插管法胰腺空肠端侧吻合预防Whipple手术后胰瘘

目的 评价插管法胰腺空肠端侧吻合预防Ｗｈｉｐｐｌｅ手术后胰腺瘘。方法 采用残胰管内插入导管,空肠壁切开浆肌切开粘膜,吻合时只缝合胰腺断端前后缘与空肠浆肌层切开的前后唇。胰管导管穿透粘膜引入空肠腔内,不必做胰管与空肠粘膜切口缝合,１２例行胰液外引流,１４例内引流。结果 ２６例均无胰瘘发生。结论 插 胰腺空肠端侧吻合手术操作简单,可预防Ｗｈｉｐｐｌｅ手术后胰瘘。     

胰十二指肠切除术后一种简易安全的胰空肠吻合术

作者1989年4月至1995年6月连续施行胰十二指肠切除术50例，对胰空肠吻合技术作了改进，方法如下：胰十二指肠切除之后，先用订合器关闭空肠近端，将之经结肠前上提至肝总管断端，用3—0丝线将肝总管与空肠作一层间断端侧吻合，不放T型管。然后根据残胰胰管的大小，选择一个适宜型号的小儿用鼻胃管插入胰管内作为支撑管，并用3—0铬肠线与胰管缝合固定。在距肝总管空肠吻合口10～15cm的远侧空肠两则壁各戳孔穿引支撑管至腹壁外。将胰腺断面后缘的部分胰腺实质及被膜与空肠后壁浆肌层用3—0丝线缝合打结，继之空肠后壁浆肌层用3—0丝线缝合打…     

空肠外翻套入式缝合在胰空肠吻合术中的临床应用

目的探讨空肠外翻套入式缝合在胰十二指肠切除胰空肠吻合术中预防胰瘘的应用价值。方法对35例行胰十二指肠切除术的患者,在游离胰腺断端后,将空肠断端约3era的黏膜外翻并灭活,先将胰腺的切缘与外翻的空肠黏膜间断缝合（缝线不穿透空肠浆膜层）,然后将外翻空肠复位。并将胰腺断端套入空肠腔内,再将空肠切缘与胰腺被膜间断缝合。结果35例均获痊愈,无胰瘘、腹腔脓肿及术后大出血等严重并发症发生。随访3个月～3年,无胰腺炎、吻合口溃疡,亦无脂肪泻等胰腺外分泌功能不足表现。结论空肠外翻套入式胰空肠吻合术可有效防止胰空肠吻合口的并发症。     

空肠反转套入式缝合在胰空肠吻合术中的应用

目的:探讨空肠反转套入式缝合在胰十二指肠切除胰空肠吻合术中预防胰瘘的应用价值。方法:对38例行胰十二指肠切除术的患者,在游离胰腺断端后，将空肠断端约3 cm的黏膜外翻并灭活，先将胰腺的切缘与外翻的空肠黏膜间断缝合（缝线不穿透空肠浆膜层），然后将外翻空肠复位，并将胰腺断端套入空肠腔内，再将空肠切缘与胰腺被膜间断缝合。结果:38例均获痊愈,无胰瘘、腹腔脓肿及术后大出血等严重并发症发生。随访2个月至3年,无胰腺炎、吻合口溃疡，亦无脂肪泻等胰腺外分泌功能不足表现。结论:空肠反转套入式胰空肠吻合术可有效防止胰空肠吻合口瘘。     

改良套叠式胰空肠吻合术应用石蕊试纸和纤维蛋白胶预防胰漏47例体会

目的 总结降低胰十二指肠切除术后胰空肠吻合口漏发病率的经验体会。方法 切除胰头后，将胰腺残端游离2．5～3．0cm，利用红色石蕊试纸遇碱性胰液变蓝的特性，帮助寻找胰腺断面被横断的小导管，丝线贯穿缝扎。将空肠袢断端2．0～2．5cm浆肌层剥除后施行套叠式胰空肠端端吻合，距浆肌层游离缘1．0～1．5cm处空肠上下壁各缝1针固定，最后用纤维蛋白胶封闭吻合口。结果 47例患者中无一例发生胰空肠吻合口漏。结论 该法操作较简便，适用于胰腺残端各种情况的处理。     

