远端胰腺切除手术方法改进

目的　降低远端胰腺切除术后胰漏的发生率。方法　对 3 4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 ,断面缝扎止血 ,联合应用带血管蒂胃浆肌瓣或空肠浆肌瓣与纤维蛋白胶粘合缝闭胰腺残端。结果　 3 4例患者均未发生胰漏、腹腔感染、脓肿及胰腺假性囊肿。结论　带血管蒂胃、空肠浆肌瓣有利于促进胰断面愈合 ,联合应用纤维蛋白胶能有效地预防胰漏。     

近端胃切除浆肌瓣吻合的历史及现状

随着早期胃上部癌及食管胃结合部腺癌的检出率逐渐增高,近端胃切除术的安全性得到验证,保功能的近端胃切除术逐步得到广泛应用。然而,近端胃切除破坏了食管胃结合部的正常解剖结构,导致患者术后胃食管反流症状较重,严重影响生活质量。在各种抗反流术式中,重建"贲门-阀门"因与正常抗反流原理类似,一直是相关学者探索的热点。经过多年的发...     

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     

胰腺切除与胰腺外伤手术胰漏的诊断及防治措施

虽然生长抑素的应用对预防胰漏发挥了重要作用,但胰漏仍然是临床常见的致死性并发症.虽然有作者提出不同的胰肠吻合方式术后胰漏的差异无统计学意义[1],但积极探索预防胰漏的有效方法仍然是临床医生面临的重要课题.近年来,在强调加强围手术期处理、精细化手术操作及充分有效引流等措施的同时,在胰腺切除及胰腺外伤修复手术中采用了一系列新方法,有助于降低胰漏发生率,现就具体措施及方案作一介绍.     

应用带血管蒂空肠浆肌片移植修补食管破裂

我院自1994年以来，应用带血管蒂空肠浆肌片移植修补食管破裂患者21例，获得了满意的效果，现报告如下。手术方法：(1)切口选择：根据食管碘油造影所见食管破裂的位置，结合胸部X线检查确定切口。左侧一般选择后外侧标准切口，右侧则需选择经胸腹二切口。(2)彻底清创：首先清除胸腔内积液及食管裂口外溢污染物。     

带血管蒂的趾短伸肌肌瓣治疗跗跖骨慢性骨髓炎

慢性骨髓炎的病理比较复杂,可导致炎症持续或反复的发作,是临床治疗的难点。作者采用带血管蒂的趾短伸肌肌瓣治疗跗、跖骨骨髓炎4例,取得了满意效果。1 临床资料 本组男3例,女1例;年龄16～50岁;病史6个月～24年,均系外伤后感染所致;部位:第三跖骨1例,骰骨2例,第三楔骨1例;4例均有窦道形成,清创后组织缺损1.5 cm2～     

带腓血管蒂腓骨肌复合瓣的临床应用

肢体因肿瘤切除或外伤所致大段骨与肌组织联合缺损者,如能以带血供的骨肌复合瓣,一次完成骨和软组织缺损的修复并重建其功能,这样既缩短了疗程,又减轻了患者的痛苦和经济负担,乃最佳选择.如上供区,当以带腓血管腓骨肌复合瓣为首选,因可获得充分长度的骨与肌组织.作为腓骨肌复合瓣的肌肉必须与腓骨相邻,并能由腓动脉供血者,而且该肌肉被切取后,其原有功能可由其他肌肉部分代偿之.符合上述条件者有长屈肌、腓骨长肌和比目鱼肌外侧半[1-3].现就本复合瓣的解剖与临床应用要点分述如下.     

胰腺中段切除——胰瘘和胰腺残端的处理

胰腺中段切除（MP,middle pancreatectomy）是较胰十二指肠切除术和远端胰腺切除术手术范围缩小的一种胰腺节段切除手术,旨在尽可能保留正常的胰腺组织,     

移植带血管蒂小肠浆肌片修补食管破裂

食管破裂的手术治疗是比较困难的，术后再穿孔率高达２７．２％。我们采用带血管蒂小肠浆肌片修补食管破裂，获得满意效果。本组５例病情各异的食管破裂病人采用此术式均获痊愈。带血管蒂小肠浆肌片愈着能力好、抗感染能力强、材料充足、取材方便、作者对肠片制作方法；、修补步骤作了介绍，并对些手术的优点及适应证进行了讨论。     

带血管蒂的趾短伸肌瓣的临床应用解剖研究

作者对130例小腿标本进行了趾短伸肌瓣及相应血供的应用解剖研究,发现下列血管是恒定的:足背动脉(管经2.95mm±0.32);腓动脉穿支(0.87mm±0.34);外踝前动脉(1.02mm±0.28);支配趾短伸肌瓣的外侧动脉弓(0.97mm±1.9);跗外侧动脉(1.50mm±0.22);外侧动脉弓(0.97mm±1.9)和跗外侧动脉(1.50mm+1.22)形成的血管网,设计了带血管蒂的趾短伸肌瓣,并于1995年应用于临床,修复足部软组织缺损。本研究提示:该肌瓣具有知名血管,解剖位置恒定,血运丰富,技术操作简便,成活率高,是修复足部软组织缺损的一种理想方法。     

