Whipple's pancreaticoduodenectomy: Outcomes at a tertiary care hospital

Background

Pancreaticoduodenectomy is a formidable surgery and was associated with high morbidity and mortality. Though the mortality rates have steadily improved, morbidity continues to be high. There is lack of published data on outcomes following pancreaticoduodenectomy in Armed Forces hospitals. The aim of this study was to analyze the short term outcomes at our center and to compare it with the published literature.

Methods

A retrospective review of prospectively maintained data base was done. Preoperative, intraoperative and postoperative data was analyzed with emphasis on the morbidity and mortality rates. Follow up data was analyzed to look at disease recurrence.

Results

Between Jan 2008 and March 2014, 69 patients underwent Whipple''s pancreaticoduodenectomy with a median age of 64 years. All had a malignant etiology with periampullary carcinoma being the commonest (42%). Overall, intra-abdominal complications occurred in 46% of patients which included postoperative pancreatic fistula (20%) and delayed gastric emptying (24%). The mortality rate for the whole was 11% which reduced to 8% in the second half of the study.

Conclusion

The short term outcomes at our center were comparable to those in published literature. The mortality rates showed a decreasing trend with time.     

Whipple's pancreaticoduodenectomy: Outcomes at a tertiary care hospital

Background

Pancreaticoduodenectomy is a formidable surgery and was associated with high morbidity and mortality. Though the mortality rates have steadily improved, morbidity continues to be high. There is lack of published data on outcomes following pancreaticoduodenectomy in Armed Forces hospitals. The aim of this study was to analyze the short term outcomes at our center and to compare it with the published literature.

Methods

A retrospective review of prospectively maintained data base was done. Preoperative, intraoperative and postoperative data was analyzed with emphasis on the morbidity and mortality rates. Follow up data was analyzed to look at disease recurrence.

Results

Between Jan 2008 and March 2014, 69 patients underwent Whipple's pancreaticoduodenectomy with a median age of 64 years. All had a malignant etiology with periampullary carcinoma being the commonest (42%). Overall, intra-abdominal complications occurred in 46% of patients which included postoperative pancreatic fistula (20%) and delayed gastric emptying (24%). The mortality rate for the whole was 11% which reduced to 8% in the second half of the study.

Conclusion

The short term outcomes at our center were comparable to those in published literature. The mortality rates showed a decreasing trend with time.     

胰十二指肠切除术后胰胃吻合术与胰空肠吻合术前瞻性对照试验的荟萃分析

目的 比较胰十二指肠切除术(PD)后胰胃吻合术(PG)与胰空肠吻合术(PJ)的安全性.方法 检索2010年12月以前EMBASE、MEDLINE、Cochrane Library、Cochrane协作网随机对照试验注册数据库、中国期刊全文数据库(CNKI)、中国生物文献数据库(CBM)等数据库,纳入前瞻性对照试验,评估文献质量并提取数据资料,应用RevMan5.0对其进行荟萃分析.结果 纳入6个前瞻性对照试验,其中4个随机对照试验(RCT),2个非随机的前瞻性对照试验,共867例PD病例,行PG手术患者440例,PJ手术患者426例.采用前瞻性研究(包括RCT)和单纯RCT分组进行荟萃分析:前瞻性对照试验组(包括RCT)荟萃分析中PG在术后并发症[OR0.53,95％ CI(0.30,0.95),P=0.03]、胰瘘[OR 0.47,95％ CI(0.22,0.97),P=0.04]、腹腔积液[OR 0.42,95％CI(0.25,0.72),P=0.001],这3项指标中明显优于PJ,腹腔内并发症、病死率等指标上两种吻合方式差异未见统计学意义;RCT研究组荟萃分析中PG在术后腹腔积液[OR 0.46,95％ CI(0.26,0.79),P=0.005]这项指标中明显优于PJ,在术后并发症、胰瘘、腹腔内并发症、病死率、胃排空延迟这些指标上两种吻合方式差异未见统计学意义.结论 前瞻性对照试验进行荟萃分析后可以发现PG在术后并发症、胰瘘、腹腔积液方面优于PJ.单纯对RCT进行荟萃分析后发现PG仅在术后腹腔积液方面优于PJ.表明PG在安全性上并不低于PJ.     