带血管蒂空肠浆肌瓣对胰腺切除和缝合的改进

目的　探讨一种降低全胃切除联合远端胰腺切除术后胰漏发生的术式。　方法　 1996年 3月～ 2 0 0 2年 12月 ,2 9例远端胰腺切除时 ,胰腺断端稍外凸 ,呈“ >”形 ,然后结扎主胰管 ,创面止血 ,利用代胃空肠制作带血管蒂浆肌瓣 ,用纤维蛋白胶将浆肌瓣与胰腺残端贴敷后丝线缝合 ,以保护胰腺残端。　结果　无胰漏、腹腔感染或脓肿及胰腺假性囊肿发生。　结论　带血管蒂空肠浆肌瓣有利于促进胰断面愈合 ,能有效地预防胰漏。     

剥离空肠浆肌层的胰肠套叠式端端吻合术174例观察

目的探讨剥离空肠浆肌层的胰肠套叠式端端吻合术应用价值。方法自1985年8月至2008年10月共施行胰十二指肠切除174例,术后游离胰腺残端2．5～3．0cm,将准备与胰腺吻合的空肠袢断端2．0～2．5cm浆肌层剥除,施行胰肠套叠式端端吻合术,最后在距浆肌层游离缘1．0～1．5cm处空肠上下壁各缝一针,同定套入的胰腺残端。吻合口周围喷撒纤维蛋白胶封闭剂。观察患者消化道重建后恢复和并发症发生情况。结果174例患者中,术后胰漏8例（4．6％）,保守治疗愈合,无腹腔感染及大出血等严重并发症。结论施行胰十二指肠切除消化道重建过程中,采用剥离空肠浆肌层的胰肠套叠式端端吻合术,有助于减少胰漏,适用于胰腺残端各种情况的处理,利于患者顺利康复。     

保留与去空肠黏膜的胰肠套入吻合方式在胰十二指肠切除术中的应用比较

目的 对胰十二指肠切除术采用保留空肠黏膜与去空肠黏膜胰肠直接套入加捆扎两种不同的吻合方式进行探讨.方法 2003年2月 2012年12月对58例胰十二指肠切除术患者采用胰空肠套入吻合术;其中A组28例采用保留空肠黏膜残胰直接套入空肠3～4 cm,在距离残胰腺断端2～3 cm处将包盖于残胰腺体的空肠段用7-0丝线予以捆扎.B组30例则为去黏膜化,空肠黏膜外翻3 cm并去黏膜化处理并行肠黏膜下肌层与残胰体断端缝合,之后将空肠复位,随后按A组方法将包盖于残胰体的空肠予以捆扎.结果 A、B两组胰-肠吻合时间比较,A组比B组平均缩短(36±0.34) min(P ＜0.001);A组和B两组术后并发胰瘘分别为0和20.0％;A组和B两组术后迟发性残胰断端出血分别为3.6％和3.3％.结论 在胰十二指肠切除术采用保留空肠黏膜与去空肠黏膜两种不同胰肠吻合方式中,前者不受残胰质地、胰管大小影响和具有操作简便以及可以降低胰瘘发病率的优点.     

