非胰腺手术后胰腺假性囊肿的治疗

目的探讨非胰腺手术后胰腺假性囊肿的治疗方法。方法对近11年来治疗的28例非胰腺手术后胰腺假性囊肿进行回顾性临床分析。结果保守治疗4例。B超引导下经皮多次穿刺10例(其中穿刺后置管外引流3例)。手术行外引流6例,内引流8例。1例外引流无效后,改行内引流。28例均痊愈出院。结论手术后胰腺假性囊肿应采用个体化的治疗原则,早期应采取保守治疗、穿刺抽液或外引流,内引流可作为治疗的最后选择。     

Pancreaticodigestive anastomosis and the postoperative management strategies to prevent postoperative pancreatic fistula formation after pancreaticoduodenectomy

Over the past 100 years, advances in surgical techniques and perioperative management have reduced the morbidity and mortality after pancreaticoduodenectomy (PD). Many techniques have been proposed for the reconstruction of the pancreaticodigestive anastomosis to prevent the development of a postoperative pancreatic fistula (POPF), but which is the best approach is still highly debated. We carried out a systematic review to determine and compare the effectiveness of various methods of anastomosis after PD. A meta-analysis and most randomized controlled trials (RCTs) showed that the mortality, POPF rate and incidence of other postoperative complications were not statistically different between the pancreaticogastrostomy and pancreaticojejunostomy (PJ) groups. One RCT showed that a binding PJ significantly decreased the risk of POPF and other postoperative complications compared with conventional PJ. External duct stenting reduced the risk of clinically relevant POPF in a meta-analysis and RCTs. The prophylactic use of octreotide after PD does not result in a reduced incidence of POPF. In conclusion, our findings suggest that the successful management of pancreatic anastomoses may depend more on the meticulous surgical technique, surgical volume, and other management parameters than on the type of technique used. However, some new approaches, such as binding PJ, and the use of external stents should be considered in further RCTs.     

术后胰漏的治疗分析

目的探讨胰腺手术后胰漏的治疗方式。方法前瞻性收集42例胰腺手术后病人的腹腔内引流液行淀粉酶测定，严格以术后3d或者以上，腹腔引流液淀粉酶测定值大于正常血清淀粉酶测定值上限3倍作为胰漏诊断标准，将术后出现胰漏的病人分为3级，针对不同分级采用具体的治疗措施。结果42例病人中有12例出现胰漏，发生率为28.5％。其中Ⅰ级胰漏8例，占胰漏的66.67％；Ⅱ级胰漏4例，占胰漏的33.33％；未见Ⅲ级胰漏。Ⅰ级和Ⅱ级胰漏之间腹腔引流管留置时间、术后住院时间均无差别（P〉0.05）。胰漏病人中无1例死亡，经相应处理，胰漏均能愈合，但腹腔引流管留置时间将明显延长（P=0.007）。结论胰漏应分级治疗，Ⅰ级胰漏通畅引流即可愈合，Ⅱ～Ⅲ级胰漏要积极治疗。     

Conservative management of postoperative lymphatic fistula

We describe the case of a diabetic patient who presented with a renal abscess that was surgically managed with nephrectomy. At the forth post-surgical day, the patient showed the presence of a "milky" looking fluid amounting to 1200 ml in 24 h through a Penrose drainage placed in the surgical resection site. After several studies, a diagnosis of lymphatic fistula was made. The first dietary management technique tried was not satisfactory, and total parenteral nutrition management was decided upon, obtaining a satisfactory outcome within a few days. We reviewed the literature where we found scant reported information on lymphatic fistulas following retroperitoneal surgery and we consider that because of more aggressive surgical techniques and more advanced technology for increased patient survival, doctors will witness a higher incidence of chylous fistulas or chylous ascites, which is why it is important to be aware of this complication.     

Endoscopic management of postoperative biliary fistula

Summary Endoscopic retrograde cholangiography (ERC) was performed in two patients with persistent bile fistulae after cholecystectomy. Contrast leakage was demonstrated in a leaking cystic duct stump and an aberrant intrahepatic duct. Endoscopic insertion of nasobiliary catheters led to rapid drainage and healing of the biliary fistulae.     

Diagnosis and management of choledochoduodenal fistula

Recent advances in hepatobiliary imaging techniques have led to the increased detection of choledochoduodenal fistula. However, the diagnosis and treatment of choledochoduodenal fistula is still a challenge. In this study, we summarize how patients were diagnosed and treated for choledochoduodenal fistula at our institution. Sixty-six patients with choledochoduodenal fistula were diagnosed and treated in our department from January 2000 to June 2009. Sixty-one patients were treated operatively, whereas five patients were treated with medicine. Patients with choledochoduodenal fistula were confirmed by endoscopic retrograde cholangiography. Of the 61 patients needing surgical intervention, clinical outcomes were excellent in 57 patients, and five patients underwent successful laparoscopic surgery for repairing the choledochoduodenal fistula. Follow-up of these patients for 6 months to 10 years showed they did not suffer from further cholangitis. A patients' past history of biliary disease, upper abdominal pain, fever, and jaundice may lead to choledochoduodenal fistula. Operative therapy, including laparoscopic surgery, was the primary treatment for most patients, regardless of the preoperative diagnosis.     

