胰腺头部实性假乳头状瘤的手术治疗

目的:观察手术切除术治疗胰腺头部实性假乳头状瘤的临床疗效。方法:回顾性分析2008年11月至2014年7月间,盛京医院普通外科14例因患胰腺头部实性假乳头状瘤而行手术治疗的患者临床资料,女性12例,男性2例,平均年龄36.2岁。8例行胰十二指肠切除术,2例行保留幽门的胰十二指肠切除术,2例行胰腺部分切除术,1例行胰十二指肠切除术联合门静脉切除术,1例行胰腺部分切除术联合胰体尾空肠Roux-en-Y吻合术。评价手术效果,分析影像特点,并随访远期效果。结果:肿瘤平均7.1cm×6.1cm,所有患者术后病理及免疫组化证实胰腺实性假乳头状瘤,平均住院时间26天,有5例发生术后胰瘘,发病率35.7%,无死亡病例。术后随访8~82个月,中位随访时间27.5个月,有 1例于术后66个月复发,其余13例均无复发。结论:手术治疗胰腺头部实性假乳头状瘤是安全的,完整切除肿物远期疗效确切。     

Resting energy expenditure in patients undergoing pylorus preserving pancreatoduodenectomies for bile duct cancer or pancreatic tumors

We measured the energy expenditure weekly in patients undergoing a pylorus preserving pancreatoduodenectomy for bile duct cancer or pancreatic tumors. Twelve patients (5 women and 7 men; mean age 70.1 years) were enrolled in this study, and their resting energy expenditure levels were determined by indirect calorimetry. In these patients, a significant correlation was observed between the measured resting energy expenditures and the predicted resting energy expenditures calculated by the Harris-Benedict equation. The resting energy expenditures measured before surgery were almost the same as the predicted resting energy expenditures (measured resting energy expenditure: 22.4 ± 3.9 kcal/kg/day vs predicted resting energy expenditure: 21.7 ± 2.0 kcal/kg/day). The measured resting energy expenditure/predicted resting energy expenditure ratio, which reflects the stress factor, was 1.02 ± 0.10. After the pylorus preserving pancreatoduodenectomy, a significant increase in energy expenditure was observed, and the measured resting energy expenditure was 25.7 ± 3.5 kcal/kg/day on postoperative day 7 and 25.4 ± 4.9 kcal/kg/day on postoperative day 14. The measured resting energy expenditure/predicted resting energy expenditure ratio was 1.16 ± 0.14 on postoperative day 7, and 1.16 ± 0.18 on postoperative day 14 respectively. In conclusion, patients undergoing a pylorus preserving pancreatoduodenectomy showed a hyper-metabolic status as evaluated by their measured resting energy expenditure/predicted resting energy expenditure ratio. From our observations, we recommend that nutritional management based on 30 kcal/body weight/day (calculated by the measured resting energy expenditure×activity factor 1.2–1.3) may be optimal for patients undergoing a pylorus preserving pancreatoduodenectomy.     

Radiologic and intraoperative detection of need for mesenteric vein resection in patients with adenocarcinoma of the head of the pancreas

ObjectiveThe need for mesenteric venous resection (MVR) is determined by a combination of preoperative radiologic and intraoperative surgical assessments. A single-centre review was performed to determine how efficient these processes are in evaluating the need for MVR.MethodsA retrospective study was performed of 343 patients who received resection for adenocarcinoma of the head of the pancreas, 100 of whom underwent MVR. Three radiologic signs (abutment, fat plane obliteration, focal narrowing) were evaluated for their ability to predict the need for MVR. Pathologic assessment was performed to determine if MVR had been necessary to achieve negative-margin (R0) resection. Microscopic tumour in the vein wall, or within 1 mm of the vein wall, was considered to indicate that MVR had been necessary to achieve an R0 resection.ResultsRadiologic evaluation (showing any of the three signs) had sensitivity of only 60%. Overall, 40% of the patients who required MVR showed none of the signs. Specificity was 77%. A total of 80% of patients who underwent MVR had either microscopic invasion or abutment. R0 resection at the vein margin was achieved in 98% of patients in both the MVR and non-MVR groups.ConclusionsPreoperative radiologic evaluation is not highly reliable in predicting the need for MVR. Therefore, surgical teams performing resections of cancers of the head of the pancreas must be skilled in MVR as the need for this procedure may arise unexpectedly. Surgical assessment of the need for MVR has an accuracy of about 80% and is nearly 100% accurate in determining when MVR is not required.     

