联合血管重建胰十二指肠切除术患者的护理

总结16例合并门静脉浸润胰头癌行联合血管重建胰十二指肠切除术病人的临床护理，笔者认为术前做好血管重建的准备，术后注重心理护理，减轻病人心理负担，加强吻合血管的护理，预防并治疗胰瘘和胆瘘等并发症是确保手术成功的重要措施。     

联合血管重建胰十二指肠切除术病人的护理

总结16例合并门静脉浸润胰头癌行联合血管重建胰十二指肠切除术病人的临床护理，认为术前作好血管重建的准备，术后注重心理护理，减轻病人心理负担，加强吻合血管的护理，预防并治疗胰瘘和胆瘘等并发症是保证手术成功的重要措施。     

胰十二指肠切除术的围手术期护理观察

目的探讨对胰十二指肠切除术患者实施围手术期护理的临床效果。方法选取40例胰十二指肠切除术的患者,在围手术期全部予以术前心理护理、营养支持、准备事项和术后并发症护理等护理措施。结果本组40例患者术后有5例出现并发症,发生率为12.5%,其中包括:腹腔内出血2例,腹腔感染1例,应激性溃疡1例和胰瘘1例。5例患者出现并发症的患者均于围手术期进行对症处理后痊愈出院。结论全面加强胰十二指肠切除术的围手术期护理,可有利于调整患者术前心态、促进手术的顺利进行,同时有效降低术后并发症的发生率,有利于患者预后。     

机器人胰十二指肠切除术的技术创新

机器人胰十二指肠切除术在经历了10余年的发展后,目前已形成一套相对成熟的体系,成为主流发展方向之一。这期间,此术式经历了一个长期摸索、改变、创新的过程,使其手术适应证得到扩展、术后并发症得以降低,流程更加优化。笔者结合世界各大医学中心及所在中心经验,阐述机器人胰十二指肠切除术在理念与技术上的创新。     

机器人辅助下胰十二指肠切除术：附18例报告

目的:初步总结DaVinci机器人辅助下的胰十二指肠切除术(RPD)的经验。方法:回顾2015年11月—2018年1月18例行RPD的患者临床资料。结果:18例患者手术时间为(450±30)min,术中出血量为(525±125)mL,术中均无输血;1例(5.6%)中转开腹;术后肠道功能恢复时间(4.0±1.0)d,术后住院时间(16±4)d;术后出现并发症者7例,其中4例(22.2%)术后并发胰瘘(均为B级胰瘘)、胆瘘1例、腹腔内出血2例;无再次手术,术后病死率5%。术后病理结果显示,胰腺高分化腺癌3例、低分化导管腺癌1例、胰腺浆液性囊腺瘤3例、胰腺黏液性囊腺瘤2例、胰腺导管内乳头状黏液瘤1例、十二指肠高分化腺癌2例、十二指肠绒毛管状腺瘤2例、胆总管下段中低分化腺癌1例、胆总管下段高分化腺癌2例、胰腺慢性炎症1例。9例恶性肿瘤中8例完成R_0切除,1例R1切除;淋巴结清扫数目为(16±4)枚。结论:RPD安全可行,并未明显增加手术相关并发症,同时可以加快患者术后恢复时间。     

机器人辅助腹腔镜胰十二指肠切除术

胰十二指肠切除术(pancreaticoduodenectomy,PD)被认为是普通外科手术中较难和复杂的手术,即使对于有经验的外科医生也是如此.     

胰十二指肠切除术的围手术期管理

胰十二指肠切除术(pancreaticoduodenectomy,PD)是治疗壶腹周围癌的经典术式,其手术创伤大、牵涉脏器多、术程较为复杂.随着医疗技术水平的提高,PD安全性显著提高,无论开腹还是腔镜手术,国内外大的外科中心死亡率已控制在3％以内,但总体并发症发生率仍在20％～50％之间.而PD的围手术期管理对于降低术...     

