Results of complex treatment of patients with operable pancreatic head cancer using preoperative intra-arterial chemotherapy in combination with radiation therapy in multifractionation mode

The aim of this study was to assess the safety and efficacy of treating patients with operable pancreatic cancer after preoperative intra-arterial infusion of chemotherapy combined with conformal radiation therapy in a multi-fractionation mode. Patients (n = 40) were randomized into two groups: the main one – intra-arterial infusion of chemotherapy + radiation therapy + surgery (n = 20), and control – intra-arterial infusion of chemotherapy + surgery (n = 20). Neoadjuvant therapy consisted of intra-arterial infusion of chemotherapy (chemoembolization of a pancreatic head tumor with oxaliplatin 85 mg/m2) followed by intra-arterial chemo infusion with gemcitabine 1000 mg/m2. In the main group, radiation therapy was also carried out in two fractions per day, 2 Gy with an interval of 4–6 hours, 5 days a week, up to a total dose of 50 Gy. In the main group, the lower incidence of postoperative pancreatitis and the pancreatic fistulas were statistically confirmed, the incidence of grade 2 therapeutic pathomorphisis increased, as well as the median life expectancy.

COMPLICATIONS OF OPEN SURGICAL PROCEDURES IN PATIENTS WITH PANCREATIC CYSTS

The incidence of pancreatic cysts is constantly growing due to an increasing number of patients with a history of pancreatitis. Furthermore, complications after surgical interventions for pancreatic cysts occur in 30-40% of patients. Objective: to analyze the complications in patients with pancreatic cysts after open surgery. We observed 68 patients who underwent open surgical interventions: cystogastrostomy and cystojejunostomy. All patients with pancreatic cysts were divided into 2 groups depending on the type of procedure. In 27 patients (29%) of the first group cystogastrostomy and in 41 patients (81%) of the second group cystojejunostomy was performed. In 1st group complications were diagnosed in 8 cases (29.6%): postoperative pancreatitis (5 — 18.5%), cyst recurrence (3 — 11.1%). In the second group complications occurred in 7 patients (17.1%): postoperative pancreatitis in 4 cases (9.8%), recurrent cysts in 3 cases (7.3%). Thus, cystojejunostomy is less associated with complications than cystogastrostomy. K E Y W O R D S — pancreatic cy

Bile duct reconstruction in choledochal malformations in children

Introduction. Currently, there is ongoing discussion regarding the method of biliary tract reconstruction in children with choledochal malformations (CM).Purpose. To make a comparative analysis of the techniques applied in bile duct reconstruction in children with CM.Material and methods. For 10 years we have admitted 99 patients with CM. 84 children with CM were operated on from January 2010 to May 2020. Group 1 - patients who had Roux-en-Y hepaticojejunostomy (RYHJ, n = 68, 81%); Group 2 - patients who had hepaticoduodenostomy (HD, n = 16, 19%). The surgical access varied depending on the biliodigestive anastomosis technique. It was mini-laparotomy and laparoscopy. Surgical time, short-term and long-term postoperative outcomes were analyzed.Results. Groups were comparable in gender, age, clinical manifestations, CM complications before surgery, accompanied comorbidity (p > 0.05). It was found that CM types differ depending on the child’s age when the diagnosis was established ( p = 0.0493, Kruskal- Wallis test); there was also a statistically significant difference in the pair between CM 1C and CM 1F (p = 0.0164, paired post-test). It means that children with CM 1F were older, median age 49 months (Q1-Q3: 12-86 months), than children with CM 1C, median age 14 months (Q1-Q3: 5-30 months). In HD group, severe postoperative pancreatitis, which was not controlled with conservative therapy, developed more often (n = 2) (p <0.05) and required a number of repeated surgeries including re-hepatico and hepaticojejunostomoses, thus prolonging the length of stay in ICU and increasing much the number of bed days.Conclusion. In our study, RYHJ technique has some advantages over HD one. Therefore, at present we can recommend it as a basic one.

Percutaneous minimally invasive methods as a step-up intervention in the complex treatment of fluid accumulations in patients with acute pancreatitis

