胰十二指肠切除术后胰瘘的防治

正胰瘘是胰腺切除术后最严重、死亡率最高的并发症。据文献~([1-2])报道,胰瘘的发生率为13%~41%,如处理不当,胰腺术后胰瘘会导致腹腔内感染和出血的发生。在总的胰腺术后人群中胰瘘导致的死亡率为1%,然而合并C级胰瘘患者的死亡率可达25%~([3])。不得不说,胰瘘的发生会导致住院时间的延长和花费的增加,甚至带来悲剧。尽管胰瘘的发生会带来如此严重的后果,得到了大多数胰腺外科专家的重视,但对胰十二指肠切除术后胰瘘     

术前影像学评估胰腺软硬程度预测胰十二指肠切除术后胰瘘的研究进展

胰十二指肠切除术是壶腹周围良、恶性肿瘤首选手术方式,但是该术式技术难度高,在过去十余年中,为预防胰十二指肠切除术后胰瘘进行过许多探索,在一些大容量中心该手术死亡率已降至5%以下,但是术后胰瘘的发生率仍然在10%以上。术后胰瘘是胰十二指肠切除术后大部分并发症的主要原因,甚至会导致严重腹腔感染、脓毒症和大出血等致命性并发症。已有许多研究证明胰腺组织软硬程度是术后胰瘘的独立预测因素,而术前影像学检查是评价这一因素的较好手段。此文对目前术前影像学评估胰腺软硬程度预测胰十二指肠切除术后胰瘘的研究进展进行了综述。     

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。     

术后胰瘘

术后胰瘘是胰腺手术后最常见的并发症之一.由于各研究者对胰瘘使用的定义不同,术后胰瘘的发生率存在差异.目前对于术后胰瘘的危险因素、诊断标准、预防措施以及治疗策略等的研究并无一致的结论.笔者就此对近年有关术后胰瘘的研究文献作一综述.     

胰体尾切除术后胰瘘的相关性因素分析

目的探讨胰体尾切除术后胰瘘发生的相关性因素。方法回顾性总结了82例行胰体尾切除的患者术前、术中操作以及术后并发症和死亡率发生的情况,并分析和术后胰瘘发生的相关性因素。结果术后有36名患者出现并发症占43.9%（36/82）。其中胰瘘是最常见的并发症,发生率为37.8%（31/82）。其中是否结扎主胰管和术后胰瘘的发生具有明显的相关性（P=0.010）,而性别、年龄、是否并存糖尿病、胰腺的质地、术中失血量、是否预防性应用奥曲肽、是否用生物胶封闭胰腺断端、术后低蛋白血症和是否联合其它脏器切除均和胰瘘的发生无明显的相关性。结论胰体尾切除术后最常见的并发症仍然是胰瘘,术中单独结扎胰管可以减少胰瘘的发生率。     

胰腺手术后胰瘘综合治疗

<正>术后胰瘘(postoperative pancreatic fistula)是胰十二指肠切除术(pancreaticoduodenectomy,PD)、中段胰腺切除术(central pancreatectomy,CP)和远端胰腺切除术(distal pancreatectomy,DP)等胰腺手术后常见的并发症。PD术后胰瘘发生率为22.6%~28.9%,DP术后为15.4%~35.7%,     

胰十二指肠切除术后残留胰腺的最佳处理方法

尽管胰十二指肠切除术后死亡率逐年下降,但与残留胰腺有关的胰瘘发病率仍较高.作者复习了近5年8大组包括1865例病例的资料,总死亡率平均为6.0%(0～8O%).术后胰瘘或漏的发生率为13.5%(6%～25%).作者认为,胰十二指肠切除术后残留胰腺处理方法是影响术后胰瘘形成的重要因素.目前,几种对胰残端处理的术式备受推崇,其目的是减少术后胰瘘及与此相关的并发症.这些术式包括:端侧胰空肠吻合术,端端胰空肠套入术,全胰切除术,胰胃吻合术,胰管结扎及胰管堵塞术.然而,尚没有一种方法可以适用于所有病例.本文日的是比较胰十二指切除术后残留胰腺处理的不同方法的优劣,以明确术后发生胰瘘的相关因素.作者回顾性分析了1977年7月至1993年12月114例行胰十二指肠切除术后的连续病例资料.男性69例(61%),女性45例(39%),平均年龄66岁.87例(76%)为恶性疾患,27例(24%)为良性病变.根据胰腺解剖特点,把胰管管径小、没有梗阻或胰腺柔软质脆者归为高危组,而胰腺纤维化、质硬或胰管扩张为低危组.按术后胰瘘及残留胰腺处理方式对病人进行分组:68例行胰空肠端侧吻合术,其中13例为高危者(1A组),55例为低危者(1B组),另外37例高例危病人中,19例行胰管缝合关闭术(2组),18例行胰空肠端端套入术(3组),余下9例行全胰切除术(4组).作者认为并     

