Typing and surgical treatment choice for pancreatic ductal stone / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the improvement of typing and reasonable surgical treatment for pancreatic ductal stone (PDS).</p><p><b>METHODS</b>Totally 89 patients with pancreatic ductul stone treated underwent surgeries from January 2000 to December 2012 were involved into this study. There were 57 male and 32 female patients, the average age was (52 ± 23) years. According to the magnetic resonance cholangiopancreatography imaging and finding during surgery, pancreatolithiasis was classified into three types: type I, the stones were located in the main pancreatic duct; type II, the stones were located both in main and branch pancreatic duct; type III, the stones were diffusely scattered in the branch pancreatic duct; the position of PDS within pancreatic parenchyma were subtitled. In this group, 43 type I PDS were extracted with endoscopic papillotomy or endoscopic pancreatic sphincterotomy, or pancreatolithotomy plus pancreato-jejunal lateral anastomosis with wide anastomotic stoma; 39 type II cases were treated by pancreatolithotomy plus pancreato-jejunal lateral anastomosis or/and resection of pancreatic section; 7 type III PDS were managed with resection of pancreatic section.</p><p><b>RESULTS</b>All surgeries were performed successfully. Among complications, 6 cases (6.7%) were pancreatic leakage which recovered after systematic non-surgical treatment, 2 cases (2.2%) were anastomotic bleeding which led to 1 death, 6 cases (6.7%) were residual pancreatolithiasis in branch pancreatic duct type. Seventy-eight patients were followed up for 6 to 131 months, 57 cases were still alive so far. Five cases were intermittent abdominal pain, 7 cases were diabetes resulted from 2 subtotal pancreatectomy and 5 distal pancreatectomy, 5 cases occurred pancreatolithiasis recurrence and 3 underwent secondary surgeries.</p><p><b>CONCLUSIONS</b>The basis of this modified typing of pancreatolithiasis is the position of stone in pancreatic duct rather than pancreas parenchyma. It is more important and valuable for surgical principle of taking stones out completely and maintaining pancreatic function.</p>

"Total arterial devascularization first" technique for resection of pancreatic head cancer during pancreaticoduodenectomy / 华中科技大学学报（医学）（英德文版）

Integrated resection of the pancreatic head is the most difficult step in radical pancreaticoduodenectomy (RPD) in patients with the portal vein (PV) and superior mesenteric vein (SMV) invasion or oppression by the tumor. This study introduced a new idea and skill named the "total arterial devascularization first" (TADF) technique and its applications in RPD. Three arterial blood supplies of pancreatic head were obstructed before dissection of veins. The critical steps included exposure of the anterior surface of the abdominal aorta (AA) by completely transecting neural and connective tissue between superior mesenteric artery (SMA) and pancreatic mesounsinate, and transection of the mesounsinate from the origin of SMA to the root of the celiac trunk. From January 2012 through May 2013, a total of 58 patients with PV/SMV invasion or oppression underwent RPD using this technique. The median operative time was 5.1 h (ranging 4.5-8.1 h). The median intraoperative blood loss was 450 mL (ranging 200-900 mL). No intraoperative and postoperative bleeding of pancreatic head region occurred. Among the 58 patients, 21 were subjected to vessel lateral wall angiectomy or angiorrhaphy, and 10 to angiectomy and end-to-end anastomosis. The incidence of postoperative bleeding, postoperative pancreatic fistula and biliary fistula was 5.2%, 6.8%, and 1.7%, respectively. No patients died 3 months after operation. The TADF technique is a new method for intricate RPD and could improve the security of surgery and reduce intraoperative bleeding, which is expected to become standardized surgical approach for RPD.

