RU2776836C1 - Method for total duodenopancreatectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, oncology, endocrinology. The whole pancreas is removed with the preservation of all parts of the stomach and spleen and all arterial branches of the celiac trunk. At the same time, gradual mobilization of vessels from the mouth of the celiac trunk in the distal direction is carried out, including the splenic artery throughout with a gradual ligation of short pancreatic branches: a. pancreatica dorsalis, a. pancreatic inferior, a. caudae pancreatitis. The common hepatic artery is mobilized with preservation of the arterial arch from a. gastroduodenalis and a. gastroepiploeca dextra to the transverse artery of the pancreas. Mobilize and save a. gastrica sinistra and arterial arch of Barkov. The venous branches of the portal and splenic vein system are mobilized and preserved: anterior superior pancreatoduodenal vein, right and left gastroepiploic veins, right coronal vein, short gastric veins and Barkov's venous arch throughout.

EFFECT: method allows to preserve the arterial and venous vascular architectonics to the maximum to prevent the "block" of blood inflow and outflow, which, in turn, allows to prevent possible varicose transformation of the veins of the fornix of the stomach and the development of a portal segmental block with subsequent recurrent gastric bleeding, postsplenectomy sepsis and reduces the risk of postprandial hyperglycemia in the postoperative period.

1 cl, 1 ex

Description

The invention relates to medicine, surgery, oncology, endocrinology, and can be used to improve the immediate and long-term treatment of patients with pancreatic tumors of low malignancy potential by modifying the surgical approach to preserving blood supply to the stomach and spleen.

The history of total duodenopancreatectomy (TDPE) dates back to the end of the 19th century, when T. Billroth performed the first removal of the pancreas on a human [1]. However, until the 1940s, interventions on the pancreas were practically unbearable operations for the patient with a very high mortality rate. It should be noted that the search for various modifications of TDPE became possible only after progress in the diagnosis and understanding of the course of the disease in pancreatic tumors with a low malignant potential. The share of TPPE among all pancreatic surgeries in high-flow surgical centers is currently from 6.7 to 16.9% with a tendency to increase, however, unsatisfactory results of the postoperative period after total duodenopancreatectomy for many years required the search for ways to improve these indicators [2] .

In our opinion, postoperative complications in patients undergoing TDPE should be divided into three categories: surgical (as a rule, they are hemorrhagic - vascular), non-surgical (postsplenectomy sepsis) and endocrinological (postprandial hyperglycemia, steatorrhea, weight loss).

In the course of developing this modification of the TSPE, we turned to the experience of our Japanese colleagues.

In the work of A. Nakao, the postoperative period was studied in patients after various variants of TDPE. It was demonstrated that when saving the stomach during TDET, it is necessary to preserve at least one of the draining gastric veins to prevent postoperative bleeding [3].

One of the closest variants of TDPE to the TDPE method in the variant of the Botkin Hospital was proposed by the Korean S. Choi et al. [four]. However, with full preservation of the arterial architectonics of the stomach, splenology was performed according to the Warshaw method, which led to significant vascular complications in five patients (massive bleeding from the hilum of the spleen, varicose transformation of the veins of the gastric fornix).

Thus, we believe that the above modifications of total duodenopancreatectomy do not fully meet modern ideas about the safety and effectiveness of surgical interventions. Modification of TDPE with preservation of all parts of the stomach and spleen with splenic vessels allows to achieve the best immediate surgical performance and long-term endocrinological.

The task to be solved by the claimed invention is to expand the possibilities of the method of treatment by maintaining the anatomical integrity of the stomach and its vessels, as well as the spleen and splenic vessels.

The proposed method of treatment. In order to improve the results of TDPE, a surgical protocol was developed and implemented in the surgical clinic of the Botkin Hospital, which consists in performing TDET in a variant in which the stomach and spleen with their arterial and venous vessels are completely preserved. This surgical approach makes it possible to preserve the entire arterial and venous vascular architectonics to prevent the “block” of blood inflow and outflow, which, in turn, allows preventing possible varicose transformation of the veins of the gastric fornix and the development of a portal segmental block with subsequent recurrent gastric bleeding, postsplenectomy sepsis and reduces the risk postprandial hyperglycemia in the postoperative period. Operation procedure:

A gradual removal of all sections of the pancreas as a whole is performed, without its preliminary intersection at the level of the isthmus, with the preservation of all sections of the stomach and spleen, exclusively in the scope of duodenopancreatectomy with sequential mobilization and preservation of:

- all arterial branches of the celiac trunk, due to the gradual allocation of vessels from the mouth of the celiac trunk in the distal direction, including:

a) splenic artery throughout with ligation of short arteries to the pancreas: a. pancreaticadorsalis, a. pancreaticinferior, a.caudaepancreatitis;

b) the common hepatic artery with preservation of the arterial arch from a. gastroduodenalis and a. gastroepiploecadextra to the transverse artery of the pancreas;

c) keeping a. gastricasinistra and arterial arch of Barkov.

