Dong Shang resezione della testa del pancreas

for 10 days. This patient suffered jaundice for 10 days and then had abdominal CT in local

hospital. The CT imaging showed that marked dilation of intrahepatic and extrahepatic

bile duct and enlargement of gallbladder and then abdominal MRI showed that it may be the

distal cholangiocarcinoma and the liver function test of this patient showed that the ALT, AST,

T, ALP, and GARM-GT were very higher than normal.

And the total bilirubin is about 250 mmol per liter.

And the direct bilirubin is about 150 mmol per liter.

And the tumor markers were normal, and then we do the ERCP because of the severe jaundice,

and then we do the biopsy.

So the ERCP find a papular, so there is some lesion in the papular, and then do the biopsy,

and then injured the pancreatic ductal stent because of the pancreatitis, and then do the

EMBD, endoscopic nasal valeduct stent. When the jaundice becomes well than before,

so we do the LPD. Now, so we can see the video, and the first, we should do

to scan the generalization for the hepatic delinear ligament and to find the common hepatic

artery and the proper hepatic artery. Because of the changing signal from the 3D

laparoscopy 2D. So the video is not so very clearly. Now, because of a lot of fight, this

patient, the weight of the patient is about 80 kilometers. So there are a lot of the fight.

So there was some difficulty to do the procedure. And now we had to cut some

is a proper hepatic artery. Now we need to do some dissection and to do some

from the diabetes about three years ago. And from the MRCP, we can find an

enlarged pancreatic duct. So the patient suffered from recurrent pancreatitis and

And so there were a lot of, there was some adhesion

between the, yeah.

So way to cut the distal gastrectomy,

to do the distal gastrectomy.

And another way to dissection the duodenum

is descending duodenum.

And then there are rupture of the duodenum.

So, to prevent the tumor implantation, we should sew in the rupture of the duodenum.

Professor Shang, was the patient also an alcoholist, or did he have any pancreatic calcification of the ducts at the CT scan?

Sorry, sorry, sorry, please.

Professor Shang?

Yeah, yeah, I can hear.

Yes, can you hear?

Yes. Now the audio is back. All right. Prof Chang, I want to ask you, was the patient also an alcoholist or did he have any calcification at the CT scan at the pancreatic ducts?

At the pancreatic ducts?

Yeah. Did he have any calcifications also, having more episodes of pancreatitis?

Yeah, the patient, because there is obstruction in the distal of the common bile duct in the

ampullae, so the patient has recurrent pancreatitis, chronic pancreatitis.

Because of the tumor in the distal ampullae, so the pancreatic duct becomes enlarged, and so the patient has chronic pancreatitis.

Now, so to find it, we can see the IVC, inferior cavalier IVC, we can see the inferior venous

cavity.

So we do the dissection of the IVC and the left adrenal vein.

ascending and the third part of the duodenum. So from here to

to a trace ligament, okay, we can see it's connected to the other side, to the left side.

Yeah.

Do you do many of these cases during the year?

Yeah, yeah.

We always do this procedure about the mobilization of the aduleanum.

No. So I suggest that in our team, we do not parallel preserve the procedure because we have done some cases to preserve the pylorus.

but so there are some complication for example the delayed gastric function so

you know so it's a common complication for the phrasal pylorus procedure. Now we

cannot do this procedure. We do the distal gastrectomy. Thank you.

So the main surgeon standing on the right side of the patient and the right hand of the main surgeon is the transport chocker is about 12 millimeters, 1.2 centimeters.

And the assistant surgeon, the left trochlea is about 10 mm.

So the other trochlea is 5 mm.

Now we do the dissection of the number 8 lymph node.

I mean, if you find an anatomical variation or the branches variations, different anatomy.

Different anatomy.

Yeah, some field cases as variation of the hepatic artery is very common for the right

hepatic artery from the SMA, not from the common hepatic duct. At this time we

should pay more attention so do not to do injury to the right hepatic duct. So

So we always find a variation about the artery through the CT scan and the MRI scan.

And because of the patient has been dying the ERCP and the EMBD, so around the hepatic duodenum ligament, there was some adhesion because of the ERCP and the EMBD.

So there is some difficulty for the procedure.

So we sometimes do the endoscopy ultrasound, especially for the prebiotic head tumor.

Because of the patient, the CT and MRI is very obviously to show the distal cholangioid carcinoma or periampular carcinoma.

tumor, so we did not do endoscopy ultrasound.

If we cannot do the very clearly diagnosis, we do the EOS or to do the spyglass.

Now we do the separating of the GDA.

Yeah, it's negative. Number 13 lymph node is negative. Finally, the physiological result

is all of the lymph nodes are negative, including the number 8 lymph node. From the video,

During the procedure, we think the number eight is maybe positive, but finally the result

is negative. Now we cut the CVD and we should do the frozen biopsy about the

common hepatic duct. And we do the separation of the pancreatic head before the portal vein.

and then we cut the pancreatic duct.

