胰十二指肠切除术后胃排空障碍相关危险因素分析

目的探讨胰十二指肠切除术后发生胃排空障碍的相关危险因素,为临床的防治提供参考。方法回顾性分析2005年1月至2013年7月间收治的120例胰头癌患者的临床资料,采用病例对照研究方法,将其中发生胃排空障碍的25例患者作为病例组,未发生胃排空障碍的95例患者作为对照组,对两组患者进行单因素分析和多因素非条件Logistic回归分析。结果单因素分析结果显示,手术后胰漏、手术方式、术后白蛋白水平、手术时间、术前总胆红素、术后血红蛋白、腹腔感染、术后输血量、术后空腹血糖、术后生长抑素例数及术前减黄与胰十二指肠切除术后胃排空障碍发生有关(P<0.05)。多因素非条件的Logistic回归分析显示,术后胰漏、手术方式、腹腔感染、术后空腹高血糖是胰十二指肠切除术后发生胃排空障碍的独立危险因素(P<0.05)。结论术后胰漏、手术方式、腹腔感染、术后空腹高血糖是胰十二指肠切除术后发生胃排空障碍的独立危险因素。     

胰十二指肠切除术后发生胃排空延迟影响因素的meta分析

目的通过meta分析,探讨胰十二指肠切除术后发生胃排空延迟的影响因素及其相关危险度。方法 通过检索Cochrane Library、Medline、Pubmed、Ovid、Embase,搜集近二十年发表的关于胰十二指肠切除术后发生胃排空延迟影响因素的相关文献,进行meta分析,计算每个危险因素的优势比(OR值)及95%CI。结果 meta分析共纳入研究文献26篇,其中6篇RCTs,9篇队列研究,11篇病例对照研究。经meta分析,计算合并OR值分别为:保留幽门2.35(95% CI,0.72-7.61),术后早期肠内营养0.93(95% CI,0.64-1.35),术后腹部并发症6.14(95% CI,3.47-10.85),Billroth I式胃肠重建(与Billroth II相比)4.30(95% CI,1.00-18.43),结肠前胃肠吻合0.12(95% CI,0.05-0.27)。结论 胰十二指肠切除术后,腹部并发症是发生胃排空延迟的一个危险因素;保留幽门不增加胃排空延迟的发生率;术后早期肠内营养与胃排空延迟发生无关;结肠前及Billroth II式胃肠重建可能会降低胃排空延迟的发生率。     

Prophylactic octreotide and delayed gastric emptying after pancreaticoduodenectomy: Results of a prospective randomized double-blinded placebo-controlled trial

Aims

To evaluate the impact of prophylactic octreotide on gastric emptying in patients undergoing pancreaticoduodenectomy. Postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE) are common complications after pancreaticoduodenectomy. Whereas several prospective randomized trials propose the prophylactic use of octreotide to prevent pancreatic fistula formation, somatostatin has, however, been associated with delayed gastric emptying after partial duodenopancreatectomy.

Methods

In this prospective, randomized, double-blinded, placebo-controlled trial we analyzed the influence of prophylactic octreotide on delayed gastric empting after pancreaticoduodenectomy. Patients were randomized to the placebo group (n = 32) and the octreotide group (n = 35). Primary endpoint was the incidence of delayed gastric emptying, secondary endpoints included perioperative morbidity other than DGE. DGE was measured by clinical signs, gastric scintigraphy and the hydrogen breath test. Risk factors for DGE other than octreotide were analyzed by univariate and multivariate analyses.

Results

DGE measured by clinical signs was similar between both groups studied (∼20% of the patients). Gastric scintigraphy (T_1/2) was 76.3 ± 15.2 min in the octreotide group and 86.7 ± 18.0 min in controls at day 7, respectively. The H₂ breath test was 65.0 ± 6.5 min in octreotide treatment group and 67.0 ± 5.7 min in controls at day 8. POPF grade C occurred in ∼3% of the patients, although prophylactic treatment of octreotide did not reduce the incidence of POPF. Multivariate analysis showed that postoperative intraabdominal bleeding and infection were independent risk factors for DGE. Furthermore preoperative biliary stenting reduced postoperative DGE after partial duodenopancreatectomy.

Conclusion

Prophylactic octreotide has no influence on gastric emptying and does not decrease the incidence of postoperative pancreatic fistula after pancreaticoduodenectomy.     

