改良胰十二指肠切除术185例手术体会

摘 要：［目的］ 探讨胰十二指肠切除术中胰腺空肠端侧吻合技术。［方法］ 回顾性分析185例胰十二指肠切除术行胰腺空肠端侧吻合患者的临床资料,结合术后并发症及死亡率、住院时间等,探讨胰腺空肠端侧吻合技术。［结果］ 根据患者胰腺的情况如质地、厚度、胰管直径、胰管后壁胰腺组织的厚度、有无炎症,结合空肠的直径、空肠壁的厚度选择胰管空肠黏膜—黏膜吻合、端侧套入式吻合等不同的吻合方式。术中胰肠重新吻合9例。术后胰瘘11例、胆瘘4例、死亡4例。胰管空肠黏膜—黏膜吻合时间较长。［结论］ 根据胰腺和空肠的情况进行个体化的胰管空肠黏膜—黏膜吻合、端侧套入式吻合等不同的吻合是胰十二指肠切除术中胰腺空肠吻合的理想选择。     

人工乳头植入式胰-空肠吻合的初步应用(附10例临床应用体会)

背景与目的:胰腺空肠吻合口是胰十二指肠切除术成败的关键,近年来虽然对胰肠吻合方式不断改进,但是胰瘘的发生率仍然较高.本文介绍一种改良的胰-空肠端侧吻合方法.方法:胰腺残端术中冰冻切片证实切缘无肿瘤残留,游离远端胰腺2.0～2.5 cm,沿主胰管周围0.2～0.3 cm处呈“0”型或“C”型切开胰腺组织,深约0.6～0.8 cm.鱼口状(“V”型)切除主胰管两侧0.8～1.0 cm的残端胰腺组织后,内翻缝闭,使人工乳头呈“一头双肩”状凸出于胰腺残端.经横结肠系膜戳孔作结肠后人工乳头植入式胰-空肠吻合.结果:10例患者胰-空肠吻合时间为15～20 min,手术后检测引流液淀粉酶,无胰瘘、胆瘘及出血等并发症.术后6～9 d拔除引流管,术后平均住院天数为11 d.结论:人工乳头植入式胰-空肠吻合法简单易行,吻合可靠,术后恢复快,是一种新的安全有效的吻合方法.     

胰胃吻合术在胰十二指肠切除术中的应用

胰十二指肠切除术中采用胰胃吻合术作为消化道再建术式,临床应用取得满意疗效.手术方法:切除幽门侧胃1/3,依病灶情况切除部分胰腺,胰管内置入有侧孔之硅胶管作支架引流,残胃后壁横行切开,将胰断端引入胃内约1.5cm,缝合固定,胰管导管自胃前壁引出体外,胃空肠端端吻合、胆管空肠端侧吻合,胆管内置T管引流.本术式安全性高,并发症少,残存胰腺与胃后壁毗邻,易吻合;胰蛋白酶、糜蛋白酶在胃内低pH环境下以酶原形式存在,为吻合口愈合提供有利条件,且胰液可中和胃酸,防止吻合口溃疡发生.     

胰十二指肠切除术要点的探讨

目的探讨壶腹部周围癌施行胰十二指肠切除术（ＰＤＲ）过程中，如何减少术中大出血、提高手术切除率和预防胰瘘的发生。方法暴露门静脉和肠系膜上静脉，在胰钩状突切除胰腺时，采用边夹边切边缝扎的方法，使胰腺组织与门静脉、肠系膜上静脉之间的静脉短支得到良好缝扎。门静脉有浸润时，作门静脉部分切除后修补或门静脉端端吻合。行含肠系膜上静脉门静脉（ＳＭＰＶ）在内的ＰＤＲ。在胰肠对端吻合时，尽量使主胰管接近胰腺残端的中央，预防胰瘘发生。结果采用Ｍａｃｈａｄｏ法重建消化道２７例，无１例发生胰瘘和胆瘘。结论在ＰＤＲ过程中，防止术中大出血，根据门静脉是否有肿瘤浸润作相应的门静脉处理和Ｍａｃｈａｄｏ法重建消化道，能提高ＰＤＲ的切除率和提高患者的生存率和生活质量。     

