胰十二指肠切除术的技术改进

目的 探讨改进胰十二指肠切除术,预防术后并发症,提高手术疗效的方法。方法 采用保留幽门、胰管空肠粘膜吻合＋胰肠遮盖套入式吻合、胰管支撑外流充分切除胰钩突的术式,并观察其疗效。结果 全组未发生胰瘘及胰断面出血。保留幽门胰十二批肠切除术（ＰＰＰＤ）者有１例术后发生胃潴留,其余胃排空正常。结论 ＰＰＰＤ只要操作得当,可避免术后胃潴留。胰肠遮盖套入式吻合操作简便,可防止术后胰瘘、胰断面出血等并发症。     

Preservation of the pylorus during pancreaticoduodenectomy —Evolution and current indications

The Whipple procedure has been improved by preservation of afunctioning pylorus. A functioning pylorus is important because marginal ulceration is avoided and, compared to the standard Whipple procedure with hemigastrectomy, more patients can gain weight postoperatively. The most common indications for this procedure are severe complication of chronic pancreatitis and periampullary tumors. In patients with pancreatic adenocarcinoma, the pylorus-preserving variety results in equal or better survival rates than those of the standard Whipple procedure with hemigastrectomy. Surgery alone is not sufficient to improve survival rates in patients with adenocarcinoma of the pancreas. Improved imaging modalities are required to diagnose the disease earlier. The most likely combination of treatment to prolong survival time is a combination of resection for cure in a patient with an early diagnosis plus an aggressive adjuvant chemoradiotherapy protocol. This protocol is most likely to be completed if a patient has preserved endocrine, exocrine, and digestive ability. A radical (R1) pylorus-preserving Whipple procedure would have the following advantages to result in the best survival rates — the patients can gain weight and thereby withstand the chemoradiotherapy protocol while, at the same time, the weakest aspect of the radical resection is addressed, i.e., the retroperitoneal margin of the pancreatic head.     

十二指肠肿瘤的诊断及手术方法的探讨--附12例临床分析

手术治疗十二指肠肿瘤患者 12例 ,术前分别行B超、螺旋CT、钡剂造影、内镜检查 ;术中行常规冷冻病理切片检查 ;确诊良性肿瘤 8例 ,恶性 4例。除降部 3例恶性肿瘤行传统胰十二指肠切除术外 ,其余病例行十二指肠节段性切除。结果 :B超、钡剂造影、螺旋CT、内镜检出率分别为 5 / 7、81 8% ( 9/ 11)、8/ 9及 83 3 % ( 10 / 12 ) ;十二指肠节段切除手术平均时间 2 5h ( 1 5～ 4h) ,胰十二指肠切除术平均 5 5h( 4 5～ 6 5h)。所有病例术后恢复良好 ,无手术并发症出现。平均住院时间 18d( 12～ 2 3d)。随访时间 3 0 ( 3～ 48)个月 ,无肿瘤复发。回顾分析结果显示 ,螺旋CT在诊断十二指肠肿瘤方面具有优势 ,十二指肠降段及水平段良性或低度恶性肿瘤行十二指肠节段切除安全简便 ,切实可行     

Superior mesenteric artery first approach versus standard pancreaticoduodenectomy:a systematic review and meta-analysis

BACKGROUND: The superior mesenteric artery (SMA) first approach was proposed recently as a new modification of the standard pancreaticoduodenectomy. Increasing evidence showed that a periadventiceal dissection of the SMA with early transection of the inflow during pancreaticoduodenec-tomy associates better early perioperative results, and setup the scene for long-term oncological benefits. The objectives of the current study are to compare the operative results and long-term oncological outcomes of SMA first approach pan-creaticoduodenectomy (SMA-PD) with standard pancreatico-duodenectomy (S-PD).DATA SOURCES: Electronic search of the PubMed/MEDLINE, EMBASE, Web of Science and Cochrane Library was performed until July 2015. We considered randomized controlled trials (RCTs) and non-randomized comparative studies (NRCSs) comparing SMA-PD with S-PD to be eligible if they included patients with periampullary cancers.RESULTS: A total of one RCT and thirteen NRCSs met the in-clusion criteria, involving 640 patients with SMA-PD and 514 patients with S-PD. The SMA-PD was associated with less in-traoperative bleeding, less blood transfusions and higher rate of associated venous resections. The pancreatic fistula and delayed gastric emptying had a significantly lower rate in the SMA-PD group. There were no differences between the two approaches regarding overall complications, major complica-tion rates and in-hospital mortality. There was no difference regarding R0 resection rate, and one-, two- or three-year over-all survival. The SMA-PD was associated with a lower local, hepatic and extrahepatic metastatic rate.CONCLUSIONS: The SMA-PD is associated with better perioperative outcomes, such as blood loss, transfusion re-quirements, pancreatic fistula, and delayed gastric emptying. Although the one-, two- or three-year overall survival rate is not superior, the SMA-PD has a lower local and metastatic re-currence rate.     

Paraaortic dissection in “total mesopancreas excision” and “mesopancreas-first resection” pancreaticoduodenectomies for pancreatic cancer: Useless,optional, or necessary?A systematic review

The mesopancreas does not have well-defined boundaries but is continuous and connected through its components with the paraaortic area. The mesopancreatic resection margin has been indicated as the primary site for R1 resection after PD in pancreatic head cancer and total mesopancreas excision has been proposed to achieve adequate retropancreatic margin clearance and to minimize the likelihood of R1 resection. However, the anatomy of the mesopancreas requires extended dissection of the paraaortic area to maximize posterior clearance. The artery-first surgical approach has been developed to increase local radicality at the mesopancreatic resection margin. During PD, the artery-first approach begins with dissection of the connective tissues around the SMA. However, the concept of the mesopancreas as a boundless structure that includes circumferential tissues around the SMA, SMV, and paraaortic tissue highlights the need to shift from artery-first PD to mesopancreas-first PD to reduce the risk of R1 resection. From this perspective the “artery-first” approach, which allows for the avoidance of R2 resection risk, should be integrated into the “mesopancreas-first” approach to improve the R0 resection rate.In total mesopancreas excision and mesopancreas-first pancreaticoduodenectomies, the inclusion of the paraaortic area and circumferential area around the SMA in the resection field is necessary to control the tumour spread along the mesopancreatic resection margin rather than to control or stage the spread in the nodal basin.     

Antecolic gastrointestinal reconstruction with pylorus dilatation. Does it improve delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy?

Objective. The aim of our study focuses upon prevention of delayed gastric emptying (DGE) after pancreaticoduodenectomy using a alternative reconstruction procedure. Method. Forty consecutive patients underwent a typical pylorus-preserving pancreaticoduodenectomy (PPPD) with antecolic reconstruction in a two-year period (January 2002 until January 2004), while a similar group of 40 consecutive patients underwent PPPD with application of pyloric dilatation between January 2004 and January 2006. Early and late complications were compared between the two groups. Results. DGE occurred significantly more often in the group of patients treated by the classical PPPD technique (nine patients −22%) compared with those operated on with the addition of pyloric dilatation technique (two patients −5%) (p<0.05). The incidence of other complications did not differ significantly between the two groups. Conclusions. The application of dilatation may decrease the incidence of DGE after PPPD and facilitates earlier hospital discharge.