改良术中操作对保留幽门胰十二指肠切除术后并发症的预防

目的　探讨保留幽门胰十二指肠切除术 (PPPD)后胃排空障碍及胰漏的防治方法与机理。方法　应用自制气囊 ,扩张幽门环肌 ,使其暂时麻痹 ,处于开放状态。用单层胰肠套入捆绑吻合 ,胰腺断缘浆膜化处理、吻合周围放置自制双套管被动冲洗引流。结果　 5 1例患者术后 3d开始测定引流量及引流液淀粉酶含量 ,无 1例胰漏 ,术后 3～ 7d胃肠功能恢复 ,正常拔除胃管 ,分别于术后 2周、4周、8周钡餐透视检查胃排空正常。结论　球囊扩张幽门环肌 ,是预防PPPD术后胃排空障碍的有效措施。良好的胰断处理、胰肠吻合及有效冲洗引流是预防胰漏的关键。     

食管切除术中加行幽门引流术的必要性及安全性的Meta分析

目的 系统评价食管切除术中加行幽门引流术(幽门成形、幽门括约肌切开术)的必要性及安全性.方法 通过电子搜索PubMed、Cochrane图书馆、Medline、Ovid、中国生物医学文献光盘数据、中文科技期刊全文数据库、CNKI数据库,对2000年1月至2010年12月有关食管切除术中加行幽门引流术(幽门成形术或幽门括约肌切开术)的随机对照实验及回顾性队列研究进行评价,并用RevMan 5.0进行Meta分析.结果 共纳入文献5篇,1018例患者.荟萃分析结果 显示:术后胃排空障碍、吻合口瘘、吸入性肺炎、其他呼吸系统并发症发生率,幽门引流组与对照组比较两组间差异无统计学意义(P>0.05).结论 食管切除胃代食管吻合术中行幽门引流术不能够有效降低术后胃排空障碍及其他术后并发症的发生率.     

气囊扩张幽门加捆绑式胰肠吻合预防保留幽门十二指肠切除术后并发症

目 探讨预防保留幽门胰十二指肠切除术后胃排空障碍及胰漏防治方法与机理。方法 应用自制所囊，扩张幽门环肌，使其暂时麻痹，处于开放状态，用单层胰肠套入捆绑吻合，胰腺断缘的浆膜化处理，吻合周围放置自制双套管被动冲洗引流。结果 51例患者术后3d开始测定引流量及引流液淀粉酶含量，无一例胰漏，术后3-7d胃肠功能恢复，正常拔除胃管，分别于术后2周、4周、8周钡透检查胃排空正常。结论 球囊扩张幽门和良好的断端处理及冲洗引流，是预防PPPD术后胃排空障碍的有效方法，良好的胰断端处理，胰肠吻合及有效冲洗引流是预防胰漏的关键。     

食管癌手术后胃排空障碍的治疗与预防

目的 探讨食管癌手术后胃排空障碍的治疗与预防。方法 对过去十年所做的食管癌手术患者进行回顾性统计。结果 共有13例患者出现胃排空障碍症状。6例胃排空延缓(给予保守治疗)，7例幽门梗阻(行幽门成形术)。按年龄段统计：50岁以上组患者发病率明显高于50岁以下组。结论 解决胃排空障碍有效方法是幽门成形术，因此，在行食管癌根治术时，行幽门成形术，对避免术后出现胃排空障碍具有重要意义。     

胰十二指肠切除术不同消化道重建技术对减轻术后胃排空延迟的影响

正目前,胃排空延迟(DGE)仍然是胰十二指肠切除术(PD)后最常见的并发症之一,发生DGE会对患者的术后恢复造成很大影响。过去的研究表明其发生率可能与术中消化道重建方式有关。目前较为常用的消化道重建方法有Billroth II吻合和Roux-en-Y吻合,Billroth II吻合又分为结肠前Billroth II吻合和结肠后Billroth II吻合。本研究旨在通过对这三种不同吻合方式的RCT研究进行网状meta分析,以评价能保证最低的     

