大网膜包裹胰腺残端预防胰腺远端切除术后胰漏的实验研究

目的 在动物模型胰腺远端切除术中,采用大网膜包裹胰腺后缝合胰腺残端的术式,探索一种能有效减少胰漏率且简单实用的新方法.方法 行胰腺远端切除术后,将50只新西兰兔随机分为两组:对照组,单纯应用5-0 Prolene线U型锁边缝合胰腺残端;实验组,先将大网膜包裹胰腺一圈后,使其紧贴于胰腺表面,再缝合胰腺残端.术后记录第1至7天腹腔引流液量并检测其淀粉酶值,测量术后第1、3、5、7天血淀粉酶、WBC、CRP数值.两周后将动物处死检查,胰腺残端行石蜡切片病理学检查.结果 实验组与对照组的胰漏率分别为8.3％和36.0％(P=0.020),病理学显示实验组可见胰腺残端边缘有纤维组织形成的厚而致密的“帽子”状结构,可起到预防胰漏的作用.结论 胰腺远端切除术中应用大网膜包裹胰腺残端可有效降低术后胰漏的发生率.     

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。     

远端胰腺切除术中两种胰腺残端封闭技术对比研究

目的 对比远端胰腺切除术中两种胰腺残端封闭技术的疗效,为胰腺外科手术医生选择合理的胰腺残端封闭技术提供参考。方法 回顾性分析2012-01-01至2013-09-30因“胰体尾占位性病变”在第二军医大学附属长海医院胰腺外科行开放的远端胰腺切除术的部分病人资料,分为切割闭合器组（99例）和手工缝合组（57例）,对比两组之间术中、术后及随访情况。结果 两组病人性别、年龄、体重指数、手术时间、术中出血、术中输血量、引流液淀粉酶值及胰瘘、术后输血率、术后体温（T）≥38℃、术后心率≥100次/min、术后再次手术、术后住院天数、术后30 d内再住院率及术后30 d内病死率差异均无统计学意义;术后输血量和总住院费用手工缝合组均少于切割闭合器闭合组,两组之间差异有统计学意义（P<0.05）。结论 建议胰腺外科医生在行开放的远端胰腺切除术时优先考虑选用手工缝合的方法来封闭保留侧胰腺残端。     

胰腺厚度对胰体尾切除术后胰漏的影响

目的:探讨胰腺厚度与胰体尾切除术后胰漏发生率的关系。方法 :回顾性分析我院2014年12月至2015年12月收治的行胰体尾切除术156例病人的临床资料,根据术后胰漏情况分为术后胰漏组和无胰漏组,比较两组病人胰腺切缘厚度。再根据中位胰腺厚度分为厚胰腺组和薄胰腺组,比较应用手工缝合法和切割闭合器法处理胰腺残端时两组病人的胰漏发生情况。结果:胰漏组病人胰腺厚度明显大于无胰漏组病人[(26.80±4.95)mm比(24.17±5.86)mm,P0.05)。结论 :胰腺厚度是胰体尾切除术后胰漏的危险因素。对肥厚的胰腺可优先考虑手工缝合,或在切割闭合器的基础上行手工缝合加强,对减少胰漏可能有效。     

胃癌扩大根治术中胰腺残端的处理

目的　降低胃癌扩大根治联合远端胰腺切除术后胰漏的发病率。　方法　自 1992年 8月至 2 0 0 0年 2月 ,对 15例患者施行远端胰腺切除时 ,近端稍外凸 ,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　未发生 1例胰漏或腹腔感染。　结论　浆肌瓣有利于促进胰断面愈合 ,能有效地预防胰漏     

