保留十二指肠的胰头切除术12例临床分析

目的 总结保留十二指肠的胰头切除术(DPPHR)在治疗胰头良性和低度恶性病变的经验.方法 回顾性分析我院1998年5月至2010年3月施行该术式12例患者临床资料.尽量靠近胰十二指肠动脉弓弧形切除十二指肠内侧胰腺组织,并完整切除钩突,间断严密缝合十二指肠缘残留胰腺组织并以胰后被膜覆盖缝合.为了保留胰内段胆总管,必要时切开胆总管置入探条引导.结果 无手术死亡.术后发生胰瘘2例,经非手术治疗后痊愈.无胰腺假性囊肿及腹腔脓肿形成.术后12例患者均随访半年以上,无术后糖尿病、胆总管狭窄、慢性消化不良发生,1例囊腺癌患者术后3个月出现肿瘤复发.结论 对于胰头良性病变,DPPHR是一种安全、有效的手术方式.     

胰十二指肠切除术后早期并发症的防治

目的 探讨胰十二指肠切除术后早期并发症的预防和治疗. 方法 回顾性分析60例胰十二指肠切除术后并发症的发生情况及治疗方法. 结果 术后出现胰漏、胆漏、出血、感染等早期并发症16例,发生率为26.7%(16/60),手术死亡率为3.3%(2/60). 结论 积极预防、细致操作和合理诊治是降低胰十二指肠切除术后早期并发症的主要措施.     

经T管引流胰液预防胰十二指肠切除术后胰瘘

目的 探讨经T 管胰液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1996 年1 月至2007 年12 月42 例行胰十二指肠切除后在Child 术式基础上经T 管胰液引流的病例资料.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l3 例,包括肺部感染6 例、右胸腔积液3 例、切口裂开2 例,胃排空延迟2 例,腹腔脓肿l 例,局限性腹膜炎2 例,予以相应处理后治愈.无死亡病例.结论 经T 管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.     

胰腺十二指肠联合损伤的诊断和治疗

目的 探讨胰腺十二指肠联合损伤的诊断和治疗方法,以提高临床疗效.方法 回顾性分析11例胰腺十二指肠联合损伤的临床资料.胰头十二指肠联合损伤7例,胰体十二指肠联合损伤4例;全组施行胰十二指肠切除术2例,胰头、十二指肠修补术5例(包括胰头修补+十二指肠修补术1例,胰头修补+带蒂空肠瓣十二指肠修复术2例,胰头、十二指肠修补+十二指肠憩室化手术2例);胰体尾部修补+十二指肠修补术1例,带脾脏胰体尾部切除+十二指肠修补术1例,胰体尾切除+十二指肠切除+空肠十二指肠端端吻合术2例.结果 术后3例发生胰漏(27.3%),经持续低负吸引治愈.全组9例痊愈(81.8%),2例死亡(18.2%).结论 早期诊断、及时手术以及正确的手术方式是治疗成功的关键.     

扩大胰十二指肠切除术治疗胰头癌

目的 探讨扩大的胰十二指肠切除术的适应证和手术要点.方法 回顾分析12例因胰头癌行胰十二指肠切除合并肠系膜上静脉-门静脉切除术的临床资料.结果 本组患者无围手术期死亡,无胆瘘、上消化道大出血及人工血管感染等并发症发生.术后出现胃肌轻瘫3例,胰瘘1例,均经保守治疗后好转,术后复查彩超、人工血管及门静脉内均无血栓形成.术后病理报告:浸润性导管癌8例,胰腺细胞癌3例,恶性淋巴管瘤1例,切除血管上下缘,无肿瘤浸润.胰腺切缘没有肿瘤累及,门静脉受癌肿侵犯8例,炎性粘连4例.术后9个月死于重度营养不良1例,术后18个月死于癌肿复发肝转移1例,其余10例目前尚在随访中,其中存活3年3例,2年4例,1年3例.结论 扩大的胰十二指肠切除术能提高胰头癌手术切除率,改善患者的生活质量和提高生存率,应该作为胰头癌患者合理手术方式的一种选择.     

胰十二指肠切除术并发症的预防

目的: 探讨胰十二指肠切除术后并发症的预防方法. 方法: 全部病例均在多功能手术解剖器的辅助下,行胰十二指肠切除术、捆绑式胰肠吻合术,同时注重精细操作和围手术期处理. 结果: 16例病人中除1例术后出现应激性渍疡外,无其他严重并发症发生. 结论: 通过改进手术技巧和方法,可有效地预防胰十二指肠切除术后胰瘘、胆瘘、腹腔内出血等并发症的发生.     

