Surgical resection is the treatment method to obtain the best results for pancreatic cancer patients; however, more than 80% of pancreatic cancer patients are lost to surgery due to late stage of the disease, and performing surgery on these patients does not improve the survival rate of patients. Therefore, before treating patients, necessary imaging examinations and assessment of the whole body condition should be completed, with abdominal surgery as the main focus, including diagnostic imaging, chemotherapy and radiotherapy, including multidisciplinary treatment teams to determine the resectability of the tumor and develop specific treatment plans.
1.The following principles should be followed in surgery.
(1) Tumor-free principle: including the principle of tumor non-contact, the principle of whole tumor resection and the blockage of tumor supply vessels.
(2) Adequate resection scope: the scope of pancreaticoduodenectomy includes 1/2-1/3 of the distal stomach, the lower part of the common bile duct and/or gallbladder, the pancreatic head cutting edge on the left side of the superior mesenteric vein/3 cm from the tumor, all of the duodenum, and 15 cm of the proximal segment of the jejunum; adequate resection of the fascia in front of the pancreas and the soft tissue behind the pancreas. Tissue in the region of the hooked region with local lymphatic fluid return, and the nerve plexus in the region. The loose connective tissue around large blood vessels, etc.
(3) Safe margins: pancreaticoduodenectomy for pancreatic head cancer requires attention to six margins, including the pancreas (pancreatic neck), common bile duct (common hepatic duct), stomach, duodenum, retroperitoneum (refers to skeletal clearance of the superior mesenteric artery), and other soft tissue margins (such as posterior pancreatic), among which the margins of the pancreas should be greater than 3 cm, and frozen pathological examination of the margins can be performed during surgery to ensure adequate margins.
(4) Lymph node dissection: the ideal histological examination should include at least 10 lymph nodes. If there are less than 10 lymph nodes, although the pathological examination is negative, the N grade should be pN1 instead of pN0. The peri-pancreatic region includes the lymph nodes around the abdominal aorta. metastasis of the para-aortic lymph nodes is one of the causes of postoperative recurrence.
2. Preoperative yellowing reduction.
(1) The main purpose of preoperative yellowing reduction is to relieve symptoms such as pruritus and cholangitis, as well as to improve liver function and reduce surgical mortality.
(2) For patients with severe symptoms, accompanied by fever, sepsis and septic cholangitis, preoperative yellow reduction is feasible.
(3) Yellowing can be reduced by drainage and/or stent placement, and cholecystostomy is feasible in hospitals without conditions.
(4) Generally, after 2 weeks of the reduction, the bilirubin will drop by more than half of the initial value, liver function will be restored and body temperature and blood count will be normal when the tumor is removed again.
3. Indications for radical surgical resection.
(1) Age <75 years old, good general condition.
(2) Pancreatic cancer with clinical stage II or below.
(3) No liver metastasis and no ascites.
(4) The cancer is confined to the pancreas and does not invade important vessels such as the mesenteric portal vein and superior mesenteric vein.
(5) No distant spread and metastasis.
4.Surgical methods.
(1) Pancreaticoduodenectomy is feasible when the tumor is located in the head and neck of the pancreas.
(2) If the tumor is located in the tail of the pancreatic body, pancreatic body tail plus splenectomy can be performed.
(3) If the tumor is large and the scope includes the head, neck and body of the pancreas, total pancreatectomy is feasible.
5. Stump anastomosis technique after pancreatic resection.
The purpose of post-pancreatic resection stump management is to prevent pancreatic leakage, and pancreatic-intestinal anastomosis is the commonly used anastomosis, and there are several types of pancreatic-intestinal anastomosis.
6. The problem of palliative surgery.
For patients with preoperative unresectable pancreatic cancer, if jaundice and gastrointestinal obstruction are also present, palliative surgery is feasible if systemic conditions allow, and biliary-intestinal and gastrointestinal anastomoses are performed.
7. Management of complications and principles of treatment.
(1) Postoperative bleeding: postoperative bleeding is acute within 24 hours after surgery, and delayed bleeding is more than 24 hours. It mainly includes abdominal bleeding and gastrointestinal bleeding.
(1) abdominal bleeding: mainly due to incomplete intraoperative hemostasis, the illusion of bleeding point hemostasis in the intraoperative hypotensive state or ligature line detachment, electrocoagulation scab detachment reasons, insufficient pre-closing abdominal examination, coagulation mechanism disorder is also one of the causes of bleeding. The main prevention and control methods are strict hemostasis during surgery, careful examination before closing the abdomen, important vascular sutures, and preoperative correction of coagulation function. When abdominal bleeding occurs, great importance should be attached to it. Small amounts can be observed by hemostatic transfusion, and in large amounts, surgical hemostasis is performed as soon as possible while correcting microcirculatory disturbances.
② Gastrointestinal bleeding: stress ulcer bleeding, mostly occurs more than 3 days after surgery. Its prevention and control is mainly preoperative correction of the patient’s nutritional status, to minimize the impact of surgery and anesthesia, treatment is mainly conservative treatment, the application of hemostatic drugs, acid suppression, gastrointestinal decompression, can be injected through the gastric tube ice positive renal saline gastric lavage, but also by gastroscopy to stop bleeding, angiography embolization to stop bleeding, by conservative invalid can be surgical treatment.
(2) pancreatic fistula: where 7 days after surgery still drainage of fluid containing amylase should be considered the possibility of pancreatic fistula, Johns Hopkins criteria is the content of pancreatic enzymes in the abdominal drainage fluid is greater than three times the serum value, the daily drainage is greater than 50 ml. pancreatic fistula management is mainly adequate drainage, nutritional support.
(3) Gastroparesis.
(1) There is no unified standard for gastroparesis, and the commonly used diagnostic criteria are confirmed by examination that there is no obstruction of the gastric outflow tract; gastric fluid >800ml/d for more than 10 days; no obvious abnormalities in water-electrolyte and acid-base balance; no underlying diseases that cause gastric weakness; and no use of smooth muscle contraction drugs.
②Diagnosis is mainly based on medical history, symptoms and signs, gastrointestinal imaging, gastroscopy and other examinations.
③The treatment of gastroparesis is mainly adequate gastrointestinal decompression, enhanced nutritional psychotherapy or psychological suggestion therapy; application of gastrointestinal motility drugs; treatment of underlying disorders and disorders of nutritional metabolism; gastroscopy can be tried and repeatedly and rapidly inflated and discharged into the stomach, and treatment can be repeated for 2-3 days.