胰十二指肠切除术后胰瘘的防治近况

目的总结胰十二指肠切除术后胰瘘的防治近况.方法综合近年来国内外文献有关胰瘘防治的方法和进展,对各种预防胰瘘方法进行评价.结果胰腺残端的处理是预防胰瘘的关键,各种胰肠吻合术预防胰瘘作用有不同结果,胰胃和胰肠吻合术胰瘘的发生率分别为12.3%和11.1%左右.捆绑式胰肠吻合术,在连续100例的临床应用中,其胰瘘率为0,效果独特.结论各种胰腺残端的处理方法各有利弊,其中胰肠吻合为最常用的方法,捆绑式胰肠吻合术对预防胰瘘的发生有确切效果,值得推广应用.     

胰十二指肠切除术后胰兼的防治近况

目的：总结胰十二指肠切除术后胰瘘的防治近况，方法：综合近年来国内外文献有关胰瘘防治的方法和进展，对各种预防胰兼方法进行评价。结果：胰腺残端的处理是预防胰瘘的关键，各种胰肠吻合术预防胰兼作用有不同的结果，胰胃和胰肠吻合术胰兼的发生率分别为12．3％和11．1％左右，捆绑式胰肠吻合术，在连续100例的临床应用中，其胰瘘率为0，效果独特。结论：各种胰腺残端的处理方法各有利弊，其中胰肠吻合为最常用的方法，捆绑式胰肠吻合术对预防胰兼的发生有确切效果，值得推广应用。     

胰十二指肠切除术中胰消化道吻合的演变

胰腺残端处理方法与胰十二指肠切除术（PD）后胰瘘发生密切相关，胰管闭塞法导致胰腺功能不全、胰瘘而淘汰。胰消化道吻合包括胰空肠、胰胃和胰十二指肠吻合，吻合方法的改进使胰瘘发生率明显下降，甚至为零。     

胰体尾切除术后胰瘘预防及处理

胰体尾切除术术后胰瘘发生率较高,主要与胰腺质地、胰管直径及胰腺残端的处理方式等有关。依据胰腺质地及病理检查结果合理选择胰腺残端处理方式是减少胰瘘发生的关键。胰腺肥厚或水肿质脆者胰瘘发生率较高,推荐残端手工缝合;如近端胰管存在梗阻并伴胰管扩张,建议行胰管-空肠吻合;对于胰腺扁平且质地柔软者,推荐使用直线切割闭合器。胰体尾切除术术后胰瘘经非手术治疗多可治愈。通畅引流可有效预防腹腔感染和出血的发生,是促进胰瘘愈合的关键。非手术治疗无效时可考虑胰管支架置入,部分难治性胰瘘病人须行窦道-空肠吻合。     

预防胰十二指肠切除术后胰瘘发生的体会

预防胰十二指肠切除术后胰瘘发生的体会王先桂，杜永旭，陈绪丰我院自１９８５年４月～１９９３年９月共施行胰十二指肠切除术１４例．采用Ｃｈｉｌｄ法重建胃肠道，在对胰残端的处理和胰肠端端套入吻合的技术上作一些改进，收到较好的手术效果．现报告如下。一般资料本组...     

胰十二指肠切除术后胰瘘发生的危险因素及风险预测

目的总结胰十二指肠切除术后胰瘘发生的危险因素并探讨胰瘘风险预测系统的临床应用。方法复习近年来国内外有关胰十二指肠切除术后胰瘘危险因素及风险预测系统研究的相关文献并进行综述。结果胰十二指肠切除术后胰瘘发生的危险因素众多,包括患者自身因素(性别、年龄、基础疾病等)、疾病相关因素(胰腺质地、胰管直径、病理类型等)及手术相关因素(手术时间、术中失血量、吻合方式、胰管引流等)。胰瘘风险预测系统对胰十二指肠切除术后胰瘘发生的预测具有较好的准确度。结论胰十二指肠切除术后胰瘘发生最重要的危险因素为胰腺质地软、胰管直径小;胰瘘风险预测系统的临床应用价值大,有助于术后胰瘘的预防。     

Kissing式胰肠吻合在胰十二指肠切除术中的应用

胰腺残端的处理是胰十二指肠切除术的关键步骤,一旦发生胰漏或胰腺残端出血将大大增加围手术期病死率[1].受启发于尿道会师的原理,我们提出了Kissing式胰肠吻合,即不直接缝合胰管和肠黏膜,而是让它们尽量接近后(kissing),用内支架支撑使其自然愈合.从2006年开始我们利用该方法已完成胰十二指肠切除术81例,现报告如下.     