胰腺癌胰十二指肠切除术后并发症回顾性分析

目的 回顾分析胰十二指肠切除术（PD）后并发症的相关因素，探讨预防减少术后并发症的措施。方法 回顾性研究我院1994年1月至2006年12月问138例PD病例，分析影响PD术后并发症的危险因素，比较不同胰肠吻合方式及幽门保留与否对胰瘘的影响。比较保留幽门的PD（PPPD）与不保留幽门的PD对术后胃潴留发生率的影响。结果 术后胰瘘总发生率23．18％（32／138），其中胰空肠黏膜对黏膜侧侧吻合组22．48％（29／129），胰残端空肠端侧传统套入组33．33％（3／9）。PPPD术后胃潴留发生率显著高于PD。胰肠吻合方式、保留幽门与否并不显著性的影响胰瘘的发生。多数手术近期吻合口出血与应用胃肠吻合器有关。结论 胰肠吻合方式、保留幽门与否未能显著的影响PD后胰瘘的发生，但保留幽门后会增加胃潴留的发生率；慎重应用胃肠吻合器，人工手法细心进行胃肠吻合可能有助于预防胰腺癌手术后近期出血的发生。     

食管胃吻合术后胃排空障碍探讨

目的　探讨食管胃吻合术后胃排空障碍的原因、合理的预防措施及其有效的治疗方法。方法　回顾性分析我科 1982年 1月～ 2 0 0 2年 4月间 32例食管胃吻合术后胃排空障碍病人的临床资料。结果　 32例胃排空障碍病人 ,食管胃颈部吻合 2 4例 ,胸腔内吻合 8例。占同期食管癌手术 1378例的 2 .3%。 2 5例功能性胃排空障碍病人中 2 2例经保守治愈 ,1例死亡 ,死亡率为 4 .0 % ;7例机械性胃排空障碍病人经手术治愈。结论　胃排空障碍多见于高位食管胃吻合术后 ,以食管胃颈部吻合者多见 ,其发生与手术操作和术后处理不当有关 ,胃排空障碍多为功能性 ,少数为机械性。前者大多可经保守治疗而痊愈 ,后者则必须手术解除梗阻。本文还对食管癌术后胃排空障碍的定义、诊断与鉴别诊断进行了探讨     

食管、贲门癌术后胸胃排空障碍14例

目的探讨食管、贲门癌术后胸胃排空障碍的治疗措施,以提高术后胸胃排空障碍的疗效。方法14例食管、贲门癌术后发生胸胃排空障碍患者中有3例给予保守治疗,11例经保守治疗效果不佳者在胃镜下安置鼻空肠营养管行肠内营养支持治疗,其中2例仍无效者行剖腹探查,幽门成形加空肠造瘘术。结果所有患者全部康复,其中3例经保守治疗1周治愈;11例在胃镜下安置鼻空肠营养管给予肠内营养治疗者中有9例于2周内拔除胃管,恢复正常饮食,2例行幽门成形加空肠造瘘术,术后2周治愈出院。所有患者随访3～6个月,进普通食物无恶心、呕吐。消化道X线钡餐检查显示：吞服钡剂后胸胃无钡剂潴留和明显扩张。结论在胃镜下安置鼻空肠营养管给予肠内营养是治疗胸胃排空障碍的一种有效方法,且安全可靠、方便经济;对疗效欠佳的患者,宜尽早行剖腹探查加幽门成形术。     

胃术后排空障碍的临床分析

胃大部分切除术后上消化道重建术后，吻合口排空障碍，一般分为功能性通过障碍与器质性通过障碍。前者主要由吻合口炎症、水肿，胃肠运动功能减弱所致胃排空延迟，常在术后早期发生，保守治疗一段时间，多可治愈。国内根治性远端胃大部切除术后胃排空障碍的发生率约为4.7％。本文回顾性分析我院2001年2月至2012年2月诊治的20例胃排空障碍患者的临床资料，浅谈胃术后胃排空障碍的原因及防治。     

食管胃吻合术后胃排空障碍探讨

目的 探讨食管胃吻合术后胃排空障碍的原因、合理的预防措施及其有效的治疗方法。方法 回顾性分析我科1982年1月～2002年4月问32例食管胃吻合术后胃排空障碍病人的临床资料。结果 32例胃排空障碍病人，食管胃颈部吻合24例，胸腔内吻合8例。占同期食管癌手术1378例的2．3％。25例功能性胃排空障碍病人中22例经保守治愈，1例死亡，死亡率为4．0％；7例机械性胃排空障碍病人经手术治愈。结论 胃排空障碍多见于高位食管胃吻合术后，以食管胃颈部吻合者多见，其发生与手术操作和术后处理不当有关，胃排空障碍多为功能性，少数为机械性。前者大多可经保守治疗而痊愈，后者则必须手术解除梗阻。本文还对食管癌术后胃排空障碍的定义、诊断与鉴别诊断进行了探讨。     

Pylorus resection in partial pancreaticoduodenectomy: impact on delayed gastric emptying

Background

Partial pancreaticoduodenectomy (PD) is complicated by postoperative delayed gastric emptying (DGE) in up to 45% of patients. The aim of this study was to evaluate the impact of pylorus resection on DGE following PD.

