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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1841_Библиотеки_им_академика_М_И_Перельмана.pdf
PANCREATITIS
63
Fig. 1.42 Initial mobilization
of the duodenum allows
the tumour to be assessed
and will give an idea of
size. Further mobilization
may demonstrate a lack of
mobility due to involvement
of surrounding structures.
Fig. 1.43 Full Kocherization
of the duodenum allows
retropancreatic nodes
(usually the first to be
involved) to be sampled
for frozen section.
PANCREAS
64
Fig. 1.44 Bimanual palpation after full Kocherization allows a more accurate
assessment of size and mobility and gives an indication of possible portal vein
(PV) or superior mesenteric artery (SMA) involvement.
Fig. 1.45 A Tru-cut biopsy
of the pancreatic mass
is taken through the
duodenum for frozen
section examination to
confirm adenocarcinoma.
PANCREATITIS
65
Any positive frozen section result from extrapancreatic sites or nodes is a
contraindication to a Whipple’s procedure and we would perform a biliary
bypass (see ‘Biliary bypass procedure (hepaticojejunostomy)’). If all frozen
sections are negative, the tumour is less than 3.5cm in size after mobilization,
and a Tru-cut biopsy of the mass confirmed adenocarcinoma, we would
perform a Whipple’s procedure. Tru-cut biopsies should be performed
transduodenally after Kocherizing the duodenum, to minimize risks of leakage
if the mass proves inoperable and a biliary bypass is performed. We do not
proceed until histology confirms pancreatic adenocarcinoma as focal pancrea-
titis is a real entity, can occur without an overt attack, and can be clinically
indistinguishable. Even if the decision is to perform a biliary bypass, histologi-
cal proof that the mass is an adenocarcinoma is essential to allow an informed
postoperative discussion with the patient, and to justify chemotherapy. We
believe positive intraoperative histology is important and do not rely on paraf-
fin resections. If the first frozen sections are negative, we will continue to take
samples until either we have a positive result or we are convinced that the mass
represents a genuine case of focal pancreatitis. In this situation we would
perform a biliary bypass.
Reliance on paraffin sections can result in a very difficult situation if they fail
to confirm malignancy. It is also generally not possible for these patients to be
entered into clinical trials without histopathology and we therefore always
confirm the diagnosis with frozen sections intraoperatively. This avoids confu-
sion in the postoperative period in these vulnerable patients who are trying to
come to terms with their illness. CA 19.9 is valuable but is elevated in inflam-
mation and the wide range generally precludes its use as a diagnostic tool or as
a robust-enough measure to justify chemotherapy. It is useful when it falls into
the normal range after resection and like other tumour markers it can then be
used in follow-up strategies (although there is no surgical option in the recur-
rent pancreas cancer other than procedures aimed at symptomatic relief).
Biliary bypass procedure (hepaticojejunostomy) ( Figs. 1.46 – 1.57 ) The biliary
bypass procedure used for inoperable pancreatic tumours (the bile duct aspect)
is the same technically as that used to repair bile duct injuries, following the
excision of bile duct tumours and for benign biliary disease (stone disease,
choledochal cysts). We always remove the gallbladder in these patients as we
prefer to divide the bile duct above the entry of the cystic duct. In patients with
a good long-term result, the development of gallstones with or without low
grade cholangitis is a difficult situation.
A gastroenterostomy is performed initially and this is antecolic as in all
malignancies.
PANCREAS
66
Fig. 1.47 The enterotomy and gastrotomy are created with diathermy.
Fig. 1.46 The posterior
wall of the gastroenteros-
tomy is performed with
4/0 PDS.
The gastroenterostomy technique is by either a single or double layer of
continuous 4/0 PDS (depending on operator preference) and we leave a 70 cm
limb distal to the anastomosis, divide the jejunum, and create a 70 cm Roux
loop.
The jejunum is divided with a straight stapler and the Roux loop oversewn
with 4/0 PDS ( Fig. 1.49 ).
PANCREATITIS
67
Fig. 1.48 The inner layer of continuous 4/0 PDS sutures is placed.
Fig. 1.49 After completing
the gastroenterostomy,
the efferent limb is
divided with a stapler,
70cm distally.
