慢性钙化性胰腺炎的分型与手术治疗

目的探讨慢性钙化性胰腺炎的分型与手术治疗。方法采用回顾性描述性研究方法。收集2015年1月至2019年12月湖南省人民医院收治的121例慢性钙化性胰腺炎患者的临床资料;男99例,女22例;中位年龄为43岁,年龄范围为10~78岁。Ⅰ型慢性钙化性胰腺炎选择行胰十二指肠切除术、保留十二指肠胰头全切除术、保留十二指肠胰头勺式切除术,合并胰周假性囊肿行假性囊肿外引流术。Ⅱ型慢性钙化性胰腺炎选择行胰体尾+脾切除术、胰管切开取石+胰管空肠Roux-en-Y吻合术。Ⅲ型慢性钙化性胰腺炎选择行胰十二指肠切除术、保留十二指肠胰头勺式切除术,合并胰周假性囊肿行假性囊肿外引流术。Ⅳ型慢性钙化性胰腺炎行胰管盆式内引流术。观察指标:(1)手术情况。(2)术后情况。(3)随访情况。采用门诊和电话方式进行随访,了解患者术后疼痛复发或再发胰腺炎、血糖情况、新发糖尿病及腹泻。随访时间截至2020年1月。正态分布的计量资料以±s表示;偏态分布的计量资料以M(范围)表示。计数资料以绝对数表示。结果(1)手术情况:48例Ⅰ型慢性钙化性胰腺炎患者中,15例行胰十二指肠切除术,手术时间为(6.8±1.9)h,术中出血量为(398±110)mL;8例因胰管不扩张行保留十二指肠胰头全切除术,手术时间为(3.7±0.8)h,术中出血量为(137±62)mL;25例胰管扩张均行保留十二指肠胰头勺式切除术,手术时间为(3.9±1.5)h,术中出血量为(123±58)mL。8例Ⅱ型慢性钙化性胰腺炎患者中,2例行胰体尾+脾切除术,平均手术时间为5.1 h,平均术中出血量为200 mL;6例行胰管切开取石+胰管空肠Roux-en-Y吻合术,手术时间为(2.7±0.8)h,术中出血量为(145±39)mL。49例Ⅲ型慢性钙化性胰腺炎患者,4例行胰十二指肠切除术,手术时间为(7.2±1.4)h,术中出血量为(415±98)mL;45例因胰管扩张行保留十二指肠胰头勺式切除术,手术时间为(4.3±1.1)h,术中出血量为(135±47)mL。16例Ⅳ型慢性钙化性胰腺炎患者均行胰管盆式内引流术,手术时间为(3.3±1.3)h,术中出血量为(150±27)mL。(2)术后情况:48例Ⅰ型慢性钙化性胰腺炎患者中,15例行胰十二指肠切除术患者术后首次肛门排气时间、进食流质食物时间、住院时间分别为(2.9±1.1)d、(3.5±1.1)d、(14.8±2.7)d;术后3例发生并发症,其中2例发生消化道出血(1例胃镜下止血后痊愈,1例经介入治疗后痊愈),1例发生A级胰瘘,延迟拔管后愈合,无胆瘘发生。8例行保留十二指肠胰头全切除术患者上述指标分别为(2.0±0.5)d、(2.5±0.4)d、(9.5±2.5)d;术后1例发生A级胰瘘,延迟拔管后胰瘘愈合。25例行保留十二指肠胰头勺式切除术患者上述指标分别为(2.4±0.8)d、(2.5±1.3)d、(9.8±3.1)d;1例发生消化道出血,经介入治疗后痊愈,1例发生A级胰瘘,延迟拔管后愈合。8例Ⅱ型慢性钙化性胰腺炎患者中,2例行胰体尾+脾切除术患者术后平均首次肛门排气时间、平均进食流质食物时间、平均住院时间分别为3.0 d、3.5 d、14.0 d;围术期未出现任何并发症。6例行胰管切开取石+胰管空肠Roux-en-Y吻合术患者术后首次肛门排气时间、进食流质食物时间、住院时间分别为(2.5±0.5)d、(2.5±0.7)d、(8.5±1.5)d;术后2例发生A级胰瘘,延迟拔管后胰瘘愈合。49例Ⅲ型慢性钙化性胰腺炎患者中,4例行胰十二指肠切除术患者术后首次肛门排气时间、进食流质食物时间、住院时间分别为(3.2±0.8)d、(4.1±1.2)d、(15.3±2.4)d;术后1例发生A级胰瘘,延迟拔管后愈合,无出血、胆瘘发生。45例行保留十二指肠胰头勺式切除术患者上述指标分别为(2.5±1.6)d、(2.8±0.9)d、(10.1±2.8)d;术后1例发生胰肠吻合口出血,再次手术后愈合,1例发生A级胰瘘,延迟拔管后愈合,1例发生B级胰瘘,予以穿刺置管、反复冲洗后愈合。16例Ⅳ型慢性钙化性胰腺炎行胰管盆式内引流术患者术后首次肛门排气时间、进食流质食物时间、住院时间分别为(2.6±0.7)d、(3.3±0.5)d、(10.4±3.0)d;术后1例发生腹腔内少量出血,表现为桥襻引流管引流少量暗红色液体,予以去甲肾上腺素氯化钠溶液冲洗后愈合。(3)随访情况:121例患者中,113例(Ⅰ型44例、Ⅱ型7例、Ⅲ型46例、Ⅳ型16例)获得随访,随访时间为3~58个月,平均随访时间为34个月。随访期间13例(Ⅰ型5例、Ⅱ型1例、Ⅲ型6例、Ⅳ型1例)术后疼痛复发或再发胰腺炎,55例(Ⅰ型15例、Ⅲ型40例)腹痛明显改善,45例(Ⅰ型24例、Ⅱ型6例、Ⅳ型15例)未诉腹痛。37例(Ⅰ型13例、Ⅱ型2例、Ⅲ型17例、Ⅳ型5例)合并糖尿病患者中,20例(Ⅰ型6例、Ⅱ型2例、Ⅲ型12例)血糖恢复正常,17例(Ⅰ型7例、Ⅲ型5例、Ⅳ型5例)血糖需要药物控制;术后新增5例(Ⅰ型4例、Ⅲ型1例)糖尿病患者。3例(Ⅱ型1例、Ⅲ型2例)患者术后发生腹泻。2例Ⅲ型患者死亡,其中1例行胰十二指肠切除术后18个月因胰腺癌死亡,1例行保留胰十二指肠勺式切除术后5个月因再发重症急性胰腺炎死亡。结论慢性钙化性胰腺炎为良性病变,治疗应尽量保留胰腺功能组织;不同类型的慢性钙化性胰腺炎应选择不同的手术方式。     

