It is a common type of cancer. In most cases, the prognosis has rather bad consequences. During the examination, doctors detect the presence of secondary metastases that affect healthy tissue in other organs.

The main disadvantage of this disease is that no symptoms of the manifestation of the disease are observed. At the same time, cancer cells begin to grow with great force. If a large number of metastases are found, the patients are not subjected to surgical procedures.

Pancreatoduodenal resection technology

For whom can pancreatoduodenal resection be recommended? Surgical intervention is indicated only for those patients in whom cancerous tumors are clearly localized within the pancreas. Such surgery acts as a healing process.

Before starting the operation, the attending physician conducts a complete diagnosis of the affected organ. Thanks to ultrasound examination and a variety of analyzes, the picture of the disease indicates the type of surgery.

If a cancerous tumor is located in the head of the pancreas or in the area of \u200b\u200bthe opening of the pancreatic duct, then doctors perform a Whipple operation. In the presence of a malignant process in the area of \u200b\u200bthe body or the tail of the pancreas, surgeons perform pancreatectomy.

The operation (pancreatoduodenal resection or Whipple operation) was first performed in early 1930 by the physician Alan Whipple. At the end of the 60s, mortality from such an intervention had a fairly high statistics.

Today, pancreatoduodenal resection is considered completely safe. Mortality rates dropped to 5%. The final result of the performed intervention directly depends on the professional experience of the surgeon.

What is the process

Let's take a closer look at how pancreatoduodenal resection is performed. The stages of the operation are outlined below. In the process of carrying out this kind of operation, the patient is removed from the head of the pancreas. In severe disease, partial removal of the bile duct and duodenum is performed. If a malignant tumor is localized in the stomach area, then its partial removal is performed.

After pancreatoduodenal resection, doctors connect the remaining segments of the pancreas. The bile duct is directly connected to the intestine. The time for such an operation is about 8 hours. After the operation, the patient is on outpatient treatment, which takes about 3 weeks.

Whipple Laparoscopy

This method of treatment is carried out based on the location of the malignant neoplasm. Whipple's laparoscopy can significantly shorten the patient's rehabilitation period. This type of surgical intervention is performed in patients with ampullar cancer.

Laparoscopic surgery is performed through small incisions in the abdominal region. It is done by experienced surgeons using special medical equipment. In the usual Whipple operation, cavity incisions are made of impressive size.

During laparoscopic surgery, surgeons note the least blood loss in the process of surgical manipulations. They also note the minimal risk of various kinds of infections.

When is Whipple surgery necessary

There are a number of indicators at which the operation can completely correct the patient's condition. These include:

• Cancer of the head pancreas (pancreatoduodenal resection of the pancreas is performed).
• Malignant neoplasm in the duodenal region.
• Cholangiocarcinoma. In this case, the tumor affects the healthy cells of the liver bile ducts.
• Ampular cancer. Here, the malignant neoplasm is located in the area of \u200b\u200bthe pancreatic duct, which removes bile into the duodenum.

This kind of surgery is also used in benign tumor disorders. These include a disease such as chronic pancreatitis.

Approximately 30% of patients undergo this type of treatment. They are diagnosed with tumor localization within the pancreas. Due to the lack of precise symptoms, in most cases, patients experience the process of metastasis of other organs. It makes no sense to carry out an operation with this course of the disease.

Pancreatoduodenal resection begins with an accurate diagnosis of the affected parts of the organ. Passing the appropriate tests will show a picture of the course of the disease.

The small size of the cancerous tumor allows for laparoscopic intervention. As a result, surgeons manage to completely remove the affected area, while not harming other organs of the abdominal cavity.

Treatment results

Most patients ask the same question: what are the consequences of pancreatoduodenal resection? Over the past 10 years, the patient mortality rate has dropped to 4%. The fact is that a positive result is achieved with the vast experience of the surgeon performing the operation.

With adenocarcinoma of the pancreas, Whipple's operation can save the life of about 50% of patients. With the complete absence of tumors in the lymphatic system, such measures increase the survival rate of patients several times.

At the end of the operation, the patient is prescribed a course of radio- and chemotherapy. This is necessary in order to destroy the spread of cancer cells to other organs.

Further treatment after surgery is contraindicated in patients with a benign tumor, as well as with neuroendocrine changes.

Pancreatoduodenal resection: surgical technique

Surgery removes most of the organ that produces insulin. In turn, it helps control blood sugar levels. Partial resection significantly reduces insulin production. As a result, the risk of developing a disease such as diabetes mellitus increases dramatically in most patients.

Patients with high blood sugar levels are most susceptible to this type of disease. A normal glucose level in a patient without chronic pancreatitis dramatically reduces the development of diabetes.

At the end of the rehabilitation process, the attending physician recommends adhering to a diet. Too fatty and salty foods must be excluded from the diet. Often, after this kind of intervention, many patients had an intolerance to sweet food. In this case, its use is contraindicated.

Complications after Whipple surgery

This type of treatment has a fairly high risk of complications. The professional experience of the surgeon significantly reduces the occurrence of any troubles. Potential problems include:

• The appearance of a pancreatic fistula. During the operation, the surgeon connects the gland with the intestinal section. The soft tissues of the pancreatic organ interfere with the rapid healing of the suture. During this period, there is a loss of pancreatic juice.
• Partial paralysis of the stomach. At the end of the operation, the patient is prescribed a course of injection through a dropper. This is necessary in order to restore the normal functioning of the stomach.

Nutrition after pancreatoduodenal resection must be correct, all bad habits must be excluded. If all the recommendations are followed, a person gradually returns to normal life.

