胰体尾切除术后胰瘘防治研究进展

胰体尾切除术(DP)较胰十二指肠切除术后胰瘘发生率更高,胰瘘的有效防治是保障胰体尾切除术后安全的关键。诸多危险因素可以导致DP术后胰瘘的发生,具体划分为非技术因素和技术因素两个部分。但目前关于DP术后胰瘘危险因素的分析多为回顾性研究,且研究结果差异性较大,目前尚无统一的DP术后胰瘘的危险因素或预测模型。胰瘘的预防和治疗一直是胰腺外科关注的热点和焦点。预防DP术后胰瘘包括诸多措施,如胰腺断面处理方式及主胰管结扎等,胰瘘发生后的基础治疗主要有抑酸,抑酶,抗炎等。DP术后如何减少胰瘘,仍然是一个挑战。     

远端胰腺切除术后胰瘘发生的危险因素分析

目的:探讨影响远端胰腺切除术后胰瘘发生的相关性因素。方法:回顾2010年2月—2016年5月所实施的100例远端胰腺切除术患者临床资料,对相关因素进行单因素与多因素分析。结果:100例患者中32例(32%)发生术后胰瘘,包括A级胰瘘(无临床意义)18例(18%),有临床意义的胰瘘14例(14%),其中B级胰瘘8例,C级胰瘘6例。单因素分析中,高体质量指数(≥25kg/m~2)与术后胰瘘发生有关(χ~2=4.128,P=0.042),但与有临床意义的胰瘘发生无关(χ~2=1.545,P=0.214),软胰腺质地与胰瘘及有临床意义的胰瘘发生均明显有关(χ~2=4.569,P=0.033;χ~2=11.374,P=0.001)。多因素分析中软胰腺质地是胰瘘及有临床意义的胰瘘发生的唯一独立危险因素(OR=2.476,P=0.043;OR=8.012,P=0.003)。结论:胰腺质地是远端胰腺切除术后胰瘘发生的重要影响因素,对于胰腺质地软者,应采取积极防治措施。     

胰腺远端切除术后残端不同处理方法对术后胰瘘的影响

[摘要]目的探讨胰腺远端切除术中,胰腺残端不同处理方法与术后胰瘘的关系。方法回顾性分析我院2009年3月至2012年12月期间,行胰腺远端切除术的患者临床资料46例,其中胰腺残端行连续锁边缝合10例（A组）;残端行主胰管结扎＋连续鱼嘴状缝合16例（B组）;残端断面局部行“8”字缝合＋连续鱼嘴状缝合20例（C组）。比较上述3种方式对术后并发胰瘘的影响并行统计学分析。结果术后发生胰瘘病例数,A组6例（60％）,B组2例（12．5％）,C组3例（15％）。其中,A组与B组、A组与C组比较有统计学差异（P〈0．05）;B组和C组比较无统计学差异（P〉0．05）。结论胰腺远端切除术中,胰腺残端行主胰管结扎＋连续鱼嘴状缝合,或者行残端断面局部“8”字缝合＋鱼嘴状连续缝合,是防止术后胰瘘安全有效的方法。     

超声刀联合大网膜包裹预防胰腺远端切除术后胰瘘的实验研究

目的探讨超声刀联合大网膜包裹胰腺残端预防胰腺远端切除术后胰瘘的效果。方法将40只实验用猪随机分为2组:研究组和对照组。对照组(n=20):超声刀横断胰腺后用4-0 Prolene线"U"形交锁缝合胰腺残端,主胰管单独缝扎,将带蒂大网膜包裹胰腺残端一圈并紧贴胰腺表面;研究组(n=20):超声刀横断胰腺,用4-0 Prolene线缝扎出血点及主胰管,将带蒂大网膜包裹胰腺残端一圈并紧贴胰腺表面。术后观察胰瘘及腹腔出血情况,并于术后29 d将发生胰瘘动物处死,进行尸检,观察胰腺残端愈合情况,并将胰腺切除后行病理检查。结果 40只猪均顺利完成手术,无1只死亡,平均手术时间为96.8 min(71～132 min)。(1)并发症:对照组20只中7只(35%)出现胰瘘,平均持续时间为15.4 d(9～28 d),3例胰瘘持续时间达到4周;研究组20只中有1只(5%)出现胰瘘,术后1周痊愈,为生化瘘,2组胰瘘发生率差异有统计学意义(P=0.04);2组猪均无术后腹腔出血。(2)尸检及病理组织学检查:研究组发生胰瘘的胰腺残端组织愈合良好,对照组发生胰瘘的胰腺残端尸检可见胰腺组织缺血坏死,病理检查可见胰腺...     

