323例简化捆绑式胰肠吻合的临床疗效

目的 探讨简化捆绑式胰肠吻合的临床疗效.方法 回顾性分析2005年3月至2010年5月华中科技大学同济医学院附属同济医院实施根治性胰十二指肠切除术治疗323例壶腹部周围癌患者的临床资料.胰肠吻合均采用简化的捆绑式胰肠吻合:胰腺断端游离3～4 cm;将6号或8号硅胶导尿管插入胰管内4～5 cm,胰腺断端外硅胶管为6～8 cm,用可吸收缝线将其缝合固定在胰腺断端上;胰腺断端交锁缝合止血.将空肠断端外翻2～3 cm,电灼损伤黏膜1 cm;回复外翻空肠,在空肠断端的系膜及其对侧和两者的中点与胰腺的下缘、上缘及其之间的胰腺被膜各对称性地缝合1针;并将空肠套在胰腺断端后打结固定.在确定空肠完整地套在胰腺游离段上后,用1-0可吸收线将空肠断端捆绑在胰腺游离段上.消化道重建均采用Child法.结果 323例患者顺利完成了简化的捆绑式胰肠吻合;1例胰肠吻合口出血患者于缝扎出血点后第3天发生胰瘘,置管引流出院1个月后自行痊愈.2例胆总管下端癌和2例胰腺钩突部癌患者分别于术后3、6和8、11 d发生胰瘘,经引流等保守治疗后痊愈.胰瘘发生率为1.5%(5/323).结论 简化的捆绑式胰肠吻合简单易行、安全、可靠,可明显降低胰瘘的发生率.     

改良套叠式胰空肠吻合术应用石蕊试纸和纤维蛋白胶预防胰漏47例体会

目的 总结降低胰十二指肠切除术后胰空肠吻合口漏发病率的经验体会。方法 切除胰头后，将胰腺残端游离2．5～3．0cm，利用红色石蕊试纸遇碱性胰液变蓝的特性，帮助寻找胰腺断面被横断的小导管，丝线贯穿缝扎。将空肠袢断端2．0～2．5cm浆肌层剥除后施行套叠式胰空肠端端吻合，距浆肌层游离缘1．0～1．5cm处空肠上下壁各缝1针固定，最后用纤维蛋白胶封闭吻合口。结果 47例患者中无一例发生胰空肠吻合口漏。结论 该法操作较简便，适用于胰腺残端各种情况的处理。     

胰十二指肠切除术中胰肠吻合口的重建

胰肠吻合口的重建是胰十二指肠切除术中重要的组成步骤,也是影响其成败的关键。根据重建方式的不同,主要分为胰腺-空肠吻合和胰胃吻合。根据胰腺残端与空肠吻合位置的不同,分为端端吻合和端侧吻合。在目前的随机对照研究中,胰腺-空肠吻合和胰胃吻合在胰漏的发生率方面无明显的差异。捆绑式胰肠和捆绑式胰胃吻合分别建立在经典胰肠（胃）吻合的基础上,操作简便,预防胰肠吻合口瘘效果确切。胰肠吻合口成功与否的影响因素包括胰腺质地和胰管大小等,胰管支撑管的放置可能有助于减少胰肠吻合口瘘的发生。胰十二指肠切除术中的消化道重建,应遵循简单、有效的原则,才能将胰肠吻合口瘘的发生减至最低。     

胰十二指肠切除术中胰肠吻合方式的选择策略

目的 评价胰肠吻合方式选择策略在胰十二指肠切除术中应用的临床效果.方法 回顾性分析2007年6月至2012年6月第四军医大学西京医院收治的455例行胰十二指肠切除术患者的临床资料.对于胰管直径≥4 mm的患者采用胰管空肠黏膜吻合术(胰管空肠黏膜吻合组,210例);对于胰管直径＜4 mm的患者,其胰肠吻合术式由胰腺残端直径和空肠管腔口径决定,空肠管腔口径＜胰腺残端直径者选择改良Child胰肠吻合(改良Child胰肠吻合组,140例),空肠管腔口径≥胰腺残端直径者选用捆绑式胰肠吻合(捆绑式胰肠吻合组,105例).比较分析各组临床疗效及术后并发症发生率.计数资料采用x2检验,计量资料采用t检验.结果 胰管空肠黏膜吻合组的胰管直径为(4.4±0.7)mm,显著大于改良Child胰肠吻合组的(2.8±0.6)mm和捆绑式胰肠吻合组的(2.3 ±0.7)mm(t =2.25,2.48,P＜0.05).改良Child胰肠吻合组胰腺残端直径为(36 ±5)mm,显著大于捆绑式胰肠吻合组的(21 ±6)mm(t =21.65,P＜0.05).总体胰液漏发生率为8.4％(38/455).3组患者胰液漏、腹腔出血、腹腔感染、消化功能异常、平均住院时间比较,差异无统计学意义(x2=0.53,0.88,1.63,5.34,F=2.53,P＞0.05).结论 在胰十二指肠切除术中根据胰管直径、胰腺残端直径和空肠管腔口径合理选择胰肠吻合方式可取得较好的临床效果.     

