Forty-five pancreatoduodenectomies had been performed in our hospital from 1981 to 1994, of which 35 cases were diagnosed as carcinomas of Vater’s ampulla or pancreatic head, and 10 (cases) as benign lesions. Through analysis of misdiagnosed cases, the authors emphasize that it is important to take correct history of jaundiced patients in detail according to the character of the jaundice and associated symptoms before any operation done. Secondly, all clinical materials must be thoroughly collected and special examinations for diagnosis should be chosen scientifically to avoid relying only on one sort of examination result as diagnostic standard. Thirdly, during operation the area of pancreatic head should be explored carefully and any lesions in doubt should be examined pathologically by puncture biopsy and frozen section to avoid misdiagnosis and thus performing pancreatoduodenectomy.
Objective The objective of this study is to evaluate the effect of enhanced recovery after surgery (ERAS) in the perioperative period of pancreatoduodenectomy. Methods This article conducted the forward-looking analysis on the information of 227 patients undergoing the pancreatoduodenectomy in West China Hospital from January 2016 to June 2017, and then compared the differences between the patients subjected to ERAS (ERAS group) and thosesubjected to regular measures (control group) with respect to time of setting in sickbed, time of mobilizing out ofsickbed, time of starting drink water, time of resumption of diet, exhaust time, defecation time, the time of nasogastric tube, postoperative hospitalization duration and expenses, postoperative complications, and postoperative pain scores. Results ① Postoperative indexes: by comparison of the ERAS group and the control group, it was found that the ERAS group had shorter (or lower) time of setting in sickbed, time of mobilizing out of sickbed, time of starting drink water, time of resumption of diet, exhaust time, defecation time, the time of nasogastric tube, postoperative hospitalization duration and expenses (P<0.05). ② Postoperative complications: of all postoperative complications, including pancreatic fistula, postoperative hemorrhage, delayed gastric emptying, biliary fistula, abdominal infection, incision complication, lung infection, and heart complication were without statistically significant differences (P>0.05) between the 2 groups.③ Reoperation and readmission: there was no significant difference on the incidences of reoperation and readmission between the 2 groups (P>0.05). ④ Postoperative pain scores: except 22 : 00 of the 6-day after operation, the pain scores in the ERAS group were all lower than those in the control group at 2 h and 8 h after operation, and the time points of 1–6 days after operation (8 : 00, 16 : 00, and 22 : 00), with statistically differences (P<0.05). Conclusion Without increasing the incidence of complications, ERAS may speed up the rehabilitation of patients undergoing the pancreatoduodenectomy and mitigate the pain of patients.
ObjectiveTo compare the short-term clinical outcomes of laparoscopic pancreaticoduodenectomy (LPD) with open pancreatoduodenectomy (OPD).MethodsClinical data of 29 patients receiving LPD and 27 patients receiving OPD in the department of hepatobiliary surgery of the Second Affiliated Hospital of Chongqing Medical University from March 2016 to December 2018 were collected. Note that both LPD and OPD were performed by the same chief surgeon. Effectiveness and safety of LPD were compared with those of OPD.ResultsThere was no significant difference in age, sex, body mass index, total bilirubin level, direct bilirubin level, preoperative morbidities, focus size, TNM stage and ASA grade between the LPD group and the OPD group (P>0.05). The operative time of the LPD group was significantly longer than that of the OPD group ［(482±86 ) min vs. (349±73) min, P<0.01］. Patients in the LPD group had shorter postoperative anal exhaust time than that in the OPD group ［(3.3±0.8) d vs. (5.3±1.0) d , P<0.05］. There was no significant difference in the length of hospital stay after operation, blood loss in operation, transfusion, second operation, death and postoperative complications between the LPD group and the OPD group (P>0.05).ConclusionsThe preliminary results of this study suggest that compared with OPD, LPD can shorten the postoperative anal exhaust time but not increase the incidence of postoperative complications and blood loss in operation. Nevertheless, this conclusion is needed to be validated by clinical studies with large sample size.
