Nghiên cứu ứng dụng phẫu thuật nội soi cắt khối tá tụy tt tiếng an
MINISTRY OF EDUCATION AND TRAINING
MINISTRY OF NATIONAL DEFENCE
VIETNAM MILITARY MEDICAL UNIVERSITY
HOANG CONG LAM
THE STUDY APPLICATION OF LAPAROSCOPIC PANCREATICODUODENECTOMY Speciality: Gastrointestinal surgery Code: 90 20 104
Ph.D THESIS ABSTRACT
Hanoi - 2019
THE THESIS WAS COMPLETED IN
VIETNAM MILITARY MEDICAL UNIVERSITY
Scientific supervisors: 1. TRAN BINH GIANG, M.D., Ph.D., Prof. 2. HOANG MANH AN, M.D., Ph.D., Assoc. Prof.
Thesis reriewer 1:PHAM NHU HIEP, M.D., Ph.D., Prof. Thesis reriewer 2:TRIEU TRIEU DUONG, M.D., Ph.D., Assoc. Prof. Thesis reriewer 3: NGUYEN NGOC BICH, M.D., Ph.D., Prof.
The Thesis was presented at the University Scientific Research Council of Vietnam Military Medical University at............................., 2019 Thesis can be found at: 1 2
Vietnam National Library Library of Vietnam Military Medical University
3 A. INTRODUCTION *QUESTION Laparoscopic pancreaticoduodenectomy (LPD) is technique of block resection of the duodenum, the pancreatic head, a part of the common bile duct, gallbladder, a part of the stomach and the first part of the jejunum, which Whipple successfully performed for the first time in humans in 1935. In 1994, LPD was performed by Gagner and Pomp. There have been studies compared between open pancreaticoduodenectomy (OPD) and LPD, which showed that the laparoscopic surgery reduced blood loss, longer surgery time, no significant statistical difference of complication rate, shorter hospital stay; a greater number of dredged lymph nodes, and especially, less level of pain. Indications for LPD are usually only compatible for tumor lesions of the pancreatic head, Vater ampulla, low common bile duct, duodenum, and chronic pancreatitis at their early stage, etc. Some prestige healthcare facilities have reported the mass application of pancreaticoduodenectomy with complete endoscopy or
supportive endoscopy such as Viet Duc Friendship Hospital, 103 Military Medical Hospital, Bach Mai Hospital, University of Medicine and Pharmacy, Ho Chi Minh City, etc. In which, initial outcomes were comparable or better than open surgeries. However, there has not been a systematic assessment of the indication, complete description of the technical characteristics, advantages, and disadvantages of each step, but only the outcomes of this method. So, it is necessary to have follow-up studies on LPD, in order to have a
4 comprehensive assessment which is based on to build up guidelines of necessary indications and recommendations for surgeons. Stemming from the above reasons, authors conducted the research
pancreaticoduodenectomy" with 2 objectives: 1. Identify indications and technical specifications of LPD. 2. Assess the outcomes of LPD * NEW MAIN CONTRIBUTIONS OF THE THESIS The study was a retrospective and prospective study of 36 patients
pancreaticoduodenectomy was designed for diseases related to tumors at the pancreatic head, Vater tumors, low common bile duct tumors, tumors at the second part of the duodenum, chronic pancreatitis with tumor size <3.5cm, without invasive superior mesenteric artery and/or portal vein, and no metastasis. 63.9% of the complete laparoscopic surgery used 5 trocars while 36.1% of them used 4 trocars in supportive endoscopy. The bleeding complication in the step of liberating, removing the injured part of the pancreas, and repositioning the pancreatic uncinate process was 22.2%. The group of patients with chronic pancreatitis had a higher rate of intraoperative bleeding than the rest. The conversion rate to OPD was 11.1%. 100% of patients had intestinal pancreatic digestive circulation, reducing pressure on hepato-pancreatic ampulla 87.5%, and 100% needed a connection of gastrointestinal tract and anterior transverse colon. Intraoperative outcomes: average operating time was 315.9 minutes; average blood loss was 372.6ml, the rate of postoperative
