Pathomorphological and cytological control of the pancreatic remnant and main pancreatic duct during radical operations in patients with pancreatic adenocarcinoma
Authors: M. S. Zagriichuk  , I. I. Bulik  , A. I. Hutsuliak  , K. P. Tumasova  , Y. V. Nezhentseva  , O. O. Pidopryhora  , D. M. Skrypka  
Published: October 2019

The aim — to determine the diagnostic and predictive value of intraoperative study of pancreatic remnant during radical operations in patients with ductal adenocarcinoma of the pancreas. To investigate the role and place of determining the cleanness of the cut and purity of the main pancreatic duct by the method of pathomorphological and cytological research both during the operation stage and in the planned order.Materials and methods. Includes 8 patients with G2 adenocarcinoma of the pancreas treated in the period from 2015 to 2019. Men were 5, women 3. The average age of patients was 62 ± 2.4 years. The patients with I — II stage of the ductal adenocarcinoma of the pancreas were selected. The staging was carried out according to the TNM system, with 5 patients with І stage stage, with ІІ stage 3 patients. Pancreatico‑duodenal resection for Whipple was performed in 6 patients, distal subtotal resection of the pancreas with splenectomy in 2 patients. Patients were divided into 2 groups, the first group included 4 patients with cytologically verified tumor cells on the remnant of the pancreas or main pancreatic duct, and the second — where no tumor cells were detected. The average duration of Whipple was 348 ± 34 minutes, distal resection of the pancreas with splenectomy 168 ± 21 minutes, average blood loss was 560 ± 175 ml, there were no lethal cases, the incidence of complications in the immediate postoperative period was 28.4 %. The following criteria were analyzed such as the validity of the cytological evaluation, the value of the dissemination coeficient at the beginning and at the end of the operation, the duration of the non‑recurrent period, the median survival, and the duration of the period from the moment of surgery to the death of the patient.Results and discussion. Cytological monitoring of peritoneal imprints from 5 zones at the beginning and at the end of the operation was performed. The study analyzed patients with a dissemination rate of 1 — 2. In 4 patients of the control group, cytologically tumor cells were not verified. In 4 patients of the main group, cytologically tumor cells were found on the anterior surface of the pancreatic stump. In three of them, 75 %, tumor cells were found on the surfers of the pancreatic stump. In two of them, 66 %, tumor cells were found in the middle of the duct length, and in one case, 33.3 % tumor cells were found at the end of the main pancreatic duct. The prints taken from the resection plane of the pancreatic stump immediately after removal of 1 mm of the parenchyma thickness for a pathological study of the «purity of the resection edge». After removal of tumor, intraoperative hyperthermic chemotherapeutic lavage and abdominal lavage with 5 to 6 liters of saline were performed, after which the presence of tumor cells in the abdominal cavity was repeated by the method of peritoneal imprints. In the control group, no tumor cells were found in 4 patients, so the dissemination coefficient was 1. In the main group of four patients at the end of the operation 50 % were not found on the anterior surface of the tumor cell stump, the dissemination coefficient in them was reduced from 2 to 1. In 25 % tumor cells were found in the main pancreatic duct, but they were not found on the surface of the gland stump. In the comparison group, life expectancy was 22.4 ± 1.2 months, and the duration of the unrecurent period was 13.8 ± 2.4 months, respectively. In the main group, the life expectancy since the operation was 18.1 ± 2.4 months, and the duration of the unrecurent period was 9.6 ± 1.9 months.Conclusions. In 50 % of patients cytologically tumor cells were found on the surface of the pancreatic remnant and in the main pancreatic duct. Long‑term results in cytologically absent tumor cells and their complexes are better than those in which tumor cells were found on the surface of the pancreatic remnant and in the main pancreatic duct. Intraoperative rapid analysis of cytological imprints of the resection plane and the main pancreatic duct in combination with pathologic study of «purity of the region» can determine the resection area of the organ in order to R0 resection. Further research is needed on more observations in order to statistically validate the prognostic and clinical value of the methodology.