The application of intraoperative vascular and biliary tract imaging in laparoscopic duodenum-preserving pancreatic head resection

The application of intraoperative vascular and biliary tract imaging in laparoscopic duodenum-preserving pancreatic head resection | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report The application of intraoperative vascular and biliary tract imaging in laparoscopic duodenum-preserving pancreatic head resection Zhengchao Shen, Bin Jiang, Shihang Xi, Daohai Qian, Suhang Chen, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4451710/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective To investigate the value of applying intraoperative indocyanine green fluorescence imaging in laparoscopic duodenum-preserving pancreatic head resection. Methods The clinical data of 12 patients with benign pancreatic head tumors who underwent fluorescence laparoscopic duodenum-preserving pancreatic head resection (FLDPPHR) at the Department of Hepatobiliary Surgery, the First Affiliated Hospital of Wannan Medical College, from June 2021 to October 2023 were retrospectively analyzed. All patients received an intravenous injection of indocyanine green (2.5 mg/ml, 1.5 ml) for biliary tract imaging half an hour before surgery. Indocyanine green (2.5 mg/ml, 1 ml) was intravenously injected into the peripheral vein when blood vessels needed to be exposed during the operation. Results FLDPPHR was successfully performed in all 12 patients without conversion to open surgery. The tumor diameter was 3.6±0.1 cm, the operation time was 366.7±24.2 minutes, and the intraoperative blood loss volume was 270.8±25.7 ml. The median number of intraoperative vascular visualizations was 3 (2-4). Postoperative pathological diagnosis revealed intraductal papillary mucinous neoplasm (IPMN) in 6 patients, serous cystadenoma (SCN) in 4 patients, and mucinous cystadenoma (MCN) in 2 patients. The median postoperative hospital stay was 10 (7-40) days. No long-term complications occurred during the follow-up of more than 7 months. Conclusion Real-time exposure of the common bile duct during indocyanine green fluorescence imaging is helpful for reducing damage to the common bile duct, visualizing vessels in the pancreatic neoplasms fluorescence laparoscopy biliary complications pancreatic fistula Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1 Materials and Methods 1.1 Clinical data From June 2021 to October 2023, 12 patients with benign tumors of the pancreatic head underwent FLDPPHR at our center. The perioperative data of the 12 patients, including age, sex, preoperative tumor markers, tumor size, operation time, intraoperative blood loss, intraoperative blood vessel visualization time, postoperative hospital stay, postoperative pathology, postoperative complications and postoperative follow-up data, were retrospectively analyzed. All patients provided written informed consent in accordance with the approval of the hospital ethics committee and in accordance with the Declaration of Medical Ethics of Helsinki. 1.2 Surgical methods All patients underwent three-dimensional visualization imaging before the operation to obtain a complete understanding the pancreaticoduodenal artery arch and branch vessels (Fig. 1 a). Preparation for biliary imaging: 2.5 mg/ml of 1.5 ml indocyanine green was injected into the peripheral vein half an hour before surgery. After the administration of general anesthesia, the patient was placed in the supine position. A 10 mm incision was made at the lower edge of the umbilicus to puncture a pneumoperitoneum needle into the abdominal cavity. Carbon dioxide gas was then injected to inflate the cavity to achieve a pneumoperitoneum pressure of 13 mmHg. Subsequently, a Trocar was inserted for lens entry, and the trocars were placed using the "five-hole" method (Fig. 1 b). After entering the abdominal cavity, the abdominal cavity was explored, and no obvious metastasis was found. The gastrocolic ligament was cut off by an ultrasonic scalpel into the retrogastric space, the lesser omental sac was opened, and the stomach wall was suspended by an 8-gauge red catheter. The superior mesenteric vein (SMV) and Henle trunk were exposed. The "C" ring of the pancreas was exposed after the Henle trunk and its branches were cut off. The portal vein triangle was dissected along the upper edge of the pancreas through the tunnel behind the pancreatic neck, approximately 1 cm away from the pancreatic tumor. The pancreatic parenchyma was gradually cut off by an ultrasonic scalpel, and the pancreatic duct was cut off by scissors. After exposing the gastroduodenal artery (GDA), the right omentum vessel was transected above the level of the GDA vessels, and transection continued to the lower part along the GDA. Whether to transection the anterior superior pancreaticoduodenal artery (ASPDA) should be determined according to the anatomical location of ASPDA, but attention should be given to protecting the posterior superior pancreaticoduodenal artery (PSPDA)(Fig. 1 c). Under the guidance of fluorescence laparoscopy, approximately 0.5 cm of the pancreatic tissue of the medial wall of the duodenum was retained, the pancreatic tissue of the head of the pancreas was separated from the top to the bottom, and the medial wall of the duodenum was protected to the lower end of the common bile duct. The space between the uncinate process and the duodenum mesentery was dissociated from the side to the head. At this time, the blood vessels could be immediately visualized during the operation (1 ml of 2.5 mg/ml indocyanine green was injected intravenously peripheral to the uncinate process) for About two minutes. The vascular arch of the pancreaticoduodenal artery could be visualized during the operation. The anterior inferior pancreaticoduodenal artery (AIPDA), the posterior inferior pancreaticoduodenal artery (PIPDA), and their branches were preserved, and care was taken to avoid injury to the vessels of the pancreaticoduodenal arterial arch (Fig. 2 ). The uncinate process was gradually lifted; the main pancreatic duct was dissociated, ligated and severed; and the inner segment of the common bile duct was visible above it. Under the guidance of fluorescence laparoscopy, the main common bile duct (CBD) was exposed, and attention was given to distinguish the main common bile duct from the tumor (Fig. 3 ). The encapsulated pancreatic tissue was dissociated while avoiding damage to the blood supply of the lower end of the common bile duct. After the upper and lower confluence, the specimen was cut off, and the specimen was sent for rapid pathological analysis during the operation. One milliliter of indocyanine green was injected into the peripheral vein again to detect whether the mesenteric vessels of the duodenum were intact and ischemic. If the intraoperative case suggested that the tumor was malignant or the ischemic necrosis of the duodenum was found during the operation, pancreaticoduodenectomy (PD) was performed. A 4 − 0 vascular suture was used to reinforce the medial wall of the duodenum with possible serosal damage and some residual pancreatic tissue. The reconstruction of the anastomosis involved pancreatojejunostomy (Fig. 4 ): the pancreatic duct was dissected, the stent was placed, the jejunum was cut 15 cm away from the Treitz ligament, and the distal end of the jejunum was lifted from the right side of the middle colic artery. Under direct vision, pancreatojejunostomy was performed by continuous penetrating suturing (3 − 0 barbed suture + 5 − 0 PDS line pancreatojejunostomy to mucosa). Side-to-side jejunal anastomosis was performed approximately 45 cm from the site of pancreatojejunostomy. 