total pancreaticoduodenectomy

Total pancreaticoduodenectomy is suitable for pancreatic ductal carcinoma, total pancreatic involvement or multiple pancreatic lesions. Pancreatic cancer is still confined to the pancreas, and there is no extensive metastasis or mesenteric vascular invasion. Treating diseases: pancreatic cancer Indication Total pancreaticoduodenectomy is available for: 1. Pancreatic ductal carcinoma, total pancreatic involvement or multiple pancreatic lesions. 2. Pancreatic cancer is still confined to the pancreas without extensive metastasis or mesenteric vascular invasion. Contraindications 1. Advanced and extensive metastasis of pancreatic cancer is not an indication for total pancreaticoduodenectomy. 2. Unconditional long-term diabetes treatment after surgery. 3. Those who are over 70 years old or have important organ dysfunction should not be treated with 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 1. The original plan for the implementation of pancreaticoduodenectomy, the upper abdominal curved incision, from the right side of the 11th rib end through the mid-abdominal midpoint to the left 11th rib end, cut the abdominal wall muscles, sputum The ligamentous ligament and the round ligament of the liver, after retracting the upper edge of the incision, the upper abdomen and the left and right sides of the abdomen can be well exposed; if the right marginal oblique incision is used in the beginning of the exploration operation, it is decided to do the whole pancreatic 12 fingers. After bowel resection, it should be changed to bilateral oblique incision of the costal margin; if the incision is a right rectus abdominis incision, a transverse incision is required, which is above the umbilicus to the left of the 11th rib end. 2. The surgical procedure for understanding the extent of pancreatic tumors and their relationship with the superior mesenteric vessels and portal veins is the same as that of pancreaticoduodenectomy. Intraoperative cryosection pathology is often required in multiple parts of the pancreas. Generally speaking, if the pancreatic tail tissue is about 20% of the pancreas, the treatment of diabetes after surgery may not be as difficult as after pancreatectomy. 3. After deciding to perform total pancreatectomy, the gastric collateral ligament and the gastric spleen ligament were cut off, and the corpus corpus was cut at about 50% to 60% of the resected gastric tissue, and the double-sided suture of the proximal gastric small curved side of the stomach was closed. The blood vessels in the stomach wall are all under the submucosal suture to stop bleeding. The distal end of the stomach turns to the right. 4. Incision of the spleen and ligament and spleen and kidney ligament, the surgeon with the right hand to free the spleen and the body of the pancreas to the front and turn to the right, cut the blood vessels of the gastric spleen ligament, and gradually turn the spleen and pancreas to the right Reveal the back of the spleen. Since the spleen is generally not swollen and there is no huge mass in the tail of the pancreas, it is not necessary to ligature the splenic artery in advance or pre-separate the body of the pancreas. The retroperitoneal anatomical space on the back of the pancreas is also easily identifiable. 5. Gradually clamp the peritoneum, fibrous adipose tissue, small blood vessels, and lymphatic vessels of the upper and lower margins of the pancreas, so that the pancreas and the spleen can be further turned to the right side. The upper edge of the pancreas reaches the spleen artery and the pancreas, under the pancreas. The margin of the inferior mesenteric vein is transferred into the splenic vein. If the confluence point of the inferior mesenteric vein is mutated, it can be separated to the junction of the splenic vein and the superior mesenteric vein. 6. When the splenic artery meets the upper edge of the pancreas, the splenic artery is isolated, and the splenic artery is cut at the distal side of the double-wire ligation, and the distal end is ligated or sutured with a silk thread; if the splenic artery is thick, or has atherosclerosis, When the spleen artery ligation can cause endometrial rupture and hemorrhage, it is better to use a 4-0 vascular suture to sew the broken end to control the blood flow. In elderly patients, atherosclerotic lesions are severe, and the splenic artery may break down when it is separated and clamped. It is very difficult to handle, so care should be taken to avoid such accidents. The splenic vein can generally be cut off at the distal side of the inferior mesenteric vein. The proximal end is closed with a vascular suture, and the distal end is ligated to stop bleeding. If the confluent point of the inferior mesenteric vein is mutated, a non-invasive vascular clamp can be used to clamp the mesentery. After the side wall of the vein, the splenic vein was cut, the opening was closed with a vascular needle thread, and the distal end was ligated. When cutting the splenic vein, in order to reduce the risk of bleeding due to accidental loosening of the vascular clamp, the method of cutting and suturing is used during the operation. 