插管法胰腺空肠端侧吻合预防Whipple手术后胰瘘

目的 评价插管法胰腺空肠端侧吻合预防Ｗｈｉｐｐｌｅ手术后胰腺瘘。方法 采用残胰管内插入导管,空肠壁切开浆肌切开粘膜,吻合时只缝合胰腺断端前后缘与空肠浆肌层切开的前后唇。胰管导管穿透粘膜引入空肠腔内,不必做胰管与空肠粘膜切口缝合,１２例行胰液外引流,１４例内引流。结果 ２６例均无胰瘘发生。结论 插 胰腺空肠端侧吻合手术操作简单,可预防Ｗｈｉｐｐｌｅ手术后胰瘘。     

Invaginated duct to mucosa pancreaticojejunostomy reduce postoperative pancreatic leakage: A matched case-controlled study

Postoperative pancreatic leakage is an obstacle in pancreaticoduodenectomy, which always follows pancreaticojejunostomy (PJ) failure. Dozens of PJ procedures have been reported, and none have shown superiority over others. Therefore, the present study is conducted to assess the potential advantages of invaginated duct-to-mucosa (D-M) PJ.We retrospectively analyze the related data from patients who underwent pancreaticodedunostomy due to malignant tumors at the First Affiliated Hospital of Henan University of Science and Technology from January 2017 to August 2019. According to the different PJ procedures, the patients are divided into custom D-M group and invaginated D-M group. Matching by sex, age, pancreatic duct size, and pancreatic texture is performed. Pancreatic leakage and other complications are compared, and SPSS 16.0 is employed for analysis.A total of 48 pairs of patients are included. Patients in both groups has almost the same baseline characteristics in terms of sex (P = 1.000), age (P = .897), American Society of Anesthesiologists status (P = .575), body mass index (P = .873), pancreatic duct size (P = .932), pancreatic texture (P = 1.000) and tumor origin (P = .686). No significant difference is observed in operative outcomes, such as operative duration (P = .632), PJ duration (P = .748), blood loss (P = .617) and number of required transfusions (P = .523). Pancreatic leakage is significantly decreased in the invaginated D-M group (P = .005). The differences in other complications, such as bleeding (P = .617), biliary leakage (P = .646), pneumonia (P = .594) and thrombosis (P = .714), do not reach statistical significance. The postoperative hospitalization duration is almost the same for both groups (P = .764).Invaginated D-M PJ may reduce pancreatic leakage following pancreaticoduodenectomy.     

Tailored pancreatic reconstruction after pancreaticoduodenectomy: a single-center experience of 892 cases

BACKGROUND: Pancreatic reconstruction following pancre-aticoduodenectomy (PD) is still debatable even for pancreatic surgeons. Ideally, pancreatic reconstruction after PD should reduce the risk of postoperative pancreatic fistula (POPF) and its severity if developed with preservation of both exo-crine and endocrine pancreatic functions. It must be tailored to control the morbidity linked to the type of reconstruction. This study was to show the best type of pancreatic reconstruc-tion according to the characters of pancreatic stump. METHODS: We studied all patients who underwent PD in our center from January 1993 to December 2015. Patients were categorized into three groups depending on the presence of risk factors of postoperative complications: low-risk group (ab-sent risk factor), moderate-risk group (presence of one risk fac-tor) and high-risk group (presence of two or more risk factors). RESULTS: A total of 892 patients underwent PD for resection of periampullary tumor. BMI >25 kg/m2, cirrhotic liver, soft pancreas, pancreatic duct diameter <3 mm, and pancreatic duct location from posterior edge <3 mm are risk variables for development of postoperative complications. POPF de-veloped in 128 (14.3%) patients. Delayed gastric emptying occurred in 164 (18.4%) patients, biliary leakage developed in 65 (7.3%) and pancreatitis presented in 20 (2.2%). POPF in low-, moderate- and high-risk groups were 26 (8.3%), 65 (15.7%) and 37 (22.7%) patients, respectively. Postoperative morbidity and mortality were significantly lower with pan-creaticogastrostomy (PG) in high-risk group, while pancre-aticojejunostomy (PJ) decreases incidence of postoperative steatorrhea in all groups. CONCLUSIONS: Selection of proper pancreatic reconstruc-tion according to the risk factors of patients may reduce POPF and postoperative complications and mortality. PG is superior to PJ as regards short-term outcomes in high-risk group but PJ provides better pancreatic function in all groups and therefore, PJ is superior in low- and moderate-risk groups.     