结肠癌术后功能性胃排空障碍的诊断和治疗

目的：探讨结肠癌术后功能性胃排空障碍的原因,诊断及治疗,方法：回顾性分析6例结肠癌术后功能性胃排空障碍的临床资料。结果：6例均发生于术后4－6天,症状持续时间15－42天,均经非手术治疗痊愈出院。结论：结肠癌术后功能性胃排空障碍系多种因素作用的结果,精神紧张、失眠、营养不良、低蛋白血症、淋巴清检查方法;联合应用胃动力药物的综合治疗可取得较好疗效。     

Effect of preservation of the right gastro-epiploic artery on delayed gastric emptying after cytoreductive surgery and HIPEC: A randomized clinical trial

Background

Delayed gastric emptying (DGE) is a main complication with unknown origin after a cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy (CRS-HIPEC). The aim of this study was to investigate if preservation of the right gastro-epiploic artery (GEA) during standard omentectomy would have a positive effect on gastric emptying after CRS-HIPEC.

Methods

Forty-two patients subjected to a CRS-HIPEC were randomized into two groups perioperatively before performing an omentectomy: in Group I (N = 21) omentectomy was performed with preservation of the GEA; in Group II (N = 21) omentectomy was performed with resection of the GEA. The primary endpoint was the number of days to full oral intake of solid food. Secondary endpoints were number of days to intended occlusion of gastrostomy catheter and total hospital admission time.

Results

No significant differences were discovered between both groups in any of the study endpoints after CRS-HIPEC. No significant differences were observed in patient or operation characteristics between the randomized groups.

Conclusions

No association was demonstrated between preservation of the gastro-epiploic artery during omentectomy and gastric emptying after CRS-HIPEC. The extensive intestinal manipulation or the heated intra-peritoneal chemotherapy during surgery are more plausible causes of this phenomenon.This clinical trial was registered in the Netherlands at the Central Committee on Research involving Human Subjects (CCMO) under registration number P06.0301L.     

胰十二指肠切除术后应激性溃疡出血的危险因素分析

目的 探讨胰十二指肠切除术后发生应激性溃疡出血的危险因素.方法 对285例壶腹周围癌患者行胰十二指肠切除手术,分析患者的临床特点、手术情况、病理结果、术后治疗和术后篌并发症等,以未发生应激性溃疡出血患者为对照组,研究发生应激性溃疡出血的危险因素.结果 全组发生应激性溃疡出血35例,其中胰腺癌5例,十二指肠癌8例,胆总管下端癌10例,壶腹癌11例,实性假乳头状瘤1例.单因素分析结果显示,饮酒史、术前高胆红索水平、手术时间、淋巴结转移、术后出现其他并发症和术后前白蛋白降低是术后发生应激性溃疡出血的影响因素(均P<0.05).Logisitic回归分析显示,术前高胆红索水平、手术时间、术后出现其他并发症和术后前白蛋白降低是胰十二指肠切除术后发生应激性溃疡出血的独立危险因素(均P<0.05).结论 应激性溃疡出血已成为胰十二指肠切除术常见并发症之一,术前高胆红素水平、手术时间、术后其他并发症和术后前白蛋白降低是发生应激性溃疡出血的危险因素.     

食管癌切除术后胃排空障碍的原因及防治

 目的　探讨食管癌切除术后胃排空障碍的原因及防治措施。方法　对食管癌术后并发胃排空障碍 17例患者的临床资料进行回顾性分析。结果　本组均发生于术后 7～ 12天 ,其中 12例功能性胃排空障碍经保守治疗 ,治愈 11例 ,死亡 1例 ,5例机械性胃排空障碍均经手术治愈 ,本组死亡率为 5 .88%。结论　迷走神经切断及胃解剖位置的变化是胃排空障碍的主要原因 ,其次胃排空障碍也与胃扭转、术后粘连等因素有关。X线钡剂造影及胃镜检查是诊断本病的主要方法。功能性胃排空障碍 ,一般行保守治疗 ;机械性胃排空障碍 ,应尽早手术。术前充分准备 ,手术操作认真、规范 ,术后恰当处理 ,可减少胃排空障碍的发生     

根治性胃大部切除术后胃排空障碍25例临床分析

目的探讨胃癌根治术后胃瘫综合征（PGS）的发生原因、临床特点和处理方法。方法对1997年1月至2007年12月胃癌根治术后出现胃瘫综合征25例患者的临床资料进行回顾性分析。结果糖尿病、低蛋白血症,术前存在幽门梗阻,毕Ⅱ式胃肠吻合,患者PGS发生率较高。25例患者均经非手术保守治疗而治愈。结论上述因素可能是胃大部切除术后PGS发生的高危因素,在围手术期应纠正或避免这些高危因素。胃癌根治术后PGS采用非手术疗法可愈。     

The delayed massive hemorrhage after gastrectomy in patients with gastric cancer: Characteristics,management opinions and risk factors

Aims

This study was designed to investigate the clinical features of delayed massive hemorrhage (DMH) after gastrectomy in patients with gastric cancer (GC).