- all venous branches of the portal and splenic veins are mobilized and preserved:

a) anterior superior pancreatoduodenal vein

b) right and left gastroepiploic veins,

c) right coronary vein,

d) short gastric veins and Barkov's venous arch throughout.

Examples of specific implementation of the method

In the surgical clinic of the Botkin Hospital for a ten-year period (2009-2019), 2879 patients with a tumor lesion of the pancreas were treated. At the same time, 30 total duodenopancreatectomy were performed, while TDPE in the modification of the Botkin hospital was performed in 7 patients.

To assess the results of treatment, the patients were divided into two groups: the first included patients who underwent TDET in the modification of the Botkin Hospital, the second included patients operated on in the traditional way.

In the first group, the age of patients was 67.2±6.3 years (from 44 to 77 years), the ratio of men and women was 2:5. At the same time, in a new modification, TDET was performed in four patients with type IPMNI, one patient with type IPMNIII, one patient with IPMN in combination with WON, and one patient in combination with MCN.

In the second group, TDET was performed in 12 patients with type IPMNI, four patients with type IPMNIII, and seven patients with pancreatic ductal cancer.

The indicators of the second group were as follows: the total number of patients was 23, the age of the patients was 61.7±7.3 years (from 39 to 74 years), the ratio of men and women was 8:15. Total duodenopancreatectomy was performed in all patients according to the standard technique with antrum resection of the stomach and spleen.

Four patients from both groups underwent the installation of non-contact 24-hour blood glucose monitors after the operation. The perioperative management of patients by endocrinologists and gastroenterologists played an important role in improving the results of surgical treatment of patients undergoing TDPE: adequate administration of polyenzymatic drugs, glycemic control, patient education, and the use of modern insulins also contributed to improving the results of treatment of these patients. In our study, a comprehensive assessment of postoperative complications was carried out. Both general (according to the Clavien-Dindo classification) and specific surgical complications were analyzed - these are gastrostasis and hemorrhagic complications according to the ISGPS 2016 classification. The postoperative bed-day and the need for insulin were also assessed.

General surgical complications were analyzed using the Clavien-Dindo classification. Six complications were noted in the first group of patients. Category I - 2, II - 2, III - 1, IV - 0, V - 1. In the second group, the number of complications was 37: 1 - 6, II - 8, III - 6, IV - 12, V - 5. As It can be seen that mortality in TDPE in our modification was 14.3%, and in the classical version of the intervention it was 43.5%. Also noteworthy is a significant decrease in the number of severe postoperative complications in the main group. In the first group of patients, the phenomena of gastrostasis were detected in one (14.3%) patient (class "A"). There were no hemorrhagic complications. The average postoperative bed-day was 15.4 days. In the comparison group, gastrostasis phenomena were detected in 10 (43.5%) patients. In 6 (26%) patients - class "A", in three (13%) - class "B", class "C" - in one (4.3%). Postoperative bed-day was 18.9 days.

The proposed modern modification of the operation of total duodenopancreatectomy can significantly improve the results of treatment of patients with pancreatic tumors with low malignancy potential.

Bibliography

1. ReMineW. H. et al. Total pancreatectomy // Annals of Surgery. - 1970. - T. 172. - No. 4. - C. 595.

2. Stoop T.F. et al. Surgical outcomes after total pancreatectomy: a high-volume center experience // Annals of Surgical Oncology. - 2020. - C. 1-9.

3. Nakao A. et al. Gastric venous congestion and bleeding in association with total pancreatectomy // Journal of Hepato-biliary-pancreatic Sciences. - 2018. - T. 25. - No. 2. - C. 150-154.

4. Choi S.H. et al. Pylorus-and spleen-preserving total pancreatoduodenectomy with resection of both whole splenic vessels: feasibility and laparoscopic application to intraductal papillary mucin-producing tumors of the pancreas // Surgical endoscopy. - 2012. - T. 26. - no. 7. - C. 2072-2077.

Claims (1)

A method for treating patients with pancreatic tumors, characterized in that the entire pancreas is removed, while all parts of the stomach and spleen and all arterial branches of the celiac trunk are preserved, for which a gradual mobilization of vessels from the mouth of the celiac trunk in the distal direction, including the splenic artery, is carried out throughout with gradual ligation of short pancreatic branches: a. pancreatica dorsalis, a. pancreatic inferior, a. caudae pancreatitis; mobilize the common hepatic artery while maintaining the arterial arch from a. gastroduodenalis and a. gastroepiploeca dextra to the transverse artery of the pancreas; mobilize and preserve a. gastrica sinistra and arterial arch of Barkov; mobilize and preserve the venous branches of the portal and splenic vein system: anterior superior pancreatoduodenal vein, right and left gastroepiploic veins, right coronal vein, short gastric veins and Barkov's venous arch throughout.