根据胰管直径等因素选择不同胰肠吻合方式对患者术后恢复的影响

目的 评价根据胰管直径等因素选择的不同胰肠吻合方式对患者术后恢复的影响,为胰肠吻合方式的选择决策提供依据.方法 回顾性分析我院在2010年1月至2013年1月间行胰十二指肠切除术305例患者的临床资料.对于胰管直径≥3 mm的患者采用胰管空肠黏膜吻合（胰管空肠吻合组,120例）;对于胰管直径＜3 mm者,进一步比较胰腺残端与空肠管径的直径大小,若胰腺残端较粗大,且大于空肠管径者采用改良Child胰肠吻合（改良Child胰肠吻合组,80例）,若胰腺残端直径小于空肠管径者选择捆绑式胰肠吻合（捆绑式胰肠吻合组,105例）.比较不同胰肠吻合方式术后并发症的发生率,评价临床疗效.结果 胰管空肠黏膜吻合组胰管直径显著大于其他两组（P＜ 0.05）,改良Child胰肠吻合组胰腺残端直径明显大于捆绑式胰肠吻合组（P＜0.05）.本组研究总体胰瘘发生率为11.1％ （34/305）.比较三组患者术后胰瘘、腹腔出血、腹腔感染、消化功能异常、平均住院时间及术后死亡,差异无统计学意义（χ^2=1.51,2.78,1.16,3.75,1.94,F=2.13,P＞0.05）.结论 在行胰十二指肠切除术时,可以根据胰管直径、胰腺残端直径及空肠管径合理选择不同的胰肠吻合方式.     

保留与去空肠黏膜的胰肠套入吻合方式在胰十二指肠切除术中的应用比较

目的 对胰十二指肠切除术采用保留空肠黏膜与去空肠黏膜胰肠直接套入加捆扎两种不同的吻合方式进行探讨.方法 2003年2月 2012年12月对58例胰十二指肠切除术患者采用胰空肠套入吻合术;其中A组28例采用保留空肠黏膜残胰直接套入空肠3～4 cm,在距离残胰腺断端2～3 cm处将包盖于残胰腺体的空肠段用7-0丝线予以捆扎.B组30例则为去黏膜化,空肠黏膜外翻3 cm并去黏膜化处理并行肠黏膜下肌层与残胰体断端缝合,之后将空肠复位,随后按A组方法将包盖于残胰体的空肠予以捆扎.结果 A、B两组胰-肠吻合时间比较,A组比B组平均缩短(36±0.34) min(P ＜0.001);A组和B两组术后并发胰瘘分别为0和20.0％;A组和B两组术后迟发性残胰断端出血分别为3.6％和3.3％.结论 在胰十二指肠切除术采用保留空肠黏膜与去空肠黏膜两种不同胰肠吻合方式中,前者不受残胰质地、胰管大小影响和具有操作简便以及可以降低胰瘘发病率的优点.     

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。     

胰肠插入荷包式吻合术防胰瘘效果的临床观察

胰瘘是胰十二指肠切除术后较常见的并发症 ,是引起术后病人死亡的重要原因。 1996年底我们设计了胰肠插入荷包式吻合术 ,经临床使用 ,效果满意。现将我院近 17年来传统胰肠端端套入式吻合术与胰肠插入荷包式吻合术的资料作一比较 ,结果如下。1.资料和方法 :(1)手术方式 :全组病例均按Child法重建消化道。空肠与胰腺的吻合分为两种术式 :一种是传统的胰肠端端套入式 ,即将胰腺端与空肠端吻合后 ,再将胰腺套入空肠内 3cm ,行空肠浆肌层与胰腺被膜结节缝合。另一种是胰肠插入荷包式吻合 ,即将胰腺端直接插入空肠内 3cm ,空肠端与胰腺被膜缝合 …     