胰胃吻合在胰十二指肠联合切除术中的临床应用

目的探讨采用胰胃吻合术式在行胰十二指肠联合切除术中的临床应用。方法回顾性总结了10例因胰头癌和壶腹周围癌行胰十二指肠联合切除术,采用胰胃吻合术式重建消化道的病例资料。术后通过监测腹腔引流液中淀粉酶含量判断胰瘘的发生。结果术后10例患者均无胰瘘发生。结论胰十二指肠联合切除术采用胰胃吻合术式方法简便、安全、有效,明显减少了胰瘘的发生率,生活质量较好。     

Meta-analysis of pancreaticoduodenectomy prospective controlled trials: pancreaticogastrostomy versus pancreaticojejunostomy reconstruction

Background  Pancreaticogastrostomy (PG) has been proposed as an alternative to pancreaticojejunostomy (PJ), assuming that postoperative complications are less frequent. The aim of this research was to compare the safety of PG with PJ reconstruction after pancreaticoduodenectomy.

Methods  Articles of prospective controlled trials published until the end of December 2010 comparing PJ and PG after PD were searched by means of MEDLINE, EMBASE, Cochrane Controlled Trials Register databases, and Chinese Biomedical Database. After quality assessment of all included prospective controlled trials, meta-analysis was performed with Review Manager 5.0 for statistic analysis.

Results  Overall, six articles of prospective controlled trials were included. Of the 866 patients analyzed, 440 received PG and 426 were treated by PJ. Meta-analysis of six prospective controlled trials (including RCT and non-randomized prospective trial) revealed significant difference between PJ and PG regarding postoperative complication rates (OR, 0.53; 95% CI, 0.30–0.95; P=0.03), pancreatic fistula (OR, 0.47; 95% CI, 0.22–0.97; P=0.04), and intra-abdominal fluid collection (OR, 0.42; 95% CI, 0.25–0.72; P=0.001). The difference in mortality was of no significance. Meta-analysis of four randomized controlled trials (RCT) revealed significant difference between PJ and PG regarding intra-abdominal fluid collection (OR, 0.46; 95% CI, 0.26–0.79; P=0.005). The differences in pancreatic fistula, postoperative complications, delayed gastric emptying, and mortality were of no significance.

Conclusions  Meta-analysis of six prospective controlled trials (including randomized controlled trials (RCT) and non-randomized prospective trial) revealed significant difference between PJ and PG regarding overall postoperative complications, pancreatic fistula, and intra-abdominal fluid collection. Meta-analysis of four RCT revealed significant difference between PJ and PG with regard to intra-abdominal fluid collection. The results suggest that PG may be as safe as PJ.

     

术后胃瘫的观察与护理

通过对73例腹部手术后胃瘫病人的观察与护理。认为主要护理措施包括有效的胃肠减压，循序渐进的饮食护理，遵循浓度从低到高、容量由少到多、速度由慢到快原则的肠内营养护理，严密监测血糖和血电解质的变化，指导病人进行早期活动等。本组胃肠功能均在2-8wk内全部恢复，无行再次手术的病例。     