Do you find a specific anatomical spot

maybe behind the pancreas to be safe in the dissection?

Yeah, it's because it's not the pancreatic head carcinoma,

So the portal vein is very easy to be separated from the pancreatic head.

So we can see the pancreatic duct because there was a stent in the pancreatic duct.

It's very easy to find the pancreatic duct.

How long before the operation was the ERCP performed with the position of the stent?

It's about one week.

We wait for the jaundice to decrease to about 100 mmol per liter.

process. The image of the video are very clear profile and your anatomy is excellent.

Yeah we always use this observable clip so it's not as

it is not observable clip so the tip of the clip is not very sharp it cannot to destroy the

the vein. So we can see the SMA. We can see here is the mesoteric pancreatic

the procedures and to help the surgeon to do the sewing or stop the bleeding.

So the laparoscopic length is 30 or 30, so not very clear.

So we also do the dissection, the number eight lymph node.

Okay, next we will do the anastomosis.

Based on the Congress tissue, big or small. If they're small, apparently small, so we just do

whole thickness. And the jejunum is a posterior layer of the serum muscular layer. And the

The 3-0 pearl in the needle is bigger,

so it's very easy to do the whole thickness

of the prongiatic tissue.

The second suture to strong again the posterior wall of the jejunum.

Prof, this suture is a full thickness on the jejunum, isn't it?

Yeah, yeah. The second suture is the full thickness of the jejunum, the whole thickness.

We do not use the summer study, no.

I think there is no,

there is no operation in fact about

to prevent some of the pangreatitis

or the leakage of the pangreatal jejunostrum.

So we do the other ephyra for thickness of the jejunostrum

and jejunum.

semi-pouch suture and then we will do the other semi-pouch suture and then completely to

close the hole with the pancreatic tissue. Of course the knots of the two semi-pouches

jejunostomy is to

do the pancreatic stent injured in the jejunum

and to do the implantation into the jejunum. And then we will do

three or four sutures to do the anterior

Excuse me, Prof. The technician just approached me and he told me that you are aware about this, but apparently we only have the link with you for the further 10 minutes, unfortunately. Anyway, the quality of your video is excellent, but we still have 10 minutes to go. So, go ahead. Thanks very much.

Okay. Thank you. Thank you.

Just to let you know, Prof, we have 22 channels simultaneously linked to the five continents, I believe.

And as you know, this is all on the web.

We don't have surgeons here in Rome.

only, I think, 20 surgeons, including me, from all Italy, commenting, watching beautiful

operations from all over. But of course, there are a few thousands of people on streaming,

watching you, of course. Okay, and then we will do the cholangial jejunostomy,

and then the gastrointestinal nostril.

So this kind of method of the pancreatic gastrointestinal nostril I think is very safe.

So we have done those cases of the LPD.

So the pancreatic leakage, only one case had a C leakage, the other is a B or A leakage,

So that's one case C grade leakage.

Prof. Zhang, do you leave any drain at the end of the procedure?

Yeah, yeah, yeah, yeah.

We will do two to drain.

What about, do you position them?

Yeah, the right and the left side, each other one drainage.

Sorry, Prof, I'm not with you. What did you say?

Which kind of method, which kind of anastomosis to do the pancreatic jejunostomy during the PD procedures?

caesars. More or less it's the

same, prof, although I appreciate

very much the trick

of the semi-pouches, which was

a very excellent

suggestion.

Yes, okay.

of noise, a lot of interference

below. And now you

hear me?

Well, we have only a couple of minutes. Anyway, in the meantime, I don't know whether you can still hear me, but thank you very much, Prof. Sangha, for your participation, your nice video, excellent procedure.

Now it's better?

It's a bit better.

He's still trying.

Yes.

Prof. Sanger.

Yes.

Hello.

Hello.

Good morning.

Hello.

Yes.

You hear me?

I hear you very well.

And you?

Okay, good.

So I will equip Dr. Azara when you are ready for presentation.

Interesting.

Just tell me when we go to the live.

Professor Shang, can you hear me?

Yeah, I can hear you.

Unfortunately, we have to drop the link because there are other channels.

Anyway, I want to thank you on behalf of Professor Palazzini

for participating in the Congress and also for the beautiful video

there was an excellent video

on anatomical

exposure

unfortunately we can't follow all of it

but the most important part

for us which was the

pancreatic reconstruction

very good

thanks very much again

we hope to see you in Rome

whenever possible

thanks very much

for your participation again

ok thank you

thank you very much

Thank you.

Bye-bye.

Thank you.

Thank you.

Bye-bye.