200例胰十二指肠切除术后早期并发症危险因素分析(英文)

目的胰十二指肠切除术是目前许多壶腹周围良恶性疾病的首选治疗方式。本研究目的是寻找出胰十二指肠切除术后的早期并发症发生的危险因素。方法回顾分析1996年10月至2002年9月共200例胰十二指肠切除术的临床资料。其中包括标准胰十二指肠切除术176例,加做扩大腹膜后淋巴结廓清术者为24例,无保留幽门括约肌者。对于胰腺质地硬且胰管扩张患者采用端侧粘膜对粘膜胰肠吻合,而胰腺质软且胰管扩张不明显患者行对端套入胰腺空肠吻合。通过单因素及多因素方法分析早期并发症发生的相关因素。结果术后并发症发生率为21%(42/200),胰肠吻合口瘘最为常见。高龄(优势比2.162),术前合并糖尿病(优势比4.0862),术前血清总胆红素水平高于171.1μmol/L(优势比7.556),端端胰肠吻合(优势比2.616)以及术中输血量超过1000 mL(优势比2.410)是术后早期并发症发生的独立危险影响因素。而胆肠吻合口留置 T 管(优势比0.100)可以显著减少术后早期并发症的发生。结论已经发表的关于胰十二指肠切除术早期并发症危险因素的相关文献之间的可比性不强。对于不同的专业组及患者,胰十二指肠切除术应当个体化,以期获得最好的治疗效果。     

改良胰十二指肠切除术185例手术体会

摘 要：［目的］ 探讨胰十二指肠切除术中胰腺空肠端侧吻合技术。［方法］ 回顾性分析185例胰十二指肠切除术行胰腺空肠端侧吻合患者的临床资料,结合术后并发症及死亡率、住院时间等,探讨胰腺空肠端侧吻合技术。［结果］ 根据患者胰腺的情况如质地、厚度、胰管直径、胰管后壁胰腺组织的厚度、有无炎症,结合空肠的直径、空肠壁的厚度选择胰管空肠黏膜—黏膜吻合、端侧套入式吻合等不同的吻合方式。术中胰肠重新吻合9例。术后胰瘘11例、胆瘘4例、死亡4例。胰管空肠黏膜—黏膜吻合时间较长。［结论］ 根据胰腺和空肠的情况进行个体化的胰管空肠黏膜—黏膜吻合、端侧套入式吻合等不同的吻合是胰十二指肠切除术中胰腺空肠吻合的理想选择。     

胰肠吻合方式对胰十二指肠切除术后胰瘘的影响

目的:探讨胰肠吻合方式对胰十二指肠切除术后胰瘘的影响。方法:回顾性分析2008年10月至2013年8 月天津医科大学肿瘤医院收治的145 例术前诊断为壶腹周围肿瘤行胰十二指肠切除术患者的临床资料。对影响术后胰瘘发生的相关因素进行统计分析。结果:本组患者中27例术后发生胰瘘。在4 种胰肠吻合方式中，胰管空肠黏膜吻合和Blumgart 吻合的胰瘘发生率低，且皆无C 级胰瘘。多因素分析应用Logistic回归，结果表明不同的胰肠吻合方式及性别为术后胰瘘发生的独立预后因素。结论:胰肠吻合方式是影响胰十二指肠切除术后胰瘘发生的危险因素。      

改良胰腺空肠套入式吻合在胰十二指肠切除术中的应用

目的:比较在胰十二指肠切除术(PD)中,改良胰腺空肠套入式吻合与胰管空肠黏膜吻合两种胰肠吻合方式术后胰瘘等相关并发症的发生率.方法:回顾性分析2014年1月至2016年12月盛京医院胰腺内分泌外科实施的59例PD手术患者的临床资料,其中采用改良胰腺空肠套入式吻合35例,采用胰管空肠黏膜吻合24例,比较两组术后胰瘘等相关并发症的发生率.结果:比较改良胰腺空肠套入式吻合与胰管空肠黏膜吻合两种胰肠吻合方式,发现手术时间和术中出血比较无统计学差异;术后胰瘘等相关并发症指标、住院时间、死亡率等无统计学差异.结论:改良胰腺空肠套入式吻合与胰管空肠黏膜吻合相比,同样安全可靠,具有操作方便,易于掌握,胰肠吻合严密牢固的优点,尤其适用于胰管直径小的病人,值得临床应用.     

