VATER (Vater) surgical treatment of periampullary carcinoma

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Periampullary cancer, refers to the ampulla of Vater, common bile duct and duodenal papilla and near duodenal mucosa cancer etc.. These diff


Periampullary cancer, refers to the ampulla of Vater, common bile duct and duodenal papilla and near duodenal mucosa cancer etc.. These different sources of tumor, because the special anatomic site, have the same clinical manifestations and surgical treatment method is also difficult to be separated, it is referred to as periampullary carcinoma.

The development of the disease is slow, jaundice appears early, resection rate of about 70%, the cure rate of five years to reach 45 ~ 55%. While the previous habit of carcinoma of head of pancreas are also included, but in fact both in tumor cell biological characteristics, disease duration, surgical resection rate, both radical surgery and prognosis of different pancreatic head cancer develops quickly, the rapid emergence of surrounding tissue, lymph node or distant organs (such as liver and lung metastasis), jaundice later, the majority of patients are diagnosed at middle and late stage, the resection rate is only about 20%, the cure rate of five years was less than 10%, so this is not included in the discussion to the category of pancreatic head carcinoma.

1 overview of clinical pathology

Endoscopic observation, tumor morphology can be divided into four types: mass, ulcer type, mixed type and special type (Figure 1, ERCP clinical picture from the "graphic"), with clinical mixed type is the most common, most tumor is huge, endoscopic diagnosis easily (Figure 2, 3), part is hidden, the need for cytology brush biopsy to confirm the diagnosis. For ampullary carcinoma adenocarcinoma, most of the high and middle differentiated adenocarcinoma, poorly differentiated adenocarcinoma accounted for 15%, in addition to the histological classification of adenocarcinoma, as papillary carcinoma, mucinous carcinoma, undifferentiated carcinoma, reticulum cell sarcoma, leiomyosarcoma, carcinoid. Due to the special position of the tumor, easily blocking the common bile duct and main pancreatic duct, resulting in drainage of bile and pancreatic juice of the poor, causing obstructive jaundice, hyperamylasemia, severe cases can cause liver damage or pancreatitis; direct tumor infiltration of the intestinal wall to form lumps or digestive ulcer, and mechanical injury, liquid food that can cause duodenal obstruction, local ulceration and hemorrhage of upper digestive tract. The mode of transfer is as follows: firstly, it spreads directly to the head of pancreas, portal vein and mesenteric vessels. After the transfer, such as duodenal hepatoduodenal ligament, pancreatic head under the lymph node lymph node. Liver metastasis. Late may have more extensive metastasis.

2 clinical manifestations and diagnosis

Age of onset in 40 to 70 years old, the gender difference is not obvious, the vast majority of patients with painless jaundice, liver, gallbladder enlargement, intermittent gastrointestinal bleeding is the main symptom, accompanied by abdominal fullness, anorexia, weight loss. Half of the patients in our country are about 3 months from symptom onset to diagnosis, and about 10% of patients have been admitted to a large medical center for more than one year. The main clinical features are as follows:

2.1.: painless jaundice appears early, progressive, but a small number of patients because of tumor necrosis, bile duct recanalization and jaundice disappeared or reduced, but later deepened, fluctuating jaundice, newly diagnosed when mistaken for cholelithiasis or hepatocellular jaundice. Have dark urine, feces and bile salts in the subcutaneous shallow color pigmentation and stimulate the nerve terminal skin itching.

2.2., abdominal distension, pain: the early part of the patient (about 40%) due to dilatation of common bile duct or pancreatic juice discharges due to disruption caused by the intraluminal pressure increased, and xiphoid can dull pain radiating to the back. After eating is obvious, but did not pay attention to, late because of tumor invasion scope, or accompanied by inflammation and pain, only unbearable back pain, but not early.

2.3. fever and chills: combined with biliary tract infection (20%) inflammation or adjacent, may have chills, fever, or even toxic shock, some patients also as first symptom.

2.4. gastrointestinal symptoms: because of bile and pancreatic juice can not participate in the normal digestion, the patients have a poor appetite, bloating, indigestion, diarrhea, fatigue and weight loss. Due to partial necrosis of ampullary carcinoma after chronic hemorrhage, that black stool occult blood test was positive, and the emergence of secondary anemia; if the peritoneal metastasis and portal vein metastasis and ascites.

2.5. liver, gallbladder enlargement: for bile duct obstruction, bile stasis caused by, often can touch the swelling of the liver and gallbladder, liver texture hard, smooth.

2.6. tests, imaging, endoscopy: according to the symptoms and signs, doctors can obtain preliminary impression and judgment, for further diagnosis, it should be checked as follows:

The laboratory examination: WBC and neutrophils increased red blood cell anemia; early amylase can increase; liver function as enzymes increased, total protein and albumin decreased, serum bilirubin more generally in the 13.68 ~ mol/L (8mg); fecal occult blood test of about 85 to 100% of patients were positive.

B ultrasound examination: prompt intrahepatic and extrahepatic bile duct expansion of the whole process, liver enlargement, gallbladder swelling and swelling significantly, ruled out due to gallstones, experienced (physicians) can be observed in the ampulla of cancer.

The CT examination: Observation of extrahepatic bile duct dilatation degree, the exact level of obstruction, and the head of the pancreas, have significance in differentiating pancreatic cancer, can be roughly display position and contour of the ampulla and duodenal tumor. Enhanced scan can be observed around the lesion of vascular erosion, lymph node metastasis.