胰空肠反转套入式吻合术

目的：探讨胰十二指肠切除胰空肠反转套入式吻合术防止胰空肠吻合口瘘发生的效果及术式优点。方法：游离胰腺断端后,将空肠断端约3cm的黏膜外翻,分别用2％碘酊和75％酒精破坏其黏膜,将胰腺的切缘与外翻的空肠黏膜间断缝合,注意缝线不宜穿透空肠浆膜层。将反转空肠黏膜翻回原状,使3cm的胰腺断端套入空肠腔内,然后将空肠切缘与胰腺包膜缝合。结果：本组26例病人均获痊愈,无胰瘘及消化道出血等严重并发症发生,无手术死亡,1年、3年、5年生存率分别为92．3％、60％、34．6％。结论：胰空肠反转套入式吻合术防止胰空肠吻合口瘘操作简便,效果可靠,疗效满意,有很好的实用推广价值;同时加强围手术期处理是手术成功的重要环节。     

套入式胰肠浆肌层U型贯穿缝合固定术——简易的胰肠吻合新方法

探讨一种安全可靠的胰肠吻合新方法,以预防术后胰肠吻合口瘘的应用价值。2011年6月—2014年10月笔者完成自行设计的"套入式胰肠浆肌层U型贯穿缝合固定术"23例,胰肠吻合方法采用1)先行空肠后壁浆肌层3-0 Prolene线缝合;2)U型贯穿胰腺全层;3)胰腺断面与空肠开口常规缝合;4)用上述同一Prolene线空肠前壁浆肌层缝合套入结扎,分析此吻合术式的可行性、疗效及并发症。本组患者手术均取得成功,其中胰肠端端套入方式9例,胰肠端侧套入方式14例,平均吻合时间15(10~25)min,术后均无胰瘘、胆瘘、胃肠瘘及大出血等重大并发症,无死亡病例。套入式胰肠浆肌层U型贯穿缝合固定术在胰肠吻合应用中安全性强,方法简单,疗效可靠,基本不发生胰瘘,有明显的临床应用价值。     

End-to-side pancreaticojejunostomy without stitches in the pancreatic stump

In patients undergoing pancreaticoduodenectomy, leakage from the pancreatic anastomosis remains an important cause of morbidity and contributes to prolonged hospitalization and mortality. Recently, a new end-to-end pancreaticojejunostomy technique without the use of any stitches through the pancreatic texture or pancreatic duct has been developed. In this novel anastomosis technique, the pancreatic stump is first sunk into deeply and tightened with a purse string in the bowel serosa. We modified this method in an end-to-side manner to complete the insertion of the pancreatic stump into the jejunum, independent of the size of the pancreas or the jejunum. We tested this new anastomosis technique in four pilot patients and compared their outcomes with four control patients who underwent traditional pancreaticojejunostomy. No severe pancreatic fistulas were observed in either group. There were no differences in morbidity or hospital stay between the groups. This new method can be performed safely and is expected to minimize leakage from pancreaticojejunostomies.     

Pancreaticojejunal anastomosis, using a stent tube, in pancreaticoduodenectomy

We report our technique for pancreaticojejunostomy, using a stent tube, and examine the literature with regard to the use of a stent tube in pancreaticojejunostomy. The total number of stitches in the anastomosis of the pancreatic parenchyma and seromuscle layer of the jejunum should be more than 20, and there should be more than 8 stitches in the anastomosis of the pancreatic duct and parenchyma and all layers of the jejunal wall, even in a normal-sized main pancreatic duct. There is no dead space between the cut end of the pancreatic parenchyma and the jejunal wall. None of the 114 consecutive patients who underwent pancreaticoduodenectomy in our series died. We use a stent because this makes it easier to perform anterior wall anastomosis of the pancreaticojejunostomy. It is easy to find the pancreaticojejunal anastomosis at the anterior wall anastomosis. We never stitch the posterior wall of the anastomosis with a stent tube in place at the anterior wall anastomosis. If the anastomosis leaks, the massive flow of pancreatic juice around the anastomosis is prevented because of the pancreatic juice flowing out of the pancreatic tube.     

