胰腺损伤的诊断与手术选择

目的　探讨胰腺损伤的诊断及合理的手术方式。方法　对 2 3例胰腺损伤患者的临床资料进行回顾性分析。结果　术前确诊 5例 ,其余 18例术中确诊。行单纯外引流 8例 ,胰头侧缝合加胰尾脾切除 6例 ,胰头侧缝合 ,胰体尾侧断端与空肠吻合 3例 ,胰腺次全切除 1例 ,十二指肠憩室化 5例。发生胰瘘 3例 ,腹腔内出血 1例 ,腹腔内感染 1例 ,胰腺内分泌功能低下 1例 ,死亡 5例。结论　术前确诊胰腺损伤较为困难 ,多需经术中探查确诊。根据胰腺损伤的部位和损伤程度以及伤者的全身状态 ,选择恰当的手术方式 ,可有效地减少其并发症 ,降低死亡率。     

胰瘘的预防

预防胰瘘是治疗胰腺肿瘤的重要课题。本文介绍了有关药物在预防胰瘘方面的应用 ;特别着重阐述了手术方法与胰瘘的关系 ,如胰腺空肠吻合、胰腺胃吻合、胰管支架和引流等     

胰肠吻合方法改进与应用的临床研究（附38例报告）

目的探讨胰十二指肠切除术（pancreaticoduodenectomy,PD）胰肠吻合的一种新方法,以及预防术后胰空肠吻合口瘘的应用价值。方法自2009年6月-2013年8月共收治胰十二指肠切除术患者38例,胰肠吻合均采用空肠粘膜剥离双荷包缝合套扎＋吻合cr胰上下缘缝扎法,回顾性分析此吻合术式的可行性、疗效及并发症。结果本组38例患者手术及胰肠吻合（采用“空肠粘膜剥离双荷包缝合套扎法”）,均取得成功,胰漏2例,发生率为5．26％（2／38）,其中胰头癌1例,胆管癌1例,分别发生于术后第7和第10天,每日引流液量少,约20～100mL,经用生长抑素（善得定或施他宁等）药物3周后治愈。12～18天拆线,其他患者恢复良好,未发生腹腔感染、胆瘘、肠瘘及大出血等严重并发症。无死亡病例。结论空肠粘膜剥离双荷包缝合套扎＋吻合口胰上下缘缝扎法,在胰肠吻合中可行性强,方法简单,疗效可靠,胰瘘发生率低,有明显的临床优势。     

不同胰－空肠吻合方式对胰十二指肠切除术后胰瘘发生的影响

目的：研究不同胰－空肠吻合方式对胰十二指肠切除术后胰瘘发生的影响。方法选择行胰十二指肠切除术的80例患者作为研究对象,随机分为两组,每组40例。观察组行改良胰空肠端端吻合,对照组行传统套入吻合。观察两组手术一般情况和术后胰瘘发生率。结果观察组治疗后胰瘘发生率为12．5％,显著低于对照组的42．5％,差异具有统计学意义（P＜0．05）。观察组术中出血量和住院时间分别为（362．25±58．76）mL和（18．84±4．52）d,显著低于对照组的（402．73±68．82）mL和（23．76±7．63）d,差异具有统计学意义（P＜0．05）。结论改良后胰肠端端吻合可显著降低胰十二指肠切除术后胰瘘发生率,且术中出血量较少,住院时间较短。     

瘘管空肠Rous－y吻合治疗胰外瘘

瘘管空肠Ｒｏｕｓ－ｙ吻合治疗胰外瘘杨学伟，姜学海，碧波，李秋波，李馥，苏君志，张宗文哈尔滨医科大学第二医院１５００８６哈尔滨市２４２医院１５００６６双城市人民医院１５０１００自１９８５年～１９９４年对１１例胰外疾病人采用压管空肠Ｒｏｕｘ—ｙ吻合术治疗...     

