胰肠吻合方式与胰瘘(附477例报告)

目的 :本文探讨胰十二指肠切除术胰肠吻合方式与胰瘘预防的关系。方法 :回顾 1 988年 1月至 2 0 0 2年 4月477例胰十二指肠切除术病例 ,胰肠吻合方式包括端端套入吻合、端侧套入吻合、胰管空肠端侧黏膜吻合 ;胰管支撑和胰液引流包括胰管支撑内引流、胰管支撑外引流和无胰管支撑等。结果 :术后胰瘘总发生率为 2 .52 % (1 2 477) ,96年前为 6 .78% (8 1 1 8) ,死亡 2例 ;1 996年后为 1 .1 1 % (4 359) ,死亡 1例。同时期吻合方式比较 ,1 996年前的两种主要吻合方式中 ,胰管空肠端侧黏膜吻合法的胰瘘发生率显著低于端端套入法 (χ2 =4.30 34 ,P <0 .0 5)。1 996年后的两种主要吻合方式中 ,胰管空肠端侧黏膜吻合法的胰瘘发生率显著低于端侧套入吻合法 (χ2 =1 3 .5778,P<0 .0 1 )。端端套入吻合法放置胰管外引流的胰瘘发生率显著低于单纯内支撑 (χ2 =4.82 4 4 ,P <0 .0 5) ;胰管空肠端侧黏膜吻合法放置胰管外引流与单纯内引流相比相差不显著 (χ2 =0 .2 842 ,P >0 .0 5)。结论 :操作技术的熟练程度是影响胰瘘发生率的重要因素。胰管空肠端侧黏膜吻合法优于端侧套入和端侧套入吻合法。在吻合技术不熟练时 ,放置胰管支撑外引流有助于减少胰瘘发生率     

胰十二指肠切除改良胰管空肠吻合预防胰瘘的临床研究

目的探讨胰十二指肠切除术改良的胰管空肠端侧黏膜对黏膜胰管空肠套入式吻合方式预防胰瘘的临床应用价值。方法回顾性分析111例胰十二指肠切除术患者的临床资料,其中残胰重建方式为胰管空肠黏膜对黏膜套入式端侧精确吻合(改良胰管空肠吻合)者41例(改良组),胰空肠端端常规套入吻合手术者70例(常规组),比较两种胰肠吻合方法对术后胰瘘发生率的影响。结果改良组41例术后恢复顺利,无一例发生胰瘘;常规组发生胰瘘13例(18.57%)。两种术式间胰瘘发生率差异有统计学意义(P<0.05)。2组其他并发症发生率如消化道出血、胃排空障碍、胆瘘、腹腔感染、肺感染和切口感染以及生存率方面的差异均无统计学意义(P>0.05)。结论胰十二指肠切除术胰管空肠端侧黏膜对黏膜套入式吻合在预防胰瘘发生方面具有明显优势,值得在临床工作中推广运用。     

两种胰肠吻合方式对胰十二指肠切除术后并发症的影响

目的 分析胰十二指肠切除术后胰管空肠黏膜对黏膜吻合和套入式胰肠端端吻合术后并发症发生情况,为选择最佳的胰肠重建方式提供依据.方法 回顾性分析2004年6月至2008年5月于四川大学华西医院接受胰十二指肠切除术的342例患者的临床资料.根据吻合方式的不同将患者分为黏膜-黏膜吻合组(179例),采用胰管空肠黏膜对黏膜吻合;套入式吻合组(163例),采用套入式胰肠端端吻合.根据Clavien术后并发症诊断和分级标准分析胰管空肠黏膜对黏膜吻合和套入式胰肠端端吻合与术后并发症发生率及其严重程度的关系.计量资料采用t检验,计数资料采用x2检验.结果 本组患者术后总体并发症发生率为48.8％(167/342),其中黏膜-黏膜组术后并发症发生率为38.0％(68/179),套入式吻合组为60.7％(99/163),两组比较,差异有统计学意义(x2=17.667,P＜0.05).在术后并发症的严重程度分级中,黏膜-黏膜组患者Ⅱ级和Ⅴ级并发症发生率分别为16.8％(30/179)和1.1％(2/179),显著低于套入式吻合组的28.2％(46/163)和5.5％(9/163),两组比较,差异有统计学意义(x2=6.484,5.316,P＜0.05).结论 胰十二指肠切除术采用胰管空肠黏膜对黏膜吻合的术后并发症发生率显著低于套入式胰肠端端吻合,胰管空肠黏膜对黏膜吻合可能更有利于患者术后的恢复.     

