Videos/Film

PRESERVATION G. Tiberio, S.M. Giulini, L. CanEiottl, N. Portolani Department of SurgeryBRESCIAItaly The film illustrates the pancreatoduodenectomy operation carried out on a 60 year-old patient, affected by an ampullary adenocarcinoma. The technique adopted involves the removal of the duodenumpancreatic section with pyloric preservation according to the technique proposed by Traverso and Longmire with the aim of simplifying the surgical procedure and of improving the post-operatlve nutritional state of the patient. Gastric preservation doesn’t preclude the possibility of a radical lymphadenectomy, the perigastric and splenic nodes being only on exception site of metastasis in such pathology. The first step is the mobilization of the hepatic flexure of the colon and of the second duodenal portion; the isolation of the distal choledoch duct and of the upper mesenteric vein in its retropancreatic section allows the completion of the mobilization of the pancreatic head and of the third and fourth duodenal portions. The technical shrewdness that the operation foresees is seen in the film: the accurate saving of the innervation and of the vascularization of the proximal duodenal section, realised in the specific case with the respect of the gastoduodenal artery and of both of the gastric vascular arches, the supramesocolic transposition of a loop of Jejunum dorsal to the mesenteric vessels in the bed of the resected duodenum, the accurate surgical technique turned towards preventing the formation of haematic and lymphatic gatherings which can induce a transitory postoperative gastric paresis. The pancreatic and biliary anastomoses are subsequently carried out by means of a termino-lateral technique in a two layer fashion in re-absorbable synthetic material; the end-to-side JeJunostomy, carried out with continuous stitches results as technically easy and, even though it is a short distance from the pylorus, does not compromise, its function. The accurate perlanastomotic drainage completes the operation, resulting free of complications.

the technique proposed by Traverso and Longmire with the aim of simplifying the surgical procedure and of improving the post-operatlve nutritional state of the patient. Gastric preservation doesn't preclude the possibility of a radical lymphadenectomy, the perigastric and splenic nodes being only on exception site of metastasis in such pathology. The first step is the mobilization of the hepatic flexure of the colon and of the second duodenal portion; the isolation of the distal choledoch duct and of the upper mesenteric vein in its retropancreatic section allows the completion of the mobilization of the pancreatic head and of the third and fourth duodenal portions. The technical shrewdness that the operation foresees is seen in the film: the accurate saving of the innervation and of the vascularization of the proximal duodenal section, realised in the specific case with the respect of the gastoduodenal artery and of both of the gastric vascular arches, the supramesocolic transposition of a loop of Jejunum dorsal to the mesenteric vessels in the bed of the resected duodenum, the accurate surgical technique turned towards preventing the formation of haematic and lymphatic gatherings which can induce a transitory postoperative gastric paresis. The pancreatic and biliary anastomoses are subsequently carried out by means of a termino-lateral technique in a two layer fashion in re-absorbable synthetic material; the end-to-side JeJunostomy, carried out with continuous stitches results as technically easy and, even though it is a short distance from the pylorus, does not compromise, its function. The accurate perlanastomotic drainage completes the operation, resulting free of complications. Duodenocephalopancreasectomy represents the only change for cure of ampullary and periampullary tumors. But digestive and nutritional sequelae have been registred after the standard pancreaticoduodenectomy ( Whipple procedure ). Pylorus and gastric preservation, according to Traverso Longmire technique, seems not to riduce the oncologic radicality, has the advantage of a shorter operative time and a simpler esecution and it showed assure less digestive postoperative sequelae with better nutritional status of patients. The AA. present a case of ampullary carcinoma treated by pyloruspreserving duodenopancreasectomy; the postoperative radiologic and manometric studies have demonstrated a good pyloric function with phisiological empting of the stomach. carcinomas, carcinomas of the head of the pancreas, tumors of the papilla and duodenum. The following operation shows a partial duodeno-pancreatectomy with extended retroperitoneal lymphadenectomy. The operation starts with the dissection of the ventral surface of the right kidney. Afterwards the caval vein and the confluence region of the renal veins are exposed. The mobilized tissue from these structures remains at the duodenum, to be removed later on with the resectate. After cholecystectomy the common bile duct is transsected. The hepatic artery is isolated and freed from lymphatic tissue up to the celiac trunc.
