Pancreaticoduodenectomy in a soft pancreas

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Abstract

Aim. To evaluate the effects of different techniques of the pancreaticoduodenectomy (PD) on the frequency and severity of postoperative complications and mortality in patients with a "soft" pancreas.

Material and methods. The results of 141 PDs were evaluated (76 were exposed the conventional surgery and 65 were exposed to the expanded volume of pancreatic resection, considering angioarchitectonics). In all cases, the pancreas was "soft", which was confirmed by morphological examination. The arterial architectonics of the cephalocervical segment of the pancreas was studied in the anatomical part of the study on 94 preparations, as well as clinical and radiological examination in 62 people.

Results. In patients with "soft" pancreas, an increased volume of resection during PD, considering arterial architectonics in the cervical region, allowed for a slight improvement in the immediate results of the operation: the number of specific postoperative complications decreased from 51.3% to 43.1%, mortality decreased from 7.9% to 4.6%. The probability of a postoperative pancreatic fistula (POPF) increased in cases where the dorsal pancreatic artery was not a branch of the splenic artery. The formation of an anastomosis with a pancreatic stump on an isolated loop and the preservation of the gastrointestinal ligament at the stage of mobilization reduced the aggressiveness of postoperative complications.

Conclusion. The expanded volume of pancreatic resection to ensure adequate blood supply of the stump of the organ appears to be an effective option only in cases of dorsal pancreatic artery withdrawal from the splenic artery. It is not possible to avoid ischemia of the pancreatic stump in other variants of the arterial anatomy of this vessel. In case of POPF, reconstruction involving two loops of the jejunum can reduce its aggressiveness. Mobilization of the complex with preservation of the gastrointestinal ligament facilitates the identification of the superior mesenteric vein and reduces the frequency of gastrostasis in the postoperative period.

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About the authors

Vsevolod Nikolaevich Galkin

Moscow City Hospital named after S.S. Yudin, Moscow Healthcare Department

Author for correspondence.
Email: vsgalkin@gmail.com

M.D., Professor, Chief Medical Officer

Russian Federation, Moscow

Andrey Germanovich Kriger

Moscow City Hospital named after S.S. Yudin, Moscow Healthcare Department; Russian Medical Academy of Continuing Medical Education of the Ministry of Health of the Russian Federation

Email: krigerAG@zdrav.mos.ru

M.D., Professor, Chief Researcher, Professor of the Department of Emergency and General Surgery named after Professor A.S. Ermolov

Russian Federation, Moscow; Moscow

David Semenovich Gorin

Moscow City Hospital named after S.S. Yudin, Moscow Healthcare Department

Email: davidc83@mail.ru

M.D., Chief

Russian Federation, Moscow

Nikolay Alekseevich Pronin

Ryazan State Medical University named after academician I.P. Pavlov

Email: proninnikolay@mail.ru

Ph.D., Docent of Anatomy Department

Russian Federation, Ryazan

Vladmir Igorevich Panteleev

Russian University of Economics named after G.V. Plekhanov

Email: vpantel@mail.ru

Ph.D., senior researcher at the scientific laboratory of health informatics and economy in healthcare

Russian Federation, Moscow

Alexander Alexandrovich Goev

Moscow City Hospital named after S.S. Yudin, Moscow Healthcare Department; State University of Education

Email: a_goev@mail.ru

Ph.D., surgeon in the Surgery Department №5, Associate Professor

Russian Federation, Moscow; Moscow

Tigran Artashesovich Martirosyan

Moscow City Hospital named after S.S. Yudin, Moscow
Healthcare Department; A.V. Vishnevsky National Medical Research Center

Email: robatik2015@gmail.com

surgeon, resident of Abdominal

Russian Federation, Moscow; Moscow

Gleb Vsevolodovich Galkin

Moscow City Hospital named after S.S. Yudin

Email: igkebgalkin@gmail.com

surgeon in the Surgery Department №5

Russian Federation, Moscow

Evgeniy Alexandrovich Ahtanin

Moscow City Hospital named after S.S. Yudin, Moscow Healthcare Department

Email: ahtanin.evgenii@mail.ru

Ph.D., Head of Surgery Department №1

Russian Federation, Moscow

Alexander Alexandrovich Sokolov

Moscow City Hospital named after S.S. Yudin, Moscow Healthcare Department

Email: alexandrklv@gmail.com

Head of the Ultrasound Department

Russian Federation, Moscow

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Supplementary files

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2. Fig. 1. Scheme of the reconstructive stage of pylorus-preserving PDЕ on two loops of the jejunum.

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3. Fig. 2. Intraoperative photographs. Stages of access to the pancreas with preservation of the gastrocolic ligament. A. Separation of the posterior duplication of the greater omentum from the mesentery of the transverse colon. B. Partially isolated superior mesenteric vein (indicated by the dotted line).

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4. Fig. 3. The origin of the DPA from the splenic artery (classic version of the structure of the pancreatic arteries): 1 - splenic artery, 2 - DPA, 3 - large pancreatic artery, 4 - caudal pancreatic artery.

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5. Fig. 4. Origin of the DPA near the mouth of the splenic artery in two different complexes (if interpreted incorrectly, for example, by X-ray angiography or CT angiography, it can be interpreted as the origin of the DPA from the celiac trunk): 1 – celiac trunk, 2 – splenic artery, 3 – common hepatic artery, 4 – DPA.

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6. Fig. 5. Origin of the DPA in the area of the orifice of the common hepatic artery (A – view of the posterior surface of the complex, B – view of the anterior surface of the complex): 1 – celiac trunk, 2 – common hepatic artery, 3 – splenic artery, 4 – DPA.

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7. Fig. 6. The beginning of the DPA from the superior mesenteric artery in two complexes: 1 – superior mesenteric artery, 2 – splenic artery, 3 – DPA.

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8. Fig. 7. Reconstruction on 2 loops. A. “Soft” pancreatic stump: 1 – pancreatic duct. B. View after reconstruction: 1 – Roux-en-Y loop carrying hepaticojejunostomy; 2 – isolated intestinal loop anastomosed with the pancreatic stump (intussusception anastomosis).

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9. Fig. 8. Ultrasound image of intussusceptional pancreatojejunostomy (7 days after surgery): 1 – pancreatic stump (yellow dotted line), 2 – jejunal loop (white dotted line), 3 – splenic vein, 4 – superior mesenteric vein (blue dotted line), 5 – nodal sutures along the anastomosis line.

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Copyright (c) 2025 Galkin V.N., Kriger A.G., Gorin D.S., Pronin N.A., Panteleev V.I., Goev A.A., Martirosyan T.A., Galkin G.V., Ahtanin E.A., Sokolov A.A.

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This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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