4 − 0 barbed sutures were used to close the common opening. Drainage tubes were placed behind the pancreatojejunostomy site and at the pancreatic head wound. 1.3 Postoperative management All patients were routinely treated with somatostatin after surgery, the drainage tube was irrigated intermittently, and the drainage tube was kept unblocked. The content of amylase in the drainage fluid was measured on the third day after surgery. The diagnostic criteria for pancreatic fistula were based on the 2016 definition of pancreatic fistula of the International Pancreatic Fistula Study Group (ISGPF) [2]. Upper abdominal CT was performed on the fifth day after the operation to determine the condition of the surgical area. Routine follow-up was performed after discharge, and May 1, 2024, was the date of the last follow-up. 2 Results All patients successfully completed the operation without conversion to open surgery. There were 4 males and 8 females. The tumor diameter was 3.6 ± 0.1 cm, the operation time was 366.7 ± 24.2 minutes, and the intraoperative blood loss volume was 270.8 ± 25.7 ml. The median number of intraoperative vascular visualizations was 3 (2–4). All 12 patients achieved R0 resection by postoperative pathology. Postoperative pathological diagnosis revealed intraductal papillary mucinous neoplasm (IPMN) in 6 patients, serous cystadenoma (SCN) in 4 patients, and mucinous cystadenoma (MCN) in 2 patients. One patient developed a biliary fistula with a daily volume of approximately 300 ml, and the biliary fistula was cured by placing a biliary stent under ERCP one month after the operation. The abdominal drainage tube was removed one week later, and the biliary stent was removed three months later (see Fig. 5 ). Four patients had biochemical fistulas, and all of them underwent intermittent peritoneal irrigation after the operation. Two patients were discharged after the removal of the drainage tube after improvement during hospitalization, and the other two patients were discharged with a drainage tube. The drainage tube was removed after no obvious fluid outflow was observed. No serious complications, such as grade B/C pancreatic fistula, abdominal hemorrhage, gastroparesis, or duodenal ischemia, occurred. The median postoperative hospital stay was 10 (6–35) days. No long-term complications occurred during the follow-up of more than 7 months. No patients had pancreatic pseudocysts, biliary strictures, diabetes mellitus, chronic dyspepsia, or tumor recurrence after the operation (Table 1 ). Table 1 Basic clinical characteristics and operation outcomes of 12 patients Case Age Sex Tumor length (cm) Operation time (min) Blood loss (ml) Number of angiograms (n) Complications POHS (days) Pathology 1 63 F 3.3 480 400 3 Biliary fistula 40 SCN 2 57 F 3.1 300 300 2 7 IPMN 3 67 M 2.8 390 350 3 10 IPMN 4 42 F 4.2 280 200 2 8 SCN 5 55 F 3.6 480 200 2 Biochemical fistula 14 IPMN 6 57 M 3.4 420 100 3 10 IPMN 7 51 F 3.8 380 300 3 9 MCN 8 72 M 4.0 240 200 2 8 SCN 9 49 F 3.6 280 350 4 Biochemical fistula 12 IPMN 10 45 F 4.5 300 300 3 Biochemical fistula 18 MCN 11 62 M 3.3 450 350 4 Biochemical fistula 13 IPMN 12 55 F 3.5 400 200 3 7 SCN Median (range)/mean ± SD a 56.3 ± 8.8 3.6 ± 0.1 366.7 ± 24.2 270.8 ± 25.7 3(2–4) 10(7–40) F female, M male, POHS postoperative hospital stay. a Normally distributed data are expressed as the mean ± standard deviation (SD); skewed data are expressed as the median (range). 3 Discussion With the development of and progress in medical imaging technology, the detection rate of benign pancreatic tumors is increasing annually. However, some benign pancreatic tumors have different degrees of malignant tendency and need early surgical treatment. The previous surgical method for benign tumors located in the head of the pancreas is pancreaticoduodenectomy, but this surgical method requires extensive resection of the bile duct system, duodenum, and most of the pancreatic tissue and multiple digestive tract anastomoses, resulting in severe surgical trauma and many postoperative complications [3,4,5]. DPPHR can preserve the integrity of the digestive tract and protect the integrity and function of the anatomical structure of the pancreaticoduodenal region to the greatest extent while removing pancreatic lesions. However, DPPHR was initially used only for the treatment of inflammatory masses in the head of the pancreas [1]. With advances in technology, DPPHR has gradually been applied in the treatment of benign, borderline and low-grade malignant tumors in the head of the pancreas, as well as refractory pancreatic duct stones.[6,7,8,9] From the point of view of metabolism, DPPHR reduces the incidence of pancreatic exocrine dysfunction compared with that in PD. Related reports [10] have shown that the incidence of pancreatic exocrine insufficiency (PEI) after DPPHR is 34% (12/35), while the incidence of PEI in PD is 59%. The difference in incidence between the procedures was statistically significant. In terms of endocrine dysfunction, it has been reported that 10.6–15.7% of patients develop postoperative new-onset diabetes mellitus (pNODM) after PD of benign tumors; however, only 5%-6% of patients develop pNODM after DPPHR [11,12]. The literature suggests that the duodenum, rather than the pancreas, is responsible for metabolic dysfunction because PD and DPPHR are equivalent in pancreatectomy. The preservation of the duodenopancreatic nerve connection ensures the release of endocrine and exocrine regulatory hormones, thereby maintaining endocrine and exocrine functions. In this study, none of the 12 patients developed PEI or pNODM during the postoperative follow-up. In addition, in terms of postoperative overall quality of life, the latest meta-analysis involving 976 patients (456 who underwent DPPHR and 520 who underwent PD) showed that the overall quality of life of DPPHR patients was better than that of PD patients[13] in studies with follow-up times between 2 and 7 years. However, although DPPHR has many advantages over PD, the postoperative complication rate is still as high as 23%-40%[1415], which limits the promotion and application of this procedure. Related studies have shown that the incidence of biliary leakage varies from 12.5–16.7% [16,17]. Due to the lack of clear visualization of the location of the common bile duct during DPPHR, especially the pancreatic segment of the common bile duct, cystic tumors in the head of the pancreas cannot be distinguished from those in the wall of the common bile duct in some patients, resulting in bile duct injury. In addition, during the process of splitting the pancreatic head, the pancreaticoduodenal arterial arch is not clearly visible, and the mesenteric vessels of the duodenum can be injured during the operation, leading to duodenal ischemia and even necrosis, which forces conversion to PD or reoperation. Therefore, clearly exposing the blood supply of the common bile duct and the duodenum mesentery during surgery is key to successful DPPHR. In 2009, Ishizawa introduced the technique of indocyanine green (ICG) fluorescence imaging to visualize the bile duct during surgery and to identify the anatomical structure of the biliary tract in real time to avoid bile duct injury [18]. In this study, fluorescence laparoscopy clearly revealed the whole course of the common bile duct, especially when the cystic tumor of the pancreatic head was close to the common bile duct. Because the cystic tumor could not be visualized, it was in sharp contrast with the developed common bile duct. In recent years, a series of successful cases have