Indications for pancreaticoduodenectomy:

• Malignant neoplasms of the head of the pancreas and major duodenal nipple
• Pancreas cancer
• Periampullary cancer
• Abscess of the head of the pancreas

Tests before pancreaticoduodenectomy:

• General analysis of urine and blood
• Analysis for tumor markers CA 19 9 and CEA
• Endoscopic ultrasound
• Abdominal CT

Technique for pancreatoduodenal resection:

This is a very serious operation that is performed under general anesthesia. The surgeon makes a transverse incision in the abdominal cavity. During the operation, part of the stomach, part of the pancreas, gallbladder and duodenum are removed. Regional lymph nodes are excised. After resection of these organs, the surgeon connects the stomach to the jejunum - creating a gastroesterostomy. All excised tissue is sent for histological examination to determine further treatment.

Operation duration:

From 5 to 7 hours

Rehabilitation period:

At the end of the operation, the patient is transferred to the intensive care unit, and after stabilization, to the surgical department. The patient is under round-the-clock supervision by the medical staff of the Scientific and Practical Hospital. Painkillers are prescribed intravenously. An IV is installed through which food and fluids enter the body until the patient is able to eat and drink on his own. He will then be provided with four therapeutic dietary meals a day. The medical staff of the Scientific and Practical Surgery Center provides the patient with a full range of rehabilitation procedures aimed at restoring functions and a speedy return to a normal lifestyle. The patient is discharged on days 7-10.

1 State Healthcare Institution "Ulyanovsk Regional Clinical Center for Specialized Types of Medical Care"

2 Federal State Budgetary Educational Institution of Higher Professional Education "Ulyanovsk State University"

The purpose of this study was to retrospectively evaluate the possibilities of pancreaticoduodenectomy (PDR) in the treatment of patients with adenocarcinoma of the head of the pancreas (PG) in the emergency department. The results of examination and surgical treatment of 82 patients with tumor-like formations of the pancreaticoduodenal zone are presented. According to the results of the examination, it was revealed: in 64 - cancer of the biliopancreaticoduodenal zone; 11 had pseudotumorous pancreatitis complicated by hyperbilirubinemia; 7 had a cyst of the head of the pancreas, complicated by obstructive jaundice. Radical surgery, PDR, was performed in 10 patients (8.2%), and palliative interventions were performed in 72 patients (91.8%). Death in the early postoperative period (6–7 weeks after surgery) was observed in 2 patients. The cause of death was failure of pancreatojejunostomy. Of all the operated patients, 8 patients were discharged in satisfactory condition 16–48 days after surgery. Long-term results were monitored in 6 patients over a period of 2–5 years; there were no deaths. Thus, patients are admitted to emergency surgery departments late, due to complications that have developed; most of the patients were treated by a general practitioner or infectious disease specialist for 2–4 weeks before admission to the surgical department. Late diagnosis causes a low percentage of radical surgical interventions. The high traumatic nature of the operation, expressed by cholemic and tumor intoxication, explains the significant number of complications in the postoperative period and high mortality. PDR remains in the highest risk category for life-threatening complications that limit the range of radical surgery. A comprehensive search for ways to rationally expand the boundaries of radical surgery for pancreatic head cancer and chronic pancreatitis complicated by jaundice, improve surgical techniques and improve results is necessary.

pancreatic head cancer

radical surgery

pancreaticoduodenectomy

1. Baichorov E. Kh., Novodvorsky S. A., Khatsiev B. B. et al. Pancreaticogastroanastomosis during pancreaticoduodenectomy surgery // Surgery. – 2012. – No. 6. – P. 19-23.

2. Gorodnov S.V., Nabegaev A.I., Tyurina T.M. et al. Experience in the treatment of obstructive jaundice in tumor pathology of the pancreaticoduodenal zone // Oncology today: patient, state, medical community. VII Russia. scientific-practical conf. (Ulyanovsk, October 20–21, 2011). – Ulyanovsk, 2011. – P.82-84.

3. Davydov M.I., Aksenov E.M. Statistics of malignant neoplasms in Russia and the CIS countries in 2004 // Bulletin of the Russian Cancer Research Center named after. N. N. Blokhin RAMS. – 2006. – 132 p.

4. Kubyshkin V. A., Vishnevsky V. A., Buriev I. M. et al. PDR with preservation of the pylorus // Surgery. – 2003. – No. 3. – P.60–63.

5. Patyutko Yu. I., Kotelnikov A. G., Abgaryan M. G. et al. Cancer of the head of the pancreas: modern treatment and further prospects // Bulletin of surgical gastroenterology. – 2007. – No. 3. – P. 5-16.

6. Shetveryan G. A. Pancreaticoduodenal resection in the treatment of cancer of the head of the pancreas and periampullary zone: Abstract of thesis. dis... cand. honey. Sci. – M., 2006. – 25 p.

7. Wenger F. A., Jacobi C. A., Haubold K. et al. Gastrointestinal quality of life after duodenopancreatectomy in pancreatic adenocarcinoma. Preliminary results of a prospective randomized study: pancreatoduodenectomy or pyloruspreserving pancreatoduodenectomy // Chirurg. – 1999. – Vol.70, No. 12. – R. 1454-1459.

Introduction

Pancreaticoduodenectomy (PDR) remains a rare operation in our country, although the real need for it both for pancreatic tumors and chronic pancreatitis is very high. Based on publications in the literature, we can say that radical surgical treatment is performed in a minority of patients for whom this treatment is indicated. Detection of pancreatic cancer in the initial stage ranges from 10 to 30%, and radical treatment is possible in up to 10% of patients. Thus, in the United States, more than 29,000 cases of pancreatic adenocarcinoma are diagnosed every year. Of these patients, only 10-20% have resectable tumors, and 25,000 (83%) patients die within 12 months. after diagnosis. The mortality rate from pancreatic cancer in Russia among men is 10.7, among women - 8.7 per 100 thousand. In the structure of mortality of the Russian population from malignant tumors in 2004, the relative frequency of pancreatic cancer in men is 4.6% (6 place), among women - 5.1% (7th place).

The scope of medical care in the emergency surgery department does not initially provide for radical treatment of cancer patients. This, according to the organization of medical care in the Russian Federation, should be done by oncology dispensaries. But, unfortunately, there is a category of cancer patients who are admitted to the on-duty surgical department, bypassing the outpatient clinic: either by self-referral, but most often by the ambulance service. This group of patients with so-called complicated cancers of various localizations. The emergency surgery department treats these patients. Unfortunately, this category of patients is increasing from year to year. Thus, in Russia, the incidence of pancreatic cancer in 1995 was 8.6 people per 100,000 population, which corresponds to 3% of all malignant neoplasms. The largest number of cases are people over 60 years of age. Over the five-year period since 1991, the incidence of pancreatic cancer in men increased by 7.4% and in women by 4.9%. A similar situation with the growth of cancer patients, including cancer of the pancreaticoduodenal zone, was noted in our clinic, even after 20 years of medical development.

Purpose of the study: to retrospectively evaluate the possibilities of pancreaticoduodenectomy in the treatment of patients with adenocarcinoma of the head of the pancreas in an emergency department.

