Application of vascular control technology in pancreaticoduodenectomy surgery Zhao Yuzhou Han Guangsen* General Surgery Department, Henan Cancer Hospital Zhengzhou 450003 Journal of Medical Forum, 2011, No.1 Abstract: Objective To summarize the effect of vascular control technology in pancreaticoduodenectomy surgery. Methods To retrospectively analyze the differences in operation time, intraoperative bleeding, number of lymph node dissection, complication rate, and postoperative hospitalization time between 37 cases of 96 cases of pancreaticoduodenectomy from January 2004 to December 2010 and the traditional surgery group. Results The operation time, intraoperative bleeding, number of lymph node dissection and postoperative hospitalization time in the two groups were 115.2±23.6min and 198.3±15.2min, 206±42ml and 637±186ml, 6.7±1.8 and 6.3±2.2, 13.9±1.7h and 17.1±2days, and the complication rates were: 10.8% and 28.8%. It showed that the operative time was significantly shortened, bleeding was significantly reduced, and the complication rate was significantly reduced in the group applying vascular control technology, and the differences were statistically significant P < 0.05. The number of lymph node dissection and the hospitalization time were consistent with those of the traditional surgery group. Conclusion Pancreaticoduodenectomy surgery applying vascular control technology surgical resection can significantly shorten the operation time, reduce the amount of bleeding, and reduce the incidence of complications. Zhao Yuzhou, Department of General Surgery, Henan Tumor Hospital Keywords: periportal tumors; pancreaticoduodenectomy; vascular control technology *Corresponding author CCTS: R656.6+4 Application of Blood Vessel Controlling Skill in Pancreatoduodenectomy (Henan tumor hospital, Zhengzhou, 450003) ZHAO Yu-zhou, HAN Guang-sen*, Li Zhi, REN Ying-kun, LU Chao-min, GU Yan-hui Abstract Objective To evaluate the Objective To evaluate the effect of blood vessel controlling skill in Pancreatoduodenectomy. Methods Clinical data on 96 patients with pancreatoduodenectomy were collected prospectively. 59 patients underwent traditional surgery. Prospectively. 59 patients underwent traditionalmethod and 37 patients under went amending procedure under the blood vessel controlling skill. In the two groups, the comparation of the blood vessel controlling skill in Pancreatoduodenectomy was performed. In the two groups, the comparison of the mean operative time, the blood loss, the numberof lymph nodes dissection and the mean time of hospital stay was done. Results In two groups, the mean operative time, the blood loss, the number of lymph nodes dissection and the mean time of hospital stay were 115.2±23.6 minutes and 198.3±15.6 minutes respectively. minutes and 198.3±15.2minutes, 206±42ml and637±186ml, 6.7±1.8and6.3±2.2 , 13.9±1.7h days and17.1±2 days. the complication incidence is 10.8%, 28.8% separately. 28.8% separately.There are statistically significant difference of the mean operative time, the blood loss, and complication incidence.Conclusion Amending pancreatoduodenectomy under the blood vessel controlling skill can shorten operative time, reduce the blood loss, reduce the complications. KEY WORDS Peri-ampullar carcinoma; Pancreatoduodenectomy; Blood vessel controlling skill Pancreaticoduodenectomy is the method of choice for the treatment of pancreatic cancer, peripelvic cancer, duodenal tumors and other diseases [1]. The traditional method of pancreaticoduodenectomy is traumatic, long, bleeding, and a big blow to the patient, which limits the extensive development of this procedure in surgical clinics [2]. In recent years, we have used a modified pancreaticoduodenectomy and reconstruction method to shorten the time of this procedure to less than 2 hours [3]. This article focuses on the experience of vascular control techniques in this procedure. 1 Data and Methods 1.1 General Data There were 37 cases in the vascular control technology surgery group (observation group), 23 male cases and 14 female cases; 20 cases were under 60 years old and 17 cases were over 60 years old; postoperative pathological types: 14 cases of cancer of pancreatic head, 13 cases of cancer of the lower part of choledochal duct, and 10 cases of cancer of jugular abdominal region. In the traditional surgery group (control group), there were 59 cases, 38 males and 21 females; 41 cases below 60 years old and 18 cases above 60 years old; 28 cases of pancreatic head cancer, 17 cases of lower bile duct cancer, and 14 cases of jugular abdominal cancer. All patients did not undergo surgery for reduction of yolk before operation. 