I. Introduction
Pancreaticoduodenectomy is a complex and invasive abdominal surgery, which includes part of the pancreas, adjacent duodenum, lower bile duct, part of the stomach and upper jejunum, and requires anastomosis of the common bile duct, pancreatic duct, stomach and jejunum. The surgical procedures include pancreatic head duodenectomy, extended pancreatic head duodenectomy, pylorus preserving pancreaticoduodenectomy, total pancreatectomy, etc. JI Wu, General Surgery Department, General Hospital of Nanjing Military Region
II. Indications and contraindications
Indications.
1. cancer of the head of the pancreas, cancer of the lack of special pot belly, cancer of the lower part of the common bile duct, and duodenal cancer around the pot belly.
Among them, the efficacy of pancreatic head cancer is poor, and the efficacy of peri-pot belly cancer is better.
2. Other diseases such as duodenal smooth muscle sarcoma, carcinoid tumor, pancreatic cystic adenocarcinoma, etc. can be selected for this operation when necessary.
Contraindications.
Metastasis to the liver; metastasis to the common bile duct and hepatic duct; extensive metastasis to the hilar, peribiliary and suprapancreatic lymph nodes; tumor has invaded the portal vein and superior mesenteric vein; the head of the pancreas or around the jugular has been closely adhered to the inferior vena cava or aorta.
For patients with long-term severe jaundice and very poor condition, they may first undergo end-lateral anastomosis of the proximal segment of the gallbladder and jejunum or first PTCD or ERCP drainage, and then undergo stage II or elective radical resection after the condition improves. The second-stage surgery is usually performed about 10 days after the first-stage surgery, and no later than 2 weeks. The second-stage surgery is often difficult due to adhesions, so in principle, we should strive for the first-stage radical surgery.
Development of curative effect
The incidence of pancreatic cancer is increasing, and it is reported that pancreatic cancer is the fourth most common cancer-related death in the United States, surpassing gastric cancer. Cancer of the head of the pancreas, cancer of the lower part of the common bile duct, and cancer of the duodenal mucosa around the jugular belly of the lack of ate all occur within a 3-cm diameter of the head of the pancreas. The symptoms and signs of these tumors are similar, but the prognosis is not the same. Although pancreatic head duodenectomy is a more effective treatment for these tumors, its efficacy is still not satisfactory. The head of the pancreas is the worst, and other types of cancer are slightly better, but the overall surgical resection rate is only 30%, and the surgical mortality rate and five-year cure rate after resection are only about 10%.
The head of the pancreas includes the lower bile duct and duodenum, which are closely related from embryogenesis and anatomy, and the combination of pancreatic head resection with duodenectomy was considered inevitable. Pancreaticoduodenectomy (PD) and pylorus-preserving pancreaticoduodenectomy (PPPD) are considered to be the classic procedures for masses and benign tumors in the head of the pancreas in chronic pancreatitis. In 1972, Beger advocated pancreatic head resection with preservation of the duodenum for the treatment of pancreatic head masses in chronic pancreatitis. Subsequently, many scholars have improved on the basis of Beger’s procedure.
IV. Surgical procedure
1. Routine exploration: to check whether there are distant metastases and cancer invasion in the abdominal cavity, and to determine whether it can be resected initially. In progressive stage pancreatic head cancer, it sometimes infiltrates the root of transverse colon mesentery to form cancer contracture (or cancer umbilicus), which means that the superior mesenteric vein is infiltrated by cancer. The sclerotic sensation when touching the head of the pancreas needs to be differentiated from the calcification of pancreatitis. The contents of the hepatoduodenal ligament, including the presence of tumors and stones in the common bile duct, also need to be noted; when palpating the duodenum, the presence of masses in the medial papilla of the descending part should be noted. The gastrocolic ligament should be severed and the loose tissue between the transverse colonic mesentery and the head of the pancreas should be cut to reveal the descending part of the duodenum and the front of the head of the pancreas, at which time a fine biopsy needle can be used for multi-point puncture to extract tissue specimens for pathological cytological examination, and attention should be paid to the direction of needle entry, as much as possible to the anterior and superior part of the pancreas to avoid damage to the main pancreatic duct. As for cutting local biopsies for frozen section examination, we should be cautious because there are often changes of chronic pancreatitis around the pancreatic cancer mass, which may cause misdiagnosis or leakage if the material is not properly taken, and there is still a risk of pancreatic leakage, bleeding and abscess if the cancer cannot be removed.
