胰腺残端捆绑结扎对胰腺远端切除术后胰瘘的影响

目的:探讨胰腺残端捆绑结扎对胰腺远端切除术后胰瘘的影响。方法:采用回顾性病例对照研究方法。收集2011年1月至2018年8月内蒙古医科大学附属医院收治的60例胰体尾部病变行胰腺远端切除术病人的临床资料;男24例,女36例;中位年龄为45岁,年龄范围为19~68岁。60例病人中,36例离断胰腺仅采用直线切割闭合器,设为未...     

胰腺残端处理方式对胰体尾切除术后胰瘘的影响

目的探讨预防胰体尾切除术后胰瘘的胰腺残端处理方式。方法回顾性分析我院1996至2008年186例因胰腺或胰外病变行胰体尾切除术患者的临床资料,胰腺残端处理方法分别为：结扎主胰管、残端结扎、间断缝合、Prolene线连续缝合、胰腺空肠吻合及闭合器钉合六种方式,比较上述六种方式对术后胰瘘的影响并行统计学分析。结果186例患者中围手术期死亡5例（2．7％）,术后总并发症发生率34．9％（65／186）,胰瘘发生率21．0％（39／186）。8例胰腺残端结扎术后4例发生胰瘘,11例胰腺空肠吻合患者无胰瘘发生;17例Endo—GIA关闭胰腺残端者有胰瘘4例;结扎主胰管组、连续缝合组、间断缝合组胰瘘发生率分别为13．9％（5／36）、15．6％（10／64）、32．0％（16／50）,前两者与后者差别具有统计学意义（P〈0．05）。结论胰体尾切除术中残端结扎和间断缝合容易发生胰瘘,选择性缝扎主胰管或Prolene线连续缝合能降低胰瘘发生率,尤其后者更简单易行。近端胰管梗阻患者可选用胰肠吻合预防胰瘘;闭合器钉和胰腺残端要根据胰腺大小和质地选择性使用。     

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.     

胰腺远端切除术胰腺残端处理方法进展

随着手术方法的不断完善和手术技术的不断改进,胰腺远端切除术(distal pancreatectomy,DP)并发症发生率有了明显的降低,DP已成为治疗胰腺肿瘤、慢性胰腺炎、胰腺创伤的一种常用手术方式[1]。Billroth在1884年完成了第1例DP,并定义肠系膜上血管以左的胰腺切除为远端胰腺切除。虽然DP并发症发生率与胰腺其他部位切除术相比较     

生物膜包裹残端预防胰腺远端切除术后胰漏的实验研究

目的 探讨猪胰腺远端切除后牛心包生物膜包裹残端对术后胰漏的预防作用,评价该材料在胰腺手术中应用的安全性及可行性.方法 小型猪32只随机分成对照组(n=16)与实验组(n=16),2组均接受胰腺远端切除手术,对照组远端胰腺切除后采用传统的单纯手工缝合法,实验组则先用牛心包生物膜包裹住胰腺残端,用同样缝线穿过被裹住的胰腺组织后手工缝合;测定各组术后每日腹腔引流量及引流液淀粉酶水平至术后第10天,判断胰漏情况;术后3周处死动物,观察腹内情况并取残端胰腺组织作病理学检查.结果 实验组胰漏率低于对照组(6.2％比46.7％,P＜0.05),术后引流量实验组低于对照组(25.1 ml比54.2 ml,P＜0.01),术后3周剖腹探查,两组实验动物未见明显差异;胰腺残端组织病理结果两组均显示炎症细胞浸润并伴有少许坏死组织. 结论 胰腺远端切除术后,利用牛心包生物膜包裹残端后缝合可有效减少术后胰漏的发生,是安全可行的.     

