A total of 14 patients were successfully treated with laparoscopic pancreas duodenum resection. There were 10 cases of complete laparoscopic digestive tract reconstruction. The other 4 cases received open digestive tract reconstruction via a small incision in the middle epigastric site to shorten the operation time due to poor general condition.
The operative details and postoperative outcomes are summarized in Table 2. The surgical time was 6 to 12.5 hours, and the average was 7.5 hours. The surgical time for the first 5 cases was longer (7.0–12.5 hours) than the latter 9 cases (6–8 hours). The intraoperative hemorrhage was 230 mL to 650 mL, and the average was 310 mL. In 6 cases, intraoperative blood transfusions were given. The patients were aerofluxus in 3 to 5 days postoperatively, and the average was 4.5 days. After aerofluxus the nasogastric tube was removed, the patients were given a liquid diet. The average postoperative eating time was 5 days (4–8 days).
The incidence of perioperative complications was 14.2% (2/14). One case developed a pancreatic fistula and was discharged with a drainage tube after adequate drainage. The patient recovered 2 months later after the drainage tube was withdrawn. The other patient had postoperative bile leakage. The initial leakage was approximately 50 mL daily; 7 days later, the leakage stopped. The other patient was discharged after drainage tube withdrawal. The length of postoperative stay was 10 to 15 days, and the average was 12.6 days. There were no cases of gastric emptying disorder, postoperative hemorrhage, or perioperative death. The postoperative pathological examinations showed 7 cases of periampullary carcinoma, 2 cases of carcinoma of the lower segment of the common bile duct, and 5 cases of early pancreatic head carcinoma. The average postoperative pathologic lymphatic detection was 12.2 (9–16). There were 13 cases of R0 resection. One case of pancreatic head carcinoma received an R1 resection based on postoperative pathological examination.
All 14 cases had postoperative periodic follow-up, and the average follow-up was 5.5 months (2–16 months). There was a retroperitoneal lymph node metastasis found in 1 case of pancreatic cancer 6 months after surgery. The patient survived for 10 months. There were no other patient deaths during follow-up.
Compared with traditional surgery, laparoscopic surgery offers advantages of rapid recovery, fewer trauma, less hemorrhage, and shorter hospitalization.5 However, the development of laparoscopic surgery has been slow.6,7 The difficulty of adopting laparoscopic pancreatic surgery is possibly due to the complexity of the pancreatic-duodenal anatomical structure. Also, the perfect performance of digestive tract reconstruction requires a skilled laparoscopic suture technique and substantial experiences, which serves as one of the important aims of this study. In this study, we achieved successful LPD experiences in 14 patients with minimized complication rates with several important aspects to be considered for completing pancreatic duodenal laparoscopic resection.
The first aspect is patient selection. In our study, there were 14 cases, and 7 cases were periampullary carcinoma. There were also 2 cases with carcinoma of the lower segment of the common bile duct. The remaining 5 cases were early pancreatic head carcinoma. For the first 2 cases, the dilation to the bile duct and pancreatic duct was obvious because of early jaundice. The confirmation with preoperative pathological examination and the laparoscopic resection with digestive tract reconstruction was relatively easy in those cases. For the patients with pancreatic head cancer, it was difficult to make an early diagnosis because of the invasion into surrounding tissues, and potential distant metastases. Also, the dilation of the bile duct and pancreatic duct was not obvious. A mass >3 cm was difficult to remove, and the digestive tract reconstruction was therefore more complex. Thus, our experiences suggested that laparoscopic pancreatic duodenal resection is more suitable for periampullary cancer, lower bile duct cancer, and pancreatic head carcinoma with a mass <3 cm. This view is also consistent with other researchers.8
With respect to the surgical approach, our experiences suggested that cutting the gastrocolic ligament to expose the lower edge of the pancreas and the SMV and then separating the portal vein is beneficial for determining whether the tumor can be removed. In this study, an extension Kocher incision was used on the horizontal part of the duodenum, and the site behind the duodenum and pancreas uncinatus was fully freed. The hepatoduodenal ligament lymph nodes were clear, and the common bile duct was freed (the bile duct was not cut). After the distal stomach was cut, the pancreas neck was cut along the SMV and portal vein (with care taken to find and mark the pancreatic duct). After the jejunum was cut, it was pulled to the right behind the mesenteric vessel. The pancreatic head was pulled to the upper right, and the pancreas uncinatus was resected from the bottom up to the lower common bile duct. The hepatoduodenal ligament lymph nodes were cleared after resection of the gallbladder. The common bile duct was cut to excise the whole piece of the gallbladder. There are some important suggestions for this surgery from the authors. First, be gentle. Excessive pull may cause venous branch tearing, and the surgery will not be able to proceed due to obstructed visual fields. Second, the coarser vascular branch should be blocked with biological clamps, and 5 mm small biological clamps are preferred because they are convenient and flexible. Third, the resection of pancreas uncinatus should be complete; avoid damaging the superior mesenteric artery.9
Useful and substantial experience was obtained in reconstructing the digestive tract. First, in the pancreatic duct-jejunum end-side anastomosis, the jejunum openings should be close to the front bowel wall and should be sutured with 4-0 Prolene line to protect the pancreas from damage. A supporting tube is necessary for assisting the mucous membrane suture. Second, in the bile duct-jejunum anastomosis, the jejunum opening is close to the front of the duct. Thus, stitching of the back wall should be performed from left to right. After knotting on the right side, the anterior wall should be sutured from right to left. Third, compared with the stomach posterior wall, the gastric anterior wall-jejunum anastomosis with Endo-GIA is simple. Suturing anastomosis with a barbed line is safe and fast.10,11 Adding a Braun anastomosis can effectively prevent bile reflux and anastomotic fistula.
By minimizing surgical complication incidences, patient rehabilitation is improved, which is the primary goal of the surgeon. Among our 14 cases, there were only 2 postoperative complications, which is significantly fewer than previous reports.6 The following reasons could be responsible for the low complication rates. First, the case selection was performed relatively cautiously, and the patients had early cancer and acceptable general health. Second, we performed meticulous operative technique to minimize the unnecessary damage and accidental hemorrhage. The digestive tract reconstruction method was especially important. High-quality stitching and a skilled laparoscopic suture technique avoided the occurrence of postoperative anastomotic fistulas. The percentage of complications after open pancreas duodenum resection, such as total postoperative complications, pancreatic fistula, biliary leakage, anastomotic leakage and abdominal infection, gastrointestinal emptying dysfunction, and anastomotic hemorrhage, was not significantly different from the complications after LPD.3
In conclusion, we demonstrated that LPD could achieve similar perioperative outcomes as open surgery for patients with early pancreas head cancer, distal bile duct carcinoma, periampullary adenocarcinoma, and duodenal cancer. In addition, patients may potentially suffer from fewer trauma, and result shorter healing time. Furthermore, the surgical complications such as incision bleeding and infection can be minimized, and the postoperative recovery could be fast. This procedure does require technical skills to ensure good results as described in this article, but it is applicable and proficiency can be achieved with a short learning curve following our experience.
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Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. Health, Inc. All rights reserved.
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