The modern view on the problem of the surgical treatment of patients with pathology of the pancreas accompanied by obstructive jaundice

Catedra de chirurgie nr.2, Curs de chirurgie pediatrică, Universitatea Națională de Medicină, Odessa, Ucraina, Al XII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova cu participare internațională 23-25 septembrie 2015Introducere: Rezultatele tratamentului chirurgical la pacienții cu patologie pancreatică pe un fundal de icter mecanic depind nu numai de cauza bolii de bază, dar de asemenea de diagnosticul oportun, durata icterului și volumul tratamentului chirurgical realizat. Scopul studiului a fost îmbunătățirea rezultatelor tratamentului chirurgical al pacienților cu sindrom de icter mecanic prin crearea unei metode de diagnostic diferențiat al patologiei de bază, cu determinarea ulterioară a volumului intervenției chirurgicale. Material și metode: Pe parcursul perioadei 2010-2015 în Clinica noastră au fost supuși tratamentului chirurgical 114 pacienți cu sindrom de icter mecanic. Algoritmul de diagnostic a inclus obigatoriu ultrasonografia, CT, MRI, FEGDS și ERCP. În unele cazuri a fost efectuată analiza genetică pentru prezența unor tipuri de mutații genice specifice. Evident pentru leziunile maligne ale pancreasului cefalic au fost verificați marcherii specifici oncogenici (CEA, CA 19-9). Cancerul de pancreas a fost confirmat la 42 (36,8%) pacienți, diferite forme de pancreatită cronică a fost găsite la 72 (63,2%) pacienți. Rezultate: Decompresia asistată laparoscopic sau cu ghidaj ultrasonografic a arborelui biliar a fost efectuată la 96 (84,2%) pacienți. La 17 pacienți cu pancreatită cronică s-a efectuat intervenție chirurgicală economă – procedeul Beger în volumul Bernese. La pacienții rămași (55) s-a efectuat rezecția pancreatoduodenală (RPD) prin metode proprii. RPD pentru cancer s-a efectuat la 42 pacienți, 7 pacienți au decedat. Rata de mortalitate a constituit 6.1%.The results of surgical treatment of patients with pathology of the pancreas on a background of jaundice is not only due to the nature of the underlying disease, but also its timely diagnosis, length of jaundice and volume of performed surgery. The aim of the study was to improve the results of surgical treatment of patients with obstructive jaundice syndrome by creating a new approach to the differential diagnostics of underlying disease with subsequent determining of the surgical intervention volume. Materials and methods_ From 2010 to 2015 in our clinic the surgical treatment of 114 patients with the obstructive jaundice syndrome was performed. The diagnostic algorithm includes the mandatory implementation of ultrasound, CT, MRI, FEGDS,ERCP. In certain cases, a genetic analysis for the presence of type-specific gene mutations was carried out. Obviously, for malignant lesions of the head of the pancreas verification of specific oncomarkers (CEA, CA 19-9) levels were estimated. Pancreatic cancer was verified in 42 (36.8%) patients, different forms of chronic pancreatitis were found in 72 (63.2%) patients. Results_ Ultrasound-guided or laparoscopy-assisted decompression of the biliary tree was performed in 96 (84.2%) patients. In17 patients with chronic pancreatitis sparing surgery in the volume of Bernese type of Beger’s procedure was done. In the rest patients (55) pancreatico-duodenal resection (PDR) by own methods was performed. PDR for cancer is performed in 42patients, 7 patients died. The mortality rate was 6.1%

The Eurasian Forensic Network in the Field of Protection of Wild Flora and Fauna

This article presents the current status and prospects of development of the Eurasian forensic expert network in the field of protection of wild fauna and flora, established to assist in the investigation of crimes against wild flora and fauna, the necessity of forming a Eurasian forensic network

The influence of RF plasma treatment at low pressure on the permeability of a polyurethane nanocomposite

The statistical model of treatment of a polyurethane nanocomposite by low-energy ionic streams in RF plasma at pressure in the range 13.3-133 Pa is developed. The dependence of the permeability of a filled nanocomposite on the filler mass fraction, both before and after RF plasma treatment, is theoretically investigated. © 2014 Allerton Press, Inc

Possibility of prognostication for unfavorable results of the pancreaticoduodenal resection on background of the obturation jaundice syndrome