远端胰腺切除术后胰瘘发生的危险因素分析

目的:探讨影响远端胰腺切除术后胰瘘发生的相关性因素。方法:回顾2010年2月—2016年5月所实施的100例远端胰腺切除术患者临床资料,对相关因素进行单因素与多因素分析。结果:100例患者中32例(32%)发生术后胰瘘,包括A级胰瘘(无临床意义)18例(18%),有临床意义的胰瘘14例(14%),其中B级胰瘘8例,C级胰瘘6例。单因素分析中,高体质量指数(≥25kg/m~2)与术后胰瘘发生有关(χ~2=4.128,P=0.042),但与有临床意义的胰瘘发生无关(χ~2=1.545,P=0.214),软胰腺质地与胰瘘及有临床意义的胰瘘发生均明显有关(χ~2=4.569,P=0.033;χ~2=11.374,P=0.001)。多因素分析中软胰腺质地是胰瘘及有临床意义的胰瘘发生的唯一独立危险因素(OR=2.476,P=0.043;OR=8.012,P=0.003)。结论:胰腺质地是远端胰腺切除术后胰瘘发生的重要影响因素,对于胰腺质地软者,应采取积极防治措施。     

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。     

预防胰腺切除术后胰瘘的研究进展

不同形式的胰腺切除术在临床治疗中具有重要作用。胰十二指肠切除术（ＰＤ）是根治胰头壶腹周围癌、十二指肠癌、进展期胃癌、结肠癌、胆囊癌等疾病的有效治疗措施。而胰腺切缘或吻合口瘘是胰腺切除术、尤其是ＰＤ术后的最常见并发症之一,可直接影响病人的预后及术后生存...     

重视胰腺外科术后胰瘘预防及处理

胰瘘是胰腺切除术后最常见的并发症,其继发的腹腔感染和出血是导致病人死亡的重要原因。胰瘘定义和分级标准的统一对其预防及临床研究具有重要意义。目前,尚无一种理想的技术方法能够从根本上杜绝胰瘘的发生,充分的术前评估、重视手术质量、根据病人情况选择最熟悉的术式、加强围手术期管理和手术团队的专业化将有助于降低胰瘘的发生率和严重程度。     

胰管空肠吻合胰腺残端套入法预防Whipple术后胰瘘

采用胰管空肠吻合胰腺残端套入法预防Whipple术后胰瘘12例，其中胰头癌5例，Water氏壶腹癌3例，十二指肠乳头癌2例，胆总管下段癌及慢性阻塞性胰腺炎各1例。经临床观察，效果尚满意，无1例并发胰腺疾。作者认为，胰腺瘘的发生同术式和操作技术有一定关系。采用胰管空肠吻合及胰腺残端套入法，对防止胰腺瘘有重要作用，加之置管引流，不仅使胰管内减压，而且有支撑管的作用和使胰液远离吻合口，有助于胰腺空肠吻合口的愈合。     

保留脾脏的胰体尾部良性肿瘤切除

目的探讨保留脾脏胰体尾切除的可行性和安全性以及并发症预防。方法回顾性分析总结2009年1月至2011年12月行保留脾脏胰体尾切除术5例资料,其中保留脾脏血管的开腹保脾胰体尾切除3例,切断(或切除)脾脏血管的保脾胰体尾切除术1例,腔镜下保脾胰体尾部切除术1例。结果本组无手术死亡,术后均未发生胰瘘、脾梗死、脾脓肿及脾出血等。随访3～6月,无并发症发生。结论胰体尾部良性肿瘤,应首选保留脾脏的胰体尾切除方法,手术安全,效果好,且避免了脾脏的不必要切除。     

Roux-en-Y Drainage of the Pancreatic Stump Decreases Pancreatic Fistula After Distal Pancreatic Resection

Clinically relevant fistula after distal pancreatic resection occurs in 5–30% of patients, prolonging recovery and considerably increasing in-hospital stay and costs. We tested whether routine drainage of the pancreatic stump into a Roux-en-Y limb after distal pancreatic resection decreased the incidence of fistula. From October 2001, data of all patients undergoing pancreatic distal resection were entered in a prospective database. From June 2003 after resection, the main pancreatic duct and the pancreatic stump were oversewn, and in addition, anastomosed into a jejunal Roux-en-Y limb by a single-layer suture (n = 23). A drain was placed near the anastomosis, and all patients received octreotide for 5–7 days postoperatively. The volume of the drained fluid was registered daily, and concentration of amylase was measured and recorded every other day. Patient demographics, hospital stay, pancreatic fistula incidence (≥30 ml amylase-rich fluid/day on/after postoperative day 10), perioperative morbidity, and follow-up after discharge were compared with our initial series of patients (treated October 2001–May 2003) who underwent oversewing only (n = 20). Indications, patient demographics, blood loss, and tolerance of an oral diet were similar. There were four (20%) pancreatic fistulas in the “oversewn” group and none in the anastomosis group (p < 0.05). Nonsurgical morbidity, in-hospital stay, and follow-up were comparable in both groups. Wagner and Gloor both contributed equally in this work.     

