Wei CHENG Laparoscopic Pancreaticoduodenectomy

provincial hospital. I'm Dr. Chen Wei. It's my great honor for me and our group to take part in

one of the greatest meetings in the world, the Italia Surgeons Meeting. And we have been invited

by professors to take part in this meeting and share what we do, the precision, all over the

world and we come from the Hunan provincial just at the center of China

and our hospital have to have four thousand beds one of the biggest

hospital in the middle for China and we have the hepatobiliary and pancreatic

department for six six hundred beds and we do the procedure the procedure of

of hepatobiliary and pancreatic precision about 10,000 in one year and it's an opportunity

for us to show what we do the pancreas surgery today today we have a case with the laparoscopic

pancreas diadenonectomy and the surgery group including Dr. Li Jian and Dr. Xie Qin

And the anesthesiologist, the chair is Liu Jitong,

and the surgical nurses are Zhao Xiaoni and Wang Saiping.

And thank you all.

And we have Dr. Wang Xitao to introduce the case.

Okay, thank you.

Dr. Wang Xitao Thank you.

Thank you. We are truly honored to have Professor Wei Cheng today at the 36th Congress of Assyriac Digestive System.

And we look forward to this live demonstration of a laparoscopic pancreatic dodenectomy. Thank you.

I'm Dr. Wang Xitao from Hunan Provincial People's Hospital.

Next, I will give a brief introduction of our case.

This is a 51-year-old female with a BMI of 24.8

who presented with painless jaundice lasting for more than 20 days.

The jaundice was associated with dark yellow urine,

pruritus, generalized fatigue, and poor appetite.

She was evaluated at an outside hospital

where ERCP revealed a malignant structure in the middle common bile duct.

Biopsy confirmed a moderately differentiated adenocarcinoma.

She was then admitted to our hospital.

Her past medical history is notable only for a caesarean section 20 years ago.

On physical examination, an EMPD tube was inserted and patented, draining dark green bile.

No additional abnormal findings.

liver function tests demonstrated a total bilirubin of 97.2 micromoles per liter

direct bilirubin was 69.6 micromoles per liter alt is 550.3 units per liter and the ast is

is 346.5 units per liter.

The tumor marker of CA-99 was elevated at 65.88 units

per liter millimeter.

And the other laboratory test venues

were within normal limits.

The imaging studies reviewed circumferential wall

thickening and the luminal narrowing

of the common haptic duct

and both upper and lower

segments of the common bile duct.

Next, let's show

the image of the patients.

Next is the MRCP

of the patient.

The preoperative ERCP demonstrated marked dilatation of the intrahepatic bile ducts.

The upper segment of the common bile duct measured approximately 1.3 cm in diameter,

and a segmental structure about 2 cm in length was identified in the middle common bile duct.

Under direct visualization with the spyglass system, a circumferential narrowing with nodular

musical thickening was noted, causing significant luminal obstruction. Three biopsies, the specimens

were obtained from the lesion. The tissue was firm in consistency. Pathology confirmed a

moderately differentiated adenocarcinoma of the common bile duct. Preoperatively, the patient

underwent endoscopic nasal biliary drainage to relieve jaundice. At present, her total bilirubin

is 64.9 micromoles per liter with direct bilirubin at 47.1 micromoles per liter and indirect

bilirubin at 17.8 micromoles per liter.

Our working diagnosis is ectra-heptic conangio-casinoma, clinical stage T2NXMO accompanied by obstructive

jaundice.

status post EMBD the plant surgical procedure is a LPD okay next I will

introduce the two commanders of our operation the first one is profess

Lucey Paul come from the first assiliate hospital of Nanjing Medical University

He has a lot of titles of academic and administration, so here we'll give a brief introduction.

He is a member of Royal College of Surgeons of Edinburgh, and a standing committee member,

Pancreatic Tumor and Youth Session, China Chapter of IHPBA, member of Pancreatic Cancer

Cancer Expert Committee, Chinese Clinical Oncology Society.

And the next one is Professor Kong Yuanwei,

the first affiliated hospital of Xi'an Jiao Tong University.

He is a doctor of surgery.

He's a doctor of surgery, graduated from University of Heidenberg, Germany.

The founding member of International Society for Minimally Invasive Pancreatic Surgery.

He is also a member of the International Working Group on Ampullinary Tumors.

Let's welcome the two commenters.

Thank you.

Thank you very much for the presentation.

We are ready for starting the surgery when you want.

Just a moment.

We'll be showing you the operating field through the laparoscopic view.

Just a moment.

Now we can see. Perfect.

Okay.

Yes, the patient had previously had C-section.

We just use the ultrasonica to location the carcinoma,

and we decide to do the LPD because the length of the carcinoma is very long.

Let's see here.

The carcinoma is here, and we use the ultrasonica to identify the resection margin.

of the common bile duct, maybe to the junction of the left

and the right haptic duct here.

Okay.

Now we do the COCO procedure to isolate the duodenal.

I'm sorry, for the organization,

you have to unshare the screen because we don't see,

at least myself, I don't see the surgery on the main screen.

Okay, just a moment. Let's adjust the screen.

I don't know if you have the same problem.

Yes, same here.

Okay, thank you.

Mr. Mario, we have the same problem here.

Okay, thanks.

By the way, meanwhile, nice to meet you.

I'm Giuseppe from Verona, Italy.

把那个PPT的共享关掉

不是手术画面

我这边来操作一下

好了

Dr. Mario, is that okay for you?

Sorry?

Now it's okay for you, right?

You can see the...

Yeah, I see a big screen with a lot of people trying to click

on the surgery screen

Not there yet

Yes, good. Yes. All right. I can see pretty well now. So my first question is pretty obvious.

And why laparoscopic instead of robotic surgery? Is there any particular reason for that?

In China, the main concern would be the economic or cost concern for the patients.

Sometimes they cannot afford robotic procedures.