Afterwards the portal vein is isolated. The preparation continues with the lymphadenectomy between the vena cava and the aorta proximally and distally of the left renal vein. Thereby the superior mesenteric artery is isolated and freed from lymphatic tissue. The stomach is transsected after skleletonization. After skletonization of the first jejunal loop and distal duodenum, the resectate is transsected from the superior mesenteric vein and removed.
The reconstruction is performed with two jejunal loops. /if, h t, hese effort, s 8 ptf, ent, s survived for 3 years or toore, and he 5-year survival rafes in paf, ienf, s wit, h cancer of he pancreaf, ic head who ,olerat, ed macroscopic curaf, ive resection became 36.5. L:ymph node met, asf, asis was nesa,ive in 6 cases (35.3) and positive in 11 The positive mefasafic cases consisted of ? cases wifh n, 3 witch n and one wif, h n. tghile t, he nesaive measf, af, ic Stoup showed a one-year survival rafe of 100, a 2 t,o 3-/ear survival rat, e of 83.3 and a 3 o z-year survival rat, e of 66.7, 27.3 of fhe posifive pat, ient, s survived one year, only one, 2 ,ears or more and 5 tears. These f indinss show 'chat, more exensive surser is necessary for t, he f, reaf, menf, of he pancreat, ic cancer. University, Ube, Yamaguchi, JAPAN The procedure of our modified pylorus-preserving pancreatoduodenectomy is presented on a 66 year old male with cancer of the ampulla of Vater. The duodenum is resected with the pancreatic head tissue, but the jejunum is preserved completely the oral dissected duodenal margin is 3 to 4 cm distal to the pyloric ring, and the anal duodenal margin is the fourth portion of the duodenum. Dissection of the lymph nodes along the superlor mesenteric artery, the hepatic artery and the hepatoduodenal ligament is made; but the right and left gastric arteries as well as the hepatogastric ligament are all preserved. The Billroth type of reconstruction is adopted. First of al l,an end-to-end duodenoduodenostomy i s performed. Then an end-to-side pancreatojejunostomy is made I0 cm anal to this duodenoduodenostomy; and 5 cm anal to the pancreatojejunostomy, an end-to-side hepatidochojejunostomy is added. No Braun anastomosis is made. The stent tube inserted into the main pancreatic duct is drawn out from the anterior wall of the stomach. After this type of resection and reconst- To improve the poor survival after resection of ductal carcinoma of the head of the pancreas, the most frequent evidence of it's recurrence in the liver and local retroperitoneum should be controlled.

References
The major cause of the early liver metastasis, we assume, might be due to migration of the carcinoma cells into the portal vein during the operative manipulation, while the local retroperitoneal recurrence would be caused by incomplete resection of the retroperitoneal tissue.
Accordingly, we devised a new method of non-touch pancreatic-resection -"Isolated Pancreatectomy". This is pancreatectomy performed under occlusion of the blood flow around the head of the pancreas or tumor, achieved by clamping of the portal vein, splenic vein and superior mesenteric vein, with preceeding ligation of the gastroduodenal artery and inferior pancreatic artery.
These vessels are removed together with the pancreatic tumor, thus giving a wide surgical field facilitating extensive removal of the retroperitoneal lymph nodes and nerve plexus.
During this procedure for retroperitoneal skeletonization under dividing of the portal vein for one or two hours, a catheter bypass of the portal flow into the femoral vein is effective for avoiding portal congestion.
Reconstruction of the portal vein is always necessary.
We have used this method in nine patients over the past two years, and both hepatic and local recurrence has been reduced.
The film shows the details of this method. The radical therapy of insulinomas is exclusively surgical,consisting either in enucleation of the tumor or in pancreatic resection. The relatively less frequent localization in the head and neck gives rise to problems of technical choice, especially if the tumor is two centimeters in diameter or larger.Tumorectomies of the neck are associated with high risk of injury to the main pancreatic duct; on the other hand a subtotal pancreatic resection entails the risk of post-operative diabetes (Yasugi et a1.1976). As for the insulinomas of the head of the pancreas, a Whipple operation would appear unjustified in most cases,owing to the fact that 80% to 90%of such tumors are benign (Stefanini et al. 1974). Once again the simple tumorectomy is not free of risk of inadvertent damage to the pancreatic duct, to the intrapancreatic portion of the common bile duct or to the mesenteric vessels. The two cases we propose offer two different technical solutions to avoid extensive parenchymal demolition.