胰管空肠黏膜吻合对胰十二指肠切除术后胰瘘发生率的影响

目的 探讨胰管空肠黏膜对黏膜吻合术对胰十二指肠切除术后胰肠吻合口瘘发生率的影响.方法 回顾性分析我院120例胰十二指肠切除术患者的临床资料,胰肠吻合分别采用套入式胰肠吻合和胰管空肠黏膜对黏膜吻合两种术式,其中套入式胰肠吻合组66例,胰管空肠黏膜对黏膜吻合54例,分别观察两组术后胰瘘发生的情况及临床效果.结果 两组患者在...     

胰十二指肠切除改良胰管空肠吻合预防胰瘘

目的：分析胰十二指肠切除术（PD）胰管空肠端侧粘膜对粘膜及胰管空肠套入式吻合方式,以其预防术后胰瘘发生。方法：2003年1月～2007年1月回顾性分析25例PD的临床资料,残胰的重建方式分别按胰管空肠粘膜对粘膜套入式端侧吻合,胰管支撑管胰液体外引流。结果：PD24例术后恢复顺利,未发生胰瘘;1例术后腹腔创面广泛渗血,多器官功能衰竭围手术期死亡,其余随访无远期并发症。结论：PD胰管空肠端侧粘膜对粘膜套入式吻合有明显避免胰瘘及并发症的发生,真正临床应用价值有待更大量的对照随机前瞻性大样本研究才能作出正确可靠的评价。     

人工乳头植入式胰-空肠吻合的初步应用(附10例临床应用体会)

背景与目的:胰腺空肠吻合口是胰十二指肠切除术成败的关键,近年来虽然对胰肠吻合方式不断改进,但是胰瘘的发生率仍然较高.本文介绍一种改良的胰-空肠端侧吻合方法.方法:胰腺残端术中冰冻切片证实切缘无肿瘤残留,游离远端胰腺2.0～2.5 cm,沿主胰管周围0.2～0.3 cm处呈“0”型或“C”型切开胰腺组织,深约0.6～0.8 cm.鱼口状(“V”型)切除主胰管两侧0.8～1.0 cm的残端胰腺组织后,内翻缝闭,使人工乳头呈“一头双肩”状凸出于胰腺残端.经横结肠系膜戳孔作结肠后人工乳头植入式胰-空肠吻合.结果:10例患者胰-空肠吻合时间为15～20 min,手术后检测引流液淀粉酶,无胰瘘、胆瘘及出血等并发症.术后6～9 d拔除引流管,术后平均住院天数为11 d.结论:人工乳头植入式胰-空肠吻合法简单易行,吻合可靠,术后恢复快,是一种新的安全有效的吻合方法.     

胰腺癌手术治疗进展

胰腺切除已成为一种挽救胰腺癌病人的治疗手段 ,随着近年来外科技术日臻成熟 ,某些高难度手术不断得以发展。现在 ,胰瘘等严重并发症逐渐减少 ,患者术后生活质量也有进一步改善。1　胰头癌手术胰腺癌可发生于胰腺的任何部位 ,但以胰头部最多见 (占 65%～ 75% )。其手术切除方式常采用胰十二指肠切除术 (Whipple procedure) ,该术式进展主要集中在如何减少胰瘘等并发症和扩大切除术以提高根治率。1 .1　胰腺断端和胃肠道吻合重建胰肠吻合有胰腺空肠端侧吻合和端端吻合两种。无论何种吻合 ,胰管内置入支撑管 ,另一端置入肠腔 ,此术式被公认为…     

胰胃吻合术在胰十二指肠切除术中的应用

胰十二指肠切除术中采用胰胃吻合术作为消化道再建术式,临床应用取得满意疗效.手术方法:切除幽门侧胃1/3,依病灶情况切除部分胰腺,胰管内置入有侧孔之硅胶管作支架引流,残胃后壁横行切开,将胰断端引入胃内约1.5cm,缝合固定,胰管导管自胃前壁引出体外,胃空肠端端吻合、胆管空肠端侧吻合,胆管内置T管引流.本术式安全性高,并发症少,残存胰腺与胃后壁毗邻,易吻合;胰蛋白酶、糜蛋白酶在胃内低pH环境下以酶原形式存在,为吻合口愈合提供有利条件,且胰液可中和胃酸,防止吻合口溃疡发生.     