Pancreaticojejunostomy by simple introduction after pancreaticoduodenectomy

The method which most surgeons still prefer in the treatment of the pancreatic stump after pancreaticoduodenectomy is pancreaticojejunostomy. In this article, we describe our preliminary experience with a fast, effective method, consisting in an end-to-end pancreaticojejunostomy by simple introduction, in 11 cases operated on without morbidity or mortality. From 1998 to 2002, 11 patients with pancreatic head or distal bile duct neoplasms underwent pancreaticoduodenectomy. After removal of the specimen, the residual pancreatic stump was prepared towards the left for about two centimetres, mobilizing the posterior surface from the porto-meseraic axis. A single layer of interrupted suture, consisting only in two posterior stitches, was enough in all cases; each stitch was done taking the stump full-thickness at about one centimetre from the transection margin (so as to introduce a corresponding portion of parenchyma into the jejunal lumen), and from the superior and inferior margin, respectively, of the pancreas. On the intestinal side, the stitches were passed full-thickness from the inner surface to the outside, 6 to 7 millimetres from the transection margin. After introducing the stump completely into the intestinal lumen, three anterior stitches were always done and knotted between the pancreatic capsule and the jejunum. All the anastomoses proved to be perfectly sealed.     

捆绑式胰管对黏膜吻合术

目的 研究一种与捆绑式胰肠吻合术和捆绑式胰胃吻合术互补的术式--捆绑式胰管对黏膜吻合术的可行性.方法 (1)动物实验:对6只成年新西兰兔行胃肠造瘘术,两个造瘘口分别用导尿管、硅胶管、输液器管作为支撑管连接,导管两端分别置入胃腔与肠腔内,造瘘口荷包缝合,胃壁与肠壁浆膜层拉拢缝合周定.观察胃肠造瘘口处渗漏及愈合情况,显微镜下观察胃黏膜与空肠黏膜愈合情况.(2)临床实践:对7例患者施行捆绑式胰管对黏膜吻合术.手术方法包括:胰端的准备、肠侧的准备、胰断端与空肠对合固定的准备、吻合的实施、最后施行胰断端与空肠的对合固定.术后定期检测腹腔内引流管和血淀粉酶以及各种并发症的情况.胰漏按来源不同分为胰腺实质漏(胰创面漏)和吻合口漏两种.结果 动物实验结果显示愈合良好.临床全部病例均未出现吻合口漏,但有2例腹腔内引流液淀粉酶出现一过性增高,引流量均未超过50 ml/d,未影响患者康复,属于胰腺实质漏(胰腺创面漏).结论 捆绑式胰管对黏膜吻合术是一种简单安全的吻合方法,给外科医生提供了一种新的选择,以便在面对不同的患者时,能够灵活采用不同的方法去取得最理想的治疗效果.

Abstract：

Objective To study the feasibility of binding pancreatic duct to mucosa anastomosis (BDM)-a complementary procedure to both binding pancreaticojejunostomy and binding pancreaticogastrostomy. Methods (1) Animal experimental study: gastrostomy and jejunostomy were performed on six adult New Zealand rabbits. The gastrostomy and jejunostomy shared a same stent (rubber urethral catheter, silicone tube or plastic infusion tube). Both ends of the stent were placed in gastric and enteric cavity. Purse-string suture was performed around the stent before the jejunum and the stomach were brought together for fixation by few stitches. And to observe whether the purse-string suture around a plastic tube,rubber tube or silicon tube inserted into jejunum and/or stomach can prevent leaking out of the jejunal or gastric content to cause peritonitis. (2)Clinically 7 patients were performed with BDM anastomosis. The procedure was consisted of five steps: preparation of the pancreatic stump; preparation of the jejunum;preparation of the fixing sutures between the pancreatic stump and the jejunum; implementation of the anastomosis; lastly, fixation of the jejunum beside the pancreas stump. Post-operative periodic examination of the blood amylase and the amylase in the abdominal drainage. Pancreatic fistula was classified in to two categories: parenchymal fistula (pancreatic cut surface fistula) and anastomotic leakage. Results Animal experiment did not show any leakage around the plastic tube or silicon tube inserted into jejunum and(or) stomach. There was no anastomotic leak in all the patients. There was transient increase of amylase in two cases, but the volume of drainage did not exceed 50 ml/d and the recovery of the patients was not affected.Conclusions BDM is a simple, safe and easy procedure to perform. It provides to the surgeons with a new option in different situations to achieve the most ideal surgical result.     