机器人胰十二指肠切除术进展

胰十二指肠切除术(pancreaticoduodenectomy,PD)一直被认为是普外科手术中最具挑战性的手术。由于该手术是在大血管附近广泛切除,并行复杂的消化道重建,且术后可能发生致命性胰漏等并发症,所以直到1994年Gagner等[1]才报道了第1例腹腔镜胰十二指肠切除术(laparoscopic pancreaticoduodenectomy,LPD)。但由于腹腔镜器械的局限性及其带来的技术困难,使LPD饱受争议[2-3]。然而,正是由于这些缺点,使机器人手术系统     

胰十二指肠切除术173例临床体会

目的总结胰十二指肠切除术(pancreaticoduodenectomy,PD)的临床经验。方法回顾性分析2015年8月至2016年7月本院施行PD的173例临床资料。结果 173例PD术后病理检查明确诊断:胰腺癌83例(48.0%),十二指肠乳头腺癌28例(16.2%),胆管癌22例(12.7%),壶腹癌12例(7.0%),神经内分泌肿瘤8例(4.6%),其他20例(11.6%)。术后并发症:低蛋白血症172例(99.4%),肝功能不全56例(32.4%),肺不张或者肺部感染35例(20.2%),胰瘘28例(16.2%),胸腔积液21例(12.1%),腹腔出血3(1.7%),胃肠吻合口瘘1例(0.6%),上消化道出血1例(0.6%),死亡2例(1.2%)。结论妥善的围手术期处理,精细的手术操作,特别是胰瘘的预防和处理是成功实施PD的关键。     

46例胰十二指肠切除术的护理体会

目的 总结46例胰十二指肠切除术后患者的护理。方法 收集2014年9月至2017年1月我科46例胰十二指肠切除（Whipple术）患者的术后护理资料,包括一般护理、腹部症状及体征、管道护理、并发症的观察与护理、心理护理等。结果 46例胰十二指肠切除患者中33例术后无并发症发生,康复出院。12例术后患者发生并发症,通过干预治疗,好转出院,一例患者因多种器官疾病放弃治疗。结论 规范或标准化护理、早期发现问题、医护沟通畅通三是Whipple术的围手术期护理的重要节点。     

机器人辅助胰十二指肠切除术在高龄患者的应用

目的探讨达芬奇机器人辅助胰十二指肠切除术(robotic pancreaticoduodenectomy,RPD)在高龄患者的安全性及临床效果。方法回顾性分析2016年12月至2020年5月于中山大学附属第一医院胆胰外科接受RPD、年龄≥70岁患者的临床资料,分析术后转归。结果共16例年龄≥70岁的患者接受RPD,其中男9例、女7例;年龄70~85岁,平均(73.6±4.2)岁。所有患者均顺利完成RPD,无中转开腹。病因包括6例壶腹癌、6例胰腺导管腺癌、1例胰腺神经内分泌肿瘤、1例胰管内乳头状黏液性肿瘤、1例十二指肠乳头癌、1例十二指肠乳头腺瘤伴高级别上皮内瘤变。中位手术时间413 min(IQR:366~522 min),中位术中出血量50 ml(IQR:50~62.5 ml),16例患者均获得R0切除。3例(18.8%)患者术后发生并发症,包括1例(6.2%)术后早期胰肠吻合口出血,通过再手术止血;3例(18.8%)B级胰瘘合并腹腔内感染;1例(6.2%)胃排空延迟。无围手术期死亡。中位术后住院时间13 d(IQR:12~18 d)。结论RPD对于高龄患者安全可靠,近期治疗效果满意。     

老年病人胰十二指肠切除术可行性评价

目的 探讨对老年病人实施胰十二指肠切除术的可行性,总结降低术后并发症发生率和病死率的经验。方法 回顾性分析2002年5月至2007年5月复旦大学附属华东医院普外科行164例胰十二指肠切除术的临床资料,分析老年和非老年病人术前身体状况的评估指标、术后并发症和死亡危险因素。结果 老年与非老年病人术前ASA评分及心功能分级差异有统计学意义。老年病人术后院内病死率高于非老年病人,死亡病例多发生在术后30d以后,两组术后并发症发生率的差异无统计学意义。术前低蛋白血症、术中失血＞1000mL是术后并发症发生的危险因素。术后院内死亡的危险因素为年龄＞70岁、术前低蛋白血症、术前合并冠心病和心功能分级＞2 。结论 老年病人并不是胰十二指肠切除术的绝对禁忌证,术前改善营养状况,加强术后监护及治疗是降低并发症发生率和术后病死率的有效手段。     