Annotation. Analysis of recent publications on the definition of fluid accumulation in patients with complicated forms of acute pancreatitis and the possibility of their correction by minimally invasive methods according to the clinic, analysis of a clinical case that demonstrates the possibility of staged percutaneous drainage of fluid accumulation in acute infected necrotic pancreatic. The results of treatment of 622 patients who were hospitalized in the surgical department of MNPE City Clinical Hospital of Ambulance and Emergency Care during 2020 were analyzed. The mean age of patients was 48.2±2.2 years. The patient examination plan included a comprehensive clinical, laboratory and instrumental examination. Puncture and drainage of fluid accumulations were performed under local anesthesia under ultrasound control using a linear sensor with a frequency of 7.5 MHz in gray-scale mode. Statistical data processing was performed by the method of mathematical statistics with StatSoft Statistica 6.0 software and Microsoft Office Excel. It is established that the cause of acute pancreatitis in 270 (43.4%) patients was a biliary factor, in 155 (24.9%) – alcohol, 135 (21.7%) – acute pancreatitis developed on the background of triglyceridemia, in 21 (3.4%) the patient had postoperative pancreatitis, medical – in 8 (1.3%) patients and without establishing a clear etiology – in 33 (5.3%) patients. In order to eliminate fluid accumulations in 12 (1.9% of the majority of patients with acute pancreatitis and 7.6% of 157 with fluid accumulations) patients were used percutaneous puncture-drainage method under ultrasound control, among them in 5 cases the method was used to eliminate fluid accumulations due to acute peripancreatic fluid accumulation, in 2 cases – acute necrotic effusion, limited necrosis – in 2 cases, and pancreatic pseudocyst – in 3 cases. A clinical case of acute necrotic pancreatitis complicated by the development of acute necrotic effusion is presented, for the treatment of which a combination of transcutaneous minimally invasive and open surgical methods of treatment was used at different stages of the disease. So, fluid accumulations around the pancreas belong to the local complications of acute pancreatitis and are recommended for correction by conservative or minimally invasive methods. The question of choosing the optimal minimally invasive method of treatment requires an individual approach. This clinical case demonstrated the possibility of using puncture-drainage method under the ultrasound control as a “step-up” intervention in early stage of treatment and allowed to postpone the open surgery.

STRUCTURAL ANALYSIS OF CLINICAL AND LABORATORY AND INSTRUMENTAL DIAGNOSIS AND TREATMENT OF ACUTE PANCREATITIS

Summary. The purpose of the study: to analyze the causes of development, terms of hospitalization, the frequency of severe type, complications and overall mortality in acute pancreatitis according to the clinic data. Materials and methods: the results of treatment of 622 patients with acute pancreatitis were analyzed. Among them there were 336 women (54.1 %) and 286 men (45.9 %). The mean age of patients was (48.2 ± 2.2) years. The diagnosis of acute pancreatitis was made according to the recommendations (Atlanta, 2012). All patients with acute pancreatitis underwent ultrasound examination of the abdominal cavity and computed tomography, enhanced by intravenous contrast. Results and discussion: Etiological factors of acute pancreatitis were: biliary factor in 270 (43.4 %) patients, alcohol — in 155 (24.9 %), acute pancreatitis on the background of triglyceridemia — in 135 patients (21.7 %), 21 (3.4 %) patients had postoperative pancreatitis, medication — in 8 (1.3 %) patients and without a clear etiology — in 33 (5.3 %) patients. The terms of hospitalization of patients are as follows: after 24–48 hours from the onset of the disease — 215 (34.6 %) cases, after 6–24 hours after the onset of the disease — 204 (32.8 %) cases, after 48 hours and later from the time of the disease — 129 (20.7 %) cases and 74 (11.9 %) cases of hospitalization up to 6 hours from the onset of the disease. Severe acute pancreatitis developed in 147 (23.6 %) patients and was accompanied by the development of organ failure lasting > 48 hours. 594 (95.4 %) patients with acute pancreatitis received only conservative infusion therapy. 28 (4.5 %) patients required surgical treatment. The overall mortality in patients with acute pancreatitis was 9 (1.4 %) cases. Conclusions: Hyperdiagnosis of acute pancreatitis is a common problem in modern surgery. Formulation of the diagnosis according to the unified diagnostic criteria considerably facilitated diagnosis. The dominant factors of acute pancreatitis are biliary (43.4 %) and alcoholic factors (24.9 %). Most often (34.6 %) patients were admitted to the department on the second day after the onset of the disease. Remains high level of severe acute pancreatitis, which amounted to 23.6 % of cases. 594 (95.4 %) patients with acute pancreatitis received infusion therapy. 28 (4.5 %) patients underwent surgical treatment. The total mortality in acute pancreatitis according to our clinic was 9 (1.4 %) cases, the majority of them (7 patients) died in the early period of acute pancreatitis.

Lack of Association between Postoperative Pancreatitis and Other Postoperative Complications Following Pancreaticoduodenectomy

Background: Prediction of post-pancreaticoduodenectomy (PD) morbidity is difficult, especially in the early postoperative period when CT (Computed Tomography) scans are not available. Elevated serum amylase and lipase in postoperative day 0 or 1 may be used to define postoperative acute pancreatitis (POAP), but the existing literature does not agree on whether POAP is significantly associated with postoperative pancreatic fistula (POPF). Methods: We analyzed the data obtained from a previously published randomized controlled trial. POAP was defined as elevations in serum amylase above 110 U/L on postoperative day 0 or 1. Clinically relevant POAP (CR-POAP) was defined as elevations in C-reactive protein level (CRP) on postoperative day 2 in those with POAP. Postoperative complications including severe complications (Clavien–Dindo ≥ IIIa), POPF, and clinically relevant POPF (CR-POPF) were analyzed. Results: In 246 patients, POAP did not show significant associations with total postoperative complications (odds ratio (OR) 0.697; 95% CI, 0.360–1.313; p = 0.271), severe complications (OR 0.647; 95% CI, 0.258–1.747; p = 0.367), and CR-POPF (OR 0.998; 95% CI, 0.310–3.886; p = 0.998) in multivariable analysis. Conclusions: In patients undergoing PD, POAP was not significantly associated with postoperative complications including POPF. Caution should be taken when using POAP as a predictor of POPF.