Psychosocial factors and surgical outcomes: an evidence-based literature review

The influence of psychosocial factors on clinical outcomes after surgery has been investigated in several studies. This review is limited to surgical outcomes studies published between 1990 and 2004 that include (1) psychosocial variables (eg, depression, social support) as predictors of outcome and that focus on (2) clinical outcomes (eg, postoperative pain, functional recovery) using (3) specific multivariate analytic techniques with (4) relevant clinical variables (eg, presurgical health status) included as covariates. Twenty-nine studies met these criteria. Results indicate that psychosocial factors play a significant role in recovery and are predictive of surgical outcome, even after accounting for known clinical factors. Attitudinal and mood factors were strongly predictive; personality factors were least predictive. The results suggest that preoperative consideration of attitudinal and mood factors will assist the surgeon in estimating both the speed and extent of postoperative recovery.     

Lateral lumbar corpectomy: Indications and surgical technique with review of the literature

Lumbar corpectomy is an effective surgical option for various pathologies of the lumbar spine including trauma with neurologic deficit, infection, tumor, and deformity correction. Lumbar corpectomy can be accomplished through various surgical approaches including anterior, posterior, and more recently lateral. Each approach comes with its own risks and benefits and is often dictated based on the pathology that needs to be addressed, as well as surgeon comfort and training. The present paper focuses on indications and surgical technique of lateral lumbar corpectomy, with a review of the current literature.     