Material and research methods

In the period from 2006 to 2012, in the 5th surgical department of the Ulyanovsk Regional Clinical Center for Specialized Types of Medical Care, where the clinic of the Department of Hospital Surgery of Ulyanovsk State University is located, 82 patients with tumor-like formations of the pancreaticoduodenal zone were treated. The incidence of malignant tumors of the pancreaticoduodenal zone continues to increase. In 2006, the 5th surgical department treated 41 patients with complicated cancer of various localizations, of which 7 patients were diagnosed with pancreatic cancer, and in 2012 there were 87 such patients, of which 16 were pancreaticoduodenal cancer (Table 1).

Table 1. Number of cancer patients in the emergency surgery department

Patients were admitted to the hospital already with complications, the main of which, characteristic of pancreatic cancer, are hyperbilirubinemia, renal-liver failure and a host of other complications. This can be explained by the lack of primary prevention of pancreatic and periampullary cancer.

Of the 82 patients, 64 patients were diagnosed with cancer of the biliopancreaticoduodenal zone (the diagnosis was made on the basis of anamnesis, clinical picture, ultrasound and computed tomography data; some of the patients were admitted from an outpatient oncology clinic for the purpose of performing palliative surgery for obstructive jaundice). And in 11 patients, pseudotumorous pancreatitis, complicated by hyperbilirubinemia, was diagnosed (the diagnosis was made solely on medical history - this is at least 3-4 episodes of acute pancreatitis in the past, with patients usually in the intensive care unit, alcohol abuse), and in 7 - cyst of the head of the pancreas, also complicated by obstructive jaundice (the diagnosis was confirmed by ultrasound data). Of the 82 patients, 100% were operated on.

Radical surgery, pancreaticoduodenectomy, was performed in 10 patients (8.2%), and palliative interventions (bypass biliodigestive anastomoses, diagnostic laparotomy) were performed in 72 patients (91.8%). The age of radically operated patients ranged from 43 to 66 years, of which 6 were men and 4 were women.

Of 10 patients, PDR was performed for: 1 - pseudotumorous pancreatitis (histologically - chronic sclerosing pancreatitis), 3 - cancer of the large duodenal papilla of the duodenum with growth into the head of the pancreas, 4 - cancer of the head of the pancreas itself (Fig. 1), 1 - cancer of the right kidney with metastatic damage to the head of the pancreas, 1 patient with a cyst of the head of the pancreas, complicated by massive arterial bleeding into the gastrointestinal tract (Fig. 2).

Fig.1. Cancer of the head of the pancreas, patient F. (case report No. 445 dated February 24, 2008)

Rice. 2. Cyst of the head of the pancreas, complicated by bleeding into the gastrointestinal tract, patient M. (case file No. 2253 dated 08/04/2009)

Research results

All patients were hospitalized urgently due to complications of the underlying disease: 8 people with symptoms of obstructive jaundice of varying severity (the level of total bilirubin on admission ranged from 82.54 mmol/l to 235.62 mmol/l), one with symptoms subcompensated duodenal stenosis, one patient with gastrointestinal bleeding and severe anemia.

Simultaneous surgery was performed on 2 patients with a tumor of the head of the pancreas without obstructive jaundice. Contraindications to simultaneous intervention were: high hyperbilirubinemia, duration of jaundice for more than 14 days, and signs of renal and hepatic failure. Eight patients with obstructive jaundice and a high level of hyperbilirubinemia underwent two-stage interventions. At the first stage, a decompressive operation on the biliary tract was performed, with the goal of reducing cholemic intoxication - 6 patients underwent cholecystojejunostomy with interintestinal anastomosis according to Brown, 1 - choledochoduodenoanastomosis, 1 - drainage of the common bile duct according to Vishnevsky. Radical surgery was performed at the second stage, 10-14 days after decompressive intervention. At this point, patients experienced either normalization or a significant decrease in total bilirubin levels.

After removal of the pancreaticoduodenal complex, restoring the continuity of the gastrointestinal tract and including the stump of the pancreas and bile duct can be done using different methods. Previously, pancreato- and biliodigestive anastomosis, on the one hand, and duodenojejunal anastomosis, on the other.

Pancreaticoduodenectomy was performed using the classical Whipple technique and involved removal of a complex of organs, including the head of the pancreas, the entire duodenum, at least 1/2 of the stomach, and the distal part of the common hepatic duct. The reconstructive stage of pancreatoduodenal resection was carried out in the accepted sequence: biliodigestive, pancreatojejunostomy and then gastroenteroanastomosis.

Pancreatojejunostomy is performed in Galeev's modification. The duration of the operations ranged from 2 hours 45 minutes to 4 hours 5 minutes.

What motivates surgeons to perform PDR in the emergency department?

According to statistics, about 30% of patients die a month after diagnosis, and the average survival rate is 6 months. In oncology hospitals there is a waiting list for this operation, which increases the duration of the disease. All this forces surgeons to carry out the most aggressive surgical tactics for diagnosed tumors of the pancreaticoduodenal zone.

However, based on our experience, in addition to cancer patients, there is a category of patients who also need to undergo such a complex operation, which is PDR. These are patients with pseudotumorous pancreatitis complicated by obstructive jaundice. And also, as our personal experience has shown, with cysts of the head of the pancreas, complicated by bleeding.

Death in the early postoperative period (6-7 weeks after surgery) was observed in 2 patients. The cause of death was failure of pancreatojejunostomy. In one patient, the early postoperative period was complicated by the development of pancreatitis, which was treated conservatively. It should be noted that acute postoperative pancreatitis was observed in 9 patients, to varying degrees, so intensive prophylaxis was carried out before, during and after surgery. And only one patient had no signs of acute pancreatitis - a patient with pseudotumorous pancreatitis, type 2 diabetes mellitus, insulin-dependent, whose iron was clearly not functioning during surgery. Of all the operated patients, 8 patients were discharged in satisfactory condition 16-48 days after surgery. Long-term results were monitored in 6 patients over a period of 2-5 years - there were no deaths.

Pancreaticoduodenectomy is the only radical treatment method for cancer of the head of the pancreas, cancer of the periampullary part of the common bile duct and the major duodenal nipple. PDR is used much less frequently: for pseudotumarous pancreatitis, abscess of the head of the pancreas, penetration of a stomach tumor into the head of the pancreas, cysts of the head of the pancreas, complicated by bleeding into the gastrointestinal tract.

Patients are admitted to emergency surgery departments late, due to complications that have developed; most of the patients were treated by a general practitioner or infectious disease specialist at their place of residence for 2-4 weeks before admission to the surgical department. Late diagnosis causes a low percentage of radical surgical interventions.

The high traumatic nature of the operation, expressed by cholemic and tumor intoxication, explains the significant number of complications in the postoperative period and high mortality.

Pancreaticoduodenectomy remains a category with the highest risk of life-threatening complications that limit the range of radical surgery.

All these data indicate the need for a comprehensive study of the problem and, above all, a search for ways to rationally expand the boundaries of radical surgery for pancreatic head cancer and chronic pancreatitis complicated by jaundice, improve surgical techniques and improve results.

