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UDC 616.37-002-089.168.1-06
CAUSES OF UNSATISFACTORY RESULTS OF DUODENUM-PRESERVING PANCREATIC RESECTIONS
1 Altai State Medical University, Barnaul
2 Regional Clinical Hospital, Barnaul
V.G. Lubyansky1, V.V. Seroshtanov1, I.V. Arguchinsky2, Ye.N. Semenova2
In the clinic, 111 patients with chronic pancreatitis were operated. All were examined using CT with bolus contrast, biochemical examination of markers CA-19-9. Frey's operation was performed in 106 (95.4%) patients, 5 (4.6%) - Beger's operation. In the near postoperative period, complications occurred in 12 (10.8%) patients. Lethality was 2.7% (3 patients). In the long term, 31 patients were examined at the clinic. 13 patients noted a good result. 18 had unsatisfactory outcomes. When analyzing the causes of unsatisfactory results, patients are divided into 3 groups: First group - stenosis of pancreatic anastomosis, associated with the incompetence of pancreatic anastomosis and the presence of fistula. The second group of pancreatic tail hyperplasia, caused by the progression of the fibroinflammatory process. The third is the occurrence of cancer after duodenum retaining resections. Patients of the first group underwent reconstruction of pancreatic anastomosis. Patients of the second group underwent tail resection and arterial infusion of 5-fluorouracil or hydrocortisone. The third group performed one pancreatectomy, one pancreaticoduodenal resection and chemotherapy. Thus, in order to prevent unsatisfactory outcomes, it is necessary to use precision technologies of pancreatic anastomosis and sealing substances based on fibrin glue. In the second group, it is advisable to use repeated pancreas resections, and in some cases, the use of regional arterial infusion of anti-inflammatory drugs.
Key words: chronic pancreatitis, stenosis of pancreatoenteroanastomosis, pancreatic cancer.
In recent years, duodenum-preserving pancreatic resection has been an operation of choice in the treatment of chronic pancreatitis. Pancreati-coduodenal resections are performed only in special cases: if pancreatic cancer can not be excluded and by bulbous pancreatitis. In the literature, there are data on recurrences of pain syndrome after duodenum-preserving resections. Along with this, the problem of pancreatic cancer on the background of CP is actively discussed [1].
There are several points of view on this issue. The first is the addition of CP to the existing pancreatic cancer that occurs as a result of genetic mutations [2]. The second is the development intraep-ithelial metaplasia and neoplasia in patients with CP in the epithelium of the ducts [3].
The objective is to find out the causes of unsatisfactory results after Frey's operation and determine the tactics of patients management.
Materials and methods
In clinic, 111 patients with chronic pancreatitis were operated. Indications for the operation were complications and pain syndrome. 51 patients had cystic forms, 33 had retention forms and 27 had pseudotumor head lesions. Frey's operation was most often performed, which was done in 106 (95.4%) patients, Beger's operation - in 5 (4.6%). The technique of Frey's operation consisted in resection of the head of the pancreas followed by the imposition of longitudinal pan-creatoenteroanastomosis. Beger's operation consisted in the complete intersection of the pancreas at the left edge of the superior mesenteric vein,
the removal of the head tissue with the preservation of a narrow band with pancreaticoduodenal vessels and the intrapancreatic part of the common bile duct along the medial surface of the duodenum.
Before the operation and in the postoperative period, all patients were subjected to clinical and biochemical studies with the determination of blood amylase, analysis of drainage fluid from the abdominal cavity in the postoperative period to the a-amylase level, tumor markers CA-19-9. Instrumental examination included ultrasound of abdominal organs on Esaote Mylab apparatus, MSCT of abdominal cavity (SOMATOM Definition-128 device) with intravenous bolus contrast "Ultravist 370", endosonograph. FGDS was performed to assess the condition of the duodenum and to reveal a violation of the drainage function of the large duodenal papilla.
During the operation, the pancreatic tissue site was excised for a cytohistological examination followed by examination of the permanent preparations.
Results and discussion
In the near postoperative period, complications occurred in 12 (10.8%) patients. The most common cause was the inconsistency of pancreatic anastomosis. Lethality was 2.7% (3 patients).
In the long terms, there were examined 31 patients. Of these, 6 showed excellent, 3 good, 4 satisfactory, and 18 - unsatisfactory results. The subject of analysis was unsatisfactory outcomes. They
were divided into three groups according to causes of origin.
The first group consisted of 6 patients who developed stenosis of pancreatoenteroanastomosis (Fig. 1a, b).
The second group consisted of 4 patients who had fibrotic pancreatic tail hyperplasia with the onset of pain syndrome. (Figure 2).
Figure 1 b. Stenosis of pancreatoenteroanastomosis after Frey's operation. Probe in the duct of the pancreas.
Figure 2. Inflammatory-fibrous hyperplasia of the tail of pancreas. Increase in the size of the body and tail of pancreas.
The third group consisted of 8 patients who had pancreatic cancer diagnosed within 6 months to 2 years (Figure 3a, b).
Figure 3b. Histological structure of the pancreatic tissue: Papillomatous proliferation of ductal epithelium (1), alteration of the epithelium with increasing number of nuclei, signs of dysplasia, hyperplasia (2), increase in the number of small ducts (3), lymphocytic and plasmocyte infiltration in the periprotic and acinar structures 4). Zoom 10x10. Staining:
hematoxylin-eosin.
The analysis of the causes of stenosis of pancreatic anastomosis revealed that among factors contributing to its occurrence, the presence of pancreatic fistula in the early postoperative period or the inconsistency of pancreatoenteroanastomosis is important. Apparently, even minimal percolation of enzymes in the early postoperative period through the joint zone can lead to a progression of the processes of fibrosis. One of the reasons for the stenosis of pancreatic intestinal anastomosis may be gastroenteral reflux, which appears to play a significant role in stimulating the epithelium filling of the cavity formed in the head of the pancreas and developing in the field of pancreatic intestinal fibrosis.
