Recent refinements and advances for pancreatoduodenectomy
- VernacularTitle:Нойр булчирхайн толгой хэсгийг дээрх гэдэсний хамт тайрах мэс заслын сүүлийн үеийн ололт амжилтууд
- Author:
Yuji Morine
;
Mitsuo Shimada
;
Satoru Imura
;
Tetsuya Ikemoto
;
Yusuke Arakawa
;
Syuichi Iwahashi
;
Yu Saito
;
Shinichiro Yamada
;
Daichi Ishikawa
- Collective Name:the University of Tokushima, Japan
- Publication Type:journal article
- From:Innovation
2014;8(4):136-137
- CountryMongolia
- Language:English
-
Abstract:
Background: The technique of pancreatoduodenectomy (PD) has evolved, and
artery first’ approach was considered for the intraoperative early determination
of resectability for borderline resectable cases before the ‘point of no return’
and avoidance of blood congestion resulted in the reduction of blood loss. Also,
active application of energy device was useful for the reduced operative time and
blood loss. Recently, 3D simulation for hepatobiliary pancreatic surgery has been
useful and mandatory. In this presentation, we introduced our recent refinements
and advances for PD.
‘Artery first’ approach and vessel sealing system for PD: ‘Artery first’ approach
were considered as six different methods as follows; 1) Superior approach, 2)
Anterior approach, 3) Posterior approach, 4) Left posterior approach, 5) Right/
medial uncinate approach and 6) Mesenteric approach. A while ago, we
preferably applied the mesenteric approach to PD, and also the combination of
this approach with vessel sealing system (VSS) significantly reduced intraoperative
blood loss (Mesenteric approach with VSS, n=21 vs. non-‘Artery first’ approach
without VSS, n=78; 320±174ml vs. 486±263ml, p<0.01).
Modified de-rotation method as complete ‘Artery first’ approach: Most recently,
for further refinement of operative procedure, we refined a right/medial uncinate
and posterior approach as modified de-rotation method. Point of view in this
method was the complete clockwise rotation of small intestinal mesentery
including ascending colon, in order to linearize from duodenum to jejunum
and look at the direct front of superior mesenteric artery (SMA), vein (SMV) and
some branched jejunal vessels originated from SMA and SMV (Fig.). Thereby, in
the posterior view, the easy dissection of all pancreatic branch originated from
SMA can be done. This modified de-rotation method was possible to achieve the
complete ‘Artery first’ approach.
Preoperative 3D simulation of arterial and venous anatomy:
Until now, we applied 3D volumetery software (SYNAPSE VINCENT®) as
preoperative simulation for hepatic resection. And recently, for evaluation of the
position relationship between arteries and veins surround pancreas head, we
adopted this software before PD. As first step, arteries and veins are automatically
identified, and small vessels are manually traced on the axial CT view. After
that, 3D arterial and venous simulations are combined. Grasp of detailed vessel
anatomy and its relationship using preoperative 3D simulation enable to safely
perform PD, even in young surgeons (operative time; young 512±49 vs. senior
445±41 min, p<0.01), (blood loss; young 353±203 vs. senior 246±109 ml,
p=0.16).
Conclusion: Those refinements and advances are possible to safely and easily
perform pancreatoduodenectomy.
