加速康复外科模式对腹腔镜下胰十二指肠切除术后患者肠道黏膜屏障影响的研究

目的研究加速康复外科(ERAS)模式对腹腔镜下胰十二指肠切除术(LPD)术后患者的肠黏膜屏障功能的影响。方法回顾性分析2015年1月至2018年12月接受LPD术的患者145例,根据干预方案不同分为ERAS组78例及传统组67例。数据采用SPSS 24.0进行统计学分析,术后并发症发生率等计数资料采用χ^2检验;围术期各项指标、肠黏膜屏障功能指标以(±s)表示,独立t检验;P<0.05为差异有统计学意义。结果ERAS组术后恢复情况均优于传统组,其中首次排气时间、首次进食时间、引流管拔管时间及术后住院时间差异均有统计学意义(P<0.05);两组术后死亡率差异无统计学意义(P>0.05);ERAS组患者胃排空延迟的发生例数(3例,3.8%)明显少于传统组(5例,7.5%)(P<0.05),其余并发症比较差异无统计学意义(P>0.05);两组患者术后肠黏膜屏障功能指标ERAS组患者优于传统组,但差异无统计学意义(P>0.05)。结论加速康复外科能使LPD术获得更好的临床效果,并可促进LPD患者术后肠黏膜屏障功能的恢复。     

快速康复理念在胰十二指肠切除术中应用的有效性及安全性评价

目的探讨快速康复理念在胰十二指肠切除术中应用的安全性及有效性。方法在Pub Med,Web of Science,Cochrane Library,中国知网等全文数据库检索"快速康复"与"胰十二指肠切除术"相关研究,最终纳入7篇研究进行定量分析。结果快速康复组患者手术时间明显短于对照组(P0.05),术后肠功能恢复时间、初次排气时间、住院时间、总费用均明显低于对照组(P0.05),快速康复组与对照组术后严重并发症发生率差异无统计学意义(P0.05)。结论快速康复能加速胰十二指肠切除患者术后的恢复,且不增加术后并发症。     

The novel use of a biodegradable stent placed by percutaneous transhepatic cholangiography for the treatment of a hepaticojejunostomy biliary leak following an extended left hepatectomy and pancreaticoduodenectomy

A 61-year-old man presented with jaundice, and subsequently underwent an extended left hepatectomy and pancreaticoduodenectomy for a cholangiocarcinoma invading the head of the pancreas. The patient developed sepsis due to a biliary leak at the hepaticojejunostomy. We describe the original use of a biodegradable stent, deployed via percutaneous transhepatic cholangiography into the Roux limb, resulting in good drainage and resolution of sepsis. The chief benefit of this procedure is the lack of need for subsequent removal as well as purported reduced biofilm accumulation. We believe this to be the first reported case of this type and the literature surrounding the subject is also discussed.     

Intraoperative amylase level of pancreatic juice as a simple predictor of pancreatic fistula after pancreaticoduodenectomy

IntroductionA soft remnant texture of the pancreas is commonly accepted as a risk factor for postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD). However, its assessment is subjective. The aim of this study was to evaluate the significance of intraoperative amylase level of the pancreatic juice as a risk factor of POPF after PD.MethodThis study included 75 patients who underwent PD between November 2014 and April 2020 at Jikei University Hospital. We investigated the relationship between pancreatic texture, intraoperative amylase level of pancreatic juice, results of the pathological evaluations, and the incidence of POPF.ResultsTwenty-three patients (31%) developed POPF. The significant predictors of POPF were non-ductal adenocarcinoma (p < 0.01), soft pancreatic remnant (p < 0.01), high intraoperative blood loss (p < 0.01), high intraoperative amylase level of pancreatic juice (p < 0.01), and low pancreatic fibrosis (p < 0.01). Multivariate analysis revealed that the significant independent predictors of POPF were high intraoperative blood loss (p < 0.01) and high intraoperative amylase level of pancreatic juice (p = 0.02). Receiver operating characteristic (ROC) analysis showed that the cut-off value for the intraoperative amylase level of pancreatic juice was 2.17 × 10⁵ IU/L (area under the curve = 0.726, sensitivity = 95.7%, and specificity = 50.0%)ConclusionsThe intraoperative amylase level of pancreatic juice is a reliable objective predictor for POPF after PD.     