胰头癌手术范围对预后的影响

目的: 探讨胰头癌切除范围对预后的影响。方法: 对比分析95例胰头癌患者中44例行经典胰十二指肠切除及51例行扩大胰十二指肠切除的生存期、手术并发症和死亡率等。结果: 扩大切除组和经典切除组术后1、3、5年存活率分别为72.5%、45%、17.5%和47.73%、19.35%、6.45%,两组间比较差异有显著性,扩大切除组1、3、5年存活率较经典切除组明显提高(P<0.05);两组手术并发症和死亡率 分 别 为 29.41%、5.88%和25%、4.55%,二者比较差异无显著性。结论: 扩大切除能改善胰头癌患者的预后。     

腹腔镜胰腺手术后胰瘘的防治体会

目的 探讨腹腔镜胰腺切除术后胰瘘(POPF)发生的原因及其处理.方法 我院2008年2月至2012年3月间施行腹腔镜胰腺手术25例,其中腔镜辅助下胰十二指肠切除术( LAPD) 10例,完全腹腔镜下胰体尾切除术(LDP)15例,术中及术后采取相应的胰瘘防治措施.结果 本组资料中发生POPF5例.胰瘘发生率为20％,其中胰瘘A级2例,胰瘘B级1例,胰瘘C级2例.5例患者均保守治疗而痊愈.结论 腹腔镜胰腺手术POPF发病率仍然较高.术中、术后对患者的恰当处理是减少POPF发生的关键.     

射频消融与姑息手术治疗胰头癌的临床对比分析

目的 评估术中冷循环射频消融治疗不能切除的胰头癌的有效性和安全性.方法 回顾性分析比较15例使用冷循环射频消融+姑息手术与13例单用姑息手术治疗不能切除的胰头癌患者的术后并发症和生存率.结果 所有患者均获得随访,围手术期死亡率为0.使用冷循环射频消融+姑息手术治疗的患者存活12个月以上10例.最长者已达42个月,中住生存期24.6个月.单用姑息手术治疗的患者中位生存期10.2个月.冷循环射频消融治疗患者术后腰背部疼痛减轻明显.但术后胰瘘、消化道出血等并发症的发生率增加.结论 术中冷循环射频消融治疗不能切除的胰头癌是安全有效的.     

胰腺及十二指肠肿瘤合并胰管结石4例报告

目的: 探讨胰腺及十二指肠肿瘤伴胰管结石的诊断、治疗及预后.方法: 回顾性分析胰腺及十二指肠肿瘤伴胰管结石4例的临床资料.结果: 4例患者中,全胰癌1例,胰头癌1例,十二指肠腺癌1例,十二指肠腺瘤1例,均伴胰管结石.临床症状为腹痛,皮肤巩膜黄染.4例患者入院前均有手术史,诊断为胰腺癌晚期不能切除而放弃根治性手术,入院后诊断为胰腺及十二指肠肿瘤伴胰管结石,均行根治性手术,其中全胰切除术2例,胰十二指肠切除术1例,十二指肠乳头部肿块局部切除术1例.术后随访至今6月~4年,均存活.结论: 胰管结石影响胰腺及十二指肠肿瘤可切除性的判断,从而影响胰腺及十二指肠肿瘤的治疗及预后.如果术前CT等检查发现有胰体钙化或胰管结石,术中发现胰腺质地硬,或扪及结石,应考虑为胰腺及十二指肠肿瘤伴胰管结石而非晚期、不可切除之肿瘤,可行胰十二指肠切除术、全胰切除术等根治性手术.     