远端胰腺切除术后发生胰瘘的危险因素分析

目的 探讨远端胰腺切除术（distal pancreatectomy,DP）后发生术后胰瘘（postoperative pancreatic fistula,POPF）的危险因素。方法 回顾性分析2014年1月至2018年10月在西南医科大学附属医院肝 胆外科接受诊治的81例胰腺远端肿瘤性病变行DP的临床资料,对可能导致POPF的相关因素进行单因素 分析和Logistic回归分析。结果 81例患者DP术后发生生化漏13例,B级胰瘘9例,C级胰瘘3例。单因 素分析显示POPF可能与手术时间、术中失血量及内脏脂肪面积有关（P＜0.05）;Logistic回归分析显示, 手术时间（OR 1.060,95%CI 1.021～1.102,P=0.003）及内脏脂肪面积（OR 1.116,95%CI 1.046～1.190, P=0.001）是 POPF的独立危险因素。结论 手术时间和内脏脂肪面积是DP术后发生临床胰瘘的独立危险 因素。对内脏脂肪面积较大的患者需采取积极预防措施。     

胰腺残端处理方式对胰体尾切除术后胰瘘的影响

目的探讨预防胰体尾切除术后胰瘘的胰腺残端处理方式。方法回顾性分析我院1996至2008年186例因胰腺或胰外病变行胰体尾切除术患者的临床资料,胰腺残端处理方法分别为：结扎主胰管、残端结扎、间断缝合、Prolene线连续缝合、胰腺空肠吻合及闭合器钉合六种方式,比较上述六种方式对术后胰瘘的影响并行统计学分析。结果186例患者中围手术期死亡5例（2．7％）,术后总并发症发生率34．9％（65／186）,胰瘘发生率21．0％（39／186）。8例胰腺残端结扎术后4例发生胰瘘,11例胰腺空肠吻合患者无胰瘘发生;17例Endo—GIA关闭胰腺残端者有胰瘘4例;结扎主胰管组、连续缝合组、间断缝合组胰瘘发生率分别为13．9％（5／36）、15．6％（10／64）、32．0％（16／50）,前两者与后者差别具有统计学意义（P〈0．05）。结论胰体尾切除术中残端结扎和间断缝合容易发生胰瘘,选择性缝扎主胰管或Prolene线连续缝合能降低胰瘘发生率,尤其后者更简单易行。近端胰管梗阻患者可选用胰肠吻合预防胰瘘;闭合器钉和胰腺残端要根据胰腺大小和质地选择性使用。     

胰腺残端胰腺腺泡细胞数量在PD术后胰瘘的应用价值研究

目的评估术后胰瘘与胰腺残端腺泡细胞数量的相关性,并评估其是否可以作为胰瘘的危险因素。方法回顾性分析2015年4月～2018年4月期间我院69例行PD手术的患者。根据术后有无发生胰瘘分为胰瘘组和非胰瘘组,对比分析两组患者的临床数据以及实验室参数,运用Spearman相关性检验分析胰腺残端腺泡细胞数量和引流液淀粉酶含量之间的相关性,使用logistical回归分析确定术后胰瘘的独立危险因素,单变量分析中P0.05的变量纳入到多变量分析中。结果最终胰瘘组20例,无胰瘘组49例。胰瘘组的软胰腺的比例较非胰瘘组显著升高(45.0%和10.2%,P0.001),并且术后第3天引流液中淀粉酶含量和住院时间均显著高于非胰瘘组(P0.001)。此外,胰瘘组的胰腺残端腺泡细胞计数显著高于非胰瘘组(898.9±161.8和443.1±127.6,P0.001)。胰腺残端胰腺腺泡细胞的数量与引流液中淀粉酶含量呈正相关性(r=0.991,P0.001)。多因素分析结果显示显示胰腺质地软(OR:5.060,95%Cl:1.252～7.798,P0.001),较高的胰腺残端胰腺腺泡细胞计数(OR:2.662,95%Cl:1.132～3.947,P0.001)是PD后发生胰瘘的独立危险因素。结论胰腺质地和胰腺残端的腺泡细胞计数是PD术后出现胰瘘的独立危险因素。     

