Prevention of complications of transpapillary endoscopic interventions

This study analyzed the treatment results of 345 patients who underwent planned and emergency transpapillary surgical interventions for various diseases of the biliopancreatoduodenal region. Among these patients, 68.9% were women and 31.1% were men aged 1892 (mean age, 63.7 4.5) years. The study included patients who used various types of transpapillary endoscopic interventions as a treatment method, such as endoscopic papillo-sphincterotomy (71.9%, including choledocholite extraction in 68.7% of the patients), endoprosthetics of the common bile duct and main pancreatic duct (17.8%), balloon dilatation and bougienage of bile duct strictures (6.2%), mechanical lithotripsy (2%), nasobiliary drainage (1%), endoscopic wirsungotomy (0.8%), and endoscopic papillectomy (0.3%). Variants of the inflow of hepaticoholedochus and Wirsung duct were assessed using magnetic resonance cholangiopancreatography. The active implementation of preventive measures regulated by the global community made it possible to reduce the overall incidence of complications of transpapillary interventions to 13.1% and the rates of postoperative mortality to 1.3% (p 0.05). The use of these measures led to a significant decrease in the incidence of acute post-manipulation pancreatitis from 10.3% to 4.8%, postoperative bleeding from 8.9% to 5.5%, cholangitis from 2.8% to 0.7%, and a low incidence of retroduodenal perforation in 1.1%. Personalized consideration of the modern recommendations of the global endoscopic communities (Europeans, Americans, and Japanese) when performing endoscopic retrograde cholangiopancreatography, as well as original approaches associated with the determination of the anatomical features of the structure of the Vater papilla with variants of fusion of hepaticocholedochus and Wirsung duct, helped to significantly reduce the overall incidence of complications following transpapillary endoscopic procedures from 22.2% to 13.1%.

Utility of CT to Differentiate Pancreatic Parenchymal Metastasis from Pancreatic Ductal Adenocarcinoma

Purpose: To report the computed tomography (CT) features of pancreatic parenchymal metastasis (PPM) and identify CT features that may help discriminate between PPM and pancreatic ductal adenocarcinoma (PDAC). Materials and methods: Thirty-four patients (24 men, 12 women; mean age, 63.3 ± 10.2 [SD] years) with CT and histopathologically proven PPM were analyzed by two independent readers and compared to 34 patients with PDAC. Diagnosis performances of each variable for the diagnosis of PPM against PDAC were calculated. Univariable and multivariable analyses were performed. A nomogram was developed to diagnose PPM against PDAC. Results: PPM mostly presented as single (34/34; 100%), enhancing (34/34; 100%), solid (27/34; 79%) pancreatic lesion without visible associated lymph nodes (24/34; 71%) and no Wirsung duct enlargement (29/34; 85%). At multivariable analysis, well-defined margins (OR, 6.64; 95% CI: 1.47–29.93; p = 0.014), maximal enhancement during arterial phase (OR, 6.15; 95% CI: 1.13–33.51; p = 0.036), no vessel involvement (OR, 7.19; 95% CI: 1.512–34.14) and no Wirsung duct dilatation (OR, 10.63; 95% CI: 2.27–49.91) were independently associated with PPM. The nomogram yielded an AUC of 0.92 (95% CI: 0.85–0.98) for the diagnosis of PPM vs. PDAC. Conclusion: CT findings may help discriminate between PPM and PDAC.

Modified “Blumgart-Type” Suture for Wirsung-Pancreaticogastrostomy: Technique and Results of a Pilot Study