5 complications was 43.7%; pancreatic fistula was 6.3%; postoperative bleeding was 3.1%; delayed gastric emptying was 3.1%; bile leak was 3.1%; residual abscess was 6.3%; No perioperative mortality. Postoperative outcomes: 89.5% of patients reported quite good and good quality of life. The average extra-life time of cancer patients was 33 months and the number of patients who live more than 5 years after surgery was 16.7%. * STRUCTURE The thesis consists of 132 pages with 31 images, 42 tables, and 8 charts. The thesis is structured into 4 basic chapters: Introduction (2 pages), Chapter 1 - Overview (35 pages), Chapter 2 - Subjects and research methods (23 pages), Chapter 3 - Research Outcomes (29 pages), Chapter 4 – Discussion (41 pages); Conclusion (2 pages); References (117 literatures including 21 in Vietnamese, 95 in English and 1 in French), 16 of which have been published since 2015 onwards. CHAPTER 1 - DOCUMENT OVERVIEW 1.1. Pancreas: Anatomy and pathology The colon is in "C" shape that holds the head of the pancreas. The sticky part behind the pancreatic head and duodenum is called the ligament of Treitz lining. Kocher procedure is to remove the duodenum and the pancreatic head from the posterior abdominal wall, which means the dissection of the ligament of Treitz. The pancreas receives blood from 2 two sources: the celiac trunk and the superior mesenteric artery. All veins bring blood back to the upper mesenteric vein.
6 The pancreatic fluid contains some digestive enzymes in the inactive form. These enzymes are activated in the duodenum through enterokinase. Activated pancreatic enzymes are the main cause of reducing the lesion healing. 1.2. Indication for LPD Indicate LPD for injured pancreatic head tumors, Vater tumors, tumors at the second part of the duodenum, tumors at the lower part of the common bile duct, and chronic pancreatitis. Tumors should be at a small size, no metastasis, no tumor cell intravasation or invasion. Caruso (2017) recommended laparoscopic pancreaticoduodenectomy should be indicated for tumor size <3.5 cm and also without invasion or intravasation. Based on results of clinical examination, hematological test, blood biochemical test, CA 19-9, ultrasound, CT scan, duodenal gastric endoscopy, laparoscopic ultrasonography, etc, and the actual assessment
pancreaticoduodenectomy is compatible. 1.3. LPD techniques Patients were in supine position with two legs separated. The operating surgeon stood between the legs of the patient, the first assistant stood on the left side of the patient. The second assistant held a camera at a 30degree angle and on the right side of the patient. Usually, 4 trocars were used in the supportive laparoscopic surgeries and 5 trocars were used to tin the complete laparoscopic surgeries. Slightly pumped CO2 and maintained the pressure below 12 mmHg.
7 After placing the trocars, proceeded to examine and detect peritoneal metastases, liver metastases, tumor invasion to the surrounding
pancreaticoduodenectomy. Basic steps of LPD began with cutting gastrointestinal ligaments with ultrasound knife and moved to the posterior epithelium of the spleen; the gastrol-omental vein had to be cut. Cut the colorectal liver ligament to lower the colon near the liver. The stomach was raised up and systematically examined the whole pancreas. The common hepatic artery was examined and then removed all lymph nodes (group 8) around the superior pancreaticoduodenal artery. The duodenal arteries were separated by 2 clips and cut, then the anterior portal vein is exposeed from the upper side of the pancreatic neck. Then detach the superior mesenteric vein from nearby structures to the lower side of the pancreatic neck. The surgeon should be careful with the middle colon vein. Create a tunnel behind the pancreatic neck, in front of the mesenteric vein, and under the hepatic portal vein with Kelly forceps or straws. Free the back of the pancreaticoduodenal with Kocher method to the left renal vein and the superior mesenteric artery. Cut the neck of the gallbladder and remove the bile liquid (due to cholestasis). Cut the pyloric canal and cut the duodenum 3cm – 4cm under the pylorus with a laparoscopic stapler. Cut the first jejunum loop with the stapler 15 - 20 cm far from the angle of Treitz, cut the first jejunum loop with LigaSure knife (Covidien firm) along the walls of the jejunum. Treitz ligament is cut. The jejunum loop is pulled through the space between the superior mesenteric vein and transverse colon on the right. The pancreatic
