during pancreatoduodenal resection one drain

Decompression of the bile and pancreatic ducts during pancreatoduodenal resection one drain

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.

Pancreatoduodenectomy with the superior mesenteric vein resection without vascular reconstruction

The paper describes a clinical case of pancreaticoduodenectomy for pancreatic ductal adenocarcinoma with superior mesenteric vein resection without its reconstruction. This is the first case study of the kind found in Russian-language literature. In total, 16 such clinical observations have been described in the relevant world literature to date. A 74-year-old female patient was diagnosed with ductal adenocarcinoma of the pancreatic head 1.1 × 1.1 cm in size adjacent to the superior mesenteric vein. After four courses of ineffective neoadjuvant therapy, the tumor completely obliterated the superior mesenteric vein. The control multislice spiral computed tomography (MSCT) showed that the tumor was complete with the formation of a distinct collateral between the superior mesenteric and the inferior mesenteric veins. The patient underwent pancreatoduodenal resection with resection of the involved vein segment without vascular reconstruction. The histopathological diagnosis was pT1cN1M0R0. The patient was discharged on the next day after the operation.

Single vein resection in surgery for pancreatic ductal carcinoma as a criterion of resectability

Background. Pancreatic ductal carcinoma (PDC) with involvement of the superior mesenteric vein (SMV) or/ and portal vein (PV) remains a discussible subject. We have evaluated vein invasion as a criterion of borderline resectability and long-term outcome. Material and methods. In our center, 68 patients underwent either 65 standard pancreatoduodenal resections or 3 pancreatoduodenectomies for PDC. Resection of SMV/PV was performed in 18 cases (26.5 %). Three patients received neoadjuvant chemotherapy (NACT), and adjuvant chemotherapy (ACT) was assigned to 37 patients (54.4 %). Results. Morbidity (42.0 vs 50.0 %, р=0.590) and mortality rates (4.0 vs 16.7 %, р=0.111) had no significant differences in groups of standard and angioplasty operations respectively. ACT was completed in 10 (16.7 %) patients only. There was true vein invasion in 12 of 18 patients with vein resection. рN+ (р=0.012) and angioplasty by itself (р<0.001) were found out as independent predictors of overall survival (OS). the median OS was 9.4 mo in patients with vein resection. in the group of standard operations, the median OS was 26.9 mo (р<0.001). The median OS in patients with vein resection and complete chemotherapy was 17.7 mo in contrast to 8.9 mo in those who did not receive chemotherapy (р=0.439). Conclusions. PDR with vein resection and incomplete chemotherapy cannot be regarded as a reasonable procedure. PDR with vein resection may be appropriate after efficient NACT.

Carbohydrate metabolism in patients after pancreatoduodenal resection

Introduction. Pancreatic resection is a common surgical treatment option for chronic pancreatic diseases. Diabetes mellitus, which develops as a result of surgical interventions on the pancreas, belongs to a specific type – pancreatogenic. To assess the state of carbohydrate metabolism in patients after surgery in the volume of pancreatoduodenal resection (PDR), a retrospective single-stage single-center study was performed.Aim. Assessment of the state of carbohydrate metabolism in patients after surgery in the volume of PDR.Materials and methods. In Botkin City Clinical Hospital 70 case histories of patients who underwent PDR were selected. The reason for the PDR was pancreatic head cancer (55 people), chronic pancreatitis (7 people), chronic calculous pancreatitis (8 people). Data on age, gender, date of surgery, glycemia levels before and after surgery, as well as C-peptide, insulin, and HbA1c were analyzed.Results. Out of 70 people in the initial group, diabetes mellitus was diagnosed before surgery in 8 people or in 11.5% of the entire sample. Indicators of carbohydrate metabolism did not differ significantly from each other. However, the level of C-peptide decreased in all patients, while in the group of patients with malignant tumors of the pancreas, despite the decrease in C-peptide, the level of fasting glycemia also decreased.Conclusion. If before the operation diabetes mellitus was diagnosed in 11.5% of patients, then after the operation the diagnosis of diabetes mellitus was established in 23.6%. Late detection of diabetes mellitus worsens not only the quality of life of patients, but also the overall prognosis, morbidity, and tolerability of chemotherapy. Obviously, the postoperative monitoring algorithm should include regular monitoring of glycemia, glycated hemoglobin at least once a year with normoglycemia in order to early diagnose carbohydrate metabolism disorders and prescribe therapy.