<b><i>Introduction:</i></b> Postoperative pancreatic fistula (POPF) represents the principal determinant of morbidity and mortality after pancreaticoduodenectomy. Since 1994 we have been performing pancreaticogastrostomy with duct-to-mucosa anastomosis (Wirsung-pancreaticogastric anastomosis [WPGA]), but postoperative morbidity, although limited, was still a concern. An original pancreas-transfixing suture technique, named “Blumgart’s anastomosis” (BA), has shown efficacy at reducing fistula rates from pancreaticojejunostomy. Few cohort studies have shown that WPGA with pancreas-transfixing stitches may help reduce the rate of POPF. We designed a novel “Blumgart-type” modification of WPGA (B-WPGA) aiming at harnessing the full potential of the Blumgart design. <b><i>Methods:</i></b> A prospective development study was designed around the application of B-WPGA after pancreaticoduodenectomy for primary periampullary tumors. It focused on describing the early iterations of this technique and on assessing the rate of POPF and delayed post-pancreatectomy hemorrhage (DPH) (primary outcomes), along with other perioperative outcomes. Technically, after mobilizing the pancreatic remnant for a few centimeters, the Wirsung duct is cannulated. A lozenge of seromuscular layer is excised from the posterior gastric wall, matching the shape and size of the pancreas’s cut surface. Two to four transparenchymal pancreatic-to-gastric submucosa U stitches with 4/0 Gore-Tex are positioned cranially and caudally to the Wirsung duct, respectively, mounted on soft clamps, and tied onto the gastric serosa only after duct-to-mucosa anastomosis. Postoperative follow-up was standardized by protocol and included a pancreatic enzyme check on the drain output. <b><i>Results:</i></b> From February 2018 to June 2019, in 15 continuous cases, B-WPGA was performed after pancreaticoduodenectomy. Indications for pancreaticoduodenectomy were mainly ampulla of Vater and pancreatic head adenocarcinomas. There was no operative mortality and no pancreatic anastomosis-related morbidity. Two events (13%) of transiently elevated amylase in the drain fluid, not matching the definition of POPF, were identified in patients with a soft pancreas on postoperative day 2. No DPHs were recorded after a minimum follow-up of 18.6 months. <b><i>Discussion/Conclusion:</i></b> The principles of BA may be safely applied to the WPGA model. B-WPGA allows (1) gentle compression and closure of the small secondary ducts in the pancreatic remnant; (2) partial invagination of the pancreatic body in the gastric wall, with the pancreatic cut surface protected by the gastric submucosa; and (3) prevention of parenchymal fractures, as the pancreaticogastric stitches are tied onto the gastric serosa. Despite the limited number of cases in this study, the absence of mortality and anastomosis-related complications supports further reproduction of this technical variant. Larger studies are necessary to determine its efficacy.

THE CHOICE OF PANCREATOJEJUNO-ANASTOMOS TECHNIQUE FOR PANCREATO-DUODENAL RESECTION

Summary. Objective. Development of an algorithm for choosing the method of pancreatojejunoanastomosis in pancreatoduodenal resection, taking into account the degree of change in the pancreatic parenchyma. Materials and methods. Pancreatoduodenal resection was performed on 291 patients with obstructive diseases of the pancreatoduodenal zone. Three options were used for pancreatojejunoanastomos: invagination ductopancreatojejunal — in 210 (72.4 %), invagination pancreatojejunal — in 68 (23.4 %), pancreatojejunal with bandage repair of the crescent ligament of the liver — in 13 (4.4 %) patients. Results. The pancreatic parenchyma was assessed by the following factors: puffiness, infiltration, obesity, degree of pancreatic parenchyma fibrosis, location and diameter of the Wirsung duct. High and low risk factors for the development of pancreatic fistula were identified. Diagnosis of pancreatic fistula was carried out according to the classification of ISGPF (2016). A differentiated approach was applied to the choice of pancreatojejunoanastomosis depending on the degree of changes in the pancreatic parenchyma, the diameter and location of the Wirsung duct. Conclusion. Evaluation of the degree of pancreatic parenchyma changes, the diameter and location of the Wirsung duct allows you to choose the optimal technique for pancreatojejunoanastomosis in pancreatoduodenal resection. The use of a differentiated approach to the choice of pancreatojejunoanastomosis technique for pancreatoduodenal resection, taking into account the degree of change in the pancreatic parenchyma, can reduce the incidence of PF (type B, C).

Short-and long-term results of distal pancreatectomy

Aim. To assess the results of distal pancreatectomy for malignant and benign tumors and chronic pancreatitis complications. Materials and methods. Forty-seven patients, who underwent distal pancreatectomy, were under observation during the period from 01.01.2008 to 28.02.2019. Results. The long-term results of surgical treatment demonstrated the following complications: pancreatic fistulas – 15 % of observations, pancreatogenic diabetes mellitus – 12.7 %, subphrenic abscesses – 10 %. In the long-term period after the surgery – from 10 years and not less than one year – 30 patients were followed up, constituting 63.8 % of the total number. Conclusions. To prevent complications in the form of pancreatic fistula with pathological Wirsung duct dilatation more than 4–5 mm in diameter, it is necessary to form anastomosis between the pancreatic stump and the small bowel.

Editorial acerca de “Fístula pancreática posduodenopancreatectomía. Pancreatogastrostomía vs. pancreatoyeyunostomía”

Pancreatic fistula is the most dreaded complication after pancreaticoduodenectomy due to its morbidity and mortality. Multiple procedures to reduce the incidence of this complication have been described: a- Systematic inhibition of pancreatic enzyme secretion using octapeptide in the postoperative period; bUse of biological fibrin-based adhesive to cover and reinforce the anastomosis; c- Use of omentum flap to wrap the pancreatic anastomosis with the jejunum; dAnastomosis with Wirsung duct stenting; e- Telescopic anastomosis; f- Duct-to-mucosa anastomosis (the most commonly used technique today); g- Use of magnification, etc