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。     

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.     

改良捆绑式胰肠吻合术32例报告

目的探讨改良捆绑式胰肠吻合术在胰十二指肠切除术后预防胰瘘的临床价值。方法回顾性分析2001年7月~2004年12月施行改良捆绑式胰肠吻合术32例。在彭淑牖等设计的胰肠捆绑式吻合法基础上进行改良,游离胰远断端3 cm,胰管内置入硅胶管,电灼破坏空肠断端3 cm黏膜,胰断端套入空肠内3 cm,空肠黏膜与胰断端无需吻合,距空肠断端约1~2 cm处用粗丝线环绕空肠捆绑一道。并用生物蛋白胶外涂一周。结果经过连续32例采用此法治疗的患者,均顺利出院,未发生胰瘘。结论改良捆绑式胰肠吻合术设计合理,操作简便,疗效确切,值得临床推广应用。     

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...     

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.     

保留幽门胰胃吻合的胰十二指肠切除术(附6例报告)

我院自1992年5月至1993年5月,为6例壶腹周围癌行保留幽门胰胃吻合的胰十二指肠切除术,效果满意,报告如下:1 资料 本组男3例,女3例,年龄49～66岁.胰头癌3例,壶腹癌3例.均行保留幽门胰胃吻合胰十二指肠切除术.距幽门2cm处横断十二指肠与空肠行端侧吻合,胰腺断端与胃后壁吻合.胰管内置一引流管经胃前壁引出体外.术后无胆瘘及胰瘘并发症.5例经随访钡餐检查无明显胃滞留现象.2 讨论     

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。     

胰十二指肠切除术非去黏膜化的胰空肠直接套入吻合二例

胰瘘是胰十二指肠切除术胰肠吻合术后最常见也是最严重的并发症.为进一步研究和寻求更好的吻合方式,我们在本院历年来开展的各式胰一肠吻合比较的基础上,分别对胰头癌和胰头类癌2例患者行胰十二指肠切除术后将残胰直接套人空肠(非灭活空肠黏膜)的胰一肠吻合方法.手术后恢复顺利,未发生胰瘘.现报告如下.     

胰十二指肠切除术近期合并症及技术改进

目的:探讨如何提高壶腹周围肿瘤的切除率以及降低胰十二指肠切除术后的主要并发症-胰漏的发生.方法:1995年3月～2000年12月本院行胰十二指肠术126例,除经典的手术步骤,作者对手术方法进行了改进,完整切除胰腺钩突,在门静脉与胰头粘连时应仔细分离,受到浸润时可合并门静脉侧壁或部分切除,胰肠端侧吻合时,将胰腺残端确切地套入空肠,并在吻合口两角危险区及前壁覆盖一束大网膜.结果:胰十二肠切除技术的改进,提高了切除率和生存率,而且并发症并未增加,本组患者1、3年生存率分别为71.4%、48.6%;胰肠端端吻合胰漏的发生率为4.8%,端侧吻合加吻合口周围附以带蒂大网膜无胰漏发生.结论:随着外科学的进步,胰十二指肠切除及合并门静脉部分切除已是安全有效的手术方式,胰肠端侧吻合加吻合口周围覆盖大网膜能有效地避免胰漏的发生.     

Peng‘s Pancreaticojejunal Anastomosis（Binding Pancreaticojejunostomy） for the Pancreatoduodenectomy

Obuective To evaluate the safety and feasibility of a new operative procedure called binding pancreaticojejunostomy (BPJ) for the preven-tion of pancreatic leakage after pancreatoduodenectomy(PD). Methods Binding pancreaticojejunostomy was perfomed in 100 patients from 1996 to 2000.During the operation,the cut end of the je-junum(3 cm) was everted,the everted mucosa of the jejunum was destroyed with carbolic acid .Meanwhile 3 cm long remnant of pancreas was isolated and sutured to 3 cm away form the jejunum cut end, care being taken not to penetrate the sero-muscular layer.Then,the everted jejunum was restituted to its nomal position and the remnant of the pancreas was naturally pushed into the jejunal lumen for 3 cm.Finally,the surface of pancreatic remnant was closely in contact with destroyed jejunal mucosa surface,and a piece of absorbable thread was used to bind circumferentially this jejunum and the pancreatic remnant together,so no gap existed between the jejunal mucosa and pancreatic remnant. Results No pancreatic leakage occurred in the 100 patients with BPJ. Conclusion Binding pancreaticojejunostomy procedure can effectively prevent the occurrence of anastomatic leakage and can be applied broadly.     