胰十二指肠切除术后胃排空延迟发生及严重程度的危险因素分析

目的分析胰十二指肠切除术后胃排空延迟发生及病情严重程度的危险因素。方法回顾性分析208例在我院进行胰十二指肠切除术患者的临床资料。采用多因素Logistic回归分析进行危险因素分析。结果术后83例出现胃排空延迟,发生率为39.90%,其中A级31例(14.90%),B级27例(12.98%),C级25例(12.02%)。保留幽门、Child法重建消化道、术中出血量≥1000 mL、手术时间≥360 min、术后腹部并发症术后胃排空延迟的发生率更高(P<0.05),其中Child法、术中出血量、术后腹部并发症是胃排空延迟发生的独立危险因素(P<0.05)。术后年龄≥60岁、保留幽门、手术时间≥360 min、术后腹部并发症术后胃排空延迟病情更严重(P<0.05),其中年龄、术后腹部并发症是胃排空延迟病情严重程度的独立危险因素(P<0.05)。结论胰十二指肠切除术后胃排空延迟发生率高,采用改进型消化道重建方式、减少术中出血量和术后腹部并发症有助于降低发生率;高龄和合并术后腹部并发症的患者发生胃排空延迟的严重程度明显增加。     

Child胰肠吻合术后功能性胃排空障碍的危险因素分析

目的:探讨Child胰肠吻合术后功能性胃排空障碍(DGE)的影响因素。方法:对2002~2012年行Child胰肠吻合术的132例患者的临床资料进行回顾性分析。结果:术后DGE 47例,发生率为35.61%;患者DGE发生率在性别、年龄、是否合并高血压、是否合并糖尿病、直接胆红素水平、手术时间、术后早期是否肠内营养间差异均无统计学意义(P0.05),而患者术前WBC水平、白蛋白(ALB)水平、术中出血量、术后有无胰瘘对DGE的发生均有影响(P0.05~P0.01);多因素分析显示,患者ALB与DGE的发生呈负相关关系(OR=0.797,P0.01),术中出血量、手术时间、术后是否胰瘘与DGE的发生呈正相关关系(OR分别为2.275、1.756和2.885)。结论:改善患者营养状态、减少术中出血量、缩短手术时间可减少DGE的发生,术后胰瘘可增大DGE的发生率。     

早期拔除腹腔引流管减少胰十二指肠切除术后胰瘘的回顾性研究

目的 探讨胰十二指肠切除手术(pancreaticoduodenectomy,PD)后早期拔除腹腔引流管能否减少术后胰瘘发生.方法 回顾性分析西南医院肝胆外科2013年1月至2015年10月收治并依据纳入排除标准归入研究对象的305例PD手术患者的临床资料,按术后腹腔引流管拔除时间分为:A组,术后≤5 d拔除;B组,术后＞5d拔除.比较两组患者术后并发症等发生情况,对胰瘘发生的相关因素进行单因素和多因素分析.结果 术后胰瘘(3.1％vs12.1％)、腹腔感染(9.2％ vs 20.3％)以及总并发症(24.5％ vs 42.0％)发生率A组均显著低于B组(P＜0.05),术后住院时间也明显缩短[13.0(4 ～44)d vs 15.5(9 ～64)d,P＜0.05].单因素分析示:性别(P＜0.05)、术前有无显性黄疸(P＜0.05)、胰管直径(＜3 mm vs ≥3 mm,P＜0.05)、肿瘤发生部位(胰腺vd胰腺外,P＜0.01)、腹腔引流管拔除时间(≤5dvs ＞5d,P＜0.05)为术后胰瘘发生的影响因素;多因素Logistic回归分析示:男性、胰管直径＜3 mm、胰腺外肿瘤(胆总管远端、十二指肠乳头部、胆胰壶腹部肿瘤)、腹腔引流管拔除时间＞5d为胰瘘发生的独立危险因素(OR=4.424,2.369,3.874,5.028,P＜0.05).结论 对于PD术后早期无胰瘘发生的患者,术后5d内拔除腹腔引流管能够显著减少术后胰瘘、腹腔感染等并发症,延长腹腔引流管留置时间会增加术后胰瘘发生率.     

胃大部切除术后残胃无张力症的诊治体会

目的 探讨胃大部切除术后残胃无张力症(胃排空障碍)的原因、诊断与治疗.方法 分析我院外科1990～2007年32例胃大部切除术后残胃排空障碍的诊疗经过.结果 残胃排空障碍发生于术后4～8d,27例经保守治疗治愈.保守治疗时间8～24d,平均13d.5例因保守治疗无望而中转手术,术中发现残胃排空障碍均与粘连有关,其中4例是与大网膜粘连团块压迫吻合口与输出段空肠有关.结论 胃大部切除术后并发残胃排空障碍多数是功能性的,可经保守治疗治愈,但若经3w以上保守治疗仍未奏效者,应考虑机械性梗阻的存在.胃钡餐(GI)与胃镜检查有助于明确诊断,应尽早中转手术.     

