ObjectiveTo explore the prognostic factors of malignant tumors in ampulla, lower bile duct, head of pancreas, uncinate process, and neck of pancreas after operation.MethodThe recent literatures on malignant tumors in this region at home and abroad were summarized.ResultsThe prognosis of five groups of malignant tumors in ampulla, lower bile duct, head of pancreas, uncinate process, and neck of pancreas was correlated with their origin, growth site, tumor diameter, nerve invasion, vascular invasion, lymphatic metastasis, pathological and histological classification, and cutting edge status. The different location and pathological classification of tumors made the different neurovascular invasion rate, lymphatic metastasis rate, and R0 resection rate.ConclusionsBy summarizing and analyzing the origin, growth site, diameter, nerve invasion, vascular invasion, lymphatic metastasis, pathological and histological classification, and cutting edge status of tumors, we can improve the clinical prediction of tumors in this region, select appropriate surgical methods before operation, and formulate more reasonable adjuvant treatment plan after operation, in order to improve the pertinence of the treatment of tumors in this region, improve the prediction, and finally better serve the clinical work.
Objective To explore the hepatic artery variations encountered in laparoscopic pancreaticoduodenectomy (LPD) surgery and its significance. Methods The clinical datas of 26 patients who underwent LPD from January 2020 to January 2023 were retrospectively collected. Preoperative evaluation of hepatic artery variability and its types based on relevant clinical and imaging data, as well as targeted measures taken during surgery, and patients’ prognosis were analyzed. Results According to preoperative abdominal enhanced CT, arterial computer tomography angiography imaging and intraoperative skeletonization of the hepatoduodenal ligament, hepatic artery variation was found in 9 of 26 patients undergoing LPD. The left hepatic artery was substituted in 1 case, the right hepatic artery was substituted in 2 cases, 2 cases were the left accessory hepatic artery, and the common hepatic artery originated from the superior mesenteric artery in 3 cases. There was 1 case, right hepatic artery coming from the abdominal aorta, whose arterial variation was not included in the traditional typing. The variant hepatic artery from superior mesenteric artery was separated by posterior approach during operation, and the variant hepatic artery from left gastric artery was separated by anterior approach during operation. Nine patients with hepatic artery variation recovered well after operation, and no serious complications occurred. Conclusions Various hepatic artery variations during LPD need to be carefully evaluated before surgery. During surgery, it should be determined whether to retain the mutated blood vessel based on its diameter and changes in liver blood flow after occlusion, so that reasonable operation can be performed during the operation to avoid hepatic artery damage.
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.
Objective To compare the clinical efficacy between total enteral nutrition and enteral nutrition combined with parenteral nutrition after pancreaticoduodenectomy. Methods A total of 70 patients who underwent pancreaticoduodenectomy in our hospital from July 2012 to July 2015 were collected prospectively, and all patients were divided into 2 groups randomly: enteral nutrition group and combined nutrition group. Patients in enteral nutrition group received total enteral nutrition, and patients in combined nutrition group received enteral nutrition combined with parenteral nutrition. Compared the nutritional indicators, other related indexes, and morbidity between the 2 groups. Results ① The nutritional indexes. Compared with before treatment, the body mass index (BMI), white blood cell count, serum albumin level, serum albumin level, and total lymphocyte count at 1 week and 2 weeks after treatment improved (P<0.05). At the same time point (before treatment, 1 week after treatment, and 2 weeks after treatment), there was no significant in the BMI, white blood cell count, serum albumin level, serum albumin level, and total lymphocyte count between the 2 groups (P>0.05). ② Other related indexes. The anal exhaust time, defecation time, and hospital stay of the patients in the combined nutrition group were shorter than those of enteral nutrition group, and the cost of treatment in combined nutrition group was less than that of the enteral nutrition group (P<0.05). ③ Morbidity. There was no significant difference in the total morbidity between the combined nutrition group〔11.4% (4/35)〕 and enteral nutrition group 〔20.0% (7/35)〕,P>0.05. Conclusion Total enteral nutrition and enteral nutrition combined with parenteral nutrition after pancreaticoduodenectomy both can obtain well curative effect, but enteral nutrition combined with parenteral nutrition can make the patients recover faster with lower cost, which is suitable for promotion.