Complications of chronic pancreatitis prior to and following surgical treatment: A proposal for classification

BACKGROUNDChronic pancreatitis (CP) is a long-lasting disease frequently associated with complications for which there is no comprehensive pathophysiological classification. AIMThe aims of this study were to: Propose a pathophysiological classification of the complications of CP; evaluate their prevalence in a surgical cohort prior to, and following surgical management; and assess the impact of the surgical treatment on the occurrence of new complications of CP during follow-up. We hypothesized that optimal surgical treatment can resolve existing complications and reduce the risk of new complications, with the exclusion of pancreatic insufficiency. The primary outcomes were prevalence of complications of CP at baseline (prior to surgical treatment) and occurrence of new complications during follow-up.METHODSAfter institutional review board approval, a prospective observational cohort study with long-term follow-up (up to 20.4 years) was conducted. All consecutive single-center adult patients (≥ 18 years of age) with CP according to the criteria of the American Pancreas Association subjected to surgical management between 1997 and 2021, were included. The prevalence of CP complications evaluated, according to the proposed classification, in a surgical cohort of 166 patients. Development of the pathophysiological classification was based on a literature review on the clinical presentation, course, and complications of CP, as well a review of previous classification systems of CP. RESULTSWe distinguished four groups of complications: Pancreatic duct complications, peripancreatic complications, pancreatic hemorrhages, and pancreatic insufficiency (exocrine and endocrine). Their baseline prevalence was 20.5%, 23.5%, 10.2%, 31.3%, and 27.1%, respectively. Surgical treatment was highly effective in avoiding new complications in the first and third groups. In the group of peripancreatic complications, the 15-year Kaplan-Meier prevalence of new complications was 12.1%. The prevalence of pancreatic exocrine and endocrine insufficiency increased during follow-up, being 66.4% and 47.1%, respectively, at 15 years following surgery. Pancreatoduodenal resection resulted optimal results in avoiding new peripancreatic complications, but was associated with the highest rate of pancreatic exocrine insufficiency.CONCLUSIONThe proposed complication classification improves the understanding of CP. It could be beneficial for clinical decision making, as it provides an opportunity for more comprehensive judgement on patient’s needs on the one hand, and on the pros and cons of the treatment under consideration, on the other. The presence of complications of CP and the risk of development of new ones should be among the main determinants of surgical choice.

Pancreatico-Gastrostomy: A Modified Two-Layered Technique.

Introduction: Pancreato-duodenal resections are commonly done for periampullary carcinomas. The outcome of the procedure is decided by pancreato-enterostomy. Pancreato-jejunostomy (PJ) has been employed largely as pancreato-enterostomy. Recently, there has been a renewed interest in pancreato-gastrostomy (PG). The debate continues on the choice of reconstruction.Methods: A hundred cases of periampullary carcinoma were subjected to modified pancreatico-gastrostomy. The pancreatico-gastrectomy was evaluated by drain fluid amylase done on days 1, 3, and 5 post-operatively and clinical findings. The leaks were classified according to the International Study Group of Pancreatic Fistula (ISGPF) classification of biochemical leaks, postoperative pancreatic fistula (POPF) B and POPF C. The leaks were evaluated against pancreatic factors like duct diameter, consistency of the pancreas, the thickness of the pancreatic neck, and duct location. Observations: Eighty percent of patients had no leaks. The biochemical leak was seen in 10% of cases. POPF B and C were observed at 5% each. Mortality was 3%. The diameter of the pancreatic duct of more than 3 mm and the firm consistency of the pancreas were favourable factors in the outcome of the anastomosis.Conclusion: A modified pancreatico-gastrostomy technique appears to be technically feasible and safe. The leak rates and mortality appear to be low. We need a higher number of patients to confirm the efficacy of this modified pancreatico-enterostomy.

The first experience of applying a new pancreatoenteroanastomosis with a «soft» pancreatic stump in pancreatoduodenal resection

The OBJECTIVE was to improve the results of pancreatoduodenal resection by reducing the incidence of pancreatoenteroanastomotic leak and postoperative pancreatitis with a «soft» pancreatic stump.METHODS AND MATERIALS. A new method for the formation of pancreatoenteroanastomosis has been developed and implemented: precision wirsungojejunoanastomosis with additional wide atraumatic peritonization of the pancreatic stump cutoff with the loop of the small intestine. From February 2016 to March 2018, this method was tested in 18 patients.RESULTS. Pancreatoenteroanastomotic leak of class A was noted in 2 (11.1 %) patients, was transient, asymptomatic, did not require additional medical measures and did not extend the duration of the postoperative period. There were no pancreatoenteroanastomotic leak of classes B and C, pancreonecrosis of the stump, lethal outcomes. Objectively worst statistical results were obtained in the comparison group.CONCLUSION. The formation of the small intestine anastomosis with a «soft» pancreatic stump according to the proposed method for pancreatoduodenal resection reduces the incidence of postoperative pancreatitis of the stump and pancreatoenteroanastomotic leak.

Two distinct episodes of life-threatening hemobilia due to a lesion of common bile duct and delayed intrapancreatic arteriobiliary fistula managed by emergency pancreatoduodenal resection.