1.2 Enrollment criteria ① Preoperative CT and intraoperative exploration confirmed that the diameter of the lesion was <6cm and there was no extensive mass metastasis. ② The main vessels of the superior mesenteric vein portal vein system were not involved. 1.3 Surgical approach Surgical procedure for pancreaticoduodenectomy with vascular control technique: ① 1. Make a Kocher's incision ②. Open the gastrocolic ligament and investigate the lower edge of the pancreas and the inferior mesenteric vein ③. Cut off the right gastric vessel ④ Cut off the gastroduodenal artery, explore the pancreas, and bluntly separate the neck of the pancreas from the portal vein and the superior mesenteric vein from top to bottom ⑤ Remove the gallbladder ⑥. Clean the hilar, common hepatic duct and lymph nodes adjacent to the left gastric vessel (7). Cutting and ligating the vessels on the side of the curvature of the stomach at the point of gastric pre-resection ⑧. Dissection of the stomach with an occluder ⑨. Dissection of the common bile duct ⑩. Free and cut off the neck of the pancreas 11.Complete resection of the leptomeninges 12.Free and cut off the gastrocolic venous trunk 13.Cut off the ascending part of the duodenum and resect the specimen 14 Digestive tract reconstruction 15 Placement of drains to clear and close the abdomen. 1. 4 Statistical methods Comparison of intraoperative bleeding, operation time, number of lymph node dissection and postoperative gastrointestinal function recovery time between 37 cases in the group of surgery with application of vascular control technology and 59 cases in the group of traditional surgery. SPSS13.0 statistical software was used for data processing, t-test was used to compare the mean of each observation index of the two groups, and χ2 test was used to compare the count data, and the difference between the two groups was considered to be statistically significant at P＜0.05. 2 Results 2.1 Indicators of operation time, intraoperative bleeding, average number of lymph nodes cleared and postoperative hospitalization time of the two groups ,see Table 1. Table 1 Statistics of operation time, intraoperative bleeding, average number of lymph nodes cleared and postoperative hospitalization time of the two groups Observation group Control group t-value P-value Operation time (min) 115.2±23.6 198.3±15.2 2.815 0.013 Bleeding volume (ml) 206±42 637±186 3.475 0.020 Number of lymph nodes cleared (pcs) 6.7±1.8 6.3±2.2 0.947 0.253 Number of postoperative hospitalization days (days) 13.9±1.7 17.1±2 2.369 0.021 Note: The p-value of the chi-square test for each observation index is greater than 0.05. 2.2 Observation group Complications occurred in 4 cases (10.8%) and 17 cases (28.8%) in the control group, and the statistical difference between the two groups was significant (P < 0.05). 3 Discussion Most of the patients with pancreatic head duodenal jugular abdominal tumors were accompanied by advanced age, late consultation, malnutrition, jaundice, abnormal liver function and low immunity. For many years, pancreaticoduodenectomy has been the classic surgical procedure for the treatment of pancreatic head and duodenal jugular abdominal tumors. The procedure not only involves many organs and high surgical difficulty, but also has a long history of high surgical risk, trauma, time-consuming, and high incidence of postoperative complications, which is not conducive to the development of this type of surgery by primary care physicians. Some data show that postoperative complications are still high 50%, so about how to improve the safety of pancreaticoduodenectomy, while reducing the occurrence of postoperative complications has become one of the hotspots of clinical research in recent years [4]. In recent years, the authors' department has combined vascular control technology with surgical operation through clinical anatomy research, which has been applied to the clinical operation of various abdominopelvic surgeries, such as right hemicolectomy [5, 6], radical gastric cancer surgery, pancreaticoduodenectomy, etc. In particular, in the case of pancreaticoduodenectomy, the vascular control technology has been used to improve the safety of the pancreaticoduodenal resection. Especially in the process of pancreaticoduodenectomy, we have shortened the operation time of