Laparoscopic duodenum-preserving pancreatic head resection guided by the two-stage indocyanine green fluorescence imaging

This protocol aims to demonstrate the integration of indocyanine green (ICG) fluorescence imaging into laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) to enable real-time visualization of the biliary tree and minimize the risk of common bile duct (CBD) injury. Adult patients with benign or low-grade malignant tumors of the pancreatic head are selected. Preoperatively, 5 mg of ICG is administered intravenously to achieve optimal hepatic uptake and biliary excretion. During LDPPHR, a near-infrared camera system is employed to detect fluorescence and delineate the CBD and its anatomical relationships. Trocars are placed to optimize instrument access, and stepwise dissection exposes the pancreas and biliary tract. Fluorescence imaging guides precise skeletonization and protection of the CBD during pancreatic head separation. The pancreatic neck is divided using ultrasonic energy; reconstruction is performed via duct-to-mucosa pancreaticojejunostomy. Intraoperative ultrasound is utilized as an adjunct to confirm anatomical margins and vascular proximity. Postoperative management includes drain placement and monitoring guided by amylase measurements. In a series of six patients, this protocol enabled accurate biliary identification, prevented bile duct injury, and was associated with favorable outcomes. This fluorescence-guided technique enhances surgical safety and may facilitate the adoption of organ-preserving strategies in selected pancreatic head lesions.

In 1972, Beger et al.1 first described duodenum-preserving pancreatic head resection (DPPHR) for patients with severe chronic pancreatitis. Then DPPHR also was proved capable of providing comparable long-term oncologic outcomes in the setting of benign or low-grade malignant tumors.2 As an organ-preserving procedure, DPPHR preserves the integrity of the digestive tract and improves the patient's quality of life compared with pancreaticoduodenectomy (PD),3 although DPPHR is more technically challenging, especially in protecting the bile duct and the pancreaticoduodenal vascular arch.4,5 The indocyanine green (ICG)-enhanced fluorescence imaging system in laparoscopic surgery can identify the biliary and vascular anatomy clearly to ensure a safe cholecystectomy and an adequate vascular supply for colectomy or nephrectomy.6 Nevertheless, to date, no report has described ICG-enhanced fluorescence in laparoscopic duodenum-preserving pancreatic head resection (LDPPHR). This article describes the technique of LDPPHR using a video of a real-time ICG fluorescence imaging system. A 29-year-old woman received a diagnosis of chronic pancreatitis and an inflammatory mass in the head of the pancreas. A computed tomography (CT) scan showed atrophy of the pancreas, dilation of the main pancreatic duct, and heterogeneous enhancement of the pancreatic head parenchyma (Fig.1). Her other preoperative examination results were normal except for high blood sugar. To avoid an extended PD for this young patient, LDPPHR was performed. The patient was placed in supine position with her two legs apart. The observing trocar (10mm) was located at the inferior umbilicus. Four trocars (two 5-mm trocars and two 12-mm trocars) were distributed symmetrically at the midclavicular line and anterior axillary line. Another 5-mm trocar located at the subxiphoid was used for traction of the stomach with a rubber band. Before the operation, ICG (5mg) was injected intravenously from the elbow vein. The gastrocolic ligament was opened, and the hepatic flexure of the colon was taken down to explore the head of the pancreas without making a Kocher's maneuver. After hanging of the distal stomach with a rubber band, both the right gastroepiploic vein and Henle's trunk were dissected. The number 8a lymph node was dissected for intraoperative rapid frozen pathology. A post-pancreatic neck tunnel was built, and the pancreatic neck was transected with an ultrasonic scalpel. The main pancreatic duct was identified and transected with cold scissors. The superior mesenteric vein (SMV) was hung with another rubber band and retracted to the left. The uncinate process of the pancreas was retracted to the right, and subcapsular dissection was performed, with particular attention paid to protection of the anterior inferior pancreaticoduodenal artery (AIPDA), the posterior inferior pancreaticoduodenal artery (PIPDA), and their branches that go into the duodenum. Then the gastroduodenal artery (GDA) was identified, and the anterosuperior pancreatic duodenal artery (ASPDA) was dissected. The upper part of the pancreatic head was separated to expose the common bile duct (CBD) with the help of real-time ICG fluorescence imaging (Fig.2). The pancreas was dissected from the left edge of the duodenum and the right and ventral edges of the CBD. The posterosuperior pancreatic duodenal artery (PSPDA) was identified at the dorsal edge of the CBD. The PSPDA and its branches going into the distal CBD as well as the ampulla of Vater were carefully preserved. The proximal side of the main and accessory pancreatic duct was identified and sutured. Pancreatic anastomosis was performed using the technique of Bing's anastomosis.7 Fig.1 Enhanced computed tomography (CT) scan showing atrophy of the pancreas, dilatation of the main pancreatic duct, and heterogeneous enhancement of the pancreatic head parenchyma Fig.2 The common bile duct was separated and exposed from the head to the tail by the assistance of the real-time indocyanine green (ICG)-enhanced fluorescence imaging system RESULTS: The operation time was 251min, and the estimated blood loss was 150ml. The postoperative course was uneventful, with a hospital stay of 13days. From February 2019 to November 2019, LDPPHR was used by the authors to manage 24 cases, including chronic pancreatitis (6 cases), pancreatic intraductal papillary mucinous tumors (6 cases), pancreatic neuroendocrine tumors (4 cases), pancreatic solid pseudopapillary tumors (4 cases), serous cystadenoma (3 cases), and mucinous cystadenoma (1 case). Indocyanine green-enhanced fluorescence in laparoscopic duodenum-preserving pancreatic head resection was safe and may offer a benefit for maintaining the integrity of the biliary system.