胰十二指肠切除术后胰瘘的预防

目的 总结胰十二指肠切除术后胰瘘的预防经验.方法 回顾性分析1992年1月至2010年11月97例行胰十二指肠切除术的病例资料.结果 本组术后无胰瘘发生,术后肺部感染9例,腹部伤口感染6例(其中伤口裂开2例,右胸腔积液2例,胰腺残端出血、腹腔脓肿形成、胃排空延迟各1例),术后因高渗性昏迷死亡1例.结论 完全性胰液外引流...     

胰十二指肠切除术中胰腺残端的处理

胰十二指肠切除术中胰腺残端的处理／ＢｒｅｗｅｒＭＳ／ＡｍＪＳｕｒｇ，１９９６，１７１：４３８胰十二指肠切除术最常见的并发症是胰漏，进而导致许多并发症，甚至死亡。目前已有许多处理胰腺残端的方法，但任何一种都非完美无缺。本文介绍的一种成功的方法是，首先在...     

胰腺切除不伴胰瘘的形成

作者介绍一种胰腺切除不伴胰瘘形成的手术方法。在10例的胰十二指肠切除术后,胰腺的残端的处理方法是:(1)用可吸收的聚乙二醇酸000缝线缝扎胰管(作荷包缝合);(2)将胰腺残端套入空肠腔内,用000丝线作二层缝合,其内层缝合空肠壁和胰腺包膜及其包膜下实质,外层缝合使空肠呈袖套状固定在胰包膜上;(3)在此空肠上作一侧孔插入-18F 导管,以引流邻近胰空肠吻合处的胆汁和胰液。在15例远端胰大部切除术后胰腺残端的处理方法是:(1)结扎胰腺;(2)用褥式缝合和大网膜填塞,以闭合胰腺的切面。作者认为暂时结扎胰管可防止胰空肠吻合口愈合前激活的胰酶在空肠腔内的作用,这是防止胰瘘形     

The Role of “Fatty Pancreas” and of BMI in the Occurrence of Pancreatic Fistula After Pancreaticoduodenectomy

Introduction  

Pancreatic fistula (PF) after pancreaticoduodenectomy (PD) is still a serious complication. We hypothesized that the amount of fatty tissue in the pancreatic parenchyma could be associated with the occurrence of PF after PD with pancreatogastrostomy.     

A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy.