2

1 GUZ "Ulyanovsk Regional Clinical Center for Specialized Types of Medical Care"

2 FSBEI HPE "Ulyanovsk State University"

The aim of this study is to retrospectively evaluate the possibilities of pancreatoduodenal resection (PDR) in the treatment of patients with adenocarcinoma of the pancreatic head (RV) in an emergency department. The results of examination and surgical treatment of 82 patients with tumor-like formation of the pancreatoduodenal zone are presented. The examination revealed: 64 - cancer of the biliopancreatoduodenal zone; 11 - pseudotumorous pancreatitis complicated by hyperbilirubinemia; 7 - pancreatic head cyst complicated by obstructive jaundice. Radical surgery, PDR, was performed in 10 patients (8.2%), and palliative interventions 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 the failure of pancreatojejunoanastamosis. Of all the operated patients, 8 patients were discharged in satisfactory condition on 16–48 days after the operation. Long-term results could be traced in 6 patients in terms of 2–5 years - there were no deaths. Thus, patients are admitted to the emergency department late, against the background of the developed complications, 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 leads to a low percentage of radicalism in surgical interventions. The high trauma of the operation, pronounced cholemic and tumor intoxication, explains a significant number of complications in the postoperative period and high mortality. PDD remains in the highest risk category for life-threatening complications, which limits 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, to improve the surgical technique and improve the results.

pancreatic head cancer

radical surgery

pancreatoduodenal resection

1. Baychorov E. Kh., Novodvorskiy SA, Khatsiev BB and others. Pancreaticogastroanastomosis during pancreatoduodenal resection surgery // Surgery. - 2012. - No. 6. - S. 19-23.

2. Gorodnov SV, Nabegaev AI, Tyurina TM et al. Experience in the treatment of obstructive jaundice in tumor pathology of the pancreatoduodenal zone // Oncology today: patient, state, medical community. VII Russia. scientific and practical. conf. (Ulyanovsk, October 20-21, 2011). - Ulyanovsk, 2011 .-- P.82-84.

3. Davydov MI, Aksyonov EM Statistics of malignant neoplasms in Russia and the CIS countries in 2004 // Bulletin of the Russian Oncological Center. N.N.Blokhin RAMS. - 2006 .-- 132 p.

4. Kubyshkin VA, Vishnevsky VA, Buriev IM and others. PDR with preservation of the gatekeeper // Surgery. - 2003. - No. 3. - P. 60–63.

5. Patyutko Yu. I., Kotelnikov AG, Abgaryan MG and others. Cancer of the pancreatic head: modern treatment and further prospects // Bulletin of surgical gastroenterology. - 2007. - No. 3. - S. 5-16.

6. Shetveryan GA Pancreatoduodenal resection in the treatment of cancer of the head of the pancreas and periampullary zone: Author's abstract. dis ... cand. honey. sciences. - 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 pylorus preserving pancreatoduodenectomy // Chirurg. - 1999. - Vol. 70, No. 12. - P. 1454-1459.

Introduction

Pancreatoduodenal resection (PDR) in our country remains a rare operation, although the real need for it both in pancreatic tumors and in chronic pancreatitis is very high. According to publications in the literature, it can be said that radical surgical treatment is performed in a smaller proportion 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 up to 10% of patients. For example, in the United States, more than 29,000 cases of pancreatic adenocarcinoma are diagnosed each 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 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 dealt with by oncological dispensaries. But, unfortunately, there is a category of cancer patients who enter the surgical department on duty, bypassing the outpatient department: either by self-referral, but most often by the ambulance service. This group of patients with so-called complicated cancers of different localization. The department of emergency surgery deals with the treatment of 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 is over 60 years old. Over the five-year period since 1991, the incidence of pancreatic cancer in men increased by 7.4%, in women - by 4.9%. A similar situation with the growth of cancer patients, including cancer of the pancreatoduodenal zone, was noted in our clinic, even after 20 years of development of medicine.

Objective: to retrospectively evaluate the possibilities of pancreatoduodenal resection in the treatment of patients with adenocarcinoma of the pancreatic head in an emergency department.

Material and research methods

In the period from 2006 to 2012, 82 patients with tumor-like formation of the pancreatoduodenal zone were treated 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 the Ulyanovsk State University is located. The incidence of malignant tumors of the pancreatoduodenal zone continues to increase. In 2006, 41 patients with complicated cancer of various localization passed through the 5th surgical department, of which 7 patients were diagnosed with pancreatic cancer, and in 2012 there were 87 of them, of which 16 were cancer of the pancreatoduodenal zone (Table 1).

Table 1. The number of cancer patients in the emergency department

		Total cancer patients in the emergency department	Pancreatoduodenal cancer patients

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

Of 82 patients, 64 patients were diagnosed with cancer of the biliopancreatoduodenal zone (the diagnosis was made on the basis of anamnesis, clinical picture, ultrasound examination data (US) and computed tomography, some patients were admitted from an outpatient appointment of an oncological dispensary in order to perform palliative surgery for obstructive jaundice). And 11 patients were diagnosed with pseudotumorous pancreatitis complicated by hyperbilirubinemia (the diagnosis was made solely on the basis of anamnesis data - these are at least 3-4 episodes of acute pancreatitis in the past, with the presence of patients, as a rule, in the intensive care unit, alcohol abuse), and 7 - cyst of the head of the pancreas, also complicated by obstructive jaundice (the diagnosis was confirmed by ultrasound data). 100% of 82 patients were operated on.

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

Out of 10 patients, PDD was performed for: 1 - pseudotumorous pancreatitis (histologically - chronic sclerosing pancreatitis), 3 - cancer of the large duodenal papilla of the duodenum with invasion into the head of the pancreas, 4 - cancer of the pancreatic head itself (Fig. 1), 1 - cancer of the right kidney with metastatic lesion of the pancreatic head, 1 patient with a pancreatic head cyst 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 of 24.02.2008)

Fig. 2. Cyst of the head of the pancreas, complicated by bleeding into the gastrointestinal tract, patient M. (case study No. 2253 dated 04.08.2009)

Research results

All patients were hospitalized on an emergency basis due to the development of complications of the underlying disease: 8 people with 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.