Reviewers:

Ostrovsky V.K., Doctor of Medical Sciences, Professor, Head of the Department of General and Operative Surgery with Topographic Anatomy and Dentistry Course of the Federal State Budgetary Educational Institution of Higher Professional Education "Ulyanovsk State University", Ulyanovsk.

Rodionov V.V., Doctor of Medical Sciences, Professor, Head of the Department of Oncology and Radiation Diagnostics, Ulyanovsk State University, Ulyanovsk.

Bibliographic link

The main complication of pancreatoduodenal resection is the failure of the pancreatodigestive anastomosis (5–40%), and therefore a large number of different methods have been developed for the reconstructive stage of pancreatoduodenal resection, however, none of them is physiological. The author's modification of pancreaticoduodenectomy was proposed - physiological reconstruction (it was used in 14 patients), 10 patients formed the control group, in which standard pancreaticoduodenectomy was performed. Failure of pancreatojejunostomy was recorded in 1 (7%) patient of the main group and 3 (30%) of the control group. There was no postoperative mortality in both groups. The average length of hospital stay was 14.2 and 19.5 days, respectively. The developed modification of the reconstructive stage of pancreaticoduodenectomy showed its initial effectiveness.

Introduction

Pancreaticoduodenectomy (PDR), or Whipple operation, is the standard of treatment for malignant and benign neoplasms of the head of the pancreas, periampullary zone, and distal parts of the common bile duct.

The “classic” Whipple operation, first described in 1935, involves distal gastrectomy, cholecystectomy with resection of the common bile duct, removal of the head of the pancreas, duodenum, followed by a reconstructive stage: pancreaticojejunostomy, hepaticojejunostomy and gastrojejunostomy. Throughout the history of the development of pancreatic surgery, the main cause of mortality and the main insoluble problem remains the failure of the pancreatodigestive anastomosis. The overall mortality after PDR is 3–20% depending on the experience of the clinic, however, the number of complications even in specialized centers remains significant - 18–54%. Failure of the pancreatodigestive anastomosis is one of the most common complications of PDR (5–40%), along with complications such as erosive bleeding, stress ulcers, failure of the biliodigestive anastomosis, acute cholangitis, which are the causes of mortality in patients in the early postoperative period. If conservative therapy is ineffective, failure of the pancreatodigestive anastomosis leads to the development of complications requiring urgent relaparotomy (general peritonitis, septic shock, bleeding). Relaparotomy for complications of PDR is accompanied by a mortality rate of 40 to 80%.

The main pathogenetic mechanism for the development of pancreaticojejunostomotic failure is the local destructive effect of activated pancreatic enzymes in the area of ​​the suture line. Further leakage of pancreatic secretion and accumulation in the area of ​​the pancreatic stump leads to the formation of extensive foci of inflammation with the subsequent development of zones of necrosis both in the pancreas itself and in surrounding organs.

When performing standard methods of the reconstructive stage of PDR, the activation of proteolytic enzymes of the pancreas is a consequence of a violation of the physiological sequence of the movement of the food bolus, as well as the passage of bile and pancreatic juice. The mixing of the above media and their effect in the suture areas of formed anastomoses is the main cause of complications. Currently, there are more than 200 different modifications of the Whipple operation, relating both to the reconstructive stage as a whole and to the methods of forming each of the anastomoses. Consensus regarding the choice of the optimal reconstruction method has not yet been reached.

In order to increase the reliability of pancreatojejunostomy by minimizing the impact of such aggressive environments as bile and gastric juice on pancreatic tissue, as well as to reduce the risk of other complications associated with disruption of the sequence of passage of digestive juices, we have developed a method of physiological reconstruction for PDR.

OBJECT and research methods

The study was conducted from January 2009 to December 2010. A total of 24 patients who underwent PDR were included in the study. Participants were randomized into two groups. In the standard treatment group, the reconstructive stage was performed sequentially on one loop according to the Whipple method. The new method was used in 14 patients (8 men, 6 women, mean age 59.4 years; age range 37–76 years) (Tables 1 and 2).

Table 1. Patient characteristics and risk factors

Table 2. Indications for pancreaticoduodenectomy

The reconstructive stage of PDR according to the developed methodology was carried out as follows(Fig. 1 and 2):

• Pancreaticojejunostomy according to the duct-mucosal principle (end to side) with separate sutures, an internal row of sutures with Prolene thread 4–0 according to Blumgart, on a separate isolated loop of the small intestine 50 cm long from the ligament of Treitz, retrocolic, without stenting of the pancreatic duct. The second row of sutures is the serous membrane of the intestine with the pancreatic capsule (prolene 4–0);
• gastroentero- and hepaticojejunostomy were formed on the second loop of the small intestine at a distance of 40 cm from each other anteriorly (end to side), with double-row and single-row sutures, respectively (Fig. 3 and 4).
• The hepaticojejunostomy was “disconnected” from the gastroenteroanastomosis by forming an interintestinal anastomosis with a plug of the afferent loop. 50 cm distal to the hepaticojejunostomy, a loop of intestine from the pancreatojejunostomy according to Roux was “included” in the passage.

Rice. 1. Blumgart anastomosis: single circular sutures from the inside of the pancreatic duct through the entire thickness of the pancreas

Rice. 2. Blumgart anastomosis: view of the surgical field

Rice. 3. Method of isolated reconstruction: P - pancreas; F - stomach; 1T - first loop of the small intestine; 2T - second loop of the small intestine; LS - seam line of the afferent loop plug

Rice. 4. Method of isolated reconstruction - final view: 1 - hepaticojejunostomy; 2 - pancreatojejunostomy; 3 - gastroenteroanastomosis

results

The average operation time was 6.40±1.20 hours in the main group and 6.10±1.10 hours in the control group. The significant duration of operations in both groups is due to the fact that more than half of the patients underwent reconstructive operations, including those combined with resections of the vessels of the portal system; also, the standard for all operations was regional, aortocaval lymph node dissection, and mesoduodenumectomy. The proportion of complications was lower in the main group (Table 3). The main complication was failure of pancreatojejunostomy (7% in the main group and 30% in the control group), followed by the formation of abdominal abscesses. The need for relaparotomy arose in 1 patient in the main group and in 2 patients in the control group. No postoperative mortality was recorded in both groups. Patients began to drink from the first day of surgery. On the 4th day, the passage of the contrast agent through the gastrointestinal tract was studied. From the 4th day they began to eat adapted food mixtures; on the 8th day the patients were transferred to a standard diet. The median postoperative hospital stay for patients in the main group was 14.2 (9–22) days, for the control group - 19.5 (8–32) days. Complications - see table. 3.

Table 3. Complications

Median follow-up was 8.9 months. During follow-up, all patients in the main group did not report nausea, vomiting, heartburn, epigastric pain, or belching after eating. All patients in the control group noted 1 to 2 of the above complaints.

Discussion

Intracellular activation of enzymes is caused by the development of pancreatitis in the postoperative period, the trigger of which is trauma to the pancreas during the mobilization process, at the resection stage, as well as during the formation of pancreatodigestive anastomosis. In the early postoperative period, the development of pancreatitis is caused by the activation of proforms of pancreatic enzymes due to disruption of the physiology of pancreatic juice secretion, reflux of the contents of the anastomosed intestine into the pancreatic duct (the main factors of aggression are bile, enterokinase, low pH).

