Improving of surgical tactics at periampullary tumors

Validity and relevance of the dissertation subject. Over the last decade, there has been a steady growth in frequency of periampullary tumors (PAT). Seamless anatomical and functional interconnection of the head of pancreas, the terminal part of choledoch, major duodenal papilla and duodenum as well as one of the most common clinical manifestations of tumor lesions - mechanical jaundice (MJ), allows the reason to combine those tumors into «periampullary» conception. It should be noted that the average life expectancy of patients with tumors of the head of the pancreas after onset of symptoms is 6-8 months. At the same time, about 30% of patients die within 2-3 months after established diagnosis and only 1% of them succeed to live up to 5 years. On contemporary data, with early diagnosis and radical surgical treatment the five-year survival rate increases to 18%. It should be noted that up to date the diagnosis and treatment of PAT is an actual problem of modem surgery and oncology. Thus, the diagnostic search is often complicated by the MJ, while conduction of diagnostic invasive procedures often exacerbates the underlying disease.
The basic method of PAT treatment is surgical operation. However, most of the outcomes arc unsatisfactory, which is reflected in poor remote results. Therefore, during the first year after radical treatment, 30-40% of patients die from disease progression. Thrcc-and five-year survival rate can be observed only in part of patients with stage I-II disease. The median survival rate of patients, according to American data, is 4.1 months, five years survival is achieved less than in 5% of cases. The mortality to incidence ratio, according to WHO data, is equal to 0.99. Resection of the pancreas is technically and organizationally complicated operation, while its safely performance requires not only a trained and skilled surgeon, but also high flexibility of the medical care institution. Despite the fact that in recent years the postoperative mortality decreased to 5-20%, there is still a high level of postoperative complications, reaching 40-70%.
This research work was done to fulfill the objectives assigned by the State Programs, including «About measures on further intensification of health care system» program approved be Decree of the President of the Republic of Uzbekistan! OP №1652 dd. 28 November 2011 and the «About measures on furtner strengthening of material and technical basis and improvement of organization of medical institution activity » program approved be Decree of the Cabinet of the Ministry of the republic of Uzbekistan bu №91 dd. 29 March 2012 (Chapter V, item 15).
The purpose of the study to improve the results of surgical treatment of patients with periampullary tumors complicated by mechanical jaundice.
The scientific novelty of the dissertation is as follows:
diagnostic criteria have been identified in patients during diagnostic laparoscopy, which allowed to clarify stage of disease, prevalence of tumorous process and perform the proper treatment method;
based on the research, developed and refined criteria for prediction of portability of radical operations with periampullary tumors complicated with obstructive jaundice; defined Influence of prognostic factors on outcome of surgical patients with PAT, complicated by MJ;
developed the way of prevention of pancrcatodigestive anastomosis dehiscence in gastropancrcatoduodcnal resection;
the comparative estimation of the effectiveness of various methods of treatment: retrograde, antegrade transhepatic interventions, palliative and radical operations. Explored the factors that increase the effectiveness of the proposed therapies developed clinical guidelines for optimizing treatment of patients with PAT, complicated by MJ;
standardized criteria in determining ways of bile diversion in periampullary tumors, complicated mechanical jaundice, depending on the level of the block, duration of jaundice and the functional state of the organism;
explained role of MRCP in the diagnosis and planning of decompressing methods in bile diversion system in patients with periampullary tumors, complicated with MJ.
CONCLUSION
1. Diagnostics of PAT complicated with MJ should be based on the integrated use of laboratory and instrumental diagnostic methods. Using USI on pancrcaticobiliary zone with MRPChG allows defining the anatomic structure of BED, tumor block level and choosing the best way to decompress the bileexcreting system, but MSCTA allows defining resectability of tumorous process.
2. An improved algorithm of diagnosis and treatment of patients with PAT, complicated with MF, allows speeding up the diagnostic search, choosing an adequate way of decompressing BED, to improve results of surgical treatment for 88.5% and to reduce quantity of diagnostic laparotomies from 8% to 0.6%.
3. An improved approach in choosing the bile evacuation method depending on the level of BED block, duration of jaundice and type of anticipated final treatment of MJ resulting from PAT, allows to reduce the frequency of complications after PCTHChS from 13% to 6%, after endoscopic stenting of BED from 12.4% to 2.7%, and mortality from 2% to 0%.
4. Application of diagnostic laparoscopy to determine feasibility of surgical treatment of PAT, complicated with MF, allowed to perform GPDR in 16.7% of cases, apply palliative anastomoses in in 16.7%, and to avoid any surgical intervention in 66.7%.
5. Developed integrated assessment program of tolerability of radical operations for PAT, complicated with MF, based on identifying prognostic factors has made it possible to calculate the risk of specific complications and choose the way of definitive surgical treatment.
6. The developed method of external drainage of the main pancreatic duct with GPDR enables you to prevent pancreatic juice flow into the PDA area, carry out sanitization of pancreatic duct system, determine the debit of pancreatic juice, its qualitative contents and predict the risk of PF.
7. Double-staged PCTHChS technique allows reducing the period for internal BED drainage from 10.2±3.6 to 8.2±3.3 days and reducing the number of specific complications from 13 to 6%. Endoscopic BED stenting is an effective method of decompression. Efficiency increases in the absence of purulent cholangitis, expressed biliary hypertension and the technical capabilities of cannulation of BDS. Execution of palliative anastomoses is preferable with non-resectablc PAT, with projected lifetime of the patient more than 6 months. Performing GPDR, taking into account the knowledge of prognostic factors and intraoperative data can reduce the number of post-operative complications from 61 to 15.4%.