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     

Distal Pancreatectomy for Chronic Pancreatitis: Risk Factors for Postoperative Pancreatic Fistula

One of the most common complications after distal pancreatectomy is a fistula from the pancreatic remnant. Factors influencing the development of a pancreatic fistula after distal pancreatectomy have not been clearly elucidated. The records of 91 patients who underwent distal pancreatectomy for chronic pancreatitis between 1995 and 2003 were retrospectively reviewed and analyzed. Average daily volume and amylase concentration between postoperative days 2 and 20 from drains located at the pancreatic resection site were compared to clinical variables. Out of 137 pre- and intraoperative clinical variables, multivariate analysis showed serum creatinine (t = 3.05, p = 0.004), history of intraabdominal operation (t = −2.68, p = 0.01), right-sided pancreatic duct dilation (t = 2.65, p = 0.01), synchronous cholecystectomy (t = 2.53, p = 0.02), and serum albumin (t = −2.19, p = 0.04) to be independently associated with drain volume. Drain amylase concentration was linked to serum creatinine (t = 8.55, p < 0.001), blood urea nitrogen (t = −3.43, p = .001), preoperative parenteral nutrition (t = 2.56, p = .01), and serum alkaline phosphatase (t = 2.51, p = 0.01). There was no correlation between the degree of fibrosis and drain output. Technique of pancreatic transection and presence of suture closure of the pancreatic duct did not affect drain output. In conclusion, the amount and amylase concentration of postsurgical drainage after distal pancreatectomy for chronic pancreatitis is dependent on markers of renal dysfunction, malnutrition, biliary disease, and possibly inflammation. These factors, if medically reversible, should be addressed in patients who are candidates for distal pancreatectomy for chronic pancreatitis. This paper was presented, in part, at the 46th Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, IL, USA, May 14–18, 2005.     

Novel Method of Stump Closure for Distal Pancreatectomy with a 75% Reduction in Pancreatic Fistula Rate

Background  

Pancreatic fistula is a significant problem for patients undergoing distal pancreatectomy with fistula rates up to 61%. Fistulas lead to substantial morbidity. The study objective was to compare radiofrequency dissector closure with traditional stump closure for distal pancreatectomy.     

Pancreatic Fistula Rates After 462 Distal Pancreatectomies: Staplers Do Not Decrease Fistula Rates

Introduction  Pancreatic fistula is a major source of morbidity after distal pancreatectomy (DP). We reviewed 462 consecutive patients undergoing DP to determine if the method of stump closure impacted fistula rates. Methods  A retrospective review of clinicopatologic variables of patients who underwent DP between February 1994 and February 2008 was performed. The International Study Group classification for pancreatic fistula was utilized (Bassi et al., Surgery, 138(1):8–13, 2005). Results  The overall pancreatic fistula rate was 29% (133/462). DP with splenectomy was performed in 321 (69%) patients. Additional organs were resected in 116 (25%) patients. The pancreatic stump was closed with a fish-mouth suture closure in 227, of whom 67 (30%) developed a fistula. Pancreatic duct ligation did not decrease the fistula rate (29% vs. 30%). A free falciform patch was used in 108 patients, with a fistula rate of 28% (30/108). Stapled compared to stapled with staple line reinforcement had a fistula rate of 24% (10/41) vs. 33% (15/45). There is no significant difference in the rate of fistula formation between the different stump closures (p = 0.73). On multivariate analysis, BMI > 30 kg/m², male gender, and an additional procedure were significant predictors of pancreatic fistula. Conclusions  The pancreatic fistula rate was 29%. Staplers with or without staple line reinforcement do not significantly reduce fistula rates after DP. Reduction of pancreatic fistulas after DP remains an unsolved challenge. Presented at the DDW in San Diego, CA, USA, May 21, 2008.     

