Training material V
Treatment of carcinoma of pancreas head and carcinoma of ampulla
首先施行胆囊切除术，在切除胆囊的同时应探查胆总管和胰腺头部的病灶大小，侵犯的范围和周围有无与大血管的粘连侵犯等情况。除此以外，还应探查腹主动脉旁淋巴结等。根据手术探查情况，决定手术术式和手术方法。
如探查胰头癌己有广泛转移而无法切除时，可考虑施行胆总管空肠 Roux-y 吻合术，从而解除病人的黄疸问题，减少病人的痛苦和延长病人的生存期，如胆总管已有癌肿侵犯，胆囊又无法保留，则应给予肝总管切开置入T型管引流术。如术中证实无远处转移，病灶尚可活动，应考虑施行胰十二指肠切除术，但应根据以下情况进行选择。
凡诊断为壶腹部周围癌，临床上又无手术禁忌症时，均应力争一期手术切除。如病人长期有严重的黄疸，周身情况不佳，不能耐受一期手术时，可行二期切除手术。但二期手术可能由于腹腔粘连或癌肿转移固定，给手术带来困难。
术前准备:
1、黄疸病人因肝功能受到一定损害，凝血机制往往不佳，术前注射 GS、Vc、Vk1 和辅酶Q10等改善肝功能和凝血机能，促进出、凝血时间恢复正常，以免术中、术后出血，如有重度黄疸或合并胆道感染高烧者，应分期手术，即第一次开腹探查行胆囊造瘘术，或胆总管切开T型管引流术，待2-3周后黄疸消退，再行根治性切除手术。
2、老年体弱、贫血和低量白血症的病人，应适当输新鲜血，有助于凝血机制的改善, 口服胰酶类助消化药物。 配血400ml x 3以备术中应用 。
3、为了预防和治疗胆道感染，注射广谱抗菌素等。
4、术前一天给予配血 400mmlx3，以备术中应用。
5、术前应邀请麻醉科会诊，请麻醉科医师根据病人的具体情况选择麻醉的种类和方法。
6、术前应与病人家属说明病情及手术的必要性，以及手术中、术后可能出现的各种并发症，甚至发生死亡的可能，取得完全同意后并以签字为凭，方可考虑手术。
7、术前静滴20% Albumin 50 ml。
关于胰十二指肠切除手术步骤问题：
胰十二指肠切除手术步骤比较复杂，手术难度也较大，术中、术后并发症也较多，但可归纳为以下几个程序。
第一，进入腹腔后首先是探查有无远处转移和肿瘤局部的移动性，以及癌肿的原发灶是否来自胰头。
第二，如癌肿原发灶來自胰头，应进行试行分离，最后确定癌肿是否能被切除，同时还需进一步检查癌灶和腔静脉、腹主动脉、门静脉、肠系膜上静脉之间有无实质性浸润，以便最后确定肿瘤能否被切除，如确定癌肿能够根治切除时，便开始切断肝总管、胃、胰腺和空肠。
第三，切除病灶，最后切断钩状突，病变切除之。
第四，重建消化道，按胰、胆、胃或胆、胰、胃的顺序和空肠之间各别吻合。
胰十二指肠切除术式有以下几种，供手术时选择釆用：whipple 法 Child法 Cattel 法。
胰十二脂肠切除术的注意事项：
1、决定能否做胰十二指肠切除术的关键问题有二：（1）胰头后面与腔静脉、腹主动脉之间有无癌肿浸润现象。 （2）胰腺后面与门静脉和肠系膜上静脉之间有无癌肿浸润。 若其中之一有癌肿浸润时，则不适应做胰十二指肠切除术。
2、处理胰头、体与肠系膜上静脉之间小静脉时，应先结扎后切断，以免出血，如一旦出血，应立即以手指压住出血点，和肠系膜上静脉的上下两端，吸尽血液，看清损伤部位，准确钳夹止血，切勿盲目钳夹造成损伤。
3、胃的切除范围，一般在1/3-1/2不等。
4、胰瘘是胰十二指肠切除术后最危险的并发症，其发生率很高（20%-30%左右），一旦发生，往往有生命危险，必须加强预防措施，减少此一并发症的发生。
术后处理：
1、术后如血压平稳，可取半卧位。
2、腹腔引流管接计量瓶，记录24小时引流量，并观察其性状，如无其他特殊情况发生，一般在术后5-7天拔除引流管。
3、禁食, 持续胃肠减压，静滴 5% GS 和补充电解质、Vc、VB、Vk1 等，一般持续 4-5天，，待肠鸣音恢复后，拔除胃管开始进流质饮食。
4、广谱抗菌素的应用。
5、为了促进创口早期愈合，术后间隔补充血浆或全血，或 20% Albumin 50 ml。
6、注意口腔护理，鼓励病人作有效的咳嗽，并协助病人不断排痰，以防止合并胸膜炎和肺内感染或肺不张等并发症。
7、术后一周内要严密观察有无腹膜炎发生，如有腹膜炎发生，应及时给予引流
First of all, cholecystectomy should be performed. At the same time of cholecystectomy, the size, extent and periphery of lesions in common bile duct and pancreatic head should be explored, as well as whether there is adhesion invasion with large blood vessels. In addition, the para-aortic lymph nodes should also be explored. According to the surgical exploration, decide the surgical operation and surgical method.
