胰肠吻合方式选择与胰肠吻合口漏

胰肠吻合口漏一直是胰十二指肠切除术(pancreati-coduodenectomy,PD)后最常见的手术并发症之一。尽管近20年来随着外科技术的进步,PD术后病死率已降至5%以下,但胰肠吻合口漏者仍高达8%~25%,由此引起的病死率点总病死率的20%。据美国最有代表性的两个胰腺外科中心——约翰霍普金     

端侧套入式间断加连续双层缝合胰肠吻合与端侧胰管置入胰肠吻合比较

胰肠吻合口瘘是胰十二指肠切除术(pancrcati-coduodenectomy,PD)最常见的并发症之一.尽管近20年来PD术后病死率已降至5%以下,但胰肠吻合口瘘者仍高达8%～25%,由此引起的病死率占总病死率的20%[1].避免胰肠吻合口瘘的发生是降低手术死亡率的关键.     

胰十二指肠切除术不同胰肠吻合方式胰漏分析

目的探讨胰十二指肠切除术（PD）不同胰肠吻合方式对胰漏发生的影响。方法回顾2002年2月至2007年5月154例行胰十二指肠切除术病例，分别采取胰肠套埋单层吻合105例，双层吻合49例，分析与胰漏相关危险因素及两组间胰漏差异原因。结果胰漏发生率8．4％（13／154），Logistic回归多变量分析表明：男性、胰腺质地软、非单层胰肠吻合方式是3个与胰瘘相关的独立变量；两种吻合方式间胰漏（单层吻合，4．8％vs双层吻合，16．4％）、术后并发症（单层吻合，18．1％vs双层吻合，32．7％）、术后平均住院时间弹层吻合，18．45±7．11天vs双层吻合，22．75±9．73天）、质软胰腺中胰漏停嘱吻合，6％vs双层吻合，27．6％洧统计学差异。结论胰肠套埋单层吻合，特别是在质软胰腺中应用可明显减少胰漏发生率。     

捆绑式胰肠吻合术预防胰肠吻合口漏

胰肠吻合口漏(胰漏)是胰十二指肠切除术(PD)后最危险的并发症,其发生率一般为8%~19%,相关死亡率高达8%~40%。如何有效地预防胰漏是施行胰十二指肠切除术的关键。1996年1月,彭淑牖等[1]设计了捆绑式胰肠吻合术,以捆绑取代缝合,避免遗留针孔,保证吻合口的密封性,经一系列临床证实,有效地避免了胰漏的发生[2-4],得到国内外学者的赞誉。本文再谈谈捆绑式胰肠吻合术的若干关键问题。一、捆绑式胰肠吻合术预防胰肠吻合口漏的机理为了预防胰肠吻合口漏的发生,60多年来,众多外科学者致力于设计新的术式,从胰管结扎、胰管栓塞、到各种各样的胰肠吻合…     

胰十二指肠切除术不同胰肠吻合方式的选择与效果评价

目的评价不同胰肠吻合方式在胰十二指肠切除术中的临床疗效,探讨不同胰肠吻合方式的适用性。方法回顾性分析2012年1月至2014年8月收治的117例行胰十二指肠切除术患者临床资料,按吻合方式不同分为胰管空肠黏膜吻合(A组,61例)和捆绑式胰肠吻合(B组,56例),比较两种不同胰肠吻合方式术后胰漏及相关并发症的发生率。结果胰肠黏膜吻合组胰腺残端直径明显大于捆绑式胰肠吻合组(t=7.441,P0.05),捆绑式胰肠吻合组胰肠吻合时间明显小于胰肠黏膜吻合组(t=3.085,P0.05)。两组患者术后胰漏、腹腔出血、腹腔感染、胃潴留、肺部感染、平均住院时间及费用,差异无统计学意义(x2=0.257,0.308,0.737,0.896,1.096;t=1.211,1.477;P0.05)。结论胰管空肠黏膜吻合法和捆绑式胰肠吻合法是胰十二指肠切除术两种主要吻合方法,都能有效降低胰漏的发生率,应根据术中探查结果,合理灵活选择不同吻合方式。     

