胰十二指肠切除术后胃瘫的治疗体会

目的探讨胰十二指肠切除术(pancreaticoduodenectomy,PD)后胃瘫(postoperative gastroparesis syn-drome,PGS)的病因、发生机制及治疗方法。方法回顾性分析7例胰十二指肠切除术后PGS的临床资料及诊疗过程。结果PGS多发生于胰十二指肠切除术后7～14 d,经分阶段营养支持、改善胃肠动力等保守治疗,PGS均在术后4周内消除。结论胰十二指肠切除术后PGS的病因复杂,采取保守支持治疗是治疗胰十二指肠切除术后PGS的有效手段,分阶段营养支持是治疗的重要措施,不宜采用手术治疗。     

Hospital readmission after pancreaticoduodenectomy

Data exist on the morbidity and mortality of patients undergoing pancreaticoduodenectomy (PD), but there are few reports about hospital readmissions after this procedure. Our aim was to evaluate the number of and reasons for readmission after PD and the factors influencing readmission. We reviewed the initial hospitalization and readmissions for 1643 patients undergoing PD compared patients requiring readmission to patients that did not require readmission. Twenty-six percent of patients were readmitted a total of 678 times after PD. Patients readmitted were younger than those not readmitted (61.8 versus 64.6 years, P<0.0001). Vessel resection, abscess formation, wound infection, postoperative percutaneous biliary stents, estimated blood loss >1000 ml, and age ⩽65 years were independently associated with readmission. The length of stay for all patients decreased over time, from 10.5 days in 1996 to 7 days in 2003. The percentage of patients being readmitted also decreased from 33% in 1996 to 20% (P=0.004) in 2003. The readmission rate after PD was 26%. Younger age, blood loss, postoperative complications, and vessel resection were independent risk factors for readmission. The early hospital readmission rate has not increased in association with a decreased LOS, supporting the idea that reduction in LOS did not lead to increased readmission rates. Presented at the Forty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, Los Angeles, California, May 22, 2006.     

A simpler and more reliable technique of pancreatojejunal anastomosis

We herein describe the technical aspects of our method for end-to-side style pancreatojejunal anastomosis which we have been using when performing the Whipple procedure without any anastomotic complications. The method is simple and can be applied wherever an end-to-side pancreatojejunal anastomosis is required. It consists of three steps: First, a drainage tube is inserted into the pancreatic duct. Second, a direct anastomosis between the pancreatic duct and the mucosal layer of the jejunal loop is performed. The third step, which is the unique aspect of our method, is an approximation of the jejunal wall and the pancreatic stump by a one-layer suture technique that allows us not only to reduce the number of sutures but also to eliminate some of the sophisticated manipulations required by other methods. The results of our clinical experience have indicated that the present method may be comparable in terms of technical reliability to other existing methods.     

Pancreaticobiliary drainage using Y tube in pancreaticoduodenectomy

Decompression of the gastrointestinal tract and drainage of the pancreatic juice and bile are important procedures for the prevention of postoperative complications following pancreaticoduodenectomy. We have developed a new Y-silicone tube which enables the drainage of both the pancreatic juice and the bile through the same transhepatic route. This Y-tube, which we have called a retrograde transhepatic pancreaticobiliary drainage (RTPBD) tube, was employed for duodenopancreatectomized patients. While the Y-tubes were in situ, we did not experience any complications such as hemobilia or ascending cholangitis. The Y-tube is safe and efficient for drainage and can be employed for any patients undergoing pancreaticoduodenectomy.     

胰头癌根治性胰十二指肠切除术若干问题的思考

作者在为胰头癌施行根治性胰十二指肠切除术的过程中,依据实践,结合文献复习,针对目前的某些热点问题,提出应避免主动性姑息性胰十二指肠切除术.提倡淋巴结廓清至少应达二站淋巴结,建议将肝十二指肠韧带骨骼化清扫和腹膜后组织切除作为根治性胰十二指肠切除术的常规手术步骤,无论有无证据支持第13组淋巴结(胰头后淋巴结)已发生转移,均应对可切除胰头癌进行限制性腹膜后组织切除.显露肠系膜上动脉并辨清钩突下缘和左侧缘与动脉的关系,是保证钩突切除完整性的技术要点.术前评估血管成像等影像学资料,可提高主动性联合血管切除的手术比例.胰肠吻合方式的选择,手术者的经验非常重要,从自己熟悉和熟练的二三种方法中选择最适合患者的方式,作者更偏向于胰肠端侧双层套入吻合法.并认为能量外科技术平台(电外科工作站)应用应慎重,仍须积累更多的经验再做评价.