been reported [19,20], most of which revealed the advantages of intraoperative fluorescence imaging in visualizing the common bile duct. In 2021, Hong D et al. [16] reported performing LDPPHR on 22 patients and described the use of ICG to image the pancreaticoduodenal arch vessels. However, the concentration of ICG injected, the duration of fluorescence visualization of blood vessels, and the number of intraoperative blood vessels were not mentioned. In this study, the pancreaticoduodenal vascular arch of 12 patients was visualized during the operation; in particular, the blood vessels of the lower pancreaticoduodenal vessels that bifurcated into the pancreas and the mesentery of the duodenum could be clearly distinguished, which greatly protected the blood supply of the duodenum mesentery and reduced the possibility of duodenal ischemia. Factors that affect the quality of ICG fluorescence-based vascular visualization include temperature, blood pH, blood flow rate and blood viscosity. Therefore, there is no widely accepted consensus on the concentration and dosage of ICG for intraoperative real-time vascular visualization. However, through continuous exploration combined with related literature, our center found that 1 ml of indocyanine green at a concentration of 2.5 mg/ml can be injected into the peripheral vein, and the blood vessels can be visualized in approximately 20 s. The fluorescence begins to decline in 90 s, and the effective fluorescence maintenance time is about 2 minutes. Within this concentration and time, blood vessels can be well visualized for the resection of the pancreatic head while preserving the pancreaticoduodenal arterial arch. In addition, in this study, the median number of vascular visualizations needed to complete the dissection of the pancreatic head and the duodenum mesentery was 3. Pancreatic fistula is the most important complication after DPPHR [21,22]. A soft texture of the pancreas and a diameter of the pancreatic duct less than 3 mm in benign pancreatic tumors are the main risk factors for pancreatic fistula [23,24]. In addition, residual pancreatic tissue is also a potential risk factor for pancreatic fistula. The classic Beger procedure requires the preservation of 0.5-1.0 cm of pancreatic tissue. In our experience, approximately 0.5 cm of pancreatic tissue is preserved in the medial part of the duodenum. On one hand, because there is no obvious serosal protection of the inner part of the duodenum, the pancreatic tissue will be damaged when it is close to the duodenum. Secondly, the ASPDA often travels in the pancreas and is close to the medial wall of the duodenum. Separating and retaining part of the pancreatic tissue can reduce the possibility of damage to the ASPDA. In this study, 4 patients developed pancreatic fistula without obvious symptoms such as fever. A biochemical fistula was considered, and the drainage tube was removed after intermittent irrigation following the operation. Our experience is that, on the one hand, the pancreatic tissue of benign pancreatic head tumors is generally soft, which is a high risk factor for pancreatic fistula. Therefore, penetrating sutures are used in pancreatojejunostomy to reduce the tearing of pancreatic tissue caused by layered sutures. On the other hand, the residual pancreatic tissue was reinforced with vascular suturing to reduce the risk of postoperative pancreatic fistula and bleeding. Beger HG et al. [25] performed a meta-analysis of 221 DPPHR patients and reported that complete dissection of the pancreatic intramural segment of the CBD from pancreatic tissue increased the risk of damage to the CPD and the frequency of biliary fistula. This literature suggests that it is caused by damage to or ischemic lesions of the duct wall of the CBD segment within the pancreas. To avoid the development of biliary fistula, CBD stenosis, or cholangitis, the importance of preserving the posterior branch of the pancreaticoduodenal artery during the dissection of the intrapancreatic segment of the CBD is suggested. In our study, a patient developed postoperative biliary fistula whose postoperative pathology was serous cystadenoma, and the lower edge of the tumor was "C" type surrounding the lower end of the common bile duct. The internal segment of the pancreatic wall of the common bile duct was long, and the common bile duct wall was thin during the operation. One month after the operation, the biliary fistula failed to heal by itself, and the biliary fistula resolved within one week after the placement of the biliary stent. The drainage tube was removed after no bile outflow was observed. The authors believe that the occurrence of biliary fistula after DPPHR is closely related to the location of the tumor and the common bile duct and to the blood supply of the lower end of the common bile duct, especially the posterior inferior pancreaticoduodenal artery (PSPDA) behind the common bile duct and the papillary artery of Vater between the duodenum and the common bile duct. Therefore, intraoperative visualization of the common bile duct and preservation of the blood supply to the lower end of the common bile duct are particularly important. Our experience is that when dissecting the inner pancreatic wall of the common bile duct, the pancreatic tissue behind the common bile duct and between the duodenum and the common bile duct should be preserved as much as possible, which can reduce excessive invasion of the lower end of the common bile duct and protect the blood supply of the lower end of the common bile duct from the pancreaticoduodenal arterial arch. FLDPPHR is feasible for the treatment of benign tumors in the head of the pancreas, but it has strict surgical indications and is difficult to perform. FLDPPHR should be performed by experienced pancreatic surgeons. FLDPPHR is feasible for select patients due to its unique advantages. However, due to the small sample size of this study, large sample studies and long-term follow-up are still needed. Declarations Funding ： This study was supported by the 2023 research project of Wannan Medical College (Award Number: WK2023ZQNZ33 Recipient: Zhengchao Shen), and the 2023 Natural Science Research Project of Anhui Province Universities (Award Number: 2023AH040254 Recipient:Xiaoming Wang). Authors' contributions Study conception and design：Xiaoming Wang, Zhengchao Shen. Acquisition of data: Bin Jiang, Shihang Xi. Analysis and interpretation of data: Yaqi Jiang, Daohai Qian. Drafting of manuscript: Zhengchao Shen, Suhang Chen. Critical revision of manuscript: Xiaoming Wang. Competing Interests : The authors declare that they have no competing interests. In 1972, Beger et al. [1] first proposed and performed duodenum-preserving pancreatic head resection (DPPHR), namely, Beger's operation. In contrast to traditional pancreaticoduodenectomy (PD) for the treatment of pancreatic head tumors, this operation preserves the normal passage of food and has been gradually applied in recent years. With the widespread application of fluorescence laparoscopy, we attempted to apply the characteristics and advantages of fluorescence laparoscopy to DPPHR. We found that this method has unique advantages for intraoperative visualization of the common bile duct and pancreaticoduodenal vascular arch. Acknowledgements This thesis would not have been possible without the consistent and valuable reference materials that I received from XW whose insightful guidance and enthusiastic encouragement in the course of my shaping this thesis definitely gain my deepest gratitude. Permissions Neither the entire manuscript nor any part of its content has been published or has been accepted elsewhere and this manuscript has not been submitted to any other journal. No portion of the text has been copied from other material in the literature. All of the authors in this manuscript have read and approved the final version submitted, and there are no conflicts involved in this submission. 