Thoracoscopic Sympatosplanchnicectomy in the Treatment of Patients with Unresectable Pancreatic Cancer

The dissertation is devoted to substantiating the choice of the optimal extent of thoracoscopic intervention on the sympathetic division of the autonomic nervous system in patients with unresectable pancreatic cancer. The study is aimed at reducing or relieving pronounced pain syndrome and improving the quality of life of incurable patients. Based on retrospective and prospective clinical material, the structure of morbidity and mortality, the diagnostic value of clinical and instrumental methods, the effectiveness of existing analgesic therapy regimens, as well as indicators of quality of life and myoelectric activity of the gastrointestinal tract before and after thoracoscopic sympatosplanchnicectomy are analyzed. Drawing on a comparative evaluation of the results of operations of various extents, indications and contraindications for their performance are formulated, taking into account, among other things, the initial state of gastrointestinal myoelectric activity.

The author demonstrates that bilateral thoracoscopic sympatosplanchnicectomy is a minimally invasive and effective means of reducing pain syndrome and improving quality of life in this category of patients, and that pre-existing disorders of gastrointestinal myoelectric activity constitute a contraindication to its performance because of the risk of developing persistent postoperative paresis.

Relevance of the Topic.

Pancreatic cancer accounts for 5–8% of all malignant tumors of the abdominal organs. Of these, 60% to 80% are unresectable. By the time the diagnosis is established, more than 80% of patients present with advanced forms of cancer (Bottger T.C., Junginger T., 1999); in particular, 60–70% have liver metastases and 40% show dissemination throughout the abdominal cavity (Fennelly D., Kelsen D.P., 1996).

The median overall survival of patients with advanced unresectable pancreatic cancer from the moment of diagnosis is 3–6 months, and about 85% of patients die within the first year (Willett C.G., Clark J.W., 2003). The incidence of pancreatic cancer in our country has increased by 30% over the past 30 years and amounts to 9.5 in men and 7.6 in women per 100,000 population.

Most surgeons focus their attention on resectable tumors, whereas in reality by the time patients seek medical help the majority of pancreatic tumors (80%) are unresectable, and the choice of the optimal method of palliative surgery with appropriate indications is of great importance for maximizing patients' life expectancy and improving its quality.

In the study of oncological diseases, quality of life serves as the principal criterion of clinical effectiveness and is one of the key parameters in the analysis of final treatment outcomes. The main goal of the entire system of medical care in oncology is the restoration or preservation of quality of life. Recognition of the insufficiency of assessing only the biological consequences of a malignant process on the patient has elevated the restoration of quality of life to the status of a new goal of treatment.

Pain syndrome in pancreatic cancer is the leading manifestation of the disease in 70% of cases, but only 20–50% of such patients receive effective analgesia (Osipova N.A. et al., 1998). The system of specialized care for patients with advanced malignant neoplasms in our country, as in many other countries of the world, is still in the process of formation, and the relief of pain in this group of patients is provided by district oncologists and primary-care physicians who lack special training in this area. The overwhelming majority of these patients remain at home and do not receive adequate care (Osipova N.A. et al., 1998).

The "surgery of pain" for pancreatic diseases has a history of more than half a century. Earlier operations aimed at eliminating pain syndrome through autonomic denervation of the pancreas—resection of the semilunar ganglia, marginal neurotomy, resection of preganglionic nerve structures, etc.—proved insufficiently effective and highly traumatic (Trunin M.A., 1965; Trunin M.A. et al., 1967; Copping J. et al., 1969; Sadar E.S. et al., 1974; Sauvanet A. et al., 1992; White T.T. et al., 1966).

To eliminate pain syndrome in patients with unresectable pancreatic tumors, thoracoscopic splanchnicosympathectomy has become widely used at present (Strekalovsky V.P. et al., 1999; Melki J. et al., 1993; Wong G. et al., 2001). However, an opposite view exists: celiac plexus block is the method of choice for pain management in patients with advanced unresectable pancreatic cancer, and effective pain control can be achieved in most cases without splanchnicectomy, by means of celiac plexus block with a 50% alcohol solution (Shalimov S.A. et al., 2007).

Despite the divergence of opinions, the task pursued by all authors is reduced to improving the quality of life of these patients.

The objective of our work was to identify the most effective minimally invasive method aimed at stabilizing the condition and relieving pain syndrome in patients with unresectable pancreatic cancer.

Aim of the Study.

To substantiate the choice of the optimal extent of thoracoscopic intervention on the sympathetic division of the peripheral nervous system, aimed at improving quality of life through reduction or relief of pain syndrome in patients with unresectable pancreatic cancer.