OBJECTIVE: The authors hypothesized that pancreaticogastrostomy is safer than pancreaticojejunostomy after pancreaticoduodenectomy and less likely to be associated with a postoperative pancreatic fistula. SUMMARY BACKGROUND DATA: Pancreatic fistula is a leading cause of morbidity and mortality after pancreaticoduodenectomy, occurring in 10% to 20% of patients. Nonrandomized reports have suggested that pancreaticogastrostomy is less likely than pancreaticojejunostomy to be associated with postoperative complications. METHODS: Between May 1993 and January 1995, the findings for 145 patients were analyzed in this prospective trial at The Johns Hopkins Hospital. After giving their appropriate preoperative informed consent, patients were randomly assigned to pancreaticogastrostomy or pancreaticojejunostomy after completion of the pancreaticoduodenal resection. All pancreatic anastomoses were performed in two layers without pancreatic duct stents and with closed suction drainage. Pancreatic fistula was defined as drainage of greater than 50 mL of amylase-rich fluid on or after postoperative day 10. RESULTS: The pancreaticogastrostomy (n = 73) and pancreaticojejunostomy (n = 72) groups were comparable with regard to multiple parameters, including demographics, medical history, preoperative laboratory values, and intraoperative factors, such as operative time, blood transfusions, pancreatic texture, length of pancreatic remnant mobilized, and pancreatic duct diameter. The overall incidence of pancreatic fistula after pancreaticoduodenectomy was 11.7% (17/145). The incidence of pancreatic fistula was similar for the pancreaticogastrostomy (12.3%) and pancreaticojejunostomy (11.1%) groups. Pancreatic fistula was associated with a significant prolongation of postoperative hospital stay (36 +/- 5 vs. 15 +/- 1 days) (p < 0.001). Factors significantly increasing the risk of pancreatic fistula by univariate logistic regression analysis included ampullary or duodenal disease, soft pancreatic texture, longer operative time, greater intraoperative red blood cell transfusions, and lower surgical volume (p < 0.05). A multivariate logistic regression analysis revealed the factors most highly associated with pancreatic fistula to be lower surgical volume and ampullary or duodenal disease in the resected specimen. CONCLUSIONS: Pancreatic fistula is a common complication after pancreaticoduodenectomy, with an incidence most strongly associated with surgical volume and underlying disease. These data do not support the hypothesis that pancreaticogastrostomy is safer than pancreaticojejunostomy or is associated with a lower incidence of pancreatic fistula.     

Risk factors for pancreatic fistula following pancreaticoduodenectomy: A retrospective study in a Thai tertiary center

AIM To analyze the risk factors of postoperative pancreatic fistula following pancreaticoduodenectomy in a Thai tertiary care center.METHODS We retrospectively analyzed 179 patients who underwent pancreaticoduodenectomy at our hospital from January 2001 to December 2016. Pancreatic fistula were classified into three categories according to a definition made by an International Study Group on Pancreatic Fistula. The risk factors for pancreatic fistula were analyzed by univariate analysis and multivariate logistic regression analysis.RESULTS Pancreatic fistula were detected in 88/179 patients(49%) who underwent pancreaticoduodenectomy. Fifty-eight pancreatic fistula(65.9%) were grade A, 22 cases(25.0%) were grade B and eight cases(9.1%) were grade C. Clinically relevant pancreatic fistula were detected in 30/179 patients(16.7%). The 30-d mortality rate was 1.67%(3/179 patients). Multivariate logistic regression analysis revealed that soft pancreatic texture(odds ratio = 3.598, 95%CI: 1.77-7.32) was the most significant risk factor for pancreatic fistula. A preoperative serum bilirubin level of 3 mg/d L was the most significant risk factor for clinically relevant pancreatic fistula according to univariate and multivariate analysis.CONCLUSION Soft pancreatic tissue is the most significant risk factor for postoperative pancreatic fistula. A high preoperative serum bilirubin level( 3 mg/d L) is the most significant risk factor for clinically relevant pancreatic fistula.     

The Methods of Reconstruction of Pancreatic Digestive Continuity After Pancreaticoduodenectomy: A Meta-Analysis of Randomized Controlled Trials

Background  

Pancreatic fistula (PF) is an important factor responsible for the considerable morbidity associated with pancreaticoduodenectomy (PD). There have been many techniques proposed for the reconstruction of pancreatic digestive continuity to prevent fistula formation but which is best is still highly debated. We carried out a systematic review and meta-analysis to determine the effectiveness of methods of anastomosis after PD.     

How Do We Predict the Clinically Relevant Pancreatic Fistula After Pancreaticoduodenectomy?—An Analysis in 244 Consecutive Patients

Background  

The most important problem in pancreatic fistula is whether one can distinguish clinical pancreatic fistula, grade B + C fistula by the International Study Group on Pancreatic Fistula (ISGPF), from transient pancreatic fistula (grade A), in the early period after pancreaticoduodenectomy (PD). It remains unclear what predictive risk factors can precisely predict which clinical relevant or transient pancreatic fistula when diagnosed pancreatic fistula on POD3 by ISGPF criteria.     