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Beger HG, Mayer B, Poch B(2023)Duodenum-Preserving Pancreatic Head Resection for Benign and Premalignant Tumors-a Systematic Review and Meta-analysis of Surgery-Associated Morbidity.J Gastrointest Surg 27:2611–2627. https://doi:10.1007/s11605-023-05789-4. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4451710","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":310513387,"identity":"14ff1099-276c-4b8f-a367-fd26ef5f208c","order_by":0,"name":"Zhengchao Shen","email":"","orcid":"","institution":"The Fifth Clinical Medical College of Anhui Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhengchao","middleName":"","lastName":"Shen","suffix":""},{"id":310513389,"identity":"72f706e8-9e99-4cd4-b21b-da8e61d1c103","order_by":1,"name":"Bin Jiang","email":"","orcid":"","institution":"The First Affiliated Hospital of Wannan Medical College","correspondingAuthor":false,"prefix":"","firstName":"Bin","middleName":"","lastName":"Jiang","suffix":""},{"id":310513390,"identity":"93c03f24-10e1-48a4-9302-26ca8e7c077f","order_by":2,"name":"Shihang Xi","email":"","orcid":"","institution":"The First Affiliated Hospital of Wannan Medical College","correspondingAuthor":false,"prefix":"","firstName":"Shihang","middleName":"","lastName":"Xi","suffix":""},{"id":310513392,"identity":"c049b82b-ee3d-45c7-b5cf-cf76ca34bf5f","order_by":3,"name":"Daohai Qian","email":"","orcid":"","institution":"The First Affiliated Hospital of Wannan Medical College","correspondingAuthor":false,"prefix":"","firstName":"Daohai","middleName":"","lastName":"Qian","suffix":""},{"id":310513393,"identity":"1bcd19ca-36b9-4eb4-989d-45500bcba85c","order_by":4,"name":"Suhang Chen","email":"","orcid":"","institution":"The First Affiliated Hospital of Wannan Medical College","correspondingAuthor":false,"prefix":"","firstName":"Suhang","middleName":"","lastName":"Chen","suffix":""},{"id":310513394,"identity":"ddbbe5f2-3504-4a85-bf34-f2554623611d","order_by":5,"name":"Yaqi Jiang","email":"","orcid":"","institution":"The First Affiliated Hospital of Wannan Medical College","correspondingAuthor":false,"prefix":"","firstName":"Yaqi","middleName":"","lastName":"Jiang","suffix":""},{"id":310513395,"identity":"88cf34df-5318-4687-a0e4-c96693f30db3","order_by":6,"name":"Xiaoming Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuUlEQVRIiWNgGAWjYHACxgcfDCTk2NibDxCthdlwRoWFMR/PsQSitbAJ85ypSJwnkaNAnHqDG9lpzLxtEultDDkMDD8qthGh5czZbQ/ntknktjGcPcDYc+Y2YS1mx3u3G7wFaWHsS2BmbCNGy2HebRIgh7Ex8xgQqeV47zZJnjMSCWxsxGqxP3N2MzCQJQzbeNgSDhLlF8kZuRuBUVknLz//8cEHPyqI0IICDpCofhSMglEwCkYBLgAARpA8uxgT5GEAAAAASUVORK5CYII=","orcid":"","institution":"The Fifth Clinical Medical College of Anhui Medical University","correspondingAuthor":true,"prefix":"","firstName":"Xiaoming","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2024-05-21 02:39:00","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4451710/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4451710/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57922635,"identity":"dad49343-012a-49c7-9064-a70fcad2f281","added_by":"auto","created_at":"2024-06-07 13:42:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":489280,"visible":true,"origin":"","legend":"\u003cp\u003ea: Preoperative three-dimensional image showing the anterior and posterior arch vessels of the pancreaticoduodenal artery. b: FLDPPHR cannula placement position. c: Schematic representation of the vessels in the pancreaticoduodenal arterial arch, pancreiatic duct (PD), common hepatic artery (CHA), celiac axis (CA).\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4451710/v1/d261a673076e6d3483c6a9b2.png"},{"id":57923276,"identity":"f17df03a-0ca1-4589-9716-5ec593b1262a","added_by":"auto","created_at":"2024-06-07 13:50:34","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3481397,"visible":true,"origin":"","legend":"\u003cp\u003ea: Without intraoperative vascular visualization, only the main vessels can be distinguished; branch vessels cannot be distinguished. b: The main trunk and branch vessels could be clearly exposed in fluorescence mode. c: During resection, the pancreaticoduodenal artery arch was visualized by fluorescence laparoscopy. d: After pancreatic head resection, the pancreaticoduodenal arterial arch was visualized under fluorescence laparoscopy.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4451710/v1/15235abcd72608457648dd16.png"},{"id":57922640,"identity":"59824d4a-7e81-4913-bb87-3146bab4499b","added_by":"auto","created_at":"2024-06-07 13:42:34","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2529287,"visible":true,"origin":"","legend":"\u003cp\u003ea: In conventional laparoscopic mode, the relationship between the tumor and the CBD could not be accurately judged. b: The CBD and the location of the tumor could be clearly exposed after turning on the fluorescence mode. c: The space between the CBD and the tumor was completely dissociated. d: CBD and pancreatic duct stumps exposed after specimen resection, main pancreatic duct (MPD).\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4451710/v1/1245eb593ba35891ed04b3b2.png"},{"id":57922636,"identity":"5530b800-3bf9-4930-89b9-c0126dade998","added_by":"auto","created_at":"2024-06-07 13:42:34","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1207447,"visible":true,"origin":"","legend":"\u003cp\u003ea: Penetrating full-thickness pancreatic suture. b: Pancreatic duct-to-jejunal mucosa anastomosis. c: Insertion of the support tube and fixation. d: Continuous penetrating suture of the remaining pancreatic tissue.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-4451710/v1/b29a0cec6733ba6d2fab84f5.png"},{"id":57922638,"identity":"7203ad45-ef37-4eb2-8edd-4838c4af3d8c","added_by":"auto","created_at":"2024-06-07 13:42:34","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":854978,"visible":true,"origin":"","legend":"\u003cp\u003ea: Postoperative drainage tube angiography revealed that the common bile duct had developed and entered the duodenum, and biliary fistula was considered. b: ERCP was performed one month after the operation; c: A biliary stent was placed, and bile outflow was observed.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-4451710/v1/7d1c609b8720e4bb05945840.png"},{"id":58018897,"identity":"c273ab4c-1647-4403-8414-9462b7746c63","added_by":"auto","created_at":"2024-06-10 04:31:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":15666917,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4451710/v1/837ac201-1ee8-4140-8f95-37e7111a8a3e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The application of intraoperative vascular and biliary tract imaging in laparoscopic duodenum-preserving pancreatic head resection","fulltext":[{"header":"1 Materials and Methods","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Clinical data\u003c/h2\u003e \u003cp\u003eFrom June 2021 to October 2023, 12 patients with benign tumors of the pancreatic head underwent FLDPPHR at our center. The perioperative data of the 12 patients, including age, sex, preoperative tumor markers, tumor size, operation time, intraoperative blood loss, intraoperative blood vessel visualization time, postoperative hospital stay, postoperative pathology, postoperative complications and postoperative follow-up data, were retrospectively analyzed. All patients provided written informed consent in accordance with the approval of the hospital ethics committee and in accordance with the Declaration of Medical Ethics of Helsinki.