One-stage operation was performed in 2 patients with a tumor of the pancreatic head without obstructive jaundice. Contraindications to one-stage intervention were: high hyperbilirubinemia, duration of jaundice for more than 14 days, the phenomenon of renal-hepatic failure. 8 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 to reduce cholemic intoxication - 6 patients underwent cholecystojejunostomy with Brown's interintestinal anastomosis, 1 - choledochoduodenoanastomosis, 1 - Vishnevsky choledochus drainage. A radical operation was performed at the second stage, 10-14 days after the decompression surgery. By this time, the patients showed either normalization or a significant decrease in the level of total bilirubin.

After removal of the pancreatoduodenal complex, the restoration of the continuity of the gastrointestinal tract and the inclusion of the stump of the pancreas and bile duct into it can be performed by different methods. Previously, pancreato- and biliodigestive anastomosis, on the one hand, and duodenojejunal anastomosis, on the other.

Pancreatoduodenal resection was performed according to the classical Whipple technique and involved the 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 performed in the accepted sequence: biliodigestive, pancreatojejunostomy and then gastroenteroanastomosis.

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

What motivates surgeons to perform PDE in the emergency department?

According to statistics, about 30% of patients die a month after the diagnosis, and the average survival rate is 6 months. In oncological hospitals there is a queue 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 pancreatoduodenal zone.

However, based on our experience, in addition to cancer patients, there is a category of patients who also need to perform such a complex operation, which is PDR. These are patients with pseudotumarous 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 the failure of pancreatojejunoanastamosis. 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 the operation. And only one patient had no signs of acute pancreatitis - a patient with pseudotumorous pancreatitis, type 2 diabetes mellitus, insulin-dependent, iron obviously did not function during surgery. Of all the operated patients, 8 patients were discharged in satisfactory condition on 16-48 days after the operation. Long-term results could be traced in 6 patients in terms of 2-5 years - there were no deaths.

Pancreatoduodenal resection is the only radical treatment for cancer of the pancreatic head, cancer of the periampullary part of the common bile duct and the large nipple of the duodenum. Much less often PDR is used: with pseudotumarous pancreatitis, abscess of the pancreatic head, penetration of a stomach tumor into the pancreatic head, cysts of the pancreatic head, complicated by bleeding into the gastrointestinal tract.

Patients are admitted to the emergency department late, due to the development of complications, most of the patients were treated by a physician or infectious disease specialist at their place of residence for 2-4 weeks before admission to the surgical department. Late diagnosis leads to a low percentage of radicalism in surgical interventions.

The high trauma of the operation, pronounced cholemic and tumor intoxication, explains a significant number of complications in the postoperative period and high mortality.

Pancreatoduodenal resection remains one of the highest risk categories for life-threatening complications, which limits the range of radical surgery.

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

Reviewers:

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

Rodionov VV, Doctor of Medical Sciences, Professor, Head of the Department of Oncology and Radiation Diagnostics of the Federal State Budgetary Educational Institution of Higher Professional Education "Ulyanovsk State University", Ulyanovsk.

Bibliographic reference

Besov V.A., Barinov D.V., Smolkina A.V., Belova S.V., Nozhkin I.Yu., Komarov A.S., Gerasimov N.A. PANCREATODUODENAL RESECTION IN THE DEPARTMENT OF EMERGENCY SURGERY // Modern problems of science and education. - 2013. - No. 4 .;
URL: http://science-education.ru/ru/article/view?id\u003d9882 (date of access: 12.12.2019). We bring to your attention the journals published by the publishing house "Academy of Natural Sciences"

