胰十二指肠切除术后患者早期下床活动方案的构建

目的:探讨科学、可行的胰十二指肠切除术后早期下床活动方案。方法:于2020年2月成立课题组,经文献循证和专家小组讨论初步拟定早期下床活动方案,采用德尔菲法于2020年6—10月选取来自北京3家三级甲等医院的共11名专家进行2轮函询,计算专家积极系数、专家的权威系数、肯德尔协调系数,根据专家修改意见构建早期下床活动方案。...     

腹腔镜胰十二指肠切除术的个体化策略

腹腔镜胰十二指肠切除术(LPD)的安全性及有效性已逐步得到国内众多学者的认可,并有望成为壶腹周围肿瘤的标准术式。本单位是国内最早开展LPD的单位之一,经过长期的经验积累,根据不同患者的实际情况选择个体化的手术治疗策略,并逐渐形成具有自己特色的程序化手术流程,此手术流程设计充分发挥了腔镜的优势,遵循由下到上、由前到后、由左到右的手术切除顺序,有效优化手术中的操作细节,充分的利用每一个暴露好的手术野,减少了不必要的重复术野暴露,在保证手术质量的同时能明显缩短手术时间。     

腹腔镜胰十二指肠切除术的难点与争议

近年来腹腔镜胰十二指肠切除术治疗胰头癌的可行性、安全性与有效性逐渐获得认可,但仍存在争议。其中一些技术难点也影响其在更大范围的推广与应用。本文述评该领域的若干热点问题,探讨技术难点及其处理路径。     

Pancreaticoduodenectomy complicated by Budd-Chiari syndrome: A case report and review of literature

BACKGROUND Pancreaticoduodenectomy(PD)-induced morbidity, consisting mainly of the pancreatic fistula and its hemorrhagic and infectious consequences, is well described in the literature, in terms of its definition, risk factors, preventive measures, and standardized management of complications. However, some lifethreatening complications remain atypical and undescribed. CASE SUMMARY We report here the case of a 69-year-old patient with Budd-Chiari syndrome that occurred after arterial embolization of postpancreatectomy hemorrhage. Diagnosis was established with biological findings(i.e., acute liver failure) and radiological findings(i.e., compressive hematoma of the retrohepatic vena cava). Emergency surgical revision was performed to evacuate the hematoma. The postoperative course was uneventful, with rapid recovery of liver function. To our knowledge, post-PD Budd-Chiari syndrome has never been described in the literature. CONCLUSION Acute liver failure in early post-PD should prompt investigation to rule out Budd-Chiari syndrome.     

Adenocarcinoma duodenal: resultados del tratamiento quirúrgico de una serie unicéntrica de 27 pacientes

IntroductionDuodenal adenocarcinoma is a rare malignancy. Given the rarity of the disease, there is limited data related to resection results. The objective is to analyze results at our hospital after the curative resection of duodenal adenocarcinoma (DA).MethodsThe variables were retrospectively collected from patients operated on between 1990 and 2017 at our hospital.ResultsA total of 27 patients were treated. Twenty-three patients (85%) underwent pancreaticoduodenectomy, and 4 patients (15%) with tumors located in the third and fourth portions of the duodenum underwent segmental duodenal resection. The overall postoperative morbidity was 67% (18 patients). Postoperative mortality was 7% (2 patients); however, postoperative mortality related to surgery was 4% (1 patient). All patients had negative resection margins. A median of 18 lymph nodes (range, 0-38) were retrieved and evaluated, with a median of 1 involved node (range, 0-8). Median follow up was 23 (9-69.7) months. Actuarial overall survival was 62.2 (25.2-99.1) months. Actuarial disease-free survival was 49 (0-133) months.ConclusionsThe surgical treatment of duodenal adenocarcinoma is associated with a high morbidity, although it achieves considerable survival. Depending on the tumor location and if there is no pancreatic infiltration, segmental duodenal resection with negative margins is an alternative to cephalic pancreaticoduodenectomy.     

Application of single balloon enteroscopy-assisted therapeutic endoscopic retrograde cholangiopancreatography in patients after bilioenteric Roux-en-Y anastomosis: Experience of multi-disciplinary collaboration

BACKGROUND Bilioenteric Roux-en-Y anastomosis is one of the most complicated approaches for reconstructing the gastrointestinal tract, and endoscopic retrograde cholangiopancreatography(ERCP) is technically challenging in patients after bilioenteric Roux-en-Y anastomosis. The optimal endoscopic strategies for such cases remain unknown.AIM To explore the feasibility and effectiveness of single balloon enteroscopy-assisted(SBE-assisted) therapeutic ERCP in patients after bilioenteric Roux-en-Y anastomosis based on multi-disciplinary collaboration between endoscopists and surgeons as well as report the experience from China.METHODS This is a single center retrospective study. All of the SBE-assisted therapeutic ERCP procedures were performed by the collaboration between endoscopists and surgeons. The operation time, success rate, and complication rate were calculated.RESULTS Forty-six patients received a total of 64 SBE-assisted therapeutic ERCP procedures, with successful scope intubation in 60(93.8%) cases and successful diagnosis in 59(92.2%). All successfully diagnosed cases received successful therapy. None of the cases had perforation or bleeding during or after operation,and no post-ERCP pancreatitis occurred.CONCLUSION Based on multi-disciplinary collaboration, SBE-assisted therapeutic ERCP in patients after bilioenteric Roux-en-Y anastomosis is relatively safe and effective and has a high success rate.     