Research Objectives.

1. To evaluate the influence of pain syndrome on the quality of life of patients with unresectable malignant pancreatic tumors.

2. To determine the necessary extent, indications, and contraindications for performing thoracoscopic intervention on the sympathetic division of the autonomic nervous system in patients with unresectable pancreatic cancer.

3. To carry out a comparative assessment of the quality of life of patients with unresectable pancreatic tumors who underwent thoracoscopic sympatosplanchnicectomy and those who did not.

4. To study the influence of thoracoscopic interventions, depending on their extent, on the myoelectric activity of the gastrointestinal tract, pain syndrome, and quality of life of patients with unresectable pancreatic cancer.

Scientific Novelty.

The study demonstrates that bilateral thoracoscopic sympatosplanchnicectomy is a minimally invasive and effective method for improving the quality of life of patients with unresectable pancreatic cancer. The myoelectric activity of the gastrointestinal tract was examined in patients with pancreatic tumors depending on the presence or absence of pain syndrome and signs of impaired gastrointestinal motility in the pre- and postoperative periods. The influence of thoracoscopic sympatosplanchnicectomy (TSSE) on the formation of the migrating myoelectric complex (MMC) and on pain intensity in patients with unresectable pancreatic cancer was assessed. It was established that after the thoracoscopic intervention in patients with signs of impaired gastrointestinal motility the total power of the mean indicators of gastrointestinal myoelectric activity (MEA) decreases approximately fivefold due to a reduction in motor activity in all parts of the gastrointestinal tract. The absence of any influence of TSSE on MMC formation in the gastroduodenal junction zone was clarified. It was revealed that in patients with signs of impaired gastrointestinal MEA after TSSE, hyperactivation of the pacemaker in the duodenojejunal junction zone occurs. In the group with preserved MEA, the alternation of autonomous regulation of motility of both the small and large intestine is maintained, objectively reflected by a decrease in the electrical activity of the MMC in the duodenojejunal and ileocecal junction zones.

It has been proven that the presence of disorders of gastrointestinal myoelectric activity (NMA) at the preoperative stage in patients with pronounced pain syndrome in the setting of pancreatic cancer constitutes a contraindication to performing TSSE, due to the development of persistent postoperative gastrointestinal paresis.

Practical Significance. The reduction of pain syndrome and the elimination of the need for narcotic analgesics alleviate the somatic and mental state of patients and provide social support to patients with pancreatic cancer at the incurable stage of the disease, thereby improving quality of life.

Statements Defended.

1. Thoracoscopic sympatosplanchnicectomy is a minimally invasive and highly effective surgical intervention, and bilateral resection of the nerve structures is the most important factor ensuring an adequate analgesic effect in patients with unresectable pancreatic cancer.

2. To resolve the question of performing TSSE, a mandatory study of pain severity, which reduces quality of life, and of gastrointestinal myoelectric activity in the preoperative period is necessary.

3. The presence of initially impaired gastrointestinal myoelectric activity is a contraindication to performing TSSE because of the development of persistent postoperative gastrointestinal paresis.

Approbation of the Work.

The main provisions of the work were reported at a meeting of the Problem Committee on Surgery of the I.I. Dzhanelidze Research Institute of Emergency Medicine (Saint Petersburg, 2009); at the Jubilee Scientific and Practical Conference "Current Issues in Emergency Surgery" (Kharkov, 2008); at the I Congress of Surgeons–Gastroenterologists of Russia and CIS Countries "Current Issues of Surgical Gastroenterology" (Gelendzhik, 2009); at the XIV International Congress of Surgeons–Hepatologists of CIS Countries "Current Problems of Surgical Hepatology" (Saint Petersburg, 2007); and at the First International Conference on Thoracoabdominal Surgery (Moscow, 2008).

Implementation of the Work.

The scientific and practical developments of the dissertation have been introduced into the practical activity of the Department of Surgical Hepatology, the Department of Pancreatology, and the Department of Emergency Oncology of the State Institution Saint Petersburg Research Institute of Emergency Medicine named after I.I. Dzhanelidze, as well as into the educational process of the 2nd Chair of Surgery (Advanced Training of Physicians) of the S.M. Kirov Military Medical Academy.

Publications.

Eleven published works address the topic of the dissertation, including one article in a central journal recommended by the Higher Attestation Commission of the Russian Federation.

Scope and Structure of the Dissertation. The dissertation consists of an introduction, 5 chapters, conclusions, practical recommendations, one appendix, and a bibliography. The work is set out on 158 pages of typewritten text, contains 13 tables and 33 figures. The bibliography includes 136 domestic and 179 foreign sources.