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目的研究胰腺术后主要并发症对住院医疗费用的影响。方法回顾性分析复旦大学附属中山医院普外科胰腺肿瘤专业组2005年8月至2009年8月341例行胰腺切除术后病人的临床资料和各项住院费用。统计胰腺切除术后围手术期主要并发症(胰瘘、胆瘘、出血、胃排空延迟)的发生率和严重程度。以中华医学会外科学分会胰腺外科学组颁布的胰腺术后并发症定义和分级进行评估。分析围手术期主要并发症及其等级与住院费用之间的关系。结果 341例病人中,156例(45.7%)发生不同程度的胰瘘、15例(4.4%)发生胆瘘、35例(10.3%)发生胃排空延迟、17例(5.0%)发生出血并发症。未发生胰瘘病人的平均住院费用38224元(人民币,下同),随着胰瘘级别的逐渐升高,住院费用逐渐增加,C级胰瘘病人的平均住院费用为103293元,其中药品费用、ICU费用、住院床位费用增加最明显。不同胰瘘级别的住院费用之间差异具统计学意义,胰瘘级别与住院费用的增长呈正线性相关(P<0.05)。无胆瘘病人的住院费用为38758元,而发生胆瘘病人为53206元,二者差异无统计学意义;无胃排空延迟病人的住院费用为37992元,而发生胃排空延迟病人为51857元,以药品费用和住院床位费用的增加最明显,二者之间的差异具有统计学意义(P<0.05)。结论胰腺切除术后发生并发症(尤其是胰瘘)增加了病人的住院费用。胰瘘级别与住院费用的增加呈正线性相关。     

保留十二指肠胰头切除术后并发症的防治体会

目的 探讨保留十二指肠胰头切除术后并发症的防治措施.方法 回顾性分析2003-2008年期间武汉协和医院胰腺中心行保留十二指肠胰头切除术56例病人的临床诊疗经过.结果 术后发生并发症13例(23.2%),包括胰瘘7例(12.5%),十二指肠瘘2例(5.4%);胆瘘1例(2.8%);腹膜后积液和感染2例(5.4%);腹腔大出血1例(2.8%).消化道瘘经支持治疗和维持通畅引流等治疗而痊愈,腹膜后积液和感染病人在B超引导下置管引流治愈,腹腔大出血者急诊选择性腹腔动脉造影显示胃十二指肠动脉分支破裂出血,经明胶海绵和不锈钢圈栓塞后治愈.结论 胰瘘、十二指肠瘘、胆瘘、腹腔感染和出血等是DPPHR术后主要并发症,严格掌握手术适应证,术中仔细操作,尽量保留十二指肠的血液供应是减少DPPHR术后并发症和提高手术成功率的关键,一旦出现并发症应采用正确的治疗方法 .     

胰肠吻合手术方式的选择

正胰十二指肠切除术(pancreaticoduodenectomy,PD)术后并发症发生率高达50%左右,死亡率约5%,其中最常见最严重的是胰瘘(postoperative pancreatic fistula,POPF),其发生率20%左右[1-4]。PD术后发生胰瘘的相关因素包括:患者因素(如年龄、BMI、营养状况),胰腺因素(肿瘤类型、胰腺质地、胰管大小),吻合方式和术者经验等因素,其中胰管大     

Current practice patterns in pancreatic surgery: Results of a multi-institutional analysis of seven large surgical departments in germany with 1454 pancreatic head resections, 1999 to 2004 (german advanced surgical treatment study group)