Methods

This study retrospectively reviewed 1536 GC patients with major gastrectomy between 1998 and 2011. Based on the time onset of postoperative bleeding, patients were divided into early postoperative hemorrhage (EPH), delayed massive hemorrhage (DMH), and no-bleeding groups. Postoperative mortality, bleeding treatment, and risk factors of hemorrhage were explored.

Results

In sum, 15 (0.9%) patients suffered from DMH, with three (20%) dead cases. None of 18 (1.2%) patients with EPH died, but there were three dead cases in no-bleeding group. DMH had more extra-intestinal bleeding (P = 0.037) than EPH. Angiographic embolization was performed in 12 (80%) of DMH patients and successful in ten cases. Surgical procedures were applied in only two embolization-failed cases. Extended lymphadenectomy (P = 0.038), vascular skeletonization (P = 0.012) and advanced TNM stage (P < 0.001) were correlated with DMH.

Conclusions

DMH can be successfully managed with angiographic embolization, followed by alternative surgery. Extensive lymphadenectomy and vascular skeletonization should be discreetly performed during gastrectomy.     

Safety and efficacy for robot-assisted versus open pancreaticoduodenectomy and distal pancreatectomy: A systematic review and meta-analysis

Background

This meta-analysis was conducted to compare the clinical safety and efficacy of robot-assisted pancreaticoduodenectomy (RAPD) or robot-assisted distal pancreatectomy (RADP) with open surgery.

远端胃切除术后影响胃排空延迟的多因素分析及生活质量评价

目的:探讨远端胃部分切除术后胃排空延迟(DGE)发生的影响因素及对两种胃肠吻合方式的术后短期生活质量初步评价.方法:回顾性分析2013年9月至2015年6月在西安交通大学第一附属医院行远端胃部分切除术后符合纳入标准的106例患者的临床资料,探索远端胃部分切除术后DGE发生的影响因素及采用EORTC QLQ-C30对患者短期内生活质量进行评价.结果:25例患者术后发生DGE,发生率为23.58％.单因素分析结果表明,体重指数、胃肠吻合方式、术前合并糖尿病、术后下地活动时间、术后蛋白及血红蛋白水平、术后并发症与DGE的发生相关;按吻合方式进行分组,术后两组患者生活质量在功能领域和症状领域均有差异.多因素LogistiC回归分析结果表明,胃空肠吻合方式(OR=2.997,95％CI:1.010～8.896,P=0.048)、有无糖尿病史(OR=5.687,95％ CI:2.004～ 16.141,P=0.001)均为远端胃切除术后DGE发生的危险因素.结论:远端胃部分切除术后DGE的发生率较高,积极的围手术期准备、治疗、科学合理的控制血糖可有效预防术后DGE的发生以及提高患者短期生活质量.     

食管癌术后胸胃排空障碍的诊治

目的探讨食管癌术后胸胃排空障碍的病因及其防治。方法回顾性分析47例食管癌术后发生胸胃排空障碍患者的发病原因、临床诊断、处理方法、预防措施等。结果 41例患者经包括介入球囊扩张等在内的保守治疗而痊愈,6例经手术治疗治愈。结论食管癌术后发生的功能性胸胃排空障碍经过非手术治疗即可治愈,而胃扭转等机械性排空障碍应行手术治疗。诊断和鉴别术后胸胃排空障碍的主要方法为消化道造影及胃镜检查。介入球囊扩张术是有效的治疗方法。     

Pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy: A meta-analysis of randomized control trials

Background

Postoperative pancreatic fistula (PF) is the leading morbidity after pancreaticoduodenectomy (PD). The pancreatoenteric anastomosis method after PD is associated with the occurrence of PF. Evidence shows that pancreaticogastrostomy (PG) is possibly superior to pancreaticojejunostomy (PJ) in reducing the incidence of PF after PD; however, this remains to be definitively confirmed.

Methods

Randomized clinical trials (RCTs) comparing the outcomes of PG versus PJ after PD were retrieved for meta-analysis.

