The Clinical Analysis Of 42 Cases Of Pancreaticoduodenectomy

Objective: Pancreaticoduodenectomy (PD) is the priority choice to treat with the tumors surrounding Vater's Ampulla as well as the joint section of pancreas and gallbladder. With the development of surgery technology and the increasing outcome of medication therapy,either the success rate of operation or the complication risk has significantly been ameliorated. In order to deepen our understanding and acknowledgement of PD,our research has analysed and discussed the clinical data and therapy experiences of 42 cases of PD in terms of the possible measures of reducing post-operation complications as well as fatality.Methods:The author selected 42 patients who has gone through PD at the Second Hospital of Hebei Medical University in the period of Feb 2008 and Feb 2010 as the subjects of observation, and had all the clinical data sorted and analysed. With 27 male and 15 female, the age scope of the crowd was 37 to 74.It had been thoroughly verified by means of pathological diagnosis that there were 18 cases of inferior segment of cholangiocarcinoma,14 ampullary carcinoma,5 pancreatic carcinoma,2 duodenal carcinoma,and one case of gallbladder carcinoma.Alternatively there were 4 cases that combined with cholelithiasis,6 with HT and 5 with DM.The main clinical symptom was jaundice(85.7%).The pre-operation total bilirubin on average is 190.1mmol/L.Another 11 case(s26.2%) were also afflicted with hypoproteinemia. Diagnostic method:Diagnosis rate of CT scan turned out to be 95.0% (38/40) while ultra-sound was 73.8%(31/42);9 cases had gone through abdominal MRI and 11 with ERCP。10 cases (23.8%)had been treated with preoperative biliary drainage. Operation method:Standard PD,with one case combined with affected inferior vena cava resection and repair,one with affected inferior vena cava resection and end-to-end anastomos is.Pancreaticojejunostomy method : 23 cases ( 54.8% ) of end-to-end pancreaticojejunostomy,11 case(s26.2%)of binding pancreaticojejunostomy ,and 8(19.0%) end-to-side pancreaticojejunostomy.Result: Processes of each operation went on favorably with an average holding time of 5.5 hours and a perioperative fatality of 2.4%(1/42)。There were 10 cases presenting with complications out of the whole group ,adding up to an incidence of 23% ,of which pancreatic fistula has a proportion of 4.8%(2/42),biliary fistula 9.5%(4/42);post-operative hemorrhage 7.1%(3/42),pulmonary infection 4.8%(2/42),and incision infection 2.4%(1/42).Discussion:The treatment scale of PD had a coverage of the following : malignant carcinoma of medial and inferior hepatocystic duct,caput pancreatic, periphery Vater's Ampulla area and duodenum ;infiltrating carcinoma of caput pancreatis and duodenum originated from carcinoma ventriculi or colon carcinoma; severe trauma of caput pancreatis and duodenum.Some suggested that PD be applied only to the treatment of malignant tumors. However, it turned out to be the other way around, according to our experiences, that it is quite viable to enlarge the indications for excision in some experienced hospitals with abundant necessary conditions.It is of vital importance to obtain precise diagnose in early stage by means of auxiliary examination .Imaging examination gives clues on the existence and location of the lesions, whether there is any metastasis or indications for radical excision. Laboratory examination highlights on the liver functions, in which the increased BRD is the main manifestation of jaundice obstructive,and total serum protein (of which serum albumin especially) is not only a significant indicator for liver function but also as an indispensible clew on the pre-operative nourishment status .Some articles have pointed out that there is close correlation between pre-operative hypoproteinemia and post-operative complication risk. It is based on the significantly increased serum tumor markers that various malignant tumors are diagnosed.It is of high significance for the a steady and sound recovery to conduct perioperative treatments that mainly includes cardiovascular disease, respiratory system disease, DM,hypoproteinemia,liver and kidney failure as well as coagulation disorders and so on. It is when the BP of each of the 6 cases who have HT in combination are closely under control of below 160 / 90 mmHg that the operations are be performed. Post-operative early-stage electrocardiogram and BP monitors are conducted to have an in-time detection and treatment of cardiovascular accident. Respiratory system disease manifests itself mainly in the form of post-operative pulmonary infection which can be prevented by active early-stage applications of apophlegmatisant and expectorant. The 5 cases that afflicted with combined DM embarked on the BS control with the help of regular insulin and didn't have the operation until a stable BS was achieved for 1 week. Post-operative dynamic BS was monitored .Insulin application was adjusted on the basis of BS and urine sugar(US). Hypoproteinemia was dealt with aggressive correction pre-operatively and re-examination routinely as well as giving in-time supplement post-operatively. Malnutrition can be treated with the help of parenteral nutrition. Water, serum electrolyte as well as acid-base imbalances are corrected at the same time. 1 case of death was caused by post-operative liver and kidney failure. Jaundice obstructive poses the risk of leading to cholestatic hepatitis,the pre-operative prophylactic measures include high protein diet,supplement of vitamins,liver protectant application,and the improvement of liver function. Observations of urinary production, BUN and CRE are performed routinely. For those who have the tendency of pre-operative hemorrhage, coagulation factor disorders are corrected for a near-normal PTT.As jaundice obstructive has a heavy impact on the individuals,it is reasonable,in abstracto, to preoperative biliary drainage for a lower risk of complications and fatality.10 cases(23.8%) of the group had been treated with preoperative biliary drainage ,of which 7 cases was performed with ENBD ant the rest 3 with PTCD, all producing improved results that exhibited outstandingly ameliorated general conditions, nutrition status and liver function. Compared with ENBD, we have got the conclusion that PTCD is holding its own preponderance in terms of manipulative viability, post-operative complication risk,cost as well as post-operative maintenance.The prevention and treatment of operation-related complications, including pancreaticobiliary fistula and post-operative hemorrhage are the priorities for a better recovery rate. Pancreatic fistula is one of the most critical and commonplace complications of PD, as well as an important fatal element post-operatively. It will play a significant part on the prevention and treatment of pancreatic fistula if proper pancreaticoenterostomy is chosen, and a tube with free drainage is just in place .Additional factors to decrease the complications ,no less important, are the experienced surgeons themselves and the familiar operative style they prefer. If pancreatic fistula does occur, measures are taken such as delaying the extract of abdominal drainage tube, through which drainage and irrigation are achieved. Other measures such as sensible application of somatostatin,antibiotics, nutritional support are also indispensible to minimize the risks. In our research the incidence for pancreatic fistula is 4.8%, all of whom received conservative treatment for 4 weeks with full recovery. Bile leakage is often the result of inadequate drainage and nastomosis technique defect. Choleduodenostomy takes T-type tube as the exoteric drainage system that greatly alleviates the tension on the stoma and ultimately reduces the risk of bile leakage. It is often the case that bile leakage goes hand in hand with pancreatic fistula, which should never be neglected. Common considerations for post-operative hemorrhage are source back to raw surfaces or gastroenterostomy stoma, which can be precluded by means of aggressive stanch during surgery,the conviction of freedom of canales ventriculi,T-type tube and abdominal drainage tube as well as the application of gastric acid depressor.In general, the keys to prophylaxis against post-operative complications, increasing PD success rate and achievement of expected result are: early-stage tangible diagnosis, sensible chosen anastomosis style, delicate perioperative management .