P D R I am writing this for colleagues in misfortune and their loved ones, maybe it will become easier for someone when he reads this, maybe my experience will help someone. About myself: I am a sailor, for the last 11 years I have worked as a captain on ships under foreign flags under contracts. Before It started a year ago. I went, as usual, to undergo the annual medical examination. It begins with the tests .. I passed it, got the result, decided to go to the gastroenterologist and heard that the "hemoglobin" is too small, I should have done an endoscopy .. I didn't want to, of course, refused for a long time, but persuaded .. The operation is not very pleasant of course, and now, I heard .. the doctor's whispering whisper: "wow .." it turns out in the duodenum some kind of swelling of some sort of Vater's nipple ... I had not felt any unpleasant symptoms before and did not attach much importance to this:. .maybe I was kind of healthy and cheerful and was not afraid of anything .. A week later they told me to come again, do a tumor biopsy of this very Big Vater's nipple (BDS) .. Came, of course, they injected something intoxicating - anesthetic, did a pinch off. They told me to come for the result to such a hospital, to a laboratory, next to the former Executive Committee .. Then I got worried, began to read and look for information, what it could be .. It turned out that it could be a very unpleasant, to put it mildly, thing, cancer BDS. It turns out that in the human body this is an important element that few people have heard of, through this very nipple, bile and enzymes produced by the pancreas enter the duodenum ... Such cases are quite rare, about 0.5% of all cancers. Hmm ... well, I thought what to do, where to run? I went to Smolenskoe, to Xenia's grave, asked how I could help our saint ... protector and helper .. Well, and then to the laboratory, for the result. The result was this: adenocanceroma ... .. To say that he discouraged, to say nothing, I was literally knocked down, I couldn't speak .. I couldn't think .. I came home, it's even worse there. My wife, my only and last wife, children, spoke with difficulty, it is hard and simply scary to look at her. I, a person in general, not old at 50, turned out to be doomed ... overnight and unexpectedly, but nothing boded. But .. survived .. that evening somehow ... friends called, relatives supported. And now the question arose of what to do, in fact, there is only one option with such a diagnosis, to do PDR - Pancreatoduodenal resection (Whipple operation). The question was where to do? A gastroenterologist, who discovered it all, recommended to me one little-known medical center in wide circles of the population, which has a good reputation in such matters, among specialists. ... And I went there. There, indeed, they accepted it normally, without any money or bribes. They treated me with care, told and explained everything. It turns out that such an operation is one of the high-tech and very complex, they give a quota for it, the quota must be chosen, but cases like mine are rare. So I went there to the court and by the way, so I was included in the plan for the next month. The operation itself consists in removing, completely, the duodenum, part of the pancreas, possibly part of the stomach, gallbladder and all ducts, bile ducts and those that lead from the pancreas. Then from the part, the patient's own small intestine, the whole thing is reconstructed anew. I explain this as best I can, so that it is clear to non-specialists, to doctors, of course, if they read this, there will probably be something to fix ... There are several options for how to do this and different surgeons prefer different ones, but all this is undoubtedly considered aerobatics them, surgeons ... The tumor itself was 2.5 cm, the computed tomography showed nothing more ... so, a vessel was going to the tumor. The surgeons explained to me that a little more and this adenocarceroma, having grown, would have blocked the ducts and then I would have obstructive jaundice and pancreatitis at the same time, if this happened to me in the sea, the result would be unambiguous, I would play in a plastic bag and in the fish chamber of a ship's artel ( This is a grocery store), for the subsequent sending of the body to relatives at the expense of the company. The operation itself was supposed to be done by the head of the department, an honored surgeon of the Russian Federation, a person who is very experienced in such things, and has an excellent reputation. I was assigned a date when I was supposed to arrive at the hospital, they explained what to take and how what, ... or before that, it's funny to say, I never lay in the hospital .. Then, of course, I told my relatives and everyone who considered it necessary about my trouble. Calls began, sympathy, support, everything was very touching. According to statistics, about 5% of such operations end in a "tragic" outcome, and all sorts of sad postoperative complications leading to the same are also very likely .. Therefore, I put things in order, wrote my wife instructions on what and how to do if something happens, put it in he did not write his diary or testament. There was no sense and so everything would go to the one who needs it. I talked with the eldest son, explained to him what and how .. It was also necessary to put spiritual and mental affairs in order. Thanks to my old friend Igor, a man of the Church, who helped me with this. We went to his confessor, Father Valery .. He confessed and received communion, received blessing and instruction. Greatly he strengthened and encouraged me .. God grant health to this wonderful person. He himself, as it turned out, had already experienced something similar and the Lord had mercy on him .. So, early in the morning ... October 200 ... year, I arrived at the medical facility in which I had to spend almost three months .. It was well-renovated and well-equipped , by Russian standards, a former departmental hospital. There was a huge aquarium in the lobby, cozy armchairs and sofas, the staff was neat and polite. I was placed in a three-bed ward with all the comforts and began to prepare for the operation, having warned, however, that a certain amount would have to be paid for the comforts, but not very large, in comparison with the problems that had befallen me ... The preparation consisted, basically, in taking analyzes and took place for three days. On the evening before the operation, I was visited by an anesthesiologist, a doctor of a special and very important specialty, who, as a rule, uses great weight in such institutions. I have heard that it is the anesthesiologists who solve slippery material issues with patients before the operation ... and mentally prepared to discuss them, but he did not talk about anything other than the procedures ahead of me, asked me about my diseases, allergies and that's it ... No one asked for a penny from me past the health insurance fund, neither before the operation, nor after it .. Not a single sister or nanny or doctor took a penny from me during my entire stay ... All payments that went only through the cashier. I also signed a special paper - consent to the operation, which I did not particularly read, somehow it was not up to that. On the evening before the operation, I myself for a long time clumsily and painfully shaved myself in all sorts of such places .., then for the first time in my life I was given an enema .. I fell asleep calmly. I got up at 6 in the morning, folded my things, wrote a note, Tied a pectoral cross to the wrist of my right hand .. Stripped naked, put on some strange thin disposable clothes like a submariner's underwear that they gave me ... then a gurney came for me and I was taken on it head first into the operating room .. it was rather cold there, they had not yet drowned. Or maybe this is done on purpose, I don't know .. An anesthesiologist, an acquaintance, came, made me bend over and injected something into my spine, or spinal cord? The operating room was for two places and next to the table, similar manipulations were performed with the female body ... Then, I was given anesthesia and I, like, fell asleep, quietly and without any dreams, repeating as Father Valery taught me "Lord Jesus Christ, son of God, forgive and have mercy on me, a sinner. ... ". Afterwards, the question brought me out of oblivion:" Can you hear me? " only the next day in the morning, at the same time they turned off artificial ventilation of the lungs, pulling out thick corrugated tubes from the larynx .. I found myself in the following state in each nostril along a tube, somewhere inward, from the causal place a tube and from the abdomen three tubes from different sides from which something constantly oozed and dripped into special containers .. I can't say what exactly ... apparently bile, gastric juice ... and the like. ”Something was constantly and continuously poured into a vein through a dropper. I didn’t feel it, only I was very thirsty, but they didn’t give it, they also gave it to drink through a dropper, and it was like that for the first two days approximately .. When they finally gave me a little drink from a special drinking bowl, I experienced real pleasure. All the sisters were young beautiful girls, caring, competent and sweet. Among them was one guy, a paramedic and also a fine fellow. Obviously, the work of nurses in intensive care is considered prestigious and well paid. But I didn’t manage to find out exactly how much they get there. Somewhere on the second day they pulled the tubes out of my nose .. I still didn't understand why they were there, my wife brought me a receiver, it became more fun. But problems of a different kind began, firstly it