保留幽门的和标准的胰十二指肠切除术后胃排空延迟的对照研究

目的 探讨保留幽门的胰十二指肠切除术与标准的胰十二指肠切除术术后胃排空延迟的临床特点及防治方法.方法 回顾性分析哈尔滨医科大学附属第一医院胰胆外科2012年1月-2016年7月行标准的胰十二指肠切除术的401例患者的临床资料,其中行保留幽门的胰十二指肠切除术患者35例(8.7％),行标准的胰十二指肠切除术患者366例(91.3％),采用独立样本均数t检验x2检验或Fisher确切概率法、Mann-Whitney Test秩和检验等统计学方法比较保留幽门的胰十二指肠切除术组与标准的胰十二指肠切除术组术后主要并发症的发生情况以及胃排空延迟的转归情况.结果 与标准的胰十二指肠切除术组相比,保留幽门的胰十二指肠切除术组胃排空延迟的发病率(22.9％)显著高于标准的胰十二指肠切除术组(10.9％),P=0.038,其余主要并发症发生率差异无统计学意义(P≥0.05).保留幽门的胰十二指肠切除术组与标准的胰十二指肠切除术组发生胃排空延迟的严重程度(分级比较)相同(P≥0.05),但保留幽门的胰十二指肠切除术组胃排空延迟的平均恢复时间(12.13±3.09)d明显短于标准的胰十二指肠切除术组的(17.28 ±9.63) d(P=O.009).结论 保留幽门的胰十二指肠切除术增加术后发生胃排空延迟的风险,但不增加胃排空延迟的严重程度,相对于标准的胰十二指肠切除术术后胃排空延迟较易恢复,为保留幽门的胰十二指肠切除术患者围手术期管理提供依据.     

保留幽门胰十二指肠切除术与标准Whipple术围手术期观察:连续112例分析

目的　分析保留幽门胰十二指肠切除术 (PPPD)与Whipple手术在围手术期恢复情况。方法　将 49例PPPD与同期 63例Whipple术后恢复情况作对照比较。 结果　PPPD组手术时间、术后住院天数减少 ,手术并发症略低 ,术后营养状况相似 ,但均无统计学差异。PPPD组病人放置胃管时间、胃排空延迟发生率大于Whipple组 ,但无统计学差异。既往有、无腹部手术史者胃排空延迟发生率分别为 3 5 5%、11 1% ,术后有、无手术并发症者胃排空延迟发生率分别为 46 2 %、9 3 % ,两组比较差别均有统计学意义 (P <0 0 5)。结论　PPPD是一种安全的手术 ,术式本身并不影响胃排空延迟的发生及病人术后恢复     

Outcome of pancreaticoduodenectomy with pylorus preservation or with antrectomy in the treatment of chronic pancreatitis

OBJECTIVE: To compare the short- and long-term results of pancreaticoduodenectomy with pylorus preservation (PPPD) or with antrectomy (Whipple procedure) in the treatment of selected patients with chronic pancreatitis. BACKGROUND: PPPD may be preferred over Whipple because of its purported nutritional advantages and the reduced likelihood of postgastrectomy syndromes. METHODS: A retrospective review was performed of 72 consecutive patients undergoing pancreaticoduodenectomy for chronic pancreatitis between 1991 and 1997. RESULTS: PPPD was performed in 39 patients and Whipple in 33. The two patient populations had similar characteristics. Short-term complications included (PPPD vs. Whipple): pancreatic or biliary fistulas (5.1% vs. 15%), delayed gastric emptying (33% vs. 12%), cholangitis (2.6% vs. 6.1%), and death (0 vs. 3%). Delayed gastric emptying was not associated with other complications and resulted in longer hospital stays for PPPD than for Whipple patients (15 vs. 12 days). The duration of follow-up averaged 41 +/- 24 months. Long-term weight status was similar, with body-mass indices of 22.1 and 22.9 after PPPD and Whipple, respectively. Postoperative enzyme supplementation (63% vs. 77%) and new-onset diabetes (10% vs. 12%) did not differ significantly between the PPPD and Whipple groups. Dumping, bile gastritis, or peptic ulcer disease occurred in three patients after PPPD and in three after Whipple. Complete or partial pain relief was attained in 60% and 70% of patients after PPPD and Whipple, respectively. Multivariate analysis of preoperative variables revealed that site-specific pathology in the head of the pancreas was the only independent factor associated with successful pain relief after pancreatic resection. CONCLUSION: PPPD results in higher frequencies of postoperative delayed gastric emptying compared with the Whipple procedure. Both operations achieve comparable long-term nutritional results, cause new insulin dependence in surprisingly few patients, and provide equivalent pain relief to 65% of selected patients. Patients with disproportionate pathology in the head of the pancreas have a higher likelihood of successful pain relief.     