2. Separation and exploration: cut open the lateral peritoneum of the descending part of the duodenum, cut open the hepatogastric ligament and hepatoduodenal ligament, extend to the horizontal part of the duodenum and even the root of the transverse colon mesentery, bluntly separate the loose tissue behind the pancreas, turn up the duodenum and the head of the pancreas to the left side, free the duodenum and the head of the pancreas fully from the retroperitoneum, check whether there is any invasion between the cancer and the vena cava, the superior mesenteric artery and vein, the celiac artery and the hepatic artery. invasion, especially of the portal vein. The portal vein and superior mesenteric vein should be separated without obvious resistance behind the pancreas, and this step is the key to the final decision of whether to perform radical surgery.
3. Excision of lesions and surrounding tissues: excision of gallbladder, severing the common hepatic duct or common bile duct, and in case of pancreatic head cancer, the bile duct must be severed in the lower part of the common hepatic duct; excision of the distal stomach, the scope of which depends on the patient’s age and the presence or absence of hyperacidity, up to the distal 1/2 of the stomach, and the greater omentum should be treated according to the requirements of radical surgery for gastric cancer; excision of the pancreas, the scope of which is generally at the left margin of the celiac artery, while carcinoma of the jugular abdomen or some benign lesions can be removed at the the neck of the pancreas as the resection line. When cutting off the pancreas, four-point sutures at the edge of the pancreas are used first to prevent bleeding from the transverse vessels of the pancreas, and the pancreas should be incised while the pancreatic duct is stripped and carefully protected, and a silicone tube of appropriate diameter to the original pancreatic duct is inserted, and 1 to 2 stitches are used to fix the silicone tube with absorbable thread in the pancreatic duct, and attention is paid to ligating some venous vessels on the back of the pancreas. The Treitz ligament was identified at the left root of the mesentery, the superior mesenteric artery was clearly touched, the first and second branches of the jejunal artery were ligated, and the jejunum was cut off 10 cm below the Treitz ligament, the proximal end was closed, and the distal end was prepared for a sleeve anastomosis with the pancreas. Finally, when dealing with the pancreatic hook, we should pay attention to the fact that there are several small veins converging into the superior mesenteric vein, which must be carefully ligated and cut off one by one to avoid damaging the superior mesenteric vein and hemorrhage. The head of the pancreas should be completely excised and the lymph nodes around the superior mesenteric artery should be contoured at the same time.
4. Reconstruction of the digestive tract: there are mainly the Child method with the order of pancreatic-intestinal, biliary-intestinal and gastrointestinal anastomosis and the Whipple method with biliary-intestinal, pancreatic-intestinal and gastrointestinal anastomosis. At present, the more popular method is Child method, in which the pancreatic-intestinal anastomosis adopts the end-embedded anastomosis between the pancreas and jejunum, and the whole layer with pulpy muscle layer suture is performed. Sometimes the pancreatic section is wider than the jejunal cavity, and in order to prevent the obstruction of blood circulation in the intestinal wall caused by the hard sleeve, which affects the healing of the anastomosis, the upper and lower margins of the pancreas must be wedge resected or only the lower margin must be wedge resected to wedge the pancreas into it. The conventional method of biliary-intestinal anastomosis should be of appropriate size; it should not be too large and still require the placement of a T-tube, nor should it be too small. Others use the placement of a catheter for support. Finally, a gastrojejunostomy is performed, usually 40-50 cm below the pancreatic-intestinal anastomosis, and the stomach is anastomosed with the jejunum before the colon. The Whipple method is to close the distal jejunal section and pull it to the colon before the biliary-intestinal anastomosis. The pancreatic-intestinal anastomosis is divided into two types: one is the end-lateral anastomosis of the pancreatic duct jejunum, which is suitable for those with significantly thick and dilated pancreatic duct; the other is the intra-jejunal grafting method of the pancreatic duct, which requires the insertion of a silicone tube into the pancreatic duct and the fixation of the pancreatic duct. Regardless of Child method or Whipple method, in order to prevent the occurrence of pancreatic fistula, it is advocated to place a catheter in the main pancreatic duct to drain the pancreatic fluid.