A case of refractory pancreatic fistula following pancreaticoduodenectomy treated successfully by intestinal decompression catheter insertion to jejunum under local anesthesia

The case was an 80-year-old woman with inferior bile duct cancer. The patient had undergone subtotal stomach-preserving pancreaticoduodenectomy with end-to-side pancreaticojejunostomy. Postoperative pancreatic fistula was observed in a short period and was treated by somatostatin analog administration and abscess drainage. Despite these conservative therapies, pancreatic fistula resulted in abdominal bleeding from the branch of dorsal pancreatic artery, which stopped by emergent transcatheter arterial embolization. Because pancreatic fistula had become refractory, the intestinal decompression catheter insertion was performed under local anesthesia to the jejunum located directly below abdominal wall. After this surgery, pancreatic fistula was resolved over a few weeks. This technique could be safely performed and avoided the injury of drainage fistula, and was considered to be an option for treating refractory pancreatic fistula.     

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。      

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.     

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。     

胃癌术后胃排空延迟的肠-胃抑制负反馈发病机制

术后胃排空延迟（DGE）是上消化道外科手术的一种常见并发症,尤其好发于远端胃切除和胰十二指肠切除手术（Whipple手术）后,其形成机制迄今不明,进一步明确其机制有助于该并发症的预防与处理。十二指肠的机械性扩张会反馈性地抑制胃排空。我们推测这一负反馈机制在近段空肠也存在,在空肠胀满或肠壁受到牵扯的情况下会导致胃排空抑制。激活这一负反馈抑制效应的外科因素众多,当用直径比较大的管形吻合器做空肠吻合时,吻合器的插入会使空肠黏膜发生环周蹭擦损伤,形成局部炎性反应。用吻合器做肠肠吻合会使输入襻形成扭转导致十二指肠和空肠扩张。此外,胃肠吻合口有可能存在轻微的张力,尤其在实施结肠前胃肠吻合时。肠黏膜的炎性水肿会造成空肠扩张,肠襻扭转会影响其通畅性,胃肠吻合口的张力会对空肠壁形成牵扯,这些因素都可能通过负反馈机制导致DGE。     

Advances in the surgical management of pancreatic cancer

Pancreatic cancer continues to pose a major public health concern and clinical challenge. The incidence of the disease is nearly equivalent to the death rate associated with the diagnosis of pancreatic cancer. Thus, there exists a need for continued improvement in the diagnostic, therapeutic and palliative care of these patients. Surgeons play an integral role in the management of pancreatic cancer patients, with surgery providing the only potentially curative intervention for the disease. Specialized centers have reported improved hospital morbidity, mortality and survival after pancreaticoduodenectomy; however, disease-specific survival after surgical resection remains dismal. An emphasis therefore has been placed upon the accurate preoperative staging of patients in order to identify those patients who would benefit from a complete surgical resection. Surgical staging that incorporates the use of laparoscopic techniques now complements non-surgical methods of staging, including helical CT scans. While there is no defined preoperative staging approach, it is imperative that centers identify areas of expertise and experience with available modalities in any combination to effect accurate staging. Once patients have been accurately staged and deemed resectable, there exist various methods for resection of pancreas lesions, which include the standard "Whipple procedure," pylorus-preserving pancreaticoduodenectomy, regional pancreatectomy, total pancreatectomy, and en bloc vascular resection, where appropriate. Reconstructive techniques have been explored and include methods of pancreaticojejunostomy and pancreaticogastrostomy with or without pancreatic ductal stents and intraoperatively placed closed suction drains. Perioperative mortality following pancreaticoduodenectomy for cancer has a general reported incidence of 1% to 4% at high volume centers experienced with the operation. Morbidity however still remains high with that of delayed gastric emptying, pancreatic anastomotic leak or fistula, intraabdominal abscess, and hemorrhage as the leading reported complications. Researchers have investigated several agents and strategies to decrease or prevent the potential morbidity of these complications including the use of octreotide, drainage of the pancreatic bed and institution of early enteral feeding. Unfortunately, the majority of patients with pancreatic cancer present with either locally advanced or metastatic disease that precludes operative cure. The expected survival for these patients is usually less than six months from diagnosis. Therefore, a goal of therapy should be adequate palliation of symptoms of pain, biliary or duodenal obstruction and improvement of remaining quality of life with the least degree of morbidity possible.     

200例胰十二指肠切除术后早期并发症危险因素分析

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1000mL(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。