[Postoperative pancreatitis after pancreatoduodenectomy]

OBJECTIVE

Retrospective assessment of the influence of postoperative pancreatitis in development of pancreatic fistula.

MATERIAL AND METHODS

The study included 173 patients after pancreatoduodenectomy performed between 2016 and 2019. Postoperative pancreatitis within the 1^st postoperative day was verified considering blood amylase > 125 U/L. Patients with postoperative pancreatitis (n=36) were included in the main group, the control group consisted of 137 patients without pancreatitis. Postoperative pancreatic fistula was determined according to the ISGPS 2016 classification. Statistical analysis of the effect of postoperative pancreatitis on development of pancreatic fistula was carried out using relative risk and odds ratio with 95% confidence interval in both groups.

RESULTS

Postoperative pancreatitis occurred in 36 (20.8%) out of 173 patients after pancreatoduodenectomy. Pancreatic fistula occurred in 18 (50%) cases. Among 137 patients without postoperative pancreatitis, only 18 (13.1%) patients developed severe pancreatic fistula. Relative risk was 3.8 (95% CI 2.22-6.51, p<0.0001), odds ratio - 6.6 (95% CI 2.91-15.01, p<0.0001).

CONCLUSION

Postoperative pancreatitis significantly influences development of severe pancreatic fistula.

[Postpancreatectomy hemorrhage]

Surgical treatment of pancreatic diseases is always associated with a large number of complications. Postoperative hemorrhage is a specific complication of pancreatic surgery requiring a clear classification and surgical strategy. According to literature data, postoperative hemorrhage occurs in 3-30% of cases. Incidence of hemorrhages depends on intraoperative, anamnestic, histological and postoperative factors. Early postoperative hemorrhage (within 24 hours after surgery) is usually a consequence of technical errors in intraoperative hemostasis, perioperative coagulation disorders. The mechanism of delayed bleeding is more complex and often associated with various arrosive factors: pancreatic fistula, biliary fistula, abscess. Currently, there is no a single treatment algorithm for patients with postpancreatectomy hemorrhage. According to various researchers, contrast-enhanced CT is preferred for diagnosis. In recent years, the role of endovascular hemostasis has significantly increased. This problem requires further study and development of a single treatment and diagnostic algorithm that will reduce mortality in these patients.

[Prevention of pancreatic fistula after pancreatoduodenectomy]

OBJECTIVE

Prospective randomized investigation of the efficiency of somatostatin analogues and glucocorticoids in pancreatic fistula prevention after pancreatoduodenectomy by using.

MATERIAL AND METHODS

In period from December 2018 till March 2020 78 patients underwent pancreatoduodenectomy for pancreatobilliary tumors in department of abdominal surgery of National Medical Research Center of Surgery named after A.V. Vishnevsky. Intraoperative frozen section investigation of pancreatic functioning acinar structures (FAS) was held for all patients. 38 patients had more than 40% of FAC and were related with high risk of pancreatic fistula (PF), while 40 patients with less than 40% FAC were included in low risk of PF group. In both groups patients were randomized to main and control subgroups. In main subgroup of high risk group patients combination of somatostatin analogues and glucocorticoids was used, while in control subgroup patients received only somatostatin analogue. In low risk of PF group patients of main subgroup preventively got somatostatin analogue, while control group patients had no specific prophylaxis of PF. To assess the effect of drug prophylaxis on the development of pancreatic fistula we used logistic regression models with the inclusion of the drug use factor as an independent variable.

RESULTS

25 patients were included in main subgroup of high risk group. Clinically relevant pancreatic fistula (CRPF) developed in 14 (56%) cases. From 13 patients of control subgroup CRPF developed in 5 (38%) cases. In main subgroup of low risk group 18 patients were included and 3 (16%) of them had CRPF. In control subgroup were 22 patients and there were no cases of CRPF.

CONCLUSION

In our series combination of somatostatin analogue and glucocorticoid didn't show efficiency in prevention of CRPF in high risk patients, although difference between subgroups wasn't statistically significant (p=0.34). In low risk group patients prophylactic use of somatostatin analogue also didn't show decline of CRPF incidence and the difference between subgroups also wasn't statistically significant (p=0.46).

[Contrast-enhanced computed tomography in evaluation of pancreatic stump volume in pancreaticoduodenectomy]

OBJECTIVE

To analyze the role of contrast-enhanced computed tomography in evaluation of pancreatic stump volume for prediction of significant pancreatic fistula.

MATERIAL AND METHODS

A retrospective analysis enrolled 99 patients. Patients were divided into 2 groups depending on the course of postoperative period and development of clinically significant pancreatic fistula. The first group included 24 patients (25%) with clinically significant postoperative pancreatic fistula. The second group included 75 patients (75%) without postoperative complications. Pancreatic structure, pancreatic parenchyma thickness (mm), pancreatic duct diameter (mm) and volume of pancreatic stump (cm³) were preoperatively analyzed considering contrast-enhanced computed tomography data.

RESULTS

The risk of postoperative pancreatic fistula is 10 times higher in case of soft structure of the pancreas, 1,7 times higher in decrease of pancreatic duct diameter, 9,3 times higher in increased volume of residual pancreatic parenchyma, 8.6 times higher in increase of pancreatic parenchyma thickness.

CONCLUSION

Contrast-enhanced computed tomography is valuable for preoperative evaluation of the volume of residual pancreatic parenchyma and identification of patients with high risk of postoperative pancreatic fistula.