胰腺颈部断裂伤的手术处理

目的：总结与探讨胰腺颈部断裂伤的手术处理。方法：回顾性分析我院从1995年1月至2000年12月收治的17例胰腺断裂伤中13例胰腺颈部断裂伤的手术处理情况,其中2例合并胰头部严重挫伤和十二指肠损伤,行胰十二指肠切除术;4例单纯胰腺断裂或合并轻度胰腺挫伤,行胰头侧断端缝闭,远端胰空肠吻合术;7例合并胰体尾挫伤或脾破裂,行胰头侧断端缝加胰体尾切除及脾切除术,结果：12例治愈,1例死亡为右髋脱位行手法复位时出现麻醉意外。7例发生胰瘘,腹腔感染等并发症,结论：胰腺断裂伤以胰腺颈部为多,手术方法应根据胰腺损伤的情况来选择不同术式。     

胰腺损伤术后胰漏16例的原因与治疗

本院近10年收治胰腺损伤术后胰漏16例，现对其发生原因及治疗进行分析总结。1临床资料1．1一般情况本组男12例，女4例，年龄9～45岁，均为腹部闭合伤术中确诊为胰腺损伤，受伤时间2～48h。其中8例为胰体横断伤（主胰管损伤型），行远端空肠R0llX－y吻合术十近端胰腺缝合本；3例胰腺裂伤（裂伤型），5例胰腺广泛挫伤（挫伤型），均行胰腺单纯引流术。发生胰漏时间为本后5～10d。胰漏量200～1500ml／d。16例中附加空肠造口术4例。1．2胰漏的治疗及效果4例经全胃肠外营养（TPN）治疗2周后，行空肠造口管供应营养；12例经TPN治疗2周～2个月…     

胰腺损伤的外科分级治疗与胰漏并发症的防治

目的总结外伤性胰腺损伤后的外科分级治疗与并发胰漏的临床防治经验。方法回顾性分析胰腺损伤的外科住院病人59例的临床资料。结果59例创伤病人均经手术证实有不同程度的胰腺损伤，其中Ⅰ-Ⅱ级16例，行引汉术10例；Ⅲ～Ⅳ级39例，清创引流术8例，胰腺节段性切除、近端封闭、远端与空肠行Roux-en-Y吻合术28例，胰体尾切除术3例，因手术后胰漏并腹腔感染死亡1例，术后早期MODS死亡例，Ⅴ级4例，2例行胰头切除、十二指肠修补引流／转流、远端与空肠行Roux-an-Y吻合术；2例因伤重不治死亡。手术后出现引流液持续高浓度淀粉酶者（胰漏）12例，内科保守治疗近期治愈6例，胰腺假性囊肿形成4例，经内引流术治愈，死亡2例。结论胰腺损伤病人，应积极采取早期手术治疗，常规使用胰腺分泌抑制剂和简易三套管持续低负压吸引法引流，对预防和治疗胰漏有良好效果。     

胰十二指肠切除Plenk定向引流术15例

胰十二指肠切除术后，消化道重建方式较多，但术后吻合口瘘及胆汁返流性胃炎仍是棘手的问题[1,2]。我们采用Plenk定向引流术行消化道重建15例，效果满意。1临床资料1．1一般情况本组15例，男9例，女6例，平均年龄46．5岁。胰头癌11例，壶腹周围癌4例。1．2手术方法手术适应证：同胰十二指肠切除术。完成胰十二指肠切除术后，游离空肠，将空肠目结肠后上提，行空肠胰腺端端吻合．胰管内放置细枝胶管经空肠壁引出体外，距胰肠吻合口8～10cm处行胆管空肠端侧吻合术。再距空肠胆管吻合口25～30cm处行胃空肠端侧吻合术，在胃肠吻合口下方6cm处行…     

胰腺实性假乳头状瘤的诊断和外科治疗

目的 探讨胰腺实性假乳头状瘤(SPT)的诊断和治疗经验.方法 对2000年3月～2006年5月收治的21例SPT病例进行回顾性研究.结果 病例中,男2例,女19例,年龄25.6±13.4岁(9～52岁),肿瘤局部切除7例(其中1例为腹腔镜局部切除),减瘤体负荷手术2例,肿瘤扩大切除12例(包括Whipple手术2例,保留十二指肠的胰头切除1例,单纯胰体尾部切除3例,胰腺体尾部切除加脾脏切除5例,胰腺中段切除加胰尾空肠吻合术1例).术后胰瘘4例,切口裂开1例.对21例患者进行随访,平均随访时间24.4月,无死亡病例.结论 SPT是一种少见的低度恶性胰腺肿瘤,多发于青年女性,外科治疗后预后良好.     