Factors predisposing to the development of pancreatic-digestive anastomosis failure in the literature have been divided into several groups: anthropomorphic factors (age, gender, constitution, etc.), anatomical and physiological factors (consistency of the pancreas, width of the pancreatic duct, intensity of pancreatic secretion), preoperative (degree of obstructive jaundice, use of biliary stents or methods of external drainage of the bile ducts), surgical factors (sequence of reconstruction, technique of anastomosis formation, methods of drainage of the abdominal cavity, use of pancreatic duct stents) and postoperative (prescription of somatostatin analogues, timing of drainage and nasogastric tube removal, start of enteral nutrition). According to the above groups of factors, it has now been established that anatomical and physiological factors play the greatest role in the development of insolvency. Anthropomorphic factors are practically not associated with the risk of failure; it remains unclear and the assessment of the main ones - surgical factors, methods of preoperative preparation and postoperative therapy - is ongoing.

Over the more than 75-year history of the use of PDR, various surgical methods have been developed to improve the reliability of pancreatodigestive anastomosis. Among the methods of reconstruction after PDR, there are currently two most common: pancreatojejunostomy and pancreatogastrostomy.

The classic version of reconstruction involves the sequential formation of pancreatojejuno- and hepaticojejunostomies on one loop, retrocolic, followed by gastrojejunostomy, anteriorcolic. The second common reconstruction option is pancreatogastrostomy with the formation of hepaticojejuno- and gastroenteroanastomoses on one loop. In randomized trials, both types of reconstruction showed no differences in either the number of postoperative complications or technical performance characteristics.

In our opinion, the disadvantages of these methods for forming pancreatodigestive anastomosis are the aggressive effects of bile and gastric juice on pancreatic tissue in the early postoperative period. Removal of the duodenum with the ampulla during PDR and subsequent reconstruction with free entry of the pancreatic duct ensures the unimpeded penetration of bile or gastric juice (depending on the type of reconstruction) into the pancreatic stump.

The mechanism of development of bile reflux pancreatitis has been studied for more than 100 years and today is represented by a large number of clinical and experimental studies. The following works deserve the greatest attention:

• G.J. Wang and co-authors experimentally proved the destructive effect of bile acids (taurolithocholic, taurocholic and taurodeoxycholic) on pancreatic acinar cells by changing the distribution of calcium ions from apical to basal. It was previously established that the intracellular distribution of calcium ions is directly related to the regulation of the secretion of pancreatic enzymes. According to other researchers, such abnormally long-term increases in calcium concentration in pancreatic acinar cells lead to intracellular activation of trypsinogen into trypsin, a critical moment in the induction of acute pancreatitis.
• T. Nakamura and co-authors found that bile activates A 2 phosphorylase, a pancreatic enzyme that leads to the development of pancreatitis.
• A.D. McCutcheon, using a model of a closed duodenal loop in dogs, in 100% of cases noted the development of acute pancreatitis as a consequence of reflux of bile and duodenal contents into the pancreatic duct.

Thus, the technique of isolating pancreatojejunostomosis from the ingress of bile and gastric contents is quite justified from a pathophysiological point of view. An additional advantage of the developed operation is the prevention of bile and pancreatic juice from entering the gastric stump (unlike other reconstruction techniques). Isolated formation of anastomoses prevents the development of alkaline reflux gastritis and esophagitis, which can be associated with significant complications in the long-term postoperative period. It should also be taken into account that the group of common complications of PDR includes a slowdown in the evacuation of food from the gastric stump (GST), which significantly reduces the quality of life of patients. With classical reconstruction methods, VEZ may occur in 15–40% of patients. One of the mechanisms of this complication is the irritating effect of bile on the mucous membrane of the gastric stump. According to the results obtained (in the main group there was no EP clinic both early and late after surgery), the developed technique prevents the development of the second most common complication of PDR, increasing the quality of life of patients.

conclusions

The proposed modification of the reconstructive stage of PDR has shown its effectiveness - reducing the incidence of postoperative complications, the need for relaparotomies, and making it possible to improve the quality of life of patients by eliminating postoperative food stagnation in the gastric stump.

The developed method of physiological reconstruction is pathophysiologically justified, since it restores the natural passage of the bolus of food and prevents cross-reflux of bile, pancreatic juice, and gastric contents.