[Predicting of pancreatic fistula after pancreatoduodenectomy]

OBJECTIVE

Identifying the opportunity of objective prognosis of pancreatic fistula emergence after pancreatoduodenectomy.

MATERIAL AND METHODS

In the department of abdominal surgery in 2016-2019, 177 pancreatoduodenectomies for pancreatobiliary tumors were performed. 4 risk factors were identified: type of tumor, preoperative CT with an accumulation coefficient in the pancreas of more than 1, soft pancreas, the number of functioning acinar structures identified during intraoperative histological examination. Statistical data processing and predictive modeling were performed using a binary logistic regression model.

RESULTS

Clinically significant pancreatic fistula was developed in 47 (26,6%) patients. Risk indicators for the occurrence of pancreatic fistula depending on the presence or absence of risk factors were obtained. Groups of patients were identified that require various preventive and therapeutic measures aimed to treat postoperative pancreatitis and its consequences.

CONCLUSION

Predicting the pancreatic fistula emergence allows to take timely preventive and therapeutic measures, both minimal and aggressive (early extracorporeal detoxification, pancreatectomy), which may lead to complications. Well-reasoned pancreatectomy and extracorporeal detoxification is a surgeon's defense in an insured case or legal conflict.

[Metastatic renal cell carcinoma to the pancreas: experience of surgical treatment]

OBJECTIVE

To evaluate the outcomes in patients undergoing surgery for metastatic renal cell carcinoma (RCC) to the pancreas.

MATERIAL AND METHODS

A retrospective analysis included 54 patients with pancreatic metastases (PM) of RCC who underwent surgical treatment at the Blokhin National Cancer Medical Research Center and Vishnevsky National Medical Research Center of Surgery in 1995-2018. PM were synchronous in 6 (11%) patients and metachronous in 48 (89%) patients. Solitary metastases were identified in 35 (65%), single metastases - in 14 (26%), multiple metastases - in 5 (9%) patients. Thirty (56%) patients had isolated PM, 24 (44%) patients - PM associated with another metastatic site. The following surgical procedures were performed: distal pancreatectomy (n=30, 55%), pancreatoduodenectomy (n=12, 21%), total pancreatectomy (n=6, 12%), pancreatic head resection (n=3, 6%), middle-preserving pancreatectomy (n=1, 2%), middle pancreatectomy (n=1, 2%), cryosurgical destruction of tumor (n=1, 2%).

RESULTS

Median blood loss was 950 ml (interquartile range 400-1800 ml). Postoperative complications occurred in 52% patients. The 90-day mortality rate was 6%, overall 5-year survival 74±7%, median - 84 months.

CONCLUSION

Surgery is associated with an acceptable perioperative complications and long-term survival in patients with synchronous and metachronous, solitary and multiple PM of RCC, including cases of extrapancreatic disease. This approach may be considered as a management option in these patients.

Combination of laparoscopy and endoscopy as an option for treatment patients with gastric neuroendocrine tumors

Background

Neuroendocrine tumors (NETs) are relatively rare neoplasms with the increasing survival due to the development of early diagnostics. There is no universal position in treatment and follow up of small (~20 mm) gastric NETs.

Clinical cases

Two female patients 51 and 66 y.o. with multiple gastric NETs <2 cm were observed in our department. In both cases treatment was performed by combination of two minimally invasive technologies: laparoscopy and gastroscopy. According to the localization of tumors in one case intraluminal gastric resection controlled by laparoscopy was performed. In the second case laparoscopic gastric resection with gastroscopy assistance was done.

Discussion

There are two positions for surgical treatment of small NETs: to operate as the typical premalignant neoplasm or to make submucosa resections. We demonstrated combination of laparoscopy and gastroscopy as feasible approach with minimal risk of complications.

[Diagnosis and treatment of pancreatic head cancer followed by mesenteric-portal vein invasion]

AIM

To evaluate the outcomes of pancreaticoduodenectomy with mesenteric-portal vein resection for pancreatic head cancer.

MATERIAL AND METHODS

Retrospective analysis included 124 patients with pancreatic head cancer for the period 2010-2017. Mesenteric-portal vein (MPV) invasion was diagnosed in 37 (29.8%) patients, tumor contact with superior mesenteric artery as a borderline resectable state was noted in 11 cases. All patients underwent pancreaticoduodenectomy with mesenteric-portal vein resection.

RESULTS

Vein invasion was histologically confirmed in 19 (51.3%) out of 37 patients. At the same time, arterial invasion was absent in 11 patients with a borderline resectable tumor. CT-associated overdiagnosis of venous wall invasion was 6.4%, intraoperative overdiagnosis - 87.5%. R0-resection was achieved in 88.5% after conventional pancreaticoduodenectomy and in 78.4% after pancreaticoduodenectomy followed by MPV resection. Median survival was 17 months, 2-year survival - 41%. Among 11 patients with a borderline resectable tumor median survival was 11 months. Pancreaticoduodenectomy without vein resection was followed by 2-year survival near 68.1%. Differences were significant (p=0.02).

CONCLUSION

Pancreaticoduodenectomy followed by MPV resection as the first stage of combined treatment of pancreatic head cancer is absolutely justified if circumferential involvement of the vein and contact with superior mesenteric artery or celiac trunk do not exceed 50%. Vein resection can provide R0-surgery in these cases.