Okay, so a question of cost effectiveness. It makes sense actually because although

robotic platform is very convenient in terms of ergonomics, it has never been shown that

but it's more cost-effective than the laparoscopic approach.

So I think it's a good answer.

Thank you very much for your answer.

Dr. Man Liu, the reality in China is that

the patient cannot get reimbursement from the government for robotic surgery.

I see.

It's not only a cost-effective issue,

so it's like a direct investment.

so patients need to pay like extra 8 000 us dollars for that okay so if they want robotic

surgery they have to pay out of their pockets basically that's right okay i see i see i see

i see yeah we don't have the same issue in in italy because the like we have sort of a universal

universal coverage for for people and so the government will pay for robotic platform although

in Italy there's a big debate about effectiveness because platform is expensive of course and that's

the number of procedures are increasing increasing and increasing even for major surgeries like

mirror surgery pancreatic surgery esophageal surgery you know there's an issue about the

actual cost effectiveness and so there's a big debate about that and because we we have

transition directly from open surgery surgery for head resections for tail resection we passed

through um through laparoscopy to be honest for for for head resection we went directly from

open surgery to robotic surgery should i transition to laparoscopic head resection should

i go back to to laparoscopic heterosection i would be a little bit in trouble because

i've never done it i'm i'm gone straight from open to robotic surgery so i'm a bit unfamiliar

with this sort of procedure so i'm very curious to see how it is performed yeah i should say

china china is a big country for laparoscopic hpp surgery so a lot of surgeons including uh prof

the chen who is performing surgery a really expert at laparoscopic yeah yeah we can see

from the operation he went straight to the vein now we have endless trunk under vision

i think he's ligating the pancreatic branch of the endless trunk yeah yes

uh dr malik can you give the current numbers or or key numbers of like how many percentage of

of WIPO procedure being performed in Italy

or in your institute?

Oh, like the national data?

The national data, I don't know exactly, to be honest.

In my institution, it's 500 per year.

500 per year?

500 per year, yes.

For robotics, right?

No, because we have just one robotic platform.

from I mean we have my hospital has two locations and HPV is in is in one location all the other

surgical branches are in the other locations in that location we have one robot for liver

and pancreas and in the other locations there are four robots but they work for the whole hospital

so also gynecology thoracic surgery cardiac surgery and so on so we alternate we have the

robot twice a week three times a week so it's five slots every 15 days so we cannot do all procedures

just robotically because of the availability of the platform of the system so we do i think this

year is going to be around 150 160 robotically and dress laparoscopy and open circle i mean maybe for

China is not a huge volume because I've heard about like even 700, 800, even 1,000

sections annually, but for Europe, with Heidelberg, it's the highest volume.

So for being a European institution, we are pretty high in terms of annual volume.

Oh, nice.

Now it's mobilizing the Duodino, the knee of the Duodino.

Oh, no, the Duodino.

It's harmonic case.

is the same we use in laparoscopy we can see in a cover now so for the left hand

of dr. Chen he's using a bad people a laparoscopic people nuclear okay so it's

very convenient you can see he can do hemostasis with the people are very yeah it's like a robotic

surgery where you have to electrify instruments yeah the sister and the maryland force

yeah so now is i think the idea is peeling the mesocolon of the uncinate process

and free the duodenum behind to control the pancreatic head

Wow, very nice view of the major vessels here, going towards the mesentery route.

Yeah.

Yeah.

Yeah.

So for this patient, the ligament of trice is somehow more to the left.

So Dr. Chen spent more time in immobilizing the pancreas head

and the duodenum with the Cochrane maneuver.

So this is a pancreatic dorsal artery here.

Okay.

Right.

Dr. Mario, do you regularly transect the pancreatic dorsal artery in the inferior border of the pancreas?

Yes, if it's clearly seeable, yes.

Do you have any concerns that the ligation of the pancreatic dorsal artery will cause a

No, the pancreas has lots of arcades.

It's a well-vascularized organ, so I don't have any concern.

Although there is information that pancreatic fistula might depend on poor pancreatic arterial flow,

there's no evidence about that, so to be honest, I have no concern about ligation with dorsal artery.

The last time we went to talk with Giovanni Macchianni, and he is so concerned about ligating

and transacting the pancreatic dorsal artery at this point.

Me either.

So I don't think it will cause any problem.

I don't think so, honestly.

So here we are trying to transect the gastric.

I don't know, but we may still choose to do PPPB as the preferred procedure.

So, Dr. Mario and Dr. Kamarata, Dr. Chen is going to do a classical WIPO procedure today.

And classical WIPO procedure is the first choice in their institution.

I don't know what's your first choice.

it's a pylorus preserving or classical in your institution pylorus preserving pylorus we normally

do pylorus preserving um we do a weepo procedure when there's um direct signs of involvement

the pylotic area if the tumor is in the dorsal part of paper but i see i acknowledge there's

There's no difference in the literature with respect to the myeloid resecting procedure.

So it's equivalent and has no, you know, consequence on delayed gas recanting or other types of

complications.

So for the audience, it's left to the surgeon's preference.

Yes, we have the same approach also in our institution.

And also, we also choose PPPT, you know, institution as the first choice.

okay so today the stabilizer was abandoned by an ai technology so the chief to decide the speed

how you cut the tissue yeah and the company said that you'd use it quite a lot in italy

So, Dr. Chen would like to know the incidence rate of delayed gastric empty in your institution.