"Total arterial devascularization first" technique for resection of pancreatic head cancer during pancreaticoduodenectomy / 华中科技大学学报（医学）（英德文版）

Integrated resection of the pancreatic head is the most difficult step in radical pancreaticoduodenectomy (RPD) in patients with the portal vein (PV) and superior mesenteric vein (SMV) invasion or oppression by the tumor. This study introduced a new idea and skill named the "total arterial devascularization first" (TADF) technique and its applications in RPD. Three arterial blood supplies of pancreatic head were obstructed before dissection of veins. The critical steps included exposure of the anterior surface of the abdominal aorta (AA) by completely transecting neural and connective tissue between superior mesenteric artery (SMA) and pancreatic mesounsinate, and transection of the mesounsinate from the origin of SMA to the root of the celiac trunk. From January 2012 through May 2013, a total of 58 patients with PV/SMV invasion or oppression underwent RPD using this technique. The median operative time was 5.1 h (ranging 4.5-8.1 h). The median intraoperative blood loss was 450 mL (ranging 200-900 mL). No intraoperative and postoperative bleeding of pancreatic head region occurred. Among the 58 patients, 21 were subjected to vessel lateral wall angiectomy or angiorrhaphy, and 10 to angiectomy and end-to-end anastomosis. The incidence of postoperative bleeding, postoperative pancreatic fistula and biliary fistula was 5.2%, 6.8%, and 1.7%, respectively. No patients died 3 months after operation. The TADF technique is a new method for intricate RPD and could improve the security of surgery and reduce intraoperative bleeding, which is expected to become standardized surgical approach for RPD.

A new method for integrated radical resection of uncinate process of the pancreas: a report of 306 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the methods and skills of integrated radical resection of uncinate process of the pancreas for patients with periampullary malignant tumor.</p><p><b>METHODS</b>From March 2005 to March 2010, 306 cases of radical pancreaticoduodenectomy (RPD) of periampullary malignant tumor had been continuously performed. By exchanging superior mesenteric artery and controlling blood stream of pancreatic uncinate process, the integrated radical resection of uncinate process for these patients had been successfully completed. Deal with restitution of alimentary tract by all using Child method. The method of simplify binding pancreaticojejunostomy was carried out to pancreatico-jejunal anastomosis. The cases included 169 male and 137 female with 37 - 79 years old, and the mean age was 58 years. Tumor types included 151 pancreatic head and neck tumors, 48 distal bile duct tumors, 55 ampullary tumors and 52 duodenal papilla tumors.</p><p><b>RESULTS</b>Among the 306 cases with RPD, operation time were 4 - 6 h and the blood loss were 200 - 600 ml with no intraoperative and postoperative bleeding of pancreatic uncinate process site. The incidence rates of postoperative bleeding and mortality were 3.3% and 0.9% respectively. The incidence rates of postoperative pancreatic fistula and biliary fistula incidence were 1.6% and 0.6% respectively. And patients with fistula had well recovered by expectant treatment of ultrasound-guided puncture and drainage. Follow-up to March 2010, there were no patients died from the recurrence of superior mesenteric vascular tumor.</p><p><b>CONCLUSIONS</b>By exchanging superior mesenteric artery and controlling blood stream of pancreatic uncinate process, the integrated radical resection of uncinate process for those patients who have periampullary malignant tumor can be successfully completed. It can reduce the operating bleeding, operating time and the miscut of superior mesenteric vein and(or) superior mesenteric artery, it can avoid postoperative pancreas necrosis off, infection and hemorrhage caused by the pancreas uncinate process residues, and it also theoretically reduces the chance of tumor cells spreading.</p>

Prevention and cure of the complications after radical pancreatoduodenectomy / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the causes and the measures of prevention and cure of the dangerous complications (bleeding, pancreatic fistula, biliary fistula and death) after radical pancreatoduodenectomy (RPD) for periampullary malignant tumor.</p><p><b>METHODS</b>The rate and management of dangerous complications of 156 cases with RPD which were continuous performed by Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology between January 2006 and June 2008 were analyzed retrospectively, including 97 males and 59 females with 37 - 79 years old, the mean age was 56.9 years old.</p><p><b>RESULTS</b>Among the 156 cases with RPD, four patients had massive hemorrhage of gastrointestinal tract due to stress ulcer, two patients had bleeding in the pancreas-intestinal anastomosis after the operation, the rate of postoperative bleeding was 3.9% (6/156). One patient with massive hemorrhage of gastrointestinal tract due to stress ulcer had severe pulmonary infection and ARDS, and died of respiratory failure finally (the overall mortality rate was 0.7%) after ICU for two months. One patients with bleeding in the pancreas-intestinal anastomosis had pancreatic fistula (the rate of pancreatic fistula was 0.7%) 3 days after the second laparotomy to open the jejunum of the pancreas-intestinal anastomosis and make a transfixion of the bleeding points in the stump. Another patient who had the tumor located in the inferior segment of the bile common duct had biliary fistula 11 days after the operation (the rate of biliary fistula was 0.7%). Two patients with fistula had good recovery by expectant treatment of ultrasound-guided puncture and drainage.</p><p><b>CONCLUSIONS</b>Prompt and effective treatment of the complications of bleeding, pancreatic fistula, biliary fistula could maximally decrease the perioperative death rate.</p>