The second group included patients with pancreatic tail hyperplasia. It turned out that it arose in cases of head resection after Beger's operation in two patients and two patients after Frey's operation. And in one case, the patient underwent em-bolization of gastroduodenal artery due to bleeding from pancreatic anastomosis, and the other two - suturing of the upper pancreatic-duodenal artery. Apparently, with the blockage of blood flow in the head or its resection, accelerated tissue regeneration takes place in the pancreatic tail region, which in young people may be accompanied by an increase in the number of acinar tissue, and in the elderly - with the growth of fibrous tissue. The proliferation of fibrous tissue led to the onset of a pain syndrome, in which patients sought help.
Finally, the third group included eight patients with pancreatic cancer. In all these cases, there were analyzed primary biopsies in which no signs of a tumor were found. The reason for its occurrence is the proliferation of papillomatous tissue
in the pancreatic ducts, hyperplasia of small ducts and their pathological growth in chronic pancreatitis, as well as dysplasia of the protocol epithelium, which is described in the works of Raimondi S., Lowenfels A. B. [4].
The most likely cause of these phenomena is ductal hypertension, which was not eliminated during the primary operation in eight patients.
All patients were examined, 15 people were subjected to surgical treatment. Reconstruction of pancreatoenteroanastomosis with repeated resection of the body and head was undertaken in nine patients, resection of the tail of the pancreas, in occasion of its fibrous hyperplasia, was performed in two patients.
In patients with pancreatic cancer, in one case, pancreatectomy was undertaken, in one case -pancreatoduodenal resection, the remaining patients underwent chemotherapy. There were no lethal outcomes among the patients of the first two groups. All patients with tumors died within six months after treatment in the hospital.
In order to eliminate the development of repeated relapses after the first operation on the pancreas, there were proposed the following methods:
The use of adhesive sealing of pancreatic anastomosis was performed in 17 patients. In two cases, glue was applied inside the lumen of pancreatic anastomosis. Cases of inconsistency of pan-creatoenteroanastomosis and the occurrence of fistulas lacked.
In order to suppress hyperplasia of fibrous tissue, an arterial infusion into the gastroduodenal artery of hydrocortisone suspension (V.B. Gervazi-yev) or 5-fluorouracil was used.
Figure 4. Catheterization of the gastroduodenal artery for the purpose of arterial infusion. An increase in the vascular pattern of the head of the pancreas as a result of a local inflammatory process
Figure 5. After a course of intra-arterial infusion of anti-inflammatory drugs into the gastroduodenal artery, a decrease in the size and fullness of the head of the pancreas.
The most difficult is the problem of preventing the onset of pancreatic tumors. This process is largely uncontrolled, but it is advisable to conduct an in-depth histological examination and perform radical excision of the pancreatic head tissue during the primary duodenum-preserving resection.
Conclusions
1) Among the causes of unsatisfactory results after duodenum-preserving resections, the main ones are: stenosis of pancreatoenteroanastomosis, fibrotic pancreatic tail hyperplasia and develop-
ment of cancer in the left part of the pancreas.
2) In order to prevent stenosis of pancreatic an-teroanastomosis, it is advisable to perform it with the use of precision technology with additional glutinous application of fibrin glue.
3) The use of a regional infusion of 5-fluoro-uracil and hydrocortisone in a number of observations allows to slow the development of fibro-in-flammatory changes in the tissues of the pancreas in the postoperative period.
References
1. Lazebnik L.B., Vinokurova L.V., Yashina N.I. Chronic pancreatitis and pancreatic cancer. Experimental and clinical gastroenterology. 2012; 7: 3-9.
2. Grigoryeva I.N., Efimova O.V., Suvorova T.S., Tov N.L. Genetic aspects of pancreatic cancer. Experimental and clinical gastroenterology. 2014; 10(110): 70-76.
3. Hwang IK, Kim H, Lee YS et al. Presence of pancreatic intraepithelial neoplasia-3 in a background of chronic pancreatitis in pancreatic cancer patients. Cancer Sci. 2015; 106(10): 1408-1413.
4. Raimondi S, Lowenfels AB, Morselli-Labate AM, et al. Pancreatic cancer in chronic pancreatitis; aetiology, incidence, and early detection. Clinical Gastroenterology. 2010; 24(3): 349-358.
Contacts
Corresponding author: Seroshtanov Vasily Vladi-mirovich, Assistant of the Department of Faculty Surgery named after Professor I.I. Neimark, hospital surgery with course of FVE of the Altai State Medical University, Barnaul. 656056, Barnaul, ul. Lyapidevskogo, 1. Tel.: (3852) 689574. Email: basner89@mail.ru
Lubyansky Vladimir Grigorievich, Doctor of Medical Sciences, Professor, Professor of the Department of Faculty Surgery named after Professor I.I. Neimark, hospital surgery with course of FVE of the Altai State Medical University, Barnaul. 656056, Barnaul, ul. Lyapidevskogo, 1. Tel.: (3852) 689574. Email: lvg51@mail.ru
Arguchinsky Igor Vladimirovich, Candidate of Medical Sciences, Head of the department of the surgical department of the Regional Clinical Hospital, Barnaul.
656056, Barnaul, ul. Lyapidevskogo, 1. Tel.: (3852) 689574. Email: lvg51@mail.ru
Semenova Elena Nikolaevna, doctor pathologist of the Regional Clinical Hospital, Barnaul. 656056, Barnaul, ul. Lyapidevskogo, 1. Tel.: (3852) 689574. Email: lvg51@mail.ru