Methods

Forty PD patients underwent pylorus resection with complete stomach preservation (prPD). They were compared with a pair-matched group of PD patients with pylorus preservation (ppPD) in a 1:1 ratio (age, sex, histopathology). The objectives were operative parameters, DGE incidence, morbidity, and length of hospital stay.

Results

DGE incidence was significantly lower after prPD (15.0% vs 42.5%; P = .0066). Operative parameters and surgical morbidity (other than DGE) were not different (27.5% prPD vs 30.0% ppPD). There was a trend toward a shorter hospital stay in the prPD group.

Conclusions

Resection of the pylorus with stomach preservation significantly reduces the frequency of DGE after PD without showing any disadvantage when compared with standard ppPD. This finding could be of high relevance for the clinical practice in routine PD and should consequently be investigated in a large randomized multicenter trial to create further evidence.     

Comprehensive Analysis of Variables Affecting Delayed Gastric Emptying Following Pancreaticoduodenectomy

Introduction

Delayed gastric emptying (DGE) occurs commonly following pancreaticoduodenectomy (PD), and criteria for its clinical diagnosis have recently been standardized by an international consensus group. We evaluated 24 operative and peri-operative variables to assess which were independent risk factors for DGE development. Secondarily, we also examined DGE incidence over time and evaluated the consensus guidelines?? ability to diagnose DGE in patients with complicated post-operative courses.

Methods

A prospective, single-surgeon database of 235 patients undergoing PD at an academic tertiary center was retrospectively reviewed and DGE was assessed per published guidelines.

Results

DGE occurred in 42 patients overall (17.9?%), with incidence falling from 30.0 to 9.1?% during the study period. Post-operative abscess, pancreatic fistula formation, pulmonary comorbidity, and increased intraoperative blood loss were found to be independent risk factors (p?Conclusions Perturbation of the operative bed by a secondary complication seems to be the dominant risk for DGE development. The consensus guidelines for DGE diagnosis, while indispensable, may overestimate DGE incidence.     

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??Delayed gastric emptying after pancreaticoduodenectomy??A single center retrospective ananlysis of risk factors ZHAO Zhan-qiang??WANG Long-xin??JIANG Hong-chi??et al. Department of Pancreatic and Biliary Surgery??the First Affiliated Hospital of Harbin Medical University??Harbin 150001??China
Corresponding author??TAN Hong-tao??E-mail??tanhongtao2013@163.com
Abstract Objective To analyze the risk factors for delayed gastric emptying(DGE) after pancreaticoduodenectomy(PD). Methods The clinical data of patients underwent PD in the First Affiliated Hospital of Harbin Medical University from January 2012 to August 2015 were collected. The factors influencing the development of DGE following PD were statistically analyzed by univariable and multivariable logistic regression analysis. Results The incidence of DGE was 9.9%(31/312). Univariable analysis indicated upper abdominal surgery??preoperative anemia(Hb<90 g/L)??PPPD??no Braun enteroenterostomy??no postoperative ICU stay??pancreatic fistula??postoperative hyperglycemia were risk factors for DGE. Multivariable analysis using logistic regression revealed that upper abdominal surgery??preoperative anemia(Hb<90 g/L)??PPPD??no Braun enteroenterostomy??no postoperative ICU stay??pancreatic fistula??postoperative hyperglycemia were independent risk factors(OR=13.991??12.145??3.831??3.128??3.463??5.361??3.048) for DGE. PPPD and postoperative hyperglycemia were independent risk factors of Grade B and C DGE(OR=7.318, 3.975). Conclusion For patients underwent PD??we recommend to apply PPPD reasonably??apply additional Braun enteroenterostomy procedure??control postoperative hyperglycemia and establish a multidisciplinary team will reduce the incidence of DGE.     

