regional pancreatectomy

Since Whipple first reported pancreaticoduodenectomy in 1935, this procedure became the treatment of early pancreatic head cancer, lower common bile duct cancer, peripheral ampullary carcinoma, duodenal cancer, and other tumors in this area. Classic surgery. The initial mortality and complication rate are high. After several decades of improvement, the surgical mortality and complication rate have been greatly reduced. The current surgical mortality rate has been <10%, even domestic and foreign. Some reported that the surgical mortality rate has dropped to zero. However, due to the location of the lower end of the common bile duct, the pancreas and the duodenum, the operation cannot be treated according to the principle of surgical resection of malignant tumors, that is, the whole tumor is removed and its adjacent tissues and regional lymphatic drainage, so in pancreatic cancer and progression In patients with periampullary cancer, it is often found in surgically resected specimens that the cancer cells have gone beyond the scope of resection, and the residual cancer foci will recur or metastasize. Therefore, there are very few patients who can achieve 5 years after surgery. . Another anatomical feature is that the superior mesenteric vein and portal vein are surrounded by the pancreas in three directions, and the relationship between them is close to each other. Therefore, more than one third of patients with pancreatic cancer have cancer invasion at the early stage, and the general opinion is that the portal vein is violated. A sign that cannot be surgically removed. However, due to the accumulation of experience, if only the portal vein-superior mesenteric vein is locally affected, the surgical risk of pancreaticoduodenectomy including partial portal vein is not higher than that of the classic Whipple procedure. However, the portal vein is not increased. effect. In order to improve the surgical resection rate of pancreatic cancer and expand the extent of the entire resected pancreas and include its draining lymphoid tissue, Fortner proposed the concept and surgical method of "regional pancreatectomy" in 1973, which was used in 1983. For the treatment of 56 patients. According to Fortner's opinion, the posterior peritoneal space after the pancreas is the path of lymphatic drainage from the pancreas to the periorbital aorta and lymph nodes around the celiac artery, and is called the lymphatic basin after the pancreas. The gut resection of the pancreas and duodenum is through this lymphatic area, which violates the principle of surgical treatment. Fortner surgery is to remove the renal fascia (Gerota fascia) to clear the lymphatic tissue before the inferior vena cava, abdominal aorta, renal blood vessels, and make the bile duct, portal vein, hepatic artery, inferior vena cava, renal vein, superior mesenteric artery, celiac artery The blood vessels reach "skeletalization". Another important point is to remove the superior mesenteric vein and portal vein of the pancreatic segment along with the pancreas instead of separating the portal vein from the pancreas. Therefore, reconstruction of the portal vein is required; sometimes if the superior mesenteric artery or the right hepatic artery originating from the ectopic origin is involved It is also necessary to perform partial resection and reconstruction of the artery at the same time. In Fortoff's 56 patients with malignant tumors and 5 benign lesions, 37 patients underwent surgery before 1979, with a surgical mortality rate of 32% and a complication rate of 76%. After 1979, 24 patients had a morbidity rate of 8%. The complication rate was 55%. With this surgical method, the surgical resection rate can be increased to 30%, but the treatment results of pancreatic ductal carcinoma have not been significantly improved. By the time of reporting, only 20% of cases still survive, the longest is 18 months after surgery. . Therefore, there is still controversy about this surgical method. It was not accepted by most surgeons and was once indifferent. However, some Japanese scholars have advocated an enlarged pancreatic cancer radical surgery to achieve better results than the classic Whipple surgery. Treating diseases: pancreatic cancer Indication Regional pancreatectomy is available for: 1. Pancreatic ductal carcinoma. 2. Local infiltration of pancreatic cancer or local lymph node metastasis is still in the resectable range. 3. The patient's condition can withstand major surgery. Contraindications 1. Early ampullary periampullary carcinoma and pancreatic head cancer are suitable for patients with typical Whipple surgery. 2. Local invasion or lymph node metastasis has exceeded the scope of radical resection. 