PANCREAS
68
Fig. 1.51 The anterior row
of sutures (4/0 PDS, 16 or
20mm needle) is placed in
the bile duct from inside
to out.
Fig. 1.50 The Roux loop is
oversewn.
PANCREATITIS
69
Fig. 1.52 After completion
of the anterior row, an
enterotomy is made and
the posterior row of
sutures is placed (from
inside to out on the small
bowel and outside to in
on the bile duct).
Fig. 1.53 The Roux loop is ‘parachuted’ down and the posterior row of sutures tied.
PANCREAS
70
The bile duct is then divided and the lower end oversewn ( Fig. 1.50 ). Bile is
sent for culture and if a stent is present it is removed. The approach to the
bilioenteric anastomosis is standard and employs full thickness interrupted 4/0
PDS sutures. Two large clips are used to hold the smaller clips which have been
placed on the sutures to prevent them getting tangled. The procedure begins
by inserting the first row in the anterior bile duct wall from inside to out and
these are placed 2–3mm from the edge and 2–3mm apart ( Fig. 1.51 ).
When the front row is complete and all the clips holding the sutures are
retained on the larger clip, an enterotomy is performed and the posterior row
of sutures is placed ( Fig. 1.52 ).
Fig. 1.54 The anterior part
of the anastomosis is then
completed with the
sutures already placed in
the front wall of the bile
duct (outside to in, on
the Roux loop).
Fig. 1.55 Completed
anastomosis after inserting
and tying the front row of
sutures.
PANCREATITIS
71
Fig. 1.56 The enteroenter-
ostomy is completed
70cm below the
bilioenteric anastomosis.
Fig. 1.57 Completed
procedure after closure
of mesenteric defects.
PANCREAS
72
These are at the same intervals, from inside the small bowel to out, and from
out to in on the bile duct. These sutures are all placed and then the small bowel
is ‘parachuted’ down and the sutures tied ( Fig. 1.53 ).
The anterior wall of the anastomosis is then completed by suturing from
outside the enterotomy to inside ( Fig. 1.54 ).
The sutures are then tied as they are placed apart from the final four, which
are left and tied at the end ( Fig. 1.55 ).
The loop is then loosely anchored to the liver with a suture on either side of
the anastomosis, usually to the gallbladder bed and falciform ligament. The
procedure is completed with an enteroenterostomy 70cm below the bilioen-
teric anastomosis ( Fig. 1.56 ).
This is done with interrupted sero-submucosal sutures of 4/0 PDS and an
air test for integrity performed at the completion. The mesenteric defect is
then closed and, after a thorough washout, two tube drains inserted and the
abdomen closed ( Fig. 1.57 ).
Pancreaticoduodenectomy (Whipple’s procedure) ( Figs. 1.58 –
1.74 ) Operations on the head of the pancreas proved a considerable technical
challenge until the middle of the 20
th
century. Since then, considerable
advances in surgical technique, anaesthesia, and intensive care have allowed
pancreaticoduodenectomy to become a routine procedure. Nevertheless, there
remains no consensus about how the operation should be performed or
described. There are a bewildering number of methods of reconstruction after
removal of the head of the gland and there continue to be studies addressing
this issue. In addition the older term ‘Whipple’s procedure’ is being replaced
by the generic ‘pancreaticoduodenectomy’ in the knowledge that the first
operation was performed prior to Whipples’s first description in 1935 and
subsequent paper in 1941 (see Table 1.11 ).
Pancreaticoduodenectomy is performed for patients with confirmed histol-
ogy of the tumour and no contraindications to a curative procedure. The
patient must be fully informed of the nature of the procedure, the major
undertaking it represents (with a consequent morbidity and mortality) and the
likely long-term sequelae (increased risk of diabetes especially with a family
history and steatorrhoea). We prefer a pylorus-preserving approach and do
not perform an extended lymphadenectomy. The latter does not improve the
survival and is associated with significant diarrhoea (this does not resolve and
is difficult to treat).
The standard transverse incision gives very good exposure and even in obese
patients should allow sufficient access. In all resections for malignancy, we take
the greater omentum off the transverse colon completely to enter the lesser sac,