SEVERE COVID-19 IN PATIENT AT EARLY POSTOPERATIVE PERIOD AFTER WHIPPLE’S OPERATION WITH MARGINAL PORTAL VEIN RESECTION

Introduction. Pancreatoduodenectomy (PDR or Whipple’s operation) remains the only effective radical method of surgery for tumors of the pancreatic head, distal common bile duct and Vater’s papilla. The most frequent complications of the early postoperative period are: gastrostasis, pancreatic fistula, postoperative bleeding and pulmonary complications. According to World Health Organization (WHO) and reviews, severe COVID-19 usually occurs in older age patients, and in patients with oncological diseases. Case description. Patient V., 64 years old, due to a tumor of the head of the pancreas with invasion of the distal common bile duct and the development of obstructive jaundice, underwent PDR. Histopathologically, ductal adenocarcinoma of the pancreatic head, G-2, was confirmed. The PDR operation was performed within healthy tissues, which was confirmed by histopathology. On the second day after surgery, patient was admitted to ICU because of respiratory failure, the SARS-CoV-2 antigen test was positive, we suggest that the patient was in the latent period of COVID-19 disease during the surgery. Patient received hormone therapy, anticoagulants in therapeutic doses, O2-therapy. On the 5th day, because of severe ARDS, the patient was intubated, on the 7th day - convalescent plasma transfused (1 dose). On the 9th day, a tracheostomy was applied for airways care and early activation. Respiratory support was provided twelve days. Patient received early activation, exercises, as well as early enteral nutrition. After ICU discharge, patient’s condition was complicated by the gastro-intestinal bleeding, blood transfusion and embolization of the dorsal pancreatic artery were performed. On the day 66th after surgery patient was discharged home in satisfactory condition. Conclusion. General care and early activation of the patient within early tracheostomy, convalescent plasma usage and the well-coordinated work of the surgical and anesthesiological teams allows timely identification and elimination of early postoperative complications after Whipple’s operation with marginal resection of the portal vein.

Impact of Pancreatic Resection on Survival in Locally Advanced Resectable Gastric Cancer

Whether gastric adenocarcinoma (GC) patients with adjacent organ invasion (T4b) benefit from aggressive surgery involving pancreatic resection (PR) remains unclear. This study aimed to clarify the impact of PR on survival in patients with locally advanced resectable GC. Between 1995 and 2017, patients with locally advanced GC undergoing radical-intent gastrectomy with and without PR were enrolled and stratified into four groups: group 1 (G1), pT4b without pancreatic resection (PR); group 2 (G2), pT4b with PR; group 3 (G3), positive duodenal margins without Whipple’s operation; and group 4 (G4), cT4b with Whipple’s operation. Demographics, clinicopathological features, and outcomes were compared between G1 and G2 and G3 and G4. G2 patients were more likely to have perineural invasion than G1 patients (80.6% vs. 50%, p < 0.001). G4 patients had higher lymph node yield (40.8 vs. 31.3, p = 0.002), lower nodal status (p = 0.029), lower lymph node ratios (0.20 vs. 0.48, p < 0.0001) and higher complication rates (45.2% vs. 26.3%, p = 0.047) than G3 patients. The 5-year disease-free survival (DFS) and overall survival (OS) rates were significantly longer in G1 than in G2 (28.1% vs. 9.3%, p = 0.003; 32% vs. 13%, p = 0.004, respectively). The 5-year survival rates did not differ between G4 and G3 (DFS: 14% vs. 14.4%, p = 0.384; OS: 12.6% vs. 16.4%, p = 0.321, respectively). In conclusion, patients with T4b lesion who underwent PR had poorer survival than those who underwent resection of other adjacent organs. Further Whipple’s operation did not improve survival in pT3–pT4 GC with positive duodenal margins.

Clinicopathological Outcome of Patients Undergoing Whipple’s Operation- A Retrospective Study over a Decade in a Tertiary Care Centre

Introduction: The surgical procedure pancreaticoduodenectomy is popularly known as Whipple’s operation. Whipple procedure is one of the major surgeries performed in tertiary care centres. Aim: The present research was undertaken to study indications of Whipple’s operation and also to evaluate pathological findings of periampullary tumours with biochemical investigations. Materials and Methods: This retrospective study was conducted in total 155 patients who had undergone Whipple’s operation over a period of ten years from January 2009 to December 2019 at a tertiary care hospital in a central India. The hematoxylin and Eosin (H&E) stained slides were reviewed and various parameters were studied like presence or absence of the tumour, site of origin of tumour (ampulla/ head of pancreas/distal common bile duct/ duodenum), histological type (adenocarcinoma/neuroendocrine/ lymphoma), differentiation (well/moderate/poor), depth of invasion, Lymphovascular Invasion (LVI), perineural infiltration, lymph node status (metastasis), resection margin status (involved/not involved) and {Tumour (T), Nodes (N), Metastasis (M)} staging. Perioperative complications and postoperative follow-up of minimum 30 days for all patients were studied. Results: The most common indication for Whipple’s operation was periampullary carcinoma irrespective of its site of origin and was most commonly seen in males in age group of 51-60 years. Out of total 155 cases, four cases were excluded as no tumours were found in those cases. Tumours from ampulla were most common (101) followed by those from Common Bile Duct (CBD) (22) and pancreas (22) and duodenum (6). The median size of the tumour in Whipple's specimen was 1.44 cm2. Most frequent histological type was adenocarcinoma (145, 96.02%). Moderate differentiation was most commonly observed histological grade in periampullary carcinomas 116 (76.8%). Perineural and lymphovascular infiltration was seen more commonly in pancreatic cancers 90.9% (20/22). Lymph node metastasis was significantly high in pancreatic cancers. Perioperative complications were seen in 32 patients with common complications were biliary leak. The perioperative mortality was 7.9%. Distal cholangiocarcinoma was found to be more aggressive followed by pancreatic and ampullary cancers. Conclusion: Whipple procedure is associated with a unique set of common complications and continues to be associated with considerable morbidity. With careful patient selection, Whipple procedure can be performed safely.