改良胰空肠吻合预防胰十二指肠切除术后胰瘘

目的: 探讨胰十二指肠切除术中细胰管与空肠黏膜吻合技术的改进.方法: 回顾1994~2004年间接受胰十二指肠切除手术且胰管直径≤2 mm的恶性肿瘤患者61例临床资料,其中29例采取Child胰肠端端套入式吻合法(A组),32例行胰管与空肠黏膜二点或三点吻合法(B组),比较两组病人胰瘘的发生率、病死率、住院时间.结果:A组胰瘘的发生率为24.1%,B组为3.1%,差异有显著性意义(P<0.05).A组病死率为13.8%, B组病死率为0%, 差异有显著性意义 (P<0.05). A, B两组的住院天数分别为:(28.7±6.6)d,(19.4±4.6)d,差异有非常显著性意义(P<0.01).结论: 胰十二指肠切除术中对细胰管(直径≤2 mm)与空肠黏膜二点或三点吻合法能有效防治术后胰瘘,操作简单,是胰十二指肠切除术中对细胰管较可靠的处理方式.     

“悬吊式”胰管-空肠端侧连续缝合吻合在胰十二指肠切除术中的应用

目的 探讨“悬吊式”胰管-空肠端侧连续缝合吻合对胰十二指肠切除术后胰瘘发生的影响,探讨其实用性、安全性、有效性.方法 采用非随机临床对照研究,对165例施行胰十二指肠切除术的临床资料行对比分析,比较三种不同胰肠吻合方法对胰瘘及其他并发症发生率的影响.结果 总胰瘘发生率13.9％.端端或端侧套入式胰肠吻合组(A组)、端侧黏膜-黏膜胰管空肠吻合组(B组)和悬吊式胰管-空肠端侧连续缝合吻合组(C组)的胰瘘发生率分别是23.1％(12/52)、18.8％(9/48)和3.1％(2/65).C组在手术时间、术中出血及术后血浆管引流量上优于A、B两组(P＜0.05),A、B两组间差异无统计学意义(P＞0.05).其他并发症三组间差异无统计学意义(P＞0.05).结论 悬吊式胰管-空肠端侧连续吻合术能显著降低胰十二指肠切除术后的胰瘘发生率.该术式安全、实用、便捷,值得推广.     

胰十二指肠切除术后胰瘘的防治体会

目的分析胰十二指肠切除术后胰瘘的防治措施,以减少胰十二指肠切除术后并发症发生率。方法2001年1月至2005年12月对106例患者行胰十二指肠切除术,其中常规胰十二指肠切除术87例,保留幽门的胰十二指肠切除术4例,扩大胰十二指肠切除术15例。结果术后共出现胰瘘11例(10.4%),胰腺空肠端端套入式吻合、胰腺空肠端侧套入式吻合、胰管空肠黏膜吻合三种吻合方式胰瘘发生率分别为9.6%、12.9%和8.7%。术后平均胰瘘持续时间为(14.7±4.5)d。所有胰瘘患者均应用生长抑素类药物抑制胰腺外分泌治疗。结论防治胰十二指肠切除术后胰瘘的关键是改善胰肠吻合口的质量和保持引流通畅。术后应用生长抑素类药物有助于胰瘘的愈合。     

胰十二指肠切除术中悬吊式胰管-空肠端侧连续缝合吻合术式的临床研究

目的:探讨悬吊式胰管-空肠端侧连续吻合术式在胰十二指肠切除术中应用的实用性、安全性和有效性。方法:采用前瞻性、随机对照设计,对165例施胰十二指肠切除术患者分别采用端端或端侧套入式吻合(A组),端侧黏膜-黏膜吻合(B组)或悬吊式胰管-空肠端侧连续缝合吻合(C组),比较各组胰瘘及其他并发症的发生率。结果:总胰瘘发生率13.9%(23/165);A,B,C组的胰瘘发生率分别是23.1%(12/52),18.8%(9/48),3.1%(2/65),C组明显低于A,B组(均P<0.05);此外,C组在手术时间、出血量及术后血浆管引流量上亦明显优于A,B两组(均P<0.05),其他并发症3组间无明显差异(均P>0.05);A,B两组间各项指标均无明显差异(均P>0.05)。结论:悬吊式胰管-空肠断侧连续吻合术能降低胰十二指肠切除术后的胰瘘发生率;该术式安全、实用,值得推广。     