ObjectiveTo study the predictability of dynamic prediction model of clinical pancreatic fistula in patients with or without pancreatic duct stent in laparoscopic pancreaticoduodenectomy (LPD).MethodsA total of 66 patients who underwent LPD in West China Hospital of Sichuan University from November 2019 to October 2020 were enrolled in the randomized controlled trial (registration number: ChiCTR1900026653). The perioperative data of the patients were collected in real time. The patients were divided into groups according to whether the pancreatic duct support tube was retained during the operation, and the probability prediction value was output according to the model formula. The specificity, sensitivity, accuracy, discrimination, and stability of the prediction results were analyzed.ResultsFor the group with pancreatic stent tubes, the specificity, sensitivity, and accuracy of the model at the model cut-off points on the postoperative day 2, 3 and 5 were 92.0%, 76.7% and 57.1%, 50.0%, 100% and 66.7%, and 88.8%, 78.8% and 61.3%, respectively. The areas under the ROC curve were 0.870, 0.956 and 0.702, respectively. The kappa values of the prediction result based on model cut-off point and cut-off point of ROC curve were 0.308, 0.582 and 0.744, respectively. Whereas for those who without the stent tube, the specificity, sensitivity, and prediction accuracy of the model on the postoperative day 5 were 66.7%, 100% and 72%, respectively. The area under curve at different time points were 0.304, 0.821, and 0.958, respectively. The kappa values at the last two time points were 0.465 and 0.449, respectively.ConclusionsFor patients with pancreatic duct support during LPD operation, the dynamic model of clinical pancreatic fistula can more accurately screen high-risk groups of clinical pancreatic fistula, and has better stability of prediction results. For patients without supporting tube, in the case of flexible adjustment of the boundary point, the model can also be more accurate screening on the 3rd and 5th days after operation.
ObjectiveTo investigate the predictive value of preoperative D-dimer, CA19-9, neutrophil-to-lymphocyte ratio (NLR) in the diagnosis of pancreatic cancer. MethodsThe clinicopathologic data of patients who underwent pancreaticoduodenectomy for pancreatic occupying lesions in the First and Fifth Affiliated Hospitals of Xinjiang Medical University from January 2016 to December 2019 were analyzed retrospectively. According to the pathological characteristics, the patients were divided into pancreatic cancer and pancreatic benign tumour. The gender, age, accompanying diseases, preoperative D-dimer, CA19-9, lymphocyte count, neutrophil count, NLR and so on were compared between them. The receiver operating characteristic (ROC) curves of preoperative D-dimer, CA19-9, and NLR for diagnosis of pancreatic cancer were draw. ResultsA total of 142 patients were collected, including 79 patients with pancreatic cancer and 63 patients with pancreatic benign tumour. Compared with the patients with pancreatic benign tumour, the age was older (P<0.05), the number of neutrophils was more (P<0.05), the number of lymphocytes was less (P<0.05), the preoperative levels of CA19-9 and D-dimer, and the preoperative NLR were higher (P<0.05) for the patients with pancreatic cancer. The multivariate analysis of logistic regression revealed that the preoperative higer CA19-9, D-dimer, and NLR increased the incidence of pancreatic cancer (P<0.05), then the optimal cut-off value of preoperative levels of CA19-9 and D-dimer, and preoperative NLR on diagnosis of pancreatic cancer was 108 U/mL, 306 μg/L and 3.2, respectively, the corresponding area under ROC curve was 0.900, 0.891, 0.768, respectively, and which of combination of preoperative CA19-9, D-dimer, and NLR was 0.931. For the pancreatic cancer patients with preoperative NLR, CA19-9, and D-dimer higher than the optimal cut-off value, the proportions of patients with pTNM stage Ⅲ and lymph node metastasis were higher than those for pancreatic cancer patients with below than optimal cut-off value (P<0.05). ConclusionFrom preliminary study results, preoperative CA19-9, D-dimer, and NLR values have certain values in diagnosis of pancreatic cancer, and diagnostic value of combined detection of 3 indexes is higher than single index.