The technique of radical pancreaticoduodenectomy for malignant tumor in pancreatic head with pressed superior mesenteric blood vessels or portal vein / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the technique of radical pancreaticoduodenectomy for malignant tumor in pancreatic head with pressed superior mesenteric blood vessel or portal vein.</p><p><b>METHODS</b>From March 2005 to March 2007, thin slice scan and vessel-reconstruction of 56 patients of malignant tumor in pancreatic head with pressed superior mesenteric blood vessels or portal vein were carried out using multidetector spiral CT to evaluate whether peripheral vessels of pancreatic tumor were invaded and whether the tumor was resectable. During the operation, 3 vascular blocking bands for superior mesenteric vein, portal vein and spleen vein or 4 vascular blocking bands (additional one for inferior mesenteric vein) were preset. Under the cross and traction between superior mesenteric vein and superior mesenteric artery, resected the uncinate process of pancreas thoroughly. Using those methods, radical pancreaticoduodenectomy for 56 patients above-mentioned were successfully accomplished.</p><p><b>RESULTS</b>The accuracy for preoperative judging by using multidetector spiral CT whether the peripheral vessels of pancreatic cancer were invaded and whether the tumor was resectable was 98% and 100% separately. Thirty-seven of 56 patients, whose superior mesenteric blood vessels or portal veins were pressed by the tumor of pancreatic head, were operated using 3 vascular blocking bands and 2 patients using 4 vascular blocking bands, followed by suturing the bleeding points of the superior mesenteric vein with 5-0 vascular suture Proline. One patient's superior mesenteric vein was partially resected and restored. The operations cost 5-8 h each and the blood loss was 200-600 ml. There were no operative or postoperative hemorrhage or pancreatic juice leakage. According to the follow-up up to now, 2 patients died of multiple live tumor metastases 7 and 9 months separately after operation, the other 54 patients were still alive.</p><p><b>CONCLUSIONS</b>Thin slice scan and vessel-reconstruction using multidetector spiral CT can accurately judge whether the blood vessels near the pancreatic tumor were invaded and whether the tumor was resectable, using 3 vascular blocking bands or 4 vascular blocking bands and cross, traction of the superior mesenteric blood vessels, operator can easily accomplish the radical pancreaticoduodenectomy of malignant tumor in pancreatic head with pressed superior mesenteric blood vessels and portal vein, which was not resectable or need combined resection of the blood vessels in the traditional opinion.</p>

Meta-analysis on curative effects of surgical procedures for intrahepatic bile duct lithiasis / 中华外科杂志

<p><b>OBJECTIVE</b>To compare curative effects of various surgical procedures of bile duct stones.</p><p><b>METHODS</b>Two thousand nine hundred and fifty-five patients with intrahepatic bile duct lithiasis who had undergone various surgical procedures were analysed with Meta-analysis. Some of these cases were reported in Chinese Medical Journals from January 1990 to March 2001 and others were from Tongji Hospital.</p><p><b>RESULTS</b>There was a significant difference between curative effects of non-hepatectomy and that of hepatectomy (chi(2) = 62.945, P < 0.01), and the outcomes of hepatectomy were much better than those of non-hepatectomy with OR(S) equalled to 0.303 (0.222 - 0.413). There was not a significant difference between curative effect of interposed jejunum and that of hepatectomy (95% CI of RR from 0.98 to 1.04). All the other operation, effects were worse than hepatectomy (upper limit of 95% CI of RR < 1).</p><p><b>CONCLUSIONS</b>Hepatectomy is the most ideal surgery for intrahepatic bile duct stones and operation methods should be diversified since good effect could also be obtained when other operations are performed on suitable cases.</p>