Can you have a brief introduction of that information?

yes of course it's roughly about seven eight percent and we didn't find any particular

procedure which will prevent it you tried everything but I think it's some somewhat

unavoidable in a small fraction of patients for reasons we don't know like that innovation or

functional reasons we can figure out um we try to manage yes more conservatively the more

conservatively we can so ng2 for the very minimum necessary refeeding as soon as possible we try to

be aggressive and we just say to our patients is like an athlete who tore the knee and has to be

back to the pitch to the playing field as soon as possible so we we we try to be proactive in in the

dg management once upon a time i mean when i was a resident they they just had the ng tube in place

and they stood there for 15 days without having nothing kneel by mouth and so on and i have to

say that most of the times it resolves with with in in just a few days sometimes of course you have

to place it and like a feeding tube and and go for enteral nutritions for some days a week or so it

really depends but we try to be pretty proactive in the management of dg which remains fortunately

uh would say a minor complication it's unlikely that the patient will stay along in hospital just

because of dg then you have to see if dg is primary or it's something dependent on underlying

underlying cause like fluid collection or a delayed pancreatic fistula so it's important

to do a cd scan to check for for peripancreatic collections which touch you know the stomach and

cause a secondary DG but if the DG is primary again we try to be very aggressive in in its

treatment but by the way the incidence is around seven eight percent okay thank you our rate is a

light a little more higher than percent I think because we have our important

story of open surgery now we can now we are see a good trend for the minimal

invasive procedure so just a question how do you manage the more significant

the DGA cases it's a question to me to you obviously and to professor Chang okay

Okay, so I will, Professor Cheng is the protagonist of this session,

so I let him answer first, and then I will give my answer to him.

Professor Chen, they want to know,

one, what is the rate of DGE on your side,

and the second is, how do you treat or deal with these serious DGE patients?

To be honest, I don't know why,

Okay. Zhang Han, is it your translation or my translation?

Okay, I'll do this part.

So in the south part of China, where we are,

actually the rate of DG is relatively low, between 3% to 5%.

And usually it's mild.

We don't need specific treatment for that.

And in China, we're also using traditional Chinese approaches,

for example, the acupoints to treat some patients with mild DG.

that's what you mean while we are we are seeing lymph anectomy of station 8a so common hepatic

artery it's very nice so therefore hepatic artery will be isolated i also see maybe left gastric

vein exactly behind there which is appearing and then i think that once my country is isolated

the retro pancreatic tunnel will be developed going back to the to your

question I mean there's no specific treatment for for there's no specific

treatment algorithm for for DGE it really depends on patients condition so

all our all our patients are seen by a dietitian dedicated dietitian so first

we try to adjust the diet with a fractionated diet very light diet if

the patient does not tolerate it then we go for significant vomiting and we stay still for a

couple of days and then we try to put the patient basically we also sometimes try chewing gum and

coca-cola although this is not evidence-based we tried coffee in a randomized trial we are about

to publish but there there was no evidence um that coffee um speeded the recovery of patients

with dge we tried also decaffeinated coffee as a sham procedure but it didn't work either

so there's again no specific treatment so we try to manage coffee it's a cappuccino espresso

special espresso espresso espresso espresso the trial is called cops coffee in pancreatic surgery

but it was espresso it was an espresso shot for five days post-operatively in patients with

actually it was not targeted to delayed gastric emptying it was targeted to the first place

and to see if the you know within an era's pathway we were able to speed the process up even more

but it was a negative trial and even in patients with dg didn't help that much in resolving the

complication but again it was fun because we brought a coffee machine in the world

and we were making coffee for all patients and we didn't know if it was caffeinated coffee or

decaffeinated coffee so it was fun for the nurses too okay very interesting child i should say

look forward to your paper yeah yeah yeah yeah all right we are seeing the body cut tree and

the vision is a little bit blur but i can see the portal vein appearing behind there

there it's nice because in laparoscopy you have four arms simultaneously in robotic surgery we

we have um very active laparoscopic assistance i have to say so we normally use um we do the

The funnel still incision from the start,

from the outset of the operation.

And we put, we place another laparoscopic trocker

between arm three and arm four,

in order to have two ends

and assist laparoscopically from table.

And it sometimes helps for, you know,

speeding up the procedure.

Now we see four arms moving, you know,

harmonically very nicely in the field.

and this makes the procedure very smooth and quick.

It's very nice to see.

They seem very coordinated, very familiar with the procedure.

It's very beautiful to see.

There is an assistant who can use a machine to better help the separation and exposure of the

Dr. Chang, can you tell us the percentage of robotic surgery in Italy?

Dr. Chang would like to know the overall percentage of robotic surgery

surgery um in full for HPV across the whole Italy what's the percentage of robotic surgery

ah you know nationwide oh it's very hard to say it's very hard to say because although we have

um National registry like imips like International minimal invasive pancreatic contortion we have

like in italian it's called igomips it's an official registry of minimally invasive surgery

but the proportion between robotic and open procedures i don't know exactly i don't know

exactly again in my institution is about as i said before would say 25 to 30 percent but if it applies

Why is to a national level? I don't know, to be honest.

Dr. Wang and Dr. Camerata, Dr. Chen would like to know how you detect the GDA in minimally invasive weepo.

because in China we're so afraid so cautious about the pseudoneurism at

all right GDA so usually we'll have ligation with silk suture first and with

the clips so he'd like to know how you transact the GDA either laparoscopically

exactly or robotically the very same the same the same yeah we instead put only three amolok without

the uh the shooter we even place actually and nor I mean I I can't see exactly what sort of suture

it is it seems like um we we it's silk okay we use also non-reabsorbable future we use

polyester which is not reabsorbable as silk yeah so the very same

especially for uh senior patients I think you should be cautious about

They said it's the same process as yours.

Okay.

Xitao, take a look.

Here, we have found an artery.

We haven't seen it before the operation.

I don't know what this artery is.

So we don't know.

Maybe it's a goblet or artery.

Take a look.

Take a look at this artery.

So Dr. Chen, he encountered an artery, which he showed you a couple of seconds ago.

Yeah, yeah, yeah.

He didn't know that artery on the CT scan, and he thinks the right hepatic artery was behind the biotoxic, so it shouldn't be the right hepatic.

um but it comes off from the uh gda so he will dissect a little bit more and to see

yeah this is uh also uh

So Dr. Chen's team is trying to reassure the rooms of the right hepatic artery.

That's why Dr. Chen moved to the jejunum and to transcend the jejunum.