胃切除术后残胃排空延迟综合征的诊治体会

目的：探讨胃大部切除术后残胃排空延迟综合征(DGE)的诊断与治疗。方法：回顾性分析总结1985年1月至2002年12月间胃大部切除手术408例。结果：本组408例中发生残胃排空延迟综合征11例，发生率2．7％。结论：DGE可由多种因素诱发，发病机制不明。非手术治疗可治愈，手术应为禁忌。     

食管癌术后胃排空障碍的诊断及治疗

目的：探讨食管癌切除术后胸腔胃排空障碍的原因、诊断、治疗及预防。方法：对56例食管癌术后并发胃排空障碍患者采用药物和胃镜下置营养管行肠内营养。结果：56例均得明确诊断,全部治愈。结论：胃肠造影和胃镜检查可明确诊断食管癌术后胃排空障碍,使用非手术的保守治疗可获得治愈。     

食管癌、贲门癌术后胃排空障碍的诊断和治疗

目的探讨食管癌、贲门癌切除术后胃排空障碍的发生原因、诊断和防治措施。方法对2000年1月-2005年3月间实施的276例食管癌、贲门癌切除术患者的临床资料进行回顾性分析。结果本组病例发生胃排空障碍8例,发生率2.9%(8/276)。7例为功能性胃排空障碍,发生于术后7-10天,经保守治疗治愈。1例为机械性胃排空障碍,发生于术后第7天,二次手术解除梗阻后治愈。无死亡病例。结论迷走神经切断及胃解剖位置的变化是胃排空障碍的主要原因,X线造影及胃镜检查是诊断本病的主要方法。临床上须鉴别功能性亦或机械性因素所致的胃排空障碍,功能性胃排空障碍,一般行保守治疗,机械性胃排空障碍应尽早手术。     

选择性术中缝扎胰管及胰腺断面预防胰十二指肠切除术后胰瘘的临床研究

目的探讨术中可吸收线缝扎胰管及胰腺断面对胰管扩张不明显病例之胰十二指肠切除术后胰瘘的预防作用。方法对2004年1月～2011年1月符合胰管扩张不明显病例因壶腹周围肿瘤行胰十二指肠切除术的93例病例,比较胰管及胰腺断面缝扎组（A组）和胰管及胰腺断面不缝扎组（B组）胰瘘的发生情况。结果A组54例患者发生胰瘘2例,发生率为3．70％;B组39例出现胰瘘4例,发生率为10．25％,两组差异有显著意义,P〈0．05。结论胰管扩张不明显病例胰十二指肠切除术中以可吸收线缝扎胰管及胰腺断面手术操作简单,预防胰瘘效果可靠,是胰十二指肠切除术较可靠的胰管处理方式。     