The limits of surgery in the treatment of the icteric patients due to pancreatic head cancer

Aim is to present the limits of surgery, determined by the dimension of the tumor and vascular invasion, in the treatment of the icteric patients with pancreatic head cancer. This paper is a retrospective study realized in Timisoara City Hospital, Surgery Clinic, on 68 patients, hospitalized for icteric syndrome due to pancreatic head cancer. Surgery was performed in 66 patients: 4 (6%) pancreaticoduodenectomy, Whipple modified technique, 62 (94%) palliative surgery which consists in a biliodigestive shunt associated with a gastroenterostomy, and 2 patients were not operated. In palliative treatment, 10 (15%) patients had complications and 3 (4.5%) died within 1 month after surgery. In the case of the patients with duodenopancreatectomy, there was no morbidity or mortality. Survival after one year was 0% in palliative treatment and 100% in pancreaticoduodenectomy. In icteric patients due to pancreatic head cancer, the possibility of pancreaticoduodenectomy without vascular resection is reduced (6%). Modified Whipple technique was imposed by the dimensions of the tumor (more than 3 cm) and vascular invasion, determining in the first place, the dissection of the vascular tree: portal, mesenteric, caval; and pancreaticoduodenectomy was performed only if there was no invasion.     

腹腔镜胰十二指肠切除术45例体会

目的探讨腹腔镜胰十二指肠切除术治疗壶腹部周围疾病的可行性和安全性,评估腹腔镜下不保留幽门的胰十二指肠切除术（LPD）和保留幽门的胰十二指肠切除术（LPPPD）的围手术期情况及并发症发生情况。方法回顾性分析本治疗组2010年1月至2014年3月期间行腹腔镜胰十二指肠切除术治疗壶腹部周围疾病的45例患者的临床资料。根据患者手术方式分为LPD组及LPPPD组。结果本组行腹腔镜胰十二指肠切除术的45例患者中有25例行LPD,有20例行LPPPD。1围手术期情况：手术时间为（472.95±33.47）min,术中出血量为（202.84±108.74）mL,术后ICU监护时间为（1.29±3.04）d,术后住院时间为（15.07±5.48）d。LPD组和LPPPD组患者的手术时间、术中出血量、术后住院时间、术后胃肠道减压时间及术后进食时间比较,差异均无统计学意义（P〉0.05）,但LPPPD组的术后ICU监护时间明显长于LPD组（P=0.028）。2术后并发症情况：有25例（55.56%）患者术后发生了并发症,其中胰瘘10例,胆汁漏1例,胃排空障碍6例,感染3例,吻合口出血2例,肠系膜血栓形成1例,术后腹腔积液1例,乳糜瘘1例。LPD组和LPPPD组总并发症发生率及具体的并发症发生率比较,差异均无统计学意义（P〉0.05）。LPPPD组术后死亡1例。结论本组研究结果初步提示,腹腔镜胰十二指肠切除术治疗壶腹部周围疾病是可行的、安全的;另外LPPPD能够一定程度上避免幽门切除术后引起的消化液的返流等并发症,提高了患者术后的营养状态和生活质量。     

Limited pancreatectomy: significance of postoperative maintenance of pancreatic exocrine function

This study attempted to clarify whether limited pancreatectomy (duodenum-preserving total pancreatic head resection [DPTPHR], or medial pancreatectomy [MP], maintain pancreatic exocrine function more than conventional pancreaticoduodenectomy (Whipple) or pylorus-preserving pancreaticoduodenectomy (PPPD). A total of 125 patients (18 with Whipple, 71 with PPPD, 13 with DPTPHR, and 23 with MP) were studied. Fecal chymotrypsin and p-type amylase, and pancreatic function diagnostant (PFD) tests were used for evaluation. There were no differences in preoperative background. Pancreatic function was seen to be significantly lower after surgery than before surgery in patients who underwent the Whipple procedure and PPPD (P < 0.05), but there was no difference between pre- and postoperative pancreatic function in patients who underwent DPTPHR and MP. Postoperative pancreatic function was shown to be significantly worse in Whipple procedure and PPPD patients than in those with DPTPHR and MP (P < 0.05). Patients who underwent the Whipple procedure and PPPD showed significantly lower pancreatic function than patients who underwent DPTPHR and MP (P < 0.05). There was no difference in pancreatic function between patients who underwent DPTPHR and those with MP. DPTPHR and MP, both of which preserve the entire duodenum, maintain pancreatic function more than the Whipple procedure and PPPD. Received: July 10, 2000 / Accepted: August 9, 2000     

Emergent pancreaticoduodenectomy: a dual institution experience and review of the literature

Background

Emergent pancreaticoduodenectomy (EPD) is an uncommon surgical procedure performed to treat patients with acute pancreaticoduodenal trauma, bleeding, or perforation. This study presents the experience of two university hospitals with EPD.

Methods

Clinical data on EPD in trauma and nontrauma patients from 2002–2012 were extracted from the hepatopancreatobiliary surgery databases at Thomas Jefferson University and Kaunas Medical University Hospitals. Data on indications, perioperative variables, morbidity, and mortality rates were evaluated.