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Case 1 Male,aged 50, obese, with sympoms (fatigue,tremors,fasting perspiration) lasting for 3 years. Fasting blood sugar was very low and blood insulin high. Repeated provocative tests were positive for hyperinsulinism. Pre-operative US and CT scans failed to demonstrate a pancreatic tumor. After the failure of a three-months course of medical treatment, angiography demonstrated a 2 cm. hypervascularized area in the head of the pancreas, fed trought a hepatic artery originating from the superior mesenteric artery; the intraoperative US scan showed a single tumor lying adjacent to the main pancreatic duct, to the common bile duct and to the portal vein. The tumor was enucleated, and a transduodenal pancreatography showed no leak from the main duct. The post-operative period was complicated by a low-output pancreatic fistula, wich healed on day 15 after treatment with somatostatin, H2-blockers and parenteral nutrition. Normalization of glycemia and insulinemia, and discharge on day 23. Case 2: Female,aged 74,with symptoms lasting for 9 years; after 7 years of relative control under medical treatment, symptoms relapsed with fasting blood sugar values of 30-50 rng/dl and hyperinsulinism. US and CT scans showed a 18 mm. solid tumor of the pancreatic neck. The intraoperative US scan showed a single tumor occupyng the full thickness of the neck of the pancreas. We performed a segmental resection of the tumoral area with section lines 1 cm. to the right and left of the tumoral margin (intermediate pancreatectomy). After suture of the cephalic stump we performed a left end-to-end Roux-en-Y pancreojejunostomy.The post-operative period was uneventful. There was gradual normalization of glycemia,glycosuria and insulinemia. The patient was discharged on day 15. The videotape starts showing the case of a young woman of 38 who has borne the signs of Yon Recklinghausen's disease since birth. She was admitted to our Department with a ten month history of mild jaundice and moderately increased cholestasis indexes.

References
The imaging examinations, even if they confi a extrahepatic cholestasis due to an obstacle at the level of the papilla of Vater, did not propose a conclusive diagnosis of the lesion. The central part of the videotape shows the technical phases of the surgical operation" the explorative phase that showed the presence of a well-circumscribed neoformation on the level of the Vater region; the dissecting phase that was the removal of duodeno-pancreatic block with the pylorus preservation and the reconstruction phase according to the technique proposed by Traverso-Longmire. The video tape finishes showing the histological and io-histochemical analyses of the lesion" it was a neoplastic proliferation of epithelial cells with numerous granules of a neuro-secretory type containing somatostatin. Finally, general and prognostic characteristics of this rare association are discussed. was operated firstly and gallbladder was removed, section of the common duct occurred. The patient was treated by surgery four times (end-to-end anastomosis, choledocho-duodenostomy, hepatico-jejunostomy and double hepatico-jejunostomy with stent) but cholangitis continue and the patient was progressi.vely deteriorated. The operation consist in a new dissection of both hepatic ducts, removal of scar and fibrous tissue doing two specily wider separated hepatico-jejunostomy. The patient cured absolutely without cholangitis during the last three years.

Algiers, Algeria
A 30 year old man was being operated on for biliary stenosis after hepatic ducts injury.
He had jaundice 5 days after cholecystectcmy was performed for cholecystitis 2 mDnths previously in a country hospital.
A transhepatic cholangiography showed a type Iii stenosis of the bile ducts.
At laparotcmy the stenosis was located in the hilum and preoperative cholangiography showed a type IV stenosis. A bilateral cholangiojejunostcmy was perfo with a Roux en Y loop.
Intrahepatic left cholangiojejunostcmy was perfo side to side and right cholangiojejunostcmy was performed end to side with a transanastcotic tube because of an injured anterior wall of the right hepatic duct. A post operative cholangiography showed good functional anastcmosis on the 10th day and jaundice disappeared ccmpletely after 20 days. The afterwards demonstrated operation was performed in a patient with a central bile duct carcinoma Typ II according to the classification of Bismuth. The video shows the preparation of the hepato-duodenal ligament including a radical lymphadenectomy of this region. The hepatic artery and portal vein are thereby exposed and the common bile duct as well as the confluence region of central bile ducts is resected.