Impact of vascular abnormality on contrast-enhanced CT and high C-reactive protein levels on postoperative pancreatic hemorrhage after pancreaticoduodenectomy: A multi-institutional,retrospective analysis of 590 consecutive cases

Background/Objectives: This study aimed to elucidate the efficacy of CT findings and perioperative characteristics to predict post-pancreatectomy hemorrhage (PPH): a critical complication after pancreaticoduodenectomy.MethodsThe records of 590 consecutive patients who underwent pancreaticoduodenectomy at three institutes between 2012 and 2018 were included. The presence of a vascular wall abnormality or ascites with high density (vascular abnormality) on postoperative day (POD) 5–10 contrast-enhanced CT (early CT), perioperative characteristics, and any PPH or pseudoaneurysm formation (PPH events) were analyzed through a multivariate analysis.ResultsPPH events occurred in 48 out of 590 patients (8%). The vascular abnormality on early CT and the C-reactive protein (CRP) value on POD 3 were independent risk factors for PPH events after POD5 (vascular abnormality: odds ratio 6.42, p = 0.001; CRP on POD 3: odds ratio 1.17, p = 0.016). The sensitivity of vascular abnormality for PPH events was 24% (7/29), and the positive predictive value was 30% (7/23). The combination of vascular abnormality and a high CRP value (≥15.5 mg/dL) on postoperative day 3 had a higher positive predictive value of 64% (7/11) than the vascular abnormality alone. None of the seven PPH events that occurred more than one month after surgery were foreseen via early CT.ConclusionThe combination of vascular abnormality and high CRP value was associated with increasing risk of PPH events after pancreaticoduodenectomy, but the low sensitivity of early CT must be noted as an important shortcoming. The normal findings on early CT could not eliminate the risk of late PPH.     

Long-Term Survival in Patients with Locally Advanced Colon Cancer After <Emphasis Type="Italic">En Bloc</Emphasis> Pancreaticoduodenectomy and Colectomy

Purpose  Surgical indications for colon cancer directly invading the pancreas head are controversial. Methods  Between 1957 and 2007, a total of 12 patients (8 men) underwent pancreaticoduodenectomy combined with right hemicolectomy for colon cancer involving the pancreas head. Results  Mean age was 58 (range, 34–77) years. Fistula formation was observed in five patients (41 percent) preoperatively. Tumor involvement was duodenum only (n = 4), duodenum/pancreas (n = 3), stomach/pancreas (n = 1), duodenum/stomach (n = 2), duodenum/liver (n = 1), and pancreas only (n = 1). Only one postoperative death was encountered. Histologic examination showed malignant invasion to the pancreas head in nine cases (75 percent). Overall one-year, three-year and, five-year survival rates after surgery were 75, 66, and 55 percent, respectively. Five patients (41 percent) survived for more than ten 10 years. Conclusions  Pancreaticoduodenectomy for advanced colon cancer invading the pancreas or duodenum provides favorable long-term survival. Supported by a Grant-in-Aid for Basic Research to Dr. Akio Saiura from the Ministry of Education, Culture, Sports, Science and Technology. Reprints are not available.     

Feeding jejunostomy during Whipple is associated with increased morbidity

Background

Placement of a feeding jejunostomy tube (FJ) is often performed during pancreaticoduodenectomy (PD). Few studies, however, have sought to determine whether such placement affects postoperative outcomes after PD.

Materials and methods

This is a retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) database to determine the 30-d-postoperative mortality rate, major complication rate, and overall complication rate of jejunostomy tube placement at the time of PD. Univariate and multivariate comparison of postoperative outcomes between patients with and without FJ placement during PD was performed on a total of 4930 patients.