Abstract：

According our practice of raical pancreaticoduodenectomy for pancretic head carcinoma and combined with these reviews, we suggested the active and palliative pancreaticoduodenectomy should be aviod. Skeletonization of hepatoduodenal ligament and the retroperitoneal resection should be the routine procedure in pancreticoduodenectomy, and at least invovle two regional lymph nodes. In addition, regardless of the metastase of No 13 lymph node, ristricted retroperitoneal resection for resectable pancretic carcinoma was needed. Exposured the superior mesenteric artery and distinguished inferior of uncinate process of pancrease with the artery, were the key point of the uncinate process of pancrease resection. Preoperative evaluation of angiography and other images, the ratio of activeness and combination with vessel resection would be improved. The style of pancreaticojejunostomy could be selected by the experience of the operator, we are apt to the double-deck invaginated pancreaticojejunostomy. Additionally, utilization of the electronic surgical workstation, should be careful and also need to accumulate more experience.     

Prediction of post-operative pancreatic fistula in pancreaticoduodenectomy patients using pre-operative MRI: a pilot study

Background:

Post-operative pancreatic fistula (POPF) is one of the most fearful complications which may occur after pancreaticoduodenectomy (PD). The methods used to predict POPF pre-operatively have not been studied in great detail. We analyzed correlation between various parameters related to PD including pre-operative magnetic resonance imaging (MRI) signal intensity (SI), pathology of pancreatic fibrosis and occurrence rates of POPF, and verified that MRI SI results could be the determining values for pre-operative prediction of POPF.

Methods:

From January 2005 to August 2006, we retrospectively examined 43 cases of PDs by reviewing abdominal MRI findings, degree of fibrosis of remnant pancreatic stump, and other surgery-related parameters.

Results:

POPF encountered in PD were 11 cases (25.6%). Operation time and degree of fibrosis of remnant pancreatic cut surface were related to POPF (P= 0.030, P= 0.010). The pancreas–liver SI ratio (PLSI) between fistula group and no fistula group was −0.0009 ± 0.2 and −0.1297 ± 0.2, respectively (P= 0.0004). The pancreas–spleen SI ratio (PSSI) in each group was 0.423 ± 0.25 and 0.288 ± 0.32, respectively (P= 0.014). Using quantitative analysis, the SI ratios were 1.27 and 0.66 in each group (P= 0.013).

Conclusions:

When analyzing the results of POPF in 43 patients who underwent PD, PLSI, PSSI and qualitative analysis, fistula group differed significantly from no fistula group. Using these results, it will be helpful for us to predict the occurrence of POPF pre-operatively using MRI in PD patients.     

Resection of the intrapancreatic bile duct preserving the pancreas

Benign neoplasms of the distal bile duct are rare, but pose a therapeutic challenge. Usually, these lesions are resected by means of ampullectomy if located in close proximity to the ampulla of Vateri or by partial pancreaticoduodenectomy if located intrapancreatic and distant from the ampulla. Here, we present a case of an intrapancreatic benign neuroendocrine tumor that was resected by performing a pancreas-preserving distal bile duct resection. First, a duodenotomy was carried out and a probe was inserted into the pancreatic duct to avoid inadvertent injury. Subsequently, the bile duct was divided proximal the lesion and dissected towards the ampulla. Pancreatic parenchyma was dissected dorsally and closed using absorbable interrupted sutures. The duodenal incision was closed, and reconstruction was performed by an end-to-side hepaticojejunostomy and a Roux-Y jejunojejunostomy. The postoperative course of the patient was uneventful. In conclusion, pancreas-preserving distal bile duct resection might be an option for intrapancreatic benign lesions of the distal bile duct that would otherwise require a partial pancreaticoduodenectomy.     