胰空肠反转套入式吻合术

目的：探讨胰十二指肠切除胰空肠反转套入式吻合术防止胰空肠吻合口瘘发生的效果及术式优点。方法：游离胰腺断端后,将空肠断端约3cm的黏膜外翻,分别用2％碘酊和75％酒精破坏其黏膜,将胰腺的切缘与外翻的空肠黏膜间断缝合,注意缝线不宜穿透空肠浆膜层。将反转空肠黏膜翻回原状,使3cm的胰腺断端套入空肠腔内,然后将空肠切缘与胰腺包膜缝合。结果：本组26例病人均获痊愈,无胰瘘及消化道出血等严重并发症发生,无手术死亡,1年、3年、5年生存率分别为92．3％、60％、34．6％。结论：胰空肠反转套入式吻合术防止胰空肠吻合口瘘操作简便,效果可靠,疗效满意,有很好的实用推广价值;同时加强围手术期处理是手术成功的重要环节。     

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。     

捆绑式胰肠吻合术预防胰瘘35例体会

目的探讨捆绑式胰肠吻合术预防胰十二指肠切除术后胰肠吻合口瘘(胰瘘)的临床价值。方法回顾性分析我院2003年10月～2006年12月行捆绑式胰肠吻合术预防胰瘘35例的临床资料。结果全组无一例发生胰瘘。结论捆绑式胰肠吻合术操作简便,安全可靠,值得临床推广。     

323例简化捆绑式胰肠吻合的临床疗效

目的 探讨简化捆绑式胰肠吻合的临床疗效.方法 回顾性分析2005年3月至2010年5月华中科技大学同济医学院附属同济医院实施根治性胰十二指肠切除术治疗323例壶腹部周围癌患者的临床资料.胰肠吻合均采用简化的捆绑式胰肠吻合:胰腺断端游离3～4 cm;将6号或8号硅胶导尿管插入胰管内4～5 cm,胰腺断端外硅胶管为6～8 cm,用可吸收缝线将其缝合固定在胰腺断端上;胰腺断端交锁缝合止血.将空肠断端外翻2～3 cm,电灼损伤黏膜1 cm;回复外翻空肠,在空肠断端的系膜及其对侧和两者的中点与胰腺的下缘、上缘及其之间的胰腺被膜各对称性地缝合1针;并将空肠套在胰腺断端后打结固定.在确定空肠完整地套在胰腺游离段上后,用1-0可吸收线将空肠断端捆绑在胰腺游离段上.消化道重建均采用Child法.结果 323例患者顺利完成了简化的捆绑式胰肠吻合;1例胰肠吻合口出血患者于缝扎出血点后第3天发生胰瘘,置管引流出院1个月后自行痊愈.2例胆总管下端癌和2例胰腺钩突部癌患者分别于术后3、6和8、11 d发生胰瘘,经引流等保守治疗后痊愈.胰瘘发生率为1.5%(5/323).结论 简化的捆绑式胰肠吻合简单易行、安全、可靠,可明显降低胰瘘的发生率.

Abstract：

Objective To investigate the methods and techniques of simplified binding pancreaticojejunostomy for patients with periampullary malignant tumor after radical pancreatoduodenectomy (RPD). Methods From March 2005 to May 2010, 323 patients with periampullary malignant tumor received RPD at the Tongji Hospital of Huazhong University of Science and Technology, and their clinical data were retrospectively analyzed.Simplified binding pancreaticojejunostomy was applied after RPD: the distal end of pancreas was freed for 3-4 cm;a No. 6 or No. 8 silicone urinary catheter was inserted into the pancreatic duct for 4-5 cm, and the remaining urinary catheter (6-8 cm) out of the pancreatic duct was sutured to the pancreatic stump with absorbable sutures.The cutting end of the jejunum (2-3 cm) was everted, and the everted mucosa of the jejunum ( 1 cm) was injured by electrocautery, then the everted jejunum was reverted to its normal position. The cutting end of the mesentery of jejunum and its opposite side, as well as the mid-point of these two parts were sutured symmetrically with the lower and upper edges of the pancreas, and with the capsule of pancreas between them. The everted jejunum was wrapped over the pancreatic stump and sutured it to the pancreas for fixation. The cutting end of the jejunum was bound to the pancreatic stump with 1-0 absorbable suture after confirming the jejunum was completely invaginated into the pancreas. The alimentary tract was reconstructed by using Child's method. Results Simplified binding pancreaticojejunostomy was successfully completed in all patients, Pancreatic fistula was detected in one patient who was complicated with anastomotic bleeding on the third day after secondary laparotomy. The patient was discharged with catheter and spontaneously recovered one month later. Pancreatic fistula was also detected in two patients with distal bile duct carcinoma and two patients with carcinoma in the uncinate process of pancreas at postoperative day 3, 6, 8 and 11, and they were cured by expectant treatment. The incidence of pancreatic fistula was 1.5% (5/323). Conclusion Simplified binding pancreaticojejunostomy is simple, safe and feasible, and it can significantly reduce the incidence of pancreatic fistula.     

