Pancreaticoduodenectomy in the very elderly

It is estimated that by 2050, there will be a 300% increase in the elderly population (=>65 years) and a cor-responding increase in elderly patients presenting for surgical evaluation. Surgical decision-making in this population can be difficult because outcomes in the elderly are poorly defined. We reviewed 2698 consecutive pancreaticoduodenectomies (PDs) at our institution over a 35-year period (April 1970 through March 2005), with the last 1000 resections being done in the last 4 years. Data collected in-cluded surgical indication, mortality (defined as 30-day or in-hospital mortality), complications, and sur-vival. Patients were divided by age into three groups (<80, 80 89, and =>90 years) and evaluated using multiple logistic regression. Two hundred seven patients =>80 years old underwent a PD (7.7% of 2698). Patients 80 89 years of age had a mortality rate of 4.1% (8 of 197) and a complication rate of 52.8% (99 of 197), whereas patients =<79 years of age had a mortality of 1.7% and a complication rate of 41.6% (P < 0.05). There were no perioperative deaths among the 10 patients =>90 years of age, and their com-plication rate was 50% (5 of 10). One-year survival for patients 80 89 years of age was 59.1%, and that for patients =>90 years was 60%. Age was not an independent risk factor for perioperative mortality and morbidity following PD after adjusting for preoperative comorbidities. We demonstrate that PD can be safely performed in patients over 80 years of age and conclude that age alone should not be a contrain-dication to pancreatic resection. The advent of improved surgical outcomes and an aging population will likely result in a significant increase in the number of PDs performed in the next few decades. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, May 16, 2005, Chicago, Illinois (poster presentation).     

完全性胰液外引流预防胰十二指肠切除术后胰瘘

目的探讨完全性胰液外引流预防胰十二指肠切除术后胰瘘的疗效。方法回顾性分析1992年1月-2004年5月62例行胰十二指肠切除后在Child术式基础上附加胰液完全外引流的病例资料。结果本组术后无胰瘘发生，3周左右拔除胰管引流管。发生并发症13例，包括肺部感染4例、右胸腔积液2例、切口裂开2例，胰腺残端大出血、胃排空延迟、腹腔脓肿各1例，局限性腹膜炎2例，予相应处理后治愈。死亡1例，死于隐匿性糖尿病、高渗性昏迷。结论完全性胰液外引流可避免胰肠吻合口处胰液的积聚，避免胰酶对吻合口的腐蚀，对预防术后胰瘘的发生起重要作用。     

胰十二指肠切除术后胰瘘的相关因素分析及防治策略

虽然胰十二指肠切除术技术不断改进,但胰瘘仍然是术后难以避免的最严重的并发症,本文针对胰瘘的定义、影响胰瘘的相关因素及胰瘘防治措施的研究进展作进一步的综述。     

胰管空肠内固定支架粘膜吻合术预防胰十二指肠切除术后胰漏

目的探讨胰管空肠内固定支架粘膜吻合术对预防胰十二指肠切除术后胰空肠吻合口漏的效果。方法壶腹周围癌患者23例，胰十二指肠切除后行胰管空肠吻合时于胰管内放置内固定支架并引流至空肠肠腔内。结果23例均行胰管空肠内固定支架粘膜吻合术成功，术后无一例发生胰漏，均治愈出院。结论胰管空肠内固定支架粘膜吻合术可预防胰漏发生，方法简单有效，值得推广。     

External Versus Internal Pancreatic Duct Drainage for the Early Efficacy After Pancreaticoduodenectomy: A Retrospectively Comparative Study

Purpose: To compare the early efficacy of external versus internal pancreatic duct drainage after pancreaticoduodenectomy (PD), providing clinical evidence for selecting the optimal approach to pancreatic duct drainage. Material and Methods: The clinical data of 395 consecutive patients undergoing PD from 2006 to 2013 were analyzed retrospectively. All the patients were divided into external and internal drainage group. Intraoperative blood loss, surgery duration, postoperative hospitalization duration, mortality rate, PF, and other complications were compared between the two groups. The perioperative relative risk factors that might induce PF were analyzed. Results: External drainage significantly reduced the incidences of post-PD PF, delayed gastric emptying, abdominal infection, bowel obstruction, overall complications, and shortened the healing time of PF (p < .05). The univariate analysis showed that the pancreatic duct drainage method, body mass index (BMI), preoperative serum bilirubin level, perioperative blood transfusion, pancreaticojejunostomy approach, pancreatic texture, pancreatic duct diameter, and primary disease differed markedly between the two groups (p < .05). A multivariate analysis revealed that BMI ≥ 25 kg/m², internal pancreatic duct drainage, pancreatic duct diameter <3 mm, soft pancreatic texture, and ampullary disease were independent risk factors for PF. Conclusions: External pancreatic duct drainage can effectively reduce the morbidity of PF and overall complications after PD.     