Objective To explore the clinical value of preoperative neoadjuvant chemotherapy (NAC) combined with laparoscopic pancreatoduodenectomy (LPD) with multiple surgical approaches in the treatment of borderline resectable pancreatic head cancer. Methods The clinicopathologic data of 35 patients with critical resectable pancreatic head carcinoma admitted to the Department of Hepatobiliary and Pancreatic Surgery of Luoyang Central Hospital Affiliated to Zhengzhou University and the Department of Hepatobiliary and Pancreatic Surgery of the Fifth Affiliated Hospital of Zhengzhou University from January 2017 to June 2022 were retrospectively analyzed. All patients received NAC before operation (AG protocol). At the end of the course of treatment, according to the type of borderline resectable pancreatic cancer (BRPC) [venous invasion type (BRPC-V type) and arterial invasion type (BRPC-A type)], take the individualized surgical approach for LPD (BRPC-V type: inferior mesenteric vein approach; BRPC-A type: left posterior approach, medial uncinate process approach, anterior approach, or lower mesocolon approach). The intraoperative condition, R0/R1 resection rate, lymph node dissection, postoperative complications, average hospital stay, recovery, follow-up and survival were recorded. Results① Efficacy evaluation of NAC: 13 patients were partially relieved , 17 patients were stable and 5 patients were progressive after 4 weeks of treatment. Five progressive patients continued to receive comprehensive internal medicine treatment, and the remaining 30 patients underwent LPD. ② Intraoperative situation: LPD were successfully completed in 30 patients, 2 patients underwent extended pancreaticoduodenectomy combined with superior mesenteric vein (or) portal vein reconstruction among them. Among the 30 patients with LPD, there were 10 cases of inferior mesenteric vein approach, 10 cases of left posterior approach, 6 cases of medial uncinate process approach, 1 case of left posterior approach+medial uncinate process approach, 2 cases of anterior approach, and 1 case of inferior mesocolon approach. The mean operative time was (379.4±77.3) min, the intraoperative blood loss was (436.9±95.1) mL. ③ Postoperative situation: The incidence rate of postoperative surgery-related complications was 33.3% (10/30), including 4 cases of Clavien-Dindo grade Ⅰ [biliary fistula in 1 case (3.3%), A-grade pancreatic fistula in 1 case (3.3%), gastric draining dysfunction in 1 case (3.3%), diarrhea in 1 case (3.3%)], 5 cases of grade Ⅱ [pulmonary infection in 2 cases (6.6%), B-grade pancreatic fistula in 2 cases (6.6%), abdominal infection in 1 case (3.3%)], and 1 case of grade Ⅲ [gastroduodenal artery stump bleeding (3.3%)]. Among the 10 patients with complications, 9 cases recovered after symptomatic treatment, and 1 case died, with a fatality rate of 3.3% (1/30). The mean postoperative hospital stay was (17.3±5.5) days. ④ Excision rate and pathological results: R0 resection rate was 90.0% (9/10) in 10 patients with BR-PV type LPD, and R1 resection was performed in 1 patient. R0 resection rate was 75.0% (15/20) in 20 patients with BR-A type, and R1 resection was performed in 5 patients (2 patients with medial uncinate process approach; Left posterior approach in 2 cases; Submesocolon approach was used in 1 case). In 30 patients with LPD, the total R0 removal rate was 80.0% (24/30), the number of lymph nodes dissected was (11±5). Pathological type: There were 26 cases (86.7%) of ductal adenocarcinoma in 30 patients, 1 case of adeno-squamous carcinoma (3.3%), 1 case of mucinous carcinoma (3.3%), 2 cases of acinocytic cell carcinoma (6.7%). 23 cases (76.7%) of medium-high differentiation and 5 cases (16.6%) of low differentiation, two cases (6.7%) were undifferentiated. ⑤ Postoperative follow-up and survival: 30 patients were completely followed-up for 6-39 months, with a median follow-up time of 17 months. The median survival time of BRPC-V and BRPC-A patients was 24.0 months and 17.0 months, respectively. The overall survival rates of 30 patients at 1, 2 and 3 years after operation were 77.3%、46.5% and 13.7%, respectively. Conclusion The selection of preoperative NAC combined with individualized surgical approach for patients with borderline resectable pancreatic head cancer is beneficial to improve the radical resection rate and clinical therapeutic effect, and has good clinical application value.