8 neck is cut with the laparoscopic stapler, starting from the lower part of the pancreas to the upper part of the pancreas in front of the superior mesenteric vein below and the upper portal vein. The pancreas is hemostatic with the laparoscopic stapler or is stitched to the
pancreaticoduodenal artery is raised up with clips and cut. The pancreatic head and uncinate process were separated from the superior mesenteric vein, the portal vein, and the superior mesenteric artery. The gastrointestinal anastomosis was reconstructed with Roux en Y method, consisting of 3 connections: intestinal pancreas, intestinal bile (above the Y-shaped loop) and gastrointestinal tract. 1.4. Complications after laparoscopic pancreaticoduodenectomy 1.4.1. Hemorrhage Bleeding after pancreaticoduodenectomy (PD) may manifest in forms of gastrointestinal hemorrhage or intra-abdominal hemorrhage or both. 1.4.2. Postoperative Pancreatic fistula It is a common complication after PD surgery. It can be the leakage at the connection of intestinalpancreas, the pancreas parenchyma or leakage at the other area at the right border of the superiormesenteric vein. Pancreatic fistula is also a major cause of death of postoperativepancreaticoduodenectomy. 1.4.3. Delayed Gastric Emptying Delayed Gastric Emptying (DGE) is a condition that requires gastric intubation to relieve the pressure 10days after the operation or
9 renew gastric intubation. DGE is common in patients with pyloruspreservingpancreaticoduodenectomy. 1.4.4. Postoperative bile leak Detect with the concentration of bilirubin, the presence of bile salts, bilirubin in the abdominal drainagefluid; or there is a communication with the surroundings of intestinal bile connection, which is detectedon the ultrasound, CT images or during a reoperation. 1.4.5. Postoperative residual abscess: is a postoperative condition with peritoneal fluid sacwhich is more than 5 cm. The condition must be treated with aspiration or drainage. 1.4.6. Acute postoperativepancreatitis: pancreatitis happens when the blood amylase levels increase at least 3 times than normal. 1.4.7. Wound infection When the incision becomes inflamed and pus appears, it is necessary to let the incisioncontact to the air at dry. 1.4.8. Pneumonia: Detecton the X-ray film with fever. The condition must be treated with antibiotics. 1.4.9. Trocar accidents: rocar site herniation, bleeding or infection of the skin at the trocar insertion site. puncture into the gastrointestinal tract. 1.4.10. Complications of pumped CO2: Gas embolism, Hypothermia: due to prolonged operation, and much CO2 used. Other complications included: subcutaneous emphysema, pneumothorax, mediastinal emphysema, etc. 1.5. Study situation of LPDin the world and inVietnam 1.5.1. In the world
10 LPD was first described by Gagner and Pomp in 1994. Since then, there have been many literatures reported LPD. Gagner and Pomp proved that LPD is compatible and as safe as OPD. In 2006, Dulucq had a retrospective research on 25 patients with LPD from March 1999 to June 2005. In 2008, Puglieses organized a retrospective study on 19 LPD cases. In 2010, Kuroki conducted a study on LPD and made a trial ofpancreatic lift technique at the step cutting of the pancreatic head and tail from the upper mesenteric vein and portal vein for 9 patients. In 2010, Kendrick studied on 65 patients with LPD, 62of which underwent complete laparoscopy. In 2012, Suzuki studied a research to compare outcomes of LPD and OPD. During 6 years from 2005 to 2011, there were 215 patients under OPD and 53 patients with LPD. The study showed that there was a statistical difference on perioperative blood loss volume, the number of patients needed blood transfusion and time of intensive care stay after the surgery. In 2013, Honda et al researched on 26 patients with laparoscopic pancreatectomy, including 25 patients with pancreaticoduodenectomy and 1 patient with full pancreatec with splenectomy. In 2013, the study of Machado assessed types of laparoscopy related to pancreas from 2001 on 96 patients with laparoscopic pancreatectomy. According to Wang (2016), based on his retrospective study from December 2009 to November 2013, he studied on 18 patients with LPD.