充分重视上消化道重建基本原则及吻合方式合理性

手术后上消化道重建必须保持其原有的生理功能和较少的并发症。胃切除、胆道手术和胰腺手术都有其各自的特点,术后重建方式也有其各自的适应范围和优缺点。外科医师应该依据病人的疾病情况、基础状态和自身经验等,综合考虑决定重建方式,而不应固守某一种重建方式。     

No mortality after 150 consecutive pancreatoduodenctomies with duct-to-mucosa pancreaticogastrostomy

BACKGROUND AND OBJECTIVES: The mortality rate after pancreatoduodenectomy (PD) remains 0-5% at major surgical centers with the major cause of operative death being a leak at the pancreaticojejunal anastomosis. The aim of this retrospective study was to evaluate the safety of duct-to-mucosa pancreaticogastrostomy (PG) at a single institute. METHODS: One hundred fifty consecutive patients with pancreato-biliary diseases undergoing duct-to-mucosa PG following PD between 1995 and 2005 were evaluated. One hundred forty patients underwent a pylorus-preserving PD and 10 patients underwent a conventional PD (Whipple operation). External drainage of pancreatic juice was performed in 77 cases. RESULTS: The mean operating time was 378 min and the mean blood loss was 1,640 ml. Blood transfusion was not required in 97 patients (65%). The morbidity rate was 50% (75/150), but the mortality rate was 0%. Pancreatic fistulae occurred in 11 patients (7%). Gender, age, operative procedure, portal vein resection, external drainage of the pancreatic juice, operative time, blood loss and blood transfusion did not affect the rate of pancreatic fistula. The rate of pancreatic fistulae tended to be lower in pancreatic carcinoma (3%) than non-pancreatic carcinoma (11%). CONCLUSIONS: Duct-to-mucosa PG is a safe procedure for reconstruction following PD.     

The infrapyloric artery and cephalic pancreatoduodenectomy with pylorus preservation: preliminary study

Summary Cephalic pancreatoduodenectomy (CPD) with pylorus preservation has been suggested to improve the functional and nutritional result of surgery. At operation, the first two centimeters of the duodenum are preserved, the vascular arch of the lesser gastric curvature is saved and the right gastroepiploic artery is resected at its origin. The aim of this study on 15 fresh cadavers was to determine the origin of the vascularization of the remaining duodenum and also the possibilities of preserving an optimal vascularization after CPD and pylorus preservation. All of the arteries supplying the remaining duodenum and arising either from the right gastric artery or the right gastroepiploic artery were identified. The distances between the origin of the infrapyloric artery and the termination of the gastroduodenal artery on the cranial and ventral pancreaticoduodenal artery and the left gastroepiploic artery were measured. At CPD with pylorus preservation, the study demonstrated that: 1) the cranial side of the remaining duodenum remains vascularized in 80% of the cases by one or two supraduodenal branches coming from the right gastric artery; 2) ligation of the right gastroepiploic artery eliminates all vascular supply to the caudal side of the remaining duodenum in almost half of the cases; 3) in these cases, the dissection of the bifurcation of the gastroduodenal artery and the vascular section beyond the origin of the infrapyloric artery allowed a direct vascular supply to the remaining duodenum to be preserved.This work was presented at the French Section of the European Association of Clinical Anatomy meeting, Bobigny, France, 1992     

胰十二指肠切除术病人胃电图变化

通过对胰十二指肠切除术病人手术前后体表胃电图的研究，探讨手术对病人胃电及排空功能的影响。结果表明：保留幽门的胰十二指肠切除术病人术前６０％存在胃律紊乱及胃排空障碍，８０％此类病人术后出现胃电及胃排空异常。上述结果提示：对拟行保留幽门的胰十二指肠切除术病人术前胃电图检查表现胃节律紊乱及胃排空障碍者，术中应考虑胃及空肠造瘘。     

胰十二指肠切除术后腹腔并发症发生及引流留置时间预测

目的 研究分析胰十二指肠切除术后严重腹腔内并发症发生及引流留置时间的相关预测因素.方法 回顾性分析我院2010年1月至2013年12月施行的113例胰十二指肠切除术后患者腹腔内严重并发症发生与术后炎症反应持续时间、腹腔引流液淀粉酶水平等因素之间的关系.结果 在无并发症组及A级胰瘘组患者中,腹腔引流液淀粉酶值出现平稳降低,且经历较短时间的术后炎症反应（1.7±2.4）d;而在严重并发症组患者中,腹腔引流液淀粉酶值自术后第3天开始出现持续性升高,并且经历较长时间的术后炎症反应（4.5±4.4）d.结论 通过结合患者引流液淀粉酶值变化趋势及术后炎症反应天数等指标可以早期预测腹腔内严重并发症发生情况,为临床确定引流管拔除时机及制定相应治疗方案提供依据.