ObjectiveTo investigate how to shorten the learning curve of the laparoscopic pancreaticoduodenectomy (LPD). MethodsClinical data of 5 patients who underwent the LPD in our hospital from May 2015 to November 2015 were retrospectively analyzed. ResultsThe mean age of 58.8 years old. There were four patients who were diagnosed with periampullary tumor, one patient was distal bile duct carcinoma. The median operative time was 588 min, the average blood loss was 290 mL, the time of feeding was 5 days, the mean hospital stay was 25 days. One case died of cardiovascular event on postoperative day 1. One patient had postoperative bleeding after LPD, who recovered smoothly after reoperation for hemostasis laparoscopiclly. Conciusions LPD needs basic learning curve. The key of this procedure are appropriate treatment of pancreatic head and digestive tract reconstruction. Rich operative experience of surgeon in pancreaticoduodenectomy, optimization of the operation process, skilled in laparoscopic procedures, appropriate cases, appropriate perioperative management, and steady surgical team are also important factor for the success of LPD and shorten learning curve.
ObjectiveTo evaluate the effect of transecting the body of pancreas via inferior mesenteric vein (IMV) pathway during pancreaticoduodenectomy (PD) with venous resection. MethodsAccording to the inclusion and exclusion criteria, from February 1, 2016 to January 1, 2021, the patients who underwent PD with portal vein / superior mesenteric vein (PV/SMV) resection for resectable pancreatic adenocarcinoma were gathered. According to whether the traditional approach could be adopted to create a tunnel in front of the PV/SMV axis, the patients were allocated to the standard procedure group (S-group) or a modified procedure group (M-group). In the M-group, the patients who transected the pancreatic body via IMV pathway were allocated to the IMV-subgroup, while the patients who transected the pancreatic body via the left side of PV or in the middle of the pancreas were allocated to the central subgroup (C-subgroup). The clinicopathologic characteristics and survival (overall survival) were compared between the M-group and S-group, as well as between the IMV-subgroup and C-subgroup. The survival curve was drawn using Kaplan-Meier method for survival analysis, and the risk factors affecting overall survival by Cox proportional hazards regression model. ResultsA total of 142 patients were gathered, including 77 in the S-group, 65 in the M-group, 29 in the IMV-subgroup and 36 in the C-subgroup. The results of clinicopathologic data of patients among the different groups showed that the M-group had a more intraoperative bleeding (P＜0.001), longer postoperative hospital stay (P=0.021), and a proportion of vascular invasion (P=0.017), as well as the IMV-subgroup only had a higher proportion of vascular invasion (P=0.030) as compared with the S-group; At the same time, compared with the C-subgroup, the IMV-subgroup had a less intraoperative bleeding volume (P＜0.001) and a higher proportion of R0 resection (P=0.031). There were no statistically differences in other clinicopathologic data among the groups (P＞0.05). The analysis of survival curve by Kaplan-Meier method showed that the median overall survival (OS) of IMV-subgroup, C-subgroup, and S-group was 21, 17, and 22 months, respectively. The OS of IMV-subgroup was better than that of the C-subgroup (χ2=4.676, P=0.031), which had no statistical difference between the IMV-subgroup and S-group ( χ2=0.007, P=0.934). The multivariate analysis results showed that the patients with postoperative adjuvant chemotherapy [RR=0.519, 95%CI (0.324, 0.833), P=0.007] and with R0 margin [RR=0.434, 95%CI (0.218, 0.865), P=0.018] were the protective factors affecting the OS, while low tumor differentiation [RR=2.433, 95%CI (1.587, 3.730), P<0.001], PV/SMV pathological invasion [RR=2.788, 95%CI (1.543, 5.039), P=0.001], and tumor infiltration into PV/SMV intima [RR=1.838, 95%CI (1.062, 3.181), P=0.030] were the risk factors affecting the OS. ConclusionsThe results of this study suggest that, transecting the body of pancreas via IMV pathway can improve the rate of R0 resection, improve OS, and do not increase postoperative morbidity and mortality. It may provide a better selection for transecting the body of pancreas when the anterior PV/SMV and posterior surface of the neck of the pancreas are invaded by tumors or has inflammatory adhesion.