Pancreatic fistula and postoperative pancreatitis after pancreatoduodenectomy for pancreatic cancer

The most serious complication after pancreatoduodenectomy (PD) is pancreatic fistula (PF) type C, either as a consequence or independently from postoperative pancreatitis (PP). Differentiating between these two types of complications is often very difficult, if not impossible. The most significant factor in early diagnosis of PP after PD is an abrupt change in clinical status. In our retrospective study we also observed significantly higher levels of serum concentrations of CRP and AMS comparing to PF without PP. Based on our findings, CT scan is not beneficial in the early diagnosis of PP. Meantime PF type C is indication to operative revision with mostly drainage procedure which is obviously not much technically demanding, there are no definite guidelines on how to proceed in PP. Therefore the surgeon’s experience determines not only whether PP will be diagnosed early enough and will be differentiated from PF without PP, but also whether a completion pancreatectomy will be performed in indicated cases.     

The management of postoperative pancreatic fistulas

Postoperative pancreatic fistula is the most common major complication after pancreatic surgery and it can lead to prolonged hospital stay, increased costs and mortality. Its incidence is between 2 and 30%. We present a series of 100 successive patients, operated in our clinic for different pancreatic diseases. Among them, 21 had pancreaticoduodenectomies, 24- enucleation procedures for insulinomas or pancreatic adenomas, 31- distal pancreato-spleenectomies and in 24 cases a pancreatic abcess or pseudocyst was drained. A pancreatic fistula occurred in 21 patients (21%); we analyzed the treatment and outcome of these fistulas, according to our experience and to the International Study Group of Pancreatic Fistula (ISGPF) classification. 10 patients needed only medical treatment, while in 11 cases one/more new surgical procedure(s) was/were required. 15 patients had a favourable evolution and 6 other patients deceased. In persistent fistulas, as well as in those with a high output, the resection of the pancreatic remnant appears to be the best surgical option.     

Amylase level after pancreaticoduodenectomy in predicting postoperative pancreatic fistula

BackgroundIt is new clinical interest higher serum amylase level with pancreatitis after pancreaticoduodenectomy (PD) correlates with postoperative pancreatic fistula (POPF). Nevertheless, its evidence and study were scarce. We aimed to investigate correlation of serum amylase level immediate after PD and POPF occurrence.MethodsOf 163 patients who underwent PD at between January 2009 and December 2019, retrospective analysis was conducted to identify risk factors including serum amylase level immediate after PD for POPF occurrence.ResultsOverall incidence of POPF (25/163) was 15.3%. The patients occurred a POPF had significantly higher level of serum amylase on POD0 compared to in whom without a POPF (414 vs 253, p < 0.001). In univariate analysis, ASA classification, post pancreatectomy acute pancreatitis (POAP, serum amylase on POD0 >285IU/L) and Fistula Risk Grade were correlated with POPF occurrence. In multivariable analysis, Fistula risk grade and POAP were significantly associated with developing POPF.ConclusionIn patients with higher serum amylase (>285IU/L) on POD0 with higher fistula risk grade, comprehensive management to achieve mitigation of POPF is important.     

Fatty pancreas: a factor in postoperative pancreatic fistula

OBJECTIVE: To determine whether patients who develop a pancreatic fistula after pancreatoduodenectomy are more likely to have pancreatic fat than matched controls. BACKGROUND: Pancreatic fistula continues to be a major cause of postoperative morbidity and increased length of stay after pancreatoduodenectomy. Factors associated with postoperative pancreatic fistula include a soft pancreas, a small pancreatic duct, the underlying pancreatic pathology, the regional blood supply, and surgeon's experience. Fatty pancreas previously has not been considered as a contributing factor in the development of postoperative pancreatic fistula. METHODS: Forty patients with and without a pancreatic fistula were identified from an Indiana University database of over 1000 patients undergoing pancreatoduodenectomy and matched for multiple parameters including age, gender, pancreatic pathology, surgeon, and type of operation. Surgical pathology specimens from the pancreatic neck were reviewed blindly for fat, fibrosis, vessel density, and inflammation. These parameters were scored (0-4+). RESULTS: The pancreatic fistula patients were less likely (P < 0.05) to have diabetes but had significantly more intralobular (P < 0.001), interlobular (P < 0.05), and total pancreatic fat (P < 0.001). Fistula patients were more likely to have high pancreatic fat scores (50% vs. 13%, P < 0.001). Pancreatic fibrosis, vessel density, and duct size were lower (P < 0.001) in the fistula patients and negative correlations (P < 0.001) existed between fat and fibrosis (R = -0.40) and blood vessel density (R = -0.15). CONCLUSIONS: These data suggest that patients with postoperative pancreatic fistula have (1) increased pancreatic fat and (2) decreased pancreatic fibrosis, blood vessel density, and duct size. Therefore, we conclude that fatty pancreas is a risk factor for postoperative pancreatic fistula.