预防胰腺切除术后胰瘘的研究进展

不同形式的胰腺切除术在临床治疗中具有重要作用。胰十二指肠切除术（ＰＤ）是根治胰头壶腹周围癌、十二指肠癌、进展期胃癌、结肠癌、胆囊癌等疾病的有效治疗措施。而胰腺切缘或吻合口瘘是胰腺切除术、尤其是ＰＤ术后的最常见并发症之一,可直接影响病人的预后及术后生存...     

胰十二指肠切除术后胰瘘发生的危险因素分析

目的:探讨胰十二指肠切除术(PD)后导致胰瘘(PF)发生的危险因素,为临床上PD后PF的防治提供参考。方法:回顾2010年1月—2014年03月期间新疆医科大学附属肿瘤医院收治的122例行PD术患者的临床资料,针对可能与PF相关的14个危险因素进行单因素及多因素Logistic回归分析。结果:全组PF发生率为13.9%(17/122)。单因素分析结果显示,上腹部手术史(P=0.024),术前胆红素(P=0.003)、术中出血量(P=0.023)、术后血红蛋白(P=0.021)、胰腺质地(P=0.046)、胰管直径(P=0.007)为PD后发生PF有意义的因素。多因素分析结果表明,上腹部手术史、胰管直径<3 mm、术后血红蛋白<90 g/L是PD术后发生PF的独立危险因素(OR=4.308、5.052、3.958,均P<0.05)。结论:对于上腹部手术史、胰管直径<3 mm、术后血红蛋白<90 g/L的PD患者,应采取相应的措施,减少术后PF的发生。     

远端胰腺切除术中两种胰腺残端封闭技术对比研究

目的 对比远端胰腺切除术中两种胰腺残端封闭技术的疗效,为胰腺外科手术医生选择合理的胰腺残端封闭技术提供参考。方法 回顾性分析2012-01-01至2013-09-30因“胰体尾占位性病变”在第二军医大学附属长海医院胰腺外科行开放的远端胰腺切除术的部分病人资料,分为切割闭合器组（99例）和手工缝合组（57例）,对比两组之间术中、术后及随访情况。结果 两组病人性别、年龄、体重指数、手术时间、术中出血、术中输血量、引流液淀粉酶值及胰瘘、术后输血率、术后体温（T）≥38℃、术后心率≥100次/min、术后再次手术、术后住院天数、术后30 d内再住院率及术后30 d内病死率差异均无统计学意义;术后输血量和总住院费用手工缝合组均少于切割闭合器闭合组,两组之间差异有统计学意义（P<0.05）。结论 建议胰腺外科医生在行开放的远端胰腺切除术时优先考虑选用手工缝合的方法来封闭保留侧胰腺残端。     

Surgical management for the prevention of pancreatic fistula following distal pancreatectomy

Although the mortality rate related to pancreatic surgery has been reduced recently, the postoperative morbidity is still high, because of various complications. Pancreatic fistula is one of the most common complications following distal pancreatectomy, and is generally hard to cure. Several surgical techniques and devices, such as the use of fibrin-glue sealing, stapler closure, an ultrasonic dissector, or an ultrasonically activated scalpel have been advocated to prevent pancreatic fistula. In the present review we provide an overview of several devices used for the prevention of pancreatic fistula following distal pancreatectomy.     