The MRCP check: when conditions further, a comprehensive understanding of the biliary tree as the site of obstruction, tumor, metastasis. The above 3 kinds of non-invasive examination can confirm each other to achieve the purpose of preliminary diagnosis, and provide the basis for the evaluation of the surgical approach, the extent of resection, the surgical effect and prognosis.

5: the duodenal endoscopy cholangiopancreatography (ERCP) can spy on the internal wall of the duodenum and papillary lesions; and biopsy, histology and cytology evidence can be obtained; tumor of intestinal cavity, bile and pancreatic duct invasion more directly; to confirm the diagnosis and surgical treatment of the system and improve the scheme is crucial meaning. At the same time, can be inserted into the nasal duct or temporary stent, preoperative biliary decompression, reduction of yellow, control of infection of biliary tract and improve liver function, correction and adjustment within the environment of the body, enhance the patient's body for surgery (Whipple) combat capacity, reduce the postoperative complications and promote postoperative rehabilitation also positive significance.

2.7. differential diagnosis of this disease is due to epigastric discomfort, jaundice, sometimes with biliary infection, elevated serum amylase, can be misdiagnosed as biliary calculi; sometimes easily confused with carcinoma of head of pancreas; there are mistaken for bile duct cancer, liver cancer, or even mistaken for infectious hepatitis. According to the clinical history, clinical symptoms and signs, liver function, hepatic enzyme binding, detection index of viral hepatitis, AFP, CEA, CA199 and other tumor markers in differential diagnosis and diagnosis, can achieve the purpose of ultrasound, CT, MRCP and other imaging. However, the most valuable method is electronic duodenoscopy (ERCP), the surgeon can directly observe the size, shape, range of tumor tissue growth; cytology; at the same time of preoperative biliary decompression and jaundice treatment.

3 perioperative surgical treatment:

Prepare 3.1. preoperative: once the disease is diagnosed, should be treated by pancreaticoduodenectomy, which is currently the most effective treatment, due to surgical trauma, coupled with a wide range of patients with prolonged jaundice, liver and kidney function damage, digestion and absorption dysfunction, malnutrition, so we must do preoperative preparation. If the correct water and salt metabolism imbalance, adjust good internal environment; with high sugar, high protein, high vitamin diet, digestive, stressed vitamin K (intramuscular or intravenous); necessary preoperative blood transfusion, plasma albumin, and other support, to correct anemia and low blood protein; at the same time, the coexisting medical diseases (such as heart, lung and endocrine) should be given active treatment and control. Although the tumor is a limited time operation, but also to meet the requirements of surgical indications as much as possible, which is of great significance to reduce postoperative complications and promote tissue repair.

3.2. surgical treatment: radical surgery with pancreaticoduodenectomy (Whipple procedure) or pylorus preserving pancreaticoduodenectomy (PPPD). Resection should normally include part of the stomach and duodenum and proximal jejunum about 10 cm, the head of the pancreas and bile duct; assessment of tumor resectability: firstly mention colon, observe whether the mesenteric root invasion; the cut gastrocolic ligament revealed mesenteric vein in the pancreas under the edge of possibility Kocher; the incision, finger palpation was the back of the head of pancreas uncinate process; and separated and exposed on the edge of the head of the pancreas, a longitudinal incision of the hepatoduodenal ligament to the portal vein and bile duct. After a comprehensive exploration of the estimate, for those who decide to choose what type of surgery, while the situation plus first, 2 stations regional lymph node clearance.

Surgical reconstruction of digestive tract by pancreatic stump and jejunal anastomosis of bile duct jejunum anastomosis, gastrojejunostomy sequence, we usually reconstructed, is at a distance of 10cm Qu ligament cut at the proximal jejunum, duodenum, jejunum, total resection of pancreatic head removed from the wild. The distal jejunum after primary duodenal transverse mesocolon root, Qu ligament exit into the jejunum and pancreas respectively, bile duct jejunum anastomosis using the space position of the original from the duodenum, pancreatic and biliary anastomosis above 30cm at the distal gastric and jejunal mention colon front end to side anastomosis, only 3 anastomotic complete digestion road reconstruction (Figure 4). Treatment of pancreatic stump as follows: pancreas and jejunum was anastomosed to the distal (mucosa to mucosa end to side suture); the distal jejunum and pancreas were anastomosed (including pancreatic jejunal end-to-end invaginated bind type); the pancreatic duct placed within 0.3 ~ 05 of the silicone tube as a support and drainage.

Operation: 3.3. postprocessing after pancreaticoduodenectomy complications were anastomotic leakage (pancreatic fistula, biliary fistula, gastrointestinal fistula) upper gastrointestinal bleeding, liver failure (ascites, hepatorenal syndrome), followed by abdominal infection, incision infection or liquefaction, pleural effusion, pulmonary infection etc.. In recent years, due to the perioperative treatment and monitoring the progress of technology, the mortality and the incidence of complications of periampullary carcinoma were significantly decreased. The center of all the work after the surgeon is around the prevention of anastomotic leakage, prevention and treatment of complications. Therefore, to promote the growth of anastomotic repair, maintain and improve kidney function, prevent and control infection, maintain the balance of internal environment and hydropower machine is stable, the doctor patient in the perioperative period to the attention and consideration.

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