M. A. Sahakyan
In generally, the management of periampullary neoplasms requires a complex approach, including surgery and chemo-radiotherapy. However, pancreatoduodenectomy remains the only curative option leading to the relatively satisfactory outcomes. At the same time, the review of the relevant literature revealed a presence of significant controversy concerning such perioperative issues, as preoperative management of patients with jaundice, extent of surgery and technical approaches towards the reconstruction phase. Given these challenges, the improvement of the surgical outcomes problematical to date.
In this study we have investigated the impact of jaundice and preoperative interventions on the bile ducts on surgical outcomes following pancreatoduodenectomy. Morеоver, the patients were divided into different groups and scrutinized deoрending on the extent of surgery (with or without pylorus preservation), type of pancreaticojejunostomy and application of pancreatic duct stenting. A multivariate analysis wаs carried out to determine the risk factors for postoperative complications and clinically relevant pancreatic fistulae.
From 2000 to 2014, a total number of 87 patients underwent pancreatoduodenectomy at following medical centers: Oncological National Center after V.A.Fanarjyan (2000-2003), Izmirlyan MC (2003-2004), Kanaker-Zeytun MC (2004-2008), Armenia RMC (2005-2014) and ArtMed RMC (2009-2014). The most common indications for pancreatoduodenectomy were ampulla (46%) and pancreatic cancer (26, 4%). Median intraoperative blood loss and mean operating time were 500 (200-2300) ml and 302,2 (+74,9)min, respectively. Clinically relevant pancreatic fistula prevailed among postoperative complications (18,4%), where`s reoperations were performed in 8(9,2%) patients.
In patients with jaundice, serum bilirubin level above 150mol/L and preoperative interventions in bile ducts were associated with an increase in postoperative morbidity (52,6%, p=0,043 and 58,3%, p=0,032, retrospectively).
Siхteen patients (18,4%) underwent pylorus-preserving pancreatoduodenectomy, which led to a reduction in estimated blood loss compared with the standard approach (400 (200-1000) vs 500 (200-2300)ml, p=0,017). Standard pancreatoduodenectomy resulted in prolonged operating time, although the difference was not statistically significant (292 (+63,6) vs 271,8 (+39) min, p=0,085). Postoperative outcomes were comparable between the two groups.
All patients were subjected to invagination pancreaticojejumostomy. Seventy-three (83,9%) patients underwent end-to-end anastomosis, whereas end-to-side technique was applied anastomosis significantly increased the rates of intraabdominal abscess (28,6% vs 5,5%, p=0,021), reoperations (p=0,21) and postoperative mortality (21,4% vs 2,7%, p=0,028). On the other hand, the pancreatic duct stenting was associated with the significant increase in operating time (369,2 (+103,8) vs 290 (+62,4)min,p=0,01), estimated blood loss (775 (300-1860) vs 500 (200-2300)ml, p=0,024), postoperative morbidity (76,9% vs 31,1%, p=0,004), rate of clinically relevant pancreatic fistula (46,2% vs 13,5%, p=0,012) and postoperative length of stay (21 (9-59) vs 12 (7-41) days, p=0,001).
Following the multivariate analysis of the pre- and intraoperative variables, pancreatic duct stenting was identified as a risk factor for postoperative complications (p=0,02) and clinically relevant pancreatic fistula (p=0,03). In addition, diabetes mellitus was also an independent prognostic factor for the development of clinically relevant pancreatic fistula after surgery.
Based on the results of the study, we conclude that pancreatoduodenectomy should be performed without previous interventions on the bile ducts in patients with serum bilirubin level below 150 mo/L. We presume, that pylorus-preserving pancreatoduodenectomy should be considered, whenever possible, together with an end-to-end invagination pancreaticojejunostomy without pancreatic duct stenting, since the latter leads to an increase in postoperative morbidity. As a result, we suggest an algorithm for the pre- and intraoperative management of the patients with periampullary neoplasms that may improve the surgical outcomes of pancreatoduodenectomy.
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