Transection using bipolar scissors reduces pancreatic fistula after distal pancreatectomy

BACKGROUND/PURPOSE: Various methods and technique for treating the surgical stump of the remnant pancreas have been reported to reduce pancreatic fistula after distal pancreatectomy (DP). However, appropriate surgical stump closure after DP is still controversial. We aimed to clarify whether using bipolar scissors in DP reduces pancreatic fistula compared to hand-sewn suture of surgical stump closure. METHODS: Between January 1989 and December 2005, handsewn suture of surgical stump closure was performed (n = 49), and bipolar scissors was prospectively performed between January 2006 and July 2007 (n = 26). RESULTS: The overall rate of pancreatic fistula after DP was 22 patients (29%). There were significant differences between the hand-sewn suture group (41%) and bipolar scissors group (8%) concerning pancreatic fistula (P = 0.0164). A multivariate logistic regression analysis revealed that two factors, soft pancreas and hand-sewn suture compared to bipolar scissors, were independent risk factors of pancreatic fistula after DP (P = 0.011 and 0.0361, respectively). CONCLUSIONS: Bipolar scissors for transection of the pancreas is a useful device to reduce pancreatic fistula after DP.     

胰体尾切除术后胰瘘的相关性因素分析

目的探讨胰体尾切除术后胰瘘发生的相关性因素。方法回顾性总结了82例行胰体尾切除的患者术前、术中操作以及术后并发症和死亡率发生的情况,并分析和术后胰瘘发生的相关性因素。结果术后有36名患者出现并发症占43.9%（36/82）。其中胰瘘是最常见的并发症,发生率为37.8%（31/82）。其中是否结扎主胰管和术后胰瘘的发生具有明显的相关性（P=0.010）,而性别、年龄、是否并存糖尿病、胰腺的质地、术中失血量、是否预防性应用奥曲肽、是否用生物胶封闭胰腺断端、术后低蛋白血症和是否联合其它脏器切除均和胰瘘的发生无明显的相关性。结论胰体尾切除术后最常见的并发症仍然是胰瘘,术中单独结扎胰管可以减少胰瘘的发生率。     

Preoperative endoscopic pancreatic stenting for prophylaxis of pancreatic fistula development after distal pancreatectomy

BACKGROUND AND OBJECTIVE: Pancreatic fistula is a common complication of distal pancreatectomy (DP). Although various surgical procedures have been proposed for DP in an attempt to decrease the high incidence of pancreatic fistula, the prevention of pancreatic fistula remains a major problem in DP. Endoscopic pancreatic stenting for the treatment or prophylaxis of such a fistula has been rarely described. METHODS: We reviewed 9 patients who underwent preoperative endoscopic pancreatic stenting for the prophylaxis of pancreatic fistula development after DP. RESULTS: Preoperative endoscopic pancreatic stenting was successfully performed with a 7F stent in all the 9 patients. Two patients, both with intraductal papillary mucinous tumor, developed mild acute pancreatitis after the stent placement. None of the 9 patients developed pancreatic fistula. The pancreatic stent was removed from 8 to 28 days (mean 11 days) postoperatively. CONCLUSIONS: Preoperative endoscopic pancreatic stenting may be an effective prophylactic measure against pancreatic fistula development following DP in selected patients.     

Endoscopic management of pancreatic fistula after distal pancreatectomy and enucleation

Background

Preoperative endoscopic pancreatic sphincterotomy (EPS) has been proposed to prevent postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) or enucleation (EN). The use of EPS as a curative treatment for POPF has been scarcely reported. We reported 10 consecutive patients who were successfully treated by EPS for a prolonged POPF.

Study design

Ten patients underwent EPS for prolonged POPF (median duration = 40 days, range 20-114; median daily output = 80 mL, range 50-250) after 6 DPs, 2 ENs, and 2 medial pancreatectomies.

Results

EPS was performed in all patients, with stent insertion in 4. No patient developed a specific complication because of EPS. POPF healed within a median delay of 4 days (range 1-12). One patient underwent a repeated endoscopy to treat stent malposition. The median delay of discharge after EPS was 13 days (range 8-15). With a 20-month median follow up, 1 patient developed early transient POPF recurrence because of spontaneous stent migration.

Conclusions

EPS is indicated for prolonged POPF after DP or EN because it is highly feasible, shortens healing, and is well tolerated.     