The reconstruction is not as usual performed in a Rouxen-Y technique but by a cholangio-duodenal interposition of a 20 cm jejunal segment. Emergency surgical drainage and wide spectrum antibiotics were the ordy therapeutic resorts.
In the ]as ten years a number of auxiliary procedures improved the diagnostic capacity and reduced morbidity and operative mora] ity. We present our percutaneous approach to the Biliary Tract for the patients with obstructive jaundice by Video.
Firstly obstructive jaundice is diagnosed by Ultrasonography and should be drained as soon as possible. We prefer PTBD to Endoscopic Stenting because we need the fine information of the hepatic bile duct for surgical operations.
Secondly the PTBD tracz is dilated and biopsies are taken under X-TV.
Thirdly a Cholangioscope is inserted through the dilated PTBD fistula. We can observe the stricture site and take biopsy under direct vision. Consequently we decide the resection point and operative method.
In the case of non-resectable or recurrent tumors, we place a double mushroom stent across the stricture of the bile duct.
Since 1986 we have performed PTBD in 92 cases and 84 of these cases were successful (91.3%). Percutaneous stenting was tried in 14 cases out of 92 (15.2%) and 12 cases were successful (85.7%).
These procedures take 2 or 3 weeks, but usually reducing of icterus takes more than 2 weeks.
Obviously the advantage of the percutaneous approach is to get details of the lesion. Most of the Bile Duct Cancers have scirrhous invasion pathologically.
Therefore to know the microscopic findings of the bile duct near the tumor is particularly important for the curative operations. The data in worldwide literature shows that the treatment of  With advances in endoscopic techniques and instrumentation it is now possible to directly inspect the bile duct and the pancreatic duct using the endoscopic retrograde mute. Direct visual access to the biliary tree opens up new horizons in the diagnosis and therapy of biliary diseases. This video illustrates peroral choledochoscopy using the "Mother and Baby" endoscope system and electrohydraulic lithotripsy of large common duct stones under direct endoscopic control.
Per-oral choledochoscopy uses two endoscopes. The "Mother" scope (Olympus XTJF-5.5) is a jumbo-sized side viewing duodenoscope with an external diameter of 14.8mm. It has a 5.5mm instrument channel which can admit the "Baby Scope". The "Baby" scope (Olympus CHF-B20) has a working channel of 1.7mm, water and air insufflation, and two way (up-down) control for tip deflection. The procedure is performed under intravenous sedation. The "Mother" scope is first inserted into the duodenum in the short scope position. The "Baby" scope is then passed through the instrument channel of the mother and manipulated into the bile duct (or the pancreatic duct) through a prior endoscopic sphincterotomy. Direct inspection of intra-ductal abnormalities such as tumour or strictures and biopsies of these lesions can be obtained through the "Baby" endoscope.
The technical difficulty of endoscopic stone extraction from the common bile duct increases with the size of the stone. Because the size of a safe endoscopic sphincterotomy is limited, large stones need to be fragmented before endoscopic removal. If the stone can be engaged in a Dormia basket they can be crushed mechanically. Giant stones may be difficult or impossible to engage in baskets because of lack of space in the duct to open the basket. Fragmentation of giant common duct stones using electrohydraulic lithotripsy through the "Mother & Baby" endoscope system is demonstrated. The lithotripsy probe is passed through the channel of the "Baby" scope and pressed against the stone. Because of the risk of duct damage if the probe is fired against the duct wall, direct visual control of electrohydraulic lithotripsy is necessary. A naso-biliary catheter is used to fill the bile duct with saline and to clear away debris generated during lithotripsy. After lithotripsy the stone fragments are removed with Dormia baskets and balloon catheters. Encouraging results are achieved with billary extra corporal shock-wave Lithotripsy (B-ESWL). Therapy in leading centres result in a successful fragmentation rate up to 98% and when combining B-ESWL with dissolution therapy in 80 to 90% final success is achieved. The answer to the questions whether this therapy has a long standing endresult, whether it is cost efficient and whether the good results are reproducible also out of highly experienced centres should be given. To enable answering these questions we have chosen for a multlcentre approach, using mobile Dornier MPL 9000 Lithotripsy unit. The basic consideration of the concept is to enable the patient suffering biliary llthiasis access to a new therapeutic