Literature

• 1. Grace P.A., Pitt H.A., Longmire W.P. (1990) Pylorus preserving pancreatoduodenectomy: an overview. Br. J Surg 77: 968–974.
• 2. Peters J.H., Carey L.C. (1991) Historical review of pancreaticoduodenectomy. Am. J Surg 161: 219–225.
• 3. Moossa A.R. (1987) Surgical treatment of chronic pancreatitis: an overview. Br. J Surg 74: 661–667.
• 4. Rossi R.L. Rothschild J., Braasch J.W. et al. (1987) Pancreatoduodenectomy in the management of chronic pancreatitis. Arch. Surg., 122: 416–420.
• 5. Bachelier P., Nakano H., Oussoultzoglou P.D. et al. (2001) Is pancreaticoduodenectomy with mesentericoportal venous resection safe and worthwhile? Am. J Surg 182(2): 120–129.
• 6. Tseng J.F., Raut C.P., Lee J.E. et al. (2004) Pancreaticoduodenectomy with vascular resection: margin status and survival duration. J. Gastrointest. Surg., 8: 935–949.
• 7. Yeo C.J., Cameron J.L., Lillemoe K.D. et al. (2002) Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized controlled trial evaluating survival, morbidity, and mortality. Ann. Surg., 236: 355–366.
• 8. Aranha G.V., Aaron J.M., Shoup M. et al. (2006) Current management of pancreatic fistula after pancreaticoduodenectomy. Surgery, 140(4): 561–568.
• 9. Goonetilleke K.S., Siriwardena A.K. (2007) Nationwide questionnaire survey of the contemporary surgical management of pancreatic cancer in the United Kingdom & Ireland. Int. J Surg 5: 147–151.
• 10. Lygidakis N.J., Jain S., Sacchi M. et al. (2005) Reappraisal of a method of reconstruction after pancreatoduodenectomy. Hepatogastroenterology 52: 1077–1082.
• 11. Shrikhande S.V., Qureshi S.S., Rajneesh N. et al. (2005) Pancreatic anastomoses after pancreaticoduodenectomy: do we need further studies? World J Surg 29(12): 1642–1649.
• 12. Wayne M.G., Jorge I.A., Cooperman A.M. (2008) Alternative reconstruction after pancreaticoduodenectomy. World J. Surg. Oncol., 28: 6–9.
• 13. Izbicki J.R., Bloechle C., Knoefel W.T. et al. (1999) Surgical treatment of chronic pancreatitis and quality of life after surgery. Surg. Clin. North Am., 79: 913–944.
• 14. Cameron J.L., Pitt H.A., Yeo C.J. et al. (1993) One hundred and forty-five consecutive pancreaticoduodenectomies without mortality. Ann. Surg., 217: 430–435.
• 15. Buchler M.W., Wagner M., Schmied B.M. et al. (2003) Changes in morbidity after pancreatic resection: towards the end of completion pancreatectomy. Arch. Surg. 138:1310–1314.
• 16. Halloran C.M., Ghaneh P., Bosonnet L. et al. (2002) Complications of pancreatic cancer resection. Dig Surg., 19(2): 138–146.
• 17. Yeo C.J., Cameron J.L., Sohn T.A. et al. (1997) Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg 226: 248–257.
• 18. van Berge Henegouwen M.I., Allema J.H., van Gulik T.M. et al. (1995) Delayed massive haemorrhage after pancreatic and biliary surgery. Br. J Surg 82: 1527–1531.
• 19. Tien Y.W., Lee P.H., Yang C.Y. et al. (2005) Risk factors of massive bleeding related to pancreatic leak after pancreaticoduodenectomy. J. Am. Coll. Surg., 201: 554–559.
• 20. Munoz-Bongrand N., Sauvanet A., Denys A. et al. (2004) Conservative management of pancreatic fistula after pancreaticoduodenectomy with pancreaticogastrostomy. J. Am. Coll. Surg., 199(2): 198–203.
• 21. Alghamdi A.A., Jawas A.M., Hart R.S. (2007) Use of octreotide for the prevention of pancreatic fistula after elective pancreatic surgery: a systematic review and meta-analysis. Can. J Surg., 50(6): 459–466.
• 22. Balcom J.H., Rattner D.W., Warshaw A.L. et al. (2001) Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch. Surg., 136: 391–398.
• 23. Schmidt C.M., Powell E.S., Yiannoutsos C.T. et al. (2004) Pancreaticoduodenectomy: a 20-year experience in 516 patients. Arch. Surg., 139: 718–727.
• 24. DeOliveira M.L., Winter J.M., Schafer M. et al. (2006) Assessment of complications after pancreatic surgery: A novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann. Surg., 244(6): 931–937.
• 25. Poon R.T., Lo S.H., Fong D. et al. (2002) Prevention of pancreatic leakage after pancreaticoduodenectomy. Am. J Surg 183(1): 42–52.
• 26. Farley D.R., Schwall G., Trede M. (1996) Completion pancreatectomy for surgical complications after pancreaticoduodenectomy. Br. J Surg 83(2): 176–179.
• 27. Balzano G., Zerbi A., Cristallo M. et al. (2005) The unsolved problem of fistula after left pancreatectomy: the benefit of cautious drain management. J. Gastrointest. Surg., 9: 837–842.
• 28. Gouma D.J., van Geenen R.C., van Gulik T.M. et al. (2000) Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume. Ann. Surg., 232: 786–795.
• 29. Winter J.M., Cameron J.L., Campbell K.A. et al. (2006) Does pancreatic duct stenting decrease the rate of pancreatic fistula following pancreaticoduodenectomy? Results of a prospective randomized trial. J Gastrointest Surg., 10: 1280–1290.
• 30. Marcus S.G., Cohen H., Ranson J.H. (1995) Optimal management of the pancreatic remnant after pancreaticoduodenectomy. Ann. Surg., 221(6): 635–645.
• 31. Grobmyer S.R., Hollenbeck S.T., Jaques D.P. et al. (2008) Roux-en-Y reconstruction after pancreaticoduodenectomy. Arch. Surg., 143(12): 1184–1188.
• 32. Kamisawa T., Kurata M., Honda G. et al. (2009) Biliopancreatic reflux-pathophysiology and clinical implications. J Hepatobiliary Pancreat Surg, 16(1): 19–24.
• 33. Bassi C., Falconi M., Pederzoli P. (1994) Role of somatostatin and somatostatin analogues in the treatment of gastrointestinal diseases: prevention of complications after pancreatic surgery. Gut, 3: 20–22.
• 34. Catel R.B. (1948) A technique for pancreatoduodenal resection. Surg. Clin. North. Am., 28: 761–775.
• 35. Blumgart L.H. (2007) Surgery of the Liver, Biliaru Tract, and Pancreas. 4 th ed. Saunders Elsevier, Philadelphia, PA, 1838 r.
• 36. Bassi C., Falconi M., Molinari E. et al. (2005) Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy: results of a comparative study. Ann. Surg., 242(6): 767–771.
• 37. Marcus S.G., Dobryansky M., Shamamian P., et al. (1998) Endoscopic biliary drainage before pancreaticoduodenectomy for periampullary malignancies. J. Clin. Gastroenterol., 26: 125–129.
• 38. Heslin M.J., Brooks A.D., Hochwald S.N. et al. (1998) A preoperative biliary stent is associated with increased complications after pancreatoduodenectomy. Arch. Surg., 133: 149–154.
• 39. Sagar P.M., Kruegener G., MacFie J. (1992) Nasogastric intubation and elective abdominal surgery. Br. J Surg., 79: 1127–1131.
• 40. Heslin M.J., Harrison L.E., Brooks A.D. et al. (1998) Is intra-abdominal drainage necessary after pancreaticoduodenectomy? J Gastrointest Surg 2: 373–378.
• 41. Moon H.J., Heo J.S., Choi S.H. et al. (2005) The efficacy of the prophylactic use of octreotide after a pancreaticoduodenectomy. Yonsei Med. J., 46(6): 788–793.
• 42. Sakorafas G.H., Friess H., Balsiger B.M. et al. (2001) Problems of reconstruction during pancreatoduodenectomy. Dig. Surg., 18: 363–369.
• 43. Hamanaka Y., Nishihara K., Hamasaki T. et al. (1996) Pancreatic juice output after pancreatoduodenectomy in relation to pancreatic consistency, duct size, and leakage. Surgery, 119: 281–287.
• 44. Shrikhande S.V., D’Souza M.A. (2008) Pancreatic fistula after pancreatectomy: evolving definitions, preventive strategies and modern management. World J. Gastroenterol., 14(38): 5789–5796.
• 45. Opie E.L. (1901) The etiology of acute hemorrhagic pancreatitis. Johns Hopkins Hospital Bulletin, 12: 182–188.
• 46. ​​Niederau C., Niederau M., Lüthen R. et al. (1990) Pancreatic exocrine secretion in acute experimental pancreatitis. Gastroenterology, 99(4): 1120–1127.
• 47. Senninger N. (1992) Bile-induced pancreatitis. Eur Surg Res., 24(1): 68–73.
• 48. Arendt T., Nizze H., Monig H. et al. (1999) Biliary pancreatic reflux-induced acute pancreatitis-myth or possibility? Eur. J. Gastroenterol. Hepatol., 11: 329–335.
• 49. Wang G. J., Gao C. F., Wei D. et al. (2009) Acute pancreatitis: etiology and common pathogenesis. World J. Gastroenterol., 15(12): 1427–1430.
• 50. Bolender R.P. (1974) Stereological analysis of the guinea pig pancreas. I. Analytical model and quantitative description of nonstimulated pancreatic exocrine cells. J Cell. Biol., 61(2): 269–287.
• 51. Williams J.A. (2001) Intracellular signaling mechanisms activated by cholecystokinin-regulating synthesis and secretion of digestive enzymes in pancreatic acinar cells. Annu Rev. Physiol., 63: 77–97.
• 52. Raraty M., Ward J., Erdemli G. et al. (2000) Calcium-dependent enzyme activation and vacuole formation in the apical granular region of pancreatic acinar cells. Proc. Natl. Acad. Sci USA, 97(24): 13126–13131.
• 53. Krüger B., Albrecht E., Lerch M.M. (2000) The role of intracellular calcium signaling in premature protease activation and the onset of pancreatitis. Am. J. Pathol., 157(1): 43–50.
• 54. Nakamura T., Okada A., Higaki J. et al. (1996) Pancreaticobiliary maljunction-associated pancreatitis: an experimental study on the activation of pancreatic phospholipase A 2 . World J Surg 20: 543–550.
• 55. McCutcheon A.D. (1968) A fresh approach to the pathogenesis of pancreatitis. Gut, 9(3): 296–310.
• 56. Klaus A., Hinder R.A., Nguyen J.H. et al. (2003) Small bowel transit and gastric emptying after biliodigestive anastomosis using the uncut jejunal loop. Am. J Surg 186: 747–751.
• 57. Pescio G., Cariati E. (1996) A new reconstructive method after pancreaticoduodenectomy: the triple Roux on a “P” loop. Rationale and radionuclide scanning evaluation. HPB Surg., 9(4): 223–227.

