Name: laparoscopic pancreatoduodenectomy for pancreatic cancer using in-situ no-touch isolation technique
Uploaded: 2022-02-02T14:30:00
Description: Watch this Scientific Journal Video about Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique at JoVE.com

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本研究经广州中医药大学附属第二医院伦理委员会批准。
1. 患者选择
<ol><li>建议怀疑患有胰腺导管腺癌 （PDAC） 的患者首先进行造影增强计算机断层扫描 （CT）。然后选择以下患者：新辅助治疗后临界可切除病例，肿瘤消退明显，有根治性切除的可能;同时，可能需要SMV重建。</li>
	<li>排除以下患者：（1）转移性PDAC;（2）一般情况差，不能耐受大手术的患者;（3?...

<ol>
	<li>Hirota, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreatectomy+using+the+no-touch+isolation+technique+followed+by+extensive+intraoperative+peritoneal+lavage+to+prevent+cancer+cell+dissemination:+a+pilot+study.">Pancreatectomy using the no-touch isolation technique followed by extensive intraoperative peritoneal lavage to prevent cancer cell dissemination: a pilot study.</a> Journal of the Pancreas. 6 (2), 143-151 (2005).</li><li>Gall, T. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reduced+dissemination+of+circulating+tumor+cells+with+no-touch+isolation+surgical+technique+in+patients+with+pancreatic+cancer.">Reduced dissemination of circulating tumor cells with no-touch isolation surgical technique in patients with pancreatic cancer.</a> JAMA Surgery. 149 (5), 482-485 (2014).</li><li>Soeth, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Detection+of+tumor+cell+dissemination+in+pancreatic+ductal+carcinoma+patients+by+CK+20+RT-PCR+indicates+poor+survival.">Detection of tumor cell dissemination in pancreatic ductal carcinoma patients by CK 20 RT-PCR indicates poor survival.</a> Journal of Cancer Research and Clinical Oncology. 131 (10), 669-676 (2005).</li><li>Yap, T. A., Lorente, D., Omlin, A., Olmos, D., de Bono, J. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Circulating+tumor+cells:+a+multifunctional+biomarker.">Circulating tumor cells: a multifunctional biomarker.</a> Clinical Cancer Research. 20 (10), 2553-2568 (2014).</li><li>Fujita, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+right+hemicolectomy+with+radical+lymph+node+dissection+using+the+no-touch+isolation+technique+for+advanced+colon+cancer.">Laparoscopic right hemicolectomy with radical lymph node dissection using the no-touch isolation technique for advanced colon cancer.</a> Surgery Today. 31 (1), 93-96 (2001).</li><li>Hirota, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreatoduodenectomy+using+a+no-touch+isolation+technique.">Pancreatoduodenectomy using a no-touch isolation technique.</a> The American Journal of Surgery. 199 (5), 65-68 (2010).</li><li>Kuroki, T., Eguchi, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=No-touch+isolation+techniques+for+pancreatic+cancer.">No-touch isolation techniques for pancreatic cancer.</a> Surgery Today. 47 (1), 8-13 (2017).</li><li>Tan, Z. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+experience+of+laparoscopic+pancreatoduodenectomy+via+orthotopic+resection.">Clinical experience of laparoscopic pancreatoduodenectomy via orthotopic resection.</a> Zhonghua Wai Ke Za Zhi [Chinese Journal of Surgery. 58 (10), 782-786 (2020).</li><li>Osada, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reconstruction+method+after+pancreaticoduodenectomy.+Idea+to+prevent+serious+complications.">Reconstruction method after pancreaticoduodenectomy. Idea to prevent serious complications.</a> Journal of the pancreas. 13 (1), 1-6 (2012).</li><li>Mizrahi, J. D., Surana, R., Valle, J. W., Shroff, R. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreatic+cancer.">Pancreatic cancer.</a> Lancet. 395 (10242), 2008-2020 (2020).</li><li>Tempero, M. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreatic+adenocarcinoma,+version+2.2021,+NCCN+clinical+practice+guidelines+in+oncology.">Pancreatic adenocarcinoma, version 2.2021, NCCN clinical practice guidelines in oncology.</a> Journal of the National Comprehensive Cancer Network JNCCN. 19 (4), 439-457 (2021).</li><li>Bockhorn, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Borderline+resectable+pancreatic+cancer:+a+consensus+statement+by+the+International+Study+Group+of+Pancreatic+Surgery+(ISGPS).">Borderline resectable pancreatic cancer: a consensus statement by the International Study Group of Pancreatic Surgery (ISGPS).</a> Surgery. 155 (6), 977-988 (2014).</li><li>Tee, M. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+pancreatoduodenectomy+does+not+completely+mitigate+increased+perioperative+risks+in+elderly+patients.">Laparoscopic pancreatoduodenectomy does not completely mitigate increased perioperative risks in elderly patients.</a> HPB (Oxford). The Official Journal of the International Hepato Pancreato Biliary Association. 17 (10), 909-918 (2015).</li><li>Palanivelu, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Randomized+clinical+trial+of+laparoscopic+versus+open+pancreatoduodenectomy+for+periampullary+tumours.">Randomized clinical trial of laparoscopic versus open pancreatoduodenectomy for periampullary tumours.</a> The British Journal of Surgery. 104 (11), 1443-1450 (2017).</li><li>Wang, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+versus+open+pancreatoduodenectomy+for+pancreatic+or+periampullary+tumours:+A+multicentre,+open-label,+randomised+controlled+trial.">Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours: A multicentre, open-label, randomised controlled trial.</a> The Lancet. Gastroenterology &amp; Hepatology. 6 (6), 438-447 (2021).</li></ol>