胰腺远端切除术后残端不同处理方法对术后胰瘘的影响

[摘要]目的探讨胰腺远端切除术中,胰腺残端不同处理方法与术后胰瘘的关系。方法回顾性分析我院2009年3月至2012年12月期间,行胰腺远端切除术的患者临床资料46例,其中胰腺残端行连续锁边缝合10例（A组）;残端行主胰管结扎＋连续鱼嘴状缝合16例（B组）;残端断面局部行“8”字缝合＋连续鱼嘴状缝合20例（C组）。比较上述3种方式对术后并发胰瘘的影响并行统计学分析。结果术后发生胰瘘病例数,A组6例（60％）,B组2例（12．5％）,C组3例（15％）。其中,A组与B组、A组与C组比较有统计学差异（P〈0．05）;B组和C组比较无统计学差异（P〉0．05）。结论胰腺远端切除术中,胰腺残端行主胰管结扎＋连续鱼嘴状缝合,或者行残端断面局部“8”字缝合＋鱼嘴状连续缝合,是防止术后胰瘘安全有效的方法。     

胰体尾切除术中残端闭合与胰肠吻合的疗效对比

目的 对比胰体尾切除术（distal pancreatectomy,DP）中胰腺残端切闭联合手工缝合与胰腺-空肠端端吻合的疗效。方法 回顾性分析2017年9月至2019年3月昆明医科大学第二附属医院肝胆胰外科三病区收治的64例行胰体尾切除术患者的临床资料。根据胰腺残端处理方式分为两组：残端闭合组：DP术中胰腺使用切割闭合器切闭后联合手工加强缝合（n=30）;胰肠吻合组：DP术中胰腺残端与空肠端端套入式吻合（n=34）。观察指标包括两组的一般资料、胰腺质地、手术时间、术中出血量、术后胰瘘发生率、出血等并发症、总住院天数、费用。结果 64例均手术成功。胰肠吻合组中术后发生胰瘘5例,且均为软胰腺患者;而残端闭合组术后发生胰瘘11例,其中软胰腺7例,硬胰腺4例;胰肠吻合组术后胰瘘发生率明显低于残端闭合组,差异有统计学意义（P＜0.05）;比较两组胰瘘分级、术中出血量、术后出血等并发症,差异无统计学意义（P＞0.05）;另对于两组手术时间、总住院时间、住院总费用的比较,胰肠吻合组均大于残端闭合组,差异有统计学意义（P＜0.05）。结论 DP术中胰腺残端使用胰肠-空肠端端吻合可有效降低术后胰瘘发生率,且对于胰腺质地硬者效果更佳,安全可行,值得推广。     

横结肠无血管区系膜包裹并缝扎胰腺残端预防术后胰液漏的临床疗效

目的 探讨横结肠无血管区系膜包裹并缝扎胰腺残端预防胰体尾切除术后胰液漏的临床疗效.方法 回顾性分析2011年5月至2014年3月郑州大学附属肿瘤医院收治的69例行胰体尾切除术患者的临床资料.35例患者用丝线间断纵向缝合胰腺残端后采用横结肠无血管区系膜包裹胰腺残端并缝扎作为改良组,34例患者胰腺残端用丝线间断缝合后未做其他处理作为对照组.比较两组患者的胰腺残端处理时间、并发症发生情况、引流管放置时间以及术后住院时间.采用门诊或电话随访,随访时间截至2014年6月.两组均数比较采用t检验,计数资料比较采用x2检验.结果 改良组和对照组胰腺残端处理时间分别为(15.2 ±2.1)min和(13.2 ±3.2)min,两组比较,差异无统计学意义(t=1.565,P＞0.05).改良组患者无胰液漏发生,对照组9例患者术后发生胰液漏,两组比较,差异有统计学意义(x2=9.399,P＜0.05).改良组和对照组患者术后胰腺残端引流管放置时间分别为(6.1±2.2)d和(16.6 ±3.5)d,术后住院时间分别为(12.5±2.5)d和(21.5±3.5)d,两组比较,差异有统计学意义(t=-11.902,-9.853,P＜0.05).63例患者获得随访,随访时间为1～35个月,平均随访时间为15个月.随访期间,15例患者死亡,其余恢复良好.结论 横结肠无血管区系膜包裹并缝扎胰腺残端能有效预防胰体尾切除术后胰液漏并能缩短术后住院时间.     

