反穿刺法Braun吻合对胰十二指肠切除术后胃排空障碍及碱性返流性胃炎的影响

[摘 要] 目的 介绍反穿刺法Braun吻合（Braun enteroenterostomy,BE）,评估其对胰十二指肠切除（pancreaticoduodenectomy,PD）术后胃排空障碍（delayed gastric emptying,DGE）及碱性返流性胃炎（alkalinereflux gastritis,ARG）的影响。方法 回顾性分析2012年6月至2016年6月期间信阳市中心医院收治的87例行PD的患者的临床资料。根据术中消化道重建方式分为：PD组（41例）,PD+反穿刺BE组（46例）,比较两组患者的手术时间、术中出血量、住院天数,以及胰瘘、胃肠漏、腹腔感染、术后腹腔内出血、切口感染、DGE、ARG的发生率,评估反穿刺法BE对PD的影响。结果 所有患者均顺利完成开腹PD,无围手术期死亡。PD组、PD+反穿刺BE组患者的手术时间[（261.46±11.69）min vs （278.48±5.51）min]、术中出血量[（173.17±20.37）mL vs （166.30±17.99）mL],以及胰瘘（5例 vs 6例）、胃肠漏（3例 vs 3例）、腹腔感染（4例 vs 6例）、术后腹腔内出血（4例 vs 3例）、切口感染（2例 vs 4例）的发生率,差异均无统计学意义（P >0.05）。与PD组相比,PD+反穿刺BE组DGE（2例 vs 9例）、ARG（5例 vs 14例）的发生率更低,住院时间[（16.91±0.33）d vs （24.02±2.06）d]更短,差异均具有统计学意义（P < 0.05）。结论 反穿刺法BE手术简单易行,可减少住院时间及PD术后DGE、ARG的发生率,不延长手术时间。     

胰十二指肠切除术后导管对黏膜与套入式胰肠吻合的Meta分析

目的评价胰腺空肠导管对黏膜吻合和套入式胰肠吻合对胰十二指肠切除术后并发症的影响。方法计算机检索Cochrane library、Pubmed、OVID、Springer Linker、Science Direct、EBSCO、中国知网、维普医药信息资源系统、万方数据医药系统等中外生物医学数据库,并结合文献追溯的方式,检索2016年1月以前有关导管对黏膜与套入式胰肠吻合在胰十二指肠切除术后临床疗效的前瞻性随机对照试验。按Cochrane系统评价方法,评价所纳入研究的文献质量,并提取有效数据后采用Review Manager 5.3软件进行Meta分析。结果共纳入6篇随机对照研究文献,计有706例患者,其中导管对黏膜吻合组349例,套入式胰肠吻合组357例。Meta分析结果显示:两种胰肠吻合方式在胰瘘发生率(OR=1.24,95%CI:0.81~1.90,P=0.33)、胃排空障碍发生率(OR=0.84,95%CI:0.40~1.73,P=0.84)、围手术期死亡率(OR=0.91,95%CI:0.38~2.20,P=0.84)、并发症发生率(OR=0.97,95%CI:0.72~1.31,P=0.83)、再手术率(OR=1.40,95%CI:0.74~2.65,P=0.30)、住院时间(WMD=-1.19,95%CI:-3.49~1.12,P=0.31)、ClaveinⅢ级及以上并发症发生率(OR=1.12,95%CI:0.67~1.88,P=0.66)、软胰的胰瘘发生率(OR=1.53,95%CI:0.81~2.89,P=0.19)及B、C级胰瘘发生率(OR=1.26,95%CI:0.69~2.31,P=0.45)等方面的差异均无统计学意义。结论胰十二指肠切除术后导管对黏膜与套入式胰肠吻合对术后胰瘘发生率、围手术期死亡率、并发症发生率、再手术率、住院时间、ClaveinⅢ级及以上并发症发生率、软胰的胰瘘发生率及B、C级胰瘘发生率等的影响无差异。     