改良胰腺空肠套入式吻合在胰十二指肠切除术中的应用

目的:比较在胰十二指肠切除术(PD)中,改良胰腺空肠套入式吻合与胰管空肠黏膜吻合两种胰肠吻合方式术后胰瘘等相关并发症的发生率.方法:回顾性分析2014年1月至2016年12月盛京医院胰腺内分泌外科实施的59例PD手术患者的临床资料,其中采用改良胰腺空肠套入式吻合35例,采用胰管空肠黏膜吻合24例,比较两组术后胰瘘等相关并发症的发生率.结果:比较改良胰腺空肠套入式吻合与胰管空肠黏膜吻合两种胰肠吻合方式,发现手术时间和术中出血比较无统计学差异;术后胰瘘等相关并发症指标、住院时间、死亡率等无统计学差异.结论:改良胰腺空肠套入式吻合与胰管空肠黏膜吻合相比,同样安全可靠,具有操作方便,易于掌握,胰肠吻合严密牢固的优点,尤其适用于胰管直径小的病人,值得临床应用.     

胰腺癌手术后早期并发症的防治

胰腺癌施行胰头十二指肠切除术后早期并发症除了一般腹部外科手术并发症外,主要有胰漏（瘘）、胆漏、出血以及胃排空障碍等。如何防治这些致命性的并发性,一直是腹部外科医生关注的热点。本文就作者近年来对上述各种并发症所采取的防治措施进行探讨。１　胰漏为了预防胰漏,文献中已出现２０余种方法,大体上包括胰腺残端结扎,胰管栓塞,胰空肠吻合和胰胃吻合等。胰管结扎方法简单,但胰漏发生率高达５０％,已淘汰不用。胰管栓塞带来长期胰外分泌不足,需要长期酶替代疗法,而且并非每个病人的胰断端均能找到胰管,因此,目前使用的单位…     

胰腺残端全缝闭child’s术式预防胰十二指肠切除术后胰瘘的探讨

本文报导自１９７０年１月至１９８９年１０月间５３例胰十二指肠切除术患者，手术均按ｃｈｉｌｄ’ｓ术式，所不同的是其中３３例（甲组）胰腺残端的处理是用间断术式全缝闭再与空肠对端套入，术后无胰瘘发生。而另２０例（乙组）系重建胰肠通道，术后胰瘘发生率１５％（３／２０例），胰瘘死亡率３３．３％（１／３例）。胰瘘发生率二组相比有显著差异，Ｘ２＝５．２４７，Ｐ＜０．０２５。全部病例术前、后均经血糖、血清淀粉酶、血浆蛋白、肝肾功能以及电解质等检测。甲组有１３例（３９．４％）经动态检测上述各项达一年，均无异常变化；有８例术后血清胰岛素检测均有正常范围。术后患者在生存期内均无明显营养物质的消化吸收障碍。因此，认为胰十二指肠切除术后采以胰腺残端全缝闭并与空肠对端套入ｃｈｉｌｄ’ｓ术式对防止胰瘘是一种简便、安全和有效的方法。     

胰十二指肠切除改良胰管空肠吻合预防胰瘘

目的：分析胰十二指肠切除术（PD）胰管空肠端侧粘膜对粘膜及胰管空肠套入式吻合方式,以其预防术后胰瘘发生。方法：2003年1月～2007年1月回顾性分析25例PD的临床资料,残胰的重建方式分别按胰管空肠粘膜对粘膜套入式端侧吻合,胰管支撑管胰液体外引流。结果：PD24例术后恢复顺利,未发生胰瘘;1例术后腹腔创面广泛渗血,多器官功能衰竭围手术期死亡,其余随访无远期并发症。结论：PD胰管空肠端侧粘膜对粘膜套入式吻合有明显避免胰瘘及并发症的发生,真正临床应用价值有待更大量的对照随机前瞻性大样本研究才能作出正确可靠的评价。     

残胰直接套入空肠吻合技术在胰十二指肠切除术中的临床应用研究

目的:总结和探讨胰十二指肠切除术后空肠非去黏膜化的胰- 肠直接套入吻合方法,并观察其术后发生胰瘘及对与该手术方式有关的并发症等资料进行分析。方法:2005年3 月至2009年6 月中山大学附属东华医院行胰十二指肠切除术21例,残胰游离3.0cm,距离残胰断端2.5～3.0cm行空肠全层与部分胰腺后壁组织间断缝合,将残胰套入空肠2.5～3.0cm,再按后壁缝合方法缝合前壁,在距离残胰断端1cm处用7 号丝线环绕空肠将残胰予以捆扎。结果:除1 例出现因残胰断端出血再次手术进行缝合止血外,全组患者术后恢复顺利,无1 例发生胰瘘或出现其他并发症。结论:胰腺质地和胰- 肠吻合方式虽是胰瘘并发症的主要因素,但也与手术者胰- 肠吻合操作技巧或熟练程度、围手术期的管理或治疗措施有关。采用残胰直接套入非去空肠黏膜化的胰- 肠吻合方法与目前任何其他胰-肠吻合方法比较均较为简单,有待于进一步探讨、总结和研究。      