Results

Ten single-stage EPD patients were identified. Five underwent a classic Whipple resection, whereas five had pylorus preservation. Seven patients had traumatic indications for pancreaticoduodenectomy: three from gunshot wounds to the abdomen and four from blunt high-energy injuries (two sustained injuries by falling from height and two by direct assaults on the abdomen). Three cases of nontrauma patients had EPD surgery for massive gastrointestinal hemorrhage. The median age of the EPD cohort was 46 y (range, 19–67 y). All 10 patients were recovered and were discharged from the hospital with a median postoperative length of stay of 24 d (range, 8–69 d). There were no perioperative mortalities.

Conclusions

Despite a high morbidity rate and prolonged recovery, this dual institutional review suggests that EPD can serve as a lifesaving procedure in both the trauma and the urgent nontrauma settings.     

胰十二指肠切除术在胰头部慢性胰腺炎治疗中的应用和选择

目的 探讨胰十二指肠切除术在胰头部慢性胰腺炎治疗中的应用和选择。方法 回顾性分析我院1988年7月至1999年11月经胰十二指肠切除术和病理证实的10例胰头部慢性胰腺炎临床资料。结果 本组病人男性7例，妇性3例，年龄41－75岁，平均57.2岁。主要临床表现为腹痛、黄疸。影像学检查（B超、CT和ERCP）发现胰头部局限性肿大。9例行典型的Whipple手术，1例行保留幽门的胰十二指肠切除术。7例随访均无腹痛、糖尿病。结论 胰头部慢性胰腺炎早期诊断困难，重要的是与胰头癌相鉴别。胰十二指肠切除术治疗胰头部慢性胰腺炎的手术效果良好，其手术适应证的选择和手术时机的掌握至关重要。     

胰十二指肠切除术后顽固性呕吐发生的原因分析及护理对策

目的探讨胰十二指肠切除术(PD)后顽固性呕吐发生的原因分析及护理对策。方法选取2013年8月至2017年3月期间于我院行胰十二指肠切除术的82例患者作为研究对象,其中将术后顽固性呕吐的32例患者作为观察组,将另外的未合并顽固性呕吐的50例患者作为对照组。分别采用单因素与多元Logistic回归模型对影响PD手术术后顽固性呕吐发生的高危因素进行分析,然后提出具体的护理对策,并采用CIVIQ生活量表分析护理效果。结果 (1)经单因素分析,年龄≥60岁、术前总胆红素≥170μmol/L、术前白蛋白≥35 g/L、术前空腹血糖≥7.0 mmol/L、术中出血量≥250 m L以及术后有并发症均为胰十二指肠切除术后顽固性呕吐的影响因素(均P0.05);(2)将上述单因素分析所得的因素代入至多元Logistic回归模型之中,结果显示:影响胰十二指肠切除术后顽固性呕吐发生的危险因素包括术前白蛋白、术前空腹血糖以及术后并发症(均P0.05);(3)本组32例胰十二指肠切除术后顽固性呕吐患者护理干预前后CIVIQ评分分别为(70.20±11.21)分及(89.38±15.45)分,差异具有统计学意义(P0.05)。结论影响胰十二指肠切除术后顽固性呕吐发生的危险因素包括术前白蛋白、术前空腹血糖以及术后并发症,应注意对这些因素进行仔细观察。对此,应对患者给予必要的护理干预对策,从而提高患者的生活质量及改善患者的预后状况。     

Pylorus-preserving Pancreaticoduodenectomy in the Treatment of Chronic Pancreatitis

The pylorus-preserving pancreaticoduodenectomy (PPPD) is an alternative to the standard Whipple resection in the treatment of chronic pancreatitis. The operation is safe and can be performed with a low mortality rate. The most common early complication is delayed gastric emptying, which occurs in 25% to 30% of patients, and generally results in longer hospital stays than the standard Whipple procedure. Follow-up studies show that both operations are equally effective in relieving pain in approximately 75% of selected patients. In the long term, the PPPD successfully preserves physiologic gastric emptying, but at the cost of a higher marginal ulceration rate. The purported nutritional advantages of the PPPD over the classic Whipple resection have not been clearly established. At present, the PPPD is the procedure of choice for patients with chronic pancreatitis requiring panceraticoduodenectomy. Based on available information, this recommendation appears to arise form the fact that the PPPD is less radical than the regular Whipple procedure, and some surgeons find it technically easier. Our experience fails to show a distinct superiority of the PPPD over the Whipple operation.