I should say it's it's kind of quite lucky things to for Chinese pancreas surgeon that

our patients normally will not being so obese yes this is an issue in the western world actually

I mean Italy is not like the United States but nonetheless we have a good proportion of obese

these patients patients whose BMI is above 30 and you know these parts of the operations like

dissection of the regional loop and the mesentery route is pretty tricky in this surgery in these

patients and it's something I mean if we have an obese patient you see this this is something we

do as a first step of the operation before we do it laparoscopically before um before

before docking the robot.

So we replace the trockers,

we do this very part laparoscopically,

and then we perform the robotic docking

and we start the robotic part of the operation.

If they are very obese,

because maybe in laparoscopy it's easier to control.

You can switch the optical trocker

from one port to the other to have a better vision,

lateral vision, because in robot you can't have it,

you can move the camera.

camera so in laparoscopy it's better so we switch to a hybrid procedure that's very nice design I

should say when you have a normal like normal weight patient you can go for a full robotic

procedure so do you think um the BMI would be a selection criteria for your robotic cases nowadays

days i think yes yes um i mean when you have a very good case mix and you see the whole spectrum

of pathologies and the whole spectrum of patients you know bmi comorbidities and so on you can have

a very good selection of your patients for for minimally invasive surgery and for open surgery

Of course, going by with time elapsing, we are going towards performing more difficult

cases robotically, even pancreatic cancers with vascular resections and so on.

But initially robotic surgery was for cases like that, you know.

But yes, generally speaking in Italy, we don't have the same proportion of obese patients

they have in the United States.

uh so that's very good actually but it's i don't think it's like in eastern world like in china or

japan where like i don't have an exact figures where 70 to 80 percent normal weight or even very

thin actually i think since the lifestyle has been changed fundamentally recently so nowadays

nowadays we're having more and more these patients yeah super bees like a real obese patient will

account for like five percent of the patients and overweight will be like uh 20 to 30 percent

oh wow it's more than i thought

Let's go up there.

Let's go in and out.

The blood that came out just now.

The blood that came out here.

Let's wash it.

Is there blood coming out of the stomach?

Yes, blood coming out of the stomach.

Give me one.

What's the use?

There's a lot of blood here.

Let's wash this blood.

Don't keep vomiting.

What are you doing?

Wipe that off for me.

All right, so we are starting with the pancreatic transaction.

In China we use the method that we resection the liver to use the

it's really millimetric yes

it's peeling off the part of vein from its groove and there's going to be a posterior superior

it's important even in like more straightforward cases to mobilize the

vein as much as possible have a very nice access to the artery groove and

and control the artery better yeah i can't agree more

because the doctor chin think the artery oh no no there's a vein the wall of the vein is

so thing so he don't think the clip will be reliable yeah I guess so even angle

the inclination is not advantages so if the wall is very thin you risk to tear

it so the stitch was way the better the best option I agree

Alright, we see the last part of the Ancinex process, we must have the first jejunal down

there.

there maybe another small vein connecting the first jejunal vein with the ancient process and

then we are done there we go there we go the posterior inferior in creative pain

treatment for pancreatic ductal

adenocarcinoma.

It's a question for Dr. Chen, right?

Yeah, also

for Professor Maleo.

Just to talk

and to discuss.

Professor Chen, our Italian colleague

asked us about the

number of patients with

adenocarcinoma in China.

What is the proportion of patients with adenocarcinoma in China?

For patients with adenocarcinoma,

we are currently

So the facts and figures in Dr. Chen's institution is that they 100% for borderline receivable,

100% for local vials cases.

For receivable cases,

they only do new adjuvant therapy

in those patients with high risk factors,

such as high level of C99.

So the percentage of new adjuvant therapy

is around 30%.

Yeah, I like it with the European guidelines.

Less than well-adjusted.

right

what is cleaning the optics um yeah of course for locally advanced and more than our second

pancreatic cancer we go 100 of times for new adjuvant therapy for anatomically resectable

pancreatic cancer we use the abc criteria for inpatients with elevated ca99 or poor performance

stages we try to go always um for nuanced treatment i have to say we are switching a little

little bit towards new adjuvant therapy even in uh low-risk cases um I think evidence is coming

there was a nice Chinese trial published uh one month ago in um Journal from the cell group it

was um unusual design because patients were assigned to fulfilling of Spurs and then they

They switched up two months of chemotherapy to a salivarabraxel regimen as a standard of care.

So I think this is another target for heterogeneity.

And they saw that neoadjuvant therapy was better than a frontal section.

I don't remember exactly if it was a phase two or a phase three trial,

but the two big phase three trials of neoadjuvant therapy versus a frontal section are coming.

One is from the Netherlands, it's 3.3.

three the other one is from the united states is the alliance trial pre-open three is almost ready

and will be presented i think at asco next next year and the accrual of the alliance trial is over

so i think that in one year or so we will have some clear answer about the use of neoadjuvant

therapy in in in resectable pancreatic cancer we in italy we did a big trial which was published

like um one week ago in the lancet but it's not about adjuvant uh versus upfront surgery

it's about the best regimen in the neoadjuvant setting and we show that uh quadruplet um which

is called xg is basically a combination which is alabana braxane plus um oxaliplatin and and five a

few is better than full phoenix in the new adjuvant setting and this is pretty similar actually if you

think about that to the chinese trial because they combine full phoenix and it's about the

braxane so the concept is the same having the two backbones together i mean the platinum-based

chemotherapy and inside of a base chemotherapy together as a one to target pancreatic cancer

in the more energetic way possible and this is also consistent with the results of the

pre-op and two trials from the netherlands where for phoenix was not superior to gen

sideband based chemo radiation for for resectable and locally and more respectable patients in the

new argument second so the field is moving really fast and again i think that in one year or so we

will have more precise answer to to these questions so we can put the radiotherapy aside

this is another interesting question i don't know exactly because if you stick to trials

you know radiation therapy um i mean it depends if you if you consider pre-op on two

two, gemcitabine-based chemoradiation, so it's sort of a standard radiation, was equivalent

to modified for filinox as a primary new adjuvant chemotherapy.