胰十二指肠切除术改进胰肠及胃肠吻合方式52例观察

目的探讨胰十二指肠切除术改进胰肠及胃肠吻合方式对患者近期和远期并发症的影响。方法对52例行胰十二指肠切除术的患者进行消化道重建,方式为胰肠、胆肠和胃肠顺序。胰肠吻合在完成胰十二指肠切除后,游离胰腺残端2．5～3．0cm,将准备与胰腺吻合的空肠袢断端浆肌层剥除,制成黏膜瓣,长度与胰腺断面前后径相当,施行黏膜瓣覆盖胰腺断面的套叠式胰空肠端端吻合术;胃肠吻合是在胃或十二指肠球部与胰胆侧肠袢之间问置30cm空肠施行胃肠道重建。结果术后发生胰漏2例（3．8％）,经充分引流并给予生长抑素、肠内营养等保守治疗愈合,无腹腔感染及大出血等严重并发症。术后随访3年,随访率为88．5％（46／52）,术后半年95．0％（38／40）的患者消化吸收功能基本正常,营养状况良好,未发生逆行性胆管炎、胆汁反流性胃炎、胃肠吻合口溃疡。结论施行胰十二指肠切除消化道重建过程中,采用黏膜瓣覆盖胰腺断面的套叠式胰空肠端端吻合术有助于减少胰漏等近期并发症在胃或十二指肠球部与胰胆侧肠袢之间间置空肠,可减少胃肠道反流等远期并发症。     

胆肠、胰肠双磁吻合在胰十二指肠切除术中的应用

目的 探讨胆肠、胰肠同时使用磁吻合技术在胰十二指肠切除术中的可行性、安全性及有效性。方法 从2012年1月至2019年12月9例胰十二指肠切除术中使用磁吻合技术完成胆肠及胰肠重建。收集术前患者一般资料、手术方式、胰肠吻合时间、胆肠吻合形成时间、磁体排出时间、术后并发症等指标。所有患者出院后电话或门诊随访,随访时间至2020年2月。结果 9例患者均为恶性肿瘤,术前胆道、胰管均明显增宽,直径分别为16（8～23）mm、7（6～14）mm。所有患者均顺利完成胰十二指肠切除术,其中7例为开腹,2例为腹腔镜。9例患者胰肠吻合使用均传统磁吻合装置,胆肠吻合5例使用传统磁吻合装置,4例使用胆肠磁吻合器。胆肠吻合时间8（5～16）min,胰肠重建的手术时间为10（8～15）min,胆肠吻合与胰肠吻合时间亦无统计学差异（t=-1.6,P＞0.05）。术后1例A级胰瘘,保守治愈,无胆瘘。5例胆肠吻合形成时间18（15～33）d,9例胰肠吻合形成时间18（10～33）d。术后经过37（20～60）d,所有患者磁体均排出体外。术后随访15（3～25）个月,胆肠吻合口狭窄1例,经PTCD+球囊扩张治愈。结论 对于胆、胰管均扩张的恶性肿瘤行胰十二指肠时,磁吻合技术完成胆肠及胰肠重建简便、省时,术后无明显胆胰瘘发生。     

带蒂大网膜包裹胰肠吻合在胰十二指肠切除术中的应用

目的 探讨降低胰十二指肠切除术后胰肠吻合口漏的预防措施。方法 回顾性分析1999～2004年间施行的46例胰十二指肠切除术中采用大网膜包裹胰肠吻合口的手术方法。结论 46例患者术后出现胰漏1例,占2．17％,无围手术期死亡。结论 带蒂大网膜包裹胰肠吻合口,覆盖操作简单,对预防胰十二指肠切除术后胰肠吻合口漏有良好效果。     

胰肠吻合方式和保留幽门对胰瘘发生的影响

目的探讨胰肠吻合方式和保留幽门对胰十二指肠切除术后胰瘘发生的影响。方法回顾性分析我院1994年1月至2007年5月间142例胰十二指肠切除术患者临床资料，探讨胰瘘发生的危险因素，比较胰肠黏膜对黏膜胰管空肠端-侧吻合、胰腺空肠端-端套入式吻合及保留幽门与否对胰瘘发生率的影响。结果术后胰瘘总发生率22％（32／142），其中黏膜对黏膜吻合组21％（29／132），传统胰腺空肠端-端套入组33．33％（3／9）。结论胰肠吻合方式、保留幽门与否对胰瘘发生率无显著性的影响。     