Modification of the reconstructive stage of pancreatoduodenal resection - method of physiological reconstruction

I.B. Shchepotin, A.V. Lukashenko, O.O. Kolesnik, O.V. Vasilyev, D.O. Rozumiy, V.V. Priymak, V.V. Sheptitsky, A.I. Zelinsky

National Institute of Cancer, Kiev

Summary. The main difficulty of pancreaticoduodenal resection is the impossibility of pancreaticodigestive anastomosis (5–40%), due to which a large number of different techniques have been developed at the reconstructive stage of pancreaticoduodenal resection, proteolytic They are not physiological. The author's modification of pancreaticoduodenal resection was proposed - physiological reconstruction (it was established in 14 patients), 10 patients became a control group, in which standard pancreaticoduodenal resection was performed. The failure of pancreaticojejunostomy was registered in 1 (7%) patient in the main group and in 3 (30%) in the control group. There was no postoperative mortality in both groups. The average hour of stay in a hospital became 14.2 and 19.5 days. A modification of the reconstructive stage of pancreatoduodenal resection was introduced and showed its effectiveness.

Key words: pancreaticoduodenal resection, impossibility of pancreaticojejunostomy.

Modification of the reconstruction
after pancreaticoduodenectomy - physiologic reconstruction

I.B. Shchepotin, A.V. Lukashenko, E.A. Kolesnik, O.V. Vasylyev, D.A. Rozumiy, V.V. Priymak, V.V. Sheptytsky, A.I. Zelinsky

National Cancer Institute, Kyiv

Summary. Pancreatic anastomotic failure remains among the most common (5–40%) and potentially lethal postoperative complications after pancreaticoduodenectomy. Despite a large number of reconstructive methods after pancreaticoduodenectomy, none of them are physiological. We develop a new reconstructive method - physiological reconstruction. A trial involving 24 patients who underwent pancreatic head resections. Reconstruction by an original technique was performed in 14 patients. Our method was associated with reduction of the incidence of pancreatic anastomotic leak, (7% vs 30%) and average hospital stay (14.2 days vs 19.5). First results of the developed method are promising.

Key words: pancreatic cancer, pancreaticodudenectomy, anastomotic failure.

Diseases of the pancreas often pose a question to the doctor and patient - which treatment tactic to choose - surgery or conservative therapy.

Surgery is a radical treatment used in cases where drug therapy is pointless and does not give positive results.

The main indications for surgical treatment are:

• pancreatic head cancer;
• chronic pancreatitis, subject to the presence of pain that cannot be relieved by the use of analgesics;
• multiple cysts of the head of the pancreas;
• lesions of this part of the organ in combination with stenosis of the duodenum or duct through which bile exits;
• complications or stenosis after pancreatojejunostomy surgery.

Chronic inflammation of the head is considered the main indication for surgery. Because in addition to the presence of pain and various complications, inflammation can be accompanied by an oncological process or even hide the tumor. This is a disease in the etiology of which alcohol induction plays a major role.

Due to the pathological effects of ethanol, a chronic inflammatory focus develops in the tissues of the gland, disrupting its endocrine and exocrine functions. The molecular and pathobiochemical mechanisms leading to focal inflammation and fibrosis of the pancreas are largely unknown.

A common feature of the histological picture is infiltration of leukocytes, changes in the pancreatic duct and lateral branches, focal necrosis and further fibrosis of the organ tissue.

Gastropancreatoduodenal resection in patients with alcoholic chronic pancreatitis, in whom the inflammatory process has developed in the head of the pancreas, leads to a change in the natural course of the disease:

1. Changes in pain intensity.
2. Reduced frequency of acute episodes
3. Eliminate the need for further hospitalization.
4. Decrease in mortality rate.
5. Improving quality of life.

Pain in the upper abdomen is the leading clinical symptom associated with increased pressure in the ducts and tissues of the pancreas. Pathological changes in sensory nerves, increased nerve diameter and perineural infiltration of inflammatory cells, are considered the main causes of pain.

Features of the Whipple operation

The subgroup of patients with chronic pancreatitis consists predominantly of men under 40 years of age. These patients usually have severe abdominal pain that is resistant to analgesic treatment and is often accompanied by local complications.

This group of patients are candidates for surgical treatment, since in addition to chronic changes in the pancreas, they often have other lesions of this organ and nearby ones, for example, tumors of the duodenum, stomach or biliary tract.

The Whipple procedure, or pancreaticoduodenectomy, is a major surgical procedure most often performed to remove malignant or precancerous tumors of the head of the pancreas or one of the nearby structures.

The method is also used to treat injuries of the pancreas or duodenum, or as a method of symptomatic treatment of pain in chronic pancreatitis.

The most common technique of pancreatoduodenectomy consists of removing the following structures:

• distal segment (antrum) of the stomach;
• the first and second parts of the duodenum;
• head of the pancreas;
• common bile duct;
• gallbladder;
• lymph nodes and vessels.

The reconstruction consists of attaching the remaining part of the pancreas to the jejunum, attaching the common bile duct to the jejunum (choledochojejunostomy) so that digestive juices and bile flow into the gastrointestinal tract accordingly. And fixation of the stomach to the jejunum (gastrojejunostomy) to restore the passage of food.

The difficulty of surgical interventions on the pancreas lies in the presence of the enzymatic function of this organ. Thus, such operations require refined execution technique in order to prevent the pancreas from starting to digest itself. It is also worth noting that the tissues of the gland are very delicate and require careful handling; it is difficult to apply sutures to them. Therefore, such operations are often accompanied by the appearance of fistulas and bleeding. Additional obstacles are:

Organ structures are located in this section of the abdominal cavity:

1. superior and inferior vena cava.
2. abdominal aorta.
3. superior mesenteric arteries.
4. veins.

In addition, the common bile duct and kidneys are located here.