If you look at the American data, the Alliance trial, another trial from the Alliance group,

it's a phase two trial, it's a small trial, but stereotactic body radiation therapy was

was not associated to any advantage in combination.

I don't know.

I mean, radiation therapy is a very heterogeneous world.

It depends on what type of radiation you do.

If it is a conventionally fractionated radiation,

if a hypofractionated protocol,

the dose you deliver, the target you have,

If you want to radiate a big field with lymph nodes or if you just want to target the interface and you deliver in that very small volume a greater dose.

knows it so it really depends but there's you know no data which which is actually reproducible and

which shows a a specific role for for radiation therapy in the context of borderline resectable

pancreatic cancer nothing advanced maybe it's a little bit different because they're the primary

you know concept is controlling the disease rather than converting to surgery then if of course if

the patient as a surgical option of course we go for for exploration and possible protection even

with vascular restrictions but their radiotherapy is more a form of disease control rather than a

strategy to help disease to an operable one so in locally advanced pancreatic cancer we are more

liberal with stereotactic body radiation therapy with a dual purpose if we observe the patient

patient after a couple of months and we see the disease is stable then we may consider also going

to the OR because we saw you know in our experience that stereotactic body radiation therapy is not

associated with an increased risk of bleeding or an increased risk of surgical difficulty but again

even in this context that there are heterogeneous opinions there are many surgeons who are concerned

concerned about about reasons and bleeding when you when you get high doses already

um near major vessels like SMA or celiac trunk or whatever we we didn't have any

you in this respect but again it's very variable from percent to center yeah good point now

Now, meanwhile, we are seeing a nice dissection of SMA.

And also, I think Dr. Chen has just ligated the transect to IPDA.

Now we saw the SMA here.

are yeah yeah yeah we saw the ligation of small branches maybe the ipda ipda right

there the first one is ipda the second one is yeah

so you can see how you can manage the level of dissection according to the disease and to

to the potential involvement of the artery.

We do exactly the same in these cases.

We don't go for divestment.

We leave the adventitial plane there

in order to avoid late complications

like diarrhea or high leak.

Will you do a hideable triangle resection for this case?

um i have to say for pancreatic cancer i do always but

um to be honest not because i think it will ameliorate will improve the prognosis

i do it as a standard procedure because i learned it that way and i think an operation

like we put procedure has to be reproducible and teachable I had my personal which includes the

triangle and block and I think it's better for the pathologist to have wider margin to analyze

so I think that we have a better information about our status if you incorporate the triangle

you have for sure more lymph nodes included in your specimen especially station 8 posterior 8p

and 14a so you have a more comprehensive information of what is the disease status

then if it translates to a real improvement of patient prognosis in terms of local recurrence

or even less distant recurrences for you know tumor spread along lymphatics or vessels these

i don't know to be honest and the available trials from korea and we don't have any they do not

support the standard triangle procedure there's a giant in germany of course from the heidelberg

group and other centers in germany which will um show more data i hope but to be honest when

i have the pancreatic cancer i try to incorporate the triangle in in in in my resection i normally

start with a top-down approach not bottom down i mean this is distal cholangio so it's completely

completely different I would go with the very same approach we are seeing if it's if it's a

pancreatic cancer especially some cases I I I I do in open so borderline case a case where there's

a clear infiltration I go for a top-down approach so I start from the body car three I three I dissect

lymph nodes behind the hepatic artery and behind the portal vein and then I go for the time go

go behind the lymph nodes goes behind the artery and then i take away from the artery itself from

top to bottom um i think it's more controllable and it gives you a better clearance but it's you

know i also think that surgery you go you do your surgery according to how your brain works

so it's not a question of what's better or what's worse for the patient it's what's what's more

convenient for your brain you know in order to perform operations smoothly and safely yeah so

it doesn't actually make the difference for for for a patient if you go top to top top down or

bottom up it's it's the same basically yeah um as for the triangle operation and do we have ever

tried to test the newer invasion in the air spaceman of the triangle operation or just for

the limit for node stations i i'm sorry but i was hearing you bad so can you say it again

i mean that in the triangle operation you do the spaceman or the triangle operation the zones

triangle have ever tested as a neural evasion not just for the limit for node station the neural

Neuroinvasion in the triangle section.

What percentage of neuroinvasion?

Ah, okay, sorry.

The line is a little bit disturbed, so I couldn't hear.

So you want to know what is the rate of neural invasion in the triangle?

Yeah.

Ah, well, I have to say it's very high.

I think this depends on the pathologic examination

information on my microsoft information and if i can't answer i i don't have any exact data but

so almost always okay

This is consistent biologically with cancer spreads along the neural sheaths.

And because lots of publications have proved that the neural ovarian has a very strong connection with the recurrence of the disease or the cancer,

so that's why i asked for the trial operation for this specimen maybe the neural variant is more

important than the lymph node very yeah yeah oh we lost the signal

so now we can imagine the operation

okay now he's gone back to that hepatic cartridge that vessel

It was not clear.

So,

Dr. Chen thinks it's probably

a cystic artery.

So,

yes, it's wise to dissect

the gallbladder

first.

And then see where...

Yeah, to be sure.

It's a very

prudent approach which I like because you never have to be too sure about the

anatomy you always have to double-check

fastest cold-blooder ever

and maybe they have a different conclusion about our survey versus the new general chemistry

that's the information like firstly it's about three is that new adjuvant therapy seems to be

better but we yep but we don't have the final date i mean maybe in the netherlands they have

have but this is not official not presented in any meeting so we can't say yes just look forward

artery and the other very small I should say the branch to the liver yeah so uh Dr Chen will

probably sacrifice the the

I said, let's go this way.

Let's go this way first.

Come on, little Hamlok.

I said, I'll go this way first, and then this way.

Let's see if there's anything.

Let's see if there's anything.