3种胃肠重建方式对2型糖尿病降糖效果的meta分析

目的 对比毕Ⅰ式、毕Ⅱ式、Roux-en-y胃肠重建手术对2型糖尿病降糖效果.方法 检索中国生物医学文献数据库、中文生物医学期刊文献数据库、中国知网、维普、万方、MEDLINE,1994-01至2013-10发表的不同消化道重建手术对2型糖尿病疗效对比的文献,筛选、提取、质量评价,用RevMan5.0软件进行meta分析.结果 共有7篇文献入选,病例总数378例,毕Ⅰ式74例,毕Ⅱ式184例,Roux-en-y120例.meta分析结果：（1）毕Ⅰ式、毕Ⅱ式以及Roux-en-y术后3个月血糖水平均明显低于术前;（2）毕Ⅰ式与毕Ⅱ式术后3个月血糖水平无差别;（3）毕Ⅰ式术后3个月血糖水平明显高于Roux-en-y;（4）毕Ⅱ式与Roux-en-y术后3个月血糖水平无差别;（5）毕Ⅰ式术后6个月血糖水平明显高于毕Ⅱ式和Roux-en-y;（6）毕Ⅱ式与Roux-en-y相比术后6个月血糖水平无差别;（7）毕Ⅰ式术前与术后6个月血糖水平无差别;（8）毕Ⅱ式和Roux-en-y术后6个月血糖水平均明显低于术前;（9）毕Ⅱ式与Roux-en-y术后6个月糖尿病治疗有效率无差别.结论 毕Ⅱ式和Roux-en-y对2型糖尿病的治疗均有效.     

假性胰腺囊肿手术时机与术式选择

目的总结假性胰腺囊肿外科手术治疗经验。方法对我院行内引流手术治疗的假性胰腺囊肿39例进行回顾性分析。结果一次性手术治愈37例,二次手术治愈1例,发生囊壁坏死、吻合口瘘及结肠穿孔,再次手术囊肿外引流、结肠造口1例。随访3个月至13年,术后3个月死亡1例,为二次手术囊肿外引流、结肠造口者,1例因糖尿病死亡,反复发作的慢性胰腺炎4例,其余33例无特殊异常。结论对假性胰腺囊肿手术治疗是主要方法,手术时机和手术方式的选择是手术成败的关键,应根据患者病情及囊肿情况,结合影像学等方面综合考虑、评价,以力求达到较好的治疗效果,较小的风险和并发症。     

External transluminal drainage of the pancreatic duct due to fistula caused by post biopsy pancreatic necrosis

BACKGROUND: Pancreatic fistulas are not frequent after the needle biopsy of the pancreatic head. The aim was to present a patient with this type of fistula who was managed using the surgical method never previously applied in our surgical practice. CASE REPORT: In our patient, pancreatic fistula appeared at the site of the needle biopsies due to the development of the necrosis. Since the conservative treatment with octreotide and the total parenteral nutrition were without result, we turned to the surgical treatment by placing a silicone prosthesis along the pancreatic duct into the duodenum, next through the Roux-en-Y flexure to provide the external drainage of a pancreatic juice. Postoperatively, applying the conservative treatment, pancreatic fistula disappeared, and a silicone prosthesis was removed three weeks later. CONCLUSION: The described surgical procedure can be successful i managing fistulas which occur after the pancreatic necrosis.     