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Surgical methods\u003c/h2\u003e \u003cp\u003eAll patients underwent three-dimensional visualization imaging before the operation to obtain a complete understanding the pancreaticoduodenal artery arch and branch vessels (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea). Preparation for biliary imaging: 2.5 mg/ml of 1.5 ml indocyanine green was injected into the peripheral vein half an hour before surgery. After the administration of general anesthesia, the patient was placed in the supine position. A 10 mm incision was made at the lower edge of the umbilicus to puncture a pneumoperitoneum needle into the abdominal cavity. Carbon dioxide gas was then injected to inflate the cavity to achieve a pneumoperitoneum pressure of 13 mmHg. Subsequently, a Trocar was inserted for lens entry, and the trocars were placed using the \"five-hole\" method (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb). After entering the abdominal cavity, the abdominal cavity was explored, and no obvious metastasis was found. The gastrocolic ligament was cut off by an ultrasonic scalpel into the retrogastric space, the lesser omental sac was opened, and the stomach wall was suspended by an 8-gauge red catheter. The superior mesenteric vein (SMV) and Henle trunk were exposed. The \"C\" ring of the pancreas was exposed after the Henle trunk and its branches were cut off. The portal vein triangle was dissected along the upper edge of the pancreas through the tunnel behind the pancreatic neck, approximately 1 cm away from the pancreatic tumor. The pancreatic parenchyma was gradually cut off by an ultrasonic scalpel, and the pancreatic duct was cut off by scissors. After exposing the gastroduodenal artery (GDA), the right omentum vessel was transected above the level of the GDA vessels, and transection continued to the lower part along the GDA. Whether to transection the anterior superior pancreaticoduodenal artery (ASPDA) should be determined according to the anatomical location of ASPDA, but attention should be given to protecting the posterior superior pancreaticoduodenal artery (PSPDA)(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec). Under the guidance of fluorescence laparoscopy, approximately 0.5 cm of the pancreatic tissue of the medial wall of the duodenum was retained, the pancreatic tissue of the head of the pancreas was separated from the top to the bottom, and the medial wall of the duodenum was protected to the lower end of the common bile duct. The space between the uncinate process and the duodenum mesentery was dissociated from the side to the head. At this time, the blood vessels could be immediately visualized during the operation (1 ml of 2.5 mg/ml indocyanine green was injected intravenously peripheral to the uncinate process) for About two minutes. The vascular arch of the pancreaticoduodenal artery could be visualized during the operation. The anterior inferior pancreaticoduodenal artery (AIPDA), the posterior inferior pancreaticoduodenal artery (PIPDA), and their branches were preserved, and care was taken to avoid injury to the vessels of the pancreaticoduodenal arterial arch (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The uncinate process was gradually lifted; the main pancreatic duct was dissociated, ligated and severed; and the inner segment of the common bile duct was visible above it. Under the guidance of fluorescence laparoscopy, the main common bile duct (CBD) was exposed, and attention was given to distinguish the main common bile duct from the tumor (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The encapsulated pancreatic tissue was dissociated while avoiding damage to the blood supply of the lower end of the common bile duct. After the upper and lower confluence, the specimen was cut off, and the specimen was sent for rapid pathological analysis during the operation. One milliliter of indocyanine green was injected into the peripheral vein again to detect whether the mesenteric vessels of the duodenum were intact and ischemic. If the intraoperative case suggested that the tumor was malignant or the ischemic necrosis of the duodenum was found during the operation, pancreaticoduodenectomy (PD) was performed. A 4\u0026thinsp;\u0026minus;\u0026thinsp;0 vascular suture was used to reinforce the medial wall of the duodenum with possible serosal damage and some residual pancreatic tissue.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe reconstruction of the anastomosis involved pancreatojejunostomy (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e): the pancreatic duct was dissected, the stent was placed, the jejunum was cut 15 cm away from the Treitz ligament, and the distal end of the jejunum was lifted from the right side of the middle colic artery. Under direct vision, pancreatojejunostomy was performed by continuous penetrating suturing (3\u0026thinsp;\u0026minus;\u0026thinsp;0 barbed suture\u0026thinsp;+\u0026thinsp;5\u0026thinsp;\u0026minus;\u0026thinsp;0 PDS line pancreatojejunostomy to mucosa). Side-to-side jejunal anastomosis was performed approximately 45 cm from the site of pancreatojejunostomy. 4\u0026thinsp;\u0026minus;\u0026thinsp;0 barbed sutures were used to close the common opening. Drainage tubes were placed behind the pancreatojejunostomy site and at the pancreatic head wound.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e1.3 Postoperative management\u003c/h2\u003e \u003cp\u003eAll patients were routinely treated with somatostatin after surgery, the drainage tube was irrigated intermittently, and the drainage tube was kept unblocked. The content of amylase in the drainage fluid was measured on the third day after surgery. The diagnostic criteria for pancreatic fistula were based on the 2016 definition of pancreatic fistula of the International Pancreatic Fistula Study Group (ISGPF) [2]. Upper abdominal CT was performed on the fifth day after the operation to determine the condition of the surgical area. Routine follow-up was performed after discharge, and May 1, 2024, was the date of the last follow-up.\u003c/p\u003e \u003c/div\u003e"},{"header":"2 Results","content":"\u003cp\u003eAll patients successfully completed the operation without conversion to open surgery. There were 4 males and 8 females. The tumor diameter was 3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1 cm, the operation time was 366.7\u0026thinsp;\u0026plusmn;\u0026thinsp;24.2 minutes, and the intraoperative blood loss volume was 270.8\u0026thinsp;\u0026plusmn;\u0026thinsp;25.7 ml. The median number of intraoperative vascular visualizations was 3 (2\u0026ndash;4). All 12 patients achieved R0 resection by postoperative pathology. Postoperative pathological diagnosis revealed intraductal papillary mucinous neoplasm (IPMN) in 6 patients, serous cystadenoma (SCN) in 4 patients, and mucinous cystadenoma (MCN) in 2 patients. One patient developed a biliary fistula with a daily volume of approximately 300 ml, and the biliary fistula was cured by placing a biliary stent under ERCP one month after the operation. The abdominal drainage tube was removed one week later, and the biliary stent was removed three months later (see Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Four patients had biochemical fistulas, and all of them underwent intermittent peritoneal irrigation after the operation. Two patients were discharged after the removal of the drainage tube