Go up, go up, go up.

So, Professor Chen, you're going to cut off the gallbladder first,

and then look at the branch at the back, right?

Yes, I'll leave it here.

Leave it here.

Leave it here.

Leave it here.

That's the meridian.

I think it just needs twice a day to come out I think dr. Chang is trying to

dissect the large a little bit more to confirm that he has preserved the right

hip I've got my country yeah because it is very hard to identify the artery so

So, I isolated the common haematical artery and the...

I put it up and then went to find its path.

I put it up.

Is this a lymph node or what?

It's a lymph node.

Look at this.

Look at this.

Look at this.

Look at this.

Wipe it off.

This is the meridian.

This is the blood vessel.

This is where the meridian is going to go.

Can you see it?

This is the screen.

Blood.

It's all 08-yue, 08-yue, 08-yue.

Okay, okay, okay.

08-yue.

08-yue, 08-yue.

It's still a bit watery.

Oh, 08-yue.

I'll start from here.

Dr. Shen, do you usually have this part of the jaw lightened?

Or is it because this is the middle of the gallbladder?

We have a regular light here, especially the one-line jaw.

Unless it's a 12-inch jaw line, it may not be light here.

Okay, got it.

Let's see.

Let me see.

Come on, come on, come on.

Lift it up.

The leg is bent.

Is this the liver and the waist?

This should be the liver and the waist.

This is the liver and the waist.

如果发现有阳性的话,你会终止手术?

阳性可能就终止了。

So Dr. Chen said this is not in the standard resection range of people

and not for a case with biliary cancer,

not for a case with pancreatic cancer.

But if he can see the enlargement of the station number 16,

I would say the same, it's not part of the standard procedure for list of cholangio or

pulmonary cancer.

In pancreatic cancer it depends on the circumstances, but sometimes when you have concerns about

resectability or about distance spread and you see enlarged nodes and you want to send

them frozen section, we do it.

Of course if we find metastasis at the station 16 level, we strongly consider aborting resection

of course because they are considered as distant truly distant metastasis there's

a lot of controversy about that especially in the past years there's an

Italian trial ongoing accruing pretty slowly I have to say about you know

randomized patients to dissection to start to routine dissection of 16 versus

versus non-dissection to see whether it translates to better prognosis.

But it's in pancreatic cancer, but still ongoing.

The cruel has been a little bit slower than expected,

maybe because of the steady uptake of neoadjuvant therapy,

even in resectable pancreatic cancer,

but we hope to see results in next year in the following years procedure almost

over right CBD and then it's done

So I asked Dr. Shen if he would perform another ultrasound to confirm the transaction margin

of the biliary duct, and he said he already done that before the surgery, after exploration,

And he has already marked the transaction level of the binary dot.

Okay.

Will he do a front-end section of the common bond-back margin?

He will send that for the front-end section.

I'll split it up again.

You can relax.

You go up.

You go up.

You go up.

Good.

Good.

Give me the scissors.

I'll just cut this part.

Let's put it here.

Professor Lu,

let's take a look at the

cleaning effect.

This is the triangle of the sea.

I think Dr. Chen has downed the triangle resection already, but preserved the artery.

拍灯。

你现在就取标本了,是吧?

我先把标本储出来送快捷。

无影灯。

开那个可修线。

You are pulling out the specimen out of the abdominal cavity and to send the following section.

You are right.

Does he have any plan for reconstruction?

Any idea of the pancreatic anastomosis he will be performing?

You mean how he will do the anastomosis?

Yeah, pancreatic.

Which technique?

Okay.

Professor Chen, what method do you use to complete the clinical integration?

Can you explain the clinical integration?

Can you explain the clinical integration?

It's the purest integration I use.

I don't have one.

It's a bit like Blancard.

But there are still some differences.

I can only say that it's improved.

I can only say that it's improved, Blancard.

Can you explain it to him?

It's okay.

Dr. Chen, he plans to do the anastomosis, PEJ, as the Chen style, but the Chen is another

Professor Chen in China, so it's more or less like a modified bloom gut.

The technical details you will see by yourself.

I will see, okay, very curious.

because I think the I know that technique and I think that technique is

very easy for you to learn when you look at it but it's very hard to describe it

we do it with to describe okay I'm sorry it's out of my capability okay I think

I think we have a very good case today, and surgery is, the patient is well selected,

and the surgical condition is very strong, and I think the doctor performed the surgery very nicely.

Absolutely. It was less than two hours, so very good, remarkable.

Now it's in Italy, for the young HPV surgeons, you will have like a formal training program

for like open surgery, robotic surgery, that's for sure.

But probably you want to train your young guys

with the laparoscopic skills, you know, or?

Ah, it's a very tricky question

because there's no standard.

We don't have like a subspecialty program for training.

Then you get a different type of training according to the program you join.

When you join the Prana program, you get more training in HPV surgery.

In other cities, it's more about colorectal surgery.

But it's not that you at some point in time, at some point during your training,

you take an HPV career or you take a colorectal career or you take an upper GI career formally.

normally, you get what you get and then you decide where to go.

There's no former fellowship program, for example.

In what about Verona?

Do you train your young guys with the laparoscopic?

Yes.

I mean, at this point in time, we do a pretty few laparoscopic cases,

Because as I told you before, we do like, I think, 90% of our invasive cases, we do robotically.

So, for a couple of years, they do like virtual simulators, like programming robotics to develop the basic skills.

It was pretty tricky to implement training for residents in robotic surgery

because we are like 7 surgeons now, 7, 8 surgeons, so we had to learn how to take time because, you know,

if you have a robotic platform available like twice, thrice a week,

it takes time to teach several specialized surgeons.

We've had difficult times with residents over the last 3, 4 years.

Now things are sort of reliving and they are starting to participate more actively in operations.

But the transition from open surgery to robotic surgery was a little bit, how can I say, traumatic for our residents.