胰十二指肠切除术后胃排空障碍危险因素分析

目的 分析胰十二指肠切除术（PD）后发生胃排空障碍（DGE）的危险因素。方法 回顾性分析哈尔滨医科大学附属第一医院2012年1月至2015年8月实施PD的312例病人的临床资料,对26项可能影响PD术后发生DGE的指标进行单因素及多因素Logistic回归分析。结果 312例病人中有31例（9.9%）术后发生DGE。单因素分析显示,上腹部手术史、术前血红蛋白<90 g/L、保留幽门胰十二指肠切除术（PPPD）、无空肠间布朗吻合、术后未入重症监护室（ICU）、胰瘘、术后高血糖是发生DGE的危险因素（P<0.05）。多因素Logistic回归分析显示,上腹部手术史、术前血红蛋白<90 g/L、PPPD、无空肠间布朗吻合、术后未入ICU、胰瘘、术后高血糖是DGE的独立危险因素,优势比（OR）值分别为13.991、12.145、3.831、3.128、3.463、5.361、3.048。PPPD及术后高血糖是B+C级DGE发生的独立危险因素, OR值分别为7.318、3.975。结论 术前严格把握PPPD适应证、附加空肠间布朗吻合、注重围手术期血糖控制、重视术后胰瘘的早期处理以及建立多学科综合治疗协作组（MDT）均有助于减少DGE的发生。     

Is delayed gastric emptying associated with pylorus ring preservation in patients undergoing pancreaticoduodenectomy?

Background/objectiveA high incidence of delayed gastric emptying (DGE) is observed in patients undergoing pylorus-preserving pancreaticoduodenectomy (PpPD). However, DGE incidence after pancreaticoduodenectomy varied because of heterogeneity in surgical techniques, number of surgeons, and DGE definition. This study aimed to evaluate the difference in the incidence of DGE following PpPD and pylorus-resecting pancreaticoduodenectomy (PrPD) and to analyze the risk factor of DGE by a single surgeon to determine whether pylorus preservation was the main factor of DGE.MethodsThis retrospective study included 115 patients who underwent PpPD (with pylorus ring preservation) and PrPD (without pylorus ring preservation) with laparotomy by a single surgeon at a tertiary center.ResultsThe overall incidence of DGE was 23.1%. For comparison, 20 patients (39.2%) in the PpPD group and 5 patients (8.8%) in the PrPD group had DGE, showing a significant difference (p < 0.001). On univariate analysis, hypertension, PpPD, operation time, intraoperative bleeding, packed red blood cell transfusion ≥500 mL, and clinically relevant postoperative pancreatic fistula were associated with DGE. Multivariate analysis identified pylorus preservation and clinically relevant postoperative pancreatic fistula as risk factors for DGE.ConclusionCompared with PpPD, PrPD significantly reduced the incidence of DGE.     

A comprehensive strategy for perioperative care of pancreaticoduodenectomy according to the risk stratification by pancreatic fistula and delayed gastric emptying

Background/ObjectivePancreaticoduodenectomy (PD) is highly invasive with unsatisfactory postoperative complication rates. Nutritional and fluid management after major surgery attracts much attention with regard to the reduction in severe postoperative complications. We retrospectively analyzed PD cases and proposed a novel strategy for perioperative fluid and nutritional therapy according to the risk stratification by pancreatic fistula (PF) and delayed gastric emptying (DGE).MethodsBetween 2003 and 2018, 140 patients underwent PD at our institute of which 134 patients were enrolled. We evaluated the clinicopathological factors affecting severe (≥10%) body weight loss (BWL), factors affecting the incidence of PF and intraabdominal complications (IAC), and factors related to DGE.ResultsMultivariate analysis indicated that male sex, severe PF, and DGE are significant risk factors for BWL ≥10%. PF and IAC were predominantly observed in male patients and those with non-pancreatic cancer. A fluid balance ≥6000 ml on postoperative day 2 was the sole risk factor for primary DGE. Secondary DGE significantly correlated with stomach preserving PD. Importantly, the average BWL was around 15% in grade B or C secondary DGE.ConclusionSevere postoperative complications resulted in significant BWL. Enteral feeding is unnecessary in cases with a hard pancreas and dilated pancreatic duct if appropriate perioperative fluid management is performed. Secondary DGE followed by PF or IAC is unavoidable to some extent, especially in the case of soft pancreas with a fine pancreatic duct. In such cases, enteral feeding with tube ileostomy should be considered, and stomach preserving PD is likely to be harmful.     