after improvement during hospitalization, and the other two patients were discharged with a drainage tube. The drainage tube was removed after no obvious fluid outflow was observed. No serious complications, such as grade B/C pancreatic fistula, abdominal hemorrhage, gastroparesis, or duodenal ischemia, occurred. The median postoperative hospital stay was 10 (6\u0026ndash;35) days. No long-term complications occurred during the follow-up of more than 7 months. No patients had pancreatic pseudocysts, biliary strictures, diabetes mellitus, chronic dyspepsia, or tumor recurrence after the operation (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBasic clinical characteristics and operation outcomes of 12 patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTumor length\u003c/p\u003e \u003cp\u003e(cm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOperation time (min)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBlood loss (ml)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNumber of angiograms\u003c/p\u003e \u003cp\u003e(n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePOHS (days)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePathology\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e480\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eBiliary fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSCN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eIPMN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e390\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e350\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eIPMN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e280\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSCN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e480\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eBiochemical fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eIPMN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e420\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eIPMN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e380\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eMCN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSCN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e280\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e350\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eBiochemical fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eIPMN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eBiochemical fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eMCN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e450\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e350\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eBiochemical fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eIPMN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSCN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian (range)/mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e366.7\u0026thinsp;\u0026plusmn;\u0026thinsp;24.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e270.8\u0026thinsp;\u0026plusmn;\u0026thinsp;25.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3(2\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e10(7\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eF female, M male, POHS postoperative hospital stay.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003e\u003csup\u003ea\u003c/sup\u003e Normally distributed data are expressed as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD); skewed data are expressed as the median (range).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"3 Discussion","content":"\u003cp\u003eWith the development of and progress in medical imaging technology, the detection rate of benign pancreatic tumors is increasing annually. However, some benign pancreatic tumors have different degrees of malignant tendency and need early surgical treatment. The previous surgical method for benign tumors located in the head of the pancreas is pancreaticoduodenectomy, but this surgical method requires extensive resection of the bile duct system, duodenum, and most of the pancreatic tissue and multiple digestive tract anastomoses, resulting in severe surgical trauma and many postoperative complications [3,4,5]. DPPHR can preserve the integrity of the digestive tract and protect the integrity and function of the anatomical structure of the pancreaticoduodenal region to the greatest extent while removing pancreatic lesions. However, DPPHR was initially used only for the treatment of inflammatory masses in the head of the pancreas [1]. With advances in technology, DPPHR has gradually been applied in the treatment of benign, borderline and low-grade malignant tumors in the head of the pancreas, as well as refractory pancreatic duct stones.[6,7,8,9]\u003c/p\u003e \u003cp\u003eFrom the point of view of metabolism, DPPHR reduces the incidence of pancreatic exocrine dysfunction compared with that in PD. Related reports [10] have shown that the incidence of pancreatic exocrine insufficiency (PEI) after DPPHR is 34% (12/35), while the incidence of PEI in PD is 59%. The difference in incidence between the procedures was statistically significant. In terms of endocrine dysfunction, it has been reported that 10.6\u0026ndash;15.7% of patients develop postoperative new-onset diabetes mellitus (pNODM) after PD of benign tumors; however, only 5%-6% of patients develop pNODM after DPPHR [11,12]. The literature suggests that the duodenum, rather than the pancreas, is responsible for metabolic dysfunction because PD and DPPHR are equivalent in pancreatectomy. The preservation of the duodenopancreatic nerve connection ensures the release of endocrine and exocrine regulatory hormones, thereby maintaining endocrine and exocrine functions. In this study, none of the 12 patients developed PEI or pNODM during the postoperative follow-up.\u003c/p\u003e \u003cp\u003eIn addition, in terms of postoperative overall quality of life, the latest meta-analysis involving 976 patients (456 who underwent DPPHR and 520 who underwent PD) showed that the overall quality of life of DPPHR patients was better than that of PD patients[13] in studies with follow-up times between 2 and 7 years.\u003c/p\u003e \u003cp\u003eHowever, although DPPHR has many advantages over PD, the postoperative complication rate is still as high as 23%-40%[1415], which limits the promotion and application of this procedure. Related studies have shown that the incidence of biliary leakage varies from 12.5\u0026ndash;16.7% [16,17]. Due to the lack of clear visualization of the location of the common bile duct during DPPHR, especially the pancreatic segment of the common bile duct, cystic tumors in the head of the pancreas cannot be distinguished from those in the wall of the common bile duct in some patients, resulting in bile duct injury. In addition, during the process of splitting the pancreatic head, the pancreaticoduodenal arterial arch is not clearly visible, and the mesenteric vessels of the duodenum can be injured during the operation, leading to duodenal ischemia and even necrosis, which forces conversion to PD or reoperation. Therefore, clearly exposing the blood supply of the common bile duct and the duodenum mesentery during surgery is key to successful DPPHR. In 2009, Ishizawa introduced the technique of indocyanine green (ICG) fluorescence imaging to visualize the bile duct during surgery and to identify the anatomical structure of the biliary tract in real time to avoid bile duct injury [18]. In this study, fluorescence laparoscopy clearly revealed the whole course of the common bile duct, especially when the cystic tumor of the pancreatic head was close to the common bile duct. Because the cystic tumor could not be visualized, it was in sharp contrast with the developed common bile duct. In recent years, a series of successful cases have been reported [19,20], most of which revealed the advantages of intraoperative fluorescence imaging in visualizing the common bile duct. In 2021, Hong D et al. [16] reported performing LDPPHR on 22 patients and described the use of ICG to image the pancreaticoduodenal arch vessels. However, the concentration of ICG injected, the duration of fluorescence visualization of blood vessels, and the number of intraoperative blood vessels were not mentioned.