pancreaticoduodenectomy to 70 minutes through the programmed design of the surgical resection process in a fixed pattern and the improvement of the postoperative anastomosis. The main feature of this operation is that the vascular control technique is used throughout the whole process of specimen resection. It makes it simple, safe, reproducible and easy to promote. The main points of vascular control are: 1. freeing along the vascular sheath and vascular tunica; 2. tissue dissection and clearance of perivascular lymph nodes under left-handed control; and 3. partial resection and reconstruction of blood vessels. In these measures, there is no obvious change in the conventional technical operation aspects, but the vessels are under the control of the left hand, which can effectively control the hemorrhage, overcome the intimidation during the anatomical operation, and make the difficult operation relatively easy, relaxed and fast, and at the same time, it can effectively reduce the intraoperative hemorrhage, shorten the operation time to reduce the complications, and accelerate the patient's postoperative recovery [5]. We summarize the application of vascular control technology in pancreaticoduodenectomy as the following five important party steps: Step 1: the first line Kocher during surgery lays the foundation for the control of the entire surgical operation process, the operator's left hand can effectively control from the hepatic hilar to the upstream of any mesenteric arterial artery trunk and its belonging to the branch. Typically, the Kocher incision is made from the lesser omental bursa down to the level of the duodenum, with the left side marked by the exposure of the left renal vein. Step 2: Exploration of the inferior border of the pancreas and the superior mesenteric vein is not only an important step in the intraoperative assessment of resectability, but also in this maneuver the entrance of the superior mesenteric vein at the inferior border of the pancreas is freed and visualized, and the pretreatment maneuver is performed for separating the neck of the pancreas from the anterior wall of the superior mesenteric vein [7, 8]. At the same time, once partial involvement of the portal vein is detected on exploration during subsequent separation, but R0 resection is still possible with partial portal vein resection and reanastomosis, the superior mesenteric vein can be quickly cut at or downstream of the site and anastomosis can be performed. It also facilitates hemostasis in the event of injury to the portal vein or superior mesenteric vessels due to unforeseen circumstances associated with the surgical procedure [9]. Step 3: After cutting off the right gastric vessel, the gastroduodenal artery can be fully exposed and cut off under direct vision, which not only facilitates the lymph node dissection next to the common hepatic artery, but also helps in the direct exploration of the pancreatic neck from the pancreatic neck to see if the tumor involves the portal wall, and helps in the separation and dissection of the neck of the pancreas. In step 4, the method of separating the neck of the pancreas from the anterior wall of the portal vein wall used a top-down blunt or sharp separation. This not only makes the separation level more clear, but also effectively reduces accidental bleeding due to portal vein injury. This makes it possible to complete the separation process in minutes or even seconds, which usually takes more than 10 minutes or tens of minutes. Especially for pancreaticoduodenectomy due to duodenal tumors, the operator can detach the pancreas from the upper edge of the pancreas with the index finger bluntly downward along the anterior wall of the portal vein, which can often be accomplished within a few seconds. None of the 25 surgical operations using this method since 2006 in this study have resulted in portal vein injury [10]. In clinical work, this method can be effectively extended to cases requiring combined pancreaticoduodenal dissection due to gastric sinus cancer involving the duodenum, right hemicolonic cancer invading the duodenum, and so on. Regarding the 5th step of vascular control: focusing on the resection of pancreatic hook and the treatment of gastrocolic venous trunk, it was found that the blood vessels emanating from the right wall of portal vein to the pancreatic hook were mainly concentrated in the upper 1/3 region of the pancreatic hook, and after carefully separating the upper part of the hook with