modallty in his own region of inhabitants avoiding the necessity of referral, enable physicians to treat their patients at local hospital using the optimal equipment dedicated for this particular application. The mobile Dornier MPL 9000 Lithotripsy unit is presented, the essential technical aspects of the equipment are demonstrated and briefly discussed. An example of treatment using this system is shown and the technical aspects of the procedure as medication, the treatment itself and the dissolution threrapy following Lithotripsy are discussed. The essential points of the protocol study, used by the Worldgroup for gallstone Lithotripsy using a mobile Lithotripsy system, are briefly presented. The preliminary experience, gained in 12 in this project already effectively participating hospitals and the experience with the first i00 patients treated, shows that use of the mobile B-ESWL system fulfils the expectation. The drawbacks limiting spread of a method as limited number of patients in a single hopsltal on a year base suitable for B-ESWL and the high costs of dedicated equipment are this way overruled. A mulicentre approach offers a unique opportunaty for a porspective study of all the aspects of a method in huge patients population on a long term base. Several surgical techniques have been used in recent years for treatment of hydatid cysts of the liver. Conservative surgery implies removal of the contents leaving pericystium in situ; the residual internal cavity is closed by capitonnage, that is by joining the surfaces with interrupted suture in absorbable material, or it is closed by tunnellization onto an external drainage. Demolitive or radical operations include total or subtotal removal of pericystium, sometime associated to some kind of hepatic resection.
Conservative surgery, undoubtedly simpler and low-risk, is however a frequent cause of prolonged post-operative recovery and is followed by high risk of recurrences (about 15-20 per cent), due to failure of pericystium removal and exogenic vesciculation. Radical surgery, although more difficult and with higher operative risk, has better expectancy of complete recovery. We strongly prefer the radical operations, but in our opinion the choice between the various surgical techniques (total, subtotal or partial pericystectomy) should be established for each patient, after evaluation of several factors: patient's age and general conditions; number, size and topography of cysts and specially their relationship with vasculo-biliary structures.
Personal experience  Patients operated 56 with 72 cysts Tecniques: cystectomy with partial pericystectomy cystectomy with subtotal pericystectomy total cistopericystectomy Complications: infections residual cavity recurrent cysts Operative and perioperative mortality: 0 Mean hospital stay 11 days (range 8-17) The surgical management of gallbladder cancer is influenced considerably by the anatomic spread of tumor and tumor staging. /e will show a film of hepatic central bisegmentectomy for gallbladder cancer with direct invasion of the liver.
The patient was a 73-year-old fele complaining of right hypochondric pain. CT showed a clumpy ass in the fundus of the gallbladder extending to Segment IV and V of liver. Endoscopic retrograde cholangiogra shoed the obstruction of the cystic duct and narrowing of the common hepatic duct. Introperative echogram showed that the gallbladder mass ha expanded to within 2c on the rit of the falcifor ligament. The common bile duct was divided at the suprduodenl region. The comon hepatic artery, proper hepatic rtery, portal vein and supra esenteric artery were encircled by tapes to dissect en block hepatoduodenal ligament lymphnodes, celiac lyodes, retropancreaticoduodenal lymphnodes and lymphnodes around common hepatic artery. After the gallbladder was freed fro the liver bed, the anterior branch of the right hepatic artery and portal vein, iddle hepatic artery, caudate branch of portal vein and caudate short hepatic veins were divided from below toward the cephalad as far as we coultL After the division of the left hepatic duct and the anterior branch of the right hepatic duct, a centrl bisetmentectomy was done with total caudate lobectomy by dividing the iddle hepatic vein using the CUSA syste by extending from the left incision at the sulcus of the falcifor ligament to the right side t lobar plane of the demarcation line. Rorto caval lymphnode dissection around the left renal vein was done. A Roux-enloop of jejunu was brought up in a retrocolic fashion and anastomosed to the left hepatic duct. A triple clamping was performed during 8 Minutes for closing a tear of the anterior face of the vena cava. The operation lasted height hours (one third of the duration was due to the film) and the blood loss was 2.8 liters.