Hemobilia is an extremely rare cause of upper gastrointestinal bleeding. It often has intermittent manifestation, which may lead to significant diagnostic delay. In 65% of the cases, the causes are iatrogenic, in 7% the cause is malignancy, in 5% - gallstones, in 8% it is inflammation (cholecystitis, parasites, reflux cholangitis), vascular abnormality is the cause in 7% (most commonly pseudoaneurysm of the hepatic artery), and pancreatic pseudocyst causes hemobilia in 1%. In almost all cases, the bleeding originates from intrahepatic or extrahepatic bile ducts, and rarely from the pancreas.

The strategy of surgical treatment of patients with tumor diseases of the pancreatoduodenal zone

Aims. To improve the results of surgical treatment of patients with tumor diseases of the pancreatoduodenal zone. Materials and methods. The cohort study included 94 patients with tumor diseases of the pancreatoduodenal zone who underwent pancreatoduodenal resection in 2014–2019. All patients belonged to the category of resectable and borderline resectable. Two groups of patients were formed. II (comparison group) — patients who received treatment in 2014–2017 (n=49). In this group of patients, the risk of developing postoperative pancreatic fistula was not calculated and the choice of the technique for the formation of pancreatoenteroanastomosis was carried out depending on the preferences of the operating surgeon. I (main group) — patients who were treated in 2018–2019 (n=45). In this group of patients, the choice of the technique for the formation of pancreatoenteroanastomosis was carried out in accordance with the developed algorithm, depending on the risk of postoperative pancreatic fistula development, and also, according to indications, a new method of reservoir terminolateral pancreatojejunostomy was used. A comparative analysis revealed the representativeness of the studied groups in terms of the main parameters (gender, age, comorbidity index, anesthetic risk, the presence of obstructive jaundice, tumor localization, stage of the disease). Results. The use of the developed algorithm led to a significant decrease in the incidence of postoperative complications from 73.4 to 37.8% (p<0.01), postoperative pancreatic fistulas from 28.6 to 6.6% (p<0.05), postoperative pancreatitis from 32.6 to 11.1% (p<0.05) and arrosive bleeding from the intervention area from 18.3 to 2.2% (p<0.05). Conclusions. The use of a differentiated algorithm for choosing the formation method made it possible to improve the immediate results of surgical treatment of patients suffering from tumor diseases of the pancreatoduodenal zone.

Combined drainage of the bilic and virsung ducts for the prevention of postoperative complications during pancreatoduodenal resection

Pancreatoduodenal resection is a standard procedure usually performed for benign and malignant tumors of the biliopancretoduodenal zone. The development and implementation of new technologies and techniques has made it possible to significantly reduce postoperative mortality to 5% over the past decade in specialized institutions around the world. But the number of postoperative complications still remains high - from 30% to 60% according to different authors; such as postoperative pancreatic and biliary fistulas, intra-abdominal infection, and late gastric emptying. Among them, pancreatic and biliary fistulas are the most frequent serious complications after pancreatoduodenal resection with a frequency of up to 30-60%, which is the main cause of postoperative mortality. In this work, we analyzed the internal intraoperative combined drainage of the pancreatic and bile ducts in 7 patients.

Experience of performing pancreatoduodenal resection in children

Introduction. The article is devoted to the experience of treating children with pancreatic tumors who underwent pancreatoduodenal resection (PDR) at the Department of Pediatric Surgery, Faculty of Pediatrics, N. I. Pirogov Russian National Research Medical University and at the Center for the Treatment of Developmental Anomalies and Diseases of the Hepatopancreatobiliary System in Children on the basis of the N. F. Filatov Children’s City Clinical Hospital. This type of operation was performed in children with tumors of the head of the pancreas, with the spread of fibroinflammatory changes to nearby organs in chronic pancreatitis and with complicated forms of chronic duodenal obstruction. Materials and methods. For the period from 2010 to 2021 9 PDEs were performed in patients aged 1 to 16 years. The results of treatment in this category of patients were assessed as satisfactory. It is noted that the postoperative period has a number of features: prolonged restoration of gastric motility and passage through the gastrointestinal tract (100% of patients), exacerbation of chronic pancreatitis (100% of patients). Against the background of conservative therapy in all children (100% of patients), the symptoms of pancreatitis were stopped in the period from 26 to 41 postoperative days, the evacuation function of the stomach was fully restored within 2-4 weeks after the operation. Discussion and conclusions. Among the postoperative complications, there were: stenosis of biliary and pancreatic-digestive anastomoses (22% and 11% of those studied, respectively), adhesive intestinal obstruction (11% of cases), intra-abdominal bleeding (11% of patients). One patient had a lethal outcome after repeated surgical interventions for pancreatic head limphangioma complicated by intra-abdominal bleeding and biliary peritonitis. The prognosis in this category of patients is favorable - in the follow-up after surgical treatment in all children (100% of patients), the passage through the gastrointestinal tract is not disturbed, the endo- and exocrine function of the pancreas is preserved (100% of patients), there were no indications for prescribing enzyme therapy and insulin preparations …