胰肠吻合方式和保留幽门对胰瘘发生的影响

目的探讨胰肠吻合方式和保留幽门对胰十二指肠切除术后胰瘘发生的影响。方法回顾性分析我院1994年1月至2007年5月间142例胰十二指肠切除术患者临床资料，探讨胰瘘发生的危险因素，比较胰肠黏膜对黏膜胰管空肠端-侧吻合、胰腺空肠端-端套入式吻合及保留幽门与否对胰瘘发生率的影响。结果术后胰瘘总发生率22％（32／142），其中黏膜对黏膜吻合组21％（29／132），传统胰腺空肠端-端套入组33．33％（3／9）。结论胰肠吻合方式、保留幽门与否对胰瘘发生率无显著性的影响。     

袖套式prolene线单层连续缝合在胰肠吻合中的应用

目的:探讨袖套式prolene线单层连续缝合在胰肠吻合中的应用价值。方法:采用前瞻、随机对照设计,将2009年8月—2014年3月124例行胰十二指肠切除术(PD)患者根据不同胰肠吻合方式分为3组,分别采用传统端端或端侧套入式吻合(套入式吻合组),胰管空肠黏膜端侧吻合(黏膜端侧吻合组),袖套式prolene线单层连续缝合(袖套式缝合组),比较各组胰瘘发生率及其他手术相关指标。结果:袖套式缝合组的胰肠吻合时间明显短于另两组(均P<0.05);全组总胰瘘发生率18.5%(23/124),袖套式缝合组胰瘘发生率(4.8%)明显低于套入式吻合组(29.3%)与黏膜端侧吻合组(22.0%)(均P<0.05);3组间其他并发症差异均无统计学意义(均P>0.05)。按胰管直径与胰腺质地分层后的组间比较显示,胰管直径<3 mm时,袖套式缝合组胰瘘发生率(7.1%)明显低于黏膜端侧吻合组(50.0%)(P<0.05);软质地胰腺时,袖套式缝合组胰瘘发生率(11.8%)明显低于套入式吻合组(53.3%)与黏膜端侧吻合组(53.8%)(均P<0.05)。按胰管直径与胰腺质地分层后的组内比较显示,套入式吻合组中,硬质地胰腺亚组胰瘘发生率(15.4%)明显低于软质地亚组(53.3%)(P<0.05);黏膜端侧吻合组中,大直径胰腺亚组(7.4%)胰瘘发生率明显低于小直径胰管亚组(50.0%),硬质地亚组胰瘘发生率(7.1%)明显低于软质地亚组(53.8%)(均P<0.05);袖套式缝合组中,各亚组间差异无统计学意义(均P>0.05)。结论:袖套式prolene线单层连续缝合方法安全简便,能降低PD术后的胰瘘发生率,尤其在胰管直径<3 mm或软胰腺质地时采用此法优势明显。     