保留幽门的胰十二指肠切除术后施行结肠前与结肠后十二指肠空肠吻合效果比较的Meta分析

目的比较保留幽门的胰十二指肠切除术（PPPD）后采用结肠前十二指肠空肠吻合（ADJ）与结肠后十二指肠空肠吻合（RDJ）的效果。方法计算机检索Cochrane Library、Pub Med数据库、Embase数据库、Web of Science、中国生物医学文献数据库（CBM）、中国期刊全文数据库（CNKI）、维普和万方数据库中关于PPPD后ADJ和RDJ效果的文献,检索时间均为建库至2014年4月。同时在Google搜索引擎进行检索,追查纳入研究的参考文献。根据Cochrane协作网推荐的＂风险评估工具＂进行偏倚风险评估后,采用Rev Man 5.1软件进行Meta分析。结果共纳入4个随机对照研究,共462例患者。Meta分析结果显示,ADJ组和RDJ组的手术时间（MD=14.02,95%CI：-41.42-69.46,P=0.62）、术后总并发症发生率（RR=1.09,95%CI：0.81-1.48,P=0.56）、胃排空延迟发生率（RR=0.63,95%CI：0.31-1.28,P=0.20）、胰瘘发生率（RR=1.13,95%CI：0.72-1.75,P=0.60）、腹腔脓肿发生率（RR=0.92,95%CI：0.54-1.58,P=0.77）及死亡率（RR=0.61,95%CI：0.24-1.60,P=0.32）比较差异均无统计学意义。结论 PPPD后施行ADJ和RDJ的效果并无明显差异,外科医生可以按照自己的偏好进行吻合方式的选择。     

胰十二指肠切除术后应用胰胃吻合与胰空肠吻合的Meta分析

目的 评价胰十二指肠切除术后胰胃吻合术与胰空肠吻合术的疗效.方法 计算机检索Cochrane Library（2014年第5期）、PubMed（1978年1月至2014年5月）、EMBASE（1966年1月至2014年5月）、SCI（1961年1月至2014年5月）、中国生物医学数据库（CBM）（1978年1月至2014年5月）、中国期刊全文数据库（CNKI）（1994年1月至2014年5月）,维普（1989年1月至2014年5月）和万方数据库（1998年1月至2014年5月）,同时在Google搜索引擎进行检索,并追查纳入研究参考文献,收集胰十二指肠切除术后胰胃吻合术与胰空肠吻合术的所有随机对照试验.根据Cochrane协作网推荐的“风险评估工具”进行偏倚风险评估,用RevMan5.2软件进行统计学分析.结果 纳入7项随机对照试验,共1 121例患者.Meta分析结果显示,与胰空肠吻合组相比,胰胃吻合组能降低胰十二指肠切除术后胰瘘发生率（RR=-0.56;95％ CI：0.41～0.75; P=-0.0001）、胆漏发生率（RR=0.43;95％ CI：0.19～ 0.95;P=-0.04）腹腔内多发并发症（OR=-0.26; 95％ CI：0.12 ～ 0.56;P=-0.0007）和腹腔内积液的发生（OR=-0.54;95％ CI：0.38～ 0.77;P=0.0005）,但两者在术后并发症、胃排空延迟、围手术期病死率方面差异均无统计学意义.结论 目前随机对照试验研究显示胰十二指肠切除术后消化道重建胰胃吻合术优于胰空肠吻合术.     

胰十二指肠切除术后胰胃吻合和胰肠吻合安全性与疗效的Meta分析

目的：系统评价胰胃吻合（PG）和胰肠吻合（PJ）两种胰十二指肠切除术（PD）后胰腺消化道吻合术的安全性及疗效。 方法：检索国内外数据库中有关PD术中应用PG和PJ的前瞻性随机对照试验,由2名研究者独立进行文献数据的提取,按照Cochrane Handbook 5.1对纳入的文献进行严格的质量评价,并应用Review Manager 5.2软件进行Meta分析。 结果：共纳入7篇文献,包括1 121例患者,其中PG组562例,PJ组559例。Meta分析结果显示,PG组在胰瘘（OR=0.60,95% CI=0.44~0.82,P=0.001）、胆瘘（OR=0.42,95% CI=0.18~0.93,P=0.03）、腹腔积液（OR=0.50,95% CI=0.34~0.74,P=0.0005）发生率方面优于PJ组;两组在胃排空障碍（OR=0.98,95% CI=0.53~1.82,P=0.95）、术后腹腔出血（OR=1.29,95% CI=0.95~1.96,P=0.24）、二次手术率（OR=0.96,95% CI=0.61~1.52,P=0.87）、病死率（OR=0.82,95% CI=0.43~1.58,P=0.56）方面差异无统计学意义。 结论： PD在减少胰瘘、胆瘘、腹腔积液发生率方面较PJ更有优势,但两者的安全性与远期疗效尚值得进一步研究验证。     