胆胰双支撑引流对预防胰十二指肠切除术后胰瘘的作用

目的探讨应用胆胰双支撑引流在胰十二指肠切除术后预防胰瘘的价值。方法胰十二指肠切除术31例,采用Child方式重建消化道,胰管内置入硅胶管引入肠腔,于胆肠吻合口上方的肝总管另行戳孔置入T管引流入空肠。结果31例中发生并发症5例(16.1%),其中胰瘘1例(3.2%),无死亡病例。结论在胰十二指肠切除术中应用双支撑引流,有利于降低术后胰瘘发生率,值得推广应用。     

胰十二指肠联合门静脉切除治疗胰头癌

目的: 总结胰十二指肠联合门静脉切除治疗胰头癌的经验 。方法: 对4例肿瘤侵犯门静脉胰头癌患者行胰头十二指肠联合门静脉的切除术,门静脉阻断时间分别为20分钟、25分钟、29分钟和37分钟,手术方法和步骤独特 。结果: 术后患者顺利恢复,无并发症发生 。结论: 对于癌肿侵犯门静脉系统的胰头癌患者,施行含门静脉在内的联合切除术是必要的。     

完全性胰液外引流预防胰十二指肠切除术后胰瘘的机理分析

目的探讨完全性胰液外引流预防胰十二指肠切除术后胰瘘的机理。方法35例胰十二指肠切除术,在Child术式基础上附加完全性胰液外引流,再分别对胃管、腹腔引流管、胰液引流管内的引流液进行淀粉酶定量测定分析。结果各引流管引流液淀粉酶平均测定结果为：胃管引流液412．3（254～626）U／L,腹腔引流液23．5（15—46）U／L,胰液引流管为128196．1（16474—295640）U／L。全组无胰瘘发生,无围手术期死亡病例。结论完全性胰液外引流可以使胰肠吻合口处于相对“无胰酶”状态,对预防胰十二指肠切除术后胰瘘的发生起着关键作用。     

Histological prognostic parameters for adenocarcinoma of the pancreatic head. Proposal for a scoring system for prediction of outcome

To find new histopathological prognostic parameters for adenocarcinoma of the pancreatic head, 27 of these carcinomas, at stage IV according to the Japan Pancreas Society, which had been curatively resected, were histologically examined. In addition to previously recognized histological prognostic parameters, sections were examined for the following factors: fibrotic focus (FF), direct invasion of the tumor into the lymph node (DILN), and tumor necrosis (TN). Frequency of tumor recurrence or death was higher in patients with any one of the three new factors than in those without any of these factors. To develop an accurate system for predicting the outcome, the presence or absence of each factor and lymphatic permeation was given a score of 1 (present) or 0 (absent), and the total score was than calculated for each patient. All patients with a score of 0 were alive without tumor recurrence, at a mean follow-up of 20 months, whereas all seven patients with a score of 4 had experienced tumor recurrence, and six died subsequently. The results of this study demonstrated that FF, DILN, and TN are good histological parameters of ductal adenocarcinoma of the pancreatic head, and that the scoring system proposed in this paper is useful for prediction of the outcome of the disease.     

联合门静脉／肠系膜上静脉切除的胰头癌根治术

目的探讨胰头癌侵犯门静脉（portalvein，PV）和（／或）肠系膜上静脉（superior mesentericvein，SMV）时根治切除的可行性。方法回顾分析11例PV／SMV受侵的胰头癌患者临床资料，均行扩大胰十二指肠切除术。其中7例行血管壁部分切除，3例行血管节段性切除及对端吻合，1例行受侵血管切除＋人工血管移植。脾静脉与SMV端侧吻合4例，脾静脉结扎3例。消化道重建采用Child术式。结果本组PV阻断时间平均为18．1（9～32）min。全组患者术后均未发生血管栓塞、肠坏死、肝衰竭等并发症，均康复出院。11例均获随访，时间6～20个月，3例术后1年内死亡，4例术后1—2年死亡，患者平均生存时间15（7～20）个月。结论对单纯侵犯PV／SMV的胰头癌施行联合PV／SMV切除的胰头癌扩大根治术是安全可行的。     

腹腔镜与开腹胰十二指肠切除术的安全性和疗效对比研究

目的 比较腹腔镜胰十二指肠切除术（LPD）和开腹胰十二指肠切除术（OPD）的安全性和疗效。方法 回顾性分析2016年1月至2021年8月期间施行胰十二指肠切除术患者的临床资料,将符合标准的49例患者分成LPD组（n=23）和OPD组（n=26）,比较两组患者的手术时间、术中出血量、术后并发症、术后住院时间、术后肿瘤学结果及预后等方面的差异。结果 LPD和OPD两种术式的术中输血率和术后胰瘘、胆瘘、术后出血、胃排空延迟、腹腔感染、并发症发生率等手术安全性指标相近（P>0.05）;LPD组较OPD组手术时间延长,但术中出血量减少（P<0.05）。两种术式术后入住ICU人数、非计划再次手术人数、标本肿瘤长径、术中淋巴结清扫数目、淋巴结阳性患者例数、R0切除率、肿瘤分化程度、术后病理分期、肿瘤来源、出院30 d内再次入院率、术后复发率、术后90 d死亡率及术后1年、2年、3年生存率等手术疗效指标相近（P>0.05）。与OPD相比,LPD术后首次下床活动时间和肛门排气时间提早,术后住院日缩短,术后疼痛评分降低和基本日常生活活动能力评分提高（P<0.05）。结论 与OPD相比,LPD安全可靠,可获得同样的肿瘤学根治效果,手术疗效值得肯定,在临床上是可行的。     