胰头十二指肠切除术中胰腺断端的处理方法

胰头十二指肠切除术（PD）是治疗胰腺恶性及某些良性疾病的主要方法。但是PD的术后并发症的发生率非常高,其中胰肠吻合口瘘（PF）是最常见、最危险的并发症之一。文献报道PF是影响胰腺术后死亡率的独立因素,而胰腺断端处理方法的选择可以影响胰瘘的发生。因此在处理胰腺断端时,术式的选择是相当重要的。正常胰腺组织柔软、脆弱且供血丰富,在与消化道直接缝合时,易使缝线处的胰腺组织撕裂是胰腺断端较难处理的原因之一。因此,正确的吻合方式可在一定程度上减少PF的发生。但是至今仍然没有一种吻合方式显示相对较好的预后,胰腺断端的吻合方式目前仍是一个值得探讨的问题。本文就目前国际常用的术式,即胰腺断端的处理方式及其手术的适应症和优缺点进行介绍,以期对降低PD术后胰瘘的发生和改善PD术后生活质量提出一定借鉴。     

Risk factors and outcome of pancreatic fistula after consecutive pancreaticoduodenectomy with pancreaticojejunostomy for patients with malignant tumor

Objective:Pancreatic fistula (PF) is a common complication after pancreaticoduodenectomy (PD) and there is no consensus regarding the criteria to define PF. The study was undertaken to determine the risk factors for PF according to the definition of the International Study Group on Pancreatic Fistula (ISGPF) and to delineate its impact on patient outcome. Methods:Between March 1994 and May 2009, data from 153 consecutive patients with malignant tumors underwent a PD with pancreaticojejunostomy in the Peking University People's Hospital were recorded prospectively. A total of 24 factors were examined with univariate analysis and multivariate logistic regression analysis was used to estimate relative risks, and their 95% confidence intervals (95% CI) and odds ratio (OR). Methods:Our institution belonged to medium-volume center and PF occurred in 30 patients (19.6%). Pancreatic texture, early postoperative hemorrhage and pancreatic pathologies correlated with PF rates significantly in univariate analyses. But in multivariate regression, soft gland (OR, 4.934; 95% CI, 1.132-7.312) and early postoperative hemorrhage with conservative therapy (OR, 4.130; 95 % CI, 1.057-21.112) were predictive. The mean postoperative length of stay in patients with PF was longer (32.7±23.9 versus 60.5±56.2 days) than patients without PF (P=0.001). Overall 30-day mortality was not affected by the development of PF (P=0.657). There was no difference in reoperation rates between patients with and without PF (10.0% versus 6.5%, P=0.787). Concerning the sum of postoperative complications, there were 36 complications for 30 patients with PF, while 64 for 123 patients without PF. When patients with distal cholangiocarcinoma, ampullary and duodenal cancer were considered as a whole for survival analysis, the median survival for patients with PF was 20 months, whereas the median survival for patients without PF was 26 months. Kaplan-Meier survival curves for patients with and without PF were not statistically different (P=0.903). Conclusion:Soft texture and early postoperative hemorrhage with conservative therapy are independent correlates of increased rate of PF. Anastomotic technique for pancreaticojejunostomy does not have impact on the development of PF in our experience. PF contributes to early postoperative morbidity and the length of hospital stay, but it dose not affect postoperative 30-day mortality, reoperation rate and overall survival.     