Closure of the distal pancreatic stump with a seromuscular flap

We describe herein our new method for transecting the pancreas and closing its stump in distal pancreatectomy, devised to decrease the risk of pancreatic fistula formation. With this technique, the pancreas is transected in such a way that a convex stump is left, whereby the pancreatic secretions from the parenchyma near the pancreatic stump are fully drained into the main pancreatic duct. A pedicled seromuscular flap of the stomach or jejunum is then used to cover the cut surface of the pancreas. This new technique provides tight closure of the pancreatic stump after distal pancreatectomy.     

Stump closure of a thick pancreas using stapler closure increases pancreatic fistula after distal pancreatectomy

Background

The appropriate surgical stump closure after distal pancreatectomy (DP) is still controversial. This study investigated the benefits and risks of stapler closure during DP.

Methods

The risk factors of pancreatic fistulas were investigated in 122 DPs among 3 types of stump closure: hand-sewn suture (n = 32), bipolar scissors (n = 45), and stapler closure (n = 45).

Results

There was no significant difference in the incidence of pancreatic fistula between the 3 types of stump closure (hand-sewn suture [44%] vs bipolar scissors [37.7%] vs stapler closure [35.5%]). By using receiver operating characteristics curves, 12 mm was the best cutoff value of the thickness of the pancreas for pancreatic fistulas after DP using stapler closure. Three factors (ie, male sex, body mass index >25 kg/m², and stapler closure) were independent risk factors of pancreatic fistulas after DP with a pancreas thicker than 12 mm.

Conclusions

A pancreas thicker than 12 mm significantly increased the incidence of pancreatic fistulas after DP using stapler closure.     

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...     

The VIO soft-coagulation system can prevent pancreatic fistula following pancreatectomy

BACKGROUND/PURPOSE: The VIO soft-coagulation system (SC) is a new device for tissue coagulation. We hypothesized that this device would be an effective tool for sealing small pancreatic ducts, thus reducing pancreatic fistula following pancreatectomy. METHODS: To confirm whether the SC could be used to seal small pancreatic ducts, we measured the burst pressure in sealed ducts in mongrel dogs. Eight dogs underwent distal pancreatectomy, with the remnant stump coagulated by using the SC. The animals were necropsied on postoperative day 10. In a clinical trial, 11 patients who underwent pancreatoduodenectomy with SC treatment (SC group), and 24 patients who underwent pancreatoduodenectomy without SC treatment (non-SC group) were compared. RESULTS: In the experimental study, the burst-pressure test revealed that the SC had efficiently sealed the small pancreatic ducts. Histological examination revealed completely obstructed pancreatic ductal structures, ranging from large pancreatic ducts (diameter, 500 mum) to microscopic ducts. No pancreatic leakage was observed following distal pancreatectomy without main pancreatic duct (MPD) suturing in dogs that had an MPD diameter of less than 500 mum. In the clinical trial, pancreatic fistula developed in only one patient (9.1%) in the SC group, but a pancreatic fistula developed in five patients (20.8%) in the non-SC group. CONCLUSIONS: This novel technique using the SC is an effective procedure for preventing the development of pancreatic fistula following pancreatectomy.     

Surgical management for the prevention of pancreatic fistula following distal pancreatectomy

Although the mortality rate related to pancreatic surgery has been reduced recently, the postoperative morbidity is still high, because of various complications. Pancreatic fistula is one of the most common complications following distal pancreatectomy, and is generally hard to cure. Several surgical techniques and devices, such as the use of fibrin-glue sealing, stapler closure, an ultrasonic dissector, or an ultrasonically activated scalpel have been advocated to prevent pancreatic fistula. In the present review we provide an overview of several devices used for the prevention of pancreatic fistula following distal pancreatectomy.     

Preoperative endoscopic pancreatic stenting for prophylaxis of pancreatic fistula development after distal pancreatectomy

BACKGROUND AND OBJECTIVE: Pancreatic fistula is a common complication of distal pancreatectomy (DP). Although various surgical procedures have been proposed for DP in an attempt to decrease the high incidence of pancreatic fistula, the prevention of pancreatic fistula remains a major problem in DP. Endoscopic pancreatic stenting for the treatment or prophylaxis of such a fistula has been rarely described. METHODS: We reviewed 9 patients who underwent preoperative endoscopic pancreatic stenting for the prophylaxis of pancreatic fistula development after DP. RESULTS: Preoperative endoscopic pancreatic stenting was successfully performed with a 7F stent in all the 9 patients. Two patients, both with intraductal papillary mucinous tumor, developed mild acute pancreatitis after the stent placement. None of the 9 patients developed pancreatic fistula. The pancreatic stent was removed from 8 to 28 days (mean 11 days) postoperatively. CONCLUSIONS: Preoperative endoscopic pancreatic stenting may be an effective prophylactic measure against pancreatic fistula development following DP in selected patients.     