PDAC是最致命的恶性疾病之一。尽管总体 5 年生存率仍然不尽如人意，但到目前为止，手术仍然是唯一的治疗方法10.根据美国国家综合癌症网络（NCCN）和国际胰腺癌研究小组（ISGPS）的说法，诊断为PDAC的患者应被定义为临界可切除病例，而门静脉-肠系膜上静脉可疑受累，为了提高R0切除率，建议这些队列实施同步静脉切除术11，12.在这?...

胰十二指肠切除术（PD）是胰十二指肠区域癌症的标准外科手术。Kocher 操作广泛用于常规 PD 期间十二指肠和胰腺头的有效暴露。手术过程中胰十二指肠区域的动员和挤压可能在周围血管结扎之前引起肿瘤细胞转移1。最近的一项研究表明，由于外科医生对肿瘤区域的处理和挤压，肿瘤细胞有可能被挤压到门静脉（PV）中，这可能会进一步增加手术后肝转移的风险2。
随着生物医学技术的发展，科学家可以检测实体肿瘤细胞（包括胰腺癌细胞）作为循环肿瘤细胞（CTC）扩散到血管中的扩散3，4。
已用于结肠癌的非接触式隔离程序可能会阻止癌细胞（例如循环肿瘤细胞）从原发肿瘤中扩散5。一些研究报告了在剖腹胰十二指肠切除术6，7 期间使用非接触式隔离技术治疗胰头癌。该手术的概念是，外科医生在结扎和解剖胰头周围的血管（动脉和静脉）之前不会触摸十二指肠和胰头区域（包括肿瘤）。
LPD 中已有非接触式分离技术用于胰十二指肠区肿瘤的报道8.本文提出了一种改良的原位非接触隔离LPD，在新辅助治疗后对胰腺癌进行部分切除和重建SMV，首先解剖所有流入动脉，以足够的边缘横断受累静脉，原位切除肿瘤，并整体取出标本。
这种方法的目标和优点是确保所有步骤都遵循无接触的肿瘤学原理，以降低肿瘤细胞转移的风险。开发和使用该技术背后的基本原理是，肿瘤应在最后阶段动员，包括在肿瘤流入动脉和流出静脉闭塞后原位切除肿瘤和整体取出标本。然而，由于当外科医生决定是否使用这种方法时，这种手术需要复杂的切除和重建技术，他们需要估计自己的情况，例如学习曲线、肿瘤类型、血管状况和其他因素。