ObjectiveTo compare the short- and long-term efficacy of artery-first approach pancreatico-duodenectomy (AF-PD) and standard approach pancreaticoduodenectomy (S-PD).MethodsThe PubMed, EMbase, The Cochrane Library, Web of Science, CBM, WanFang, and CNKI databases were searched, relevant literatures were included, and relevant data were extracted for meta-analysis.ResultsA total of 30 articles were included, including 2 750 cases underwent pancreaticoduodenectomy. The results of meta-analysis showed that in terms of short-term efficacy when compared with S-PD group, the AF-PD group had less intraoperative blood loss (WMD=–175.87, P<0.001), lower intraoperative blood transfusion rate (OR=0.36, P=0.002), higher R0 resection rate (OR=1.83, P<0.001), lower postoperative pancreatic leakage rate (OR=0.71, P=0.005), and shorter postoperative hospital stay (WMD=–2.69, P=0.007). However, there were no statistically significant differences in the operation time and overall postoperative complication rate between the two groups (P>0.05). In terms of long-term efficacy when compared with S-PD group, the AF-PD group had lower tumor local recurrence rate (OR=0.43, P=0.004) and tumor liver metastasis rate (OR=0.60, P=0.010), but had higher 1-year (OR=1.95, P=0.007), 2-year (OR=2.04, P<0.001), 3-year (OR=2.09, P=0.001), and 5-year (OR=2.06, P=0.003) overall survival rates, and there were no significant differences in the rates of lung metastasis and peritoneal metastasis between the two groups (P>0.05).ConclusionsAF-PD is better than S-PD in some short-term and long-term outcome indicators such as R0 resection rate, pancreatic leakage rate, overall survival rate, and so on. However, due to the limited quality of the included literatures, more high-quality studies are still needed to verify in the future.
Objective To investigate the effect of common iliac vein allograft replacing the portal vein-superior mesenteric vein transition area invaded by pancreatic cancer. Methods The clinical data of a patient with pancreatic cancer admitted to the Beijing Tsinghua Changgung Hospital in December 2021 who underwent pancreaticoduodenectomy combined with common iliac vein allograft replacing the junction of portal vein, superior mesenteric vein and splenic vein were analyzed retrospectively. The patient was a 77-year-old man who complained of “epigastric pain for 1 month and pancreatic mass was found for 1 week”. After admission, the patient was diagnosed with pancreatic cancer through inspection, and then the surgery was required. Preoperative examination and intraoperative exploration confirmed that the junction of portal vein, superior mesenteric vein, and spleen vein was invaded by tumor. In addition, the length of the invaded vessels measured by preoperative 3D reconstruction image was 5.5 cm, and the distance between the broken end of portal vein and the broken end of superior mesenteric vein measured was 4.5 cm during the operation. After tumor and vessels were resected, vascular anastomosis could not be performed directly. After accurate evaluation, pancreaticoduodenectomy combined with common iliac vein allograft replacing the junction of portal vein, superior mesenteric vein and splenic vein was performed. The operative time was 11 h, and the intraoperative blood loss was 400 mL. After the operation, the routine treatment was performed in ICU and was transferred to the general ward on the 7th day. Postoperative laboratory tests were performed to monitor liver function changes routinely, and imaging examination were was performed to monitor portal venous system blood flow. Results Postoperative complications such as biliary fistula, pancreatic fistula, hemorrhage, infection and thrombosis were not occurred. Postoperative pathological diagnosis: pancreatic ductal adenocarcinoma, medium-low differentiation. Enhanced CT reexamination on the 2nd and 13th day after the operation showed that the blood flow at the junction of portal vein, superior mesenteric vein and splenic vein of the common iliac vein allograft was unobstructed, and there was no stenosis or thrombosis at each anastomosis. Conclusions The application of common iliac vein allograft replacing the portal vein-superior mesenteric vein transition area invaded by pancreatic cancer is safe and feasible. The short-term efficacy is satisfactory, and long-term prognosis remains to be further observed.
ObjectiveTo summarize of clinical application and progress of duodenum-preserving pancreatic head resection (DPPHR).MethodThe relevant literatures published recently at domestic and abroad about the clinical application and progress of DPPHR were collected and reviewed.ResultsFor the benign lesions, low-grade malignancies and borderline tumors of the head of pancreas, the DPPHR could achieve the same expected therapeutic effect as the classical pancreatoduodenectomy. The DPPHR could reserve the continuity of stomach and duodenum while resecting lesions and improve the symptoms of patients, reduce the reconstruction of digestive tract and the resection of pancreas and surrounding tissues as much as possible, and retain the pancreas-intestinal axis, which was more in line with the physiology of human beings.ConclusionsAt present, DPPHR is worthy of further development and promotion in department of pancreas surgery, but current studies only focus on occurrence of short-term complications after operation. Because patients with benign diseases of pancreatic head have better prognosis and longer survival time after operation, we should pay attention to the long-term complications such as diarrhea, anemia and reflux cholangitis. More clinical studies need in future to be demonstrated superiority of DPPHR in clinical efficacy and to evaluate occurrence of long-term complications and their impact on quality of life of patients with DPPHR by comprehensive analysis of multiple evaluation indicators.