began to hurt to lie on the back, secondly, problems with blood sugar began, in the third he began to cough, which was very painful, since there was a huge incision sewn with threads across the entire abdomen, and indeed all the insides were cut and sewn on a new one ... It turns out that the sugar rose to 17 due to the fact that I was injected with glucose intravenously as a food .., and my pancreas was partially swollen and apparently did not produce insulin, in the required amount. She, the pancreas, in general, on the first day made a burst of her secret, which, as they explained to me, began to dissolve everything in my intestines and abdominal cavity that did not get in, which caused huge problems, but that later. In the meantime, I attended to my cough. As far as I remember, mortality from pneumonia was among the main factors in mortality after such operations. And the operation itself took place at such a temperature that it was no wonder not to catch a cold. During the morning round, and he regularly took place at 09:00, where I was examined by the attending doctors and hospital authorities, I shared my doubts about my lungs and pneumonia. .. To my surprise, very soon a portable X-ray machine was brought to the intensive care unit. I saw this for the first time. They made me a fluorography and determined that phlegm had accumulated in the left lung. Soon other people came with a special device for suction of sputum from the lungs .. the anesthesiologist immediately appeared, who said: "Look now, he will become prettier" and injected me with promedol. Not to say that I experienced heavenly bliss, but it became much more pleasant to live and not so painful. I swallowed a special intestine without any problems and through it the sputum was successfully pumped out of my lungs ... They began to inject me with insulin, so this sugar also became easier, but my back continued to ache dullly due to continuous lying on it. Life in the intensive care unit begins very early: at 6 in the morning a sister comes and hands over thermometers to everyone .. then the selection of blood tests and other liquids begins, then bypassing and prescribing treatment after that they begin to take out someone, bring in someone new, sometimes the composition turns out to be mixed female-male, someone groans, someone wheezes, someone snores and someone screams .. in general, after a week spent in intensive care, the outlook on life changes dramatically: you start to treat naked men and women and their natural shipments. Somewhere on the sixth day, they didn’t load me a cart and drove back to the ward from which I left a week ago. I was very optimistic and they promised to discharge me in a couple of weeks. I found myself on my wide bunk, made my way to the toilet and sipped some soup ... and generally began to feel like I was recovering. I remember that on the second or third day I was visited by Indian students from pediatrics with whom I had a nice conversation in their own way about my diseases and their native Bombay, where I had to be repeatedly and at the same time I remembered a new word before which I did not have to use-guts (intestines). And most importantly, I was informed that I had the first stage of cancer, which gave me some chances for a fairly long life, well, for example, for about five years. It seemed that everything was getting better .., but no, from one tube that was sticking out from the right side of my abdomen, something poured out, such, well, not what is needed. The temperature in the evenings began to rise to 38.5, they said that I had an abscess due to the fact that the secret of the pancreas dissolved something there ... On the same day I was transferred to the purulent department of the medical center, which was located in another wing of the building ... Every day, they began to clean my wound in my right side, and they did it without local anesthesia, which was very painful. They cleaned it like this: put a turunda into the wound and then took it out. The disgusting word turunda means such a flagellum from a bandage ... They also poured brilliant green or hydrogen peroxide into the wound ... when they poured brilliant green for the first time, they just started pounding me and I started shaking with a small shaking ... Such is the reaction. It soon became clear that all this had no effect, and therefore a well-known anesthesiologist appeared in my ward, made me a soporific stab and, under general anesthesia, another incision was made in the abdominal cavity above the first hole from which, as it turned out, pus was flowing. Now, on the right, I already had two holes. By that time, the holes on the left were already sealed with plasters and the tubes were removed from them. During the daily dressing, peroxide or some other disinfectant liquid was poured into the upper right one and it poured out from the bottom ... Turundas were also pushed there to pull them out of the lower hole .. In general, something was pouring from the bottom constantly and especially strongly into night time .. and soon it became clear that my abdominal cavity communicates with the intestines through a fistula and half-digested food gets from it into the wound .. What is characteristic, the department head took all this quite calmly, said that everything was as it should be and that my fistula will overgrow by itself. Surprisingly, this is how it happened. Obviously, this was really an Honored Doctor and a person highly experienced in matters of purulent surgery ... but so far everything only got worse and I could no longer get out of bed myself. My wife brought me a rope and I tied it to the back, reached for it and got up, but it was very painful and excruciating ... The turn of the third operation, in succession, under general anesthesia came. Again, a soporific ukolchik, again an incision in the area of \u200b\u200bthe abscess, again severe postoperative pain. Now I could only get up with the help of my sister or a roommate ... In the evenings there was still a high fever, pus was pouring from the wounds, pouring sheets and clothes ... and so every day ... for about twenty days ... They did not give me any antibiotics, that was the tactic of treatment, they explained that this was the last resort and it was better to do without it. By the end of the first month of my stay in the hospital, I lost 25 kg, moved with great difficulty and even sat with difficulty, there was nothing on, the muscles on my butt disappeared somewhere, only bones remained. During this time, I already became my own people in the hospital, met everyone, saw all kinds of patients and heard a lot of different stories from them, usually sad ones. My roommate, and she was a double, a retired military engineer and military-industrial complex worker in civilian life, fell, for example, a victim of domestic medicine. While on a fishing trip, he unsuccessfully jumped from the boat to the shore and ran into a bitch on the popliteal area of \u200b\u200bhis leg ... went to the clinic there he was treated on an outpatient basis and healed to the point that his hematoma turned into a huge abscess that had to be opened, so he ended up in the department purulent surgery. Every day they cleaned and bandaged his huge wound, and in the evening he also had a fever and blood and pus oozed through the bandages. He angrily swore at everyone and tried to complain. We watched TV with him 24 hours a day without interruption and, to be honest, I hated the cops, Glukharev and the characters of all the other idiotic TV shows.It was possible to watch normally only programs about fishing, football, Culture and sometimes our Fifth Channel, the rest was just nauseous. In general, we were fed decently, but I had a very bland diet N1, nothing but pureed soups and cereals. About once a week, they started talking to me about the fact that they would definitely dismiss me on the next one, but then the temperature rose again and they left me. Every day I was bandaged and finally one day I was told that my abdominal wounds looked "better". Therefore my discharge was scheduled for next week. I was ordered to appear every other day for dressing, that is, trudge across the city. And now, the significant day of my discharge came, my uncle came for me with great difficulty and with the help of my wife I got to the car and we drove home. Every hole and tram rail ached in my cut belly, there were traffic jams in the city, but about an hour later we arrived home. To be honest, I didn’t expect to return to my cat and sofa. Then there were painful dressings again for a month, I had to go to the medical center by taxi. Then there was a visit to the regional oncologist and the people's "vale of grief" - the city oncological dispensary on Berezovaya, where they did not register me, they decided that there was no need. I myself did not begin to formalize my disability, because I did not see any point in it. And now about a year has passed. During this time, there was everything. All kinds of complications: thrombophlebitis, liver, continuous digestive problems, hemorrhoids .. But with the help of my friends I found a job that completely satisfies me and, most importantly, I realized how valuable every day of your life is in itself. Of course, I understand that a patient with such a diagnosis and such an operation does not have a duty ... but how to know what is measured for me? Recently I went to a Chinese teahouse and a parrot pulled out a leaf for me from a bag with a prediction, it turned out to be Omar Khayyam: “Once again, the day disappeared like the wind, a slight groan, From our life, friend, he fell forever. But I, as long as I'm alive, will not worry, About the day that I departed and the day that was not born. "