V. Major complications after surgery
1. pancreatic fistula
It is often the fatal and most common complication after pancreatic resection. It mostly occurs 5 to 7 days after surgery. Patients present with abdominal distension, abdominal pain, high fever, increased abdominal drainage, and if the amylase of abdominal drainage fluid is elevated, pancreatic fistula can be identified. Non-surgical treatment is generally used, as surgery is difficult to repair. During surgery, attention is paid to the tightness of the pancreatic-intestinal anastomosis, especially the placement and drainage of the catheter in the main pancreatic duct, and the abdominal drainage should be adequate, preferably using a Pan-type drainage tube, with double-lumen drainage tubes for drainage if necessary. Early and continuous application of drugs that inhibit pancreatic fluid secretion, such as growth inhibitors and their derivatives.
2. Abdominal bleeding
There are two types of bleeding: primary and secondary. Primary hemorrhage is often early in the operation, mostly due to fresh blood flowing from the drainage tube, mostly due to incomplete intraoperative hemostasis or coagulation dysfunction; it should be closely observed, with immediate fluid and blood transfusion and application of hemostatic drugs, and if the condition does not improve, the abdomen should be opened immediately for investigation. Secondary bleeding mostly occurs 1 to 2 weeks after surgery, mostly due to pancreatic fistula pancreatic fluid flow into the abdominal cavity, digestion and erosion of surrounding tissues, non-surgical treatment should be actively taken; if there is active bleeding, angiography can be considered, but sometimes it is still difficult to find the site of bleeding, surgical hemostasis is often difficult to succeed, should be cautious attitude. Primary bleeding can also occur in the incisional margin of the pancreas or jejunum, mainly due to incomplete hemostasis during surgery, resulting in local bleeding and formation of hematoma after surgery, and hematoma compression further makes the anastomosis poorly hemorrhaged, resulting in anastomotic fistula or pancreatic fistula, so local bleeding is often associated with various fistulas, and the drainage tube needs to be closely observed, and if there is persistent bleeding, re-operation should be performed immediately. The main prevention is to stop bleeding thoroughly during surgery, in addition, bioprotein gel can be applied to the broken end of the pancreas and around the anastomosis to stop bleeding on the one hand, and to have a proper adhesive effect on the other.
3. Gastrointestinal bleeding
Early postoperative bleeding can be considered as incomplete hemostasis under the gastric mucosa or coagulation dysfunction. Bleeding about 1 week after surgery is mostly considered as stress ulcer bleeding, which can be treated as stress ulcer bleeding, and antacids are routinely applied early after surgery.
4. Intra-abdominal infection
It is a serious complication, mostly caused by pancreatic fistula, biliary fistula or abdominal leakage combined with infection. There may be abdominal pain and high fever, physical exertion, occurrence of anemia and hypoproteinemia, etc. Intensify systemic supportive treatment and apply highly effective broad-spectrum antibiotics.
5. biliary fistula
It is less common, and once it occurs, it can be cured mainly by unobstructed drainage; those with poor drainage and signs of peritoneal irritation should be surgically explored.