Outcome after pancreaticoduodenectomy for cancer in elderly patients

During the last decade, the outcome after pancreaticoduodenectomy (PD) for cancer showed a continuous improvement. Therefore, an increasing number of patients, especially elderly patients, have been considered for this procedure. However, the debate on the possible deleterious influence of patients’ advanced age on their postoperative outcome after pancreaticoduodenectomy still continues. From June 1995 to October 2003, 70 elderly patients (range, 70–84 years) underwent pancreaticoduodenectomy with pancreatogastrostomy for cancer. Among them, 38 patients were 70–75 years old and 32 were ⩾75 years. Patients were identified from a prospective database of a single institution, and their records were reviewed retrospectively. Patient and tumor characteristics, postoperative morbidity and mortality, length of hospital stay, readmission rate, and overall survival were compared between the two groups. There were no statistical differences regarding the postoperative mortality (P=0.205), overall morbidity (P=0.267), mean length of hospital stay (P=0.345), and readmission rate (P=1) between both groups. Only delayed gastric emptying was significantly more frequent in patients ⩾75 years (P=0.039). The median overall survival was 20 months. Survival was significantly influenced by the pathological type of the tumor, with worse results for patients with ductal pancreatic adenocarcinoma. In elderly patients, age does not seem to influence the postoperative outcome after pancreaticoduodenectomy with pancreatogastrostomy.     

Marginal ulceration after pylorus-preserving pancreaticoduodenectomy

Marginal ulceration is a serious problem after both standard pancreaticoduodenectomy (PD) and pylorus-preserving pancreaticoduodenectomy (PPPD). The relationship between this complication and the method of reconstruction after PPPD was analyzed in this study. Patients who underwent standard PD (n = 72) or PPPD (n = 28) in the 20-year period from 1978 to 1997 were retrospectively reviewed. After PPPD, 4 patients (14.3%) developed marginal ulceration on the jejunal side of the duodenojejunal anastomosis, while none of the patients had marginal ulceration after standard PD. The marginal ulcer occurred in 3 of 14 patients treated with the Roux-en-Y method, and in 1 of 9 treated with pancreatogastrostomy. In the Roux-en-Y method, the anal jejunal loop anastomosed to the bulb was directly exposed to gastric juice without neutralization by pancreatic juice from the oral jejunal limb. Of the 4 patients with marginal ulceration, 2 of those treated by the Roux-en-Y method required gastrectomy; the other 2 patients were treated medically. Our analysis of the literature showed that the Roux-en-Y method had the highest incidence of marginal ulcerations. The gastrointestinal reconstruction method without a mixture of gastric juice and pancreatic juice may be a causal factor in the marginal ulceration that occurs after PPPD. In reconstruction after PPPD, we should not create a jejunal loop that is exposed to gastric juice alone. Received for publication on July 26, 1999; accepted on Sept. 6, 1999     

胰十二指肠切除术后并发症

１９８５年１月～１９９５年１２月，我院行胰十二指肠切除术１１５例，术后死亡率７０％（８例）。并发症发病率为３７４％（４３例），包括胃排空延迟１９１％（２２例），胰空肠吻合口漏７８％（９例），腹腔脓肿７０％（８例），胆肠吻合口漏６１％（７例），应激性溃疡８７％（１０例）和腹腔内出血７０％（８例）。并发症与高龄，手术时间长和术中大量出血有关，大多数以非手术治疗而愈。当需再次手术，死亡率增加。术后并发症的处理以简单和保守为原则。     

