保留幽门胰十二指肠切除术后胃排空障碍的预防和治疗

目的 研究保留幽门十二指肠切除术（ＰＰＰＤ）后的胃排空障碍（ＤＧＥ）的防治。方法对４４例ＰＰＰＤ术后ＤＧＥ的病人进行回顾性分析,选择性地进行胃造口安置减压组合管（ＰＳⅡ型管）观察其疗效。结果 本组病例ＤＧＥ的发生率为２５％。通过ＰＳⅡ型管胃造口可获得满意效果,没有相关并发症。结论ＰＳⅡ型管有减压和营养功能,通过胃造口安置可有效地防治ＰＰＰＤ术后ＰＧＥ,既安全又可减少病人痛苦     

保留幽门的胰十二指肠切除术(附12例报告)

目的 探讨保留幽门的胰十二指肠切除术(PPPD)的手术适应证、捆绑式胰肠吻合术的特点及胃排空障碍的治疗。方法 12例均行PPPD,消化道重建按Child法,胰肠吻合均采用捆绑式胰肠吻合。结果 除l例术后第21天并发切口裂开、肺栓塞死亡外,其余ll例均顺利出院,平均住院时间24d,随访1年,l例术后8个月死亡,余均健在。结论 PPPD是治疗胰头癌及壶腹周围癌的一种具有广阔应用前景的术式,捆绑式胰肠吻合有望作为胰肠吻合的标准术式。     

保留幽门胰十二指肠切除术的研究进展

保留幽门的胰十二批肠切除术（PPPD）由于能提高术后病人的生活质量和防止胃切除术后综合征的发生，有逐渐取代经典的胰十二指肠切除术（PD）的趋势，本文就PPPD的手术方式、适应证、术后常见并发症及与PD相比较等方面的研究进展作一综述。     

保留幽门的胰头十二指肠切除术

1978年Traverso和Logmire报道2例保留幽门的胰头十二指肠切除术（PPPD），1例为慢性钙比性胰腺炎合并胰头部囊肿，另1例为十二指肠水平部肿瘤浸润胰头，术后经过良好。本手术保留了胃的贮存与消化功能，避免了胃切除术后可能发生的并发症，减少了手术创伤，有利于病人的恢复。胃液分析显示正常的胃酸分泌，钡餐透视幽门及胃排空功能正常。自SO年代以来，由于对生存质量的重视，PPPD的手术适应证不断地扩大，目前用于：①胰头及其周围的良性病变，如肿块型胰腺炎、胰胆管合流异常以及外伤等；②壶腹癌，胆管中下段痛，十二指肠癌；③恶…     

保留幽门的胰十二指肠切除术

保留幽门的胰十二指肠切除术（PPPD）与胰十二指肠切除术（PD）相比，保留了幽门及十二指肠球部，病人术后的营养状态较接受PD术明显改善，近年PPPD较快地得以普及，其适应证不断扩大，以PPPD治疗胰头癌的报告亦逐渐增多，经观察，两种术式对壶腹部癌，胆管下段癌的疗效无明显差别，对胰头癌采用何种术式尚存争议。PPPD术后主要并发症为胃排空延迟，但具有自限性，通常在一个月左右自然恢复。     

保留幽门的胰十二指肠切除术

保留幽门的胰十二指肠切除术（ＰＰＰＤ）的切除范围是保留全胃、幽门及十二指肠球部，在幽门下２～４ｃｍ切断十二指肠，在十二指肠水平部与升部之间或空肠起始部切断肛侧肠管。切除胆囊，胆管的切断线与胰腺的切除范围应根据病变部位、性质与通常的胰十二指肠切除术相同（图１）。认为该术式保留了胃贮存和消化功能、促进消化、预防倾倒综合征以及有利于改善营养。８０年代以来由于对生存质量的重视，保留幽门的胰十二指肠切除术的适应证不断扩大。　　良性病变不切断胃右动脉　恶性病变为廓清第（１４ｄ）组淋巴结，于Ｔｒｅｉｔｚ…     

保留幽门胰十二指肠切除术的研究进展(文献综述)

保留幽门的胰十二指肠切除术 (PPPD)由于能提高术后病人的生活质量和防止胃切除术后综合征的发生 ,有逐渐取代经典的胰十二指肠切除术 (PD)的趋势 ,本文就 PPPD的手术方式、适应证、术后常见并发症及与 PD相比较等方面的研究进展作一综述。     

G路径保留幽门的胰十二指肠切除术

胰十二指肠切除术被认为是一位成熟消化外科医师应该掌握的最复杂和最具挑战性的手术.基于对患者术前影像学资料的精细评估,我们倡用一种称为G路径的新型保留幽门的胰十二指肠切除手术程式.G路径胰十二指肠切除术可以标准化手术步骤、简化手术流程、节约手术时间,按照精细的术前规划达到R0切除,避免了传统手术操作中的反复探查和分离,降低了医源性肿瘤转移的风险.本文以1例胰头癌并梗阻性黄疸患者为例,介绍G路径胰十二指肠切除术并讨论其关键技术.     