胰十二指肠切除术13例报告

目的：评价改良的胰十二指肠切除术效果，减少并发症，降低死亡率。方法：回顾性分析1995－05－2000－05，作者采用改良的胰十二指肠切除术治疗胰腺癌等恶性肿瘤共13例，观察手术效果。结果：无胰瘘、胆瘘及胃肠吻合口瘘发生，无手术死亡，随访生存11－56个月，效果较好，结论：手术方法正确，吻合技术操作可靠，是减少并发症，降低死亡率的关键。     

A Minimally Invasive Approach for Postoperative Pancreatic Fistula

Pancreas fistula is a well-known and severe complication of pancreaticoduodenectomy. It is difficult to control with conservative therapy, inducing further complications and severe morbidity. Until now, re-operation has been the only way to resolve pancreatic fistula causing complete dehiscence of the pancreatic-enteric anastomosis (complete pancreatic fistula). Percutaneous transgastric fistula drainage is one of the treatments for pancreatic fistula. This procedure allows both pancreas juice drainage and anastomosis re-construction at the same time. This is effective and minimally invasive but difficult to adapt to a long or complicated fistula. In particular, dilatation of the main pancreatic duct is indispensable. This paper reports the successful resolution of a postoperative pancreatic fistula by a two-way-approach percutaneous transgastric fistula drainage procedure. Using a snare catheter from the fistula and a flexible guidewire from the transgastric puncture needle, it can be performed either with or without main pancreatic duct dilatation.     

Percutaneous catheter drainage of external fistulas of the pancreatic ducts

The aim of this study was to describe catheterization techniques and report the results of percutaneous drainage of external pancreatic fistulas. Twenty patients with external pancreatic fistulas in whom medical therapy had failed, were referred for radiologically guided treatment. Fifteen patients had postoperative and five primary fistulas. Sixteen were high-output fistulas (H-OF) and four were low-output fistulas (L-OF). All patients were treated percutaneously. Percutaneous catheter drainage was successful in 16 of 20 patients (80 %). The fistula healed in 13 of 15 postoperative cases (86.6 %) and in three of five primary fistulas (60 %). Treatment was successful in 14 of 16 patients (87.5 %) with H-OF and in two of four patients with L-OF. Percutaneous catheterization of the pancreatic ducts was successful in eight of 20 patients (40 %); seven of these patients were cured. Catheterization was not achieved in 12 patients and treatment failed in three (25 %). Conservative treatment of external pancreatic fistulas with percutaneous catheter-directed drainage is thus a reasonable alternative to surgery, particularly in patients with H-OF. Received: 15 July 1997; Revision received 4 September 1997; Accepted 5 September 1997     

CT features of pancreatic fistula after pancreaticoduodenectomy

OBJECTIVE: Our objective was to establish the CT features that are indicative of pancreatic fistula after pancreaticoduodenectomy. CONCLUSION: A fluid collection seen on CT around the pancreaticojejunostomy site and in the pancreatic bed may be caused by pancreatic fistula in patients who have undergone pancreaticoduodenectomy. CT depiction of air bubbles in the fluid at these sites may strongly suggest the diagnosis of pancreatic fistula.     

损伤控制剖腹术治疗严重胰腺损伤19例

目的 总结损伤控制剖腹术（damage control laparotomy，DCL）治疗严重胰腺损伤的经验。方法回顾性分析采用DCL治疗的19例严重胰腺损伤患者的手术方式选择和后续治疗情况。结果6例行快速止血、清创及引流（32％），3例行改良Cogbill手术（16％），10例行消化道未重建的胰十二指肠切除（53％）。SICU复苏后，所有患者均接受再次确定性手术。死亡2例（11％），死亡原因与手术无关；治愈17例（89％），术后出现胰瘘2例（11％），经保守治疗痊愈。结论符合DCL指征的严重胰腺损伤的患者，应根据不同损伤胰腺部位和程度，积极选用适宜的方式，分次手术治疗。     

Transvenous embolization and stent placement for an internal iliac arteriovenous fistula with central iliac vein occlusion

The authors present a case of traumatic arteriovenous fistula of the internal iliac vessels treated with attempted surgical ligation of the common iliac artery and external iliac artery. The fistula persisted after the operation, and because the patient received no further treatment for the following 6 years, a venous outflow occlusion also developed as a result of high-flow angiopathy. Because the arterial route was eliminated at previous surgery, the fistula and venous occlusion were percutaneously treated via a transvenous approach.