If extensive metastasis of carcinoma in the head of pancreas cannot be resected during exploration, Roux-y choledochojejunal anastomosis can be considered, in order to relieve the patient's jaundice, reduce the patient's pain and prolong the patient's survival time. If there is invasion of common bile duct carcinoma and the gallbladder cannot be preserved, T-tube drainage through incision of common hepatic duct should be performed. If it is confirmed during surgery that there is no distant metastasis and the lesion is still mobile, pancreaticoduodenectomy should be considered, but the choice should be made according to the following circumstances.
All patients diagnosed with periampullary cancer and without clinical contraindication to surgery, should strive to a surgical resection. If the patient has severe jaundice for a long time and has poor general condition and cannot tolerate the primary operation, the secondary resection can be performed. However, the second-stage operation may be difficult due to abdominal adhesion or cancer metastasis fixation.
Preoperative preparation:
- Patients with jaundice suffer from certain damage to liver function and often suffer from poor clotting mechanism. Pre-operative injection of GS, Vc, Vk1 and coenzyme Q10 can improve liver function and clotting function, promote bleeding and restore clotting time to normal so as to avoid intraoperative and postoperative bleeding. In case of severe jaundice or patients with concurrent biliary tract infection and high fever, staged operation should be performed, i.e., the first laparotomy and fistulization of gallbladder or T-tube drainage of common bile duct incision. After the jaundice disappears two to three weeks, radical resection should be performed.
- the elderly, weak, anemia and low volume of patients with hyperlipidemia, should be appropriate to lose new blood, help to improve the clotting mechanism, oral trypsin digestive drugs. Blood matching 400ml x 3 for intraoperative application.
- in order to prevent and treat biliary tract infection, injection of broad-spectrum antibiotics, etc.
- one day before surgery with blood 400mmlx3, for intraoperative application.
- preoperative anesthesia department consultation should be invited, please anesthesiologists according to the specific situation of the patient to choose the types and methods of anesthesia.
- preoperative should explain the condition with the patient's family and the necessity of surgery, and surgery, postoperative complications may occur, and even the possibility of death, after obtaining full consent and with signature, can consider surgery.
- Intravenous 20% Albumin 50 ml is given before operation.
Problem about surgical procedures of pancreaticoduodenectomy:
Pancreaticoduodenectomy is a complicated procedure with great surgical difficulty and many intraoperative and postoperative complications, but it can be summarized into the following procedures.
First, after entering the abdominal cavity, we first need to explore whether there is distant metastasis and local mobility of the tumor, and whether the primary tumor of cancer comes from the head of pancreas.
Second, if the primary tumor of cancer comes from the head of pancreas, we should try to separate it and finally determine whether the cancer can be removed. At the same time, we need to further check whether there is any substantial infiltration between the cancer and vena cava, abdominal aorta, portal vein and superior mesenteric vein, so as to finally determine whether the tumor can be removed. If it is determined that the cancer can be completely removed, we will start to cut off the common hepatic duct, stomach, pancreas and jejunum.