Influence of bile contamination for patients who undergo pancreaticoduodenectomy after biliary drainage

BACKGROUND The influence of bile contamination on the infectious complications of patients undergoing pancreaticoduodenectomy(PD) has not been thoroughly evaluated.AIM To evaluate the effect of preoperative biliary drainage and bile contamination on the outcomes of patients who undergo PD.METHODS The database of 4101 patients who underwent PD was reviewed. Preoperative biliary drainage was performed in 1964 patients(47.9%), and bile contamination was confirmed in 606 patients(14.8%).RESULTS The incidence of postoperative infectious complications was 37.9% in patients with preoperative biliary drainage and 42.4% in patients with biliary contamination, respectively. Patients with extrahepatic bile duct carcinoma,ampulla of Vater carcinoma, and pancreatic carcinoma had a high frequency of preoperative biliary drainage(82.9%, 54.6%, and 50.8%) and bile contamination(34.3%, 26.2%, and 20.2%). Bile contamination was associated with postoperative pancreatic fistula(POPF) Grade B/C, wound infection, and catheter infection. A multivariate logistic regression analysis revealed that biliary contamination(odds ratio 1.33, P = 0.027) was the independent risk factor for POPF Grade B/C. The three most commonly cultured microorganisms from bile(Enterococcus, Klebsiella,and Enterobacter) were identical to those isolated from organ spaces.CONCLUSION In patients undergoing PD, bile contamination is related to postoperative infectious complication including POPF Grade B/C. The management of biliary contamination should be standardised for patients who require preoperative biliary drainage for PD, as the main microorganisms are identical in both organ spaces and bile.     

胰十二指肠切除术后急性肾损伤的危险因素分析

目的探讨开腹胰十二指肠切除术后急性肾损伤(acute kidney injury, AKI)的危险因素。方法回顾性分析2011年11月—2018年4月行开腹胰十二指肠切除术患者389例,男219例,女170例,年龄25～79岁,ASAⅠ—Ⅳ级。收集相关围术期资料,统计术后AKI、性别、BMI、合并梗阻性黄疸、服用血管紧张素转换酶抑制剂(ACEI)或血管紧张素Ⅱ受体阻滞剂(ARB)类降压药和术后Hb等情况。采用多因素Logistic回归分析术后AKI的独立危险因素。结果术后AKI有46例(11.8%)。多因素Logistic回归分析显示,男性(OR=2.33,95%CI 1.13～4.82,P=0.023)、BMI≥24 kg/m~2(OR=2.39,95%CI 1.23～4.65,P=0.010)、合并梗阻性黄疸(OR=3.29,95%CI 1.70～6.37,P0.001)、服用ACEI或ARB(OR=3.93,95%CI 1.08～14.38,P=0.038)和术后Hb中重度下降(OR=3.81,95%CI 1.13～12.89,P=0.031)是开腹胰十二指肠切除术后AKI的独立危险因素。结论男性、BMI≥24 kg/m~2、合并梗阻性黄疸、服用ACEI或ARB、术后Hb中重度下降是开腹胰十二指肠切除术后AKI的独立危险因素。     

机器人辅助下胰十二指肠切除术：附18例报告

目的:初步总结DaVinci机器人辅助下的胰十二指肠切除术(RPD)的经验。方法:回顾2015年11月—2018年1月18例行RPD的患者临床资料。结果:18例患者手术时间为(450±30)min,术中出血量为(525±125)mL,术中均无输血;1例(5.6%)中转开腹;术后肠道功能恢复时间(4.0±1.0)d,术后住院时间(16±4)d;术后出现并发症者7例,其中4例(22.2%)术后并发胰瘘(均为B级胰瘘)、胆瘘1例、腹腔内出血2例;无再次手术,术后病死率5%。术后病理结果显示,胰腺高分化腺癌3例、低分化导管腺癌1例、胰腺浆液性囊腺瘤3例、胰腺黏液性囊腺瘤2例、胰腺导管内乳头状黏液瘤1例、十二指肠高分化腺癌2例、十二指肠绒毛管状腺瘤2例、胆总管下段中低分化腺癌1例、胆总管下段高分化腺癌2例、胰腺慢性炎症1例。9例恶性肿瘤中8例完成R_0切除,1例R1切除;淋巴结清扫数目为(16±4)枚。结论:RPD安全可行,并未明显增加手术相关并发症,同时可以加快患者术后恢复时间。