胰十二指肠切除术中胰肠吻合方式与术后胰漏及吻合口出血的相关性研究

目的分析胰十二指肠切除术（PD）中胰肠吻合方式与术后胰漏及吻合口出血的关系。方法回顾性分析2008年1月至2012年9月期间我院行PD的526例患者的临床资料。526例PD患者行胰肠吻合的方式：胰管空肠端侧黏膜对黏膜吻合（简称黏膜对黏膜吻合）359例,其中149例硅胶引流管内置（简称引流管内置）,130例硅胶引流管引流至体外（简称引流至体外）,80例硅胶引流管未放置（简称引流管未置）;胰腺空肠端侧套入式吻合165例（简称套入式吻合）,均未放置硅胶引流管;胰肠侧侧吻合2例（简称侧侧吻合）,均未放置硅胶引流管。结果526例PD患者术后共发生胰漏34例（6.46%）,胰肠吻合口出血8例（1.52%）,死亡32例（6.08%）。①黏膜对黏膜吻合的胰漏发生率明显低于套入式吻合〔4.18%（15/359）比11.52%（19/165）,χ2=10.029,P=0.002〕;黏膜对黏膜吻合与套入式吻合的吻合口出血发生率比较差异无统计学意义〔1.67%（6/359）比1.21%（2/165）,χ2=0.159,P=0.691〕。②黏膜对黏膜吻合术式中,引流管内置者和引流至体外者的胰漏发生率均分别明显低于引流管未置者〔2.68%（4/149）比11.25%（9/80）,χ2=7.132,P=0.008;1.54%（2/130）比11.25%（9/80）,χ2=9.410,P=0.002〕;引流管内置者与引流至体外者的胰漏发生率比较差异无统计学意义〔2.68%（4/149）比1.54%（2/130）,χ2=0.433,P=0.510〕。引流管内置者与引流至体外者的吻合口出血发生率比较差异无统计学意义〔2.68%（4/149）比1.54%（2/130）,χ2=0.433,P=0.510〕。结论黏膜对黏膜吻合方式胰漏的发生率明显低于套入式吻合方式,但吻合口出血的发生率无明显差异。胰管内硅胶引流管内置或引流至体外均能降低术后胰漏的发生率,但是对于吻合口出血的发生率无明显影响。     

Roux-en-Y Drainage of the Pancreatic Stump Decreases Pancreatic Fistula After Distal Pancreatic Resection

Clinically relevant fistula after distal pancreatic resection occurs in 5–30% of patients, prolonging recovery and considerably increasing in-hospital stay and costs. We tested whether routine drainage of the pancreatic stump into a Roux-en-Y limb after distal pancreatic resection decreased the incidence of fistula. From October 2001, data of all patients undergoing pancreatic distal resection were entered in a prospective database. From June 2003 after resection, the main pancreatic duct and the pancreatic stump were oversewn, and in addition, anastomosed into a jejunal Roux-en-Y limb by a single-layer suture (n = 23). A drain was placed near the anastomosis, and all patients received octreotide for 5–7 days postoperatively. The volume of the drained fluid was registered daily, and concentration of amylase was measured and recorded every other day. Patient demographics, hospital stay, pancreatic fistula incidence (≥30 ml amylase-rich fluid/day on/after postoperative day 10), perioperative morbidity, and follow-up after discharge were compared with our initial series of patients (treated October 2001–May 2003) who underwent oversewing only (n = 20). Indications, patient demographics, blood loss, and tolerance of an oral diet were similar. There were four (20%) pancreatic fistulas in the “oversewn” group and none in the anastomosis group (p < 0.05). Nonsurgical morbidity, in-hospital stay, and follow-up were comparable in both groups. Wagner and Gloor both contributed equally in this work.     

胰腺星状细胞在胰腺纤维化中的作用

目的介绍胰腺星状细胞在胰腺纤维化中的作用及抗胰腺纤维化研究进展。方法复习相关文献资料并作综述。结果胰腺星状细胞的活化与胰腺纤维化密切相关,抑制胰腺星状细胞活化可为临床治疗慢性胰腺炎提供新的途径。结论胰腺星状细胞是胰腺纤维化发病的关键环节,并逐渐成为抗胰腺纤维化及治疗慢性胰腺炎的重要靶标。     

胰腺手术后胰瘘的治疗现状

瘘是消化系统常见的疾病或并发症 ,发病率高 ,治疗棘手 ,疗程较长 ,花费较多。我刊经常收到热心读者来函或来电咨询相关问题 ,例如 :胰腺假性囊肿与胰瘘的关系 ,如何采取干预措施预防向胰外瘘的发展 ;再如 ,肝外伤特别是钝性伤时 ,如何在手术过程中避免遗漏肝内胆管损伤等。为了能使读者较为系统全面地认识这个问题 ,本期诚邀国内这一领域的相关专家进行讨论 ,希望能抛砖引玉 ,使更多医生、研究人员提高认识 ,如果读者在临床工作中有好的经验 ,欢迎大家踊跃来稿继续讨论     

Anatomy-Specific Pancreatic Stump Management to Reduce the Risk of Pancreatic Fistula After Pancreatic Head Resection

Background  

The anatomical status of the pancreatic remnant after a pancreatic head resection varies greatly among patients. The aim of the present study was to improve management of the pancreatic remnant for reducing pancreatic fistula after pancreatic head resection.     