全胃并尾侧半胰加脾切除时胰腺残端的处理（附26例报告）

本文报告我科近两年来对26例全胃并尾侧半胰加脾切除时胰腺残端的处理方法。首先确定胰腺的切断线,然后行垂直切除,遇索状管条用钳夹之,切断后再在胰腺断面中央仔细观察寻找主胰管用细丝线结扎之,继之将胰腺残端用粗丝线“8”字缝扎一道,结扎时松紧度要合适,以无活动性出血及胰液外漏为宜。作者采用以上措施,26例中无1例胰瘘发生。     

Pancreatic resections: early results and functional behaviour of the stapled pancreatic stump

Pancreaticoduodenectomy is the standard surgical treatment for patients with pancreatic head cancer. Morbidity and mortality rates following this procedure have constantly decreased over the past several years. Leakage of the pancreaticoenteric anastomosis is one of the most serious complications, often responsible for a fatal outcome. Several methods for the management of the pancreatic stump have been described in order to reduce the worrisome incidence of this complication, with variable results. In this series, the Authors review their experience of 75 pancreatic resections and analyze the early results and functional behaviour of 6 patients in which the pancreatic stump was stapled without pancreaticoenteric anastomosis.     

Laparoscopic pancreatoduodenectomy for a metastatic tumor in a portal annular pancreas

BackgroundPortal annular pancreas (PAP), also called circumportal pancreas, is a congenital pancreatic anomaly in which the portal and/or mesenteric veins are surrounded by pancreatic parenchyma [1,2]. Joseph et al. classified PAP into three types (according to the fusion pattern of the pancreatic parenchyma and ductal system [1]), each of which they subdivided (based on the relation to the portal confluence) into the suprasplenic, infrasplenic, and mixed type [1,3]. The most common type is IIIa [1,4], where the portal vein (suprasplenic) is encased by the uncinate process with an anteportal main pancreatic duct.MethodsThe patient was a 78-year-old woman who had undergone left nephrectomy for renal cell carcinoma five years prior. We performed laparoscopic pancreatoduodenectomy for a metastatic tumor of the head of a type IIIa PAP (Fig. 1). The anteportal pancreas was transected, and dissection was performed around the superior mesenteric artery using a right approach. The retroportal pancreas was transected using a linear stapler with bioabsorbable polyglycolic acid felt. We performed pancreatojejunostomy for the anteportal stump of the pancreas containing a main pancreatic duct; the retroportal stump was not reconstructed, because it had no major pancreatic ducts on preoperative imaging.ResultsThe operative time was 505 minutes, and the blood loss was 70 ml. The postoperative course was uneventful, and the patients was discharged on postoperative day 12.ConclusionLaparoscopic pancreatoduodenectomy was performed successfully in a patient with a type IIIa PAP. The retroportal pancreas can be transected using a linear stapler, without reconstruction.     

胰十二指肠切除联合血管重建治疗胰头、十二指肠恶性肿瘤

背景与目的：胰头癌、十二指肠癌的治疗，手术切除仍是唯一可能根治的有效方法。但临床确诊时，多数为晚期，常累及门静脉／肠系膜上静脉、下腔静脉即属手术禁忌症。本研究旨在探讨累及门静彬肠系膜上静脉、下腔静脉的胰头癌、十二指肠癌切除的处理方法，以提高切除率及生存率。方法：总结2002年2月-2005年6月5例联合血管重建胰十二指肠切除术的临床资料及经验，其中胰头癌合并门静脉／肠系膜上静脉切除人工血管重建3例，十二指肠癌合并下腔静脉切除人工血管重建2例。结果：本组病例无围手术期死亡。无人工血管感染、阻塞并发症。随访10个月死亡1例，24个月死亡1例，术后存活超过3年2例，超过4年1例。结论：对累及门静彬肠系膜上静脉、下腔静脉的胰头癌、十二指肠癌行胰十二指肠切除联合血管重建手术是安全的，可提高肿瘤切除率，延长患者生存时间。     

Radiofrequency-induced heating versus mechanical stapler for pancreatic stump closure: in vivo comparative study

