Surgical management of pancreatoduodenal tumors: the experience of using the developed operation technique

Relevance: The results of surgery in patients with pancreaticoduodenal cancer remain unsatisfactory. This complicates the choice of an optimal surgical technique in modern oncology. Surgery in the pancreaticoduodenal zone is associated with complications due to anatomical and physiological features of the pancreas and technical challenges of this surgical intervention. Despite preventive actions and innovative technologies, such a traumatic operation as pancreatoduodenal resection often produces complications, though recently fewer. This article describes a pancreaticoduodenal resection technique that reduces postoperative complication frequency and lethality in operable pancreaticoduodenal cancer. The purpose of the study was to assess the efficiency of an authorial pancreaticoduodenal resection technique (pancreaticojejunal invagination anastomosis) in pancreaticoduodenal cancer. The proposed pancreaticojejunal anastomosis-forming technique allowed reducing the postoperative complication frequency from 54.2% to 38,0% and postoperative lethality from 22.8% to 9,5%. Conclusion: This highly traumatic surgery is associated with postoperative complications (up to 50-70% of cases), which are quite severe and difficult to resolve and result in high fatality. The proposed pancreaticojejunal anastomosis forming technique has efficiently reduced postoperative complications and fatality to a significant extent.

Surgical management of pancreatoduodenal tumors: the experience of using the developed operation technique

Relevance: The results of surgery in patients with pancreaticoduodenal cancer remain unsatisfactory. This complicates the choice of an optimal surgical technique in modern oncology. Surgery in the pancreaticoduodenal zone is associated with complications due to anatomical and physiological features of the pancreas and technical challenges of this surgical intervention. Despite preventive actions and innovative technologies, such a traumatic operation as pancreatoduodenal resection often produces complications, though recently fewer. This article describes a pancreaticoduodenal resection technique that reduces postoperative complication frequency and lethality in operable pancreaticoduodenal cancer. The purpose of the study was to assess the efficiency of an authorial pancreaticoduodenal resection technique (pancreaticojejunal invagination anastomosis) in pancreaticoduodenal cancer. Results: The proposed pancreaticojejunal anastomosis forming technique allowed reducing the postoperative complication frequency from 54.2% to 38.0% and postoperative lethality from 22.8% to 9.5%. Conclusion: This highly traumatic surgery involves quite severe and difficult to resolve postoperative complications (up to 50-70% of cases) and the resulting high fatality. The proposed pancreaticoduodenal anastomosis forming technique has efficiently reduced postoperative complications and fatality to a significant extent

USEFULNESS OF BIODEGRADABLE STENT IN THE PREVENTION OF PANCREATIC FISTULA AFTER PANCREATIC SURGERY

INTRODUCTION Postoperative pancreatic fistula (POPF) remains the most important cause of morbidity after cephalic pancreaticoduodenectomy (PD), affecting up to one third of cases. The aim of this paper is to present a prospective single-center study with 16 patients undergoing PD in whom a biodegradable stent was placed, analyzing morbidity and mortality, the presence of POPF and the correct position and degradation time of the stent. MATERIAL Y METHODS A duct-to-mucosa end-to-side anastomosis was performed for the pancreaticojejunal anastomosis and the biodegradable stent (“Archimedes”, amg International GmbH, Germany) was placed from the pancreatic duct to the jejunum (Figure 1). The stent has a helical shape that facilitates the flow of pancreatic juice. POPF was defined as drainage fluid amylase value of > 5000 U/L on the first day after surgery. RESULTS Only one patient developed POPF in the postoperative period and it was successfully treated with interventional radiology drainage and somatostatin analogues. There was no mortality at 30 days after PD. An abdominal radiograph was performed to asses well-positioning of the stent on postoperative day 7. To evaluate the degradation after three months we used the CT scan. A complete degradation was defined as < 25% of stent length or stent fragments visible at CT. Completed degradation occurred after 3 months in all cases. CONCLUSION The use of resorbable internal pancreatic stent could be a valid alternative to prevent the development of pancreatic fistula after a pancreaticoduodenectomy.

Initial Experience with Biodegradable Pancreatic Stents in the Prevention of Postoperative Pancreatic Fistula after Cephalic Pancreaticoduodenectomy

Background: Postoperative Pancreatic Fistula (POPF) remains the most important morbidity after pancreaticoduodenectomy. There is no consensual technique for pancreatic reconstruction and many surgeons use a transanastomotic drain. Currently, the stents used are not degradable and they can cause obstruction, stricture and pancreatitis. The use of biodegradable stents that disappear a few months after the intervention could have a role in the prevention of pancreaticojejunostomy complications. The aim of the study was to evaluate technical success of implantation and safety of newly available biodegradable stents in 16 patients undergoing cephalic duodenopancreatectomy. Materials and Methods: A single-center prospective non-randomized study was conducted with patients undergoing PD. A total of 16 patients were included. A duct-to-mucosa end-to-side anastomosis was performed for the pancreaticojejunal anastomosis and the biodegradable stent (Archimedes) was placed from the pancreatic duct to the jejunum. Results: One of the patients developed POPF, which was successfully treated with interventional radiology drainage and somatostatin analogues. Completed degradation occurred after 3 months in all cases. There was no mortality at 30 days after PD. Conclusion: Based on our experience, the use of resorbable internal pancreatic prostheses could be a valid alternative to prevent POPF after a pancreaticoduodenectomy, also avoiding the main complications related to the use of non-absorbable prostheses.