Results

After a thorough search of the English literature published until March 23rd, 2014, we identified seven RCTs involving 1095 patients (PG group, 548; PJ group, 547) for final analysis. Meta-analysis revealed that the incidence of PF was significantly lower in the PG group (15.7%) than in the PJ group (23.0%, 126/547; OR = 0.61, 95% CI: 0.45–0.83, P = 0.002). Furthermore, the incidence of intra-abdominal fluid collection was also lower in the PG group than in the PJ group (OR = 0.43, 95% CI: 0.28–0.65, P < 0.0001). No significant differences were found between the PG and PJ groups in terms of delayed gastric emptying, hemorrhage, overall morbidity and mortality.

Conclusions

PG seemed to be superior to PJ in reducing the incidence of PF and intra-abdominal fluid collection after PD.     

A comparison of pancreaticoduodenectomy with pylorus preserving pancreaticoduodenectomy: A meta-analysis of 2822 patients

Background

The gold-standard for surgical excision of peri-ampullary tumours has not been established despite numerous studies, due to conflicting outcomes.

Aim

To consolidate the published evidence and compare outcomes between pancreaticoduodenectomy (PD) and pylorus preserving pancreaticoduodenectomy (PPPD) across all published comparative studies.

Methods

Using meta-analytical techniques the study compared: operative details, post-operative adverse events and survival following PD and PPPD. Comparative studies published between 1986 and 2005 of PD versus PPPD were included. A random effect model was employed, with significance reported at the 5% level.

Results

32 studies comprising 2822 patients (1335 PD and 1487 PPPD), including 5 randomized controlled trials with 421 patients (215 PD and 206 PPPD) were included. Patients undergoing PPPD were found to have smaller tumours (weighted mean difference (WMD) −0.54 cm, p = 0.030), although no significant difference in the number of patients with stage III or IV disease existed between the groups (odds ratio, OR 1.55, p = 0.320). Decreased operating times (WMD −41.3 min, p = 0.010) and fewer blood transfusions (WMD −0.9 units, p < 0.001) were observed in the PPPD group. There was no difference in post-operative complications, including pancreatic and biliary leaks or fistulae, between the two groups. It was suggested that peri-operative mortality was decreased in the PPPD group (OR 1.7, p = 0.040), and overall survival was better (hazard ratio (HR) 0.66, p = 0.02), although this did not remain significant on subgroup analysis.

Conclusions

Both PD and PPPD had similar peri-operative adverse events, however, in overall analysis PPPD has lower mortality and improved long-term patient survival, although this was not reflected in the sub-group analysis.     

Risk factors for surgical site infections after breast surgery: A systematic review and meta-analysis

Background

Breast surgical site infections (SSIs) are major sources of postoperative morbidity and mortality, and it's established that surveillance of risk factors is effective in reducing hospital-acquired infections. However, studies about risk factors for breast SSIs were still under controversy because of limited data, contradictory results and lack of uniformity.

Materials and methods

We searched the electronic database of PubMed for case–control studies about risk factors for breast SSIs, and a meta-analysis was conducted.

Results

Eight studies including 681 cases and 2064 controls were eligible, and data was combined if the risk factor was studied by at least two studies. Of the 20 possible risk factors involved, 14 were proved significant for SSIs as follows: increased age, hypertension, higher body mass index (BMI), diabetes mellitus, American society of anesthesiologists (ASA) 3 or 4, previous breast biopsy or operation, preoperative chemoradiation, conservation therapy versus other surgical approaches, hematoma, seroma, more intraoperative bleeding, postoperative drain, longer drainage time and second drainage tube placed. However, other factors like smoking habit, immediate reconstruction, axillary lymph node dissection, preoperative chemotherapy, corticosteroid usage and prophylactic antibiotic didn't show statistical significance.

Conclusions

This meta-analysis provided a list of predictable or preventable factors that could be taken measures to reduce the rate of breast SSIs and excluded some negligible factors. This could be useful for developing effective prevention and treatment policies for patients with SSIs and improving the overall quality of life.     

胰十二指肠切除术后胰瘘的影响因素研究进展

胰十二指肠切除术(Pancreaticoduodenectomy,PD)是治疗壶腹周围恶性肿瘤、癌前病变和部分良性疾病的标准术式。PD手术切除范围广,吻合口多,手术并发症较多。近年来,PD手术死亡率已经由最初的大于50%下降到目前的小于5%,手术并发症发生率也显著下降。PD术后主要并发症有胰瘘、出血、腹腔感染、胆瘘、乳糜瘘、术后胃排空障碍等。其中,胰瘘是导致PD术后早期死亡的主要原因。本文就影响PD术后胰瘘的全身因素、局部因素和手术相关因素进行综述,为降低PD术后胰瘘发生率提供临床可操作性。     

Improved survival after pancreatic re-resection of positive neck margin in pancreatic cancer patients. A systematic review and network meta-analysis

