Duodenum-preserving pancreatic head resection (DPPHR) is a widely accepted procedure for treating benign and premalignant pancreatic head lesions. The crucial goal is to find the lower common bile duct (CBD) and preserve the blood supply to the duodenum and lower CBD. Recently, indocyanine green (ICG) has been applied to assess blood supply and anastomosis leakage during biliary system and liver-segment surgery. However, ICG fluorescence navigation in DPPHR has not been precisely established. Herein, we report an intraoperative angiography technique using ICG fluorescence imaging to visualise blood flow, tissue perfusion, CBD navigation and bile leakage assessment.
A 36-year-old female presented with recurrent episodes of abdominal pain for about 2 months. She had a history of diabetes for 4 years. The enhanced magnetic resonance imaging scan revealed pancreatic atrophy and dilated pancreatic duct containing multiple stones, of which the largest was about 13 mm × 25 mm in size [Figure 1]. A diagnosis of chronic pancreatitis with pancreatic duct stones was made.
A laparoscopic DPPHR (LDPPHR) and pancreatolithotomy with Roux-en-Y side-to-side pancreaticojejunostomy were performed. The ICG was used as follows: 5 mg (2.5 mg/mL) was administered intravenously 1 h before the operation (the first injection). Every 5 mg was injected intermittently during the operation if needed.
Five trocars were positioned in a V-shape [Figure 2]. The gastroduodenal artery was identified and the anterior superior pancreaticoduodenal artery (ASPDA) was dissected. Next, the pancreatic parenchyma was dissected 0.5 cm from the left edge of the duodenum. One hour and 45 min after the first injection of ICG, the CBD could not be clearly seen under the fluorescence endoscope.
The Henle's gastrocolic trunk was cut off and superior mesenteric vein (SMV) was explored and the pancreas was transected along the SMV. The pancreatic parenchyma was gradually dissected 0.5 cm from the inner side of the duodenum. During the discontinuation, ICG was injected intermittently. In addition, we found that every 4 min after injection, the anterior inferior pancreaticoduodenal artery (AIPDA) and posterior inferior pancreaticoduodenal artery (PIPDA) could be developed clearly, and the branches of the duodenum could also be clearly shown [Figure 3].
Three hours after the first injection (2 h after operation), the CBD could be clearly seen under the fluorescence endoscope, the pancreatic parenchyma was carefully disconnected along the CBD and the posterior superior pancreaticoduodenal artery (PSPDA) could be identified under fluoroscopy after interval injections [Figure 4]. The main pancreatic duct was cut off at the left side of the ampulla. At this point, the specimen was completely dissected, and ICG was injected again to verify the blood supply to the bile duct and duodenum [Figure 5a and b]. Under fluorescence, part of the CBD was thin and was reinforced with 5-0 Prolene sutures [Figure 5c].
The distal pancreatic duct was opened 6 cm longitudinally and the stones were removed. A Roux-en-Y pancreaticojejunostomy was performed using a continuous suture made by a 3-0 Knotless Tissue Control Device (STRATAFIX Spiral PGA-PCL).
The operation time was 255 min, and the blood loss was 325 mL. ICG was injected four times: 1 h pre-operatively and three times intraoperatively. Post-operative recovery was uneventful and no post-operative pancreatic fistula or bile duct leakage was found. The patient was discharged on post-operative day 7. During the follow-up, no ischaemic biliary stricture or reoccurrence of pancreatic duct stones was found.
DPPHR was first reported by Beger to deal with chronic pancreatitis. It has gradually been accepted for the treatment of benign or borderline tumours of the pancreatic head. The key point of this procedure is to preserve the blood supply to the duodenum and pancreatic bile duct. Skilled surgeons can use their hands to palpate the pulse of arteries during a traditional laparotomy. However, during LDPPHR, the lack of manual palpation of the arteries makes the procedures more difficult, despite the magnification capabilities of the laparoscopy.
ICG fluorescence is a simple, relatively inexpensive and harmless navigation used in several surgical procedures. In recent years, it has been widely applied in visceral, hepatobiliary and pancreatic surgeries, such as vascular or digestive anastomosis stump, liver resection and biliary bile duct identification during difficult cholecystectomies. Herein, we reported the application of ICG navigation to the LDPPHR and achieved good results. In our case, the CBD was not imaged until 3 h after the first injection. We recommend the injection of ICG be carried out on the first night or 4 h before surgery to obtain a good image of the CBD.
Bile leakage was reported to occur in about 16.7% of LDPPHR. Under ICG imaging, bile leakage could be easily identified. In this case, under fluorescence, part of the CBD wall accessed too thin and was reinforced with 5-0 Prolene sutures and no bile leakage occurred post-operatively. Another difficulty of LDPPHR is to preserve the blood supply of the duodenum, especially the vascular arcades of the PIPDA/PSPDA and AIPDA/ASPDA. In our surgery, the branches of these blood vessels could be clearly displayed 4 min after intermittent injections. This helped us to assess the blood supply of the duodenum after pancreatic head removal, thus avoiding the risk of ischaemic stenosis.
Our case revealed that ICG real-time navigation was a good method during LDPPHR. However, there are also some details that should be discussed and improved in the future applications. For example, further studies are needed to evaluate the optimal timing of the first ICG injection to best visualise the CBD.
This study obeyed the principles of the 1983 Declaration of Helsinki and was approved by the Institutional Ethics Committee of Zhejiang Provincial People's Hospital.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
This study was supported by grants from the Health and Family Planning Commission of Zhejiang Province (2021KY030).
Conflicts of interest
There are no conflicts of interest.
We thank LetPub (www.letpub.com) for its linguistic assistance during the preparation of this manuscript.
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