Serous cystic neoplasm of the pancreas: a multinational study of 2622 patients under the auspices of the International Association of Pancreatology and European Pancreatic Club (European Study Group on Cystic Tumors of the Pancreas).

OBJECTIVES: Serous cystic neoplasm (SCN) is a cystic neoplasm of the pancreas whose natural history is poorly known. The purpose of the study was to attempt to describe the natural history of SCN, including the specific mortality. DESIGN: Retrospective multinational study including SCN diagnosed between 1990 and 2014. RESULTS: 2622 patients were included. Seventy-four per cent were women, and median age at diagnosis was 58 years (16-99). Patients presented with non-specific abdominal pain (27%), pancreaticobiliary symptoms (9%), diabetes mellitus (5%), other symptoms (4%) and/or were asymptomatic (61%). Fifty-two per cent of patients were operated on during the first year after diagnosis (median size: 40 mm (2-200)), 9% had resection beyond 1 year of follow-up (3 years (1-20), size at diagnosis: 25 mm (4-140)) and 39% had no surgery (3.6 years (1-23), 25.5 mm (1-200)). Surgical indications were (not exclusive) uncertain diagnosis (60%), symptoms (23%), size increase (12%), large size (6%) and adjacent organ compression (5%). In patients followed beyond 1 year (n=1271), size increased in 37% (growth rate: 4 mm/year), was stable in 57% and decreased in 6%. Three serous cystadenocarcinomas were recorded. Postoperative mortality was 0.6% (n=10), and SCN's related mortality was 0.1% (n=1). CONCLUSIONS: After a 3-year follow-up, clinical relevant symptoms occurred in a very small proportion of patients and size slowly increased in less than half. Surgical treatment should be proposed only for diagnosis remaining uncertain after complete workup, significant and related symptoms or exceptionally when exists concern with malignancy. This study supports an initial conservative management in the majority of patients with SCN. TRIAL REGISTRATION NUMBER: IRB 00006477.

[SURGICAL TACTICS IN CHRONIC PANCREATITIS WITH SIGNS OF BILIARY HYPERTENSION].

The results of treatment of 84 patients for chronic pancreatitis with the biliary hypertension signs were depicted. In 83 patients operative interventions were performed, and in 1--positive results were achieved after pancreatic cyst puncture under ultrasonographic control. In 51 patients the conduction of Frey operation have permitted to achieve a lower pressure inside biliary system, in 25--the additional procedures were applied for a biliary hypertension elimination. In 20 patients a method of pressure measurement in biliary system was used.

[ANALYSIS OF COMPLICATIONS POSTOPERATIVE CAUSES AND MORTALITY AFTER RADICAL TREATMENT FOR TUMORS OF THE LEFT ANATOMICAL SEGMENT OF THE PANCREAS].

Radical surgery for tumors of the left anatomical and surgical segment of the pancreas proved for distal resection in various versions, central resection and enucleation of tumors. The causes of early postoperative complications and mortality in 129 patients aged from 14 to 81 years, operated on for neoplastic lesions of the left anatomical segment of the pancreas in the period from 2009 to 2014 were analysed. The influence of various factors of risk of complications and mortality were studied in particular, extended resection, for tumor invasion of adjacent organs, and adjacent vessels.

[SURGICAL TREATMENT OF TUMORS OF THE LEFT PANCREATIC ANATOMICAL SEGMENT].

The results of treatment of 231 patients, suffering tumoral affection of pancreatic left anatomical segment in period of 2009-2013 yrs were analyzed. Individualized approach, using modern technologies, was applied. Radical operations were performed in 129 patients, ageing 14-81 yrs old, including pancreatic distal resections in various modifications, central resection and tumoral enucleation. Possibilities of the extended pancreatic resection performance were studied in conditions of tumoral invasion of adjacent organs, regional vessels, as well as impact of such interventions on postoperative complications and lethality rate. While performing pancreatic subtotal distal resection with simultant resection of affected main venous vessels and adjacent organs the operative intervention risk is enhanced, but possibilities of a radical operations performance in previously considered inoperable patients are expanding.

[Prophylaxis of complications in patients after pancreaticoduodenal resection].

Experience of pancreaticoduodenal resection performance was summarized in 163 patients in 2005-2009 yrs. Duodeno(gastro)enterostomy was formed in anterior position, taking an objective to reduce the risk of postoperative gastrostasis occurrence; and formation of invagination ductojejunal anastomosis--for prophylaxis of pancreatogenic complications. External pancreatic duct drainage and medicinal therapy conduction do not guarantee reduction of the postoperative complications occurrence risk.

[Pancreatic resection using laparoscopic access].

Experience of their own on performance of pancreatic resection interventions, using laparoscopic access, conducted in the clinic in 2009 - 2013 yrs, was presented. In 8 patients laparoscopic distal pancreatic resection was conducted, in 5--laparoscopic enucleation of pancreatic tumor, in 1--laparoscopic pancreaticoduodenal resection. The results were compared with such after open operations, performed in this period of time. There was not a trustworthy difference in the postoperative complications rate, intraoperative blood loss severity and the distal resection duration. The patient stationary treatment duration was trustworthy less after conduction of laparoscopic operations. The intraoperative blood loss severity and duration of laparoscopic enucleation of pancreatic tumor are trustworthy less.