\u003c/p\u003e \u003cp\u003eIn this study, the pancreaticoduodenal vascular arch of 12 patients was visualized during the operation; in particular, the blood vessels of the lower pancreaticoduodenal vessels that bifurcated into the pancreas and the mesentery of the duodenum could be clearly distinguished, which greatly protected the blood supply of the duodenum mesentery and reduced the possibility of duodenal ischemia. Factors that affect the quality of ICG fluorescence-based vascular visualization include temperature, blood pH, blood flow rate and blood viscosity. Therefore, there is no widely accepted consensus on the concentration and dosage of ICG for intraoperative real-time vascular visualization. However, through continuous exploration combined with related literature, our center found that 1 ml of indocyanine green at a concentration of 2.5 mg/ml can be injected into the peripheral vein, and the blood vessels can be visualized in approximately 20 s. The fluorescence begins to decline in 90 s, and the effective fluorescence maintenance time is about 2 minutes. Within this concentration and time, blood vessels can be well visualized for the resection of the pancreatic head while preserving the pancreaticoduodenal arterial arch. In addition, in this study, the median number of vascular visualizations needed to complete the dissection of the pancreatic head and the duodenum mesentery was 3.\u003c/p\u003e \u003cp\u003ePancreatic fistula is the most important complication after DPPHR [21,22]. A soft texture of the pancreas and a diameter of the pancreatic duct less than 3 mm in benign pancreatic tumors are the main risk factors for pancreatic fistula [23,24]. In addition, residual pancreatic tissue is also a potential risk factor for pancreatic fistula. The classic Beger procedure requires the preservation of 0.5-1.0 cm of pancreatic tissue. In our experience, approximately 0.5 cm of pancreatic tissue is preserved in the medial part of the duodenum. On one hand, because there is no obvious serosal protection of the inner part of the duodenum, the pancreatic tissue will be damaged when it is close to the duodenum. Secondly, the ASPDA often travels in the pancreas and is close to the medial wall of the duodenum. Separating and retaining part of the pancreatic tissue can reduce the possibility of damage to the ASPDA. In this study, 4 patients developed pancreatic fistula without obvious symptoms such as fever. A biochemical fistula was considered, and the drainage tube was removed after intermittent irrigation following the operation. Our experience is that, on the one hand, the pancreatic tissue of benign pancreatic head tumors is generally soft, which is a high risk factor for pancreatic fistula. Therefore, penetrating sutures are used in pancreatojejunostomy to reduce the tearing of pancreatic tissue caused by layered sutures. On the other hand, the residual pancreatic tissue was reinforced with vascular suturing to reduce the risk of postoperative pancreatic fistula and bleeding.\u003c/p\u003e \u003cp\u003eBeger HG et al. [25] performed a meta-analysis of 221 DPPHR patients and reported that complete dissection of the pancreatic intramural segment of the CBD from pancreatic tissue increased the risk of damage to the CPD and the frequency of biliary fistula. This literature suggests that it is caused by damage to or ischemic lesions of the duct wall of the CBD segment within the pancreas. To avoid the development of biliary fistula, CBD stenosis, or cholangitis, the importance of preserving the posterior branch of the pancreaticoduodenal artery during the dissection of the intrapancreatic segment of the CBD is suggested.\u003c/p\u003e \u003cp\u003eIn our study, a patient developed postoperative biliary fistula whose postoperative pathology was serous cystadenoma, and the lower edge of the tumor was \"C\" type surrounding the lower end of the common bile duct. The internal segment of the pancreatic wall of the common bile duct was long, and the common bile duct wall was thin during the operation. One month after the operation, the biliary fistula failed to heal by itself, and the biliary fistula resolved within one week after the placement of the biliary stent. The drainage tube was removed after no bile outflow was observed. The authors believe that the occurrence of biliary fistula after DPPHR is closely related to the location of the tumor and the common bile duct and to the blood supply of the lower end of the common bile duct, especially the posterior inferior pancreaticoduodenal artery (PSPDA) behind the common bile duct and the papillary artery of Vater between the duodenum and the common bile duct. Therefore, intraoperative visualization of the common bile duct and preservation of the blood supply to the lower end of the common bile duct are particularly important. Our experience is that when dissecting the inner pancreatic wall of the common bile duct, the pancreatic tissue behind the common bile duct and between the duodenum and the common bile duct should be preserved as much as possible, which can reduce excessive invasion of the lower end of the common bile duct and protect the blood supply of the lower end of the common bile duct from the pancreaticoduodenal arterial arch.\u003c/p\u003e \u003cp\u003eFLDPPHR is feasible for the treatment of benign tumors in the head of the pancreas, but it has strict surgical indications and is difficult to perform. FLDPPHR should be performed by experienced pancreatic surgeons. FLDPPHR is feasible for select patients due to its unique advantages. However, due to the small sample size of this study, large sample studies and long-term follow-up are still needed.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e：\u003c/em\u003e\u003c/strong\u003eThis study was supported by the 2023 research project of Wannan Medical College (Award Number: WK2023ZQNZ33 Recipient: Zhengchao Shen), and the 2023 Natural Science Research Project of Anhui Province Universities (Award Number: 2023AH040254 Recipient:Xiaoming Wang).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy conception and design：Xiaoming Wang, Zhengchao Shen. Acquisition of data:\u0026nbsp;Bin Jiang,\u0026nbsp;Shihang Xi. Analysis and interpretation of data:\u0026nbsp;Yaqi Jiang, Daohai Qian. Drafting of manuscript: Zhengchao Shen, Suhang Chen. Critical revision of manuscript: Xiaoming Wang.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting Interests\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e:\u003c/em\u003e\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eIn 1972, Beger et al. [1] first proposed and performed duodenum-preserving pancreatic head resection (DPPHR), namely, Beger\u0026apos;s operation. In contrast to traditional pancreaticoduodenectomy (PD) for the treatment of pancreatic head tumors, this operation preserves the normal passage of food and has been gradually applied in recent years. With the widespread application of fluorescence laparoscopy, we attempted to apply the characteristics and advantages of fluorescence laparoscopy to DPPHR. We found that this method has unique advantages for intraoperative visualization of the common bile duct and pancreaticoduodenal vascular arch.