Objective To summarized the experience in laparoscopic duodenum-preserving pancreatic head resection (LDPPHR). Methods The clinical data of four patients who underwent LDPPHR from February 2017 to June 2018 in Hunan Provincial People’s Hospital were retrospectively analyzed. The Clinical characteristics, operation time, intraoperative blood loss, biliary fistula rate, pancreatic fistula rate and follow-up data were analyzed. Results The four patients included one patient with a solid pseudopapillary tumor and three patients with a serous cystadenoma. Two patients underwent duodenum-preserving total pancreatic head resection, and two patients underwent duodenum-preserving subtotal pancreatic head resection. The operation time of the four patients was (525.8±121.8) minutes, and the blood loss (250.0±191.5) ml. Biliary duct drainage was carried out in 2 patients: one patient developed biochemical bile leakage, while another had no postoperative complication. The two patients without biliary drainage developed grade B pancreatic leakage, delayed bile leakage, abdominal bleeding and infection. All the three patients who developed postoperative complications were treated conservatively and they recovered well. Conclusions LDPPHR was designed to better preserve the integrity and function of digestive tract. However, the perioperative complications were high. This operation should only be carried out in large pancreatic centers. Routine biliary drainage is recommended to surgeons with little experience in this operation. Key words: Laparoscopes; Pancreatic leakage; Bile leakage; Duodenum preserving pancreatic head resection

Real-time fluorescence imaging with indocyanine green during laparoscopic duodenum-preserving pancreatic head resection

Pancreatic surgery is one of the most complex and challenging fields in abdominal surgery associated with extensive surgical trauma, damage to adjacent organs, a long operation time and a high incidence of postoperative complications. Since the early 1990s, laparoscopic techniques have been applied to a growing number of pancreas surgeries, and great progress has been achieved in laparoscopic pancreaticoduodenectomy. As surgeons become proficient in laparoscopic pancreaticoduodenectomy techniques, laparoscopic techniques are gradually used in other pancreatic surgeries, such as laparoscopic distal pancreatectomies and laparoscopic duodenum-preserving pancreatic head resection (LDPPHR), which may benefit patients by reducing postoperative pain and hospital stays and providing a quick recovery to normal activity. Recently, a great number of literature have introduced LDPPHR. It is a good surgical method for benign and low-grade malignant tumors of the pancreatic head. Although LDPPHR is technically feasible, it is not yet generally practicable and limited to highly skilled endoscopic surgeons, and the long-term results after LDPPHR are still not well defined. This article aims to provide a literature review of LDPPHR to assess its feasibility, safety, postoperative recovery, and future outlook according to early experiences of this technique.

It is technical challenging to perform laparoscopic duodenum-preserving pancreatic head resection (LDPPHR). Only a few case reports and case series of LDPPHR are available in the literature. From February 2019 to November 2019, 24 cases of LDPPHR were carried out in the Department of Pancreas Surgery, West China Hospital, Sichuan University. Data were prospectively collected in terms of demographic characteristics (age, gender, BMI, and pathological diagnosis), intraoperative variables (operative time, estimated blood loss, transfusion, pancreatic texture, and diameter of main pancreatic duct), and post-operative variables (time for oral intake, post-operative hospital stay, and complications). Nine male patients and fifteen female patients were included in this study. The median age of these patients was 43years. All patients underwent duodenum-preserving total pancreatic head resection laparoscopically. The median operative time was 255min. The median estimated blood loss was 200ml. One patient required blood transfusion. The median post-operative hospital stay was 10days. Three patients suffered from biliary fistula. Eleven patients (45.8%) suffered from pancreatic fistula; however, only one patient (4.2%) suffered from grade B pancreatic fistula. No patient suffered from grade C pancreatic fistula. One patient with chronic pancreatitis required re-operation for jejunal anastomotic bleeding on the first post-operative day. No patient suffered from gastroparesis, duodenal necrosis, or abdominal bleeding. The 30-day mortality was 0. LDPPHR is safe and feasible. Real-time indocyanine green fluorescence imaging may help prevent bile duct injury and bile leakage.