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>3D Laparoscope</td>
			<td>STORZ</td>
			<td>TC200,TC302</td>
			<td></td>
		</tr>
		<tr>
			<td>Absorbable hemostat</td>
			<td>ETHICON, LLC</td>
			<td>2 in x 4 in</td>
			<td></td>
		</tr>
		<tr>
			<td>Artificial Interposition Graft</td>
			<td>W.L.Gore &#38; Associates, Inc.</td>
			<td>IRTH084040W</td>
			<td></td>
		</tr>
		<tr>
			<td>Drainage tube</td>
			<td>Aiyuan</td>
			<td>424280</td>
			<td></td>
		</tr>
		<tr>
			<td>Echelon Flex Powered Plus Articulating Endoscopic Linear Cutter and Endopath Echelon Endoscopic Linear Cutter Reloads with Gripping Surface Technology</td>
			<td>Ethicon Endo-Surgery</td>
			<td>ECR60G/GST60G</td>
			<td></td>
		</tr>
		<tr>
			<td>Energy Platform</td>
			<td>COVIDIEN ForceTriad Energy Platform</td>
			<td>T2131469EX</td>
			<td></td>
		</tr>
		<tr>
			<td>HARMONIC ACE Ultrasonic Surgical Devices</td>
			<td>Ethicon Endo-Surgery</td>
			<td>HAR36</td>
			<td></td>
		</tr>
		<tr>
			<td>Laparoscopic forceps</td>
			<td>Gimmi</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Laparoscopic right angle forceps</td>
			<td>KARL STORZ</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Laparoscopic scissors</td>
			<td>AESCULAP</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Latex T-shape Catheter</td>
			<td>ZHANJIANG STAR ENTERPRISE CO., LTD.</td>
			<td>24Fr</td>
			<td></td>
		</tr>
		<tr>
			<td>Ligating Clips</td>
			<td>Teleflex Medical</td>
			<td>5,44,22,05,44,23,05,44,000</td>
			<td></td>
		</tr>
		<tr>
			<td>PDSII</td>
			<td>Ethicon, LLC</td>
			<td>W9109</td>
			<td></td>
		</tr>
		<tr>
			<td>PROLENE</td>
			<td>Ethicon, LLC</td>
			<td>W8556</td>
			<td></td>
		</tr>
		<tr>
			<td>Trocar</td>
			<td>Surgaid</td>
			<td>NPCS-100-1-12</td>
			<td></td>
		</tr>
		<tr>
			<td>Ultrasonic Surgical &#38; Electrosurgical Generator</td>
			<td>Ethicon Endo-Surgery</td>
			<td>GEN11CN</td>
			<td></td>
		</tr>
	</tbody>
</table>

laparoscopic pancreatoduodenectomy for pancreatic cancer using in-situ no-touch isolation technique

腹腔镜胰十二指肠切除术（LPD）是目前胰腺头恶性肿瘤的标准根治性手术。由于腹腔镜切除和重建技术复杂，局部晚期胰腺头癌患者在新辅助治疗后难以进行LPD。我们的团队使用 原位 非接触式隔离技术启动LPD。这种改进的无接触分离技术的创新和优化强调在通过结肠下肠系膜入路评估可切除性之前探索肠系膜上静脉 （SMV）的远端和肠系膜上动脉（SMA）的左侧，这是一种理想的探索方法。之后，我们使用SMA方法的中前和左后路切断胰头的血流，使肿瘤完整地分离出来，然后移动并解剖肿瘤。这是一个符合无肿瘤手术原理的过程。本文旨在证明使用 原位 非接触隔离技术进行LPD的可行性和安全性，该技术可能会提高R0切除率。这是一个肿瘤学上理想的手术过程。

一名患有上腹痛和消瘦的55岁男性在胰腺的未侧突中被诊断为4.2 cm x 3.1 cm肿瘤，SMV受累超过180°（图5）。患者既往健康，体重指数相对正常（19.47 kg/m2）。术前造影剂增强CT扫描未发现远处转移。进行内镜超声引导下细针抽吸（EUS-FNA）以获得腺癌的病理诊断。作为新辅助化疗，对该患者进行了8个周期的改良FOLFIRINO（mFOLFIRINOX）方案（氟尿嘧啶2，400 mg / m 2，伊立替康135...