Telescopic technique associated with mucosectomy: a simple and safe anastomosis in pancreaticoduodenectomy

Pancreatic fistula remains a common problem and a main cause of morbidity and mortality after pancreaticoduodenectomy (PD). We have developed a safe and simple method of pancreaticojejunostomy in 33 patients, in whom approximately 3 cm of jejunal mucosa was cut to improve the adhesion between the loop and pancreatic parenchyma after end-to-end invagination. Furthermore, we have performed a purse-string procedure on 21 patients to secure the jejunum to the intussuscepted pancreatic stump instead of continuous running fashion with double needles of 5-0 monofilament synthetic absorbable sutures. This procedure was proved to be much more expeditious, and only 2 of 33 patients had pancreatic leakages. Therefore, the telescopic technique associated with mucosectomy is an acceptable and safe surgery for pancreaticojejunal anastomosis.     

胰十二指肠切除术中胰肠吻合方式的选择

目的：比较胰十二指肠切除术（PD）中应用不同胰肠吻合方式的临床效果。方法：回顾性分析2008年3月—2013年3月收治的260例行PD患者的临床资料,其中胰管直径≥4 cm的患者采用胰管空肠黏膜吻合术（135例）,胰管直径<4 cm的患者,空肠管腔口径<胰腺残端直径者采用改良Child胰肠吻合（67例）;空肠管腔口径≥胰腺残端直径者采用捆绑式胰肠吻合（58例）,比较各组的临床疗效及术后并发症的发生率。结果：所有患者均顺利完成手术,3组患者并发症的发生率如胰瘘、腹腔感染、腹腔出血、消化功能异常及平均住院时间的差异均无统计学意义（均P>0.05）。1例老年患者术后第4天发生脑血管意外死亡,余患者平均随访3.2（2~4）个月,期间未发现复发、转移及死亡。结论：在PD术中应依据胰管直径、胰腺残端直径及空肠管腔口径选择胰肠吻合方式,恰当的胰肠吻合方式可取得良好的临床疗效。

     

Binding pancreaticoenteric anastomosis: from binding pancreaticojejunostomy to binding pancreaticogastrostomy

Potential mechanisms of occurrence of pancreatic leakage mainly include leakage from the needle hole and from the seam at the adjacent stitch, anastomotic blood supply, tension at the anastomosis, poor anastomotic healing, etc. Binding pancreaticojejunostomy (BPJ) is a safe and effective technique that avoids the primary complication of pancreatic anastomosis leakage. There are two problems with BPJ: a high discrepancy in the size of pancreas stump and the jejunal lumen; sutures on to the pancreas for fixation might cause exudation of pancreatic juice into the abdominal cavity. In order to avoid these two problems, binding pancreaticogastrostomy (BPG) is designed and successfully performed clinically with encouraging results. BPG is good for accommodating a large pancreas stump, and the binding technique is very helpful in minimizing the leak rate of pancreaticogastrostomy.     