Despite decreasing mortality rates, morbidity is still high after pancreatic head resection. Comparative data in the United States and Europe show a relationship between hospital volume and mortality. Treatment strategies vary frequently, partially because of the lack of evidence-based data. We performed a multi-institutional analysis in Germany evaluating current numbers, indications, techniques, and complication rates of pancreatic head resection. Questionnaires were completed by seven high-volume surgical departments regarding quantitative and qualitative aspects of pancreatic head resections in the period from 1999 to 2004 (five prospective and two retrospective institutional databases). A total of 1454 pancreatic head resections (944 for malignancy) were reported. Mean annual hospital volume ranged from 14 to 52 (10 to 43 in malignancy). Mortality was between 1.1% and 4.8%, morbidity was between 24% and 46%, and pancreatic leakage was between 9% and 20%. In malignant disease, all centers perform standard lymphadenectomy and regard arterial infiltration as a contraindication for resection. However, the rate of portal vein resection varied from 0% to 28%. No consensus is seen on the type of surgery for malignancy and chronic pancreatitis. After resection for pancreatic cancer less than one fourth of the patients receive adjuvant therapy. The results of our analysis in Germany confirm that pancreatic head resection can be performed with low mortality in specialized units. Variations in indications, operative technique, and perioperative care may demonstrate the lack of evidence-based data and/or personal and institutional experience. The low number of patients receiving adjuvant therapy after resection of pancreatic cancer suggests that more efforts must be made to establish novel adjuvant therapies under randomized study conditions. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (oral presentation).     

Are There Indications for Palliative Resection in Pancreatic Cancer?

Controversy exists about the indication for a palliative pancreatoduodenectomy. A palliative resection for patients with a pancreatic carcinoma can be performed safely nowadays with low mortality and acceptable morbidity in centers with experience. The early results in terms of mortality and morbidity are not different from resections with curative intent or even after bypass surgery. The procedure seems effective for controlling symptoms of the disease, and the quality of life after a palliative resection is acceptable and not worse than after bypass surgery. It is, however, still doubtful whether the incidence of symptom recurrence, such as jaundice, obstruction, and pain, is lower after resection than after bypass surgery. The longer survival after palliative resection could also be due to patient selection and postoperative treatment. There are no randomized trials to prove the superiority of palliative resection over bypass surgery. The safety of pancreatic resection for cancer has already changed the policy in centers with experience, and surgeons are more willing to perform a resection because the results are better or at least the same as after bypass surgery. There are, however, no results to confirm that a palliative resection should be performed routinely or to justify resection as a debulking procedure.     

Pancreatectomy with synchronous vascular resection--an argument in favour

BackgroundThe first case-series of pancreatectomy with synchronous en-bloc vascular resection with the aim to improve pancreatic cancer survival was published in 1977. Advances in surgical techniques, intensive care management and teaching centers with high volume cases have dramatically reduced mortality and morbidity of major pancreatic resections. This has led to a progressively wider use of venous and/or arterial resections during pancreatic surgery in selected patients to achieve negative resection margins.MethodsWe review the current literature and discuss our experience in pancreatectomies with en-bloc vascular resections.ResultsSurvival of patients with pancreatic cancer who undergo an R0 resection with venous reconstruction is comparable to those who have a standard pancreaticoduodenectomy with no added mortality or morbidity. Conversely, arterial resection is associated with a higher morbidity, mortality and overall poorer survival, perhaps reflecting more advanced disease.ConclusionsSince the need for vascular resection may not be always apparent on pre-operative imaging, surgeons who perform major pancreatic surgery should be familiar with vascular resection and reconstruction techniques in order to offer to these patients the best chance to prolong survival.     

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.     