胰十二指肠切除术中不同胰肠吻合方式的疗效比较

目的探讨胰十二指肠切除术中不同胰肠吻合方法的疗效。方法回顾分析我科2000年1月至2006年9月施行56例胰十二指肠切除手术,比较不同胰肠吻合时间及相关并发症。结果18例反折式双层套入胰肠吻合发生胰漏3例、上消化道出血1例;11例袖套式单层套入胰肠吻合发生胰漏1例、上消化道出血1例;6例捆绑式胰肠吻合发生上消化道出血1例,无胰漏;21例胰管空肠黏膜吻合无胰漏及上消化道出血,手术时间缩短。结论胰管空肠黏膜吻合是一种简便、安全和有效的方法。     

Femoral anastomotic pseudoaneurysms

In this paper the Authors discuss about femoral anastomotic pseudoaneurysms. They throughly consider the etiopathogenesis of this late complication of arterial prothesic surgery, pointing out the different hypothesis currently discussed. Particularly from this analysis it can be concluded that the choice of appropriate prothesic grafts and the weakness of an eventually endarterectomized arterial wall are the principal determinants in causing pseudoaneurysms. Between the different therapeutic choices the opportunity of an interposition graft is underlined, except for (rare) cases when an extra-anatomic bypass must be preferred.     

Augmented anastomotic urethroplasty

PURPOSE: During substitution urethroplasty, if the stricture contains a 1 to 2 cm region that is particularly narrow and/or fibrotic, that portion may be excised with subsequent anastomosis of the dorsal or ventral aspect of the urethra to shorten, widen and optimize the urethral wall onto which an onlay graft is to be placed. This procedure is termed augmented anastomotic urethroplasty. To determine the effectiveness of this approach we reviewed our experience with augmented anastomotic urethroplasty in an 8-year period. MATERIALS AND METHODS: We reviewed the records of patients who underwent augmented anastomotic urethroplasty between October 1997 and April 2005. Perioperative characteristics were compared between successes and failures using the Wilcoxon/Kruskal-Wallis and Fisher exact tests. RESULTS: Of 69 patients who underwent augmented anastomotic urethroplasty for recurrent urethral strictures 5 had undergone previous urethroplasty using a genital skin flap or graft. At a median followup of 34 months (range 13 to 103) 62 patients had no evidence of stricture recurrence and required no further intervention for an overall success rate of 90%. Stricture recurrence, defined as the inability to easily pass a standard flexible cystoscope through the area of repair, occurred in 7 patients (10%). Patients with stricture recurrence were significantly older (mean age 52 vs 39 years, p = 0.02) and more likely to experience postoperative urinary tract infection (28% vs 3.2%, p = 0.05) than patients without repeat stricture. CONCLUSIONS: Augmented anastomotic urethroplasty is an effective technique that allows the use of a shorter onlay graft. It may optimize overall results due to improvement in the urethral wall and the associated corpus spongiosum.     

Esophagogastric anastomotic leakage

Anastomotic leakage of esophagogastric anastomoses can be prevented by administering adequate preoperative nutritional support and by employing mechanical circular staplers. In a series of 299 intrathoracic anastomoses, 35 leakages were observed, 11 of which gave asymptomatic radiological findings. In a series of 46 cervical anastomoses, nine leakages were observed. In the majority of cases conservative treatment was adopted. This is based upon external drainage of septic collections, gastric emptying, antibiotics and intensive nutritional care. The mortality rate in cases of anastomotic fistulas was 1.74% (6 patients) in the patients with esophagogastric anastomoses.     