Delayed gastric emptying: the state of the highest level of evidence

Delayed gastric emptying (DGE) has been regarded as the most common complication after pancreaticoduodenectomy (PD). Opinions about DGE and its incidence widely vary between studies and between institutions. To crystallize current concepts of DGE we resorted to a systematic literature search of level I evidence. We found 16 randomized controlled trials (RCTs) where DGE was measured but only 4 of these trials tested methods to influence DGE (erythromycin, enteral nutrition, or antecolic duodenojejunostomy). Constant heterogeneity for the definition of DGE was observed; 13 RCTs used 6 different clinical definitions based on some form of NG tube requirement after surgery, and the 3 remaining RCTs used non-clinical objective criteria. The most common element of the clinical definitions was the need for an NG tube >10 postoperative days. Ten RCTs used some form of this definition and the reported mean incidence of DGE was 17% however the range varied from 5% to 57%. The trials with the least number of cases appeared to have the widest variation in DGE incidence. We concluded after this systematic review that the disparate opinions about DGE could not be mediated with the highest level of evidence. The studies were underpowered or compromised by a lack of homogeneity in definition and design. The incidence of DGE cannot be succinctly measured; therefore the variables that influence DGE are not understood. We can begin to make progress by using the same definition such as the recently published definition provided by the International Study Group of Pancreatic Surgery.     

Risk factors of pancreatic fistula and delayed gastric emptying after pancreaticoduodenectomy with pancreaticogastrostomy

BACKGROUND: Pancreatic fistula (PF) and delayed gastric emptying (DGE) are, respectively, the most frightening and most frequent complications after pancreaticoduodenectomy (PD). This study was undertaken to determine which independent factors influence the development of PF and DGE after PD. STUDY DESIGN: Between January 1996 and December 2005, 131 consecutive patients underwent a PD with pancreaticogastrostomy. A total of 22 items, entered prospectively, were examined with univariate and multivariate analysis. PF was defined as amylase-rich fluid collected by needle aspiration from an intraabdominal collection or from the drainage placed intraoperatively from day 3. DGE was defined as the need for nasogastric decompression beyond the 10(th) postoperative day. RESULTS: PF occurred in 14 patients (10.7%), with a mean length of hospital stay of 40.1+/-16.6 days. DGE occurred in 41 patients (31.3%), with a mean length of hospital stay of 35.5+/-13.6 days. PF and DGE increased postoperative length of stay. Multivariate analysis identified two independent factors for PF: heart disease as a risk factor and arterial hypertension as a protective factor. According to these two predictive factors, the observed rates of PF ranged from 4.1% to 66.6%. Age and early enteral feeding with nasojejunal tube were independent risk factors for DGE. DGE was statistically more frequent when surgical complications occurred or when an intraabdominal collection was present. CONCLUSIONS: Heart disease was a risk factor and arterial hypertension was a protective factor of PF. Age and early enteral feeding were independent risk factors for DGE. DGE is linked to the occurrence of other postoperative intraabdominal complications.     

Whipple术后功能性胃排空障碍诊治问题的探讨

目的：探讨经典Whipple术后功能性胃排空障碍发生的相关因素和诊治经验。方法：回顾性分析1983年9月至2001年8月所行226例经典Whipple手术。结果：226例中62例(27．4％)术后发生功能性胃排空障碍，均行保守治疗，胃蠕动平均恢复时间为2ld，最长为48d。结论：功能性胃排空障碍的发生与术前糖尿病、消化道梗阻、黄疸，术后胰瘘、腹腔感染有关。术后应用生长抑素不会增加发生胃排空障碍的危险性。     

Delayed Gastric Emptying after Pancreaticoduodenectomy: Influence of the Orthotopic Technique of Reconstruction and Intestinal Motilin Receptor Expression

Background

Delayed gastric emptying (DGE) is still a common postoperative complication after pancreaticoduodenectomy (PD). Because different reconstruction techniques after PD and the influence of motilin receptor expression are controversially discussed, the present study analyzed the influence of a total orthotopic reconstruction technique on DGE after PD.

Methods

Data from patients undergoing PD and reconstruction using a total orthotopic technique were reviewed, and correlations between DGE and clinico-pathological variables were analyzed. Motilin receptor expression was measured within the duodenum, jejunum, and terminal ileum.

Results

Three hundred seven patients received orthotopic reconstruction using a single jejunal loop. DGE grade B or C could be observed in 16.6% of the patients. DGE was significantly associated with the severity of a postoperative pancreatic fistula, the need for a reoperation, wound infections, and vascular complications. Furthermore, these parameters correlated significantly with the grade of DGE. The density of motilin receptor expression decreased significantly behind the duodenum in aboral direction.

Conclusions

The orthotopic reconstruction after PD is the shortest distance without resection of a jejunal segment, preserves the greatest length of jejunum and thus the highest density of motilin receptors, and should therefore be recommended to reduce the incidence of DGE after PD.