Therapeutic strategies for the management of delayed gastric emptying after pancreatic resection

BACKGROUND: Delayed gastric emptying (DGE) is one of the most troublesome postoperative complications following pancreatic resection. Not only does it contribute considerably to prolonged hospitalization, but it is also associated with increased postoperative morbidity and mortality. METHODS: We performed an electronic and manual search of the international literature for studies dealing with the treatment of DGE following pancreatic resection using the Medline database. The search items used were "delayed gastric emptying," "pancreaticoduodenectomy," "Whipple procedure," "pylorus-preserving pancreaticoduodenectomy," and "complications following pancreatic resection" in various combinations. RESULTS: A number of studies were identified regarding possible therapeutic alternatives for the treatment of DGE. From the class of prokinetic regimens, most studies seem to support the use of erythromycin. However, its use has not gained wide acceptance. Regarding the operative technique, both standard Whipple and pylorus-preserving pancreatic resection carry similar rates of DGE. Billroth II type-like gastrointestinal reconstruction is the most widely accepted method and is associated with lower rates of DGE. Reoperations for managing severe DGE were very rarely reported. CONCLUSIONS: The incidence of DGE in high-volume centers specialized in pancreatic surgery is well below 20%, thus following the improved rates that have been reported in the last decade regarding mortality and length of hospital stay after pancreatic surgery. DGE mandates a uniform definition and method of evaluation to achieve homogeneity among studies. Standardization of the operative technique, as well as "centralizing" pancreatic resections in high-volume centers, should aid to improve the occurrence of this bothersome postoperative complication.     

Management of pancreatic fistulas after pancreaticoduodenectomy: results in 437 consecutive patients

HYPOTHESIS: Pancreatic fistula (PF), a common and potentially lethal complication of pancreaticoduodenectomy, can be managed nonoperatively in most cases. DESIGN: Retrospective case series. SETTING: Major academic medical and pancreatic surgery center. PATIENTS: A total of 437 consecutive patients who underwent pancreaticoduodenectomy for various diagnoses between January 1, 1988, and August 31, 2004. INTERVENTIONS: Conservative management of PF with an intraoperatively placed closed-suction drain near the pancreaticojejunostomy anastomosis, computed tomography-guided percutaneous drainage, and surgery. MAIN OUTCOME MEASURES: Incidence of PF after pancreaticoduodenectomy and patient outcomes. RESULTS: Fifty-five patients (12.6%) developed a PF, which was most common after resections for ampullary tumors (21.1%) and cystic neoplasms (31.3%), and uncommon after resection for pancreatic cancer (6.5%). The mean number of complications (excluding PF) was greater in the PF group (PF, 1.24; no PF, 0.54; P<.001), but these did not prolong hospital stay (PF, 15.2 days; no PF, 13.7 days; P = .20). Biliary fistula, sepsis, reoperation, and late biliary stricture were more common in patients with PF (P<.05), but mortality rate and long-term survival in patients with either pancreatic or ampullary cancer were unaffected by the presence of PF (P>.40). Fifty-two patients (94.5%) had successful conservative management of their PF with prolonged tube drainage; 4 also required CT-guided percutaneous drainage. Three patients (5.5%) underwent reoperation and 1 died. CONCLUSIONS: Pancreatic fistula is a common problem after pancreaticoduodenectomy. It is associated with increased morbidity, but it does not affect the mortality rate. More than 90% of PF cases can be managed nonoperatively without significantly prolonging hospital stay.     

Pancreatic fistula after pancreatic head resection

BACKGROUND: Pancreatic resections can be performed with great safety. However, the morbidity rate is reported to be 40-60 per cent with a high prevalence of pancreatic complications. The aim of this study was to analyse complications after pancreatic head resection, with particular attention to morbidity and pancreatic fistula. METHODS: From November 1993 to May 1999, perioperative and postoperative data from 331 consecutive patients undergoing pancreatic head resection were recorded prospectively. Data were analysed and grouped according to the procedure performed: classic Whipple resection, pylorus-preserving pancreatoduodenectomy (PPPD) or duodenum-preserving pancreatic head resection (DPPHR). RESULTS: Pancreatic head resection had a mortality rate of 2.1 per cent; the difference in mortality rate between the three groups (0.9-3.0 per cent) was not significant. Total and local morbidity rates were 38.4 and 28 per cent respectively. DPPHR had a lower morbidity, both local and systemic, than pancreatoduodenectomy. The prevalence of pancreatic fistula was 2.1 per cent in 331 patients, and was not dependent on the procedure or the aetiology of the disease. Reoperations were performed in 3.9 per cent of patients, predominantly for bleeding and non-pancreatic fistula. None of the patients with pancreatic fistula required reoperation or died in the postoperative course. CONCLUSION: A standardized technique and a continuing effort to improve perioperative management may be responsible for low mortality and surgical morbidity rates after pancreatic head resection. Pancreatic complications occur with Whipple, PPPD and DPPHR procedures with a similar prevalence. Pancreatic fistula no longer seems to be a major problem after pancreatic head resection and rarely necessitates surgical treatment.     