Third, resection of the lesion, and finally cut off the uncinate process, the lesion resection.
Fourthly, the digestive tract is reconstructed by anastomosis between pancreas, gallbladder, stomach or gallbladder, pancreas, stomach and jejunum in that order. There are several types of pancreaticoduodenectomy, and the whipple method, Child method and Cattel method are optional for operation.
Precautions of pancreaticoduodenectomy:
- Two key issues determine whether or not pancreatoduodenectomy can be performed: (i) Whether there is cancer infiltration between the posterior part of pancreatic head and vena cava and abdominal aorta. (ii) There is no cancer infiltration between the back of pancreas and portal vein and superior mesenteric vein. Pancreaticoduodenectomy is not appropriate if one of them has invasion.
- processing of pancreatic head, small vein between the body and superior mesenteric vein, should be cut off after ligation, in order to avoid bleeding, such as once bleeding, should immediately with finger pressure bleeding point, and the upper and lower ends of the superior mesenteric vein, absorb blood, see the damage location, accurate clamping hemostasis, do not blind clamp damage.
- the scope of gastric resection, generally in 1/3-1/2.
- Pancreatic fistula is the most dangerous complication after pancreaticoduodenectomy. Its incidence is very high (about 20%-30%). Once it occurs, it is often life-threatening. Preventive measures must be strengthened to reduce the occurrence of this complication.
Postoperative treatment:
- such as stable blood pressure after surgery, desirable half a lie.
- The abdominal drainage tube was connected with a metering bottle, and the 24-hour drainage volume was recorded and observed. If no other special circumstances occurred, the drainage tube was generally removed 5-7 days after surgery.
- Fasting, continuous gastrointestinal decompression, intravenous drip of 5% GS and supplement of electrolytes, Vc, VB, and Vk1, etc., generally for 4 to 5 days. After the borborygmus recovers, the gastric tube is removed and the fluid diet is started.
- the application of broad-spectrum antibiotics.
- To promote early wound healing, plasma or whole blood, or 20% Albumin 50 ml was added at intervals after surgery.
- pay attention to oral care, encourage patients to make effective cough, and to assist patients with continuous expectoration, in order to prevent combined pleurisy and pulmonary infection or atelectasis and other complications.
- within a week after surgery to closely observe the presence of peritonitis, if there is any peritonitis, should be given timely drainage.
术后开发症：
1、胰瘘，多发生在术后5-7天，病人出现腹痛、腹胀、高烧、巩膜黄染和引流量增多现象，应考虑为胰瘘的发生。胰瘘发生后一般采取保守治疗，但必须给于支持疗法。
2、内出血。腹腔出血偶有发生，可给予止血剂的应用、输血等治疗，如有活动性出血，经保守治疗无效时，应给予再次手术止血。
3、腹腔内感染。腹腔内感染也是一种严重的并发症，一旦发生，应首先采取保守治疗。如有脓肿形成，应给予及时的手术引流，除应给予抗菌素治疗外还应给于输血，或血浆，或 20% Albumin。
4、胆瘘，很少发生，一旦发生，应充分地进行引流和体外营养液的补充。
Postoperative development:
- Pancreatic fistula occurs more than 5 to 7 days after operation. The patient suffers from abdominal pain, abdominal distension, high fever, scleral yellowing and increased drainage volume. The occurrence of pancreatic fistula should be considered. Conservative treatment is usually adopted after the occurrence of pancreatic fistula, but supportive therapy must be given.
- Internal bleeding. Abdominal bleeding occurs occasionally, and can be treated with hemostasis, blood transfusion, etc. If there is active bleeding, and the conservative treatment is ineffective, reoperation shall be performed to stop bleeding.
- Intra-abdominal infection. Intra-abdominal infection is also a serious complication that should be treated conservatively first. If an abscess is formed, prompt surgical drainage should be given and, in addition to antibiotic therapy, blood transfusion or plasma, or 20% Albumin.
- biliary fistula, rarely occurs, once occurs, should be fully drainage and supplement of nutrient solution in vitro.
This article was originally published in Proceedings of Wuhu Annual Surgical Conference,1996；28-30 Changhang Hospital, Li Mingjie
from 外科截瘫14例手术分析