胰十二指肠切除术改进胰肠及胃肠吻合方式52例观察

目的探讨胰十二指肠切除术改进胰肠及胃肠吻合方式对患者近期和远期并发症的影响。方法对52例行胰十二指肠切除术的患者进行消化道重建,方式为胰肠、胆肠和胃肠顺序。胰肠吻合在完成胰十二指肠切除后,游离胰腺残端2．5～3．0cm,将准备与胰腺吻合的空肠袢断端浆肌层剥除,制成黏膜瓣,长度与胰腺断面前后径相当,施行黏膜瓣覆盖胰腺断面的套叠式胰空肠端端吻合术;胃肠吻合是在胃或十二指肠球部与胰胆侧肠袢之间问置30cm空肠施行胃肠道重建。结果术后发生胰漏2例（3．8％）,经充分引流并给予生长抑素、肠内营养等保守治疗愈合,无腹腔感染及大出血等严重并发症。术后随访3年,随访率为88．5％（46／52）,术后半年95．0％（38／40）的患者消化吸收功能基本正常,营养状况良好,未发生逆行性胆管炎、胆汁反流性胃炎、胃肠吻合口溃疡。结论施行胰十二指肠切除消化道重建过程中,采用黏膜瓣覆盖胰腺断面的套叠式胰空肠端端吻合术有助于减少胰漏等近期并发症在胃或十二指肠球部与胰胆侧肠袢之间间置空肠,可减少胃肠道反流等远期并发症。     

A standardized technique for safe pancreaticojejunostomy: Pair-Watch suturing technique

AIM: To prevent pancreatic leakage after pancreaticojejunostomy, we designed a new standardized technique that we term the “Pair-Watch suturing technique”.METHODS: Before anastomosis, we imagine the faces of a pair of watches on the jejunal hole and pancreatic duct. The first stitch was put between 9 o’clock of the pancreatic side and 3 o’clock of the jejunal side, and a total of 7 stitches were put on the posterior wall, followed by the 5 stitches on the anterior wall. Using this technique, twelve stitches can be sutured on the first layer anastomosis regardless of the caliber of the pancreatic duct. In all cases the amylase activity of the drain were measured. A postoperative pancreatic fistula was diagnosed using postoperative pancreatic fistula grading.RESULTS: From March 2007 to July 2008, 29 consecutive cases underwent pancreaticojejunostomy using this technique. Pathologic examination results showed pancreatic carcinoma (n = 14), intraductal papillary-mucinous neoplasm (n = 10), intraductal papillary-mucinous carcinoma (n = 1), carcinoma of ampulla of Vater (n=1), carcinoma of extrahepatic bile duct (n = 1), metastasis of renal cell carcinoma (n = 1), and duodenal carcinoma (n = 1). Pancreaticojejunal anastomoses using this technique were all watertight during the surgical procedure. The mean diameter of main pancreatic duct was 3.4 mm (range 2-7 mm). Three patients were recognized as having an amylase level greater than 3 times the serum amylase level, but all of them were diagnosed as grade A postoperative pancreatic fistula grading and required no treatment. None of the cases developed complications such as hemorrhage, abdominal abscess, and pulmonary infection. There was no postoperative mortality.CONCLUSION: Our technique is less complicated than other methods and very secure, providing reliable anastomosis for any size of pancreatic duct.     

Pancreaticojejunostomy with invagination of spatulated pancreatic stump into a jejunal pouch

BACKGROUND: Pancreaticoenteric anastomosis after pancreatic resection is of major concern as anastomotic leak continues to be common. There is no unanimity for the preferred technique and overall incidence of pancreatic leak is reported to be 2% to 14%. METHODS: A new safe method of anastomosing pancreatic stump to a jejunal pouch is described. A 15-cm length of the jejunal end is detubularized and reconfigurated into a U-shaped patch. The pancreatic stump is mobilized for about 3 cm and the duct is spatulated posteriorly and anastomosed to a cut in convex margins of the patch. This is converted into a pouch invaginating the spatulated pancreaticojejunal anastomosis. RESULTS: Eleven cases of periampullary malignancy after pancreaticoduodenectomy have been operated on with no pancreatic leak. CONCLUSIONS: Even a bulky pancreas can be invaginated into the pouch. The resulting anastomosis is completely intraluminal. Spatulated mucosa to mucosa anastomosis should reduce the chances of late stenosis.