Analysis of clinical trials evaluating complications after pancreaticoduodenectomy: A new era of pancreatic surgery

Pancreatic fistula and delayed gastric emptying (DGE) are the major postoperative complications of pancreaticoduodenectomy (PD). Pancreatic fistula is life-threatening and DGE, while not life-threatening, prolongs the hospital stay, increasing costs and compromising quality of life. To establish the current consensus of pancreatic fistula and DGE after PD, we analyzed the results of randomized controlled trials (RCTs) designed to prevent these postoperative complications. Five RCTs comparing PD with pylorus-preserving pancreaticoduodenectomy (PpPD) performed for periampullary tumors showed that the two procedures were equally effective with respect to morbidity, mortality, and survival. We reviewed 15 RCTs, 2 prospective nonrandomized studies, and 2 meta-analyses of operative techniques and postoperative management designed to prevent pancreatic fistula. The results of the RCTs designed to prevent pancreatic fistula recommended duct-to-mucosa pancreaticojejunostomy or one-layer end-to-side pancreaticojejunostomy, equally. We also reviewed five RCTs of operative techniques and postoperative management designed to prevent DGE, which revealed that the antecolic route for duodenojejunostomy significantly reduced the incidence of DGE. Further RCTs to study innovative approaches to prevent postoperative complications after PD are warranted.     

Jejunum or Stomach for the Pancreatic Anastomosis After Pancreaticoduodenectomy

Objective: The authors hypothesized that pancreaticogastrostomy is safer than pancreaticojejunostomy after pancreaticoduodenectomy and less likely to be associated with a postoperative pancreatic fistula.Summary Background Data: Pancreatic fistula is a leading cause of morbidity and mortality after pancreaticoduodenectomy, occurring in 10% to 20% of patients. Nonrandomized reports have suggested that pancreaticogastrostomy is less likely than pancreaticojejunostomy to be associated with postoperative complications.Methods: Between May 1993 and January 1995, the findings for 145 patients were analyzed in this prospective trial at The Johns Hopkins Hospital. After giving their appropriate preoperative informed consent, patients were randomly assigned to pancreaticogastrostomy or pancreaticojejunostomy after completion of the pancreaticoduodenal resection. All pancreatic anastomoses were performed in two layers without pancreatic duct stents and with closed suction drainage. Pancreatic fistula was defined as drainage of greater than 50 mL of amylase-rich fluid on or after postoperative day 10.Results: The pancreaticogastrostomy (n=73) and pancreaticojejunostomy (n=72) groups were comparable with regard to multiple parameters, including demographics, medical history, preoperative laboratory values, and intraoperative factors, such as operative time, blood transfusions, pancreatic texture, length of pancreatic remnant mobilized, and pancreatic duct diameter. The overall incidence of pancreatic fistula after pancreaticoduodenectomy was 11.7% (171145). The incidence of pancreatic fistula was similar for the pancreaticogastrostomy (12.3%) and pancreaticojejunostomy (11.1%) groups. Pancreatisc fistula was associated with a significant prolongation of postoperative hospital stay (36±5 vs. 15±1 days) (p<0.001). Factors significantly increasing the risk of pancreatic fistula by univariate logistic regression analysis included ampullary or duodenal disease, soft pancreatic texture, longer operative time, greater intraoperative red blood cell transfusions, and lower surgical volume (p<0.05). A multivariate logistic regression analysis revealed the factors most highly associated with pancreatic fistula to be lower surgical volume and ampullary or duodenal disease in the resected specimen.Conclusions: Pancreatic fistula is a common complication after pancreaticoduodenectomy, with an incidence most strongly associated with surgical volume and underlying disease. These data do not support the hypothesis that pancreaticogastrostomy is safer than pancreaticojejunostomy or is associated with a lower incidence of pancreatic fistula.     