3. The patient's condition cannot withstand major surgery. Preoperative preparation 1. Examination of vital organs such as heart, lung, liver and kidney. 2. Chest X-ray to exclude metastatic lesions. 3. Inject vitamin K to increase prothrombin activity. 4. Correct the electrolyte imbalances such as low potassium and low sodium. 5. For those who have obvious malnutrition due to too little food intake, intravenous nutrition is added 1 week before surgery to transfer whole blood and plasma to correct anemia and hypoproteinemia. 6. For patients with obstructive jaundice, oral bile salt preparations 1 week before surgery to reduce bacterial growth in the intestine. 7. Serve ranitidine 150mg before surgery to reduce stomach acid. 8. Apply prophylactic antibiotics. 9. Patients with serum bilirubin >171mol/L, the physical condition is still suitable for the operator, do not emphasize the routine use of preoperative transhepatic biliary drainage (PTBD) to reduce jaundice, if PTBD has been done, special attention should be paid to Electrolyte disorders caused by loss of bile, usually performed 2 to 3 weeks after drainage, to prevent biliary infection caused by PTBD. Percutaneous transhepatic gallbladder drainage can also achieve the same goal. In the case of the condition, it is feasible to introduce the drainage through the endoscope before the operation, and insert a thicker special built-in drainage tube through the common bile duct opening to the upper of the obstruction, so that the patient's condition can be improved quickly. 10. Place the gastrointestinal decompression tube before surgery. Surgical procedure According to Fortner's experience, the procedure consists of five steps, and the surgery is divided into type I and type II based on whether the superior mesenteric artery is removed and reconstructed: 1. Regional pancreatectomy type I (1) Step 1 1 Intraperitoneal exploration, starting with a bilateral oblique inferior oblique incision, left to the outer edge of the rectus abdominis, right to the right anterior line, cut the abdominal wall muscle into the abdominal cavity for exploration. The pancreas is not first explored, but mainly the adjacent organs and peritoneal cavity are examined to understand the possibility of radical resection. Care should be taken to check for metastatic nodules in the liver, to check for peritoneal and pelvic peritoneal tumors; to check for lymph node metastasis around the hilar and celiac artery; to examine adjacent aortic lymph nodes, especially the para-aortic lymph nodes at the Treitz ligament Check the presence or absence of tumor invasion in the small mesentery, as well as the condition of the mesenteric vessels, the location and path of the right hepatic artery, and whether it is appropriate to perform vascular repair after resection. Finally, gently check the pancreatic cancer itself. After the decision to perform regional pancreatectomy, the left abdominal incision was extended to the left anterior line, and the incision margin was sutured with a sterile towel. 2 The transverse omentum to the middle of the transverse colon is attached to the greater omentum, and the peritoneum of the transverse mesenteric membrane is separated from the peritoneal to transverse mesenteric vascular arch; the hepatic colon ligament is incised, and the right colon is turned inward and downward. The right kidney, the second and third segments of the duodenum, and the front of the pancreatic head are revealed. Cut the peritoneum covering the front of the middle of the kidney, deep down to the renal fascia (Gerota fascia), separating the soft tissue to the inside, separating the soft tissue from the kidney, renal blood vessels, ureters, inferior vena cava, ligation and excision The genital vein (male is the right varicocele; the female is the right ovarian vein), continues to be separated to the medial side, clearing the fat and lymphatic tissue in front of the inferior vena cava and the abdominal aorta and between the two, down to the inferior mesenteric artery; On the left side, the left renal vein, the left margin of the inferior vena cava, and the fat and lymphatic tissue in front of the left side of the abdominal aorta were removed until the lower edge of the liver. At this time, the operator can use the left hand 4 fingers to reach the back of the pancreas, and the thumb is in front to check the condition of the pancreas and its mass. (2) Step 2 1 The gallbladder is released from the liver bed from the bottom. After all the free, the cystic duct is still connected with the common bile duct. It is not cut off, the lymph and soft tissues on the right side of the common hepatic duct are cut off, and the hepatic duct is cut at 2.0 cm below the bifurcation. The upper end is clamped with a "pug" clamp to prevent bile spillage; continue to separate