胰十二指肠切除术中胰胃吻合研究进展

正胰腺的主要吻合方式包括胰肠吻合与胰胃吻合两种。自1935年Whipple首先使用胰肠吻合完成第一例胰十二指肠切除术后,胰肠吻合经历了长期的演变,目前已经愈加成熟,但其术后胰瘘发生率仍维持在5.0%~25.0%[1]。而较其稍后出现的胰胃吻合一直未在临床上得到广泛应用。近年来,由于胰胃吻合理论上可减少胰瘘发生的优势和临床随机对照试验结果的支持,使得该技术逐渐得到外科医师的认可。本文结合最新的相关文献,对胰胃吻合方     

胰胃吻合术与胰肠吻合术临床疗效的比较

目的 比较胰十二指肠切除术胰胃吻合与胰肠吻合术的临床疗效.方法 2010年8月-2015年1月选择在某院进行胰十二指肠切除术78例,根据随机数字表法分为胰胃吻合组与胰肠吻合组各39例,胰胃吻合组施行捆绑式胰胃吻合术治疗,胰肠吻合组施行捆绑式胰肠吻合术治疗.结果 胰胃吻合组的胰胃吻合手术时间明显少于胰肠吻合组的胰肠吻合手术时间(P＜0.05),两组的手术时间、术中出血量和术中输血量对比差异无统计学意义(P＞0.05).胰胃吻合组的术后肛门排气时间、拔除胃管时间、进食半流质时间和住院时间明显少于胰肠吻合组(P＜0.05).胰胃吻合组术后胃排空障碍、切口感染、胰漏、胆漏、消化道溃疡出血等并发症发生情况明显少于胰肠吻合组(P＜0.05).结论 相对于胰肠吻合,胰胃吻合具有简单方便的特点,能促进患者的术后康复,能减少术后并发症的发生,对改善患者预后有明显帮助.     

Meta-analysis of pancreaticoduodenectomy prospective controlled trials: pancreaticogastrostomy versus pancreaticojejunostomy reconstruction

Background  Pancreaticogastrostomy (PG) has been proposed as an alternative to pancreaticojejunostomy (PJ), assuming that postoperative complications are less frequent. The aim of this research was to compare the safety of PG with PJ reconstruction after pancreaticoduodenectomy.

Methods  Articles of prospective controlled trials published until the end of December 2010 comparing PJ and PG after PD were searched by means of MEDLINE, EMBASE, Cochrane Controlled Trials Register databases, and Chinese Biomedical Database. After quality assessment of all included prospective controlled trials, meta-analysis was performed with Review Manager 5.0 for statistic analysis.

Results  Overall, six articles of prospective controlled trials were included. Of the 866 patients analyzed, 440 received PG and 426 were treated by PJ. Meta-analysis of six prospective controlled trials (including RCT and non-randomized prospective trial) revealed significant difference between PJ and PG regarding postoperative complication rates (OR, 0.53; 95% CI, 0.30–0.95; P=0.03), pancreatic fistula (OR, 0.47; 95% CI, 0.22–0.97; P=0.04), and intra-abdominal fluid collection (OR, 0.42; 95% CI, 0.25–0.72; P=0.001). The difference in mortality was of no significance. Meta-analysis of four randomized controlled trials (RCT) revealed significant difference between PJ and PG regarding intra-abdominal fluid collection (OR, 0.46; 95% CI, 0.26–0.79; P=0.005). The differences in pancreatic fistula, postoperative complications, delayed gastric emptying, and mortality were of no significance.

Conclusions  Meta-analysis of six prospective controlled trials (including randomized controlled trials (RCT) and non-randomized prospective trial) revealed significant difference between PJ and PG regarding overall postoperative complications, pancreatic fistula, and intra-abdominal fluid collection. Meta-analysis of four RCT revealed significant difference between PJ and PG with regard to intra-abdominal fluid collection. The results suggest that PG may be as safe as PJ.

     

胰肠吻合方法改进与应用的临床研究（附38例报告）

目的 探讨胰十二指肠切除术（pancreaticoduodenectomy, PD）胰空肠吻合的一种新方法在预防术后胰空肠吻合口瘘的应用价值。方 法自2009年6月~2013年8月行胰十二指肠切除术38例,胰肠吻合均采用空肠粘膜剥离双荷包缝合套扎+吻合口胰上下缘缝扎法,分析此吻合术式的可行性、疗效及并发症。结果本组38例胰十二指肠切除手术及胰肠吻合无手术死亡。胰漏2例,发生率为5.26%（2/38）,其中胰头癌1例,胆管癌1例,分别发生于术后第7天和第10天,每天约20~100 ml,经用生长抑素药物治疗3周后治愈。12~18 d 拆线,其他患者恢复良好,未发生腹腔感染、胆瘘、肠瘘及大出血等严重并发症。无死亡病例。结论空肠粘膜剥离双荷包缝合套扎+吻合口胰上下缘缝扎法,在胰肠吻合中可行性强,方法简单,疗效可靠,胰瘘发生率低,有明显的临床优势,有实用推广价值。