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Objective:To study the causes of hemorrhage after laparoscopic pancreaticoduodenectomy (LPD) and to develop countermeasures in its prevention.Methods:The clinical data of 215 patients who underwent LPD at the Department of Hepatobiliary and Pancreatic Surgery of Zhejiang Provincial People's Hospital from December 2013 to May 2020 were reviewed. The patients’ clinical data including gender, age, comorbidities and postoperative complications such as bleeding, pancreatic fistula, biliary fistula and intraperitoneal infection were studied, with the aims to analyze the causes, clinical manifestations and treatment results of post-pancreaticoduodenectomy hemorrhage (PPH) after LPD.Results:Of 215 patients, there were 132 males and 83 females, aged (60.7±10.3) years. PPH occurred in 20 patients, incidence rate was 9.30%(20/215). Early hemorrhage was mainly caused by inadequate hemostasis or loosening of vascular clips, while delayed hemorrhage was mainly caused by gastrointestinal fistula with vascular erosion, arterial injury by intraoperative energy instruments or pseudoaneurysms. Among the 20 patients, 6 patients had early hemorrhage and 14 delayed hemorrhage. There was 1 patient with grade A, 10 with grade B and 9 with grade C hemorrhage. Thirteen patients developed pancreatic fistula, 1 biliary fistula, and 2 intraperitoneal infection. One patient responded well to conservative treatment. Hemostasis was successfully achieved by gastroscopy ( n=1) and interventional therapy ( n=7). Eleven patients required laparotomy for hemostasis. In this study, 14 of 20 patients survivied PPH and 6 patients died. The mortality rate was 30% (6 of 20 patients with PPH). Conclusions:Early hemorrhage was caused by inadequate hemostasis or loosening vascular clips, while delayed hemorrhage was related to gastrointestinal fistula with vascular erosion, arterial injury by intraoperative energy instrument or pseudoaneurysm. Careful hemostasis, adequate protection of blood vessels, and accurate anastomosis should be performed in LPD. DSA angiography should be used for arterial hemorrhage which progressed very rapidly. Interventional therapy including embolism and stenting were means to control arterial bleeding in PPH. Decisive surgical exploration when interventional therapy failed was important in reducing the mortality rate of these patients.
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Objective:To study the technical and essential steps in laparoscopic selective devascularization with paraesophageal veins-preservation.Methods:To retrospectively analyze the clinical data of 13 cirrhotic patients who underwent laparoscopic selective pericardial devascularization for portal hypertension at the Department of Hepatobiliary and Pancreatic Surgery, Zhejiang Provincial People's Hospital from January 2019 to March 2020. There were 9 males and 4 females with age ranging from 41 to 83 years (median 51 years). The operative time, intraoperative blood loss, postoperative complications and follow-up data were analyzed.Results:All the 13 patients completed theoperation, no patient stopped the operation or transferred to laparotomy. The operation time was (170±32) min.The intraoperative bleeding was (160±30) ml. The postoperative hospital stay was (6.1±1.1) days. There were no complications, including pancreatic leakage and intra-abdominal infection. On follow-up which ranged from 1 to 15 months, one patient developed portal vein thrombosis, no upper gastrointestinal rebleeding.Conclusions:Preservation of esophageal veins in laparoscopic selective devascularization is an accurate surgery which requires close teamwork and rich experience in laparoscopic surgery. The preservation of the main trunk of the gastric coronary vein and integrity of the esophageal veins are the keys to the surgery which is safe and feasible.
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Objective To analyze the initial experience of total laparoscopic radical resection for patients with Bismuth type Ⅲa hilar cholangiocarcinoma.Methods A retrospective study was conducted to analyze the clinical data of three patients with Bismuth type Ⅲa hilar cholangiocarcinomatotal who underwent laparoscopic radical resection in Zhejiang Provincial People's Hospital from February to May in 2017.Results The three patients all underwent the operations successfully.The operation time ranged from 490.0 to 580.0 min.The intraoperative blood loss ranged from 300.0 ml to 1 200.0 ml.There was no severe perioperatire complication or death.One patient developed biliary leakage which responded to drainage without reoperation.Another patient developed pleural effusion treated with minimal invasive drainage.The length of postoperative hospital stay ranged from 10.0 to 18.0 days.Histopathology showed two patients with well-differentiated adenocarcinomas and one patient with poorly differentiated adenocarcinoma.The number of lymph nodes harvested ranged from 8 ～ 13.Two patients had no regional lymph node metastasis and one patient had regional lymph node metastasis (1/13).The hilar bile duct resection margins of the three patients were all negative.There was no evidence of tumor recurrence on following up for 7 ～ 10 months.Conclusions It was safe and feasible to carry out total laparoscopic radical resection in selected patients with Bismuth type Ⅲa hilar cholangiocarcinoma.More patients and longer follow-up are required to study the long term oncological results.