The oncological benefit of achieving a negative pancreatic neck margin through re-resection after a positive frozen section (FS) is debated. Aim of this network meta-analysis is to evaluate the survival benefit of re-resection after intraoperative FS neck margin examination following pancreatectomy for ductal adenocarcinoma.A systematic search of studies comparing different strategies for the management of positive FS was performed. Patients were classified in three groups based on FS and permanent section (PS): Group A (FS-, PS-R0), Group B (FS+, PS-R0), Group C (FS±, PS-R1). A frequent random-effects network-meta-analysis was made reporting the surface under the cumulative ranking (SUCRA). Primary endpoint was overall survival (OS). Secondary endpoints were pathological outcomes.Seven retrospectives studies with 4205 patients were included and 99.1% of the pancreatic resections were pancreatoduodenectomies. Group A had the highest probability of better OS (SUCRA = 90%), compared to Group B (SUCRA = 48.7%) and Group C, which was the worst prognostic scenario (SUCRA = 11.3%). Group B had still a probability of longer OS compared to Group C (SUCRA = 48.7% vs 11.3%). Pathological features were more favourable in Group A, with the highest SUCRA for T1-T2 tumors (92.6%), N0 status (89.4%), absence of perineural invasion (92.3%). Heterogeneity was low (τ-value <0.1) for OS, and moderate (τ-values: 0.1–0.6) for pT, pN, and perineural invasion.In conclusion, negative neck margin after primary resection (FS negative) or re-resection of a positive FS was associated with improved survival compared with PS-R1. However, any intraoperative positive FS can be considered as a prognostic factor associated with a more aggressive disease.     

Free intraperitoneal tumor cells and outcome in gastric cancer patients: a systematic review and meta-analysis

Purpose

Despite continuously improving therapies, gastric cancer still shows poor survival in locally advanced stages with local recurrence rates of up to 50% and peritoneal recurrence rates of 17% after curative surgery. We performed a systematic review with meta-analyses to clarify whether positive intraperitoneal cytology (IPC) indicates a high risk of disease recurrence and poor overall survival in gastric cancer.

Methods

Multiple databases were searched in December 2014 to identify studies on the prognostic significance of positive intraperitoneal cytology in gastric cancer, including: Medline, Biosis, Science Citation Index, Embase, CCMed and publisher databases. Hazard ratios (HR) and associated 95% confidence intervals (CI) were extracted from the identified studies. A meta-analysis was performed using a random-effects model on overall survival, disease-free survival and peritoneal recurrence free survival.

Results

A total of 64 studies with a cumulative sample size of 12,883 patients were included. Cytology, quantitative real time polymerase chain reaction (PCR) or both were performed in 35; 21 and 8 studies, respectively. Meta analyses revealed free intraperitoneal tumor cells (FITC) to be associated with poor overall survival in univariate (HR 3.27; 95% CI 2.82 - 3.78]) and multivariate (HR 2.45; 95% CI 2.04 - 2.94) analysis and poor peritoneal recurrence free survival in univariate (4.15; 95% CI 3.10 - 5.57) and multivariate (3.09; 95% CI 2.02 - 4.71) analysis. Subgroup analysis showed this effect to be independent of the detection method, Western or Asian origin or the time of publication.

Conclusions

FITC oder positive peritoneal cytology is associated with poor survival and increased peritoneal recurrence in gastric cancer.     

内镜黏膜下切除早期胃癌后并发迟发性胃穿孔的临床特点

目前,内镜黏膜下切除术（endoscopic submucosal dissection,ESD）已经成为无淋巴结转移风险的早期胃癌的 标准治疗方法。ESD 虽然具有显著的优点,但它依然可以引起一些并发症。ESD 术后并发迟发性胃穿孔是其中一类较为罕 见的并发症,然而,一旦该并发症发生,患者的症状通常较重,大多需要紧急处理。当前,世界上关于该并发症的研究不多, 而且主要存在两方面问题。其一,在研究对象方面,由于该并发症较为罕见,故研究对象数目较少,而且研究对象基本都 是日本人,种族来源较窄;其二,在研究结果方面,不同的研究所得出的数据及结论之间有相互矛盾之处。为解决这两方 面的问题,应当对该并发症进行进一步的研究。为使更多的研究人员关注该并发症,推动关于该并发症的调查研究,获得 更为可靠的数据及结果,从而促进该并发症在临床的预防、治疗及恢复,以减少患者的病痛,本文总结了一些该并发症相 关的研究,对 ESD 术后并发迟发性胃穿孔的发生原因、临床表现、治疗方法、预后及预防等临床特点进行综述 。