胰十二指肠切除术后胰瘘的高危因素及胰体部平扫CT值对其预测价值的分析

目的 探讨胰十二指肠切除术(pancreatoduodenectomy,PD)后胰瘘的高危因素及术前胰腺体部拟切除断面平扫期CT值(以下简称胰体部CT值)对PD术后胰瘘发生风险的预测价值.方法 回顾性分析西南医院肝胆外科2013年1月至2015年12月期间收治的408例住院行胰十二指肠切除术患者的完整病历资料,单因素分析采用Pearson卡方检验,多因素分析采用二分类Logistic回归分析,胰体部CT值与胰瘘之间的相关性采用简单线性相关分析,其对PD术后胰瘘的预测价值采用受试者工作特征(ROC)曲线下面积.结果 408例患者共发生胰瘘123例(30.14%),单因素分析显示BMI、术前γ-谷氨酰转肽酶、胰管直径、胰体部CT值、手术时间、胰腺质地软硬(术中判断)是PD术后胰瘘的危险因素;多因素分析显示BMI≥25 kg/m2、胰管直径≤3 mm、胰体部CT值<40 Hu、胰腺质地软(术中判断)软为PD术后胰瘘发生的独立高危因素.不同胰瘘严重程度分级患者的胰体部CT值相比较,差异有统计学意义(P<0.05).胰瘘严重程度与胰体部CT值呈负相关.胰体部CT值ROC曲线下面积为0.714,对PD术后胰瘘具有中等预测价值.结论 BMI≥25 kg/m2、胰管直径≤3 mm、胰体部CT值<40 Hu、胰腺质地软硬(术中判断)软为PD术后胰瘘发生的独立高危因素,胰体部CT值对PD术后胰瘘具有中等预测价值,可指导围手术期治疗方案.     

Efficacy of evidence-based institutional protocol for prevention of postoperative nausea and vomiting: A prospective observational study

BackgroundPostoperative nausea and vomiting (PONV) is the second most common complaint in the postoperative period, often resulting in increased post anaesthesia care unit (PACU) and hospital stay. Translation of knowledge into consistent practice was considered a major gap. Hence, the present study was undertaken to test the efficacy of locally developed evidence-based institutional protocol for prevention of PONV.MethodsPhase I consisted of determining the baseline incidence of PONV before introduction of the institutional protocol for PONV prophylaxis. In phase II, educational sessions for anaesthesiologists for PONV prevention and treatment were conducted, after which an institutional protocol was introduced. In phase III, this protocol was implemented, and the incidence of PONV was recorded using the same methodology as in phase I. The rate of adherence to the institutional protocol was also recorded.ResultsThe incidence of postoperative nausea (PON) dropped significantly from 32.5% in phase I to 20% in phase III (p = 0.033). Similarly, the incidence of postoperative vomiting (POV) decreased from 20.5% in phase I to 9.1% in phase III (p = 0.016). Of all anaesthesiologists, 78.18% were noted to adhere to the protocol in phase III. Incidence of PON and POV was significantly less in patients in whom PONV prophylaxis was administered in adherence to protocol (8.3% vs 57.7%, p < 0.001; 3.6% vs 26.9%, p < 0.001, respectively).ConclusionEvidence-based institutional protocols are effective in significantly reducing the incidence of PONV in adults undergoing noncardiac surgery under anaesthesia.Clinical trial number and registry URLThe trial was registered with Clinical Trials Registry of India (http:/ctri.nic.in) (CTRI/2015/12/006432).     

胰腺-空肠套入式吻合与胰管-空肠黏膜吻合对胰十二指肠切除术术后并发症发生情况的影响

目的探讨胰腺-空肠套入式吻合与胰管-空肠黏膜吻合对胰十二指肠切除术(PD)术后并发症发生情况的影响,为临床PD吻合方式的选择提供参考。方法将接受PD治疗的60例患者随机化为胰腺-空肠组与胰管-黏膜组,每组各30例,两组患者手术均由同一医生操作,胰腺-空肠组于术中行胰腺-空肠套入式吻合,胰管-黏膜组于术中行胰管-空肠黏膜吻合。考察两组患者术后的并发症发生情况。结果胰腺-空肠组死亡2例,病死率为6.67%,胰管-黏膜组死亡1例,病死率为3.33%,组间比较差异无统计学意义(P>0.05);除胰瘘(POPF)外,胰腺-空肠组的的术后并发症发生率为43.33%,胰管-黏膜组为40.00%,组间比较差异无统计学意义(P>0.05);但胰腺-空肠组的并发症严重程度高于胰管-黏膜组,III级以上并发症发生率组间比较差异有统计学意义(P<0.05);胰腺-空肠组的的术后POPF的发生率为30.00%,胰管-黏膜组为26.67%,组间比较差异无统计学意义(P>0.05),但胰管-黏膜组POPF的严重程度低于胰腺-空肠组(P<0.05);logistics回归分析发现,POPF与性别、胰管直径以及病理类型具相关性(P<0.05)。结论除胰管较细患者建议行胰腺-空肠套入式吻合外,胰管-空肠黏膜吻合在PD手术中可最大程度降低PD术后并发症。     