[Experience of ASVS-test application in diagnosis of insulin-producing pancreatic tumor].

In 2009-2013 yrs in 7 patients, suffering insulin-producing pancreatic tumors, the ASVS-test was conducted, the result of which was compared with data of standard methods of investigation, including abdominal ultrasound, computer tomography and magnetic resonance imaging. The insuloma enucleation was performed in 3 patients, distal subtotal pancreatectomy with splenectomy--in 1 and the completed total pancreatectomy--in 1. The ASVS-test conduction is indicated in patients with diagnosed hyperinsulinism while impossibility to perform a topic diagnosis of insulinoma, in accordance to data of other noninvasive methods of diagnosis.

[Principles of direct surgical procedures on the pancreas in surgical treatment of chronic pancreatitis].

An analysis of treatment of 584 patients with complicated forms of chronic pancreatitis operated during 2000-2100 years was carried out. Quality of life of postoperative patients was estimated according to a technique of calculations of modules EORTC QLQ-C30 and EORTC QLQ-PAN26. The indicators of quality of life have improved by 19.7% in performance of saving duodenal outflow of operations of pancreatic juice. Change of the surgical strategy has led to decreased number of postoperative complications by 4.6% and to satisfactory long-term results in 92.6% of the patients.

[Possibilities of preoperative studying of vascular anatomy in surgery of a periampullar zone tumors].

In 115 patients, suffering malignant pancreatic tumors as well as those, localized in periampullar zone, a CT angiography was performed preoperatively to study up the variants of vascular anatomy. The data obtained were depicted by a surgeon, anatomic variants of truncus coeliacus and mesenterical vessels were recorded in accordance with classification of Michels, Hiatt. Individualized approach for surgical treatment, using CT angiography data, was applied. In 30 patients the operative intervention with the vessels resection was performed and in 6--a no-touch method. Distal pancreatic resection, using the RAMPS technology. was performed in 7 patients for malignant tumors. Complications have had occurred in 12 (10%) patients, 2 (1.7%) of them died. Lethality after operations with vessels resection have constituted 6.6%. The data on variants of vascular anatomy, obtained preoperatively, have permitted to escape massive intraoperative blood loss with subsequent irreversible necrotic changes in the abdominal cavity organs.

[Diagnosis and treatment tactics for complicated pancreatic pseudocysts].

Experience of 84 patients treatment for complicated pancreatic gland pseudocysts is presented. Tactics of diagnosis and treatment for complicated pancreatic gland pseudocysts was elaborated and substantiated. Individualized treatment-diagnosis approach provides, first of all, the complications elimination, an adequate surgical treatment of pancreatic gland pseudocyst is possible in late period. For complicated pancreatic pseudocysts treatment miniinvasive methods were used predominantly, when their application is impossible or fails the open procedure is performed.

[Vascular risk factors for occurrence of early postoperative complications in patients after pancreaticoduodenal resection].

The results of pancreaticoduodenal resection (PDR), performed in 163 patients in 2006-2010 yrs, are summarized. In 51 (31.3%) patients the complications have occurred. All the patients are alive. The trustworthy connection was established between the rate of the early postoperative complications occurrence and the volume blood flow velocity in a portal vein as well as index of the common hepatic artery resistance before the operation. The indices of regional hemodynamics influence the results of PDR performance. The simultant vascular resection performance do not impact the operative risk level, when compared with such while a standard resection conduction. The risk of the early postoperative complications occurrence is not influenced by the antisecretory therapy regime choosed, using somatostatin analogues.

[Pancreaticoduodenal resection in the treatment of malignant periampullar tumors].

The experience of performance of pancreaticoduodenal resection (PDR) in 412 patients in 1998-2009 yrs for malignant periampullar tumors was analyzed. In 296 patients a standard PDR was done and in 116, with tumoral affection of distal part of common biliary duct and duodenal large papilla - pylorus-preserving PDR Individualized approach was used, exploiting modern technologies of pylorus-preserving PDR: saving gastroduodenal artery, selective ligation of right branch of dorsal pancreatic and lower pancreatoduodenal artery, dorsal and translateral surgical approaches usage. In 26 patients PDR was accomplished with resection of vessels. In 12 patients a no-touch procedure of PDR was applied. There were analyzed the results of application of modified extended lymphadenectomy while PDR performance. Complications had occurred in 29.5% patients, lethality was 2.7%. The survival indices had constituted at average 24 mo--in pancreatic tumors, 48 mo--in tumors of a distal part of common biliary duct and 72 mo--for localized in duodenal large papilla. Introduction of a new methods of PDR would permit to improve an early and late results of treatment.

[Intraoperative possibilities of reduction of postoperative complications frequency in pancreaticoduodenal resection on its reconstructive stage].