Pathogenesis of anastomotic aneurysms

Forty-two anastomotic aneurysms were encountered in 33 patients over a 13-year period. Thirty-six occurred after the use of prostheses, and six occurred after the the use of vein grafts. In the prosthetic group, 28 aneurysmal defects were repaired, and the cause was found in 25 cases. In 23 of these cases the defect was caused by the sutures that had pulled out of the arterial wall; suture failure was recorded in only two cases. There were no defects in any of the prostheses. The suture material was braided Dacron (Tevdek) in 25 anastomotic aneurysms, but it was not recorded in three cases. In the vein graft-related group the aneurysms occurred in the "juxta anastomotic position," with the suture lines intact. They were thus true aneurysms of the vein wall. This study shows that the predominant cause of an anastomotic aneurysm in weakness of the arterial wall and not the mechanical failure of the suture material (braided Dacron) or prosthesis. It would seem, however, that the prosthesis, by virtue of its undesirable physical characteristics-a compliant mismatch with the host artery and some dilatation with the passage of time-results in abnormal shear stress at the anastomosis, leading to disruption of the arterial wall and eventually to false aneurysm formation.     

Novel anastomotic techniques

Creating a safe and healthy bowel anastomosis remains critical for successful intestinal surgery. The selection of anastomotic technique depends on several factors, including the site of anastomosis, bowel caliber, tissue quality, and underlying disease process, but more importantly individual surgeon experience and personal preference play a major role. Other important key factors to a successful anastomosis are meticulous technique, good blood supply, and tension-free connection. However, despite the “perfect conditions” and technical advances some anastomoses continue to leak resulting in significant morbidity and mortality. Around 4% of all colonic anastomoses and even higher percentage of colorectal anastomoses leak; thus reducing this complication rate would improve mortality and health care costs. Many different techniques of colorectal anastomosis have been described in search for better outcomes and lower leak rates. In this article, I will discuss adjuncts to staplers with an emphasis on the compression anastomotic techniques and newer devices available, the potential advantages of intraoperative endoscopic evaluation of anastomosis, role of fluorescence imaging, and future directions in intestinal anastomotic technology.     

False anastomotic aneurysms

This retrospective study covers the period from 1991 to 2002, during which 3,623 patients were operated on because of aneurysmal or occlusive disease of aortoiliac and femoropopliteal segments. Among them, 87 patients (2.4%) developed a false anastomotic aneurysm in the 12-year follow-up period and were treated operatively. Most frequently, in 53 patients (6.9%), a false anastomotic aneurysm developed after aortobifemoral bypass performed owing to aortoiliac occlusive disease. The cause of false anastomotic aneurysm was infection in 21 cases (24.7%); resection and revascularization were performed with a Dacron graft in 46 cases (52.9%), with a polytetrafluoroethylene graft in 10 cases (11.5%), and with the great saphenous vein in 16 cases (18.4%). Homograft implantation in 4 patients (4.6%) or extra-anatomic bypasses in 11 cases (12.6%) were performed when graft infection was suspected. Of 87 patients who underwent surgery, 74 (85.5%) had good early results without infection, reintervention, limb loss, and mortality. The presence of infection as a cause of false anastomotic aneurysm and comorbidity increased the mortality rate significantly after the reoperation, whereas the type of graft used in treatment had no influence on early results.     

结直肠手术不同吻合平面对吻合口瘘发生的影响

目的 研究结直肠手术不同的吻合平面对结直肠吻合口瘘的影响.方法 478例结直肠手术患者,根据手术不同的吻合平面将结直肠手术患者分为三组,吻合平面分别为横结肠54例、乙状结肠或直肠上段112例、直肠中下段249例,采用χ2检验分析结直肠手术不同的吻合平面对结直肠吻合口瘘的影响.结果 吻合平面为横结肠、乙状结肠或直肠上段、直肠中下段(未行预防性横结肠造口)三组吻合口瘘的发生率分别为0%、2.7%、8.4%,三者间存在统计学差异,其中横结肠组与乙状结肠或直肠上段组吻合口瘘的发生率差异无统计学意义(P＞0.0167),横结肠组与直肠中下段组吻合口瘘的发生率差异有统计学意义(P＜0.0167),乙状结肠或直肠上段组与直肠中下段组吻合口瘘的发生率差异无统计学意义(P＞0.0167).结论 结直肠手术吻合口瘘的发生与吻合的平面密切相关,吻合平面愈低,吻合口瘘的发生率愈高.