They were used to do a lot of procedures in open surgery, including the full Whipple procedures, and so they found less space.

you know to perform procedures on their own in the last year

but i think it's just an effect of the shift of the change towards body surgery which we will fix

in in the following years coming back to your questions there's not a formal training program

in italy for sub specializations in terms of fellowship training programs and there is no

no formal training in minimally invasive surgery.

There are several courses available

that residents can attend, but there

is no formal training from the university

and from the government to train minimally invasive surgeons.

We lack this.

I don't know.

And there is a lot of heterogeneity

across the center of Italy.

From the north to the south of Italy, two different worlds.

It really depends where you are, which program you are able to join, and even within the

same program, like the historic moment, you are getting your training, you are receiving

your training.

It really depends.

So probably in the future, you can consider to send your young guys to Dr. Chen.

Yeah, definitely.

Oh, we can see that it's really tiny.

It's going to be one millimeter or two millimeter maximum.

Is he placing a stent inside?

But this is for the front section.

Yeah.

Dr Mario did you also use the internal stand we prefer when we use a stand so in risky

stamps like the one we are seeing we prefer extrinsic asthmatic externalized stands external

use a dedicated stance made for the pancreas there's a little bulge like

three four centimeters goes in the pancreas then there's a bulge which

makes the stance stay although it sometimes fixed to the juvenile stamp

with a rapidly absorbable suture to keep it in place and then we externalize

through the loop using tunnel technique like the diesel technique and it stays the stand

stays there for three four weeks and then we pull it um like we we admit the patient in the day case

unit we pull it we keep the patient in observation for a couple of hours and then we send them home

sometimes we had a mild episode of abdominal pain presumably to spillage of like enteric liquid in

the abdominal cavity but it's something mild and and which lasts a couple of hours and then it's a

couple of times we admitted patients for pain but it was just two three times in in here so it's

normally an un-eventful okay these are the stitches are you were talking about

right okay is this like for securing the stand I'm not sure let's see okay

TG just like pudding good enough this is a observable thread so so this is to

fix the the stand absorbable brightest okay okay okay I see okay okay it's a

The routine procedure for the trans-anesthmosis for PD.

Okay.

Okay.

Come closer.

Come closer.

Good.

Here.

Relax, relax, relax.

Push in.

Look at the bottom.

Push in.

Look at the bottom.

Pull up.

Right here.

Take a breath.

Okay.

Okay.

Good.

Good.

Look at it.

It's dirty, isn't it?

There's water inside.

It's all water.

So you're doing it in the original position?

Original position, yes.

Push in.

So, Dr. Cheng always put the 6855.

Okay, through the mesentery defect.

It's not from the defect of the transverse meson column.

It's behind the root of the...

Yes, a little higher.

A little higher.

OK, OK, OK.

Come on, come on.

Look here.

Then what about the wire?

I use this 685HS.

HS685, which is the blood tube wire.

This is the Prolin, which is close to 1 to 1.

Then I use two of them near the tube.

Unfortunately, it's PDS Plus.

Prolin has four bells.

Let me see.

So now he's using the 4.0 Prolink.

Prolink.

Prolink.

人家说我的理解不知道对不对啊

城市吻合它这个脊针

其实相当于是垂直的入室是吧

对

它那个blancot就是一个水平入室

看这里

它就是比blancot好的一点

它就保证了那个断断

还是有点血运

看这里

Right

So I think the

The core idea of this kind of

Anasmodic technique is to

Change the

the horizontal mattress suture of the boonguts into the vertical mattress suture.

I don't know if Dr. Mario and Dr. Camarata, if you can understand it.

Yes, I'm trying to understand. In this very moment, the bandwidth of the connection is a little bit slow.

low, so I'm not really able to follow the last 30-40 seconds of the procedure.

I understood the meaning of the stitches, yeah, now I'm seeing it back.

It's like a vertical map.

So you call it Chen anastomosis, you said before.

Chen is the family name of the professor who invented this technique.

And Professor Chen, he was the president of the China chapter of the IHPBA.

He's a surgical tycoon in China.

He also won the IHPBA Distinguished Award in 2023.

For this single suture, in order to avoid the transfixion of the pancreatic duct,

But Dr. Chen is using an absorbable suture for this very single stitch.

Okay.

when you look at video but it's very difficult to explain with the language

Here is still low-7.

Let's go in.

Let's switch.

Let's go.

Let's go.

That's the 3-0 line, right?

The long line.

Let's go.

Here we go.

Here we go.

Look at this.

It's fine.

It's very far.

Okay, let's go.

Professor Chen.

What line is the 3-0 line for your long-range nuclear?

It's the 3-0 line.

Dr Chen is using the 3-varial barbed suture, okay, like V-lock, V-lock, right, running

running suture we love running suture exactly so i discussed with a colleague to the possibility

about the possibility to train externally also the hepatic you know to me in case of

fragility of the patients or i don't know uh other situation what do you think about

this can you hear me yes just leaving the answer to yeah professor chang dr camarada

you mean the externalize of the both pancreatic duct as well as the uh

is that right yes

然后会有手术以后的这些,我们的穿刺水平是比较高的,所以能够做到有效引流,我们原来也做外引流。

就是胆移管的双外引流,是吧?

对,待会儿我这个胆管会做外引流。

你会放个踢管在前面吗?

会放个踢管,对。

Okay. So, Dr. Chen, he thinks it's a very effective strategy to mitigate the risk for these kind of cases, like small ducts, very fragile pancreas, he thinks it will prevent the gray sea,

have fistula prevent the severe hemorrhage and also prevent the

re-operation and even patient deaths in this kind of cases with with the double

internalization of the pancreatic biliary duct and he himself even used the

same technique previously but he think for this case is kind of he's thinking

is still controllable and he will put the t-tube for this patient to externalize the biliary duct

and he will also put a drainage tube with the irrigation system he think

for this case he won't externalize the pancreas duct okay so what's your idea dr mario

we do sometimes in like difficult cases where the patient is particularly frail

we have a tiny common bile duct with weak walls and sometimes we place a stent not a t-tube like

externalized stent to drain out the bile flow and similarly what we do with the pancreatic duct we

pull it out after one month but it's in very selective basis it's not it's

definitely not standard practice yeah sometimes we do it

Put it to the end, brother. Put it to the end. Put it to the end, brother.