Pylorus-preserving pancreatoduodenectomy — technical aspects

Summary Pylorus-preserving pancreatoduodenectomy is the resection of choice for patients with carcinoma of the head of the pancreas and periampullary area and for certain patients with chronic pancreatitis. Preoperative preparation, operative technique, and results are discussed.

---

Technische Aspekte der pyloruserhaltenden Pankreatoduodenektomie

Zusammenfassung Die pyloruserhaltende Pankreatoduodenektomie ist die Resektionsmethode der Wahl bei Patienten mit einem Karzinom des Pankreaskopfes und der periampullären Region and bei einigen Patienten mit chronischer Pankreatitis. Preoperative Vorbereitung, Operationstechnik and Ergebmsse werden besprochen.

     

Pylorus-preserving pancreatoduodenectomy. Experience in 20 patients.

Twenty patients underwent a pylorus-preserving pancreatoduodenectomy for benign or malignant periampullary and pancreatic disease. Eighteen patients had a partial and two patients a total pancreatectomy. There were 19 elective and 1 emergency operations. Post-operative mortality was 4% (1/20 patients) and the median follow up was 31 months (range, 15-75 months), during which period 8 patients with a malignant disease died. Pylorus-preserving pancreatoduodenectomy did not compromise survival in ampullary cancer. One patient developed a marginal ulcer during the study period and one of twelve patients, examined by technetium scintigraphy (done more than 3 months after the procedure), had delayed gastric emptying. Two patients presented with a gastric retention as the first sign of recurrent pancreatic cancer. The result of the operation was judged as excellent in 7 patients, good in 8 and as bad in only 2 of the 17 patients who survived more than 6 months. Body weight was studied in 15 patients surviving more than one year after operation; five patients had gained weight, two had lost weight and in 8 there was no difference. Pylorus-preserving pancreatoduodenectomy seems to be a valuable alternative in the treatment of patients with benign and selected malignant pancreaticobiliary disease.     

Pylorus-preserving pancreatoduodenectomy. A clinical and physiologic appraisal.

Since 1978, 252 patients from different centers in the world have undergone pylorus-preserving pancreatoduodenectomy. Fifty-five per cent of the patients had malignant tumors in the region of the head of the pancreas. The overall operative mortality rate was 2.8%. Anastomotic leakage and fistulae occurred in 19% of the patients. Pancreatic, biliary, and enteric fistulae represented 11%, 4%, and 4%, respectively. Peptic ulcers were subsequently diagnosed in seven patients (3%), two of whom required vagotomy and antrectomy. Delayed recovery of gastric function was the most common complication of this operation, with an overall incidence of 30%. Although the cause of this gastric dysfunction is unknown, its transient nature in most patients makes expectant therapy with gastric tube drainage the best remedy when the problem is encountered. Pylorus-preserving pancreatoduodenectomy decreased the incidence of postgastric surgery syndromes that are commonly associated with the standard Whipple operation. The existing data support the continued use of the operation and the need for future laboratory and clinical investigation of its physiologic impact.     

Pylorus-preserving pancreatoduodenectomy for cancer treatment: Surgical procedure, indications, and analysis of outcomes

Factors determining the prognosis of cancer of the pancreatic head were analyzed in 100 patients who had undergone surgical treatment. So as to clarify the indications for pylorus-preserving pancreatoduodenectomy (PPPD), the prognosis was compared in two sets of such patients, 25 who had undergone PPPD and 25 who had undergone the Whipple procedure. Of these 50 patients, 20 (40%) also underwent portal vein resection and 29 (58%) were found to have lymph node metastasis. Curative resection was achieved in 33 of these 50 patients (66%) and the 5-year survival rate after the curative resection (42.0%) was significantly higher in these patients that in those given a non-curative resection (P <0.01). Further, the prognosis was better for patients who did not require a portal vein excision than for those who did (P<0.01), and for patients who showed no lymph node metastasis than for those with metastasis (P<0.01). The 5-year survival rate did not differ significantly between the PPPD group and the Whipple procedure group. These results indicate that PPPD can also be a useful procedure for treating malignant diseases.     