The main complication of pancreatoduodenal resection is the failure of the pancreatodigestive anastomosis (5–40%), in connection with which a large number of different techniques for the reconstructive stage of pancreatoduodenal resection have been developed, however, none of them is physiological. The author's modification of pancreatoduodenal resection was proposed - physiological reconstruction (was used in 14 patients), 10 patients made up the control group, in which standard pancreatoduodenal resection was performed. Failure of pancreatojejunostomy was registered in 1 (7%) patient of the main group and 3 (30%) in 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 pancreatoduodenal resection showed its initial effectiveness.

Introduction

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

The "classic" Whipple operation, first described in 1935, involves distal gastric resection, cholecystectomy with resection of the common bile duct, removal of the head of the pancreas, duodenum, followed by a reconstructive stage: pancreatojejunostomy, 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 PDD is 3–20%, depending on the experience of the clinic, however, the number of complications even in specialized centers remains significant - 18–54%. Pancreatodigestive anastomosis failure is one of the most common complications of PDD (5–40%), along with such complications as erosive bleeding, stress ulcers, biliodigestive anastomosis failure, acute cholangitis, which are the causes of patient mortality in the early postoperative period. With the ineffectiveness of conservative therapy, the failure of the pancreatodigestive anastomosis leads to the development of complications that require urgent relaparotomy (diffuse peritonitis, septic shock, bleeding). Relaparotomies for complications of PDD are associated with a mortality rate of 40 to 80%.

The main pathogenetic mechanism of the development of pancreatojejunoanastomosis failure is the local destructive action of activated pancreatic enzymes in the suture line zone. Further leakage of pancreatic secretion and accumulation in the area of \u200b\u200bthe pancreatic stump leads to the formation of extensive foci of inflammation with the subsequent development of areas of necrosis both in the pancreas itself and in the surrounding organs.

When performing the standard techniques of the reconstructive stage of the PDR, the activation of proteolytic enzymes of the pancreas is a consequence of the 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 zones of the seams of the formed anastomoses is the main cause of complications. Currently, there are more than 200 different modifications of the Whipple operation, concerning both the reconstructive stage in general and the methods of forming each of the anastomoses. No consensus has yet been reached on the choice of the optimal reconstruction method.

In order to increase the reliability of pancreatojejunoanastomosis by minimizing the effect of aggressive media such as bile and gastric juice on the 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 in PDD.

OBJECT and research methods

The study was conducted from January 2009 to December 2010. In total, the study included 24 patients who underwent PDE. The participants were randomized into two groups. In the standard treatment group, the reconstructive stage was performed sequentially on one loop according to the Whipple technique. The new method was applied 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

Index	Separate reconstruction,%	Control, %
Age, years	60,9 (47–79)	56,5 (45–68)
Floor
Men	8 (57)	6 (60)
Women	6 (43)	4 (40)
Diabetes	4 (28)	7 (70)
Cardiac ischemia	10 (71)	8 (80)
Peripheral circulation disorders	2 (14)	1 (10)
Pancreatitis	2 (14)	1 (10)
Jaundice	11 (78)	7 (70)

Table 2. Indications for pancreatoduodenal resection

Index	Separate reconstruction,%	Control, %
Adenocarcinoma of the pancreas	5 (36)	7 (70)
Papilla adenocarcinoma	3 (21)	1 (10)
Tumor of the distal common bile duct	1 (7)	0
Adenocarcinoma of the duodenum	2 (14)	1 (10)
Chronic pancreatitis	1 (7)	1 (10)
Neuroendocrine tumor	1 (7)	0
Pancreatic sarcoma	1 (7)	0

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

• pancreatojejunoanastomosis according to the duct-mucosa principle (end to side) with separate sutures, the inner row of sutures with 4–0 blumgart prolene suture, on a separate isolated loop of the small intestine 50 cm long from Treitz's ligament posteriorly, without stenting of the pancreatic duct. The second row of sutures - the serous membrane of the intestine with the capsule of the pancreas (prolene 4-0);
• gastroentero- and hepaticojejunostomy formed on the second loop of the small intestine at a distance of 40 cm from each other anteriorly (end to side), double-row and single-row sutures, respectively (Fig. 3 and 4).
• hepaticojejunoanastomosis was “disconnected” from gastroenteroanastomosis by forming an interintestinal fistula with a cap of the adductor loop. Distal to the hepaticojejunoanastomosis, 50 cm, the intestinal loop from the pancreatojejunoanastomosis along Roux was included in the passage.