ObjectiveTo investigate perioperative safety of laparoscopic pancreaticoduodenectomy (LPD) in elderly patients (age ≥70 years old).MethodsThe retrospective cohort study was conducted. The clinicopathologic data of the patients underwent LPD and open pancreaticoduodenectomy (OPD) in the Affiliated Hospital of North Sichuan Medical College from January 2016 to December 2019 were collected. The patients who met the inclusion and exclusion criteria were divided into LPD with aged ≥70 years old group (group A), OPD with aged ≥70 years old group (group B), and LPD with aged <70 years old group (group C). The baseline data, intraoperative situations, and postoperative situations were compared between the group A and group B, and between the group A and group C, respectively.Results① There were no statistic differences in the age, gender, body mass index, hemoglobin, albumin, and total bilirubin, American Society of Anesthesiologists (ASA) grade, and comorbidity index before operation between the group A and group B (P>0.05). However, there were statistic differences in the hemoglobin, albumin, ASA grade, and comorbidity index before operation between the group A and group C (P<0.05). ② There were no significant differences in the operation time between the group A and group B (P>0.05), but the intraoperative blood loss of the group A was significantly less than the group B (P<0.05). The operation time, intraoperative blood loss, and conversion rate had no significant differences between the group A and group C (P>0.05). ③ There were no significant differences in the pathological pattern, tumor size, R0 resection rate, reoperative rate, and postoperative 90 d mortality between the group A and group B, and between the group A and group C, respectively. For the elderly patients, cases in the ICU, overall complications, specific complications (except for delayed gastric emptying) and Clavien-Dindo classification of complication after operation had no significant differences between the group A and group B (P>0.05), but there were more harvesting lymph nodes, lower postoperative pain score, shorter postoperative hospital stay, and less delayed gastric emptying cases in the group A than the group B (P<0.05). For the patients accepted LPD, there were no significant differences in the harvesting lymph nodes, postoperative pain score, postoperative hospital stay, and specific complications (except for pulmonary infection rate) between the group A and the group C (P>0.05), but the postoperative cases in the ICU were more, pulmonary infection rate was higher, overall complications rate and the ratio of Clavien-Dindo Ⅲ–Ⅳ classification of complication were higher in the group A as compared with the group C (P<0.05). ConclusionCompared with OPD, LPD might have some advantages in blood loss, harvesting lymph nodes, and recovery after surgery, even though perioperative safety of LPD in elderly patients is inferior to younger patients.
Objective To summarize preliminary experience of laparoscopic pancreaticoduodenectomy for periampullary carcinoma. Method The clinical data of patients with periampullary carcinoma underwent laparoscopic pancreaticoduodenectomy from July 2016 to September 2016 in the Shengjing Hospital of China Medical University were analyzed retrospectively. Results Two patients underwent complete laparoscopic pancreaticoduodenectomy, 2 patients underwent laparoscopic resection and anastomosis assisted with small incision open. The R0 resection and duct to mucosa pancreaticojejunal anastomosis were performed in all the patients. The operative time was 510–600 min, intraoperative blood loss was 400–600 mL, postoperative hospitalization time was 15–21d, postoperative ambulation time was 6–7 d. Three cases of pancreatic fistula were grade A and all were cured by conservation. No postoperative bleeding, delayed gastric emptying, intra-abdominal infection, and bile leakage occurred. The postoperative pathological results showed that there was 1 case of pancreatic head ductal adenocarcinoma, 1 case of cyst adenocarcinoma of pancreas uncinate process, 1 case of papillary carcinoma of duodenum, and 1 case of terminal bile duct carcinoma. Conclusion The preliminary results of limited cases in this study show that laparoscopic pancreaticoduodenectomy has been proven to be a safe procedure, it could reduce perioperative cardiopulmonary complications, its exhaust time, feeding time, and postoperative ambulation time are shorter, but its operative complications could not be reduced.