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Objective To investigate the value of laparoscopic total pancreastectomy for the treatment of noncancerous pancreatic lesions.Methods Clinical data of 3 cases of noncancerous pancreatic lesions undergoing laparoscopic total pancreatectomy in Zhejiang Provincial People's Hospital were reviewed retrospectively.Results One patient underwent laparoscopic total pancreatectomy,one patient underwent laparoscopic resection with robotic reconstruction and one did laparoscopic resection with open reconstruction.All were spleen preserving surgery.The operation time was 310 (280-350) minutes,estimated blood loss was 483 ml(250-700)ml and postoperative hospital stay was 27 (14-38) days.One patient had postoperative bile leakage.Insulin was used to control blood glucose level in all postoperative cases.As showed by pathology there were intraductal papillary mucinous neoplasms in two patients and multiple neurocndocrine tumor in one patient.Conclusion Laparoscopic total pancreatectomy is safe and minimally invasive for the treatment of noncancerous pancreatic diseases.
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Objective To analyze our experience on laparoscopic and Da Vinci robotic radical pancreaticoduodenectomy combined with major vascular resection and reconstruction,and to expand the indications of surgery for patients with pancreatic cancer.Methods From December 2013 to January 2016,67 patients underwent laparoscopic and Da Vinci robotic pancreaticoduodenectomy in our department.The resection was combined with major vein resection in 5 patients.We retrospectively analyzed the clinical data of these patients who had laproscopic or Da Vinci robotic pancreaticoduodenectomy with major vascular resection and reconstruction.Results The mean operation time was 378 (360 ～ 480) minutes,and the mean estimated blood loss was 360 (120 ～450) ml.4 patients underwent laparoscopic wedge-resection of PV/SMV without interruption of blood flow.After pancreaticoduodenectomy using the superior mesentery artery first approach,one patient underwent resection of a segment of portal vein and superior mesenteric vein followed by an end to end anastomosis using the Da Vinci robotic system.The total blood flow occlusion time was 35 minutes.Intraoperative frozen section biopsy and postoperative pathological results were chronic pancreatitis with pancreatic cancer in all these patients.The veins were invaded by tumor in 3 patients.In the remaining 2 patients,the vascular wall showed chronic inflammation.All the surgical resection margins were tumor negative.Postoperative complications included one patient with bile leakage,one patient with upper gastrointestinal bleeding and one patient with a grade A pancreatic fistula (PF).The patient with upper gastrointestinal bleeding was managed successfully using hemostatic treatment under gastroscopy,and the other patients all recovered well after conservative therapy.There was no death in this study.The mean postoperative hospitalization stay was 14 (9 ～35) days.Conclusions Laparoscopic or Da Vinci robotic radical pancreaticoduodenectomy combined with major vascular resection is safe and feasible in selected patients with pancreatic cancer.However,surgeons need to be experienced at both open pancreaticoduodenectomy combined with vascular resection and at standard laparoscopic pancreaticoduodenectomy.
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Objective To evaluate the prognostic value of preoperative neutrophil-to-lymphocyte ratio (NLR) on recurrence after hepatectomy for AFP negative hepatocellular carcinoma (HCC).Methods Clinical data of 68 AFP negative HCC patients undergoing radical hepatectomy from September 2010 to January 2013 were analyzed retrospectively.According to preoperative NLR,patients were divided into low NLR group (NLR ＜ 2.78) and high NLR group (NLR ≥ 2.78),respectively.Univariate analysis was performed to assess for a significant difference in clinicopathological characteristics influencing disease-free suvival after hepatectomy.A multivariate analysis was performed by Cox regression for variables significant on univariate analysis.Kaplan-Meier method was used to assess disease-free survival rate.Results The overall 1,2,and 3-year disease-free survival rate was 79.7％,37.5％,and 18.2％ respectively.The disease-free survival of high NLR group was significantly lower than the low NLR group (1,2,and 3-year overall survival were 70.3％,35.1％,and 13.5％ vs 85.2％,40.7％,and 18.5％,respectively,P =0.042).Preoperative NLR ≥2.78,tumor size (＞ 5 cm),microvascular invasion and liver cirrhosis were risk factors of poor disease-free survival.Cox regression analysis revealed that all of these four factors were independent predictors of poorer disease-free survival.Conclusions Preoperative NLR≥2.78 was one of independent adverse predictors for disease-free survival in AFP negative HCC patients after hepatectomy.
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Objective To explore the treatment of primary hepatic neuroendocrine tumors (PHNET).Methods The therapeutic treatments of 9 PHNET patients from January 2003 to January 2010 in 3 hospitals were retrospective analyzed and followed up.Results Diagnosis of PHNET was confirmed immunohistochemically and by excluding extrahepatic primary sites.The survival is significantly dependent on tumor resectability.One patient received only radiotherapy and one with only chemotherapy,one with radiofrequency ablation.Six patients received R0 resection,one received postoperative radiotherapy,one with TACE perioperatively and internal radiotherapy.Two patients were lost to follow up 3 patients died and 4 were alive.Intrahepatic recurrence was found in 1 patient and metastasis to bone in 2 patients.Survival time ranged from 11 days to 66 months.Conclusions PHNET is an extremely rare entity with difficulty in early diagnosis.Curative liver resection integrated with transarterial chemoembolization or radiotherapy is considered to be an effective modality.