胰肠吻合口内引流与外引流在胰十二指肠切除术后疗效对比的Meta分析

目的 系统评价胰肠吻合口内引流与外引流对胰十二指肠切除术（PD）术后并发症的影响,重点分析对术后胰瘘的影响,为临床应用提供循证医学方面的客观依据。方法 计算机检索Cochrane Library、PubMed、Embase、Web of Science、中国生物医学文献数据库（CBM）、中国期刊全文数据库（CNKI）、维普和万方等数据库中关于胰肠吻合口内引流与外引流对比分析的相关文献。按Cochrane系统评价的方法评价纳入研究的质量,使用RevMan 5.3软件对研究资料进行统计分析。结果 共纳入9篇文献,总计1 686例患者,其中内引流组932例,外引流组754例。Meta分析结果显示：所有纳入文献中内引流组与外引流组术后胰瘘发生率（OR 0.02,95%CI 0.08～0.3）差异没有统计学意义（P=0.44）。去除相关干扰因素,进行各种亚组分析后,结果 依然是两种引流方式术后胰瘘发生率差异没有统计学意义（P＞0.05）,其他术后并发症发生率也没有统计学差异（P＞0.05）。结论 胰肠吻合口内引流与外引流对PD术后并发症的影响没有差异,术者应根据患者具体情况,选取自己比较熟练而且对患者比较安全的引流方式。     

Braun吻合术治疗胰十二指肠切除术后高热一例

<正>胰腺手术解剖复杂、吻合难度高,机器人辅助技术凭借其可在狭小、复杂的空间内完成精细操作的优点在胰腺外科中的应用日趋广泛。尽管如此,胰十二指肠切除（pancreaticoduodenectomy,PD）术后的并发症仍长期存在。诸如胃排空延迟、反流性胆管炎等,长期而反复地影响着患者的生存质量。     

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.     

保留十二指肠的胰头切除术与胰十二指肠切除术治疗慢性胰腺炎疗效Meta分析

目的通过Meta分析的方法,对保留十二指肠的胰头切除术与胰十二指肠切除术治疗慢性胰腺炎的疗效进行评价。方法分别在PubMed、EMBASE、Cochrane Library和中国生物医学文献数据库中检索1980年1月至2012年9月间发表的有关保留十二指肠的胰头切除术与胰十二指肠切除术治疗慢性胰腺炎的临床对照试验(包括随机和非随机研究)。分别按照入选和排除标准筛选,有9项临床试验纳入研究,提取所需数据,用RevMan5.1软件进行分析。结果保留十二指肠的胰头切除术与胰十二指肠切除术相比,手术死亡率(P=0.56)及疼痛缓解(P=0.53)差异无统计学意义,而两组手术总并发症(P<0.01)、住院时间(P<0.01)、新发糖尿病(P<0.01)、生活质量(P<0.01)等均显示保留十二指肠的胰头切除术优于胰十二指肠切除术。结论从目前资料来看,保留十二指肠的胰头切除术相比于胰十二指肠切除术,在治疗慢性胰腺炎的疗效上更具有优势。     

胰十二指肠切除术胰肠吻合的进展

<正>胰十二指肠切除术(pancreaticoduodenectomy,PD)是治疗壶腹周围恶性肿瘤和某些良性疾病的主要方法。自1935年Whipple首次实施PD以来,随着外科技术的进步,PD的死亡率已降至5%以下,但术后并发症仍高达30%～40%[1],     

Braun enteroenterostomy during pancreaticoduodenectomy decreases postoperative delayed gastric emptying

Background

Modified digestive reconstruction during pancreaticoduodenectomy (PD) may affect the postoperative incidence of delayed gastric emptying (DGE). The purpose of this study is to investigate whether Braun enteroenterostomy following PD can reduce the incidence of DGE.

Methods

Four hundred seven patients who received PD with child reconstruction from June 2000 to March 2013 were divided into 2 groups: 206 patients with Braun enteroenterostomy (Child-Braun group) and 201 patients without Braun enteroenterostomy (Child-non-Braun group). Clinical data were retrospectively extracted; univariate and multivariate analyses were performed to investigate the association between Braun enteroenterostomy and DGE.

Results

DGE was less frequent in the Child-Braun group than in the Child-non-Braun group (6.7% vs 26.87%, P < .001). The multivariate logistic regression analysis showed that Braun enteroenterostomy was the only significant independent factor associated with the reduced DGE after PD with Child reconstruction, with an odds ratio of 4.485 (95% confidence interval: 2.372 to 8.482, P < .001).

Conclusion

Braun enteroenterostomy reduces the incidence of postoperative DGE associated with PD.     

Reduction of alkaline reflux gastritis and marginal ulcer by modified Braun enteroenterostomy in gastroenterologic reconstruction after pancreaticoduodenectomy

Background

The incidence of alkaline reflux gastritis (ARG) after pancreaticoduodenectomy (PD) is high. Although Braun enteroenterostomy (BEE) may reduce ARG, BEE may result in marginal ulcers (MUs) due to the additional anastomotic stoma. We conducted this study to compare clinical outcomes of using a modified BEE (MBEE) with traditional gastrojejunostomy (TGJ), by inducting a purse-string suture instead of an additional anastomotic stoma.