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??A reoperation method for pancreatic fistula with hemorrhage after pancreaticoduodenectomy WU Wen-guang, WU Xiang-song, LI Mao-lan, et al. Department of General Surgery, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
Corresponding author: LIU Ying-bin, E-mail: laoniulyb@163.com
Abstract Objective To evaluate a reasonable reoperation method for pancreatic fistula with hemorrhage after pancreaticoduodenectomy. Methods From May 2009 to December 2012, 143 cases of pancreaticoduodenectomy (PD) were performed in Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. Among them, 3 cases had pancreatic fistula with hemorrhage. Pancreatic juice external drainage, binding pancreaticojejunostomy, and binding pancreaticogastrostomy was performed in 1 case respectively for residual pancreatic reconstruction. Results Three cases had no serious complication and the first case underwent reoperation after 6 months for pancreatic juice internal drainage. Conclusion Binding pancreaticojejunostomy (pancreaticogastrostomy) describes a new binding anastomosis technique instead of direct suture for residual pancreatic reconstruction in reoperation, and is worthy of operating method for pancreatic fistula with hemorrhage after PD.     

Pancreatico-enteric fistula post pancreatic duct ligation for delayed haemorrhage complicating pancreaticoduodenectomy

IntroductionPancreatic fistula remains the main cause for postoperative morbidity following pancreaticoduodenectomy. The coincidence of sentinel bleed prior to post pancreatectomy haemorrhage (PPH) and pancreatic fistula is associated with very high mortality.Presentation of caseWe report a case of pancreaticoduodenectomy complicated by postoperative leak and hematemesis. Severe delayed haemorrhage from the pancreatico-jejunostomy necessitated re-laparotomy and complete disconnection of the pancreatic anastomosis. Hemodynamic instability precluded a pancreatectomy or creation of a new anastomosis. A follow up MRI done 3 weeks after the patient’s discharge demonstrated a fistulous tract causing a communication between both the pancreatic and biliary systems and the enteric loop.DiscussionSpontaneous development a pancreatico-enteric fistula despite ligation of the pancreatic duct and complete disconnection of the pancreatic anastomosis has never been reported in literature to date.ConclusionPancreatic duct occlusion may be considered over a completion pancreatectomy or revisional pancreatic anastomosis in hemodynamically unstable and challenging cases.     

No Mortality or Pancreatic Fistula After Full-Thickness Suture Pancreaticogastrostomy in 39 Patients Who Underwent Pancreaticoduodenectomy

Pancreaticoduodenectomy is considered the standard operation for periampullary tumors. Despite major advances in pancreatic surgery, pancreatic fistula is still an important cause of morbidity and mortality after pancreaticoduodenectomy. Meticulous surgical technique and proper reconstruction of the pancreas are essential to prevent pancreatic fistula. Pancreaticogastrostomy is a safe method for reconstruction of the pancreas after pancreaticoduodenectomy. Regardless of pancreatic texture or duct diameter, the reconstruction is performed by passing full-thickness sutures through both the anterior and posterior sides of the pancreas. In this study, we report 39 cases of reconstruction with pancreaticogastrostomy after pancreaticoduodenectomy without mortality or pancreatic fistula.Key words: Pancreaticogastrostomy, Pancreatic fistula, Pancreaticoduodenectomy, Full-thickness suturesPancreaticoduodenectomy (PD) is considered the standard treatment for periampullary tumors. Despite major advances in pancreatic surgery, overall postoperative morbidity after PD is high, even in high-volume centers.¹ While the operation-associated mortality rate of pancreatic surgery has decreased to less than 4%, the operation-associated morbidity rate is reported to be as high as 50%, largely due to the pancreaticoenteric anastomosis, the “Achilles'' heel” of pancreatic surgery.^2–4Pancreatic fistula (PF) is the most important cause of morbidity and mortality after PD. Soft pancreatic tissue texture and small pancreatic duct diameter have been identified as risk factors for PF. Pancreatic fistula may cause life-threatening complications, such as postoperative hemorrhage and peritonitis.⁵ We report the first cases without mortality or PF in 39 patients who were reconstructed with pancreaticogastrostomy (PG) after PD. In this study, we performed the PG by passing full-thickness sutures through the pancreas wall from both the anterior and posterior sides of the gland regardless of pancreatic tissue texture or pancreatic duct diameter.