Preoperative endoscopic pancreatic stenting: a novel prophylactic measure against pancreatic fistula after distal pancreatectomy

BACKGROUND/PURPOSE: The prevention of pancreatic fistula is still a major problem in distal pancreatectomy (DP). We have recently adopted preoperative endoscopic pancreatic stenting with the aim of preventing the leakage of pancreatic juice from the resection plane of the remnant pancreas after DP. We reviewed ten patients who underwent this intervention. METHODS: One to 6 days before surgery, the patients underwent an endoscopic transpapillary pancreatic stent (7 Fr., 3 cm) placement. The perioperative short-term outcomes were assessed. RESULTS: Preoperative endoscopic pancreatic stenting was successfully performed in all ten patients. Two (20%) patients, both with intraductal papillary mucinous tumor, developed mild acute pancreatitis after the stent placement. None of the ten patients developed pancreatic fistula. The pancreatic stent was removed 8-28 days (mean, 11 days) postoperatively. CONCLUSIONS: Preoperative endoscopic pancreatic stenting may be an effective prophylactic measure against pancreatic fistula development following DP.     

Stump closure of a thick pancreas using stapler closure increases pancreatic fistula after distal pancreatectomy

Background

The appropriate surgical stump closure after distal pancreatectomy (DP) is still controversial. This study investigated the benefits and risks of stapler closure during DP.

Methods

The risk factors of pancreatic fistulas were investigated in 122 DPs among 3 types of stump closure: hand-sewn suture (n = 32), bipolar scissors (n = 45), and stapler closure (n = 45).

Results

There was no significant difference in the incidence of pancreatic fistula between the 3 types of stump closure (hand-sewn suture [44%] vs bipolar scissors [37.7%] vs stapler closure [35.5%]). By using receiver operating characteristics curves, 12 mm was the best cutoff value of the thickness of the pancreas for pancreatic fistulas after DP using stapler closure. Three factors (ie, male sex, body mass index >25 kg/m², and stapler closure) were independent risk factors of pancreatic fistulas after DP with a pancreas thicker than 12 mm.

Conclusions

A pancreas thicker than 12 mm significantly increased the incidence of pancreatic fistulas after DP using stapler closure.     

胰体尾切除术后胰瘘的防治

目的探讨胰体尾切除术后胰瘘的防治。方法回顾性分析2007年1月至2014年5月间83例行胰体尾切除术病人的术前基本资料、术中操作及术后治疗等临床资料,对其中并发胰瘘的19例病人临床资料进行分析。结果行胰体尾切除术的83例病人中,术后并发胰瘘19例,发生率为22．9％,16例经保守治疗痊愈,有效率为84．2％,2例病人行放射治疗后治愈,1例死亡,死亡率为1．2％。单纯缝扎和切割闭合器处理胰腺断端后胰瘘发生率分别为21．6％和23．9％。结论胰体尾切除术后胰瘘的发生率仍然很高,术中正确处理胰腺断端及加强术后管理是预防胰体尾切除术后胰瘘的关键。胰瘘的治疗在于通畅引流、加强营养支持,并积极寻找新的治疗方法。     

Distal pancreatectomy with duct-to-mucosa pancreaticogastrostomy: a novel technique for preventing postoperative pancreatic fistula

Background

Management of the pancreatic remnant after distal pancreatectomy remains a clinically relevant problem and a significant clinical challenge. We evaluated the safety and efficacy of duct-to-mucosa pancreaticogastrostomy for preventing pancreatic fistula development after distal pancreatectomy.

Methods

Twenty-one patients underwent distal pancreatectomy using the duct-to-mucosa pancreaticogastrostomy and the clinical data were collected prospectively. Pancreatic fistula was defined and classified according to the international study group definition.

Results

The median surgical time was 236 minutes, with a median intraoperative blood loss of 250 mL. Morbidity was 5% and mortality was nil. The postoperative pancreatic fistula rate of clinically relevant grade B or C fistulae was 0%, although the biochemical grade A fistula rate was 29%. Delayed gastric emptying developed in only 1 patient (5%).

Conclusions

Duct-to-mucosa pancreaticogastrostomy may be a safe and effective technique for preventing pancreatic fistula development after distal pancreatectomy when performed by experienced surgeons who are skilled in this technique.