The resection was macroscopically and microscopically curative. The post-operative course was uneventfull and the patient was discharged from hospital on the thirtenth post-operative day. We will show film of an extended right hepatectomy with csudate lobectomy for hi far cho-Iangiocarc nom The patient was a 5-year-old male complaining of jaundice.The direct cholangiogrm showed the obstruction of the hepatic duct bifurcation and stricturc extending from the common hepatic duct to individual hepatic ducts. The thumb head sized hard tumor was palpated at the hi lar region, no hepatic metastasis could be foun& The common duct was transected and tied t the supra duodenal region and the right hepatic artery bifurcated from SMA was divide Then the common bile duct was turned upwsr Skeletonization of the hepstoduodenol ligament was completed exc ludi ng the after ies and the portal vein. Alter exposure of the right brnch of the portal vein, it was secured and divide And the portal branches to the caudate lobe were divided safely due to no vascular involvement by the tumor.
As the right hepatic vein ad hepatic short veins across the front of the vens cars were divided, the caudste hepatic veins could be approached safely by adding a direct pproach from the lesser sc after division of greater heptic omentu After dividing the left hepatic duct at the bfurcstion of the middle lobe branch, several portal middle lobe branches were ligated and divided t the right margin of the igaentum teres. And extended right lobectomy involving partial resection of S IV was done dividi the middle hepatic vein brnches using CUSA and hemoclips.
fORT was done at the srgical margin of the left hepatic duct at s dose of 25 gray.
A Roux-en-Y loop of jejunum was nstomosed to the left hepatic duct using a single layer of interrupted absorbable suture. Histological examination of the tumor showed tubular adenocsrcinom was located st the hilax region extending to the individual hepatic ducts, with slight hepatic invasion nd lymphnode involvement of the hepatoduodenal ligament, retropancresticoduodenal and celiac regions. This ptient was well 4 months after the operation.  (PD) is an anatomical variant of pancreatic ducts that appears in I-6% of normal population. The relationship between PD and pancreatitis remains controversial. The hypothesis more widely acceppted suggest that the accesory papila, in some cases of PD, may be extremely narrow, and induce obstructive pancreatitis.

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The demonstration by ultrasonography of a maintained dilatation of the main pancreatic duct after secretin stimulation in patients with PD, supports this hypothesis (I), and this method has been useful in the selection of surgical cases. MATERIAL AND METHODS. From January 1.987 to December 1.989 we have surgically treated 4 patients who presented relapsing pancreatitis secondary to PD, from a consecutive serie of 146 cases of acute pancreatitis (2,7%). This 4 patients are included in a group of 28 with PD, observed in a whole series of 12 pancreatograms (2,1%) studied by CPRE between 1.979-1.989. Of this 28 cases of PD, only in 14could be demonstrated pa creatic disease. SURGICAL TREATMENT. I patient developed main duct dilatation after episodes of acute pancreatitis, and a pancreatojejunostomy was performed.
cases were treated with sphyncteroplas ty of the minor papilla, and in one of them, a distal pancreatectomy as added due to the existence of a seudocyst in the tail of the gland. Recurrent symptoms were observed in I case, after reestenosis of the sphyncteroplasty. In all the cases, the secretin test observed preoperatively a delay in the empting of the main pancreatic duct, that resolved after dorsal sphyncteroplasty. COMMENT. PD is a variation of the pancreatic duct anatomy, that in few instances may be responsible of acute pancreatitis. This anomaly may be surgically corrected. We present in this video the rationale for the surg cal approach of HD, illustrated by the case of a 29 year old women, who presented episodes of acute pancreatitis in the last years. Others causes of pancreatitis were ruled out, except for PD, demons trated by CPRE. Secretin test was positive. The patient was treated ith a sphyncteroplasty of the papilla minor, and remains asymptomatic I year after. I. Warshaw, AL. Am J. Surg. IZ 11.5 The prolamine and silicone, even though effective, produce an intense fibrosis and atrophy of the lobe. This is not so when fibrin glue is used.
We carried on with the research to find out how and where the ductal blockade develops this therapeutic action. Likewise, new investigations were initiated on the possible application of the ductal blockade with fibrin glue or other reabsorbable substance in the transplant of pancreas. In this way the blockade is temporary and suspends the pancreatic secretion in the critical period after operation without provoking in the gland, an irreversible and dangerous fibrosis, perhaps responsible for complications renote from the graft.