Although rapid progress has been achieved in laparoscopic pancreaticoduodenectomy (PD) over the last decade, laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) remains a challenging surgery that has been rarely reported due to not only requiring complicated pancreaticojejunostomy (PJ) but also ensuring sufficient blood supplies to duodenum and common bile duct (CBD). We completed LDPPHR for 22 patients safely and efficiently with innovative techniques. Clinical outcomes, including rate of conversion to laparotomy, time of residual pancreatic duct reconstruction, incidence of postoperative complications, and time of hospital stay, were collected for 22 consecutive patients who underwent LDPPHR with innovative techniques as follows: application of indocyanine green (ICG) to visualize and preserve CBD and the vessels supplying the duodenum and CBD, Hong's PJ, and pancreatic duct end-to-end anastomosis (ETEA) for the residual pancreas. All surgeries were performed successfully under laparoscopy except for one case. The duration of ETEA was significantly shorter than PJ (18.2 ± 5.1min versus 27.5 ± 8.3min, p < 0.05). There was no significant difference in incidence of postoperative complications between the Hong's PJ and ETEA group. The overall incidence of postoperative pancreatic fistula (POPF) in the Hong's PJ and ETEA group was 23.5% and 20%, respectively, without grade C fistula. All complications were resolved after conservative treatment. By utilizing intraoperative ICG navigation, LDPPHR is a minimally invasive, safe, and efficient approach for chronic pancreatitis with pancreatic head stones by using pancreatic duct ETEA and benign or low-grade malignant tumors of the pancreatic head by using Hong's PJ.

BackgroundSingle-incision plus one-port laparoscopic duodenum-preserving pancreatic head resection (SILDPPHR+1) is yet to be reported, and therefore, its safety and efficacy have yet to be established. This study aimed to assess the short-term efficacy of SILDPPHR+1 in comparison to conventional laparoscopic duodenum-preserving pancreatic head resection (cLDPPHR).MethodsConsecutive patients who underwent SILDPPHR+1 and cLDPPHR procedures were screened. An analysis of the intraoperative and postoperative data of all patients was carried out.ResultsNineteen patients who underwent SILDPPHR+1 and 24 patients who underwent cLDPPHR at Sichuan Provincial People’s Hospital from October 15, 2021, to October 30, 2023, were enrolled in this study. All baseline parameters of both groups were comparable. There was a statistically significant difference in the cosmetic score between the groups (P<0.001). No statistically significant differences were observed between the two groups regarding postoperative recovery, postoperative pancreatic fistula (POPF), bile leakage rate, delayed gastric emptying (DGE) rate, postpancreatectomy hemorrhage (PPH) rate, abdominal infection rate, or textbook outcomes.ConclusionsSILDPPHR+1 appears to be a reliable and safe procedure for certain patients, with no increase in the operating time or complications, similar to the results of cLDPPHR. Moreover, SILDPPHR+1 offers the added advantage of superior cosmetic results.

Objective To summarize our experience of laparoscopic duodenum preserving pancreatic head resection (LDPPHR). Methods The clinical datas of a patient undergoing LDPPHR in Department of Hepatobiliary Surgery Ⅱ, Zhujiang Hospital, Southern Medical University in Mar. 2019 were analyzed retrospectively. Results The operation was successfully completed. The operation time was 280 min. The intraoperative blood loss was 50 ml, without blood transfusion. Bile leakage occurred after operation and was cured after conservative treatment. There were no postoperative bleeding, pancreatic leakage, duodenal fistula, choledochal stricture and other complications. Postoperative pathological report showed chronic inflammation of the pancreatic head. Conclusions LDPPHR is safe and feasible for the treatment of benign lesions of pancreatic head. It has the advantages of less trauma, faster recovery and improvement of postoperative quality of life. Therefore, LDPPHR is worth popularizing. Key words: Laparoscopic; Duodenum preserving pancreatic head resection; Chronic inflammation of pancreatic head

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic pancreatoduodenectomy (LPD), laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has not yet obtained wide acceptance. This could be attributed to the technical challenges involved in preserving the blood supply of the duodenum and bile duct. This study describes and demonstrates all the steps of LDPPHR. A 48-year-old woman was diagnosed with a 3.0 cm x 2.5 cm pancreatic head cystic mass, which was detected unexpectedly. The surgery was performed using the 3D laparoscopy via an inferior infracolic approach. The operation lasted approximately 310 min with 100 mL of blood loss. Postoperatively, the patient experienced no complications and was discharged 5 days later. Pathology revealed intraductal papillary mucinous neoplasms. LDPPHR via an inferior infracolic approach is feasible and safe when performed by experienced surgeons in selected patients with thin mesenteric fat layers. The described technique for LDPPHR via inferior infracolic approach should be well standardized and performed at high-volume centers with experienced surgeons in both open and laparoscopic pancreatology.