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis thesis would not have been possible without the consistent and valuable reference materials that I received from XW whose insightful guidance and enthusiastic encouragement in the course of my shaping this thesis definitely gain my deepest gratitude.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePermissions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNeither the entire manuscript nor any part of its content has been published or has been accepted elsewhere and this manuscript has not been submitted to any other journal. No portion of the text has been copied from other material in the literature. All of the authors in this manuscript have read and approved the final version submitted, and there are no conflicts involved in this submission.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Beger HG, Krautzberger W, Bittner R, B\u0026uuml;chler M, Limmer J(1985)Duodenum-preserving resection of the head of the pancreas in patients with severe chronic pancreatitis. Surgery 97:467\u0026thinsp;\u0026minus;\u0026thinsp;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, Allen P, Andersson R, Asbun HJ, Besselink MG, Conlon K, Del Chiaro M, Falconi M, Fernandez-Cruz L, Fernandez-Del Castillo C, Fingerhut A, Friess H, Gouma DJ, Hackert T, Izbicki J, Lillemoe KD, Neoptolemos JP, Olah A, Schulick R, Shrikhande SV, Takada T, Takaori K, Traverso W, Vollmer CR, Wolfgang CL, Yeo CJ, Salvia R, Buchler M(2017)International Study Group on Pancreatic Surgery (ISGPS). 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Int J Med Robot 14:e1903. https://doi:10.1002/rcs.1903.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Ghorbani P, Dankha R, Brisson R, D'Souza MA, L\u0026ouml;hr JM, Sparrelid E, Vujasinovic M(2022)Surgical Outcomes and Trends for Chronic Pancreatitis: An Observational Cohort Study from a High-Volume Centre. J Clin Med 11:2105. https://doi:10.3390/jcm11082105.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Beger HG, Mayer B, Vasilescu C, Poch B(2022)Long-term Metabolic Morbidity and Steatohepatosis Following Standard Pancreatic Resections and Parenchyma-sparing, Local Extirpations for Benign Tumor: A Systematic Review and Meta-analysis. 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J Minim Access Surg 18:632\u0026ndash;634.https://doi:10.4103/jmas.jmas_205_21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Wu H, Gao W, Chen L(2023)Indocyanine green fluorescence-assisted laparoscopic duodenum-preserving pancreatic head resection. J Visc Surg 160:470\u0026ndash;471. https://doi:10.1016/j.jviscsurg.2023.07.005.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Beger HG, Mayer B, Rau BM(2016)Parenchyma-Sparing, Limited Pancreatic Head Resection for Benign Tumors and Low-Risk Periampullary Cancer\u0026ndash;a Systematic Review. J Gastrointest Surg 20:206\u0026thinsp;\u0026minus;\u0026thinsp;17. https://doi:10.1007/s11605-015-2981-2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Guo T, Liu Y, Yang Z, Li J, You K, Zhao D, Chen S, Li C, Yang P, Hu H, Zhang H(2023)Intraductal papillary mucinous neoplasm of the accessory pancreatic duct in the pancreas uncinate process: A case report. Medicine (Baltimore). 102:e33840. https://doi:10.1097/MD.0000000000033840.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Schuh F, Mihaljevic AL, Probst P, Trudeau MT, M\u0026uuml;ller PC, Marchegiani G, Besselink MG, Uzunoglu F, Izbicki JR, Falconi M, Castillo CF, Adham M, Z'graggen K, Friess H, Werner J, Weitz J, Strobel O, Hackert T, Radenkovic D, Kelemen D, Wolfgang C, Miao YI, Shrikhande SV, Lillemoe KD, Dervenis C, Bassi C, Neoptolemos JP, Diener MK, Vollmer CM Jr, B\u0026uuml;chler MW(2023) A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula: A classification of the International Study Group of Pancreatic Surgery. Ann Surg 277:e597-e608. https://doi:10.1097/SLA.0000000000004855.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Wu Y, Wujimaimaiti N, Yuan J, Li S, Zhang H, Wang M, Qin R(2023)Risk factors for achieving textbook outcome after laparoscopic duodenum-preserving total pancreatic head resection: a retrospective cohort study. Int J Surg 109:698\u0026ndash;706.https://doi:10.1097/JS9.0000000000000251.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Beger HG, Mayer B, Poch B(2023)Duodenum-Preserving Pancreatic Head Resection for Benign and Premalignant Tumors-a Systematic Review and Meta-analysis of Surgery-Associated Morbidity.J Gastrointest Surg 27:2611\u0026ndash;2627. https://doi:10.1007/s11605-023-05789-4.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"pancreatic neoplasms, fluorescence laparoscopy, biliary complications, pancreatic fistula","lastPublishedDoi":"10.21203/rs.3.rs-4451710/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4451710/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/em\u003e To investigate the value of applying intraoperative indocyanine green fluorescence imaging in laparoscopic duodenum-preserving pancreatic head resection.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/em\u003e The clinical data of 12 patients with benign pancreatic head tumors who underwent fluorescence laparoscopic duodenum-preserving pancreatic head resection (FLDPPHR) at the Department of Hepatobiliary Surgery, the First Affiliated Hospital of Wannan Medical College, from June 2021 to October 2023 were retrospectively analyzed. All patients received an intravenous injection of indocyanine green (2.5 mg/ml, 1.5 ml) for biliary tract imaging half an hour before surgery. Indocyanine green (2.5 mg/ml, 1 ml) was intravenously injected into the peripheral vein when blood vessels needed to be exposed during the operation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e \u003c/em\u003eFLDPPHR was successfully performed in all 12 patients without conversion to open surgery. The tumor diameter was 3.6±0.1 cm, the operation time was 366.7±24.2 minutes, and the intraoperative blood loss volume was 270.8±25.7 ml. The median number of intraoperative vascular visualizations was 3 (2-4). Postoperative pathological diagnosis revealed intraductal papillary mucinous neoplasm (IPMN) in 6 patients, serous cystadenoma (SCN) in 4 patients, and mucinous cystadenoma (MCN) in 2 patients. The median postoperative hospital stay was 10 (7-40) days. No long-term complications occurred during the follow-up of more than 7 months.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e \u003c/strong\u003eReal-time exposure of the common bile duct during indocyanine green fluorescence imaging is helpful for reducing damage to the common bile duct, visualizing vessels in the\u003c/p\u003e","manuscriptTitle":"The application of intraoperative vascular and biliary tract imaging in laparoscopic duodenum-preserving pancreatic head resection","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-07 13:42:29","doi":"10.21203/rs.3.rs-4451710/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5390a710-1c72-4f51-bb70-ef8889bb623f","owner":[],"postedDate":"June 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-10T04:22:56+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-07 13:42:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4451710","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4451710","identity":"rs-4451710","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}