Prof. YE ZHANG The Diagnosis and Treatment Papillar Mucinous Neoplasma, Ductil: A Case Report

This is CT imaging, and we can see the dilation of the bi-duct. This is CT imaging, coronary imaging, so it's MRCP.

It's also MRCP, we can see the dilation of common bi-duct at the intrahepatic duct.

And this is during the ERCP procedure, we saw the clear dilation of the common by-duct.

It is more than 3, more than 30 milliliters, and we find there are a lot of filling defects.

things. What's this? So it's not stones. These are radiographies. So let's see. Then this

is the observation of the left biodegrade by pre-aerogladioscopy. It's easy to incubate.

So, that is the observation of the right biodegrade by POC.

This is a specimen after the surgical procedure, and so we can see the incision of the biodegrade.

This is a pathologic image, and the marker is 0.2 milliliter, so there is some structure.

So, it's the basic situation, and I reported it.

Thank you very much.

Let's see the videos.

I think we can discuss this case part during the sale of my videos, okay?

Wait for a minute.

Okay, let's start my video.

Okay, could you see it?

Yeah, we can see it now.

Okay.

Do you see the progression?

Yeah, I performed the de Dano scoppy. So we can observe the cavity of the gas

metric, and I push the copy into the first segment of the demo. Now, turn right the copy,

and carefully, we should find the second segment of the demo. Then, put in the copy in the

the second segment of the genome. Now we can say the major genome is popular, and we should

to pull out the scopi and make it shorter. And we can say that there is no malignant

tumor in the vascular ampulla. But we can also say that the auditory sphincter is loose

and we performed ERCP, it is relatively easy to incubate the tube. So we can say it is relatively easy.

And we performed this procedure with a wide guide.

Yes.

Yes, and we performed radiography. Yes, you can see the end of the ampoule is loose. We

performed radiography, and we can see there is a lot of jelly, mucinous liquid, coming

from the common biodegradable duct. This is a typical character of a mucinous neoplasm.

And we perform the radiography, and we can see the dilation of the common biodegradable

just like the picture in my PPT. Sometimes, when I perform the ERCP, we need to perform

the cutting of the picture, but in this case, it's not necessary.

Yeah.

Right.

Right.

Yeah.

But did you perform also a colidoscopy, actually?

Yeah.

After this procedure, I performed a pre-order colidoscopy.

So I introduced my major.

major. I performed surgical operations and I also performed endoscopy, ultrasonography,

and ERCP, and cladocoscopy. And for this patient, why I performed ERCP? Because I think if we

we have no ERCP and pre-aural cladocoscopy, the diagnosis is not definite and clear. So

I think it is good to make a precise diagnosis. So it's an ERCP procedure. But I think in

in this patient, the ERCP procedure is relatively easy, and there is no stone in the common

bile ducts, and so we can say it's just the dilation of the common bile duct and the intrahepatic

intrahepatitis by diet. Yeah, there is nothing coming out from the papilla, actually.

There is no tissue coming out from the papilla, just bile, I mean.

What? I'm not catching about the yard. No, I'm just saying that there is not any tissue coming

coming out from the papilla. There is just a bite, so that's good.

Yeah, so let's see the next procedure. It's the clangio-scopy. I will incubate this device

into the common bite duct. Usually it is difficult, but because the sphincter of this patient

is loose, so it is relatively easy. We should, yeah, let's say it.

Right, so you are performing the choledocoscopy, actually?

Yes, yes. The diameter of this choledocoscopy is about 11 frets.

Uh-huh.

Yeah, maybe 3 parts 3 milliliters.

This device is made in China. I think in the world the popular device is spyglass.

Do you know spyglass?

Yes, we know spyglass.

Okay, okay. Yeah, so now I'm observing the cavity of the bile duct.

Can we have the inside imaging too?

Major.

Okay.

Because there is dilation of common bile ducts and intrahepatic bile ducts, so we can perform

this scoping deeply.

So let's see the end of the ventral ampulla.

So you can see it is just like a fish mouth.

So it is another typical character of mucinous neoplasm.

In fact, we also see this situation in pancreas disease.

It is usually in the IPMN of the pancreas.

Yes? Okay. Okay. This video is showing the green color is coming. And because it is mixed

with fire, so the color is green. So after the observation, I draw back the gladiocos

copy. Okay, this is the first video. Let's see the second video. Wait for a minute.

Could you say it again? Yes, we can.