11 In 2017, Caruso studied from 1/2013 to 12/2015 on 31 patients undergoing pancreatectomy, 10 of them had LPD. 1.5.2. In Viet Nam In 2008, Duong Trong Hien et al made initial comments on experience of LPD from 2005 to 2008 at Viet Duc University Hospital on 4 patients. In 2010, Le Huy Luu informed a case of LPD at the Gastrointestinal Department, of Gia Dinh People's Hospital. In 2013, Nguyen Hoang Bacet al studied complete LPD from May 2010 to May 2012 on 13 patients. Chapter 2 - SUBJECTS AND METHODS OF RESEARCH 2.1. Research subjects: 36 patients were indicated with laparoscopic pancreaticduodenectomy at Viet Duc University Hospital and Military Medical Hospital 103 from 01/2010 to 12/2016. 2.2. Research Methods 2.2.1. Research design: description, retrospective and prospective research methods 2.2.2. Technical procedures used in the study 184.108.40.206. Prepare patient before surgery 220.127.116.11. Steps of LPD The procedure consists of 11 technical steps. 2.2.3. Research targets 18.104.22.168. General research targets a, General characteristics b, Clinical characteristics c, Subclinical characteristics
12 22.214.171.124. Indication for LPD Indications for FPD to remove the head of the duodenal pancreas include: Pancreatic head tumors, pancreatic head cancer, papillary pancreatic tumors, cystadenoma; low common bile duct cancer; Vater tumors; tumorsat the second part of the duodenum; chronic pancreatitis. Tumor size should be<3.5cm, no invasivion narrowing of the portal vein or invasive superior mesenteric artery on CT films. There should be no metastases and invasion to structures nearby. 126.96.36.199. The criteria for studying the technical characteristics of LPD a, Surgical characteristics: recording techniques and complications according to 11 steps. - Step 1: Insert Trocars - Step 2: Abdominal examination (abdominal condition) - Step 3: Implement Kocher procedures (separating
pancreaticoduodenal mass from the posterior abdominal wall and prevent potential complications) - Step 4: Control arteries supplying blood to pancreas (cut arteries
supplying blood to thepancreaticoduodenal mass) - Step 5: Cut the the pyloric cannal, cut the pancreas neck, reposition
the pancreatic uncinate process (depends on the enlargement of pancreas, pancreatic parenchyma; and stop the bleeding at the cutting area) - Step 6: Tighten off the blood vessels in the head of duodenal
pancreas, cut off the pancreaticoduodenal mass (in case of complications)
complications) - Step 10: Open the abdomen to remove the pancreaticoduodenal
mass, close the abdomen (size of the incision, how to close the surgery incision). - Step 11: Check hemostasis status, and establish an abdominal
drainage. 188.8.131.52. General assessment of the LPD Surgery time. Total blood loss in surgery. The number of patients must receive blood transfusions and the amount of blood transfused (ml) during surgery. 2.2.4. Outcome Accessment 184.108.40.206. Follow-up posoperative indicators Based on farting time, time to remove the intubation, time to removethe abdominal drainage, and hospital stay after the operation. General complications after surgery: postoperative hemorhage, pancreatic fistula, bile leak, delay gastric emptying (DGE), residual abscess, acute pancreatitis, wound infection, etc. Mortality: counting from the start of the surgery till discharge time. Access general health condition of patients at discharge time: Good, Fair, Medium, Bad. 220.127.116.11. Follow-up postoperative outcomes
14 The quality of life of patients after surgery wasclassified with 4 levels: Good, Fair, Medium, Bad. Clinical and subclinical examination Extra life time after the LPD surgery 2.2.5. Process the data Data was processed with SPSS 16.0 software, statistical algorithms to calculate mean values, median values, percentages, and estimated postoperative extra life time according to Kaplan Meier estimator. Chapter 3 - RESEARCH RESULTS There are a total of 36 patients qualified to participate in the study, of which there were 22 patients from Viet Duc University Hospital and 14 patients from Military Medical Hospital 103. 05 patients were under retrospective method while 31 were under prospective method. 3.1. Characteristics of the research objects 3.1.1. General features Average age ± SD: 50.4 ± 11.6. The youngest was 22. The oldest was 71. The mean age of the research group was 50.4 years old. There was 25.0% of patients over 60 years old. Male over female ratio was 1.4: 1. 2 patients who (5.6%) were with history of diabetes, was under stable status at reseaching time; and 02 patients (5.6%) were with a history of alcohol consumption. 01 patient had the history of endoscopic cholecystectomy; and a patient had the history of partial Hysterectomy. 3.1.2. Clinical symptoms