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

Fig. 2. Blumgart anastomosis: view of the operating field

Fig. 3. Technique of isolated reconstruction: P - pancreas; F - stomach; 1T - the first loop of the small intestine; 2T - the second loop of the small intestine; LSh - seam line of the leading loop plug

Fig. 4. Technique of isolated reconstruction - the final form: 1 - hepaticojejunoanastomosis; 2 - pancreatojejunostomy; 3 - gastroenteroanastomosis

results

The mean operation time was 6.40 ± 1.20 h in the main group and 6.10 ± 1.10 h 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; regional, aorto-caval lymphadenectomy, and meso-duodenumectomy were also the standard for all operations. The proportion of complications was lower in the study group (Table 3). The main complication was the failure of pancreatojejunostomy (7% in the main group and 30% in the control group), followed by the formation of abdominal abscesses. The need to perform relaparotomy in the main group arose in 1, in the control group - in 2 patients. No postoperative mortality was recorded in both groups. The patients were given water from the first day of the operation. On the 4th day, a study of the passage of the contrast agent along the gastrointestinal tract was carried out. 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 of postoperative hospital stay in patients in the main group was 14.2 (9–22) days, in the control group - 19.5 (8–32) days. Complications - see table. 3.

Table 3. Complications

Index	Separate reconstruction,%	Control, %
Mortality	0	0
Relaparotomy	1 (7)	2 (20)
Need for ultrasound-guided puncture	5 (36)	6 (60)
Slowing evacuation from the stomach stump	0	4 (40)
Wound infection	1 (7)	3 (13)
Pneumonia	1 (7)	1 (10)
Bleeding	1 (7)	0
Pancreatojejunoanastomosis failure	1 (7)	3 (30)
Intra-abdominal abscess	1 (7)	2 (20)

The median follow-up was 8.9 months. In the course of follow-up, all patients of the main group did not report nausea, vomiting, heartburn, epigastric pain, belching after eating. All patients in the control group reported from 1 to 2 of the above complaints.

Discussion

Intracellular activation of enzymes is due to the development of pancreatitis in the postoperative period, which is triggered by trauma to the pancreas during mobilization, at the stage of resection, and also during the formation of a pancreatodigestive anastomosis. In the early postoperative period, the development of pancreatitis is due to the activation of the pro-forms of pancreatic enzymes due to a violation of the physiology of the secretion of pancreatic juice, reflux of the contents of the anastomosed intestine into the pancreatic duct (the main factors of aggression are bile, enterokinase, low pH).

The factors of predisposition to the development of pancreatodigestive anastomosis failure in the literature were divided into how many groups: anthropomorphic factors (age, sex, constitution, etc.), anatomical and physiological factors (consistency of the pancreas, width of the pancreatic duct, intensity of pancreatic secretion), preoperative (the degree of obstructive jaundice, the use of biliary stents or methods of external drainage of the bile ducts), surgical factors (the sequence of reconstruction, the technique of forming an anastomosis, methods of drainage of the abdominal cavity, the use of stents of the pancreatic duct) and postoperative (the appointment of somatostatin analogs, the timing of the extraction of drains and a nasogastric tube, beginning of enteral feeding). According to the above groups of factors, it has been established today that anatomical and physiological factors play the greatest role in the development of insolvency. Anthropomorphic factors are practically not associated with the risk of insolvency, it remains unclear and continues to assess the main - surgical factors, methods of preoperative preparation and postoperative therapy.

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 PDD, two of the most common are currently possible: pancreatojejunostomy and pancreatogastrostomy.

The classic version of reconstruction involves the sequential formation of pancreatojejunostomy and hepaticojejunostomy on one loop posteriorly, then gastroenteroanastomosis anteriorly. The second widespread reconstruction option is pancreatogastrostomy with the formation of hepaticojejunostomy and gastroenteroanastomoses on one loop. In randomized trials, both types of reconstruction showed no differences in both the number of postoperative complications and the characteristics of technical performance.

In our opinion, the disadvantages of these techniques for the formation of a pancreatodigestive anastomosis is the aggressive effect of bile and gastric juice on the tissue of the pancreas in the early postoperative period. Removal of the duodenum with an ampoule during PDR and subsequent reconstruction with free confluence of the pancreatic duct causes unhindered 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 is currently represented by a large number of clinical and experimental studies. The following works deserve the greatest attention:

• G.J. In an experiment, Wang and co-authors proved the destructive effect of bile acids (taurolitocholic, taurocholic, and taurodeoxycholic) on the acinar cells of the pancreas 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 prolonged increases in calcium concentration in the acinar cells of the pancreas lead to intracellular activation of trypsinogen in trypsin, a critical moment in the induction of acute pancreatitis.
• T. Nakamura and co-authors found that bile activates A 2 -phosphorylase, an enzyme in the pancreas that leads to the development of pancreatitis.
• A.D. McCutcheon on a model of a closed duodenal loop in dogs noted the development of acute pancreatitis in 100% of cases as a consequence of reflux of bile and duodenal contents into the pancreatic duct.

Thus, the technique of isolating pancreatojejunostomy from the ingress of bile and gastric contents is sufficiently 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 stomach stump (in contrast to other reconstruction techniques). The 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 PDD includes a slowdown in the evacuation of food from the gastric stump (ZEP), which significantly reduces the quality of life of patients. With classical methods of reconstruction, EPD can 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 - the absence of an EPZ clinic both in the early and late periods after surgery), the developed technique prevents the development of the second most frequent complication of PDD, improving the quality of life of patients.

conclusions

The proposed modification of the reconstructive stage of PDR has shown its effectiveness - a decrease in the frequency of postoperative complications, the need for relaparotomy, has improved the quality of life of patients by eliminating postoperative food stagnation in the stomach stump.

