Pancreatoduodenectomy for bile duct and ampullary cancer

Abstract

Pylorus-preserving pancreatoduodenectomy has become a standard operation for distal and middle bile duct cancers. Bile duct cancer typically extends longitudinally and invades vertically. It frequently metastasizes to the lymph nodes and infiltrates the perineural spaces. The presence of residual cancer in the bile duct stump and lymph node metastases are significant prognostic factors. Negative surgical margins and D2 lymph node dissection are necessary for curative resection. The clinical course after portal vein resection for bile duct cancer with portal vein invasion is better than that of non-resectable bile duct cancer. Portal vein resection can therefore be useful. The efficacy of prophylactic portal vein resection is unclear. We describe here our methods for performing pylorus-preserving pancreatoduodenectomy for bile duct cancer.

Fig. 1

The superior vein and artery are isolated and taped

Fig. 2

The serosa of the hepatoduodenal ligament is excised transversely at the hepatic hilum, and is excised along the left side of the hepatoduodenal ligament longitudinally in front of the hepatic artery

Fig. 3

The common hepatic and left hepatic arteries, common bile duct, and portal vein are taped

Fig. 4

A nelaton tube is placed in the hepatic duct, and the hepatic duct is clamped using a Kyoto University Clamp

Fig. 5

The mesojejunum is dissected along the 1st jejunal artery and vein. The jejunum is dissected 10 cm anal to the Treitz ligament

Fig. 6

The pancreaticojejunostomy is performed using a modified Kakita’s method

Fig. 7

The drainage tubes are placed at the posterior aspect of the hepaticojejunostomy and at the anterior side of the pancreaticojejunostomy

Fig. 8

The fibrosis of the ligament of the median arcuate produces compression of the celiac artery and arterial sclerotic changes of the celiac artery, which produces stenosis or obstruction of the celiac artery