Experience of pancreaticoduodenal resection (PDR) performance in 81 patients in 2007-2008 yrs was summarized. There were studied up the risk of postoperative gastrostasis occurrence and factors, promoting such a risk lowering. In 24 patients (the main group) gastro- and duodenoenteroanastomosis were formatted in antecolic position, while in 57 (the control group) the gut continuity was restored according to standard method. Postoperative gastrostasis in a control group had occurred in 10 (17.5%) patients, while in the main group this complication was absent. Formation of gastro- and duodenoenteroanastomoses in antecolic fashion and absence of early postoperative complications are considered the factors, trustworthy influencing the risk of postoperative gastrostasis occurring. Application of a pylorus--preserving procedure of PDR had not promoted the risk of raising of postoperative gastrostasis occurrence.

Establishing of Peritoneal Surface Malignancy Treatment Program: Background in Ukraine, Patient Selection, Staff Schedule, Perioperative Outcomes of First 28 Patients.

A combination of cytoreductive intervention with the intrahepatic hyperthermic chemotherapy is a well-established treatment of peritoneal carcinomatosis. There are many challenges in establishing a new peritoneal surface malignancy program in a low-income country regarding perioperative safety and resource allocation. We analyzed the retrospective database to determine the immediate surgical outcomes of the first 28 patients with peritoneal carcinomatosis and the impact of the program on allocation of general hospital and human resources. During the preparatory stage, web conferences with international experts established the goals and general requirements of the program, formalized in a written document; and a peritoneal surface malignancy multidisciplinary team was established. The team created the patient selection criteria, perioperative management checklists, and suggested material and staff requirements for surgical and anesthesia services. Twenty-nine cytoreduction were carried out, of which 18 were followed by HIPEC. The average operative time was 6.2 h. The median blood loss was 350 mL, which did not result in additional blood transfusion requirements for the blood bank. No additional nursing and supportive staff were provided for the ICU and the surgical unit. The average postoperative stay was 8.7 days. One patient died with 30-day mortality rate of 3%. Ten patients (34.5%) developed postoperative complications, of which 6 (20.6%) had grade III and higher Clavien-Dindo complications. Establishing a peritoneal surface malignancy program is possible via staged planning, liberal use of international mentors, and thoughtful resource allocation. This new program did not result in a significant redistribution of resources among other service lines of cancer care within the same institution.

[Lumbotomic videocontrolled sanation of retroperitoneal space in patients, suffering an acute necrotizing pancreatitis].

During 2007-2008 yrs 55 patients, suffering an acute necrotic pancreatitits, were followed up. In the main group 7 patients were included, in the complex treatment of whom the lumbotomy transcutaneous sanation of necrotic foci, using nephroscope, was done. In patients of a control group the conventional operative interventions were performed. In the main group in one patient relaparotomy was performed, all the patients are alive. In a control group in 7 patients relaparotomy was performed, 5 patients died. The results of investigation performed had permitted to recommend the method of the lumbotomy transcutaneous retroperitoneal necrsequestrectomy, using nephroscope, for practical application in the staged treatment of patients, suffering infected pancreonecrosis.

[Intraductal papillary-mucinous tumors as a variant of cystic pancreatic tumors. The problems of diagnosis and surgical treatment].

Retro- and prospective investigation of the diagnosis and treatment results of 6 patients, suffering intraductal papillary-mucinous neoplasms (IPMN), was conducted. In 2 patients the central type malignant IPMN were diagnosed, in 1 - the central type of IPMN without malignization signs, in 2 - the IPMN of lateral type without malignization signs, in 1 - the multiple malignized IPMN of lateral type. The magnet resonance cholangiopancreatography, permitted to determine the pancreatic ductal system tumoral involvement, had constituted the main method of instrumental diagnosis. Radical operation was performed in 4 patients (in 3 - pancreatoduodenal resection, in 1 - subtotal distal pancreatic resection), in 2 - palliative operations. Follow-up in radically operated patients in terms from 6 to 21 months showed no recurrence of the disease.

[Application of preparations--analogues of somatostatin in surgical pancreatology].

The experience of application of shortly acting and durably acting preparations--analogues of somatostatin in complex therapy of various pancreatic diseases was summarized. There was established similar efficacy of the preparations in blockade of the pancreatic external secretion and the various duration of their inhibiting influence on the blood flow. The trustworthy differences in the complications frequency and lethality while application of various preparations--analogues of somatostatin were not revealed.

[Modern possibilities of chemotherapy in patients with ductal pancreatic adenocarcinoma].

Experience of application of preparation Gemzar as a chemotherapy agent for ductal pancreatic adenocarcinoma was analysed. In 28 patients (main group) chemotherapy using Gemzar preparation was conducted, in 30 patients (control group) chemotherapy was not conducted. The trustworthy differences of life span in patients with unresectable tumors in the main and control groups were noted. Difference of the patients life span after performance of radical pancreatic resection was not trustworthy.