Materials and methods

All 62 patients underwent standard PD at the Department of Hepatobiliopancreatic Surgery of West China Hospital between January 1, 2008 and January 31, 2012. Demographics, perioperative and postoperative factors, and follow-up morbidity were compared in those patients who underwent MBEE (n = 32, three patients were lost to follow-up) to those who underwent TGJ (n = 30, nine patients were lost to follow-up).

Results

Patients who underwent the MBEE experienced a decrease in total morbidity including ARG and MUs, relative to those who underwent TGJ (24.1% versus 58.3%, P = 0.011). With regard to the MBEE group, the total ARG rate was statistically significantly lower compared with the TGJ group (13.8% versus 37.5%, P = 0.046). In addition, the incidence of MUs was reduced.

Conclusions

In patients undergoing PD, the MBEE was safely performed with significantly more patients having reduced incidence of ARG and related sequela compared with those who underwent TGJ. These results support further study of patients undergoing gastroenterostomy after resection of the distal stomach in larger, randomized studies.     

腹部手术后胃排空障碍31例临床分析

胃排空障碍(DGE)临床并非少见,术后胃肠道运动的改变及吻合口水肿是其主要原因。现就笔者医院1998年5月至2008年5月间经治的31例腹部手术后发生胃排空障碍分析如下。     

胰十二指肠切除术后胃排空障碍的诊疗进展

目的总结胰十二指肠切除术(PD)后胃排空障碍诊疗的现状与进展。方法检索近年来国内外有关PD后胃排空障碍的相关研究文献并进行综述。结果目前胃排空障碍的病因及发病机制尚未完全阐明,与手术创伤、患者高龄、合并糖尿病、伴有其他腹部并发症等多种高危因素有关。保留幽门PD并不增加术后胃排空障碍的风险,而幽门环切除、结肠前吻合、Braun吻合、微创手术对降低其发生是有利的。胃排空障碍的治疗目前国内外仍无明显进展,但绝大多数患者可通过对症保守治疗获得痊愈。结论 PD后胃排空障碍应以预防为主,围术期应用术后加速康复策略可能是目前临床解决术后胃排空障碍的关键所在,但需进一步研究。     

胰十二指肠切除术后胃排空延迟的因素分析

目的　明确影响胰十二指肠切除术后胃排空延迟形成的因素。方法　回顾性分析1994年12月至2 0 0 3年12月接受胰十二指肠切除术的12 3例患者的病历资料。结果　胃排空延迟的发生率为2 1.1% (2 6/12 3 )。单变量分析表明:手术失血量、手术方式、近端空肠切除长度、胆瘘、腹腔感染、术后白蛋白水平、术后排气时间、术后前3d日均胃液引流量及胆汁引流量为有意义的相关因素;经Logistic回归多变量分析,确定了6个独立与胃排空延迟相关的变量:腹腔感染、手术方式、手术失血量、术后排气时间、术后前3d日均胃液引流量及胆汁引流量。结论　腹腔感染、保留幽门的胰十二指肠切除术及手术失血量≥10 0 0ml是胰十二指肠切除术后胃排空延迟发生的重要影响因素;胃排空延迟伴随有术后排气时间延长、术后前3d胃液引流量增多及胆汁引流量减少。     

Method of pyloric reconstruction and impact upon delayed gastric emptying and hospital stay after pylorus-preserving pancreaticoduodenectomy

Preservation of the pylorus at the time of pancreaticoduodenectomy has been associated with equal oncological outcomes when compared to the classical Whipple operation. Multiple studies have demonstrated that pylorus-preserving pancreaticoduodenectomy (PPPD) has equal or superior outcomes regarding quality of life when compared with the traditional Whipple operation, but many studies have suggested a higher incidence of delayed gastric emptying (DGE). DGE prolongs hospital stay, and its association with PPPD has hampered its adoption by many pancreatic surgery centers. We describe a novel surgical technique for the prevention of delayed gastric emptying following pylorus-preserving pancreaticoduodenectomy. The technique of pyloric dilatation appears to decrease the incidence of delayed gastric emptying and facilitates earlier hospital discharge, when compared with standard pylorus preserving pancreaticoduodenectomy. Presented at the 2005 American Hepato-Pancreato-Biliary Association Congress, Hollywood, Florida, April 14–17, 2005.     