Watch this Scientific Journal Video about Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique at JoVE.com

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

非接触式隔离程序可能会阻止原发性肿瘤的癌细胞扩散。然而，到目前为止，这些技术尚未在腹腔镜胰十二指肠切除术（LPD）中被广泛接受。我们在此介绍原 位 非接触式分离LPD，部分切除和重建肠系膜上静脉（SMV）用于新辅助治疗后的胰腺癌。

腹腔镜胰十二指肠切除术使用原 位 非接触式隔离技术治疗胰腺癌

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic ...

该协议证明了使用原位非接触式隔离技术进行LPD的可行性和安全性，该技术可能会提高R0切除率。该方法的主要优点是确保所有步骤都遵循非接触的肿瘤学原理，以降低肿瘤细胞转移的风险。由于复杂的切除和重建技术，该手术只能由具有开放和腹腔镜胰腺手术技能的高容量中心经验丰富的外科团队进行。这种方法是肿瘤学上理想的操作过程。首先，仔细探索腹膜内器官和腹膜表面，以发现意外的胰腺外转移。切除大网膜并通过分割胃结肠韧带打开小囊。然后结扎亨勒的胃结肠躯干静脉。探索胰颈和胰腺下缘SMV之间的间隙。横结肠及其系膜是头高。然后在肠系膜切片之后暴露十二指肠的第二和第三部分。暴露下腔静脉、左肾静脉、乳糜泻躯干、主动脉和 SMA，以再次确认可切除性，并活动胰头后部。然后沿着SMV进行解剖以清除右侧的所有组织。确保横结肠没有缺血。结扎结肠中动脉的根部以完全暴露 SMV。将整个小肠放在左侧以方便暴露，然后将远端十二指肠的解剖暴露在Treitz韧带的近端。用吻合器分隔空肠近端，并通过沿空肠动脉追踪来暴露 SMA。放置一根法国 8 导管，用于悬挂和包围 SMA 和 SMV 的背侧。将导管拉至右上方，以允许 SMA 在其左前缘的外阴平面上进行 SMA 解剖并将其与中胰腺分离。结扎肿瘤涉及的第一条空肠动脉，并处死。确定第一空肠静脉和胰十二指肠下静脉（IPDV），它们是SMV背侧的分支。结扎并剖析IPDV。圆周解剖 SMA 以识别胰十二指肠下动脉或 IPDA，它要么与第一空肠动脉形成公共干，要么直接起源于 SMA。然后牺牲IPDA。在左侧后入路，解剖 SMA，其起点在 LRV 上方，游离中胰腺。从上结肠区域开始 SMA 方法。然后，通过橡皮筋悬挂SMV，使用订书机装置将胃分开距离幽门三到五厘米。取出胆囊。分开胆总管并应用腹腔镜斗牛犬夹暂时阻塞CBD。然后解剖肝十二指肠韧带，结扎，然后解剖右胃动脉，识别胃十二指肠动脉。双重结扎或缝合 GDA，并沿 CHA、肝动脉或 PHA 和门静脉进行淋巴结切除术。探索胰腺颈部和胰腺下缘SMV之间的间隙，并用超声刀横断胰腺颈部。接下来，对胰残端进行冷冻病理检查。使用橡皮筋悬挂脾静脉，并在菱形窗口内解剖SMA的右侧和背部。从尾侧到头侧切除SMA和CA周围的脂肪和纤维组织。结扎并横断脾静脉下的突动脉，使标本附着在脾静脉SMV上。使用腹腔镜斗牛犬夹暂时夹住脾静脉和 SMV，并以足够的边缘横断受累静脉。之后，切断淋巴管并从腹膜后解剖十二指肠。用软尺测量静脉缺损的长度。如果缺损超过三厘米，请使用人工插入移植物。使用5-0 Prolene缝合线通过连续缝合从尾部到头部进行SMV重建。然后进行单层运行缝合肝空肠吻合术，从头到尾进行4-0可吸收缝合。通过导管到粘膜端对侧胰空肠吻合术使用内部支架进行胰腺吻合术。最后，进行胃空肠吻合术。代表性图像显示了胰腺未接生过程中的肿块。内镜超声引导下细针抽吸，获得腺癌的病理诊断。对患者进行了8个周期的改良FOLFIRINOX方案作为新辅助化疗。新辅助化疗后，肿瘤的最大直径从4.2厘米减小到3.5厘米。尝试此手术时，需要特别注意的步骤包括确认胰头后部的可切除性和活动性，放置法国 8 导管以悬挂和包围 SMA 和 SMV 的背侧，结扎肿瘤涉及的第一空肠动脉，以及识别 IPDA。

