Local excision of duodenal papilla tumor

Local resection of duodenal papillary tumor for surgical treatment of duodenal tumors. The traditional operation for duodenal papillary tumors is pancreaticoduodenectomy (Whipple surgery). For patients with severe disease (jaundice), high age or general condition, it is difficult to tolerate such major surgery, and biliary anastomosis is performed to relieve biliary obstruction. In the literature, local tumor resection is also used to treat duodenal papilla. Tumors, but for various reasons, failed to promote. In the past, the incidence of benign tumors in the duodenal papilla was considered to be very low. This may be due to the fact that the tumor rarely shows symptoms in the benign stage, and often cannot be diagnosed. It grows more rapidly after being converted into a malignant tumor, and is prone to obstruction of the common bile duct. It is possible to get a diagnosis. The adenoma from the stomach and large intestine can be developed into a phenomenon of adenocarcinoma. Many cancers of the duodenal papilla may also be transformed from benign adenoma. Due to the development of modern examination methods, especially B-mode ultrasound examination can detect the expansion of the common bile duct earlier and even before the clinical appearance of jaundice, the expansion of the common bile duct can be measured, fiber duodenoscopy can be The lesions of the duodenal papilla were observed directly, and a biopsy was performed to clarify the nature of the lesion. Therefore, it is possible to find more benign tumors of the duodenal papilla and early detection of cancer of the duodenal papilla. All benign tumors and some of the earlier cancers can be resolved with a partial resection of the duodenal papilla. This surgery is small in trauma, can remove the primary tumor, relieve the obstruction of the bile duct and pancreatic duct, safe and effective, less complications, but the operation can not remove the metastatic lymph nodes, the radical treatment is limited, and the current attitude of the surgery is not One. Treatment of diseases: duodenal adenocarcinoma, benign tumor of duodenum Indication 1. Duodenal papilla, including benign tumors at the end of the common bile duct. 2. Duodenal papilla, including cancer at the end of the common bile duct. 3, advanced age or body conditions are not allowed to do the pancreaticoduodenectomy for the duodenal papillary cancer. Contraindications 1, duodenal papillary carcinoma has been more advanced, has invaded the duodenal wall or pancreatic head tissue, local can not cut the original tumor. 2, pancreatic head cancer or high-level cholangiocarcinoma, is not the scope of this surgical treatment. Preoperative preparation 1, B-mode ultrasound detection and fiber duodenal microscopy and biopsy should be performed before surgery, and the location and nature of the lesions should be clearly judged. 2, in addition to the general body examination, the focus on the liver and kidney function has a more accurate assessment. 3, vitamin K11 supplementation, so that prothrombin activity can reach the normal range. 4. If there is no biliary infection, you do not need to use antibiotics in advance, you can give antibiotics on the morning of surgery. 5. Place the nasogastric tube on the morning of the operation. Surgical procedure 1. The oblique incision is made in the right upper abdomen of the incision, and the lateral side is anterior to the anterior line, and the medial side can be slightly crossed. The advantage of this incision is that it is well exposed. Although it is necessary to cut off the muscle groups of the abdominal wall, there is little incision in the postoperative incision. There is no small intestine under this incision, so there are few complications such as postoperative adhesive intestinal obstruction. The incision is superior. 2, first do a comprehensive exploration to understand whether the liver has metastatic nodules, along the liver and duodenal ligaments without swollen lymph nodes, touch the size and extent of the duodenal papilla. 3, a Kocher incision outside the duodenum, incision of the peritoneum, free duodenal descending segment, can further reduce the duodenal descending segment and the head of the pancreas between the thumb and other four fingers to touch the size of the tumor And scope. 4, dissect the free common bile duct, under the gallbladder tube into the common bile duct, as close as possible to the upper edge of the duodenum, in the anterior wall of the common bile duct, two needles of the traction line, cut the common bile duct about 1cm, with metal urethra The probe is inserted into the incision of the common bile duct and is directed down to the opening of the duodenal papilla. 5, in the duodenal nipple opposite the front outer wall of the duodenum, make a longitudinal incision, cut the duodenal wall, expose the whole picture of the duodenal papillary tumor. 6. Cut the duodenum and the anterior wall of the lower end of the common bile duct at the duodenal wall 1.5 to 2.0 cm from the upper edge of the tumor. The incision can be seen after the incision. The proximal margin of the incision duodenal wall and the proximal edge of the incision of the anterior wall of the common bile duct were intermittently sutured with a 3-0 absorbable synthetic line, and the distal side of the duodenal incision margin was The common bile duct cutting edge is also used for intermittent sutures. 7, respectively, inward and outward, around the base of the tumor 1.5 ~ 2.0cm, while cutting, while doing intermittent suture until the tumor is completely removed, when cutting to the inner and lower, can cut the end of the pancreatic duct, the pancreatic duct and twelve Refers to the suture of the intestine wall for several needles, and the suture between the pancreatic duct and the common bile duct wall is also sutured several times. 8. A T-shaped tube is pierced with a thick needle 5 to 6 cm in front of the end of its long arm, and a 2 mm diameter silicone tube is inserted through the pinhole until its distal end exceeds a short arm of the T-shaped tube. 7 to 8 cm, the V-shaped side of the short arm was cut 0.5 cm, and the silicone tube was placed in the slit. 9. Insert the above T-shaped tube from the incision of the anterior wall of the common bile duct, and place the lower short wall together with the silicone tube to the anastomosis of the duodenum and the common bile duct, and insert the silicone tube into the pancreatic duct. A fixed suture is made with an absorbable wire, and the other short arm is cut short and placed upward in the common bile duct. 10. Intermittently incision of the common bile duct with silk thread. 11. The anterior wall of the duodenum, which is cut into two layers, is used to make a transverse interrupted inversion of the anterior wall of the duodenum. Before the anastomosis, the duodenal descending section should be fully freed to reduce the tension of the duodenal incision. 12. The T-shaped tube and the silicone tube are taken out from the outer wall of the abdominal wall and fixed with a suture. 13. After flushing the field, place one cigarette or latex drainage tube on the outside of the duodenum and the liver, or place a double-chamber negative pressure drainage tube, which is led out from the outer end of the transverse incision or another incision. Stitching. complication Local excision of duodenal papillary tumor is small, safe, and rarely complication. When the anastomotic stoma of the common bile duct wall is poorly hemostasis, a small amount of bleeding may occur after surgery. A general hemostatic agent may be used. Control, if necessary, under the direct view of the fiber duodenoscope, electrocautery or spray hemostatic agent to stop bleeding. The suture of the anterior wall of the duodenum should not be leaked. In the case of poor nutritional status and hypoproteinemia, the gastrointestinal decompression time should be prolonged after surgery, the feeding time should be postponed, and intravenous nutrition therapy should be given. The anastomosis is not well healed and leaks.