Duodenal pathway ampullary tumor resection
Duodenal extravasation ampullary tumor resection for surgical treatment of duodenal tumors.
The preferred surgical treatment for Vater ampullary malignancies is pancreaticoduodenectomy (Whipple surgery), with a 5-year survival rate of 50% to 60%, an surgical mortality rate of less than 5%, and a downward trend. Abdominal resection has not been followed up in large cases to prove that its surgical resection is the same as pancreaticoduodenectomy. Because of the limited scope of ampulla resection, most scholars believe that ampullary resection is suitable for less common benign tumors such as tumors, lymphangiomas, and smooth muscle fibroids. Although the trauma of ampullary resection is small, it requires high technical level of the surgeon and serious complications may occur. When used for local resection of malignant tumors, it is important to use cryosection pathological examination as an aid. Ensure that there are no residual tumor cells at the surgical margin.Treating diseases: duodenal carcinoid Indication
Duodenal extravasation ampullary tumor resection is applicable to:
1. Duodenal papilla and benign tumor at the lower end of the common bile duct.
2, ampullary cancer did not invade the pancreatic head in the early stage, the tumor is limited to the duodenal papilla or the lower end of the common bile duct, the general condition can not withstand pancreaticoduodenectomy. However, because the operation is limited to the duodenal papilla, it is easy to cut residual tumor cells, and should be strictly selected in patients with malignant tumors.Contraindications
1, the duodenal papilla or the lower end of the common bile duct cancer has been invaded by surrounding tissues, beyond the scope of local resection.
2. A ampullary carcinoma with local lymph node metastasis.
3, for patients with good general condition can withstand pancreaticoduodenectomy, try not to do local resection, because local excision this method has limitations, the scope of resection and lymph node dissection are limited.Preoperative preparation
1. Examination of important organs such as heart, lung, liver and kidney.
2, chest X-ray film to exclude metastatic lesions.
3. Inject vitamin K to increase prothrombin activity.
4. Correct the electrolyte imbalances such as low potassium and low sodium.
5. For those who have obvious malnutrition due to too little food intake, intravenous nutrition is added 1 week before surgery to transfer whole blood and plasma to correct anemia and hypoproteinemia.
6. For patients with obstructive jaundice, oral bile salt preparations are given 1 week before surgery to reduce bacterial growth in the intestine.
7. Serve ranitidine 150mg before surgery to reduce stomach acid.
8. Apply prophylactic antibiotics.
9, serum bilirubin > 171mol / L patients, the physical condition is still suitable for surgery, do not emphasize the routine use of preoperative transhepatic biliary drainage (PTBD) to reduce jaundice, if PTBD has been done, should pay special attention to due to a large number of Electrolyte disorders caused by loss of bile, usually performed 2 to 3 weeks after drainage, to prevent biliary infection caused by PTBD. Percutaneous transhepatic gallbladder drainage can also achieve the same goal. In the case of the condition, it is feasible to introduce the drainage through the endoscope before the operation, and insert a thicker special built-in drainage tube through the common bile duct opening to the upper of the obstruction, so that the patient's condition can be improved quickly.
10. Place the gastrointestinal decompression tube before surgery.Surgical procedure
1. The incision is the right inferior oblique incision of the pancreaticoduodenectomy, which is lower than the incision of the gallbladder resection, and the right upper rectus abdominis incision can also be used.
2, after the abdomen to do intra-abdominal exploration, focusing on the size of the liver, pancreatic upper and lower margins, lymph nodes in the back of the pancreas and duodenal papilla lesions. It should be noted that the scope of tumor invasion is sometimes inconsistent with that observed under duodenoscopy. It appears to be limited under the microscope. However, the tumor has been invaded during the operation and the local parenchyma cannot be performed.
3. Make a Kocher incision on the outside of the duodenum, cut the peritoneum, completely free the descending segment of the duodenum, and completely turn the duodenum up. A two-needle traction line is placed in the anterior wall of the common bile duct of the duodenum, and the common bile duct is longitudinally cut between the two lines. Insert the metal bile duct probe into the common bile duct and continue down to the duodenal nipple at the lower end of the common bile duct to determine the location of the nipple.
Turn the duodenum inward and expose the direction of the common bile duct. There are many forms of common bile duct in the pancreatic segment, but 2/3 common bile ducts are usually wrapped in pancreatic tissue, so it is necessary to separate the pancreatic tissue wrapped around the common bile duct from the duodenal attachment and suture at the edge. .
4. Before the common bile duct enters the duodenum, use a metal probe to lift the bile duct wall. After suturing the traction line on the bile duct wall 2 cm away from the tumor or 2 cm from the nipple, the common bile duct is cut transversely on the lateral side of the common bile duct. The incision is pulled by a suture to cut off the outer side wall and the front wall of the common bile duct.
5. Cut the duodenal wall along the duodenal papilla and turn the duodenal papilla out of the duodenum. And lift it with tissue forceps.
6, at the nipple 5 to 6 o'clock, pay attention to the pancreatic duct opening. The pancreatic duct is a tube with no special color when cut, and is about 0.3 cm thick. After the pancreatic duct is incised, a silicone tube is placed in the pancreatic duct to support the drainage.
7. Intermittent suture of the common bile duct and the duodenal papilla were removed by suture, and the duodenal wall and the posterior wall of the common bile duct were sutured together. The needles of the common bile duct and the pancreatic duct were sutured, and the pancreatic duct and the duodenal mucosa were sutured for several needles. The pancreatic duct drainage tube is placed at the distal end of the duodenum or separately through the anterior wall of the common bile duct. The common bile duct has a T-shaped tube, and the common bile duct incision is interrupted.
The stomach tube is placed in the duodenum for intragastric attraction. The anterior wall of the common bile duct opening and the duodenum were then sutured intermittently and sutured in two layers. The omental tissue is covered to cover the incision. Rinse the surgical field and place a latex tube on the outside of the duodenum for drainage.complication
The extra-duodenal path of ampullary tumor resection is much smaller than that of pancreaticoduodenectomy, and the incidence of complications is small, so patients with advanced age and weakness can be well tolerated. Postoperative attention is mainly to the occurrence of duodenal fistula, pay attention to the nature of the drainage fluid and timely measurement of amylase. If the amount of drainage fluid suddenly increases and the amylase value increases, duodenal fistula should be considered.
Acute necrotizing pancreatitis is another serious complication. At this time, the patient's symptoms are often atypical, which is easily confused with the symptoms after surgery. Therefore, attention should be paid to the changes of serum amylase and peritoneal drainage amylase after operation. When pancreatitis occurs, it should be treated promptly.