Purpose: The aim of this study was to assess the capacity of two methods of surgical pancreatic stump closure in terms of reducing the risk of pancreatic fistula formation (POPF): radiofrequency-induced heating versus mechanical stapler. Materials and methods: Sixteen pigs underwent a laparoscopic transection of the neck of the pancreas. Pancreatic anastomosis was always avoided in order to work with an experimental model prone to POPF. Pancreatic stump closure was conducted either by stapler (ST group, n?=?8) or radiofrequency energy (RF group, n?=?8). Both groups were compared for incidence of POPF and histopathological alterations of the pancreatic remnant. Results: Six animals (75%) in the ST group and one (14%) in the RF group were diagnosed with POPF (p?=?0.019). One animal in the RF group and three animals in the ST group had a pseudocyst in close contact with both pancreas stumps. On day 30 post-operation (PO), almost complete atrophy of the exocrine distal pancreas was observed when the main pancreatic duct was efficiently sealed. Conclusions: Our findings suggest that RF-induced heating is more effective at closing the pancreatic stump than mechanical stapler and leads to the complete atrophy of the distal remnant pancreas.     

Higher frequency of ras oncogene activation in gastric stump carcinomas due to special conditions in the gastric remnant

Gastric stump carcinoma is now widely recognized to be due to special conditions in the gastric remnant. To examine whether the mechanism of carcinogenesis is different in gastric stump carcinoma from other gastric carcinoma, we analyzed ras mutation in 62 gastric carcinomas. The ras mutation frequency was 4/17 (23.5%) in stump carcinomas, 2/25 (8.0%) in other remnant carcinomas and 1/20 (5.0%) in proximal carcinomas. The mutation frequency in stump carcinomas was much higher than that in other gastric carcinomas. These results suggest that the mechanism of carcinogenesis in gastric stump carcinomas may be different from other gastric carcinomas.     

Extent of venous resection during pancreatectomy—finding the balance of technical possibility and feasibility

The improvement of effective multidrug agents has allowed more patients to undergo resection for pancreatic cancer (PC). In the conversion cases of initially unresectable PC after induction chemotherapy, pancreatic surgeons often encounter challenging vein resections cases such as those of long-segment portal vein (PV)/superior mesenteric vein (SMV) encasement or occlusion of the distal (caudal) SMV. Given the lack of consensus for the optimal approach for major vein resections and reconstructions in these situations, this review summarizes the literature on this topic and provides the best currently available approaches for challenging vein reconstruction cases. For long-segment PV/SMV encasement, tips for direct end-to-end anastomosis without grafts and the splenic vein (SpV) reconstruction to prevent left-side portal hypertension will be introduced. For distal SMV encasement, several bypass techniques to deal with collateralizations will be introduced. Even though some high-volume PC centers are obtaining favorable outcomes for challenging vein resection cases, existing evidence on this topic is limited. It is essential to organize the well-designed international multicenter studies for the small population of challenging vein resection cases. With the emergence of effective chemotherapies, the number of PC patients who can undergo curative resection is increasing. Achieving more successful vessel resection and reconstruction in the treatment of PC is a common goal that pancreatic surgeons should focus on together.     

Saving the musculus pectoralis minor in radical mastectomy]

Eighty-five patients were surgically treated for postmastectomy edema of the upper extremity. In 20 of them, phlebolysis of the subclavian vein was performed. It was established that the vein was most often compressed by a long stump of the small pectoral muscle. Surgery and subsequent radiation treatment create unfavorable conditions for the muscle leading to its morphologic restructuring. Classic mastectomy after Halsted-Meier is recommended.     

Geographical variance in the risk of gastric stump cancer: no increased risk in Japan?

Geographical differences may exist in the risk of gastric stump cancer. Therefore, we performed meta-analysis of literature reports in Japan (n = 3), the USA (n = 4), and Europe (n = 20) on the risk of postgastrectomy cancer. The weighted mean relative risk of stump cancer in Japan was 0.28, 95% confidence limits 0.21-0.38 as compared to 1.53, 95% confidence limits 0.98-2.41 in the USA and 1.66, 95% confidence limits 1.55-1.79 in Europe. Thus, the risk of gastric cancer in the post-gastrectomy patient seems decreased in Japan and is significantly less than in the USA or Europe, where an increased risk exists. Since there is a high risk of gastric cancer of the intact stomach in Japan, the discovery of a low cancer risk in the gastric stump may provide evidence that these gastric cancers are two different entities.