Comparison with general pancreatectomy

Sugar level

The basic concept of pancreaticoduodenectomy is that the head of the pancreas and duodenum share the same arterial supply (gastroduodenal artery).

This artery passes through the head of the pancreas, so both organs must be removed if the general blood flow is blocked. If only the head of the pancreas were removed, blood flow to the duodenum would be compromised, resulting in tissue necrosis.

Clinical trials have failed to demonstrate significant survival with total pancreatectomy, mainly because patients who undergo this operation tend to develop a particularly severe form of diabetes.

Sometimes, due to weakness of the body or improper management of the patient during the postoperative period, an infection may arise and spread in the abdominal cavity, which may require repeated intervention, as a result of which the remaining part of the pancreas, as well as the adjacent part of the spleen, is removed.

This is done to prevent the spread of infection, but, unfortunately, leads to additional injury to the patient.

Pylorus-sparing pancreatoduodenectomy

In recent years, pylorus-sparing pancreaticoduodenectomy (also known as the Traverso-Longmire procedure) has become popular, especially among European surgeons. The main advantage of this method is that the pylorus and therefore normal gastric emptying are preserved. However, some doubt remains as to whether this is an appropriate operation from an oncological point of view.

Another controversial issue is whether patients should undergo retroperitoneal lymphadenectomy.

Compared with the standard Whipple procedure, pylorus-sparing pancreaticoduodenectomy is associated with shorter operative time, fewer operative steps, and reduced intraoperative blood loss, requiring less blood transfusion. Accordingly, the risk of developing a reaction to blood transfusion is lower. Postoperative complications, hospital mortality, and survival did not differ between the two methods.

Pancreaticoduodenectomy is considered a major surgical procedure by any standard.

Many studies have shown that hospitals that perform this procedure more often have better overall results. But we should not forget about the complications and consequences of such an operation, which can be observed in all organs undergoing surgery.

When performing surgery on the head of the pancreas:

• diabetes;
• postoperative abscess.

On the part of the stomach, there is a high probability of complications such as vitamin B12 deficiency and the development of megaloblastic anemia.

From the duodenum, the following complications may occur:

1. Dysbacteriosis.
2. Intestinal obstruction due to anastomotic stenosis.
3. Wasting (cachexia).

From the biliary tract, the following complications may occur:

• cholangitis;
• biliary cirrhosis.

Additionally, liver abscesses may develop.

Prognosis for patients after surgery

By following all the doctor’s prescriptions during the rehabilitation period, the patient can reduce the risk of developing complications to a minimum.

It is mandatory to take enzyme preparations and antibacterial drugs, and it is also important to follow a diet to maintain the patency of the gastrointestinal segment.

Cancer patients should also undergo chemotherapy or radiation if necessary.

In the early postoperative period, it is important to remember about life-threatening conditions:

1. The development of shock is a drop in blood pressure.
2. Infection - increased temperature and fever, leukocytosis;
3. Anastomotic failure - development of symptoms of peritonitis;
4. Damage to pancreatic vessels, failure of ligatures—increased levels of amylase in the blood and urine.
5. The development of postoperative pancreatitis, if the operation was not performed due to inflammation of the pancreas, obstruction of the pancreatic duct develops due to swelling of the organ.

Cancer patients have the opportunity to prolong their lives. If the operation is performed at an early stage, then doctors expect complete remission; at later stages, metastases may appear, but this does not happen often and rarely causes death. For patients with chronic pancreatitis, the result of the operation may be different - with a favorable outcome, these patients are deprived of fighting sensations and problems with the functioning of the digestive system; in less fortunate circumstances, the pancreatitis clinic may remain, despite the compensated function of the organs.

All patients after pancreatic surgery are registered and undergo examination every six months. It is important to monitor the condition of all structures, since late complications are possible, such as anastomotic stenosis, the development of diabetes due to pancreatic fibrosis, as well as oncological processes.

Accelerated recovery after pancreaticoduodenectomy is described in the video in this article.

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Mobilization of the duodenum. After crossing the proper ligament of the uncinate process, the entire complex to be resected rests on the connection with the stomach and on the lower horizontal portion of the duodenum. Be very careful not to damage a. colica media of the Riolan arcade of the colon, the distal portion of the duodenum and the initial portion of the small intestine are maximally distinguished.

The duodenum, together with the pyloric part of the stomach, is highlighted as much as possible. Recently there has been a tendency towards pylorus-preserving operations. The lesser omentum is intersected between the clamps in such a way as to remove the lymph glands as much as possible. This sometimes requires preliminary ligation of the left gastric artery, moving 2-3 cm away from the stomach wall. A clamp is applied to the duodenum near the pylorus or directly on it.

A clamp is also applied proximal to it. It is best to apply staplers, which makes it easier to isolate the resected portion of the duodenum along with the head of the pancreas. Rubber caps are put on the transected duodenum to better maintain asepsis (A.A. Shalimov). This makes it easier to pass it in the area of ​​the Treitz ligament into the lower abdominal cavity through the mesocolon of the transverse colon.

Some surgeons perform this part of the operation in reverse. First, the loop of the small intestine is crossed distal to the ligament of Treitz, and then the proximal end is transferred above the mesocolon. The entire resected duodenopancreatic complex is removed. Thorough final hemostasis is performed, washing the large wound surface with antibiotic solutions dissolved in a 0.25% novocaine solution or saline solution (500.0 ml). Considering the large volume of the operation, it is mandatory to return blood from the surgical wound using the Fresenius apparatus. A general view of the surgical wound after the end of the first organ-removing stage of pancreaticoduodenectomy is shown in Fig. 105.

Rice. 105. Pancreatoduodenal resection. General view of the surgical field after completion of the first stage of the operation:
1 - common bile duct; 2 - portal vein; 3 - inferior vena cava; 4 - aorta; 5 - own hepatic artery; 6 - splenic artery; 7 - stump of the tail of the pancreas; 8 - spleen; 9 - superior mesenteric artery; 10 - pancreaticoduodenal artery; 11 - inferior pancreatic artery; 12 - transverse colon; 13 - bringing the stomach down; 14 - end of the small intestine; 15 - gallbladder

The first stage of reconstruction is the restoration of the outflow of pancreatic juice through the Wirsung duct, or its complete blocking. Their options are different (Fig. 106).

