胰外瘘防治的探讨

目的　胰外瘘 ( PF)系胰腺炎症、外伤及手术后严重并发症 ,兹探讨其防治。方法　总结治疗组 13例。因重症胰腺炎 ( SAP)坏死清除引流 4例 ;外伤单纯引流 3例 ,胰十二指肠切除 ( PD) 1例 ;十二指肠降段癌及胰头炎性肿块各 1例均行PD;假性囊肿左半胰切除 1例 ;十二指肠首段癌首段及部分降段切除 1例 ;原因不明 1例。 PF发生于术后 1～ 5 d,胰液量 10 0～ 10 0 0 m l,淀粉酶多数 >10 0 0 IU。影像学有关检查。 11例非手术治疗 ;2例手术 ,分别为瘘管空肠 Y吻合及瘘管胃吻合、脾及胰尾切除和胰空肠 Y吻合。预防组 12例 ,术前影像学检查。壶腹 (周 )癌 PD9例 (保幽 5、空肠造瘘 4 ) ,均行胰管空肠吻合并安支撑 ;胰尾癌左半胰切除 1例 ;慢性胰腺炎左半胰切除近端空肠 Y吻合 1例 ;胰管结石伴胆囊炎胆囊切除、胆总管引流、胰管切开取石 T管引流经胃窦部引出 1例。结果　非手术治疗 10例 5 d～ 9个月 PF愈合 ,1例死于原发病 SAP;2例手术治愈。预防组未发生 PF。结论　大多数 PF可非手术治愈。手术指征按 PF时间长短、引流量、有无壶腹及主胰管梗阻或狭窄等综合地掌握 ;术式按病情针对性地选择。 PF预防是多方面的 :SAP严格手术指征和时机 ;胰伤按伤情轻重、有无邻近脏器损伤、特别是有无主胰管受伤而采用适当术式

PREVENTION AND TREATMENT OF PANCREATIC EXIERNAL FISTULA

Objective Pancreatic external fistula(PF) is a serious complication of severe acute pancreatitis(SAP),pancreatic trauma and the related opererations.The authors studied the prevention and treatment of PF.Methods Summarizing the experience in our therapeutic cases(13) and preventive ones(11).The therapeutic group included sequestrectomy and drainage for SAP (4),for pancreatic trauma simple drainge (3) and pancreatoduodenectomy (PD) (1),PD for duodenal cancer (1) and inflammatory mass of pancreatic head part (1),left pancreatectomy (LP) for pancreatic pseudocyst (1),resection of the first and partial secondary parts for superior duodenal cancer (1),and uncertain origin (1).PF occurred 1-5 days postoperatively.The amount of drained pancreatic juice:100-1 000 ml/d.11 cases were treated nonoperatively.2 cases were respectively operated by fistulo-jejunostomy (1) and fistulogastrostomy,splenectomy,LP and pancreaticojejunostomy (1).Preventive group :PD with pancreaticojejunostomy and lodgement of stent for periampullary cancer (8),LP for cancer of pancreatic tail part (1),LP and pancreaticojejunostomy for chronic pancreatitis (1) and transgastric T-tube draining of the Wirsung's canal for pancreatic duct stone (1).Results PF in 10 cases recovered without operation and 1 death from the original disease (SAP).The two operated patients recovered.No PF happened in the preventive group.Conclusion Most PFs could heal spontaneously.Surgery would be synthetically adopted according to the duration of PF(2-3 mouths),amount of drained fluid(>500 ml/d) and structural lesion of pancreatic main duct (stenosis or obstruction),and operation concretely choiced.Prevention of PF should be emphasized in many respects due to its complex etiology.Surgery for SAP should be strictly indicated and delayed timing preferred when possible.Operation performed for pancreatic trauma depends on the degree and extent of the injury,especially caring for the damage of pancreatic main duct.Distal pancreatectomy for ist tail confusion coexisting with the splenic injury would be preferred.In pancreatectomy precise anastomosis between the pancreatic duct and jejunum (as in PD) and careful ligation of the duct at the end of pancreas (as in LP) are the keystones of preventing PF and somatostatin is not necessary.Under the condition of transgastric T-tube for pancreatolith, a pancreatic internal fistula would form between the pancreas and the neighboring stomach or jejunum and PF would not result when drawing the tube.At present many authors recommended pancreaticogastrostomy as a safe and practical procedure.