Research

JoVE Journal

Medicine

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Immunohistochemical Staining of B7-H1 (PD-L1) on Paraffin-embedded Slides of Pancreatic Adenocarcinoma Tissue

Immunohistochemical Staining of B7-H1 PD-L1 on Paraffin-embedded Slides of Pancreatic Adenocarcinoma Tissue

B7-H1（PD-L1）免疫组化染色石蜡的嵌入式幻灯片的胰腺癌组织

B7-H1/PD-L1, a member  of the B7 family of immune-regulatory cell-surface proteins, plays an important  role in the negative regulation of cell-mediated ...

科研

医学

Bioluminescent Orthotopic Model of Pancreatic Cancer Progression

生物荧光原位模型胰腺癌进展

Pancreatic cancer has an extremely poor five-year survival rate of 4-6%.  New therapeutic options are critically needed and depend on improved ...

Studying Pancreatic Cancer Stem Cell Characteristics for Developing New Treatment Strategies

研究胰腺癌干细胞特性开发新的治疗策略

Pancreatic ductal adenocarcinoma (PDAC) contains a subset of exclusively tumorigenic cancer stem cells (CSCs) which have been shown to drive tumor ...

Clinicopathological Analysis of miRNA Expression in Breast Cancer Tissues by Using miRNA In Situ Hybridization

Clinicopathological Analysis of miRNA Expression in Breast Cancer Tissues by Using miRNA In Situ Hybridization

利用miRNA的miRNA表达的临床病理分析乳腺癌组织<em&gt;原位</em&gt;杂交

In this article, we describe a detailed protocol for miRNA detection in breast cancer tissue using in situ hybridization with a digoxigenin-labelled LNA ...

Laparoscopic Technique for Serial Collection of Liver and Mesenteric Lymph Nodes in Macaques

腹腔镜技术在猕猴肝和肠系膜淋巴结的串行采集

The mesenteric lymph nodes (MLN) and the liver are exposed to microbes and microbial products from the gastrointestinal (GI) tract, making them ...

Visualization of Endogenous Mitophagy Complexes In Situ in Human Pancreatic Beta Cells Utilizing Proximity Ligation Assay

利用邻近结扎测定法在人类胰腺β细胞中原位内源性米托巴结物的可视化

Mitophagy is an essential mitochondrial quality control pathway, which is crucial for pancreatic islet beta cell bioenergetics to fuel glucose-stimulated ...

Laparoscopic Repair of Para-Esophageal Hernia Using Absorbable Biosynthetic Mesh

使用可吸收的生物合成网格对副食管气喘进行拉帕罗镜修复

Para-esophageal hernia repairs are challenging procedures and there is no consensus on the optimal approach to repair. Mesh reinforcement has been ...

Robotic Enucleation of an Intra-Pancreatic Insulinoma in the Pancreatic Head

胰腺内胰岛素瘤在胰腺头的机器人Enuen

Pancreatic parenchyma sparing surgery for insulinomas avoids the risk of endocrine and exocrine insufficiency, and potential high-risk anastomoses ...

Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video

胰腺癌的腹腔镜根左造影切除术：手术策略与技术视频

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological ...

腹腔镜胰十二指肠切除术使用原 位 非接触式隔离技术治疗胰腺癌

腹腔镜胰十二指肠切除术使用原位非接触式隔离技术治疗胰腺癌