7. Separate the superior mesenteric vein and the gap between the front of the portal vein and the neck of the pancreas, and cut off the connection between the left front of the portal vein and the back of the pancreas. When both the splenic artery and the splenic vein have been severed, there is no important structure attached to the pancreas. The tail of the pancreas was turned to the right side together with the spleen, and the upper and lower veins of the pancreaticoduodenum and some small veins that directly flowed from the head of the pancreas and the uncinate process to the portal vein and superior mesenteric vein were ligated. 8. Cut the upper end of the jejunum and the uncinate process membrane to remove the spleen, pancreas and duodenum. The surgical procedure is the same as pancreaticoduodenectomy. 9. The method of gastrointestinal reconstruction is to use the end-to-side anastomosis of the jejunal jejunum and the end-to-side anastomosis of the jejunum. The distance between the two anastomosis is about 40 cm. The gap between the transverse mesenteric and the jejunum is closed, because the pancreas has been removed. , eliminating the pancreatic jejunostomy. Abdominal drainage was placed in the right hepatic area. The slit is layered. complication Complications after pancreaticoduodenectomy are still common and can occur early in the postoperative period or after discharge. 1. Intra-abdominal hemorrhage occurred within 24 to 48 hours after surgery, mainly due to insufficient hemostasis. For example, in the rupture of the mesenteric mesenteric membrane, the treatment of the pancreatic stump, intraoperative injury of the blood vessels, the gastro-intestinal artery, and the pancreaticoduodenal artery are not properly handled. In severe cases with complicated operation and long time, there is intravascular disseminated coagulation (DIC) and blood clotting material to consume bleeding on the wound surface. Coagulopathy and bleeding due to vitamin K deficiency are rare in pre-operative preparation. If the amount of early bleeding after surgery is too high to stop quickly, emergency measures should be taken to detect the hemostasis. It should be avoided because the treatment is not timely or the use of blood pressure-up drugs can cause the patient to be in shock or hypotension for a long time, otherwise, although Bleeding can stop, but patients may die from multiple organ failure. 2. Postoperative gastrointestinal bleeding is more common, can be derived from 1 gastrointestinal anastomotic bleeding; 2 stress ulcer, hemorrhagic gastritis; 3 anastomotic ulcer bleeding is rare; 4 from the pancreas or other blood vessels bleeding through Intestinal. In the case of postoperative upper gastrointestinal bleeding, a fiberoptic gastroscopy should be performed to find the source of the bleeding. If the amount of bleeding is too large to stop in time, hemostasis should be performed again. The author once encountered a case of a large amount of hemorrhage due to the collapse of the gastroduodenal artery and the formation of a pseudoaneurysm that broke into the jejunum. The patient was able to recover from the hepatic artery and the proper hepatic artery. When choledochal or pancreatic fistula is combined after surgery, bleeding may occur due to corrosion of adjacent blood vessels. For those who have difficulty in locating the source of the bleeding, an emergency angiography can be performed to understand the source of the bleeding and to immediately stop embolization. 3. Timid. 4. Gastrointestinal anastomosis. 5. Intra-abdominal infection, underarm abscess is often associated with anastomotic leakage. 6. Acute renal failure. 7. Liver failure. 8. Gastric retention, gastric emptying dysfunction. 9. Other complications such as cardiovascular complications, portal vein thrombosis and so on. 10. Late complications after pancreaticoduodenectomy may include 1 biliary anastomotic stenosis and obstructive jaundice; 2 anastomotic ulcer; 3 diabetes; 4 pancreatic exocrine dysfunction.