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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

"The

study

in

the

application

of

laparoscopic

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

with

LPD:

the

thesis

showed

that

laparoscopic

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

during

surgery

to

determine

if

laparoscopic

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

organs;

and

evaluated

the

possibility

of

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

lower

and

upper

part

of

the

pancreas.

The

lower

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


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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
2.2.2.1. Prepare patient before surgery
2.2.2.2. Steps of LPD
The procedure consists of 11 technical steps.
2.2.3. Research targets
2.2.3.1. General research targets
a, General characteristics
b, Clinical characteristics
c, Subclinical characteristics


12
2.2.3.2. 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.

2.2.3.3. 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)


13
- Step 7: Reconstruct the pancreas - intestine anastomosis (stitching

method and complications)
- Step 8: Reconstruct the bile - intestinal gastrointestinal anastomosis

(stitching, setting Voëlker, complications)
- Step 9: Reconstruct gastrointestinal anastomosis (stitching and

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.
2.2.3.4. 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
2.2.4.1. 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.
2.2.4.2. 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
3.1.2.1. Functional symptoms

Common symptoms are abdominal pain (83.3%) and anorexia
(41.9%)
3.1.2.2. 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.
3.1.3.7. 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.


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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)

Rate %

Pancreatic head cancer

8

22,2

Ampullary carcinoma

8

22,2

Cancer of low common bile duct

1

2,8

Duodenal cancer

1

2,8

Cancerized hamoudi tumor

1

2,8

Non Hodgkin's Lymphoma tumor

1

2,8


20

Chronic pancreatitis

11

30,6

Brunner's gland adenoma

3

8,3

Cystadenoma tumor

1

2,8

Pancreatic neuroendocrine tumors

1

2,8

Total

36

100

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.
3.4.2.7 Common postoperative complications
Complications

Number

of

patients (n=32)

Rate (%)

Common complications

14

43.7

Pancreatic fistula

2

6.3

Bile leak

1

3.1

Delay gastric emptying

1

3.1

21
Bleeding in abdomen

1

3.1

Residual abscess

2

6.3

Transient acute pancreatitis

6

18.8

Pneumonia

1

3.1

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%).

3.4.2.8 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


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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


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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


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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