Pylorus-preserving pancreatoduodenectomy with Billroth I type reconstruction: a viable option for pancreatic head resection

Background/Purpose: The aim of this study was to investigate the efficacy of pylorus-preserving pancreatoduodenectomy (PPPD) versus standard pancreatoduodenectomy (PD). Method: A cohort of 80 patients were studied for 5 years using prospectively gathered data. PPPD was performed in 48 (60%) patients, and the other 32 (40%) underwent a standard Whipple's operation with partial distal gastrectomy (PD). In all cases, the gastric or duodenal stump was anastomosed with the first loop of jejunum as a Billroth I-type reconstruction. Results: Overall, morbidity in the cohort of patients consisted of 10 with a pancreatic fistula, 5 with postoperative hemorrhage, 5 with sepsis, 3 with delayed gastric emptying, 2 with an anastomotic leak, and 1 each with intraabdominal hematoma or myocardial infarction. Major morbidity associated with PPPD appeared in 8 of the 48 (16.7%) patients compared with 2 of 32 (6.3%) in the PD group. There were two deaths (4.2%) in the PPPD group and one (3.1%) in the PD group. The mean length of hospital stay was 14.6 days for PPPD versus 17.1 days for PD. Of the 48 patients in the PPPD group 7 (14.6%) had a hospital stay of more than 20 days versus 8 of the 32 (25%) in the PD group. Conclusions: Contrary to recent reports, in our series the PPPD patients had a shorter hospital stay; and overall, 3 of the 80 (3.75%) patients developed delayed gastric emptying, a relatively low rate. The pancreatic fistula rate was almost threefold higher in the PPPD group than in the PD group (but did not prolong the inpatient stay). This may be due to an intact antrum secreting higher quantities of gastrin. Received: May 13, 2002 / Accepted: July 1, 2002 Offprint requests to: A. Kingsnorth     

Pylorus-preserving pancreatoduodenectomy: influence of a Billroth I versus a Billroth II type of reconstruction on gastric emptying.

BACKGROUND/AIM: Delayed gastric emptying (DGE) is a frequent problem after pylorus-preserving pancreatoduodenectomy. Important risk factors are the presence of intra-abdominal complications. Searching for other causes, this study evaluates the influence of the type of reconstruction after a pancreatoduodenectomy (Billroth I vs. Billroth II; B I vs. B II on DGE. METHODS: A retrospective study was performed evaluating consecutive patients from two surgical institutes. 174 patients were included (B II type of reconstruction n = 123, period 1992-1996; B I type of reconstruction n = 51, period 1988-1998). DGE was defined by gastric stasis requiring nasogastric intubation for 10 days or more or the inability to tolerate a regular diet on or before the 14th postoperative day. RESULTS: After a B I type of reconstruction, there was significantly longer nasogastric intubation period as compared with a B II type of reconstruction (B I median 13 days, range 4-47, B II median 6 days, range 1-40; p < 0.05). There was no difference in postoperative commencement of a normal diet. Also significantly more patients had DGE after a B I (76%) as compared with a B II type of reconstruction (32%; p < 0.05). CONCLUSIONS: The results of this study indicate a significantly higher incidence of DGE after a B I type of reconstruction as compared with a B II type reconstruction. The etiology remains speculative.     

Pylorus-preserving pancreatoduodenectomy for pancreatic head cancer after surgery for esophageal cancer with gastric tube reconstruction in a long-term survivor: A case report

IntroductionTo maintain the blood circulation of the gastric tube in pylorus-preserving pancreatoduodenectomy (PPPD) for periampullary cancer after esophagectomy for esophageal cancer, it is necessary to preserve the gastroduodenal artery and its branch, the right gastroepiploic artery, which are usually resected for more convenient, complete, and effective lymph node dissection. Here we report the case of a patient with a postoperative survival period of more than 5 years.Presentation of caseA 79-year-old man, who underwent subtotal esophagectomy and gastric tube reconstruction 11 years ago, was diagnosed with pancreatic head cancer during routine examination 5 years after the esophageal surgery. After placement of a coronary artery stent for an arterial branch stenosis incidentally found during preoperative screening electrocardiogram, he underwent pancreatic surgery. As the tumor did not extend to the anterior surface of the pancreas and as there were no swollen lymph nodes in the area, the gastroduodenal artery, the gastroepiploic artery and vein could be preserved. Elective PPPD was conducted without incident, and good preoperative gastric tube circulation was maintained postoperatively. Reconstruction was performed according to the modified Child procedure with duct-to-mucosa stentless pancreaticojejunostomy. The postoperative course was uneventful and though it took the patient a long time to overcome the physical decline, he remains alive with no recurrent disease over 5 years post-operation.ConclusionAlthough PPPD may be performed after esophagectomy with gastric tube reconstruction, it is still unclear how the risk of recurrence is affected. Therefore, the indications of this procedure should always be carefully considered.     

Pylorus-preserving pancreatectomy: functional results

The pylorus-preserving technique is reported as improving the functional results of pancreatectomy but it is complicated in the early postoperative period by delayed recovery of gastric function in a proportion of patients. We have examined early and late gastrointestinal function in a prospective study of 16 patients having this procedure. The late results appear better than reported results for conventional Whipple resection and the delay in early recovery does not appear to have any late sequelae, provided that it does not require gastric bypass for relief.