单纯及复合型胰腺外伤的诊断与个体化手术体会

目的:探讨单纯及复合型胰腺外伤的诊断及个体化手术治疗方法;方法:回顾分析大庆油田总医院2005年1月至2011年12月急诊收治的42例胰腺外伤患者的临床资料;结果:术前确诊22例,其余均经术中探查确诊,治疗均采用手术治疗,Ⅰ、Ⅱ级胰腺损伤18例,其中单纯行胰周引流3例,清除胰周坏死组织、缝合止血、外引流1 3例,腹腔镜下胰周引流2例;Ⅲ级胰腺损伤15例,其中胰腺远端、脾联合切除,胰腺近端结节缝合9例,胰腺远端与空肠吻合术近端结节或褥氏缝合缝合4例,胰腺遗端胃吻合加空肠造瘘术2例,Ⅳ级胰腺损伤7例,给予行胰头坏死组织彻底清除、近侧断端缝合、远侧断端与空肠吻合、彻底引流,Ⅴ级损伤2例,行胰十二指肠切除术及改良十二指肠憩室化手术;结论:联合应用影像学及生化检查可提高术前胰腺损伤患者的诊断率,术中认真细致探查是防止遗漏胰腺损伤的重要措施,根据患者胰腺损伤级别给予个体化手术方式可提高胰腺损伤的治愈率.     

胰体尾切除术后并发胰瘘的防治

目的 探讨胰体尾切除术后胰瘘的预防及治疗措施.方法 回顾性分析2000-2009年124例胰体尾部切除病例,包括胰腺恶性肿瘤86例,胰腺假性囊肿及良性肿瘤12例,胃肠肿瘤侵犯胰体尾18例,慢性胰腺炎合并胰体尾囊肿3例,外伤5例.以单纯间断褥式缝合(A组)处理胰腺残端63例;以改良的主胰管缝扎+间断褥式交锁缝合(B组)处理胰腺残端61例.所有患者均放置负压引流,术后均常规应用生长抑素.结果 A组63例中22例术后发生胰瘘,发生率为34.9％,其中高流量胰瘘10例,低流量胰瘘12例;B组61例中9例术后发生胰瘘,发生率为14.7％,无高流量胰瘘.两组胰瘘患者中,A组住院天数明显延长(P＜0.01),术后医疗费用明显增加(P＜0.01).结论 主胰管缝扎+间断褥式交锁缝合的手术方法可减少术后胰瘘的发生,有助于减少住院天数及术后医疗费用.     

Laparoscopic pancreatic resection of pancreatic cancer

Laparoscopic pancreatic resection of pancreatic cancer is still not universally accepted as an alternative approach to open surgery because of technical difficulties and a lack of consensus regarding the adequacy of this approach for malignancy. Ten patients with pancreatic cancer underwent laparoscopic pancreatic resection, including pancreaticoduodenectomy and distal pancreatectomy in our institution. Eight of the 10 patients recovered without any complications and were discharged on the 10-29th postoperative day. The remaining 2 patients developed pancreatic fistula and were discharged on the 46 and 60th postoperative day, respectively. All lesions were well clear of surgical margins in 6 patients (R0). In the remaining 4 patients, microscopic neoplastic change was found at the surgical margin (R1). Those 4 patients developed tumor recurrence, including liver metastases or peritoneal dissemination, and 3 of the 4 died of the primary disease. Although experience is limited, laparoscopic pancreatic resection of pancreatic cancer can be feasible, safe, and effective in carefully selected patients. However, the benefit of this procedure has yet to be confirmed. Not only adequate experience in pancreatic surgery but also expertise in laparoscopy is mandatory, and careful selection of patients is essential for successful application of this procedure.     