残胰直接套入空肠吻合技术在胰十二指肠切除术中的临床应用研究

目的:总结和探讨胰十二指肠切除术后空肠非去黏膜化的胰- 肠直接套入吻合方法,并观察其术后发生胰瘘及对与该手术方式有关的并发症等资料进行分析。方法:2005年3 月至2009年6 月中山大学附属东华医院行胰十二指肠切除术21例,残胰游离3.0cm,距离残胰断端2.5～3.0cm行空肠全层与部分胰腺后壁组织间断缝合,将残胰套入空肠2.5～3.0cm,再按后壁缝合方法缝合前壁,在距离残胰断端1cm处用7 号丝线环绕空肠将残胰予以捆扎。结果:除1 例出现因残胰断端出血再次手术进行缝合止血外,全组患者术后恢复顺利,无1 例发生胰瘘或出现其他并发症。结论:胰腺质地和胰- 肠吻合方式虽是胰瘘并发症的主要因素,但也与手术者胰- 肠吻合操作技巧或熟练程度、围手术期的管理或治疗措施有关。采用残胰直接套入非去空肠黏膜化的胰- 肠吻合方法与目前任何其他胰-肠吻合方法比较均较为简单,有待于进一步探讨、总结和研究。      

Clinical risk factors of delayed gastric emptying in patients after pancreaticoduodenectomy: A systematic review and meta-analysis

Background

The clinical risk factors of delayed gastric emptying (DGE) in patients after pancreaticoduodenectomy (PD) remains controversial. Herein, we conducted a systematic review to quantify the associations between clinical risk factors and DGE in patients after conventional PD or pylorus preserving pancreaticoduodenectomy (PPPD).

Methods

A systematic search of electronic databases (PubMed, EMBASE, OVID, Web of Science, The Cochrane Library) for studies published from 1970 to 2012 was performed. Cohort, case–control studies, and randomized controlled trials that examined clinical risk factors of DGE were included.

Results

Eighteen studies met final inclusion criteria (total n = 3579). From the pooled analyses, preoperative diabetes (OR 1.49, 95% CI, 1.03–2.17), pancreatic fistulas (OR 2.66, 95% CI, 1.65–4.28), and postoperative complications (OR 4.71, 95% CI, 2.61–8.50) were significantly associated with increased risk of DGE; while patients with preoperative biliary drainage (OR 0.68, 95% CI, 0.48–0.97) and antecolic reconstruction (OR 0.17, 95% CI, 0.07–0.41) had decreased risk of DGE development. Gender, malignant pathology, preoperative jaundice, intra-operative transfusion, PD vs. PPPD and early enteral feeding were not significantly associated with DGE development (all P > 0.05).

Conclusions

Our findings demonstrate that preoperative diabetes, pancreatic fistulas, and postoperative complications were clinical risk factors predictive for DGE. Antecolic reconstruction and preoperative biliary drainage result in a reduction in DGE. Knowledge of these risk factors may assist in identification and appropriate referral of patients at risk of DGE.     

Advantage of pancreaticogastrostomy in detecting recurrent intraductal papillary mucinous carcinoma in the remnant pancreas: a case of successful re-resection after pancreaticoduodenectomy

Recently there has been an increase in the number of case reports detailing the recurrence of cancer in the pancreatic remnants following surgical resection of intraductal papillary mucinous carcinoma (IPMC) of the pancreas. A case is presented here to indicate the advantage of pancreaticogastrostomy (PG) in terms of postoperative follow-up after pancreaticoduodenectomy (PD) for IPMC. A 68-year-old man underwent PD for IPMC of the pancreatic head, and the cut margin of the pancreatic duct was diagnosed as having no cancer but moderately dysplastic epithelium by an intraoperative frozen section of histology. Thus, we decided to proceed with a PG rather than pancreaticojejunostomy (PJ) in order to facilitate easier postoperative examinations. Eight years and 6 months later, during a routine follow-up examination, duct dilation of the remnant pancreas was detected by magnetic resonance imaging (MRI). Upon examination by endoscopic gastroscopy, the anastomotic site was found to be covered with a large amount of mucin from which we easily obtained both cytologic and biopsied specimens, which subsequently proved positive for cancer. In line with our diagnosis of recurrent IPMC, the patient underwent a second surgery (resection of the remnant pancreas, total pancreatectomy) and postoperative histology confirmed that indeed the patient had experienced recurrent IPMC with no nodal involvement or invasion beyond the pancreatic confines. Based on this experience, we decided to recommend PG for all patients deemed to be at high risk for the recurrence of cancer in the pancreatic remnants following PD for IPMC of the pancreatic head.     