Yes, we can. Yeah. This is the cavity of the common

by duct. Now the position is in the downstream of the common by duct. We can see the wall

is smooth, and in the cavity there is a lot of mucinous liquid, just like jelly. Now I

I push the cladocoscopy deeply into the hiler. So we can see, yeah, there is a laser. Okay,

Okay, we can see the picture. We can see there are a lot of bugs, just like color, in the

bottom of the sea. And there are many white or light green jelly. It is difficult to

to clear this jelly. So the person is Heller, and we can push the coloscopy into the left

left intrahepatic, let's say, we should adjust the oriental. So we can say white jelly. These

are the failed defects in the radiography. It's not stone, and not a malignant tumor.

So, let's say the breath of a bile duct. Maybe we should inject some water.

Professor Zhang, but inside there is a mixture of bile and mucus or something else?

Yeah, yeah, yeah.

Okay.

So we can see the left branches of intrahepatic bile duct is also dilated, and we also see

the color-like bulges. By the cladocoscopy observation, we can make sure where is the

the laser and the scope of the laser. So, after I observed the situation in the bidect,

I draw back the gladiocoscopy. Yeah, we can observe the gravity of the bidect twice, forward

and backward. So in this patient, I think it's not necessary for a biopsy because neither

it is negative, neither it is benign or malignant. We will perform the surgical resection recently.

So I think it is not necessary to perform a biopsy.

Did you collect some bile in order to have cytology?

What?

Did you collect some of the fluid in order to have a biopsy or just a cytologic diagnosis, or you didn't?

I think the cladoscopy diagnosis is APMNB.

I think this is a relatively clear diagnosis.

So I have observed some typical characters about this disease. Although this disease

is not common. So we can see the cavity of the bile duct. Another important question

is we should make sure the scope of the laser. So, by this kaleidoscopic observation, when

I find the disease, the laser is in the left intrahepatic and common byproduct, the right

right intrahepatic is okay. So it is important for the further surgical procedure. Okay,

now I draw back the cladocoscopy. So we can also see there's a lot of jelly. Okay, another

Another question is if it is necessary for biogenesis. I think it is not necessary, because the jaundice is caused by jelly, just this, not by the obstruction of the bile duct.

We have lost your speech.

Hello?

We cannot listen to you.

pensiamo che si sia bloccato cerchiamo di risolvere la situazione saltando qualche parola non è

semplicissimo comprenderlo dietro la domanda tua era giustissima sul citologico anche perché insomma

Yes, it seems to me a little adventurous to throw myself, but it's okay.

All right, in fact.

I think so too.

I did not understand if the tumor was the left branch, intrapathic, or if it was further down.

Because if it talks about the dilatation of the total biliary veins, it means that it is in the common hepatic.

Yes, even if in reality from the image we saw before, we see a clear dilatation of the left hemisystem and the common hepatic in the right one.

And then this is what I understood in the first instance, ok.

Also the image of the first operation that you showed before.

surgical resection. So, because the laser is located in the left liver and the common

bile duct, so we performed left hemihypertectomy. That's the video. So, this is cutting off

the ligament of the liver. We performed a reverse L-incision in the skin, in the upper

abdominal range, and we performed the operation after the incision. So we can see there is

is observably hypertrophic in the left liver. It is not normal. This person is near to second

performed laparoscopic hepatotectomy. Because I think maybe it is difficult, so they performed

open operation directly. So let's see the lateral part of left liver. There is adhesion.

Yeah, the position is between second two and second two, second three, and second one.

Yeah, that's the quadratum lobe. And the tissue is compact. I think the inflammation

hypotectomy or open hypotectomy? Which one is more? In my personal experience I

perform both, but actually in the left lobe they are more laparoscopic

then open actually. Okay, okay. Depends on the case, of course. Okay, because laparoscopic

hepatoterapy is a mini trauma, yeah. Yeah. The patient maybe have rapidly recovered. So,

So, I think it is, I'm sure it is relatively difficult because, yeah, there is bleeding.

Oh, okay.

Because of hypertrophy.

It depends on the experience of the equip in laparoscopic approach and even on the numbers of cases that you get.

Yes, of course.

Yes, I think maybe this patient is performed.

leprosy. I think maybe it is more difficult. Yeah. So could

be the left lobe is really hypertrophic. Yeah, yeah, yeah.

Another question is the deletion of CBD is another difficult

factor. So let's say it. Yes, of course. Now, we say that the

the hepato-utano ligation, and we are fighting the liver artery.

Do you perform the intraoperative ultrasound?

Yeah, now we are fighting the left artery, the liver artery.

Now, this is the posterior branch of the bile duct.

It is relatively free, so we use a tube for it.

Now we continue to find the liver artery and the common bile duct.

Now the patient, the common bile duct is very dilated, now this is dissociate the gallbladder.

There is no cirrhosis, but the liver leukemia is not good.

Not normal of course.

