SURGICAL TREATMENT CHOICE FOR PATIENTS WITH NON-RESECTABLE PANCREATIC HEAD CANCER

Abstract

Introduction. Due to the late diagnosis of the pancreatic head cancer, up to 80% of patients are subjected only to palliative surgical treatment to eliminate complications, i.e., obstructive jaundice and stenosis of the duodenum by a tumor, through a hepaticojejunostomy or transpapillary stenting of the common bile duct with self-expanding metal stents (SEMS). The disadvantages of open surgery include a high incidence of postoperative complications and mortality, and those of the transpapillary stenting – obstruction of up to 40% of stents in 6-8 years after implantation. With modern polychemotherapy, the survival rate of patients exceeds a year, when the drainage function of stents is impaired, and surgical bypass functions without complications. Therefore, it is relevant to personalize the choice of treatment for the patients.

Aim. To improve the results of palliative surgical treatment of patients with unresectable pancreatic head cancer, complicated by obstructive jaundice, by improving the choice of methods and techniques of surgical interventions.

Materials and methods. The randomized prospective study is based on the analysis of the obstructive jaundice treatment outcomes after the Roux hepaticojejunostomy with prophylactic gastrojejunostomy (main group, 53 patients) or transpapillary stenting of the common bile duct with SEMS (study group, 54 patients) were performed. The authors evaluated the effect of multiple organ failure and the Karnofsky index on the choice of patient treatment strategy, on the immediate and remote results, as well as the quality of life of patients in the postoperative period, using the EORTC QLQ-C30 V.3 and EORTC QLQ-PAN26 questionnaires.

Results. The use of self-expanding metal stents for internal drainage of the biliary system, compared with open surgery of double bypass reduces the incidence of postoperative complications by 29.9% (χ2=13.7, 95% CI 14.38-44.08, p=0.0002), and mortality by 7. 5% (χ2=4.16, 95% CI - 0.05-17.79, p=0.04). However, the course of the remote postoperative period (from 8 to 11 months) is complicated in 11.1% of cases by acute, in 37.1% by chronic recurrent cholangitis, and in 7.4% of cases an obstructive duodenal obstruction develops, which deteriorates the quality of patients’ lives, and requires re-hospitalization and reconstructive interventions.

Conclusions. With a Karnofsky index <80, it is advisable to perform stenting of the common bile duct with SEMS, with a Karnofsky index >80, double biliodigestive and prophylactic gastrodigestive bypass surgery should be performed. When multiorgan dysfunction and cholangitis develop against the obstructive jaundice, the treatment consists of two stages, the first – transpapillary biliary drainage with plastic stents, the second – elective surgical intervention.