胰十二指肠切除术后胰肠和胰胃吻合方式胃管的观察与护理

[目的]总结胰十二指肠切除术后胰肠和胰胃吻合方式胃管的观察与护理。[方法]回顾性分析110例胰十二指肠切除术病人临床资料,分别观察胰肠或胰胃两种吻合方式胃管留置的部位、留置时间、堵管脱管处理、引流液的量和性质等。[结果]110例胰十二指肠切除术中胰胃吻合31例,胰肠吻合79例,平均留置胃管6d,计划拔管102例,因堵管拔管2例,病人自行拔管6例,重置胃管6例;胰胃吻合术胃管平均留置4d或5d,胰肠吻合术后平均6d或7d,1例病人出现胃瘫。[结论]加强胰十二指肠切除术后胰肠和胰胃吻合方式胃管的观察与护理是病人顺利康复的保证．     

胰十二指肠切除术后住院时间影响因素分析-回顾性研究

Background. Postoperative hospital stay after pancreaticoduodenectomy (PD) was relatively longer than other gastrointestinal operations, The aim of current study was to investigate the risk factors of postoperative hospital stay after PD. Methods. Patients who were performed PD in Cancer Hospital Chinese Academy of Medical Sciences (CHCAMS) between December 2008 and November 2012 were selected for the retrospective study. The clinical and pathological data was collected and analyzed. The primary outcome was postoperative hospital stay. Normal discharge or recovery was defined as postoperative hospital stay no more than 10 days, otherwise it was defined as delayed discharge or recovery (including hospital death). Results. Finally, 152 patients were enrolled in present study. Postoperative hospital stay was 19.7±7.7 (7-57 d). 67 of 152 patients were normal discharge, and 85 of 152 patients were delayed discharge. The overall morbidity of complications was 62.5% (95/152), and the mortality rate was 3.29% (5/152). Multiple factors analysis showed that complication morbidity (adjusted OR=10.40, 95%CI=3.58-30.22), age (adjusted OR=4.09, 95%CI=1.16-14.39), BMI (body mass index) (adjusted OR=4.40, 95%CI=1.19-16.23), surgical procedure (adjusted OR=26.14, 95%CI=4.94-153.19), blood transfusion (adjusted OR=7.68, 95%CI=2.09-28.27) and fluid input (adjusted OR=3.47, 95%CI=1.24-11.57) were significantly associated with delayed discharge. Conclusions. Postoperative complications affects the postoperative hospital discharge. Furthermore, age, BMI, transfused red blood, surgical procedure and input might prolong LOS (length of hospital stay). Studies with more patients were needed in future.     

Risk factors associated with postoperative hospital stay after pancreaticoduodenectomy: a retrospective study

Background Postoperative hospital stay after pancreaticoduodenectomy （PD） is relatively longer than after other gastrointestinal operations.The aim of the current study was to investigate the risk factors associated with prolonged hospital stay after PD.Methods Patients who had PD at the Cancer Hospital of Chinese Academy of Medical Sciences between December 2008 and November 2012 were selected for this retrospective study.Clinical and pathological data were collected and analyzed.The primary outcome was postoperative length of stay.Normal discharge or recovery was defined as a postoperative hospital stay of no more than 10 days; otherwise it was defined as delayed discharge or recovery （including hospital death）.Results Atotal of 152 patients were enrolled in the present study.Postoperative hospital stay was （19.7±7.7） days （range 7-57）.Of the 152 patients,67 were discharged within the normal time and 85 had delayed discharge.Postoperative complications occurred in 62.5% （95/152）,and the mortality rate was 3.29% （5/152）.Multiple regression analysis showed that delayed discharge was significantly associated with postoperative complications （adjusted odds ratio （OR） 10.40,95% confidence interval （CI） 3.58-30.22）,age （adjusted OR 4.09,95% CI 1.16-14.39）,body mass index （BMI） （adjusted OR 4.40,95% CI 1.19-16.23）,surgical procedure （adjusted OR 26.14,95% CI 4.94-153.19）,blood transfusion （adjusted OR 7.68,95% Cl 2.09-28.27）,and fluid input （adjusted OR 3.47,95% CI 1.24-11.57）.Conclusions Postoperative complications increase the time to postoperative hospital discharge.The length of hospital stay after PD is also associated with age,BMI,blood transfusion,surgical procedure,and fluid input.Further studies with more patients are needed in future.