All the patients administrated in The First Affiliated Hospital of Henan University of Science and Technology during January 2015 to July 2019 who had laparoscopic pancreaticoduodenectomy (LPD) for malignant tumor. All the operations were completed by the same team. This was a retrospectively designed trial. This clinical trial was approved by the ethics committee of The First Affiliated Hospital of Henan University of Science and Technology.
All the patients involved had diagnosed pathologically. All patients included were aged 18 to 80 years old; the American society of anesthesiologists (ASA) classification should be at 1 to 3. All the patients had enhanced CT and /or MRI to assess the resectability. Patients with vessel invasion weren’t recommended for LPD. Patients with distal metastasis during exploration were excluded. According to the different pattern of surgery, they were divided them into two groups: TLPD group and LAPD group.
All the operations were performed under general anesthesia. Patients were placed in French position. 5 trocars were employed for the operation. Anticlockwise pattern was adopted for the resection. After exploration of whole abdominal cavity, resection was beginning. Treitz ligament was cut off first to mobilize the beginning of jejunum which facilitated the mobilization of duodenum and uncinate process of pancreas. Second step was creating a tunnel behind the pancreatic neck. Gastrocolic ligament was cut off along the right gastroepiploic artery to access into the lesser sac; then, dissection was performed along the inferior board of pancreatic neck to detect superior mesenteric vein and Helen trunk. Gastroepiploic vessels were cut off near the Helen trunk. Stomach was cut off by an endo linear stapler to expose the pancreatic neck behind. A harmonic scalpel was employed for cutting pancreatic neck. Pancreatic duct was separated for about 2 mm before cutting to facilitate the following anastomosis. Lymph nodes dissection was along the common hepatic artery and proper hepatic artery. Gastroduodenal artery was cut off near to common hepatic artery. Kocherization of duodenum was performed. Mobilization of duodenum and pancreatic uncinate process were performed with local lymph node dissection. The beginning of jejunum was pulled retrocolic root to the right and then cut off. Pancreatic uncinate process was mobilized from superior mesenteric artery with dissection of mesentery of uncinate process of pancreas. Lymphadenectomy was simultaneously along common hepatic artery and portal vein to the level of common hepatic duct. Common hepatic duct was cut off with cholecystectomy. The difference of the two groups was the pattern of reconstruction. Four anastomoses were routinely performed. Those were pancreaticojejunostomy (PJ), cholangiojejunostomy (CJ), gastrojejunostomy and jejunojejunostommy. All the four anastomosis were completed under laparoscopy for TLPD group. The specimen was taken out through upper abdominal incision. For the LAPD, CJ was performed under laparoscopy; other three anastomoses were completed by gently lengthened upper abdominal incision. PJ was performed as modified duct to mucosa anastomosis with stent implantation in pancreatic duct. Drainages were positioned around PJ and CJ with additional pelvic drainage if necessary after a wholly peritoneal lavage by distilled water.
Percutaneous transhepatic cholangial drainage (PTCD) was performed when cholangitis existed. Anemia correction should be performed routinely to 90 g/L at least. Serum albumin should be maintained at normal level. Breathing exercises were performed at least 2 days before operation. The pressure of O2 and CO2 should be at normal level by arterial blood gas analysis.
Postoperative management was performed according to the principle of Enhanced Recovery after Surgery (ERAS) . Gastric tube was removed after operation when the patient recovered from anesthesia. Abdominal drainage amylase test was routinely performed at 1, 3, 7 day postoperatively with additional test when pancreatic leakage was suspected. Abdominal drainage tubes were removed when the drainage was less than 20 ml/d, which should be retained at least 7 days postoperatively. Abdominal CT scan was routinely performed to ensure no ascites before drainage removal. Discharged criteria were set as recovery to semifluid diet without symptomatic pancreatic leakage or biliary leakage at least 7 days postoperatively.
Pancreatic leakage was detected following the International Study Group of Pancreatic Fistula (ISGPF) . The severity of pancreatic leakage was classified according to the criteria of ISGPF. Bleeding means hematochezia or haematemesis or blood drainage from abdominal cavity. Mortality was limited to 30 days postoperatively. Total operation time counted from first skin incision to the end of abdominal closure.
SPSS 16.0 was employed to analyze the data. The measurement data, including age, BMI, pancreatic duct size, operation time, resection time, pancreaticojejunostomy time, cholangiojejunostomy time, gastrojejunostomy time, jejunojejunostomy time, blood loss, retrieved lymph nodes, incision length, visual analogue score (VAS) and postoperative hospitalization, were compared with t tests. The numerical data, such as sex, ASA classification, pancreas texture, tumor origin, number of required transfusion, conversion to open approach, pancreatic leakage, biliary leakage, bleeding, pneumonia, thrombosis, incision infection, mortality and re-operation, were compared with chi square tests. P < 0.05 was considered to be significant.