Internal Pancreatic Stent Causing Irreversible Dilatation of Pancreatic Duct

A 28-year-old woman underwent a pylorus preserving Whipple procedure for pancreatic serous cystadenoma located on the head of the pancreas. During the operation, an internal stent (7F silastic catheter, 9 cm in length) was placed within the pancreatic duct in the area of pancreaticojejunal end-to-end Dunking type anastomosis to prevent development of fistula. The stent was positioned so that one third of its length would lie into the pancreatic duct, and it was anchored to the periductal pancreatic tissue with only one rapidly absorbable chromic suture. Leakage from the anastomosis was not observed, and she was discharged without any complaint. Early postoperative abdominal CT examination revealed that the stent was retained within the normal caliber pancreatic duct (Fig. 1a). Six months after the operation, she began to complain to epigastric pain triggered by the meals. The laboratory analysis was normal, particularly liver biochemical tests and serum amylase. The internal pancreatic stent within the dilated pancreatic duct was detected by an additional CT examination (Fig. 1b). The stent was removed endoscopically at the third attempt. The pain was resolved after its removal. Control CT examination which was taken at the 18th month after removal of the stent showed dilatation of the pancreatic duct (Fig. 2a). The patient remained free of any complaint, although regressed pancreatic duct dilatation has persisted over 4 years of follow-up (Fig. 2b).     

Pancreatic cancer

During 1972-1981, a total of 177 individuals were diagnosed as having pancreatic cancer at the Central Hospital of Eskilstuna, Sweden. The mean crude incidence rate was 15.0 X 10(-5) year-1. Only 56% of the patients had the diagnosis made prior to death. 63% of the cancers had advanced beyond therapeutic range. Symptoms compatible with upper abdominal disease for more than six months prior to diagnosis occurred in 27% of the cases, and 15% had sought medical advice more than 6 months prior to diagnosis. Radical surgery was performed on 5 patients of whom one died postoperatively, and 61 patients (34%) underwent palliative treatment. The postoperative mortality rate after palliative treatment was 28%. The mean survival time for the whole series was 2.6 months, and 13% survived for one year. One patient survived for 2 years after palliative treatment. It is concluded that the only means by which the prognosis for patients with pancreatic cancer may be improved is to define populations at high risk and to develop more specific and sensitive diagnostic methods.     

Pancreatic cancer

Pancreatic cancer remains a devastating diagnosis whose prognosis has remained largely unchanged over the last two decades. Where possible, surgical resection represents the optimal treatment strategy, yet just one-fifth of patients meet the operative criteria. The non-specific nature of presentation coupled with its relative chemoresistance are partly responsible for the poor survival rates. Improvements in understanding the natural history of the disease, more sophisticated imaging techniques and increased use of endoscopic ultrasound, has allowed earlier detection and expeditious management of pancreatic cancer. The use of FOLFIRINOX and gemcitabine nab-paclitaxel regimens has shown improved median survival in patients with widespread metastatic disease. To this end, these regimens have been used with some success in the neoadjuvant setting. Future perspectives include studying the carcinogenesis of pancreatic malignancy and tumour related genetic mutations, which it is hoped will lead to new developments in the management of pancreatic cancer, and in turn improved survival rates.     

Pancreatic tuberculosis

A 63-year-old Japanese man visited our institute with fever of unknown origin. Findings on preoperative imaging modalities were consistent with pancreatic carcinoma, but a positive tuberculin skin test indicated tuberculosis infection. Negative results for MycobacteriumDNA polymerase chain reaction from sputum and bone-marrow aspiration biopsy specimens ruled out pulmonary and miliary tuberculosis, respectively. Positron emission tomography (PET) with 2-[fluorine-18]-fluoro-2-deoxy- d-glucose (FDG) showed multiple labeled spots within the pancreas body and chest. Distal pancreatectomy was performed with a diagnosis of suspected pancreatic carcinoma, but the histological and microbiological diagnosis was Mycobacterium infection. A rare case of pancreatic tuberculosis evaluated by FDG PET is reported and discussed herein.