hemostatic forceps, the lower tissues could be freed only by clamping the portal side instead of the hook side, which would seldom cause obvious hemorrhage. However, special attention should be paid to the presence of a thick branch vessel in the highest position in about 30% of patients above the hooker, which is often easily torn before hooker resection, causing unnecessary bleeding. After the pancreatic hooks are dissected, the root of the gastrocolic venous trunk can be clearly exposed along the portal wall downward, and then clamping to cut off the blood vessel can be carried out under clear vision. Accidental bleeding is rare. Although with the continuous progress of CT, MRI and color ultrasound examination technology, the prediction accuracy value of tumor resectability before pancreaticoduodenectomy can reach 90 % and 80 for CT and MRI, respectively, there are still some patients who have surgery because intraoperative exploration confirms the inability of radical resection, and then give up the surgery or change to palliative surgery to relieve jaundice or obstruction [11, 12]. Although the stages of surgical exploration, specimen pre-resection and specimen resection in the design of this surgical procedure are consecutive, any step before freeing and severing the neck of the pancreas can be readily converted to palliative surgery, such as biliary-enteric anastomosis or gastrojejunal anastomosis, due to intraoperative findings of inability to perform a radical resection of the tumor (especially in the case of excessive portal vein involvement and inability to perform resection followed by reanastomosis or artificial vascularization, and in the case of involvement of the superior mesenteric artery). Surgery. At the same time, when the surgical dissection is well advanced and the pancreatic neck is successfully separated from the portal vein, the specimen can be resected within minutes, or when partial resection of the portal vein is clearly needed, vascularization or anastomosis can be initiated within minutes, which can significantly shorten the ischemic time of the intestinal canal [10]. In conclusion, the application of vascular control technology in pancreaticoduodenectomy can significantly increase the safety of the operation, combined with the optimization of the specimen resection surgical process and lymph node dissection over the operation process, shorten the operation time, reduce the amount of intraoperative bleeding, reduce the difficulty of the operation of the method has a certain value of promotion. References [1] Tsirlis T, Vasiliades G, Koliopanos A, et al. Pancreatic leak related hemorrhage following pancreaticoduodenectomy. a case series. jop. 2009. 10(5): 492-5. [2] Ausania F, Cook N, Jamieson N, Huguet E, Jah A, Praseedom R. Impact of pancreatic leaks on survival following pancreaticoduodenectomy. JOP. 2010. 11(3): 226-9. [3] Han GS, Zhao YZ, Li Z, Wan SB. Clinical study of modified pancreaticoduodenectomy and reconstruction. Journal of Medicine Forum. 2008. (13): 24-25. [4] Welsch T, Buchler MW, Schmidt J. [Surgery for pancreatic cancer]. Z Gastroenterol. 2008. 46(12): 1393-403. [5] Wan SB, Han GS, Ren YK, Zhao YZ. Application of vascular control technique in proximal colon cancer surgery. Journal of Medicine Forum. 2009. (09): 27-28. [6] HAN Guang-Sen, WAN Xiang-Bin, LI Zhi, ZHAO Yu-Zhou. Clinical observation on modified right hemicolectomy for proximal colon cancer. Shandong Medicine. 2008. (14): 129-130. [7] Zhong DB. Severance of the pancreatic neck from the fibrous plate in pancreaticoduodenectomy. World Chinese Digestive Journal. 2009. (05): 473-475. [8] Cui Yunfu. Pancreaticoduodenectomy by superior mesenteric artery approach. Advances in Modern General Surgery in China. 2009. (12): 1018-1019+1065. [9] Yuzhou Zhao GH, Yingkun Ren ea. Clinical research of superior mesenteric vascular intrathrcal approach in right hemicolectomy. hemicolectomy. Chinese-German Journal of Clinical Oncology. 2010. 9(11): 633-636. [10] Zhao YZ, Han GS, Yingkun Ren ea. Application of retrograde pancreatic hilar separation technique in pancreaticoduodenectomy. Shandong Med. 2010. 50(50): 51-52. [11] Lall CG, Howard TJ, Skandarajah A, DeWitt JM, Aisen AM, Sandrasegaran K. New concepts in staging and treatment of locally advanced pancreatic head cancer. AJR Am J Roentgenol. 2007. 189(5): 1044-50. [12] Qiu WS, Tan YH, Wang J et al. Guidance of multislice spiral CT for pancreaticoduodenectomy. Guangdong Med. 2009. (12): 1830-1832.