Objective. To determine the possibility of prognostication of unfavorable course of postoperative period in the aspect of the planned pancreaticoduodenal resection for focal affection of pancreaticoduodenal zone on background of obturation jaundice. Materials and methods. The pancreatic head cancer was verified in 174 (64.0%) patients, cancer of the duodenal papilla magna - in 20 (7.4%), cancer of distal hepaticocholedochus - in 24 (8.8%), chronic pseudotumoral pancreatitis - in 54 (20.0%) patients. In the main group (112 patients) preparation to operative intervention was conducted in accordance to elaborated algorithm, and in a control group (160 patients) - in accordance to conventional standards. Results. Pancreaticoduodenal resection with formation of termino-lateral anastomosis in accordance to Whipple procedure was performed in 38 (14.0%) patients, termino-terminal anastomosis in accordance to procedure of Shalimov-Kopchak - in 40 (14.7%), ductomucous pancreaticojejunoanastomosis - in 127 (46.7%), pancreaticogastroanastomosis with invagination of the pancreatic stump into the gastric stump - in 35 (12.9%), pancreaticogastrostomy with  deepening of the pancreatic stump into the sleeve, made of the big gastric curvature - in 32 (11.8%). Insufficiency of pancreaticodigestive anastomosis have occurred in 32 (11.8%) patients. Mortality have constituted 5.1%

Choice of method of pancreatojejunic anastomosys at pancreatic duodenal resections

У 131 больного выполнены панкреатодуоденальные резекции по поводу рака головки поджелудочной железы (59 (45 %)), рака периампулярной зоны (43 (33 %)) и хронического псевдотуморозного головчатого панкреатита (29 (22, 1 %)). Разработанные нами методики формирования панкреатоеюноанастомозов на реконструктивном этапе ПДР обеспечивают снижение общего числа осложнений у больных в сравнении с терминолатеральным анастомозом (по Уипплу), а также терминотерминальной техникой (по Шалимову-Копчаку), соответственно, в 1, 98 и 1, 97 раза. Число больных с осложнениями уменьшается в ряду : терминолатеральный (по Уипплу) панкреатоеюноанастомоз – 25 (38, 9 %), терминотерминальный (по Шалимову-Копчаку) – 13 (9, 9 %), по методике нашей клиники – 4 (3 %), панкреатогастроанастомоз – 3 (2, 3 %).Pancreatic-duodenal resections (PDR) were performed in 131 patients among whom 105 suffered from the cancer of pancreatic-duodenal zone and 26 suffered from chronic indurative pancreatitis. The number of complications was successfully reduced in patients operated on with newly developed techniques of pancreatojejunic anastomosys creation/ Thus, this number was reduced in 1, 98 and 1, 97 times less when compared with traditionally performed PDR via such technologies as “end to end” and terminolateral anastomosys correspondently. The number of patients with complications was reduced in the next row : traditionally performed pancreatojejunostomy terminolateral 25 (38, 9 %), of “end to end” type jejunostomy 13 (9, 9 %), and newly developed technique of pancreatojejunostomy 4 (3%), gastropancreatostomy 3 (2, 3 %). Cryogenic application to pancreatic stump effectively reduced the number of complications as well as reduced the number of patients with complications under different types of surgery usage inj the course of reconstructive stage of PDR performance

Results of the application of an improved prognostic and therapeutic algorithm for the provision of radical surgical care to patients with mechanical jaundice of benign and malignant genesis