The developed method of physiological reconstruction is pathophysiologically justified, since it restores the natural pathway of the food bolus passage, 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. Bachellier 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 operation. 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: toward 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 analogs inthetreatment of gastrointestinaldiseases: prevention of complications after pancreatic surgery. Gut, 3: 20-22.
• 34. Catel R.B. (1948) A technic 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, p. 1838.
• 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. \u200b\u200bNiederau 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) Pancre-aticobiliary 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

І.B. Shchepotin, A.V. Lukashenko, O.O. Kolesnik, O. V. Vasil'ev, D.O. Rozumiy, V.V. Priymak, V.V. Sheptytsky, A.I. Zelinsky

National Institute of Cancer, Kiev

Summary. The main accelerated pancreatoduodenal resection is the inability of pancreatodigestive anastomosis (5–40%), due to which there is a large number of useful methods of reconstructive proteancreaticoduodenal resection and resection. The author's modification of pancreatoduodenal resection - physiological reconstruction (the bullet was stagnated in 14 ailments) was proponated, 10 ailments became a control group, in which a standard pancreatoduodenal resection was performed. The inability to pancreatojunoanastomosis was found in 1 (7%) sick main group in 3 (30%) controls. In both groups, there was no increased lethality. The average hour of moving to the stationary is 14.2 and 19.5 dB. Modification of the reconstructive stage of pancreatoduodenal resection has been introduced and has shown its cob efficiency.

Key words: pancreaticoduodenal resection, pancreatojunoanastomosis failure.

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 for the doctor and the patient - which treatment tactics to choose - surgery or conservative therapy.

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

The main indications for surgical treatment are:

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

Chronic inflammation of the head is considered the main indication for surgery. Since, 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, and its endocrine and exocrine functions are disrupted. The molecular and pathobiochemical mechanisms leading to focal inflammation and pancreatic fibrosis are largely unknown.

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

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

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

Pain in the upper abdomen is the leading clinical symptom associated with an increase in pressure in the ducts and tissues of the pancreas. Pathological changes in sensory nerves, an increase in 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 mainly 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, because 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.

Whipple surgery or pacreatoduodenal resection is a major surgical procedure that is most often performed to remove malignant or precancerous tumors of the head of the pancreas or one of the surrounding structures.

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

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

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

Reconstruction consists of attaching the remainder of the pancreas to the jejunum, attaching the common bile duct to the jejunum (choledochojejunostomy) so that digestive juices and bile can flow into the gastrointestinal tract, respectively. And fixation of the stomach to the jejunum (gastrojejunostomy) to restore the passage of food.

The complexity of surgical interventions on the pancreas is the presence of the enzymatic function of this organ. Thus, such operations require sophisticated execution techniques in order to prevent the pancreas from digesting itself. It is also worth noting that the tissues of the gland are very delicate and require careful handling, it is difficult to suture 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. upper and lower hollow veins.
2. abdominal aorta.
3. upper mesenteric arteries.
4. veins.

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

Comparison with total pancreatctomy

Sugar level

The basic concept of pancreatoduodenectomy is that the head of the pancreas and the duodenum have the same arterial blood supply (gastroduodenal artery).

This artery passes through the head of the pancreas, so both organs must be removed while blocking the general blood flow. If only the head of the pancreas were removed, it would jeopardize blood flow to the duodenum, leading to necrosis of its tissues.

Clinical trials have not been able to demonstrate significant survival for generalized pancreatectomy, mainly because patients who undergo this surgery tend to develop a particularly severe form of diabetes.

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

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

Pylorus-sparing pancreatoduodenectomy

In recent years, pylorus-sparing pancreatoduodenal resection (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 doubts remain as to whether this is an adequate operation from an oncological point of view.

Another controversial point is whether patients should undergo retroperitoneal lymphadenectomy.

Compared to the standard Whipple procedure, pylorus, a conserving method of pancreatoduodenectomy, is associated with shorter surgical time, fewer surgical steps, and reduced intraoperative blood loss, which requires less blood transfusion. Accordingly, the risks of developing a reaction to blood transfusion are less. Postoperative complications, hospital mortality, and survival do not differ between the two methods.

Pancreatoduodenectomy by any standard is considered the main surgical procedure.

Many studies have shown that hospitals where this surgery is performed more frequently have better overall results. But do not forget about the complications and consequences of such an operation, which can be observed from all organs undergoing surgery.

When carrying out surgery on the head of the pancreas:

• diabetes;
• postoperative abscess.

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

From the side of the duodenum, the following complications may occur:

1. Dysbacteriosis.
2. Intestinal obstruction due to stenosis of the anastomosis.
3. Exhaustion (cachexia).

From the side of the biliary tract, the following complications may occur:

• cholangitis;
• biliary cirrhosis.

Additionally, liver abscesses may develop.

Prognosis for patients after surgery

If all the doctor's prescriptions are followed during the rehabilitation period, the patient can reduce the risk of complications to a minimum.

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

Cancer patients, if necessary, should also undergo chemotherapy or radiation.

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 - fever and fever, leukocytosis;
3. Anastomotic leak - the development of symptoms of peritonitis;
4. Damage to the vessels of the pancreas, ligature failure - increased amylase levels in the blood and urine.
5. The development of postoperative pancreatitis, if the operation was not carried out in connection with inflammation of the pancreas - the obstruction of the pancreatic duct develops due to the edema of the organ.

Cancer patients get the opportunity to extend their lives. If the operation is performed at an early stage, then doctors expect a complete remission, at later stages the manifestation of metastases is possible, but this does not happen often and rarely becomes the cause of death. For patients with chronic pancreatitis, the result of the operation may be different - with a favorable outcome, these patients lose combat sensations and problems with the functioning of the digestive system, with less successful circumstances, the clinic of pancreatitis may remain, despite the compensated organ function.

All patients after operations on the pancreas are registered and are examined every six months. It is important to monitor the state of all structures, since late complications are possible, such as stenosis of anastomoses, the development of diabetes due to pancreatic fibrosis, as well as oncological processes.

About accelerated recovery after pancreatoduodenal resection is described in the video in this article.