The head is also put to the end. Is the trachea done?

Yes.

It's not stable.

Come on, give me a 15-centimeter one.

It's coming back with the same tissue.

Put it on. Come on, come on, come on, come on, come on, come on, come on.

This one may bleed.

Let's find another one to prevent it from bleeding.

这里我是两边加固一针,因为我们使用的这个刀刺线,它一旦这个崩坏的话,它整个...

然后开始那个教授问到我们在中国为什么有的时候不做机器人,

is because we spend a lot of time practicing these basic operations under the anti-magnetic lens.

Sometimes we think that under the anti-magnetic lens,

especially when two people can participate,

the effect is almost the same as that of a robot.

Sometimes we take a double-edged sword, and both people can do it.

So in terms of efficiency and safety, it may not necessarily be worse than a robot,

so we have more choices to do the anti-magnetic lens surgery.

Professor Chen said that in his team in China you know that a lot of pancreas surgeons

they do a lot of laparoscopic pancreas surgeries and then sometimes from the attending surgeons

and from the first assistant they can also perform the laparoscopic pancreas surgeries by themselves

so he called it a double surgeons model in the laparoscopic pancreas surgery so it's

very safe and effective compared to the robotic surgery that's why Professor Chen's team that's

they prefer to choose the laparoscopic surgery as a first choice

and after some seconds and Professor Chen's team will put the T-tubes invented by themselves by

their own teams. Actually I know that for the Italian for some centers as the

professor Borgi's and the professor Giovanni's and that I saw that operation

sometimes they use the external the drainage in the bio duct and MPD the

main pancreas duct so it's the same in verona or you mean this technique i am seeing now

yeah we have been dr camarello do you use the same procedures in your center no no no not this one no

not this one interesting so it's why is the professor that invented the branch going into

And Professor Chen performed this technique only in high-risk cases.

You mean in the distal cholangiocastinoma or parahelon and pulmonary cancers?

Yeah, where you have a non-dilated common by that, basically, with two walls, and a risky anastomosis.

Yes, yes.

Professor Chen, Professor Idarri, I want to ask you, do you use trachea for this kind of expanded gallbladder disease?

We use trachea almost 100%.

one reason is for the decompression of the power because it has to make the

reconstructions inside two of them in the original position of the power and

the second reason that they can detect is early the early blood loss and the

early the pH in a very short time just through the two tubes when is this

Is this T-tube removed?

Two or three months.

Two or three months?

Yes, two to three months.

I see it's a sort of a soft

tube, so you can

pull it out without

particular problems, I think.

Let the mirror come out and make it a little longer.

Wait a minute.

Come on, hurry up.

Come on, give me your hand.

Give him your hand.

Give him a hand.

Take your left hand and hold the mirror.

I'll look at this side.

Look at this side.

I'll look at this side.

Look at this side.

Look at the mirror.

This is the outside.

That's it.

Look at this side.

Back and forth.

Look at the bottom.

Okay.

Just a little bit more.

Okay.

Okay.

Okay.

I'm all out.

Okay.

Okay.

Okay.

Okay.

Okay, what time is it?

Is it here?

I'm looking at where it came from.

It came out here.

Yes, that's right.

Okay, okay, okay, okay, okay, okay.

Right here, right?

Okay, good.

Don't worry, don't worry.

Oh, it fell.

Where?

Here, here.

Okay, good.

Up here.

Look here, look here, look here.

There's still a little more water.

Don't worry, don't worry.

Here, press here.

Or else the small part will fall.

There's still a little more water.

You didn't fall below, right?

and that's the mouses.

So what is the policy about the drain placement for Professor Chen?

Okay, so Dr. Chen planned to put in

three drainage tubes

for this patient

and with

one drainage tube

with the

irrigation system

and that drainage tube

will go to the superior

border of the

PGNM losses.

bad experience of early hemorrhage after surgery from the GI and osmosis suture

yeah put a stress and suture the of the GI and osmosis this is for the

And Professor Chen's tie in the note is very, very enjoyable, especially in the laparoscopic.

yes definitely so maybe that's why they prefer the laparoscopic pancreas surgery

first

actually ten years ago I think it's about ten years ago Dr. Chen he won the

China competition for a surgery competition for pancreas surgery so he's

like the number one in laparoscopic surgery in that competition you can tell yeah it's always

funny you have competition what do you mean do you measure like operation time or what

metric do you have to establish the surgeon is like the winner so you submitted the surgical

Let's put the tube in.

Here is a line.

What time is it now?

4 o'clock?

This tube is not working.

4 o'clock.

Come on, come on, come on.

Look at this.

Come on, wash it.

Wash it.

Wash, wash, wash, wash.

OK.

Wash it.

Where's your water?

OK.

Clean it.

Professor Lu.

Yes.

We're here.

I'll put the tube in later.

I think that's it.

OK.

Clean it.

OK.

Thank you very much.

Dr. Chen is going to put in the stand

and he would like to ask you

anything you want to

discuss or want to ask him

about what

and Dr. Kamarada

do you have more questions

or more questions

no very

very very nice demonstration about the possibility and the feasibility of the

totally laparoscopic pancreatic odenectomy so I don't know if Professor

Malleo have some question some comments I think it was just a perfect procedure

very smooth dissection very nice anastomosis it's from a champion so

really nothing to say congratulation on a perfect operation yeah it's been a

honor to have you with us today thanks to all the moderator dr lu and all the present professor

maleo thank you it was a pleasure for me to be here today with you thank you thank you thank you

thank you as well have a great day thank you

什么?

是吗?

行,行,行,好好

你这个事给我讲,给我讲

干什么?

好了,行了,行了

来