Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China.
J Gastrointest Surg. 2020 Dec;24(12):2906-2907. doi: 10.1007/s11605-020-04808-y. Epub 2020 Oct 9.
Laparoscopic pancreaticoduodenectomy (LPD) technique with artificial vascular graft reconstruction for patients with borderline resectable pancreatic cancer has been rarely reported since it is a very challenging technique. However, preliminary experience for the technique has been reported at the Department of Pancreatic Surgery, West China Hospital, Sichuan University.1,2 The rising popularity of neoadjuvant chemotherapy for pancreatic cancer patients may result in the increase of operative difficulty due to tissue edema and many other factors caused by the chemotherapy. The main aim of this study was to demonstrate the feasibility, safety, and key surgical procedure for LPD using video evidence.
A three-dimensional upper abdominal computed tomography angiography (CTA) scan done to a 51-year-old man brought to the center with upper abdominal pain showed a mass in the uncinate process of the pancreas, with over 180-degree involvement of the superior mesenteric vein. Percutaneous transhepatic cholangial drainage (PTCD) was performed to reduce jaundice while endoscopic ultrasound and fine-needle aspiration (EUS-FNA) were done to confirm the diagnosis of adenocarcinoma. The patient underwent two cycles of neoadjuvant chemotherapy using albumin-bound paclitaxel gemcitabine + program. The chemotherapy helped in significantly relieving the symptoms where CA 199 reduced from 586.7 IU/ml to 36.73 IU/ml, and the tumor maximum diameter was reduced from 4.3 cm to 2.2 cm. The violated superior mesenteric vein (SMV) and the tumor were en bloc resected, and a 4.0-cm artificial vascular graft was placed for reconstruction. Bing's anastomosis was performed using pancreaticojejunostomy3 while cholangiojejunostomy was performed using continuous stitching. The gastroduodenal artery (GDA) stump was wrapped with ligamentum teres hepatis after the completion of gastrointestinal anastomosis. The specimen was then removed through the extended umbilical incision (4 cm) and the operation was completed after the drainage tube was placed.
The length of intraoperative excisional SMV, duration of artificial vascular graft reconstruction, operation time, and volume of intraoperative blood loss were 4.0 cm, 30 min, 520 min, and 800 mL, respectively. Histopathological examination of ypT2N1 indicated that 1 of the 27 lymph nodes was positive. Pathological results showed a moderately differentiated adenocarcinoma with all margins being negative.
This study demonstrated the feasibility of total laparoscopic pancreaticoduodenectomy combined with vascular resection and artificial vascular graft reconstruction in properly selected cases of pancreatic cancer with vein involvement after neoadjuvant chemotherapy. It is worth noting that skilled laparoscopic technicians and effective teamwork are necessities for safe completion of the procedure.
对于边界可切除的胰腺癌患者，腹腔镜胰十二指肠切除术（LPD）联合人造血管移植重建技术很少有报道，因为这是一项极具挑战性的技术。然而，四川大学华西医院胰腺外科已经初步报道了该技术的经验。1,2 由于化疗引起的组织水肿和其他许多因素，新辅助化疗使胰腺癌患者的手术难度增加，该技术的应用越来越广泛。本研究的主要目的是通过视频证据展示 LPD 的可行性、安全性和关键手术步骤。
对一名 51 岁男性进行了三维上腹部 CT 血管造影（CTA）扫描，该患者因上腹痛就诊，发现胰腺钩突处有一肿块，肠系膜上静脉（SMV）超过 180°受累。经皮经肝胆管引流（PTCD）以降低黄疸，同时行内镜超声和细针抽吸（EUS-FNA）以明确腺癌的诊断。患者接受了两周期白蛋白结合紫杉醇吉西他滨+方案的新辅助化疗。化疗显著缓解了症状，CA199 从 586.7 IU/ml 降至 36.73 IU/ml，肿瘤最大直径从 4.3 cm 缩小至 2.2 cm。整块切除受侵犯的 SMV 和肿瘤，并放置 4.0 cm 人造血管进行重建。使用胰肠吻合术 3 进行宾氏吻合，使用连续缝合进行胆肠吻合。胃肠吻合完成后，用肝圆韧带包裹胃十二指肠动脉（GDA）残端。然后通过延长的脐部切口（4 cm）取出标本，并放置引流管完成手术。
术中切除 SMV 的长度、人造血管重建的时间、手术时间和术中出血量分别为 4.0 cm、30 min、520 min 和 800 mL。ypT2N1 的组织病理学检查显示 27 个淋巴结中有 1 个阳性。病理结果显示为中分化腺癌，所有切缘均为阴性。
本研究证明了在适当选择的新辅助化疗后静脉受累的胰腺癌患者中，完全腹腔镜胰十二指肠切除术联合血管切除和人造血管移植重建的可行性。值得注意的是，熟练的腹腔镜技术人员和有效的团队合作是安全完成手术的必要条件。
