Results of surgical treatment of chronic pancreatitis with a high risk of developing pancreatic cancer

Abstract

Objective. To analyze the results of surgical treatment of patients with pancreatic insufficiency and a high risk of developing pancreatic cancer. Materials and methods. The study included 39 patients treated in 2019–2023. In 20 (51%) patients, it was difficult to clearly differentiate between chronic pancreatitis and pancreatic cancer. In 19 (49%) patients, the diagnosis of chronic pancreatitis was not in doubt. All patients with complicated forms of chronic pancreatitis and suspected pancreatic tumor underwent a set of laboratory tests, and routine screening methods of instrumental diagnostics were used. In addition to standard methods of examination, the levels of matrix metalloproteinases and tissue inhibitor of metalloproteinases in the blood plasma were studied. Results. The method of intraoperative multiple biopsy, improved by us, was an obligatory component of surgical care for a clear differential diagnosis of chronic pancreatitis and pancreatic cancer. In the presence of complicated chronic pancreatitis, during surgery, the biopsy was taken using a special punch instrument that resembles a pen, along the entire length of the main pancreatic duct along the upper and lower edges of the dissection in a checkerboard pattern. There were no complications of punch biopsy. Of the 20 patients in whom it was not possible to clearly differentiate between chronic pancreatitis and pancreatic cancer, 12 (60%) were diagnosed with diabetes mellitus. The characteristic changes in the pancreatic tissue gave grounds for performing extended resection interventions in these patients. In the remaining 8 (40%) patients without morphological changes inherent in malignancy, Whipple operation (2), longitudinal pancreaticoduodenectomy (2), Frey operation (2), and our proposed central pancreatic resection with preservation of the left anatomical segment (2) were performed. Drainage and resectional surgical interventions were performed in 19 (49%) patients with complicated forms of chronic pancreatitis. After radical surgical interventions for pancreatic cancer, 1 patient developed gastrostasis, and on the 11th day he underwent a relaparotomy with reconstruction of the gastroenteroanastomosis, and on the 30th day a subhepatic abscess was diagnosed in 1 patient, who underwent drainage with a subcostal mini–access with a positive effect. In 2 patients, after left–sided pancreatic resection, subdiaphragmatic abscesses were diagnosed on the left, they were treated minimally invasively with punctures and drainage under ultrasound control. Multiple organ failure occurred in 1 patient after surgery for internal pancreatic fistula, infected ascites as a complication of neglected chronic pancreatitis. The patient died. Infection of the median laparotomy wound occurred in 4 patients, and healing was achieved by controlled primary tension. Class B pancreatic fistulas occurred in 3 patients: 2 – after left–sided pancreatic resection, 1 – after longitudinal pancreaticoduodenostomy. In 1 patient, a class C permanent pancreatic fistula was formed after a combined (resection and drainage) intervention. Relaparotomy, subtotal resection with Roux–en–Y loop closure was performed. Conclusions. Morphological changes in the pancreatic tissue in chronic pancreatitis in combination with diabetes mellitus, corresponding to the development of PanIN, are direct predictors of adenocarcinoma. Multiple intraoperative pancreatic biopsies are effective in verifying pancreatic malignancy. Pre– and intraoperative diagnostics make it possible to optimize the surgical treatment of complicated forms of chronic pancreatitis and prevent the development of postoperative pancreatic fistula.