胰十二指肠切除术后胰瘘与胰肠吻合方法的关系

目的：探讨胰十二指肠切除术后胰瘘与胰肠吻合方法的关系。方法：比较两种不同的胰腺吻合方法－传统的胰肠套入式双层吻合（69例）与改良的胰肠套入式单层吻合（40例）术后胰瘘的发生情况，并对其机理进行探讨。结果：胰肠套入式双层吻合组术后发生胰瘘6例（8.7%)，其中4例经保守治疗后愈，1例再次手术引流，1例继发腹腔内大出血死亡；胰肠套入式单层吻合组术后无胰瘘发生。结论：胰十二指肠切除术后胰瘘的发生与胰肠吻合方法有关，胰肠套入式单层吻合是一种安全、实用的胰肠吻合方法。传统的胰肠套入式双层吻合术后胰瘘的发生主要与双层吻合时胰腺及其被膜易被撕裂，吻合口两端组织血运不佳以及双层吻合之间存在的潜在间隙可使沿缝针（线）裂隙外渗的胰液在吻合层面间积聚有关。     

The role of endoscopy after upper gastrointestinal bleeding in sub-Saharan Africa: A prospective observational cohort study

BackgroundUpper gastrointestinal (UGI) bleed is a common surgical disease in sub-Saharan Africa where there is often a lack of diagnostic and interventional adjuncts such as endoscopy. This study sought to characterize the role of endoscopy in management of acute UGI bleeding.Materials and MethodsThis is a prospective observational analysis of adults presenting with an UGI bleed to a tertiary center in Lilongwe, Malawi, over two years. Patients were classified as having no endoscopy, diagnostic endoscopy, or endoscopy with variceal banding. Bivariate, survival analysis, and logistic regression analyses were used to compare intervention cohorts.Results293 patients were included with 49 patients (16.7%) receiving endoscopy with banding, 65 (22.2%) patients receiving diagnostic endoscopy only, and 179 (61.1%) receiving no endoscopy. Upon survival analysis comparing to the no endoscopy group, cox hazard modelling showed an adjusted hazard ratio over 30 days of 0.12 (95% CI 0.02, 0.88, p=0.038) for the endoscopic banding group and a hazard ratio of 0.39 (95% CI 0.13, 1.16, p=0.090) for the diagnostic endoscopy only group. Physical exam findings consistent with cirrhosis and decreasing age were independent predictors of an endoscopic diagnosis of variceal bleeding.ConclusionEsophagogastric varices are a common cause of UGI bleeding in sub-Saharan Africa and can be predicted with age and physical exam findings. Endoscopy with variceal banding has a survival benefit for patients presenting with acute UGI bleed even with relatively low utilization. Appropriately triaging patients with likely variceal bleeding and improving endoscopy capacity would likely have a significant impact on mortality.     

艳山姜果实提取液对实验动物胃肠动力的促进作用研究

目的探讨艳山姜果实提取液(Alpinia zerumbet fruit extract,Afex)对实验动物胃肠运动的影响并探讨其可能的作用机制。方法灌胃给药(剂量2、4、8g/kg)后,测定小鼠甲基橙胃残留率、小肠墨汁推进百分率;RM6240生物信号采集处理系统检测大鼠胃及十二指肠电活动。结果与阴性对照组相比,艳山姜果实提取液在2～8g/kg时可使甲基橙胃残留率明显减少,小肠墨汁推进百分率明显增加,并呈剂量依赖性;大鼠胃及十二指肠电活动的慢波频率和振幅明显增加。结论艳山姜果实提取液有促进实验动物胃肠运动,该作用的发挥可能与其促进胃十二指肠电活动有关。