Binding pancreaticojejunostomy is a new technique to minimize leakage

Pancreaticoduodenectomy (Whipple procedure) has been the standard treatment for periampullary and pancreatic carcinoma. A leak or fistula from the pancreatic anastomosis is the leading cause of morbidity and mortality after pancreaticoduodenectomy. In order to effectively prevent the development of pancreatic fistulae, we designed a special technique called binding pancreaticojejunostomy, by which 3 cm of the serosa-muscular sheath of the jejunum was bound to the pancreatic remnant. We have performed this procedure in 105 consecutive patients; none of the cases developed pancreatic fistula. It is a safe, simple, and efficient technique.     

Transanal Repair of Rectourethral Fistula After a Radical Retropubic Prostatectomy: Report of a Case

Rectourethral fistula occurred in a 64-year-old man after a radical prostatectomy. Despite conservative treatment the fistula did not close spontaneously. Eleven months after the original prostatectomy, an operation was performed. We chose the Latzko technique with slight modifications as follows. The patient was placed in the prone jackknife position. The fistula was found at a site about 6.0 cm from the anal verge. An elliptical area of rectal mucosa was incised about 1.5 cm from the fistulous orifice and subsequently the rectal mucosa was denuded. The submucosa was dissected above the fistula about 2.0 cm from the edge of the incision. The fistula was then closed with one layer of side-by-side absorbable 2-0 polyglactin sutures. The dissected rectal mucosal flap was brought down over the fistula and sutured in one layer to the distal edge of the rectal muscularis propria through the mucosa with 3-0 polyglactin sutures. On postoperative day 21 a retrograde urethrogram was made and it showed no leakage of urine via the rectum. This procedure is a simple, effective, and minimally morbid technique for the repair of rectourethral fistula after a radical prostatectomy, although it is only useful for the treatment of low rectourethral fistulas. Received: March 8, 2001 / Accepted: September 11, 2001     

Telescopic technique associated with mucosectomy: a simple and safe anastomosis in pancreaticoduodenectomy

Pancreatic fistula remains a common problem and a main cause of morbidity and mortality after pancreaticoduodenectomy (PD). We have developed a safe and simple method of pancreaticojejunostomy in 33 patients, in whom approximately 3 cm of jejunal mucosa was cut to improve the adhesion between the loop and pancreatic parenchyma after end-to-end invagination. Furthermore, we have performed a purse-string procedure on 21 patients to secure the jejunum to the intussuscepted pancreatic stump instead of continuous running fashion with double needles of 5-0 monofilament synthetic absorbable sutures. This procedure was proved to be much more expeditious, and only 2 of 33 patients had pancreatic leakages. Therefore, the telescopic technique associated with mucosectomy is an acceptable and safe surgery for pancreaticojejunal anastomosis.     

Binding pancreaticoenteric anastomosis: from binding pancreaticojejunostomy to binding pancreaticogastrostomy

Potential mechanisms of occurrence of pancreatic leakage mainly include leakage from the needle hole and from the seam at the adjacent stitch, anastomotic blood supply, tension at the anastomosis, poor anastomotic healing, etc. Binding pancreaticojejunostomy (BPJ) is a safe and effective technique that avoids the primary complication of pancreatic anastomosis leakage. There are two problems with BPJ: a high discrepancy in the size of pancreas stump and the jejunal lumen; sutures on to the pancreas for fixation might cause exudation of pancreatic juice into the abdominal cavity. In order to avoid these two problems, binding pancreaticogastrostomy (BPG) is designed and successfully performed clinically with encouraging results. BPG is good for accommodating a large pancreas stump, and the binding technique is very helpful in minimizing the leak rate of pancreaticogastrostomy.     