Stapler vs suture closure of pancreatic remnant after distal pancreatectomy: a meta-analysis

Background

Suture closure and stapler closure of the pancreatic remnant after distal pancreatectomy are the techniques used most often. The ideal choice remains a matter of debate.

Methods

Five bibliographic databases covering 1970 to July 2009 were searched.

Results

Sixteen articles met the inclusion criteria. Stapler closure was performed in 671 patients, while suture closure was conducted in 1,615 patients. The pancreatic fistula rate ranged from 0% to 40.0% for stapler closure of the pancreatic stump and from 9.3% to 45.7% for the suture closure technique. There were no significant difference between the stapler and suture closure groups with respect to the pancreatic fistula formation rate (22.1% vs 31.2%; odds ratio, .85; 95% confidence interval, .66-1.08), although there was a trend toward favoring stapler closure. In 4 studies including 437 patients, stapler closure was associated with a trend (not statistically significant) toward a reduction in intra-abdominal abscess (odds ratio, .53; 95% confidence interval, .24-1.15).

Conclusions

No significant differences occur between suture and stapler closure with respect to the pancreatic fistula or intra-abdominal abscess after distal pancreatectomy, though there is a trend favoring stapler closure.     

胰体尾切除术后胰瘘的相关性因素分析

目的探讨胰体尾切除术后胰瘘发生的相关性因素。方法回顾性总结了82例行胰体尾切除的患者术前、术中操作以及术后并发症和死亡率发生的情况,并分析和术后胰瘘发生的相关性因素。结果术后有36名患者出现并发症占43.9%（36/82）。其中胰瘘是最常见的并发症,发生率为37.8%（31/82）。其中是否结扎主胰管和术后胰瘘的发生具有明显的相关性（P=0.010）,而性别、年龄、是否并存糖尿病、胰腺的质地、术中失血量、是否预防性应用奥曲肽、是否用生物胶封闭胰腺断端、术后低蛋白血症和是否联合其它脏器切除均和胰瘘的发生无明显的相关性。结论胰体尾切除术后最常见的并发症仍然是胰瘘,术中单独结扎胰管可以减少胰瘘的发生率。     

Laparoscopic distal pancreatectomy for retrieval of a proximally migrated pancreatic stent

Background and Objectives:

Pancreatic stents placed by ERCP are common in the treatment of benign and malignant pancreatic and biliary disease. Proximal migration of the stent into the duct occurs in 2% to 5% of cases, often resulting in pancreatitis. Although technically challenging, proximally migrated pancreatic stents can usually be removed endoscopically. Little has been written about surgical management of irretrievable stents, and no reports of laparoscopic approaches were found.

Methods:

We report on a case of unsuccessful ERCP retrieval of a proximally migrated pancreatic stent.

Results:

Using laparoscopy, we exposed the pancreas and used ultrasound to locate the distal end of the stent. We incised the pancreas at that point, removed the stent, and completed the distal pancreatectomy with splenectomy.

Discussion:

Several case series on retrieval of migrated pancreatic stents are reviewed.

Conclusion:

Although ERCP is often successful and sometimes requires several attempts, we recommend surgical consultation after the first or second failed ERCP.     

Transection using bipolar scissors reduces pancreatic fistula after distal pancreatectomy

BACKGROUND/PURPOSE: Various methods and technique for treating the surgical stump of the remnant pancreas have been reported to reduce pancreatic fistula after distal pancreatectomy (DP). However, appropriate surgical stump closure after DP is still controversial. We aimed to clarify whether using bipolar scissors in DP reduces pancreatic fistula compared to hand-sewn suture of surgical stump closure. METHODS: Between January 1989 and December 2005, handsewn suture of surgical stump closure was performed (n = 49), and bipolar scissors was prospectively performed between January 2006 and July 2007 (n = 26). RESULTS: The overall rate of pancreatic fistula after DP was 22 patients (29%). There were significant differences between the hand-sewn suture group (41%) and bipolar scissors group (8%) concerning pancreatic fistula (P = 0.0164). A multivariate logistic regression analysis revealed that two factors, soft pancreas and hand-sewn suture compared to bipolar scissors, were independent risk factors of pancreatic fistula after DP (P = 0.011 and 0.0361, respectively). CONCLUSIONS: Bipolar scissors for transection of the pancreas is a useful device to reduce pancreatic fistula after DP.