Solitary pancreatic tuberculosis mimicking advanced pancreatic carcinoma

A 40-year-old woman was referred for pancreatic head carcinoma invading the portal vein. The dichotomy between the radiological findings and the general condition of the patient, as well as the laboratory results (no evidence of cholestasis), cast doubt on the diagnosis. There was no history of tuberculosis. The chest radiograph revealed no pathological findings. The anatomic relationships of the lesion entailed a high risk of vascular injury if tissue biopsy were to be done; therefore, diagnostic laparotomy was performed. Biopsy revealed granulomas with caseous necrosis, consistent with tuberculosis. After 6 months of antituberculosis treatment, the lesions had completely resolved. Tuberculosis should be considered in the differential diagnosis of pancreatic masses, particularly in regions where the disease is endemic. The condition usually resembles an advanced pancreatic tumor. Performing a biopsy of inoperable lesions and maintaining a reasonable skepticism in regard to the evaluation of operable lesions (attention to nonexclusive but helpful clues, such as young patient age, history of tuberculosis, absence of jaundice) will lead to the diagnosis in most patients. Diagnostic laparotomy may be required in a small subset of patients. The response to antituberculosis treatment is very favorable. The role of resection (e.g., pancreatoduodenectomy) is very limited. Received: December 1, 2000 / Accepted: January 25, 2001     

Peroperative pancreatic aspiration for evaluating pancreatic disease

Nineteen patients who underwent peroperative pancreatic aspiration during 1976 to 1978 were retrospectively compared with 19 other consecutively chosen patients who underwent pancreatic surgery without this procedure in 1973 and 1974. In 18 of the 19 patients who had pancreatic aspiration, an accurate diagnosis was obtained. Three patients in the 1973 to 1974 series had serious postoperative complications attributable to incorrect intraoperative diagnosis and subsequent operative therapy. Peroperative pancreatic aspiration cytology provides a definitive diagnosis that may result in the most efficacious therapy for pancreatic disease.     

Internal pancreatic fistulas with pancreatic ascites and pancreatic pleural effusions: recognition and management

Background : Internal pancreatic fistulas are well recognized complications of chronic pancreatitis. Methods : Six patients with internal pancreatic fistulas were treated over a period of 5 years from 1995 to 1999. Four patients presented with ascites, one patient presented with ascites and bilateral pleural effusion and the sixth patient presented with left‐sided pleural effusion. Five patients were chronic alcoholics and in one patient the cause of pancreatitis was not clear. Although the serum amylase was mildly elevated the levels of amylase in the aspirated fluid were consistently elevated (more than 800 Somogyi units/100 mL), along with the level of proteins (> 3 g/100 mL), and on this basis the diagnosis was made. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated pancreatic ductal disruption in four cases. Initial treatment was conservative, consisting of nasogastric aspiration, nil per oral, antisecretory drugs, repeated paracentesis or thoracocenthesis and total parenteral nutrition (TPN). In two patients nasopancreatic drains (NPD) were placed across the disrupted pancreatic duct. Results : In one patient conservative treatment with NPD was successful, and the remaining five patients required surgical intervention. There was no mortality. Two patients developed surgery‐related complications that were successfully managed, but they required an extended hospital stay. Conclusion : Internal pancreatic fistulas should be treated initially non‐operatively; if this is not effective, operative therapy should be considered without delay.     

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目的总结胰腺节段切除术治疗胰腺良性肿瘤的临床经验。方法对2000年1月至2007年5月北京协和医院行胰腺节段切除术治疗的28例胰腺良性肿瘤临床资料进行回顾性分析。结果手术完整切除肿瘤,术后病人胰腺功能无明显变化,症状得到改善。术后胰瘘发生率14.2%(4/28)。25例获得随访,随访时间为2～84个月,疗效满意。结论胰腺节段切除术是一种安全、有效、保存器官功能的手术方式,适合于胰腺良性肿瘤病人。可以保存病人的胰腺内、外分泌功能,提高生活质量。     