15 18.104.22.168. Functional symptoms Common symptoms are abdominal pain (83.3%) and anorexia (41.9%) 22.214.171.124. Body symptoms Mainly was jaundice (66.7%) and enlarged gallbladder (58.3%). 3.1.3. Subclinical characteristics Patients with CA 19-9 of 200 (U/l) belonged to the group of cancer 66.7%, in which of 18 patients with CA 19-9 under 37 (U/l) there was 55.6% of patients belonged to the cancer group . 41.7% of patients was detected with tumors at the duodenum pancreatic head on ultrasound results. 88,2% of patients was detected with ampella vater tumor, pancreatic head tumor, and/or duodenal tumor on CT films. The tumor size via CT scan: 25.8 ± 14.5 mm, the smallest tumor was 10 mm and the biggest was 61,0 mm. The patients had a gastroscopy before surgery, 16 of which (48.5%) had ampulla of Vater. 02 patients (6.1%) were detected with pancreatic head tumors vialaparoscopic ultrasound. 05 patients (15.1%) had injured doudenum tumors, and of them had tumor bleeding. 126.96.36.199. Classify health status of the patients based on ASA scale - ASA type I: 32 (88.9%), ASA type II: 4 (11.1%) 3.2. Indication for LPD 3.2.1. Indication based on the perioperative diagnosis
16 Perioperative diagnosis showed 44.4% with ampulla of Vater tumors, 41.7% with pancreatic head, 13.9% with tumors at th second part of duodenum 3.2.2 . Indication based on the tumor size via ultrasound and CT films Patients having indication for LPD had tumors at mean size of 3.3 cm on ultrasound images, 2.6 cm on CT films. 3.3. Surgical features 3.3.1. Surgical steps. Record all steps and complications as agreement in the preoperative consultations. Step 1: Placing the Trocars: 36.1% of cases had 4 trocars in laparoscopic supportive surgery, 63.9% of cases had 5 trocars incomplete laparoscopic surgery. The most common complication of trocar inserting reported washemorrhage (19.4%) in the position of trocar pinned. And most of cases, after pressing the trocar and the abdominal wall, the hemorrhage was stopped. Step 2:Abdominal ExaminationComment: Distended gallbladder lesions was the most commonly detected (77,8%), Cholestatic liver enlargement (66,7%), Venous inflammation (2,8%). Step 3: Release of the duodenum and the pancreatic head Kocher procedures.Lesions of the duodenum was the most common (8,3%), Transverse colon mesenteric 5,6% but didn't affect the blood supply to the colon, injuried bile duct (2,8%) Step 4: Control, expose, tighten off and cut blood arteries which are supplying blood to dozens of pancreas. Complications of injuried
17 mesenterica superior vein in the 02 patients (6,4%). Chart 3.1. Numbers of LPD and converted to OPD Patients needed to converted to OPD was 4 ( 5,6%), 32 patients performed withLPD, were included in the technical assessment and postoperative outcome assessment. Step 5: Cutthe pyloric cannal, pancreatic neck; and move the pancreatic ucinate process: Table 3.18. Hemostatic of pancreatic remnant surface Technique Number patient Rate (n=32) (%) Suture hemostasis. 3 9,4 Electrocoagulation hemostasis 24 75,0 Suture and electrocoagulation 5 15,6 hemostasis. Electrocoagulation hemostasis was mostly applied (75,0%). There were 15,6% cases needed both suture and electrocoagulation hemostasis. Step 6: Cut vessels supplying blood to the duodenum and pancreatic head,remove the injured pancreaticoduodenalmass.
Chart 3.4: Complications after cutting vessels supplying blood to the
18 duodenum and pancreatic head,remove the injured pancreaticoduodenalmass. There were 03 cases (9,4%) suffered from hemorrhage from thehead of straps of D4 jejunum duodenum and early jejunum during the dissection. Step 7:Reconstruct the digestive pancreas – jejunum anastomosis Comment: Method of end-sideanastomosis was primarily used to reconstruct the pancreas and jejunum anastomosis (71,8%) while the end-end connection accounted for 28.2%, regardless of the condition of pancreatic parenchyma.