Necrotizing pancreatitis: Indications for surgery and surgical techniques

The term, “acute pancreatitis”, covers in terms of clinical, pathological, biochemical and bacteriological data, different entities in regard to the natural course of the disease. Interstitial edematous pancreatitis and necrotizing pancreatitis are the most frequent clinical manifestations; pancreatic abscess and postacute pseudocyst are late complications, mostly of necrotizing pancreatitis, developing after 3–5 weeks. The first choice of treatment is non-surgical management, even in patients with a severe complicated course of the disease. Patients who develop surgical acute abdomen, clinical sepsis syndrome, shock syndrome, or a severe type of mechanical or adynamic ileus must be treated surgically. Patients who do not respond to maximum intensive care measures for pulmonary, renal, cardiocirculatory, and metabolic dysfunction are candidates for surgical treatment, despite the possibility of sterile necrosis causing systemic complications. Surgical treatment is indicated in patients with infected necrosis, debridement and continuous closed lavage or open packing with re-operation being the most accepted treatment protoclos. When necrosectomy/debridement plus closed postoperative lavage was employed as a standard surgical treatment, hospital mortality was less than 20% in patients with infected necrosis as well as those with sterile necrosis. In pancreatic abscess and postacute pseudocyst, the treatment of first choice is intervention via ultrasound- or CT-guided percutaneous puncture and drainage of the abscess cavity. However, the majority of patients with a pancreatic abscess, treated interventionally, are candidates for a surgical drainage procedure because the interventional drainage fails to control the sepsis rapidly.     

Graft pancreatitis: literature review

Graft pancreatitis is an inflammatory disease leading to autodigestion of the gland. The failure of the pancreatic graft can be attributed to immunological or nonimmunological causes. It consists of a premature activation of pancreatic proenzymes. When complications such as bleeding or leaks have already occurred, surgical correction should be considered. The aim of this review is to draw the attention of surgeons to the complications that can easily be avoided.     

Observations and surgical management of chronic pancreatitis in the British Isles: A review of the twentieth century

Chronic pancreatitis was a recognized clinical entity in the British Isles at the beginning of the twentieth century, but until little more than 30 years ago, it was considered to be a rare condition and received scant attention from British surgeons. During the second half of the twentieth century, the incidence of the disease in the British Isles has increased significantly and alcohol abuse has become, by far, the most important etiological factor. Per capita consumption of alcohol in the British Isles has increased very markedly in the past 30 years and alcohol abuse is becoming a major social problem, but, although chronic pancreatitis is more common now than it was 30 years ago, the increase in its incidence is a good deal less than might be expected. British surgeons are agreed that intractable pain is the cardinal indication for surgical intervention in chronic pancreatitis and success depends on selection of the operative procedure most appropriate to the pathological state of the pancreas and, in particular, of its ductal system. In recent years, British surgeons in highly specialized units have become more radical in their approach to the treatment of chronic pancreatitis with total pancreatectomy in selected patients currently being advised more frequently than in previous decades.

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Resumen La pancreatitis crónica ha sido una entidad clínica reconocida en las Islas Británicas desde los comienzos del siglo veinte, pero hasta hace un poco más de 30 años era considerada como una enfermedad rara a la cual poca atención prestaban los cirujanos británicos. En el curso de la segunda mitad del siglo veinte la incidencia de esta enfermedad ha aumentado en las Islas Británicas en forma significativa y el abuso del alcohol ha venido a convertirse en el factor etiológico de mayor importancia. El consumo per capita de alcohol ha aumentado en las Islas Británicas marcadamente en los últimos 30 años y el abuso del alcohol representa un problema social mayor; sin embargo, aunque la pancreatitis crónica es actualmente más frecuente que hace 30 años, el incremento en su incidencia es considerablemente menor de lo que podría esperarse. Los cirujanos británicos están de acuerdo en que el dolor es la indicación principal para la intervention quinirgica en la pancratitis crónica y que el éxito depende de la selección del procedimiento operatorio según el estado del páncreas y en particular de su sistema ductal. En los años más recientes los cirujanos británicos, en instituciones altamente especializadas, han venido a ser más radicales en cuanto al tratamiento de la pancreatitis crónica y la pancreatectomía total, para pacientes seleccionados, es recomendada con mayor frecuencia que hace unos anos.