Surgical complications of pancreatectomy

The mortality for pancreatectomy has decreased to a very low level in recent years but morbidity remains high. The most frequent post-operative complications of pancreaticoduodenectomy (PD) are delayed gastric emptying (DGE) in 20% and pancreatic fistula (PF) in 10-15%. DGE is associated with other abdominal complications in half the cases; these must be delineated by CT scan and specifically treated. Isolated DGE usually resolves within three weeks with the use of nasogastric suction and pro-kinetic drugs. FP following PD may be preventable with the use of temporary trans-jejunal intubation of Wirsung's duct or by intussusception of the pancreatic margin into the jejunal lumen. FP occurring after PD will heal with conservative management (total parenteral nutrition, peripancreatic drainage, somatostatin analogues) in 80-90% of cases but secondary complications such as peritonitis, arterial erosion and pseudo-aneurysm may be life-threatening. Early hemorrhage (in the first 48-72 hours) must be treated by re-operation. Late hemorrhage (usually secondary to PF) and ischemic complications are rare (3% and 1% respectively), difficult to treat, and associated with high mortality. PF is also the main complication of distal pancreatectomy and enucleation of pancreatic tumors (10-20% and 30% respectively). These PF resolve with conservative treatment in more than 95% of cases but may justify an ERCP sphincterotomy if drainage is prolonged. After medial pancreatectomy, PF occurs in 20-30% of cases, arising from either of the two transected pancreatic surfaces.     

Does hospital volume have influence on the results of pancreatic surgery?

Hospital volume is one of the most discussed but also disputed subjects of surgery during the recent years. In no other surgical entity as in pancreatic surgery the number of performed operations has as much influence on morbidity and mortality. Despite of decreasing mortality, morbidity in pancreatic surgery remains relatively high even in specialized centres. Numerous studies demonstrated a reduction of perioperative mortality in centres with more than 10 patients per year by over 50%. In our own collective we demonstrated a significant reduction of mortality by 4% to 1% in two successive periods and a significant reduction of morbidity from 47% to 35%. We review the factors that are held responsible for decreasing mortality and complication rate in specialized centres and review published studies on this subject up to date. Our results confirm studies form other countries that increasing centre experience as well as operations performed in high volume hospitals decrease the complication rate and mortality after pancreatic head resection.     

What constitutes a "high-volume" hospital for pancreatic resection?

BACKGROUND: Annual institution resection volume has been proposed for defining centers of excellence, with various cut-offs for defining "high-volume" centers used. This study aimed to define an objective, evidence-based operative volume threshold associated with improved postoperative outcomes after pancreatic resection. STUDY DESIGN: This retrospective analysis of patients who underwent pancreatic resection in the Nationwide Inpatient Sample, a 20% representative sample of patients in the US between 1998 and 2003, was performed using multivariable logistic regression. Different models of annual hospital resection volume were analyzed and the goodness of fit of each "high-volume" model to postoperative mortality was compared through use of the pseudo r(2). RESULTS: Based on analysis of 7,558 patients who underwent pancreatic resection, median annual institution resection volume was 15 (range 1 to 254), and overall in-hospital mortality was 7.6%. The best model of "high-volume" centers was an annual institution resection volume of 19 or more, as determined by goodness of fit (r(2) of 5.29%). But there was little difference in data variance explained between this best model and other "high-volume" models. The model without any volume variable had a goodness-of-fit r(2) of 3.57%, suggesting that volume explains less than 2% of data variance in perioperative death after pancreatic resection. CONCLUSIONS: Very little difference was observed in the explanatory powers of models of "high-volume" centers. Although volume has an important impact on mortality, volume cut-off is necessary but insufficient for defining centers of excellence. Volume appears to function as an imperfect surrogate for other variables, which may better define centers of excellence.