to the medial side, so that the portal vein and the proper hepatic artery are "skeletalized", cut off the lymphatic and soft tissues inside the hepatoduodenal ligament, and properly preserve the proper hepatic artery and In the common hepatic artery, the hepatic portal tissue is pushed downwards in addition to the hepatic artery and the portal vein. 2 Incision of the peritoneum and loose tissue in front of the common hepatic artery, separating the common hepatic artery, the proper hepatic artery, and the gastroduodenal artery above the head of the pancreas, separating the gastroduodenal artery and pulling it with a silk thread. The distal end is separated until there is sufficient length, the proximal end is ligated with double wire, the distal clamp is clamped, and the suture is cut after cutting. The proximal end should have a length of about 0.5 cm, and should not be too close to the common hepatic artery; The common artery is separated upwards until it meets the celiac artery. There are usually some lymph nodes on the upper edge of the head of the pancreas. When separating, you should avoid cutting the lymph nodes directly and separating them in the gap between the lymph nodes. (3) Step 3 1 Pull the small intestine downward to make the small mesentery stretch, and then lift the transverse colon, and pull the transverse mesenteric membrane. At the root of the small mesentery, according to the position of the arterial pulsation, the peritoneum and its surrounding lymphoid adipose tissue are cut to find the superior mesenteric artery. . The soft tissue and lymph nodes cut here must be properly ligated to prevent lymphatic leakage after surgery. On the right side of the superior mesenteric artery is the superior mesenteric vein, which should be carefully separated from the surrounding tissue, cut and ligated to the lymphatic vessels around it, and the jejunal vein branch of the superior mesenteric vein and the superior mesenteric vein are separated to the pancreas. The margin generally requires a distance of 3 to 5 cm to facilitate subsequent vascular anastomosis. 2 Cut the omentum from the upper edge of the transverse colon to the transverse part of the spleen of the transverse colon, separate the anterior segment of the mesenteric ventricle to the lower edge of the pancreas, cut off the right colon, middle colon and left colon, and preserve the vascular arch on the mesentery. At this point, the transverse colon can be lowered to the lower abdomen. 3 lift the upper jejunum, cut the jejunum under the Treitz ligament, the distal suture is closed, the proximal end is ligated with silk, and pulled downward and to the right, cutting the Treitz ligament and the mesenteric vessels in the third and fourth segments of the duodenum. The proximal jejunum is pulled to the right abdomen through the posterior small mesentery, as in the case of pancreaticoduodenectomy. 4 After cutting the peritoneum and Treitz ligament to the lower edge of the pancreas, ligation and cutting of the inferior mesenteric vein, the incision and the original retroperitoneal dissociation, and continue to separate upward to the left renal vein. The tissue and lymphatic vessels cut off during retroperitoneal separation should be properly ligated to prevent lymphatic leakage after surgery. 5 cut the body of the stomach like pancreaticoduodenectomy. 6 cut the pancreas. The scope of pancreatic resection should be based on the location of pancreatic cancer. Generally, it requires 4 cm of normal pancreatic tissue from the edge of the tumor. Therefore, in the head cancer of the pancreas, the pancreas is usually cut at the upper edge of the splenic artery and the pancreas; By removing some of the pancreas, the splenic artery can be separated from the pancreas, the pancreas is cut, and at least about 5 cm of the tail of the pancreas is retained. Due to the need to cut the splenic vein and the gastric coronary vein during surgery, preservation of the splenic artery can cause acute congestion and swelling of the spleen. The spleen blood reflux disorder can cause left portal vein hypertension and gastric varices bleeding. We advocate that the splenic artery should be cut at the same time. If a pancreatectomy is required, the spleen, along with the tail of the pancreas, is detached to the right, as is a pancreaticoduodenectomy. (4) Step 4 1 The operator moves to the left side of the patient, continues to separate the left and the front of the abdominal aorta, removes the soft tissue between the superior mesenteric artery and the abdominal aorta, and cuts the outer sheath of the superior mesenteric artery to completely dissociate it. At this time, care must be taken to separate and cut off the pancreaticoduodenal artery from the superior mesenteric artery. This artery may have more than one branch. At this point, the superior mesenteric artery is separated from the pancreas. 