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Résumé On a reconnu la pancréatite chronique comme entité clinique dans les Iles Britanniques dès le début du XXe siècle mais 30 ans en arrière on la considérait encore comme rare et elle n'avait pas attiré l'attention des chirurgiens britanniques. Au cours de la 2e moitié du XXe siècle, l'incidence de las pancréatite chronique aux Iles Britanniques a augmenté de façon significative; l'alcoolisme en est la cause la plus répandue. La consommation d'alcool a considérablement augmenté depuis 30 ans et l'alcoolisme devient un problème social inquiétant. Pourtant, même si la pancréatite chronique est plus fréquente qu'il y a 30 ans, on aurait pu s'attendre à pire. Les chirurgiens britanniques s'accordent pour dire que l'indication chirurgicale principale de pancréatite chronique est la douleur invétérée. Le succès dépend de la sélection du procédé le mieux adapté à l'état pathologique du pancréas et en particulier du système canalaire. Ces dernières années, les chirurgiens britanniques dans les unités spécialisées ont adopté une attitude plus radicale dans le traitement de la pancréatite chronique; on a vu ainsi augmenter, dans les cas bien sélectionnés, la fréquence de la pancréatectomie totale.

     

Type IVa choledochal cysts: surgical management and literature review.

Type IVa choledochal cysts with cylindrical dilatation of the intrahepatic ducts constitute a relatively less recognized variety of choledochal cysts, and differ from cystic dilatation of intrahepatic ducts in their clinical manifestations and response to treatment. Five patients with type IVa choledochal cysts and cylindrical dilatation of major intrahepatic ducts who underwent cyst excision and Roux-en-Y hepaticojejunostomy are reported. The duration of symptoms was less than 1 year in all patients. Palpable abdominal mass and abdominal pain were present in 3 patients. The traid of jaundice, abdominal pain and mass was present in only 1 patient. The intrahepatic dilatation regressed after excision of the extrahepatic cyst just below the hilum of the liver. The surgical technique is described and the need for excision of the cyst is emphasized.     

Robotic surgical management of endometrial cancer in octogenarians and nonagenarians: analysis of perioperative outcomes and review of the literature

The primary aim of this article is to report the outcomes of octogenarians and nonagenarians who have undergone robotic surgery for endometrial cancer. A multi-institutional research consortium was created to evaluate the utility of robotics for gynecologic surgery (benign and malignant). IRB approval was obtained at each institution. A multi-institutional HIPPA compliant database was then created and analyzed for all patients that underwent robotic-assisted surgery with staging for endometrial cancer between the April 2003 and January 2009. In total, 395 patients were identified. A subset of patients between the ages of 80 and 95 years were then identified and analyzed for demographic data and perioperative outcomes. Twenty-seven patients in this age group were identified who underwent robotic-assisted hysterectomy and staging. The median age was 84, and median body mass index was 28. Comorbidities such as diabetes mellitus and hypertension were identified in 22 and 74% of patients, respectively. Over one-half (56%) of the patients reported a prior abdominal surgery. Final pathological analysis demonstrated that 88% of all patients had either Stage I or II disease. The median operative time was 192 min. The median estimated blood loss was 50 cc, and the median lymph node count was 16. The median hospital stay was 1.0 day. The overall intraoperative and postoperative complication rate was 7.4 and 33%, respectively. No patient received a blood transfusion. There was one conversion to laparotomy (3.7%). A comparison of the outcomes of the elderly cohort to those of all patients in the database (control group) revealed that there was no statistically significant difference between the groups in terms of operative time, blood loss, hospital stay, nodal yield, or conversion rate. Intraoperative complications were statistically similar between the groups; however, postoperative complications were significantly higher in the elderly cohort. We conclude that robotic surgery is safe, feasible, and expands surgical options for octogenarians and nonagenarians diagnosed with endometrial cancer. Age should not be considered a contraindication for robotic surgical management of patients with endometrial cancer.     