ObjectiveTo explore the safety and feasibility of the uncinate-process-first superior mesenteric artery (SMA) right posterior approach in laparoscopic pancreaticoduodenectomy (LPD). MethodsThe clinical data of 5 patients admitted to the Second Affiliated Hospital of Chongqing Medical University from December 2022 to May 2023 were retrospectively analyzed, all patients underwent uncinate-process-first SMA right posterior approach during LPD. ResultsAll 5 cases of LPD with uncinate-process-first SMA right posterior approach were successfully completed. The operative time was (366±51) min, the intraoperative blood loss was (140±42) mL, and the postoperative hospital stay was (11±2) days. All the postoperative pathological findings reached R0 resection. None of the 5 patients suffered from biliary leakage, bleeding, or gastrointestinal empties, and 2 patients suffered from biochemical fistula, the postoperative follow-up time was (7±2) months, and there was no recurrence during the follow-up period. ConclusionThe uncinate-process-first SMA right posterior approach is a safe and feasible surgical approach, especially for tumors with no obvious vascular invasion and diameter ≤2 cm.
ObjectiveTo discuss application of " counter clockwise resection” in total laparoscopic pan-creaticoduodenectomy (TLPD) and summarize it’s preliminary experiences.MethodThe clinical data of consecutive 8 patients underwent TLPD in the Department of Pancreatic Surgery, Affiliated Shengjing Hospital of China Medical University from July 2016 to January 2017 were analyzed retrospectively.ResultsThere were 3 males and 5 females in these 8 patients. The age was (64.13±15.01) years. The results of postoperative pathology included 1 duodenal cancer, 2 distal biliary tract cancers, 4 pancreatic head cancers, and 1 solid pseudopapillary tumor of pancreatic head. All the 8 patients were performed with TLPD successfully, and the time of the operation was (527.50±69.44) min, the resection time of the specimen was (241.25±38.71) min, and the blood loss was (368.75±162.43) mL, the postoperative hospitalization stay was (18.67±4.00) d. There were no postoperative bleeding, perioperative death, and delayed gastric emptying．Four patients suffered from the pancreatic fistula including 3 cases of grade A and 1 case of grade B pancreatic fistulas, and 1 case suffered from the intra-abdominal infection, who were cured after the conservative treatment. All the patients were following-up, and there was no abnormality.ConclusionPreliminary results of limited cases in this study show that " counter clockwise resection” might be a safe, effective, and easy method of TLPD, but further research is need to study.
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 investigate the advantage of superior mesenteric artery approach in laparoscopic pancreaticoduodenectomy (LPD) combined with superior mesenteric vein (SMV)-portal vein (PV) resection and reconstruction. MethodThe operation process of a pancreatic head cancer patient with SMV-PV invasion admitted to the Second Affiliated Hospital of Chongqing Medical University in April 2022 was summarized. ResultsThe resection and reconstruction of SMV-PV during the LPD through the right posterior approach and anterior approach of superior mesenteric artery was completed successfully. The operation time was 7.5 h, the intraoperative blood loss was 200 mL, and the SMV-PV resection and reconstruction time was 20 min. The patient was discharged with a better health condition on the 9th day after operation. ConclusionFrom the operation process of this patient, the arterial priority approache is a safe and effective approach in the resection and reconstruction of SMV-PV during the LPD.
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 systematically evaluate the effect of different enteral nutrition timing on patients with pancreaticoduodenectomy.MethodsPubMed, Embase, The Cochrane Library, Web of Science, CBM, CNKI, WanFang Data, and VIP databases were searched to collect RCTs for nutritional support in pancreaticoduodenectomy patients. The search time was established until March 1 2019. After two independent investigators conducted literature screening, data extraction, and evaluation of the risk of bias in the included studies, a meta-metabolic analysis was performed using the R 3.5.3 software gemtc package, JAGS 3.4.0, and Revman software.ResultsA total of 8 RCTs were included, for a total of 825 patients. The results of reticular meta-analysis showed that there was no significant difference in the duration of hospitalization for patients with pancreaticoduodenectomy, between the enteral nutrition supported at different timing. The results of the ranking probability map suggested that preoperative enteral nutrition was a better option for supporting nutrition in patients with pancreaticoduodenectomy, secondly, timing to give was 24–48 hours after operation.ConclusionsAccording to the results of mesh meta-analysis and probabilistic ranking, the nutritional status of patients is corrected before surgery, and the effect of enteral nutrition is better than other nutritional support methods. Secondly, enteral nutrition should be given at 24–48 hours after operation in combination with ESPEN and ERAS recommendations.