Decreasing Pancreatic Leak After Distal Pancreatectomy: Saline-coupled Radiofrequency Ablation in a Porcine Model

Despite marked improvements in pancreatic surgery, the high incidence and morbidity of pancreatic leak after resection has remained unchanged. The objective of this study was to evaluate the role of saline-coupled radiofrequency ablation (TissueLink) as an alternative to traditional methods of stump closure in an animal model of distal pancreatectomy. Forty swine were randomized after pancreatic transection and remnant stump was either oversewn in a traditional fashion (control) or treated with the device alone (TissueLink). Animals were killed and necropsied at 3 or 5 weeks postoperatively. Primary endpoints were the development of a pancreatic fistula defined as dye extravasation from the remnant duct, presence of undrained amylase-rich fluid collections/abscess, and greater than threefold drain/serum amylase after the third postoperative day. The incidence of pancreatic leak in the TissueLink group was 5.5 vs 42% in the control group (p = 0.01). There were no differences in operative time or other clinical parameters measured. Histologic analysis of the remnant pancreatic stumps confirmed our results. These data support our hypothesis that saline-coupled radiofrequency ablation leads to obliteration of ducts with a resultant decrease in pancreatic leak and subsequent complications. This technology may play a substantial role in preventing this dreaded complication in the clinical setting. This study was presented at the Pancreas Club on May 21, 2006 and at the Society for Surgery of the Alimentary Tract during Digestive Disease Week on May 22, 2006 in Los Angeles, CA, USA, as a poster presentation.     

Absorbable Mesh Reinforcement of a Stapled Pancreatic Transection Line Reduces the Leak Rate with Distal Pancreatectomy

Pancreatic leak remains a significant cause of morbidity after distal pancreatectomy. We report the use of an absorbable mesh to reinforce a stapled pancreatic transection line for distal pancreatectomy. Forty consecutive distal pancreatectomies (33 open and 7 laparoscopic) were performed since the introduction of mesh reinforcement. We utilized an inclusive definition of pancreatic leak to critically evaluate the staple line reinforcement material. In addition, we compared the pancreatic leak rate for this case series with the antecedent 40 cases where mesh reinforcement was not available. In the prospective series there was 1 leak in 29 cases (3.5%) in which mesh reinforcement was utilized, and 4 leaks in 11 cases (36%) when mesh was not utilized (p < 0.005). The 12.5% leak rate for the 40 cases during the prospective period, compared favorably to the 27.5% leak rate for the 40 cases preceding the study period (p = 0.09). Twenty-nine cases receiving mesh compared favorably to the 23 stapled cases in the control series, reducing leak rate from 22 to 3.5% (p = 0.04). Mesh reinforcement of the stapled pancreatic transection line reduced the pancreatic leak rate after distal pancreatectomy. Mesh reinforcement was possible with open or laparoscopic resections. No complications were attributable to the use of absorbable mesh. This study was presented in part at the 2006 American Hepato-Pancreato-Biliary Association annual meeting, March, 2006, Miami Beach, Florida.     

保留脾脏的胰体尾切除术的选择与方法

目的研究保留脾脏的胰体尾切除术(SpDP)的可行性、安全性,探讨其选择及具体方法。方法对上海交通大学附属新华医院2004年1月至2007年12月期间施行的7例SpDP患者的临床资料进行回顾性分析。结果 6例成功施行保留脾血管的SpDP,1例成功施行部分脾血管切除的SpDP,手术时间(2.93±0.38)h,术中失血量为(392.86±109.65)ml。术后发生胰瘘1例,经保守治疗后好转出院。全组患者术后血小板计数最高值为(273±43.76)×109/L,术后住院时间为(17.86±8.07)d,住院期间无死亡病例。6例肿瘤患者术后随访(49.2±14.4)个月(30～70个月),未见肿瘤复发、转移征象。结论 SpDP是一种安全、可行的术式,对于胰体尾良性占位等合适的病例有一定的临床应用价值。     

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。