Improvement of early delayed gastric emptying in patients with Billroth I type of reconstruction after pylorus preserving pancreatoduodenectomy

Background  Early delayed gastric emptying (DGE) is the most common complication after pylorus-preserving pancreatoduodenectomy (PpPD). Recently, a vertical antecolic reconstruction for duodenojejunostomy was recommended to decrease the incidence of early DGE in patients with Billroth II-type reconstruction after PpPD. However, Billroth I-type reconstruction (B-I) after PpPD is still favored in Japan. Methods  Twelve consecutive patients with B-I were prospectively enrolled. Our technique includes an end-to-side duodenojejunostomy and alignment of the stomach contours with fixation of the greater omentum to the abdominal wall in order to promote passage from the stomach through the jejunal loop. DGE was evaluated according to the consensus definition of the International Study Group of Pancreatic Surgery (ISGPS). Results  DGE was absent, with the nasogastric tube removed within 3 days in all patients. Mean duration of nasogastric tube placement was 1.5 ± 0.4 days. Mean maximum suction volume was 85 ± 32 ml/day. Conclusion  Preliminary results were encouraging simply with relief of the outflow disturbance around the duodenojejunostomy in patients with B-I after PpPD. These findings warrant further prospective randomized trials at either multiple or high-volume centers. A portion of this study was presented at the 15th United European Gastroenterology Week (UEGW) in Paris on 30 October 2007.     

Early and late complications of pylorus-preserving pancreatoduodenectomy in Japan 1998

Early (within 1 month after operation) and late (more than 1 month after surgery) complications after pylorus-preserving pancreatoduodenectomy (PpPD) were analyzed in 1066 Japanese patients collected from 74 authentic institutions in Japan. As early postoperative complications after PpPD, delayed gastric emptying was evident in 46% of patients, pancreatoenterostomy leakage in 16%, intra-abdominal infection in 14%, cholangitis in 8.9%, hepaticojejunostomy leakage in 4.7%, intra-abdominal hemorrhage in 3.5%, upper gastrointestinal hemorrhage in 3.2%, and duodenojejunostomy leakage in 2.0%. Delayed gastric emptying resolved 1–24 months after PpPD (mean, 3.1 months). The direct operative mortality (death within 1 month after the operation) was 2.4%. Univariate and multivariate analysis of pancreatoenterostomy leakage showed that male sex (P = 0.0151) and soft consistency of the pancreas (P < 0.0001) were independent significant factors. Univariate analysis of delayed gastric emptying showed that establishment of gastrostomy (P < 0.0001), length of the preserved duodenum (P = 0.0406), gastric juice output (P = 0.0001), length of gastric tube placement (P < 0.0001), and administration of cisapride (P = 0.0059) were significant variants. As late complications, stomal ulcer was evident in 3.6% of patients, cholangitis in 6.7%, and liver abscess in 1.2%. Glucose intolerance appeared in 61 patients, resolved in 15, showed no change in 170, was absent in 695, and was ameliorated in 17. As a result, the dosage of hypoglycemic agents or insulin showed no change in 187 patients, decreased in 16, and increased in 52. Diabetes appeared 0–42 months after PpPD (mean, 102 months). When present, diabetes deteriorated 0–36 months postoperatively (mean, 6.3 months). Univariate analysis of the appearance or deterioration of diabetes showed that diabetes occurred more frequently in the following patients; those with Billroth I reconstruction compared with those with Billroth II (P = 0.0041), those with pancreatogastrostomy vs those with pancreatojejunostomy (P = 0.0229), those with pancreatogastrostomy vs those with end-to-side pancreatojejunostomy (P = 0.0165), and those with total tube drainage vs those with pancreatico-whole thickness anastomosis (P = 0.0392); a high American Society of Anesthesiologist (ASA) score (P = 0.0211) and pancreatoenterostomy leakage (P = 0.0361) were also significant factors. Postoperative body weight loss (>3 kg) was evident in 62% of patients. Body weight loss reached a maximum 4.2 ± 5.8 months after PpPD (mean, 6.0 kg) and returned to the preoperative level 4.8 months thereafter. These results suggest that PpPD has been performed safely in Japan, the operative mortality being 2.4%. However, delayed gastric emptying was evident in 46% of the patients and pancreatoenterostomy leakage in 16%. Impairment of glucose tolerance occurred in about 10% of patients more than 1 month after PpPD. Therefore, during the early postoperative period, patients should be closely monitored for pancreatoenterostomy leakage and delayed gastric emptying and in the late postoperative period, glucose tolerance should be carefully followed-up. Received for publication on Feb. 19, 1999; accepted on April 21, 1999