Results

Thirty-day-postoperative mortality did not differ between the two groups (4.0% for patients with FJ versus 2.7% without, P = 0.13), whereas overall morbidity (43.3% with FJ versus 34.6% without, P < 0.0001) and serious morbidity (29.5% with FJ versus 22.8% without, P < 0.0001) were significantly higher in patients undergoing FJ placement during PD. The specific complications that occurred more frequently in FJ patients than patients without FJ included deep space surgical site infection, pneumonia, unplanned reintubation, acute renal failure, and sepsis.

Conclusion

Although FJ placement during PD is considered to be routine at many institutions, our analysis of data from NSQIP suggest that FJ placement may be associated with increased postoperative morbidity.     

Reduction of alkaline reflux gastritis and marginal ulcer by modified Braun enteroenterostomy in gastroenterologic reconstruction after pancreaticoduodenectomy

Background

The incidence of alkaline reflux gastritis (ARG) after pancreaticoduodenectomy (PD) is high. Although Braun enteroenterostomy (BEE) may reduce ARG, BEE may result in marginal ulcers (MUs) due to the additional anastomotic stoma. We conducted this study to compare clinical outcomes of using a modified BEE (MBEE) with traditional gastrojejunostomy (TGJ), by inducting a purse-string suture instead of an additional anastomotic stoma.

Materials and methods

All 62 patients underwent standard PD at the Department of Hepatobiliopancreatic Surgery of West China Hospital between January 1, 2008 and January 31, 2012. Demographics, perioperative and postoperative factors, and follow-up morbidity were compared in those patients who underwent MBEE (n = 32, three patients were lost to follow-up) to those who underwent TGJ (n = 30, nine patients were lost to follow-up).

Results

Patients who underwent the MBEE experienced a decrease in total morbidity including ARG and MUs, relative to those who underwent TGJ (24.1% versus 58.3%, P = 0.011). With regard to the MBEE group, the total ARG rate was statistically significantly lower compared with the TGJ group (13.8% versus 37.5%, P = 0.046). In addition, the incidence of MUs was reduced.

Conclusions

In patients undergoing PD, the MBEE was safely performed with significantly more patients having reduced incidence of ARG and related sequela compared with those who underwent TGJ. These results support further study of patients undergoing gastroenterostomy after resection of the distal stomach in larger, randomized studies.     

Pancreaticoduodenectomy for malignancies in children

Purpose

Malignant tumors of the common bile duct or of the pancreas head are uncommon in childhood [Perez EA, Gutierrez JC, Koniaris LG, Neville HL, Thompson WR, Sola JE. Malignant pancreatic tumors: incidence and outcome in 58 pediatric patients. J Pediatr Surg. 2009; Jan; 44 (1): 197–203]. With radical surgery being the standard cure for nonmetastatic diseases, pancreaticoduodenectomy (PD) is the best choice when the tumor is localized in the head of the pancreas, or in the lower portion of the common bile duct. The purpose of the present study is to describe five consecutive children managed by PD, and reviewing the particular aspects and results of this rare procedure in children.

Methods

Between 2007 and 2010, five patients (median age: 7 years) underwent PD for nonmetastatic malignant tumors. In two cases, PD was performed en bloc with a right hepatectomy in order to achieve the radical resection of a recurrent biliary sarcoma. Four patients benefited from a “pylorus-preserving” PD procedure. In two patients, resection of the portal vein and vascular reconstruction was performed, and in one case, an extended resection of the biliary ductal system was necessary.

Results

All resection margins were clear. The postoperative course was uneventful, with no pancreatic or biliary leakage in all of the patients. Oral refeeding was achieved by the eighth postoperative day. In two cases, a late revision of pancreatic–jejunal anastomosis was performed because of mild steatorrea and a suspected anastomotic stricture. Two of the patients, who were subsequently operated on second hand, for biliary sarcoma, died from the recurrence; while three of the others, with pancreatic malignancies, are alive and well, with a good functional outcome.

Conclusions

Surgical resection is the treatment of choice for tumors of the pancreatic head area. In the absence of regional or metastatic extension, the radicality of primary intervention is associated with favorable outcomes. Good functionality results were observed after the PD was limited to the head of the pancreas and subject to pylorus-preserving techniques.