Chart 3.5: Complications when connecting the pancreas – jejunum Comment: 87.5% needed to establishedadrainage to reduce the pressure of intestinal bile duct connection, and 12.5% didnt need to establish drainage.
19 Chart 3.6: Complications ofthe Bile duct and jejunum connection The most applicable methodwas Roux- en – Y (65,6%), and Polya counted for 34.4%. Loose stitch was used in the laparoscopic supportive surgeries and whipping or automated anastomosis was ised in laparoscopic complete surgeries. 87.5% needed to cut the pyloric cannal and 12.5% followed pyloric sphincter preservation. 3.4 General criteria of LPD 3.4.1 The parameters of LPD Mean surgical time calculated from creating the incision and placing the first trocar to the closure of the abdominal was 315,9 ± 191,4 minutes. The mean blood loss was 372.6 ± 283.0 ml, 9 patients had intraoperative blood transfusion at mean of 622.2 ± 378.3 ml. 3.4.2 Outcome Assessment Table 3.25. Postoperative anatomical diagnosis
Number patients (n)
Pancreatic head cancer
Cancer of low common bile duct
Cancerized hamoudi tumor
Non Hodgkin's Lymphoma tumor
Brunner's gland adenoma
Pancreatic neuroendocrine tumors
Postoperative anatomical diagnosis showed there was 55.6% of patients having malignant histopathological results. In which, pancreatichead cancer was 22.2%, Ampullary carcinomawas 22.2%, and chronic pancreatitis was 30.6%. Mean Farting time was 91.3 hours. The mean time to remove the drainage tube was 10,8 days. The mean time to remove abdominal drainage was 31,3%. Besides,34,4% needed blood transfusion after the surgeries;87.5% needed protein infusion; 50.0% needed albumin infusion, and62.5% needed Sandostatin injection. Comment: The mean time of antibiotic intake was 13.8 days and the mean postoperative hospitalization time was 16.3 days. 188.8.131.52 Common postoperative complications Complications
Delay gastric emptying
21 Bleeding in abdomen
Transient acute pancreatitis
Table 3.33 Common postoperative complications Comment: The most common complication was transient acute pancreatitis (18.8%), followed by residual abscess commonly incurring after pancreatitis (6.3%), delayed gastric emptying (3.1%), and bile leak (3.1%). 184.108.40.206 General health Assessment of patients at discharge time
Figure 3.7 Health status before discharge (n=32) Comment: The patients with quite good and good result of treatment accounted for the majority (83.3%), the patients with average result for 16.7%. There was no patient with bad result. 3.5. Postoperative Follow-up The longest follow-up was 90 months, and the shortest was 6 months. The number of patients monitored for over 24 months were 24 patients (77.4%) and the number of alive patients continuously monitored was 24 patients (77.4%). 3.5.1. Clinical symptoms at re-examination
22 After LPD,the majority of patients hadsignificantly improved clinical symptoms. However, sometimes, they have got stomachache at 6 – 12 months time with the incidence of 14.8 – 23.1% respectively. One patient had got clinical recurrence at 6 – 24 months time after surgery. 3.5.2. Results of abdominal ultrasound when re-examnination In the 6th month: 2/27 patients with bile dilatation (7.4%), 3/27 patients with pancreatic dilatation (11.1%). In the 12 th month: 1/26 patient was reported to recur (3.8%). In the 12 th month, 1/26 patient was reported liver metastasis (3.8%). 3.5.3 CT results at reexamination Comment: The enlargement of bile duct ranged from 3.8% to 16.7% and the longer after after the surgery, the extent of enlargement tended to increase gradually. Pancreatic dilatation appeared at the 6th month time after the surgery, accounting for 11.1% of all patients. 3.5.4 Life time Postoperative Followup
Figure 3.8. Kaplan-Meier estimator: the extra-life time of each patient group