Haemorrhagic complications of pancreaticoduodenectomy

BACKGROUND: Haemorrhagic complication occurs in 5-16% of patients following pancreaticoduodenectomy (PD). We report an analysis of patients with post-PD bleed, to identify predictors of bleed, predictors of survival following bleed and the management of post-PD bleed. METHODS: Two hundred and eighteen patients with periampullary cancers underwent PD from 1989 to 2002. Forty-four (20.2%) patients had a bleeding complication. Of these, 25 patients had an intra-abdominal (IA) bleed and 21 had gastrointestinal (GI) bleed (two had both IA and GI bleed). Clinical, biochemical and tumour characteristics were analysed to identify factors influencing bleeding complications. RESULTS: The median time to presentation was 4.5 days (0-21 days). Serum bilirubin (P = 0.000, OR: 1.090) and pancreaticojejunostomy (PJ) leak (P = 0.009, OR: 3.174) were significant independent factors predicting bleeding complications. Forty-three per cent of patients each had early bleed (<48 h after PD) or delayed bleed (7 days after PD). Comparison of early and late bleeds showed that IA bleed (P = 0.02) presented as early bleeds. Male sex (P = 0.00) longer duration of jaundice (P = 0.02), PJ leak (P = 0.001), HJ leak (P = 0.001), duct to mucosa type of PJ anastomosis (P = 0.03) and IA abscess (P = 0.00) were associated with a significantly higher incidence of late bleeds. Overall mortality after PD was 9.6% with 34% and 3% in bleeders and non-bleeders, respectively. Septicaemia (P = 0.01, OR: 5.49), and acute renal failure (P = 0.01) were associated with increased mortality. CONCLUSIONS: Bleeding complications following PD were seen in one-fifth of patients and were associated with high mortality. Serum bilirubin levels and PJ leak were significant factors associated with bleeding complications. Septicaemia and acute renal failure were significant factors associated with mortality in the bleeders.     

机器人胰十二指肠切除术

解剖胰颈下缘肠系膜上静脉,离断胃结肠干,游离十二指肠及胰头,解剖下腔静脉、左肾静脉、肠系膜上动脉并清扫淋巴结。离断空肠、胰十二指肠下动静脉及钩突;解剖变异肝总动脉(起源于肠系膜上动脉)。解剖胰颈上缘门静脉及胆管、离断胃右和胃十二指肠动脉并清扫淋巴结;离断远端胃、胰颈、胆管、切除胆囊。消化道重建：胰管内置硅胶管行内引流;4－0普理灵缝扎胰腺断端,4－0普理灵连续缝合胰腺断端与空肠浆肌层。4－0普理灵行胆肠吻合。胃后壁与空肠用3－0普理灵行连续侧侧吻合。文氏孔及胰肠吻合前置引流管。病理：中分化腺癌,T₂N₁M₀。     

Pylorus-preserving pancreaticoduodenectomy versus conventional pancreaticoduodenectomy for pancreatic adenocarcinoma

Purpose  A few randomized controlled trials have questioned the justification of pylorus-preserving pancreaticoduodenectomy (PpPD) for pancreatic cancer and periampullary cancer. However, the characteristics of pancreatic cancer are remarkably different from those of other periampullary cancers, so the outcomes of PD and PpPD for pancreatic cancer are being re-evaluated. Methods  We studied retrospectively, 55 patients who underwent PpPD at Wakayama Medical University Hospital between 1999 and 2005, when PpPD was available, for pancreatic head adenocarcinoma. The main outcome measures were the postoperative complications, mortality, and survival of the patients who underwent PpPD vs. those who underwent conventional pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma. Results  There were no significant differences between PD and PpPD in postoperative complications; however, the incidences of delayed gastric emptying (DGE) differed significantly according to the type of reconstruction (P < 0.01). The body weight ratio and the incidence of diarrhea 6 months after PpPD and PD were similar. Patients treated with PD had a higher duodenal invasion rate than those treated with PpPD (P < 0.05); therefore, the cause-specific survival of the PpPD patients was better than that of the PD patients (P < 0.05). Conclusion  The surgical outcomes and incidence of postoperative complications in this series suggest that PpPD is an appropriate surgical procedure for pancreatic adenocarcinoma.