2 The separation around the abdominal aorta continues upward and to the right until the junction of the celiac artery and the abdominal aorta and completely removes the lymphatic tissue surrounding the celiac artery, and merges with the isolated surface of the retroperitoneum at the beginning. At this point, the pancreas is completely freed from the retroperitoneum, leaving only the portal vein and superior mesenteric vein to connect with the body. (5) Step 5 1 The non-invasive vascular clamp was used to block and cut the portal vein and superior mesenteric vein at the upper and lower edges of the pancreas, and the whole specimen was removed. The small intestine and small mesentery were pushed up by the assistant, and the 5-0 vascular suture was used to make the opposite end of the portal vein and the superior mesenteric vein. There is no tension in the vascular anastomosis. It is necessary to pay attention to the alignment of the blood vessel axis to avoid the occurrence of torsion, and the anastomosis must be detailed and not leaking. 2 Lifting the upper end of the jejunum and performing end-to-side anastomosis of the jejunal pancreatic duct. The method of pancreatic duct jejunostomy during typical Whipple pancreaticoduodenectomy can also be used. The method suggested by Fortner can also be used. The Fortner method is to suture the posterior edge of the pancreatic stump and the jejunum to the mesenteric margin as the posterior layer of the anastomosis; the jejunum is cut, and the posterior wall of the pancreatic duct and the jejunal wall are sutured with a few needles. Then, the anterior wall of the pancreatic duct is sutured with the other side of the jejunal incision, and after the knotting, the mucosa of the pancreatic duct and the jejunum is anastomosed to the mucosa, and a support catheter can be placed in the pancreatic duct. Then, a few needles were sewed in the anterior pancreas of the pancreas and the jejunum wall about 1.5 to 2.0 cm from the margin of the pancreas. After sewing, the two were closed and the suture was knotted. As a result, the broken end of the pancreas is inserted into the jejunal cavity, and the pancreas and the jejunum are nested and reinforced. 3 lines of bile duct jejunal end-to-side anastomosis, and finally do gastric jejunal end-to-side anastomosis, the same method as "1.12.6.1 Whipple surgery." 4 sew the gap between the mesangium in the abdominal cavity. Drainage was placed in the left and right sides of the abdominal cavity. 2. Regional pancreatectomy type II This procedure is based on the removal and reconstruction of the arteries on the basis of type I: (1) Sometimes the right hepatic artery ectopic originates from the superior mesenteric artery, passes close to the back of the pancreatic head, and passes through the right side of the portal vein to the hilar part. This ectopic artery is often involved in pancreatic head cancer, and because of its position In the range of lymphoid tissue behind the head of the pancreas, it is not suitable to free and preserve it. Therefore, the right hepatic artery can be removed at the time of operation. After the repair of the portal vein is completed, the anastomosis of the artery is repaired. (2) In the case of a local invasion of the superior mesenteric artery, it is necessary to consider the removal of a superior mesenteric artery. After the superior mesenteric artery, an artery branch of the upper jejunum can be found and placed in a perfusion catheter to cool the heparin. The small intestine is perfused, as in the case of small bowel transplantation, and then the affected vessel is removed, and the opposite end of the superior mesenteric artery is re-synchronized. In addition, there is regional pancreatectomy, which is to preserve the superior mesenteric artery and portal vein. At this time, the tumor is mostly early, so it is generally considered that this type of surgery is not necessary. complication There are high postoperative complications and operative mortality after regional pancreatectomy. Some complications eventually lead to death. The main complications are: 1. Pulmonary complications such as acute respiratory distress syndrome (ARDS), atelectasis, pneumonia, pleural effusion, and respiratory exchange disorders. 2. Shock, hypotension, heart failure, arrhythmia. 3. Infections include sepsis, wound infection, intra-abdominal abscess, peritonitis, fungal infections. 4. Gastrointestinal bleeding and intra-abdominal bleeding. 5. Pancreatic fistula, biliary fistula, gastrointestinal anastomotic leakage. 6. Multiple organ failure. 7. Peptic ulcer is more common after regional pancreatectomy than general pancreaticoduodenectomy.