Pancreaticoduodenectomy (PD) has long been used for chronic pancreatitis (CP), but greatly affects the postoperative quality of life. A new procedure called duodenum-preserving pancreatic head resection (DPPHR) has been introduced, and has little effect on the structure and function of the digestive system. With the development of minimally invasive surgical techniques, treatment of CP can be performed with laparoscopic DPPHR (LDPPHR). We present a case of CP that was successfully treated with LDPPHR. The postoperative pathological diagnosis was pancreatitis, demonstrating the feasibility of LDPPHR. We recommend this minimally invasive surgical method as preferred treatment for CP.

Laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has been widely reported. However, due to the challenges involved in performing total pancreatic head resection during operation, there are few studies reporting it. Between November 2016 and October 2022, we performed laparoscopic duodenum-preserving total pancreatic head resection (LDPPHRt) on 64 patients in the Department of Hepatobiliary Surgery, the Second Hospital of Hebei Medical University. Perioperative data of the patients such as age, gender, body mass index, operation time, blood loss, and postoperative hospital stay were collected and analyzed. This study included 40 women and 24 men aged 41.4 ± 15.7 years. All patients completed the surgery, and none of the patients underwent laparotomy. The average operation time was 275 (255, 310) min. The average postoperative hospital stay was 12 (10, 16) days. The rate of occurrence of pancreatic fistula was 10.9% (7/64), and that of the biliary fistula was 9.4% (6/64). One of the patients underwent cholangiojejunostomy 3 months after the operation due to painless jaundice and bile duct dilatation. By dissecting the space between the pancreatic head and duodenum, the posterior pancreatic duodenal arterial arch and the surface vascular network of the common bile duct (CBD) can be preserved. This ensures the success of LDPPHRt and avoids postoperative complications in the absence of intraoperative image guidance.

Background:Solid pseudopapillary neoplasms (SPNs) of the pancreas are uncommon neoplasms and are potentially malignant. Complete resection is advised due to rare recurrence and metastasis. Duodenum-preserving pancreatic head resection (DPPHR) is indicated for SPNs located in the pancreatic head and is only performed using the open approach. To the best of our knowledge, there are no reports describing laparoscopic DPPHR (LDPPHR) for SPNs.Methods:Herein, we report a case of 41-year-old female presented with a 1-week history of epigastric abdominal discomfort, and founded an SPN of the pancreatic head by abdominal computed tomography/magnetic resonance, who was treated by radical LDPPHR without complications, such as pancreatic fistula and bile leakage. Histological examination of the resected specimen confirmed the diagnosis of SPN.Results:The patient was discharged 1 week after surgery following an uneventful postoperative period. She was followed up 3 months without readmission and local recurrence according to abdominal ultrasound.Conclusion:LDPPHR is a safe, feasible, and effective surgical procedure for SPNs.

Background: Laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) is a surgical procedure that involves the removal of the pancreatic head while aiming to preserve the integrity of the digestive and biliary tracts. With advancements in laparoscopic techniques, the utilization of LDPPHR has been increasing. Methods: We retrospectively analyzed the clinical data of 10 patients who underwent laparoscopic duodenum-preserving total pancreatic head resection (LDPPHR-t) at our center from June 2019 to October 2021. Additionally, we analyzed the use of indocyanine green (ICG) in the initial stage of LDPPHR, based on current reports. Results: LDPPHR-t was successfully performed in all patients. After surgery, 3 patients experienced pancreatic fistula (Grade B), 2 patients experienced bile leakage, and 2 patients experienced postoperative hemorrhage. However, no patient exhibited recurrence or required secondary surgery. Conclusion: LDPPHR-t is a new method for treating benign and low-grade malignant tumors in the pancreatic head. However, it is associated with a high incidence of postoperative complications. In the initial stage, the use of ICG can assist surgeons in identifying the biliary duct and pancreaticoduodenal artery arcade.

Duodenum-preserving pancreatic head resection (DPPHR) is very complicated due to its difficulty to find the lower common bile duct (CBD), and to preserve the blood supply of the duodenum and CBD. Recently, indocyanine green (ICG) has been widely applied for navigation during biliary system and liver surgery. However, the application of ICG-guided laparoscopic DPPHR has not been established. Herein, we report an intraoperative angiography technique using ICG fluorescence imaging to visualise blood flow, tissue perfusion, CBD navigation and bile leakage assessment.