Prospective Nonrandomized Comparison Between Pylorus-Preserving and Subtotal Stomach-Preserving Pancreaticoduodenectomy from the Perspectives of DGE Occurrence and Postoperative Digestive Functions

Background  To determine the influence of pylorus preservation after pancreaticoduodenectomy, we compared the postoperative course of subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) and pylorus-preserving pancreaticoduodenectomy (PPPD). Methods  A prospective, nonrandomized comparison of 77 consecutive patients undergoing PPPD (n = 37) or SSPPD (n = 40) between January 2003 and March 2007 was planned. The early postoperative course, dietary intake, and the incidence of delayed gastric emptying (DGE) were evaluated. Results  SSPPD included significantly more cases of regional lymph node dissection (D2, PPPD 53% vs. SSPPD 80%) and portal vein resection. The median duration of surgery (457 vs. 520 min) was significantly shorter, and blood loss (619 vs. 1,235 ml) was significantly less in PPPD. Regarding postoperative clinical factors, the duration of nasogastric tube intubation (1 vs.1 day), days until solid diet (7 vs. 7 days), and the incidence of DGE (9% vs.10%) were similar in PPPD and SSPPD. However, the postoperative/preoperative body weight ratio (95% vs. 93%) was significantly higher, and the postoperative hospital stay (31 vs. 38 days) was significantly shorter in PPPD (p < 0.05). Conclusions  Despite the bias of the operative factors, the incidence of DGE and postoperative dietary intake after SSPPD was comparable with PPPD, and therefore, pylorus preservation seemed to have no impact on postoperative dietary intake or DGE.     

The analysis of diagnosis and treatment for pancreatic fistula after pancreaticoduodenectomy for 105 periampullary carcinoma cases

Aim: To investigate the ways in which to decrease the morbidity of pancreatic fistula after pancreaticoduodenectomy and corresponding therapy. Methods: Double-layered end-to-side duct-to-mucosa anastomosis was applied in 105 cases of pancreaticoduodenectomy and pancreaticoenteric reconstruction, postoperative pancreatic fistula cases were treated aggressively by early surgery, effective drainage and enteral nutrition. Results: Ten cases of pancreatic fistula occurred among 105 operative cases and required reoperation. The rest of the cases recovered uneventfully, except for five cases of in-hospital death. Conclusion: Aggressively early surgery, effective drainage, comprehensive treatment and continual improvement of operative technique are the key to dealing with postoperative pancreatic fistula.     

胰十二指肠切除术中两种胰肠吻合方式疗效比较

目的 比较胰十二指肠切除术中采用胰肠套入吻合与胰管-空肠黏膜对黏膜吻合术后胰漏发生率、住院时间和费用的差异。方法 回顾2009年3月至2013年5月126例接受胰十二指肠切除术治疗病例,采用胰肠套入吻合67例,胰管-空肠黏膜对黏膜吻合59例。分析两种胰肠重建方式术后胰漏发生率及严重程度的差异,同时对两组平均住院时间及费用进行比较分析。结果 套入式胰肠重建组术后胰漏发生率为31.34%（21/67）,黏膜对黏膜胰肠重建组为13.56%（8/59）;两组术后胰漏严重程度（A、B、C级）情况分别为10.45%（7/67）,14.93%（10/67）,5.97%（4/67）和8.47%（5/59）,3.39%（2/59）,1.69%（1/59）。两组平均住院时间为（24.15 d vs 16.86 d）,费用分别为（49 882.73元 vs 38 047.80元）。两组患者术后胰漏发生率和严重程度B级所占比例、平均住院时间和费用差异均有统计学意义（P均＜0.05）。结论 采用胰管-空肠黏膜对黏膜吻合的胰肠重建方式术后胰漏发生率和严重程度（B级）、平均住院时间和费用明显低于采用胰肠套入吻合,该法可能更有利于患者术后恢复。     

Safe Modification of the Liver-Hanging Maneuver by Endoscopic-Assisted Dissection of the Retrohepatic Tunnel

As a safer approach to right hepatectomy, Belghiti et al. (J Am Coll Surg 193:109–11, 2001) described a liver-hanging maneuver. However, this procedure is performed blind, with the risks of damaging the small retrohepatic veins and consequential bleeding. To overcome this problem, we modified the procedure so that, instead of performing blind dissection using a long vascular clamp, we use a flexible choledochoscope to dissect the retrohepatic space filled by loose alveolar tissue anterior to the inferior vena cava (IVC). The avascular path is identified by a combination of saline irrigation and gentle movement of the tip of the choledochoscope. Cotton tape can then be passed around the liver parenchyma to elevate the liver away from the anterior surface of the IVC. This modification of Belghiti's liver-hanging maneuver allows direct vision along the plane anterior to the IVC, thus avoiding injury to the retrohepatic veins.