БИЛИАРНАЯ ФИСТУЛА ПОСЛЕ ПАНКРЕАТОДУОДЕНАЛЬНОЙ РЕЗЕКЦИИ

Literature searches were carried out on the Pubmed information platform and in the elibrary and Cyberleninka libraries by Keywords. Inclusion criteria are the following: availability of the full-text version of the original article, full compliance with the topic, publication period no more than 5 years. From 144 publications received, those completely duplicated and not meeting the inclusion criteria, were excluded. A total of 36 articles are included in the review. The epidemiology of biliary fistula after pancreatoduodenal resection, modern views on pathogenesis, classification, preventive measures and therapeutic and diagnostic tactics during its development are considered. In the postoperative period of pancreatoduodenal resection, biliary fistula is formed with a frequency of 1-24%. Non-modifiable risk factors include male gender, thin common bile duct, benign biliopancreatoduodenal pathology, and cancer with previous neoadjuvant therapy. Modifiable risk factors include obesity, hypoalbuminemia, obstructive jaundice, duration of hepaticojejunostomy, and prior endoscopic biliary drainage. Nowadays, effective and safe procedures are available in modern interventional radiology for the diagnosis and treatment of postoperative biliary fistula, which can be used as an alternative to endoscopic manipulations and revision interventions when the latter are associated with high risks of complications. Timely detection and treatment ensures the prevention of severe biliary fistula and repeated interventions and favorable prognosis, as well as saving medical and financial resources.

CLINICAL EXPERIENCE IN THE TREATMENT OF PANCREATORRHAGHIA IN PATIENTS WITH COMPLICATED CHRONIC PANCREATITIS

Bleeding, the source of which is in the pancreas or adjacent structures, is a rare, usually fatal manifestation of chronic pancreatitis.
 The aim of the study was to analyze the clinical experience of treatment of patient with chronic pancreatitis complicated by late pancreatorrhaghia (hemosuccus pancreaticus). 
 Materials and methods. During 2000-2021, surgical treatment of 249 patients with complicated chronic pancreatitis was performed. Pancreatorrhaghia occurred in 6 (2.4%) patients.
 Discussion. A presentation of a clinical case of bleeding in the lumen of the gastrointestinal tract in a patient who underwent pancreatoduodenal resection a year ago for complicated fibro-degenerative chronic pancreatitis. Bleeding arose from the inferior pancreatoduodenal artery, which was cut through the mattress suture after heavy exercise, which caused severe pancreatorrhaghia.
 Conclusions. To prevent the occurrence of pancreatorrhaghia in the postoperative period, the most effective way is to suture the vessels in the parenchyma of the pancreas polydioxanon and filling the defects of the pancreatic duct with fibrin or cyanoacrylic glue. Although this issue needs further study.

Surgical aspects of radical treatment of cancer of the pancreas and pancreatoduodenal zone

As many as 119 pancreatoduodenal resections are analyzed. The specific complications of the pancreatoduodenal resections are the postoperative pancreatitis development and incompetence of the pancreatojejunal anastomosis sutures. The introduction of the new treatment method of the pancreas and formation of the intussucceptional pancreatojejunal anastomosis made it possible to decrease the rate of the postoperative pancreatitis and incompetence of the pancreatojejunal anastomosis sutures up to 0,7% and the postoperative mortality up to 3,1%.

Metachronous multiple primary cancer of the pancreatic head and liver: a case of hepatocellular carcinoma 10 years after pancreatoduodenal resection

The Aim. Study of a clinical case of metachronous primary multiple cancer of the head of the pancreas and liver.Materials and methods. The work was carried out with modern domestic and foreign literature sources devoted to the problem of primary multiple malignant neoplasms. A retrospective analysis of the patient’s clinical and anamnestic data was performed, the necessary medical documentation was studied.Results. In 2011, a pancreatoduodenal resection was performed on a patient for ductal adenocarcinoma of the head of the pancreas. In 2021, an MRI scan revealed a formation in S5-S6 with dimensions up to 34x35x29 mm. According to the histological examination of the biopsy material, hepatocellular carcinoma was confirmed. Resection of the 5th segment of the liver was performed in the conditions of the NMIC Oncology in Rostov-on-Don.Conclusion. The presented case of primary multiple cancer of the head of the pancreas and hepatocellular carcinoma of the liver is of direct interest both from the point of view of oncological surgery and chemotherapy.