Surgery for Ampullary Cancer in a Patient with Pancreatic Lipomatosis Caused by Cystic Fibrosis

A patient with cystic fibrosis (CF) with pancreatic insufficiency presented with jaundice due to an ampullary tumour. CF is known for a higher incidence of gastrointestinal malignancies. The patient suffered from pancreatic insufficiency. At computed tomography (CT), pancreatic lipomatosis with absence of the pancreatic duct was seen. This is uncommon, also in patients with CF. During surgery, a total pancreatectomy was performed, because there was no possibility to construct a duct to mucosa anastomosis due to the absence of the pancreatic duct and more importantly the pancreas was already afunctional. The presence of lipomatosis increases the risk of leakage at the pancreaticojejunal anastomosis. Therefore, it is important to take this phenomenon, in this case already visible on the preoperative CT scan, into account during the workup for surgery.

Central Pancreatectomy with Roux-en-Y Pancreaticojejunal Anastomosis—Report of Two Cases

Background Central pancreatectomy (CP), a partial resection of the pancreas, is indicated for the excision of neuroendocrine tumors (NETs) of the pancreas, when located at the neck or the proximal body. Specifically, CP is preferable in functional NET and in nonfunctional sized 1 to 2 cm or/with proliferation marker Ki67 < 20% (Grade I/II). Postoperative leakage from the remaining pancreas constitutes the most frequent complication of CP (up to 63%). The aim of our study was to share the experience of our center in CP for NET, with pancreaticojejunal anastomosis. Methods In 1 year, we performed CP in two patients, following the aforementioned criteria. They presented with tumor of the body of the pancreas, which was found in random check with computed tomography, with negative hormonal blood tests and they underwent magnetic resonance imaging and endoscopic ultrasound/fine-needle biopsy/pathological examination. Results The patients underwent CP with Roux-en-Y pancreaticojejunal anastomosis of the distal pancreatic stump and jejunal patch of the proximal pancreatic stump. Histological exam revealed NET sized 2.8 cm and 1.45 cm, Grade I and II, respectively. Postoperatively both patients developed small pancreatic leakage, which did not affect their physical condition and stopped after 20 and 30 days. No one needed pancreatic enzymes supplements or developed new-onset diabetes mellitus. Conclusion CP provided adequate, functional remaining pancreatic tissue in both patients. Small leakages were treated conservatively and retreated without septic complications. As a result, CP might be considered as safe and effective technique for pancreatic neck/proximal body NET.

Duct-to-mucosa pancreaticojejunostomy can reduce the risk of pancreatic fistula after pancreaticoduodenectomy

Background: Pancreaticoduodenectomy (PD) is the most effective surgical procedure to remove a pancreatic tumor. However, pancreatic fistula occurring after surgery is associated with a high incidence of life-threatening complications. Therefore, the aim of this work was to summarize the factors influencing the development of pancreatic fistula after PD and the measures to prevent it. Methods: Clinical data of patients who were subjected to PD between January 2012 and January 2017 in the Department of General Surgery, First Hospital of Lanzhou University, China, were collected and retrospectively analyzed. The risk factors for pancreatic fistula were analyzed by univariate analysis and multivariate logistic regression analysis. Results: Among 215 patients, 42 were suffering from a postoperative pancreatic leakage, with an incidence of 19.5% (42/215). Univariate analysis showed a significant correlation between postoperative pancreatic fistula (POPF) and the following factors: pancreaticojejunal anastomosis (end-to-side “sleeve” pancreaticojejunostomy vs duct-to-mucosa pancreaticojejunostomy: 27.8% vs 11.2%, P = 0.002), pancreatic duct diameter (≤ 3 mm vs > 3 mm: 25.2% vs 13.8%, P = 0.036), and pancreatic texture (hard vs soft: 14.2% vs 25.2%, P = 0.043). Multivariate logistic regression analysis showed that pancreaticojejunal anastomosis was the independent risk factor for POPF after PD. Conclusions: High quality anastomosis is an important factor in the prevention of POPF. Pancreaticojejunal duct-to-mucosa anastomosis is a simple technique and results in a low incidence of pancreatic fistula.