Yeah, now this is common hepatic artery, and now we perform the incision of the right lateral

ligament, the right lateral of the liver. So, let's say we can say that the tissue is

thin and compact. Okay, that is the way to perform dissociation of common bile ducts.

little branch of the vessels. We ligated the right posterior branch of the

the bi-duct and cut off. Okay. We performed an incision of CBD, the thought of it. So,

we also performed a cladocoscopy.

Interoperative.

Yeah. And when we performed this procedure, because we made sure there is no malignant

tumor again, and we performed a suture. Yeah, this is a cutting match.

What is this?

Okay. And we made a suture. In fact, we also performed an iced pathological check. The specimen is the margin, upper margin and the down margin.

So you were sure that down there there was no…

Malignant.

Malignant.

It's benign.

Without any specimen or something else.

Yeah. Okay, this is the left liver artery. So we should perform the left hematectomy.

So we should cut off the left liver artery and the left branch of the portal vein. Now

Now we will find the left branch of the potovin. Okay, it is relatively difficult because it

is deeper. Now we dissociated the right liver, that is the diaphragm. Okay, the tissue is

is compact and has adhesion. Now we are finding the left branch of the portal vein. This is

the left branch of the portal vein. We ligated it and cut it off. Yes, we should do it carefully.

dissociate the left liver. Now, next step, we will perform the incision of liver leukemia,

And after the ligation of the left branch of the portal vein, we can see the dividing

line between left and right liver.

So we perform the incision.

We use ultrasonic knife.

And the left hepatic vein?

Yeah.

Okay.

Okay, we can see there is another branch of the bile duct. It's right front bile duct.

is dangerous, so we should make sure the facet is fixed. So we make a suture firstly.

And it is easy to control the bleeding. Okay, the specimen is removing.

moving. Now, this is the branch of BiDart. We use spectroscopy to observe the cavity

of it.

This is which part of BiDart?

I think it is right for fraud branch.

Okay.

Okay.

Yeah.

Now we can see two brands of bile ducts, and we make a shape-up, just a suture, yeah,

you can see.

And next step we will perform the cladoco-enteric anastomosis, yeah.

Okay.

Between the right bile duct and the jejunum?

Yeah.

Now it's calling. We find the upstream of the general and cut it off. We use a stepper.

enteric anastomosis, and we use continuous suture. Firstly, we perform the anastomosis

Which number?

Yes.

Maybe, oh, it's 5-0.

5-0.

Yeah. Now, it's front side. Front side is relatively easy.

Okay. You can see the surface of the liver.

And we use the Argon knife, we use the Argon knife, now we perform the end-to-side enteric

anastomosis.

Through a wire, yes.

Yeah, it's the last procedure, the last step.

Yeah, check it.

Okay, this is the last video, thank you very much.

Thank you.

Thank you so much, Professor Zhang. We have discussed something during the video. I don't know if our colleagues that are here with us on the Zoom would like to have extra questions or if there is anything from the audience.

We've discussed it during the operation, so I think it's enough.

Oh, okay. Okay. Thank you, Foyar.

Okay.

Thank you to you and congratulations.

Congratulations and thank you very much.

Okay, okay.

I'm very glad to start my video with you.

Thank you.

Thank you so much, Professor.

And just one question, one extra question.

I'm so curious about the eastern numbers of patients.

I mean, how many people do you treat per year?

and how many beds are in your hospital, in your surgical department? There are

115 beds in hepatobiliary surgery in our hospital.

Definitely. Eastern numbers, definitely.

Yeah, because there are many patients.

Excuse me, professor. Did you have the definitive specimen?

Specimen?

Yeah. No, the histological result.

Do you have the histological result of the specimen? What about the kind of tumor?

It should have been a papillary musculoskeletal neoplasm.

Yeah, the pathologic diagnosis is IPMNB, just compared with our estimation.

I think the key question about this patient is the diagnosis, not the surgical procedure.

So if we have no cladocoscopy, maybe it's difficult to decide how to do the surgical.

Yes, of course, I agree with you. But for this instance, it has been a good question from Professor Bisagni about the collect of something to see some cytological specimen.

Because, of course, you have just a look of the tumor, but if you have something about it, it could be more useful.

Yes, okay. In other patients, maybe we should perform a biopsy, but in this patient, I think it is necessary, because if it is a benign disease, I think it also needs an operation.

in your opinion

it was not necessary

because anyway

thank you so much Professor Zank

it has been a pleasure to meet you

and I really have to thank you

on behalf of

Professor Palacini of course

and it was great to have you here

even though if you are so far away

and if it's

so late

in your country

now it's only

three in the afternoon here in Italy

thank you so much

I really hope to meet you

very soon again, thank you

thank you everyone

welcome to China

hopefully

thank you

I hope to see you next time

next year

why not

thank you

thank you professor Zhang

Thank you, thank you for the discussion, thank you for...

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