Preoperative Fibrinogen as a Predictor for Development of Postoperative Hyperamylasemia and Postoperative Pancreatitis

Introduction: Postoperative pancreatitis complications can be separated into two main groups based on literature reviews and clinical and experimental trials. Some authors suggest that postoperative pancreatitis is a severe complication that should be treated conservatively and operatively if needed. Other authors defend an opposite opinion that only postoperative hyperamylasemia exists, which is a transitory condition with no risk of complications.

Risk Factors of Pancreatitis after Percutaneous Transhepatic Biliary Stent Implantation in Patients with Distal Malignant Biliary Obstruction

Purpose Percutaneous transhepatic biliary stent implantation (PTBS) has been widely used in the treatment of malignant obstructive jaundice (MBO)，which is an effective palliative therapy. The goal of the research was to explore the risk factors of postoperative pancreatitis in patients who had received PTBS.Materials and Methods This study retrospectively included 248 patients with distal malignant biliary obstruction (DMBO) who received PTBS from 2014 to 2019. The risk factors of postoperative pancreatitis such as clinical characteristics, laboratory and stent variables were evaluated by logistic regression analysis.Results Pancreatitis occurred in 51 (20%) patients, all of whom were mild pancreatitis. Multivariate analysis showed that stent implantation across the duodenal papilla, preoperative (within 3 days) administration of proton pump inhibitors (PPIs) were independent risk factors that related to pancreatitis (OR =13.242, 95% CI: 1.729–101.405; P = 0.013; OR =2.113, 95% CI: 1.024–4.36; P = 0.043, respectively), while preoperative administration of antibiotics was a protective factor (OR =0.466, 95% CI: 0.226–0.961; P = 0.039).Conclusion Patients with DMBO who underwent PTBS across the duodenal papilla were more likely to developing postoperative pancreatitis. Preoperative (within 3 days) administration of PPIs was also an independent risk factor for postoperative pancreatitis. Furthermore, preoperative administration of antibiotics may lower the risk of pancreatitis.

Safety assessment of preoperative oil chemoembolization with nanoparticle albumin-bound paclitaxel in patients with pancreatic head adenocarcinoma

Results of combined treatment of 36 patients suffering from pancreatic head ductal adenocarcinoma are evaluated, including preoperative chemotherapy using nanodispersed albumin-stabilized paclitaxel (nab-paclitaxel) in intraarterial oil chemoembolization or intravenous administration and radical surgical treatment. Intraarterial oily chemoembolization of the pancreatic head consisted of the introduction of 17 patients (main group) into the gastroduodenal artery of an emulsion of super-liquid lipiodol (Lipiodol Ultra Fluid) in an aqueous solution of nab-pacliaxel 50 mg/m2 and gemcitabine 400 mg/m2. 19 patients (control group) were administered nab-paclitaxel 100 mg/m2 and gemcitabine 1000 mg/m2 intravenously according to standard guidelines. Safety and tolerability assessment of combined treatment with preoperative application of nab-paclitaxel was carried out in advance. Pil-preserving pancreatoduodenal resection is considered safe on day 710, after completion of preoperative chemotherapy with nab-paclitaxel. The use of nab-paclitaxel in preoperative intraarterial oily chemoembolization of the pancreatic head requires extension of the pancreatic crossing boundary to body level. Postoperative lethality and 4th degree complications according to the Clavien-Dindo classification were not observed. In the main group, grade 3a complication was observed in 2 (12%) patients and was represented by bleeding from acute gastric erosions resolved endoscopically. In the control group, complications of degree 3 were also noted in 2 (11%) patients and were represented by: one bleeding from acute stomach erosions that required endoscopic hemostasis and an intraabdominal abscess allowed by percutaneous drainage. In the main group, complications of the 2nd degree were recorded in 8 (47%) patients: in 3 (17%) patients the formation of pancreatic fistula was noted, in 4 (23%) postoperative pancreatitis was detected, and in 1 (6%) gastrostasis phenomena that required conservative therapy. In the control group, complications of the 2nd degree were observed in 11 (58%) patients and were presented: pancreatic fistulae in 2 (10%) patients, postoperative pancreatitis in 6 (31%) and gastrostasis in 3 (16%) patients. The most common complication observed in both groups was the suppression of a postoperative wound, corresponding to the 1st degree of severity: in the main group in 5 (29%) patients, in the control group in 7 (37%) patients. Thus, the use of intraarterial oil chemoembolization with nab-paclitaxel as a preoperative antitumor treatment can be considered safe.