胰管纵向切开减压、胰管空肠侧侧吻合术治疗慢性胰腺炎的手术适应证及评价

疼痛是慢性胰腺炎最主要的主观临床症状,严重影响病人的生活质量。慢性胰腺炎产生疼痛的原因可能有多种因素,其中,胰腺导管-组织压力增高伴弹力纤维活化可能是主要的原因之一[1]。采用手术解除胰管梗阻、达到胰管减压目的,可使病人的发作性疼痛症状获得缓解和延缓胰腺实质纤维化及内外分泌功能的丢失的进程。降低胰腺和组织内压力有多种术式,其中胰管纵向切开减压、胰管空肠侧侧吻合术是一减压效果确切、临床应     

胰十二指肠切除术消化道重建方式合理选择

消化道重建是胰十二指肠切除术(PD)中最重要的手术操作环节。消化道重建方式及方法的选择是否合理、恰当,不仅涉及手术本身的完美实施,更是与术后并发症尤其是胰瘘的发生密切相关。但是,目前PD中如何选择消化道重建方式,意见尚未完全统一。鉴于此,《中国实用外科杂志》编辑部邀请国内部分专家围绕PD消化道重建方式合理选择展开讨论,希望在展示国内外最新研究成果和各单位经验的同时,为外科医师提供借鉴。     

胰十二指肠切除术中几个关键技术

胰十二指肠切除术的手术死亡率及并发症发生率已显著降低,但该手术的复杂性、高风险性仍困扰着外科医生。鉴于此,本期邀请国内多位专家围绕胰十二指肠切除术中的几个关键问题进行讨论,即联合血管切除(动、静脉及变异血管)、No.16淋巴结清扫指征及意义、胰肠吻合方式选择及评价。希望在展示国内外最新研究成果和各单位经验的同时,为外科医生提供借鉴。     

Has the Partington procedure for chronic pancreatitis become a thing of the past? A review of the evidence

Introduction

For the surgical management of chronic pancreatitis with an inflammatory pancreatic head mass, extended drainage operations such as Beger and Frey procedures were established in the 1980s as an alternative to resectional procedures like pancreaticoduodenectomy and as opposed to simple drainage operations such as lateral pancreaticojejunostomy, that is, the Partington procedure. With the relatively rapid adoption of the two procedures, it seems that the Partington procedure has become a thing of the past.

Materials and methods

The Partington procedure was re-evaluated with regard to the historical aspects and its present status by a literature review.

Results

The results show that this procedure relieves chronic abdominal pain in 66–91% of patients with a mean follow-up of 3.5–9.1 years. It is important to note that this procedure is generally used for inflammatory disease left of the gastroduodenal artery and is specifically not used as the procedure of choice for inflammatory disease of the pancreatic head.

Conclusion

For patients with a dilated main pancreatic duct but without an inflammatory pancreatic head mass, the Partington procedure is still the procedure of choice, since it is technically simple to perform with a minimum of morbidity and mortality, preserving pancreatic endocrine and exocrine function. Because it is a relatively simple technique, the laparoscopic approach will be justified as a treatment of appropriate patients in the near future.     

学习曲线期安全开展腹腔镜胰十二指肠切除术经验

正由于腹腔镜胰十二指肠切除术(laparoscopic pancreaticoduodenectomy,LPD)是普通外科领域技术最复杂的腹腔镜手术之一,具有学习曲线长、风险高的特点,若在学习曲线期不能有效控制质量,将导致其并发症发生率和病死率明显高于开放手术~([1-4])。因此,探讨如何借鉴成熟开展LPD团队的经验,提高学习曲线期LPD的质量,有助于我国LPD质量控制和普及。1必需的手术设备和器械     

捆绑式胰肠吻合术-150例临床应用

目的：介绍一种安全,有效,简单,实用的预防胰十二指肠切除术后胰肠吻合口漏的手术方法。方法：总结浙江大学医学院附属第二医院普外科及附属邵逸夫医院普外科1996年1月至2001年1月间150例捆绑式胰肠吻合术预防胰漏的临床经验和手术方法。结果：全组150例无一例发生胰漏。结论：捆绑式胰肠吻合术操作简单,安全,可以作为胰肠吻合的标准术式。     