Проблема поліпшення результатів надання хірургічної допомоги хворим із синдромом механічної жовтяниці, як ускладненням раку панкреатобіліарної зони та хронічного псевдотуморозного панкреатиту, досі дискутується. Мета – поліпшити результати надання радикальної хірургічної допомоги хворим із раком панкреатобіліарної зони та хронічним псевдотуморозним панкреатитом, що ускладнені синдромом механічної жовтяниці. Матеріали та методи. Проаналізовано результати хірургічного лікування 272 хворих із синдромом механічної жовтяниці. До основної групи увійшло 112 пацієнтів, яким застосовували власно розроблений прогностично-лікувальний алгоритм. До групи порівняння увійшло 160 пацієнтів, яким виконували передопераційну підготовку поза цим алгоритмом. Результати. Майже у всіх досліджуваних хворих основної групи відбулися однонуклеотидні генетичні мутації за генами PRSS 1 (Arg122His), SPINK 1 (Asn34Ser), TNF (G308A) та CFTR (Phe508del). У хворих основної групи за даними УЗ-еластографії щільність патологічного фокусу для раку підшлункової залози становила 7,5±0,8 од., а для хронічного псевдотуморозного панкреатиту – 5,6±0,5 од. (p<0,05). Найбільш значущі відмінності спостерігалися за частотою неспроможності панкреатодигестивного анастомозу (χ2=6,95; р=0,008) і за частотою кровотечі в післяопераційному періоді (χ2=4,29; р=0,004). Кількість загрозливих життю післяопераційних ускладнень в основній групі становила 42 (37,5%) випадки, а в групі порівняння – 102 (63,8%) випадки (χ2=18,22 df=1 p<0,0001). В основній групі померло 7 (6,3%) хворих, у групі порівняння – 19 (11,9%). Висновки. Упередження розвитку безпосередніх післяопераційних ускладнень у хворих із вогнищевою патологією панкреатобіліарної зони на тлі механічної жовтяниці досягається завдяки поєднанню молекулярно-генетичних досліджень із визначенням фенотипу хворого, УЗ-фіброеластографії та математичного моделювання показників стану хворих. Дослідження виконано відповідно до принципів Гельсінської декларації. Протокол дослідження ухвалено Локальним етичним комітетом зазначеної в роботі установи. На проведення досліджень отримано інформовану згоду пацієнтів. Автори заявляють про відсутність конфлікту інтересів.The problem of improving the results of surgical care for patients with mechanical jaundice syndrome as a complication of pancreaticobiliary cancer and chronic pseudotumor pancreatitis is still being discussed. Purpose – to improve the results of radical surgical care for patients with pancreaticobiliary cancer and chronic pseudotumour pancreatitis complicated by mechanical jaundice syndrome. Materials and methods. The results of surgical treatment of 272 patients with mechanical jaundice syndrome were analyzed. The main group included 112 patients who were treated with our own developed prognostic and therapeutic algorithm. The comparison group included 160 patients who underwent preoperative preparation outside this algorithm. Results. Almost all the patients in the main group had single nucleotide genetic mutations in the PRSS 1 (Arg122His), SPINK 1 (Asn34Ser), TNF (G308A) and CFTR (Phe508del) genes. In patients of the main group, according to ultrasound elastography, the density of pathological focus for pancreatic cancer was 7.5±0.8 units, and for chronic pseudotumour pancreatitis – 5.6±0.5 units (p<0.05). The most significant differences were observed in the frequency of pancreaticodigestive anastomosis failure (χ2=6.95; p=0.008) and in the frequency of bleeding in the postoperative period (χ2=4.29; p=0.004). The amount of life-threatening postoperative complications was 42 (37.5%) cases in the main group and 102 (63.8%) cases in the comparison group (χ2=18.22; df=1; p<0.0001). In the main group 7 (6.3%) patients died, in the comparison group – 19 (11.9%). Conclusions. Prevention of the development of immediate postoperative complications in patients with focal pathology of the pancreatobiliary zone against the background of mechanical jaundice is achieved by combining molecular genetic studies with the determination of the patient’s phenotype, ultrasound fibroelastography and mathematical modelling of patient status. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of the participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors

Functional state of the hemostasis system in patients, operated for pancreatic pseudocysts

Оперативное лечение псевдокист (ППК) поджелудочной железы (ПЖ) соапровождается изменением показателей свертывающей системы крови, которые характеризуют как гиперкоагуляционные. эти нарушения отмечают через 12-24 ч. после оперативного вмешательства, их частота существенно уменьшается при применении пентоксифиллина (ПТФ). Наиболее выраженное снижение интраоперационной гиперкоагуляции отмечено при применении эндоскопического дренирования со стентированием полости ПК.Operative treatment of pancreatic pseudocysts coincides with the indices of the blood coagulation system change, which are characterized as a hypercoagulative. These disorders are noted in 12—24 h postoperatively, their rate is reducing substantially while application of pentoxyphylline. Most significant lowering of intraoperative hypercoagulation was noted while application of endoscopic drainage with the pseudocysts cavity stenting