Longitudinal Wirsung gastrostomy in the surgical management of chronic pancreatitis

The longitudinal pancreatico-jejunostomy is a commonly used procedure in the management of the chronic pancreatitis with dilated pancreatic duct (Wirsung), however the drainage of the dilated pancreatic duct is realizable with longitudinal Wirsungo-gastrostomy to. We present one clinical case of chronic pancreatitis with dilated pancreatic duct, where the pancreatic drainage was realized with an anastomosis between the dilated Wirsung duct and the posterior wall of the stomach (longitudinal Wirsungo-gastrostomy). RESULTS: One year after Wirsungo-gastrostomy (postoperative reevaluation of the patient) a general well condition without subjective accuses, ponderal increase and stabile glucidic metabolism was found. CONCLUSION: The Wirsungo-gastrostomy could represent an alternative procedure in the management of the chronic pancreatitis with dilated pancreatic duct.     

慢性病管理质量评价指标体系的研究进展

对慢性病管理质量评价指标体系概念、国内外慢性病管理质量评价指标体系的研究现状进行综述,总结现有慢性病管理质量评价指标体系的特点及不足,以期为我国慢性病管理质量评价指标的进一步研究提供相关信息。     

Chronic pancreatitis: modern surgical management

Introduction  

Chronic pancreatitis (CP) is a disease with enormous social and personal impact. It is most commonly caused by the abuse of alcohol combined with nicotine. CP is usually characterised by an inflammatory mass located in the pancreatic head. Its natural course is characterised by persistent or recurrent painful attacks as well as progressive loss of pancreatic function due to fibrosis of the parenchyma with consecutive endocrine and exocrine insufficiency.     

Surgical management of adult spinal deformity: Indications,surgical outcomes,and health-related quality of life

Due to the aging population, as well as advancements in surgical and anesthetic technique, the rate of surgical intervention for adult scoliosis has increased. The consequences of spinal deformity regarding pain, disability, health-related quality of life, and mental health, as well as the risks and complications of surgical management can be substantial and wide reaching. Significant attention has been directed in describing which patients benefit from operative treatment and validating methods in assessing the postoperative outcomes (pain, function, self-image, mental health, and general health). In this context, the purpose of this article is to discuss the indications, outcomes, and the quality-of-life changes following surgical intervention for adult degenerative scoliosis.     

Desmoplastic fibroma of the jaws: surgical management and review of the literature

Desmoplastic fibroma of the jaws is a rare and locally aggressive tumor that has a high rate of recurrence. The cellularity, extent of the tumor, and completeness of the local excision may be factors in its tendency to recur. We reviewed the literature in an attempt to determine if there was any correlation between the histologic features of a desmoplastic fibroma, or the surgical procedure utilized, and the tumor's recurrence. From the information gathered, it was found that a more cellular desmoplastic fibroma or inadequate surgical procedure may be factors that contribute to the recurrence of the tumor. A case report of desmoplastic fibroma of the mandible in a 9-year-old child is presented. The tumor, which displayed areas of moderate cellularity, was resected via a partial hemimandibulectomy. There has been no recurrence to date (46 months).     

Open lumbar laminectomy: Indications,surgical techniques,and outcomes

Lumbar spinal stenosis is the most common indication for lumbar surgery. The objective of this article is to review the efficacy of open laminectomy as a treatment option for patients who fail conservative management. Identification of appropriate surgical candidates (those with clinical findings supported by imaging) and adequate surgical decompression affect ultimate outcomes. Review of current surgical techniques and documented outcomes indicates that laminectomy remains a viable treatment option in treating symptomatic stenosis.