Rice. 106. Options for treating the stump of the tail of the pancreas during pancreatoduodenal resection:
a - anastomosis with the outlet loop of the small intestine distal to the gastroengeroanastomosis; c - suturing tightly or piombombing the duct; c - formation of gastropancreatoanastomosis; d - terminal pancreatojejunostomy; 1 - common bile duct; 2 - stomach; 3 - sutured loop of the small intestine; 4, 8 - sutured tail end of the pancreas; 5 - gastroenteroanastomosis; 6 - pancreatojejunostomy; 7- pancreatogastroanastomosis

Rice. 107. Pancreatoduodenal resection. Operation Coli (1943): 1 - gall bladder; 2 - common bile duct; 3 - stomach stump; 4 - gastrojejunostomy; 5 - pancreatic stump; 6 - pancreatojejunostomy; 7 - disconnected loop of the small intestine according to Roux; 8 - jejunojejunostomy; 9 - loop of the small intestine; 10 - choledochojejunostomy

Fig. 108. Pancreatoduodenal resection. Operation Whipple (1947):
1 - loop of the small intestine connected to the stump of the tail of the pancreas; 2 - tail part of the pancreas; 3 - common bile duct; 4 - stump of 1/2 part of the resected stomach; 5 - gastrojejunostomy with a disconnected loop of the small intestine according to Roux; 6 - jejunojejunostomy; 7 - disconnected loop of the small intestine according to Roux; 8 - pancreatojejunostomy; 9 - choledochojejunostomy

Rice. 109. Option of the restorative-reconstructive stage of pancreatoduodenal resection (according to Sessage, 1948):
1 - hepatic duct; 2 - common bile duct; 3 - stomach; 4 - gastroenteroanastomosis; 5 - pancreatoenteroanastomosis with the tail of the pancreas; 6 - Brownian anastomosis; 7 - efferent end of the small intestine; 8 - loop of the small intestine; 9 - cholecystoenteroanastomosis

Rice. 110. Option for blocking the tail of the pancreas without anastomosing it with hollow organs: 1 - common bile duct; 2 - stomach; 3 - tail of the pancreas; 4 - outlet disconnected loop of the small intestine according to Roux; 5 - jejunojejunostomy; 6 - afferent loop of the small intestine; 7 - sutured end of the caudal part of the pancreas (according to Kochiashvili, 1964)

Rice. 111. Reconstructive stage of pancreatoduodenal resection according to V.V. Vinogradov (1964): 1 - common bile duct; 2 - stomach; 3 - tail of the pancreas; 4 - pancreatojejunostomy; 5 - gastrojejunostomy; 6 - outlet end of the small intestinal loop; 7 - choledochojejunostomy; 8 - gallbladder

Rice. 112. Reconstructive stage of pancreatoduodenal resection with preservation of the pyloroduodenal zone:
a - formation of pancreatic anastomosis distal to the gastroenteroanastomosis; b - pancreatojejunostomy proximal to the gastroenteroanastomosis; c — pancreatojejunostomy with a disconnected loop of the small intestine according to Roux

In the second option, anastomosis is performed with disconnected loops of the small intestine according to Roux. There may be a separate anastomosis with the stump of the stomach or common bile duct, pancreas. We believe that this technique is the most progressive, but it is currently used quite rarely.

In the third option, anastomosis is performed with the gallbladder and a loop of the small intestine. However, there is always uncertainty about adequate flow of bile through the cystic duct. In addition, the presence of an inflammatory process in the bladder sometimes contributes to the formation of stones in it that block the cystic duct. This technique is used as a way out.

In the fourth option, it is always necessary to connect drainage to the sutured pancreatic stump for constant aspiration.

In the fifth option, one disconnected loop of the small intestine is formed according to Roux and all the necessary anastomoses are formed with it (a modification of the Whipple operation) (Fig. 113). The peculiarity of this operation is that 1/2 of the stomach is resected. This loop is passed behind the transverse colon. Recently, a disconnected Roux-en-Y loop is not used, but simply anastomoses are formed with a loop of bowel passed behind the transverse colon. This greatly simplified the operation. The technique of this operation is as follows.

Rice. 113. Modification of the Whipple operation (a, 6 - reconstructive stage of the operation):
1 - stomach; 2 - common bile duct after cholecystectomy; 3 - stump of resected 1/3-1/2 stomach; 4 - pancreatojejunostomy (with the tail of the gland); 5 - gastroenteroanastomosis; 6 - transverse colon; 7 - loop (outflow end) of the small intestine, below the mesocolon; 8 - end of the efferent loop of the small intestine; 9 - choledochojejunostomy

Rice. 114. Pancreatoduodenal resection. Pylorus-preserving operation: a - expected extent of resection; b - resected complex of the pancreas and duodenum; 1 - duodenum; 2 - common bile duct; 3 - stump of the cystic duct; 4 - pyloric section of the stomach; 5 - pancreas; 6 - stump of the caudal part of the pancreas (the red dotted line shows the extent of the operation)

Rice. 115. Scheme of formation of choledochojejunal anastomosis:
a - undesirable; 6 - with an increase in the perimeter of the anastomosis

The latter seems to invaginate into the intestinal lumen. From our point of view, this is the most favorable type of anastomosis. Despite this, it is advisable to connect two drainage tubes with a diameter of up to 1.0 cm with holes to the anastomosis (Fig. 116). Precaution is dictated by the possible development of destructive pancreatitis along the sutures, which is the cause of suture failure. However, active aspiration allows peritonitis to be limited to local peritonitis. Another advantage in this situation is that the choledochojejunostomy is located more distally, and therefore the flow of bile into the abdominal cavity will be limited if there is no obstruction to its outflow in the distal direction along the intestine. It must be remembered that with a confirmed diagnosis of cancer of the head of the pancreas, the operation should be supplemented by removal of the omentum and regional lymph nodes.

Rice. 116. The principle of forming a pancreatojejunal anastomosis according to the “end to end” type

The opening of the omental bursa is performed in such a way as to preserve as much as possible part of the branch of the right gastrocolic artery. For this purpose, the main part of the greater omentum is preserved. Of course, this violates to some extent the principle of oncology. The duodenum is visually separated from the edge of the head. Then the restorative and reconstructive stage is carried out in two ways: according to the classical type, i.e. on two loops of the small intestine and, according to a simplified type, on one intestine. It is important that the supplied loops of intestine are located behind the transverse colon.

When performing pancreatoduodenal resection, it is necessary to ensure the entire complex of resuscitation and intensive care and, above all, restoration of circulating blood volume both during the operation and in the postoperative period. Currently, the volume of blood loss during surgery is fully compensated by the Fresenius device system (blood from the surgical wound is sucked into the device and returned to the bloodstream), and in the postoperative period, replenishment of blood loss completely depends on the intensity and adequacy of resuscitation measures.

It is necessary to understand that the postoperative surface of the wound releases a large mass of liquid blood into the abdominal cavity, which must be compensated during intensive care. Failure to replace the volume of circulating blood remained and remains the main cause of death in patients on the 1st–3rd day of the postoperative period, even with an adequately performed operation. Underestimation of this factor was one of the main reasons for the death of patients in almost 60% of cases. Thus, until 1960, mortality after pancreatoduodenal resection of the pancreas was 40-50%. By the 80s. last century it decreased to 25%, starting in the 80-90s. last century - has decreased and amounts to 5-12% (V.D. Fedorov, I.M. Kuriev, R.Z. Ikramov, 1999). We obtained approximately the same results in 40 operated patients. The best results were noted by J. Howard et al. - 199 operations had 1% postoperative mortality, J. Camoron had 145 operations without deaths.

The question of total pancreatic resections arises very rarely. Such messages are casuistic in nature (Fig. 117).

Rice. 117. Total resection of the pancreas, or pancreatectomy

Rice. 118. Safety of surgical intervention for pancreatic cysts depending on the scope of the operation (red line): 1 - puncture treatment of cysts; 2 - open drainage; 3 - internal drainage; 4 - resection (various types)

I.N. Grishin, V.N. Grits, S.N. Lagodich