Determinants of complications in pancreaticoduodenectomy.

AIMS: The factors determining complications after pancreaticoduodenectomy (PD) have not yet been identified clearly. This retrospective study examined, using reproducible classification systems, the type and severity of complications as well as the factors to predict them. METHODS: Between 1998 and 2005 PD was performed in 351 consecutive patients with peri-ampullary tumours. Logistic regression models were used in univariate as well as in corrected, multivariate analyses in order to identify the optimally combined factors related to the occurrence of post-operative complications. RESULTS: Post-operative complication rate was 50.7%, mortality 3.1% and re-operation rate 7.1%. Pancreatic fistula (12%) was responsible for higher mortality (9.5%; p=0.011) and re-operation (30.9%; p<0.001) rates. Hospital length of stay (LOS) was (p<0.001) longer for patients with post-operative complications (median 21.5 (range 1-128) vs. 14 (7-42) days) or pancreatic fistula (28.5 (8-128) vs. 17 (1-63) days), and related to the severity of complications. Surgeon (Odds ratio [OR] 2.03; confidence interval [CI] 1.20-3.41; p=0.008), male gender (OR 1.72; CI 1.05-2.81; p=0.032), and pre-operative hyperbilirubinaemia (OR 1.04; CI 1.001-1.08; p=0.046) were independent risk factors for post-operative complications. Neither prophylactic octreotide nor pre-operative biliary drainage improved post-operative outcome. CONCLUSION: Surgeon, male gender, and pre-operative hyperbilirubinaemia determine complication rate following PD. Pancreatic fistula is the most common complication and is associated with increased mortality, re-operation rate and LOS.     

Options of restorative pancreaticoenteric anastomosis following pancreaticoduodenectomy: A review

Pancreatic fistula (PF), haemorrhage and delayed gastric emptying are some of the common causes of morbidity and PF is the single most important cause of mortality following pancreaticoduodenectomy (PD). Authors, who claim to have reduced leak rates, recommend modifications of the standard technique of pancreaticojejunostomy (PJ) that are often complex and difficult to standardize for wider applications. Most individual studies, multicenter retrospective analysis and certain prospective studies report a lower leak rate with pancreaticogastrostomy (PG) when compared with PJ. However, the only three randomized controlled clinical trials (RCTs) to date have failed to demonstrate the superiority of either technique. Here we discuss the various aspects of pancreaticoenteric anastomosis following pylorus preserving pancreaticoduodenectomy (PPD) and the standard pancreaticoduodenectomy (PD).     

Extended resection for pancreatic adenocarcinoma

Adenocarcinoma of the pancreas presents a number of therapeutic challenges. Given the poor long-term outcomes after pancreaticoduodenectomy (PD), many surgeons have sought to improve survival via a radical or "extended" pancreatectomy which may include (a) total pancreatectomy (TP), (b) extended lymph node dissection (ELND), and (c) portal/mesenteric vascular resections. These themes of "extended" resection are addressed in this review. TP should not be performed for most cases of adenocarcinoma of the pancreatic head because of the nominal incidence of lymph node involvement along the body and tail of the pancreas, the scarcity of multicentric disease, and the better management of pancreatic leaks after PD. Most studies show no difference in long-term survival and demonstrate greater postoperative morbidity after TP than after PD. Performing ELND in addition to PD is not worthwhile because most studies do not demonstrate any long-term benefits from ELND and the circumferential dissection around the mesenteric vessels required to harvest distant lymph nodes increases postoperative morbidity. Major arterial resection increases postoperative morbidity after PD and worsens long-term survival as the need for arterial resection to achieve negative resection margins indicates more aggressive disease. In contrast, portal and/or mesenteric venous resection does not increase the morbidity after PD or impact long-term survival as venous resection is often performed because of tumor location and not extent of disease. The disappointing experience with extended resections underscores the need for better adjuvant systemic strategies and the interdisciplinary care of patients with pancreatic adenocarcinoma.