Treatment of pancreatic necrosis and secondary pancreatic infections

Acute pancreatitis is a disease capable of the widest clinical expression, ranging from mild discomfort to multiorgan failure and death. Moreover, the process may remain localized in the pancreas, or spread to regional tissues, or even involve remote organs. Despite several efforts, the pathophysiology of acute pancreatitis and its complications remains obscure. In the absence of an understanding of the pathogenesis and the reasons for the variations in severity, the study and management of acute pancreatitis has necessarily been empirical. There is little doubt that the development of pancreatic necrosis in patients with acute pancreatitis results in an increase in clinical severity and an escalation of the mortality risk when compared to interstitial pancreatitis. Furthermore, the mortality risk of patients with sterile pancreatic necrosis is markedly different from that of patients developing secondary infections in pre-existing pancreatic necrosis. Infected pancreatic necrosis is uniformly fatal, if untreated. While most authorities agree that surgical debridement is required for survival in patients with secondary pancreatic infections, the precise form of the subsequent drainage has become a matter of some controversy. In this paper we discuss the most recent insights relating to the nosographical classification of pancreatic necrosis and secondary pancreatic infections, along with an analysis of the findings in the literature regarding the surgical treatment of these conditions.     

Endoscopic ultrasound-guided transmural drainage for pancreatic fistula or pancreatic duct dilation after pancreatic surgery

Background

Endoscopic ultrasound (EUS)-guided drainage is widely used to manage pancreatic pseudocysts. Several studies have reported the use of EUS-guided drainage for pancreatic fistula and stasis of pancreatic juice caused by stricture of the pancreatic duct after pancreatic resection.

Methods

At the authors’ hospital, 262 patients underwent surgery involving pancreatic resection from April 2005 to March 2010. In 90 of these patients (34%), a grade B or C postoperative pancreatic fistula developed that required additional treatment. The authors performed EUS-guided transmural drainage (EUS-TD) for six patients (2.1%) with a pancreatic fistula or dilation of the main pancreatic duct visible by EUS. Percutaneous drainage was provided for 18 patients (6.8%). The success rates for EUS-TD and percutaneous drainage were compared in a retrospective analysis.

Results

In all six cases, EUS-TD was performed successfully without complications. Five of the six patients were successfully treated with only one trial of EUS-TD. The final technical success rate was 100% for both EUS-TD and percutaneous drainage. Both the short- and long-term clinical success rates for EUS-TD were 100% and those for percutaneous drainage were 61.1 and 83%, respectively. The differences in these rates were not significant (short-term success, P?=?0.091 vs. long-term success, P?=?0.403). However, the time to clinical success was significantly shorter with EUS-TD (5.8?days) than with percutaneous drainage (30.4?days; P?=?0.0013) in the current series.

Conclusions

The EUS-TD approach appears to be a safe and technically feasible alternative to percutaneous drainage and may be considered as first-line therapy for pancreatic fistulas visible by EUS.     

Technique of pancreatic procurement for pancreatic islet isolation

AIM OF THE STUDY: The allograft of pancreatic islets represents a potential alternative to insulin therapy in patients suffering from the most severe forms of Type 1 diabetes. Here we report our experience of pancreatic procurement for isolation and islet allograft. MATERIALS AND METHODS: Pancreata were procured in brain-dead donors. The islets were isolated using techniques developed and validated in pigs and men. Injection of a given preparation was decided after quantitative and qualitative controls. Islets were transplanted in Type 1 diabetic patients already grafted with a kidney or suffering from severe and/or unstable diabetes, after percutaneous or surgical settlement of an intra-portal catheter. Patients received an "Edmonton-like" immunosuppressive protocol. Grafts were repeated once or twice until a total quantity of 10,000 transplanted islet-equivalents was obtained. RESULTS: Twenty-nine pancreata were procured and 14 preparations were grafted to 7 patients. Eleven graftings were done percutaneously and three were surgical. The initial function of the 14 transplants was confirmed by secretion of C-peptide and decrease of insulin doses. Insulin therapy was completely interrupted in the 5 patients having received at least two grafts. CONCLUSION: These preliminary clinical results confirmed that the isolation technique of human islets and the technique of pancreas procurement are mastered by our team. If the results of this assay (assessment one year after graft) confirm our hopes, we will be able to offer islet allografts to an increasing number of patients with severe Type 1 diabetes.