捆绑式胰肠吻合术在胰十二指肠切除术中的应用

目的探讨捆绑式胰肠吻合术在胰十二指肠切除术中的应用价值。方法2007年8月至2010年8月收治胰头癌7例,壶腹癌8例,胆总管下段癌8例,均采用捆绑式胰肠吻合。结果本组无死亡病例,无一例术后发生胰漏。结论捆绑式胰肠吻合术操作简便,效果确切,可常规用于胰十二指肠切除术。     

保留十二指肠的胰头全切术治疗慢性胰腺炎35例报告

目的 总结保留十二指肠的胰头全切术治疗慢性胰腺炎的经验.方法 回顾分析自1999年1月至2006年12月采用保留十二指肠的胰头全切术治疗慢性胰腺炎35例的临床资料,并对患者疼痛改善情况及内分泌功能变化进行随访.结果 平均手术时间为286±55min,平均手术输血量为1.4±1.3单位压积红细胞.无手术死亡.术后并发症发生率为17%,其中1例胰瘘,3例胆漏,1例腹腔出血,1例切口裂开,无十二指肠瘘.术后患者疼痛得到缓解,QLQ-C30疼痛评分由术前的59±27降至术后的13±21.术后患者内分泌功能未继续恶化,随访过程中无新增糖尿病病例出现.结论 保留十二指肠的胰头全切术是一种安全、有效的治疗慢性胰腺炎的手术方式.较之保留十二指肠的胰头次全切除术,本手术能更彻底的切除胰头和钩突的炎性病变.     

捆绑式胰管对黏膜吻合术

目的 研究一种与捆绑式胰肠吻合术和捆绑式胰胃吻合术互补的术式--捆绑式胰管对黏膜吻合术的可行性.方法 (1)动物实验:对6只成年新西兰兔行胃肠造瘘术,两个造瘘口分别用导尿管、硅胶管、输液器管作为支撑管连接,导管两端分别置入胃腔与肠腔内,造瘘口荷包缝合,胃壁与肠壁浆膜层拉拢缝合周定.观察胃肠造瘘口处渗漏及愈合情况,显微镜下观察胃黏膜与空肠黏膜愈合情况.(2)临床实践:对7例患者施行捆绑式胰管对黏膜吻合术.手术方法包括:胰端的准备、肠侧的准备、胰断端与空肠对合固定的准备、吻合的实施、最后施行胰断端与空肠的对合固定.术后定期检测腹腔内引流管和血淀粉酶以及各种并发症的情况.胰漏按来源不同分为胰腺实质漏(胰创面漏)和吻合口漏两种.结果 动物实验结果显示愈合良好.临床全部病例均未出现吻合口漏,但有2例腹腔内引流液淀粉酶出现一过性增高,引流量均未超过50 ml/d,未影响患者康复,属于胰腺实质漏(胰腺创面漏).结论 捆绑式胰管对黏膜吻合术是一种简单安全的吻合方法,给外科医生提供了一种新的选择,以便在面对不同的患者时,能够灵活采用不同的方法去取得最理想的治疗效果.

Abstract：

Objective To study the feasibility of binding pancreatic duct to mucosa anastomosis (BDM)-a complementary procedure to both binding pancreaticojejunostomy and binding pancreaticogastrostomy. Methods (1) Animal experimental study: gastrostomy and jejunostomy were performed on six adult New Zealand rabbits. The gastrostomy and jejunostomy shared a same stent (rubber urethral catheter, silicone tube or plastic infusion tube). Both ends of the stent were placed in gastric and enteric cavity. Purse-string suture was performed around the stent before the jejunum and the stomach were brought together for fixation by few stitches. And to observe whether the purse-string suture around a plastic tube,rubber tube or silicon tube inserted into jejunum and/or stomach can prevent leaking out of the jejunal or gastric content to cause peritonitis. (2)Clinically 7 patients were performed with BDM anastomosis. The procedure was consisted of five steps: preparation of the pancreatic stump; preparation of the jejunum;preparation of the fixing sutures between the pancreatic stump and the jejunum; implementation of the anastomosis; lastly, fixation of the jejunum beside the pancreas stump. Post-operative periodic examination of the blood amylase and the amylase in the abdominal drainage. Pancreatic fistula was classified in to two categories: parenchymal fistula (pancreatic cut surface fistula) and anastomotic leakage. Results Animal experiment did not show any leakage around the plastic tube or silicon tube inserted into jejunum and(or) stomach. There was no anastomotic leak in all the patients. There was transient increase of amylase in two cases, but the volume of drainage did not exceed 50 ml/d and the recovery of the patients was not affected.Conclusions BDM is a simple, safe and easy procedure to perform. It provides to the surgeons with a new option in different situations to achieve the most ideal surgical result.