胰十二指肠切除术中连续胰肠吻合和Y形空肠内引流的应用

目的评价连续胰肠吻合和Y形空肠内引流在胰十二指肠切除术中的应用,并与传统的胰十二指肠切除术进行比较。方法本组回顾2004年12月至2006年12月间行胰十二指肠切除患者103例,其中接受连续胰肠吻合和Y形空肠内引流的患者55例作为观察组,传统胰十二指肠切除术后捆绑式胰肠吻合的患者48例作为对照组。对两组的手术时间、术中出血量、术后胰漏、术后并发症和术后住院时间以及住院费用等方面的差异进行前瞻性研究。结果两组在手术中出血量及手术后并发症比较没有统计学意义,但在手术时间、术后胰瘘、术后住院时间等方面有统计学意义(P<0.05)。结论相对于传统的胰十二指肠切除术中捆绑式胰肠吻合重建方式,连续胰肠吻合和Y形空肠内引流手术方式较容易掌握,且在术后管理上具有较为明显的优势。     

改良Child胰肠吻合预防胰漏发生

目的采用端端双层套入连续吻合法（改良Child胰肠吻合）对胰肠吻合缝合技术进行改进，预防胰漏的发生。方法对31例胰十二指肠切除术患者，采用4-0 Proene线双层胰肠端端套入式连续吻合。结果改良Child胰肠吻合法的吻合时间平均14．2min，明显缩短了手术时间，全部病例均未出现胰肠吻合口漏，没有手术死亡。结论改良Child胰肠吻合法，操作简便、省时、并发症少，是胰肠吻合术的一种有效改进。     

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.     

The usefulness of drain data to identify a clinically relevant pancreatic anastomotic leak after pancreaticoduodenectomy?

Pancreatic anastomotic leak (leak) remains a persistent problem after pancreaticoduodenectomy (PD). Recent reports indicate a mean occurrence of 10% with a range of 2%–28% of patients. However, valid comparisons for these studies cannot be made because the definition of leak is variable, and many patients deemed to have a leak are not sick. The aim of this study was to determine the meaning of the volume and amylase content of the effluent from surgical drains by comparing these values to actual clinical outcomes. From January 1996 to July 2002, 207 consecutive patients underwent PD. We considered a leak to be present if greater than 30 ml/day of drainage was observed from drains and if that drainage contained an amylase-rich fluid (greater than 5X serum) on or after postoperative day (POD) 5. Cases were then divided into three groups—no leak, chemical leak only (leak but asymptomatic), and a clinical leak group (leak that required therapeutic intervention, reoperation, readmission, or prolonged length of stay). Then the drainage volume and its amylase concentration for every postoperative day were compared between the three groups. There were no operative or hospital deaths, and the mean length of stay (LOS) was 11.2 ± 6.1 days. Prolonged LOS was set at greater than 17 days (one standard deviation beyond the mean LOS for all cases). Leak was observed in 14% of cases (n = 29) and the patients were subsequently divided into these groups: no leak (n = 178), chemical leak only (n = 12), and clinical leak (n = 17). Surprisingly, the daily drain amylase values did not differ between the chemical leak group and the clinical leak group. The daily volume of drainage on POD 5–8 for the clinical leak group was significantly greater than the volumes of the other two groups, so that a combination of greater than 200 ml/ day of drainage on POD 5 with an amylase greater than 5X serum had a positive predictive value (PPV) of 84% and a negative predictive value (NPV) of 99% for a clinically relevant leak. We used broad criteria from drainage effluent to include as many potential leaks as possible. This broad definition of leak selected 14% of the PD patients as having a leak; within this group, all of the clinical complications of leak occurred. By increasing the volume criteria from greater than 30 ml per day to greater than 200 ml per day, the PPV was increased from 59% to 84% while keeping NPV at 99%. Drain data based on the volume and amylase criteria of this study may be useful for early detection of a leak that will have clinical impact. This study’s criteria for leak may be a good definition to design a clinical trial. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004.