Objective To explore the influencing factors of pancreatic fistula after pancreaticoduodenectomy (PD), and to compare the incidence of pancreatic fistula after pancreaticoduodenectomy with internal drainage of main pancreatic duct and external drainage according to the pancreatic fistula risk score (FRS) system, to provide the basis for the best drainage scheme in clinic. Methods The clinical data of 76 patients with PD who treated in the Affiliated Hospital of Xuzhou Medical University from January 2016 to December 2017 were analyzed retrospectively, to explore the risk factors of pancreatic fistula. Single factor analysis was based on group chi-square test or Fisher exact probability method, and multivariate analysis was based on unconditioned logistic regression model. According to the results of FRS, the difference of pancreatic fistula in different risk groups was explored. The statistical method was chi-square test. Results The incidence of pancreatic fistula after PD was 31. 5% in 76 patients.Univariate analysis showed that the diameter of the main pancreatic duct and the texture of the pancreas were the related factors affecting the occurrence of pancreatic fistula after PD (P<0.05), and the soft pancreas was the independent risk factor for the occurrence of pancreatic fistula after PD (OR=3.886, P=0.011). There was no significant difference in the incidence of postoperative pancreatic fistula between the internal drainage group and the external drainage group (P>0.05). There was no pancreatic fistula occurred in the patients with negligible risk. The incidence of postoperative pancreatic fistula in patients with high risk of external drainage group was only 12.5%, comparing with patients in internal drainage group (63.6%), the difference was statistically significant (P=0.026). There was no significant difference in the incidence of postoperative pancreatic fistula between patients in the external drainage group with moderate risk and low risk compared with the corresponding patients in the internal drainage group (P>0.05). Conclusions Pancreatic texture was an independent risk factor for pancreatic fistula after PD. External drainage maybe more effective than internal drainage in preventing pancreatic fistula after PD in patients with high risk of FRS.
ObjectiveTo evaluate the predictive value of C-reactive protein/albumin ratio (CAR) for postoperative complications of pancreaticoduodenectomy (PD).MethodsThe clinical data of 134 patients with pancreaticoduodenectomy (PD) in the Department of Pancreatic Surgery of The First Affiliated Hospital of Xinjiang Medical University from 2015 to 2018 were retrospectively collected, including general conditions and postoperative complications. The predictive value of CAR was calculated.ResultsOf the 134 patients, 38 patients suffered from postoperative pancreatic fistula (POPF), 32 patients suffered from abdominal infection, 5 patients suffered from biliary fistula, 63 patients suffered from delayed gastric emptying (DGE), 13 patients suffered from post pancreatectomy hemorrhage (PPH), 8 patients suffered from wound infection, and 1 patient suffered from chyle leakage. There was no significant difference in general conditions such as gender, age, BMI, American Society of Anesthesiologists (ASA) score, tumor nature, tumor diameter, operative time, intraoperative blood loss, diabetes history, jaundice history, and drinking history (P>0.05), but the hospital stay in the complication group was longer than that of the non-complication group (P<0.05). The value of CAR in the pancreatic fistula and abdominal infection group were significantly higher than those in the non-complication group at 1 d, 3 d and 5 d (exclude 1 day after surgery on POPF), the difference was statistically significant (P<0.05). On the 3rd day after surgery, the sensitivity of CAR predicting POPF was 79.95%, the specificity was 86.46%; the sensitivity of predicting abdominal infection was 75.00%, the specificity was 81.37%, and the result was better than using procalcitonin (PCT) alone, but similar with C-reactive protein (CRP) alone or CRP+PCT.ConclusionPostoperative CAR can better predict POPF and abdominal infection after PD, and the effect is better than PCT alone.
ObjectiveTo investigate the clinical effect of end-to-side binding pancreaticojejunostomy.MethodsFrom March 2009 to December 2019 , 70 patients (pancreatic head cancer in 16 cases, duodenal papillary cancer in 27 cases, bile duct cancer in 8 cases, periampullary cancer in 2 cases, gallbladder cancer invading the pancreatic head in 1 case, intraductal papillary myxoma of pancreas in 6 cases, and mass-type chronic pancreatitis in 10 cases) were performed with end-to-side binding pancreaticojejunostomy were retrospectively analyzed, including large pancreas remnant (n=4). The main procedures included isolation of the pancreatic remnant, incising the jejunal wall and preplacing with seromuscular purse string suture around the incision, performing end-to side binding pancreaticojejunostomy.ResultsThe procedures were successful in all 70 patients. Postoperative complications included pancreatic fistula (n=3, 4.3%), of three patients cured with reoperation, jejunal loop decompression tube was not placed in 2 patients, and 1 patient had pancreatic fistula and bleeding on the eighth day after operation. One out of 3 patients developing abdominal hemorrhage which reoperation died of acute respiratory distress syndrome, 1 patient was cured with the vascular interventional hemostasis. Gastrointestinal anastomotic bleeding (n=1) and adhesive intestinal obstruction (n=1) were cured with reoperation, biliary leakage (n=1) was cured with conservative treatment.ConclusionEnd-to-side binding pancreaticojejunostomy is simple, safe and reliable.