23 Comment:Till December 31st, 2017, 50% cancer patients were still alive; the mean extra-life time of cancer group was 32.9 months. 3.5.5. Quality of life after surgery At the December 31st, 2017, 89.5% of patients (17/19) reported fair and good quality of life while 10.5% had medium quality of life. Chapter 4 – DISCUSSION 4.1. General features From 01/2010 to 12/2016 at VietDuc University Hospital (22 Patients) and Military Medical Hospital 103 (147 Patients) had total of 36 patients having LPD. A retrospective study was implemented in 5 patients and a prospective study was conducted in 31 patients. The mean age of studied patients was 50.4 ± 11.6 years old. The ratio of men/women was 1.16:1. 4.2. Clinical and subclinical features The frequent symptoms included stomachache (83.3%), anorexia (41.9%), jaundice (66.7%), and enlarged gallbladder (58.3%). The patients with CA 19-9 higher than 200 U/l in cancer group accounted for 66.7%, and of 18 patients with CA 19-9 lower than 37 U/l there were 55.6% of patients classified in cancer group. Therefore, low CA 19-9 can not be used to exclude cancer patients. 41.7% of patients hve got tumors in the pancreaticoduodenal mass on ultrasound images. Via CT scan, 77.8% patients have been detected with the tumor of ampulla of Vater, tumor in the pancreatic head, and duodenum tumor. 4.2 Indication for LPD
24 Perioperative diagnosis indicated 41.7% of patientswith pancreatic head tumors, 44.4 % of patients with Vater ampulla tumors and 13.9% for duodenum tumors. Compared with postoperative histopathology diagnosis, it was shown that the indications in our study included: pancreatic epithelioma – 8 patients (22.2%), Vater ampulla epithelioma – 8 patients (22.2%), cancer of low common bile duct – 1 patient (2.8%), duodenal cancer – 1 patient (2.8%), cancerized hamoudi tumor – 1 patient (2.8%), Non Hodgkin's Lymphoma tumor – 1 patient (2.8%), Brunner’s glands tumor – 3 patients (8.3%), neuroendocrine tumor – 1 patient (2.8%), Cystadenoma tumor - 1 patient (2.8%), chronic pancreatitis – 11 patients (30.6%). Brunschwig reported in his study that there were 60.8% had Pancreatic head tumors, 13% had ampullary tumors, 8.7% had low common bile duct tumors. The author Cameron indicated that the rate of panreatic head tumors was 40,5%, ampullary tumors was 11.3%, low common bile duct tumors was 9.5%. In our study, the size of tumors were bigger than in other studies, especially in several cases of chronic pancreatitis, the dimension of tumors on CT result were about 2.6 ± 1.4 cm. (from 1.0 to 6.1cm). Pugliese (2008) indicated LPD for tumors at size ≤ 3.5cm. Corcione (2013) set standard to select proper patients for LPD was with tumors ≤ 2.5cm 4.3 Technical features of LDP Follow 11 steps of technical process in the study 4.3.1. Step 1: Insert Trocars
25 Our study has shown that generally 5 trocars were enough for a successful LDP (63.9%). 36.1% of cases used 4 trocars applied in supportive endoscopy. 4.3.2. Step 2: Explore abdomen In our study, it was shown that the most common was gallbladder enlargement with 77.8%, followed by distended cholestasis in liver with 66.7%. There were two cases with greatmembranes strongly sticking liver and gallbladder in the patient who got gallbladder removal 6 months before. 4.3.3 Step 3: Release pancreaticoduodenal mass – Kocher minor procedure Kocher procedure was implemented from right side of the duodenum (D2), from top to bottom and from outside to inside. The purpose of this movement was to expose pancreaticoduodenal mass, vena cava below the liver, the abdominal aorta, the vein of left kidney and the right side of superior mesenteric vein. 4.3.4 Step 4: Control, expose, tighten off and cut blood vessel providing for pancreaticoduodenal mass The authors of the research recommends when exposing the portal vein above the pancreatic neck, it is nesseary not to break the small vein, causing hemorrhage. , leading to bleeding without paying attention. We faced the injuries in vena cava (3.2%), the bleeding in duodenal artery (3.2%) due to dropping clip, the injuries in superior mesenteric vein and bleeding from branches of mesenteric. Our study had 4 patients transferred open operation with the rate of 5.6%, all these patients had inflammed tumor sticking gread blood vessels such as vena cava, superior mesenteric vein while