中国实用外科杂志

中国实用外科杂志

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腹腔镜胰十二指肠切除术学习曲线分析（附251例报告）

张建生，李秋生，刘建华，邢中强，冯    峰，王天阳，刘润田，路文彦，吕海涛，闫长青，王文斌，边    伟   

  1. 河北医科大学第二医院肝胆外科，河北石家庄 050000
  • 出版日期:2018-04-01 发布日期:2018-03-30

  • Online:2018-04-01 Published:2018-03-30

摘要：

目的    探讨腹腔镜胰十二指肠切除术（LPD）的学习曲线和围手术期疗效。方法    回顾性分析河北医科大学第二医院肝胆外科自2013年11月至2017年7月实施LPD 251例病人的临床资料，根据相应技术节点的突破，将学习曲线分为起步期：开始尝试LPD实施至胰腺全系膜切除实施前的19例；进步期：胰腺全系膜切除实施后至联合血管切除重建实施前的99例；成熟期：实施联合血管切除重建后的133例。比较进步期和成熟期的手术相关指标及围手术期疗效，对其学习曲线及技术节点进行分析。结果    251例中96例行胰腺全系膜切除，8例行联合血管切除重建，5例行全胰切除。61例（24.3%）病人发生术后并发症，其中发生B、C级胰瘘22例（8.8%）。围手术期死亡10例（4.0%），包括进步期4例和成熟期6例。起步期19例手术时间为（565.5±43.4）min，术中出血量为（650.0±447.9）mL，术后4例（21.1%）发生并发症，术后住院时间为（24.2±11.5）d。进步期与成熟期比较，手术时间从（459.3±87.4）min降至（409.5±78.4）min（P=0.003）；术中出血量由（451.6±329.7）mL降至（413.1±304.1）mL（P=0.006）；术后住院时间由（18.4±7.8）d下降为（13.9±8.5）d（P=0.001）。成熟期中转开腹率（4.5%）低于进步期（7.1%），但差异无统计学意义（P=0.402）。进步期27例（27.3%）发生术后并发症，成熟期为30例（22.6%），差异无统计学意义（P=0.409），其中B、C级胰瘘发生率由进步期的11.2%下降至成熟期7.0%，差异也无统计学意义（P=0.244）。成熟期围手术期病死率略高于进步期，两组比较差异无统计学意义（P=0.861）。结论    腹腔镜下视角适应、缝合及吻合技术、胰腺全系膜切除、血管切除重建技术是LPD学习曲线的技术节点。在丰富开腹手术经验的基础上，经过近20例左右的起步期突破视角适应及缝合吻合技术的技术节点后可实施完全LPD，再经过近百例的进步期并突破胰腺全系膜切除的技术节点后可实施联合血管切除重建LPD。联合血管切除重建是LPD成熟的标志。

关键词: 腹腔镜胰十二指肠切除术, 学习曲线, 胰腺全系膜切除, 联合血管切除重建

Abstract:

Analysis of learning curve for laparoscopic pancreaticoduodenectomy: A report of 251 cases        ZHANG Jian-sheng，LI Qiu-sheng，LIU Jian-hua，et al. Department of Hepatobiliary Surgery，the Second Hospital of Hebei Medical University，Shijiazhuang 050000，China
Corresponding author：LIU Jian-hua，E-mail: ljh@medmail.com.cn
Abstract    Objective    To analyze the learning curve and perioperative results of laparoscopic pancreaticoduodenectomy（LPD）. Methods    Retrospective review of 251 patients undergoing LPD in the Second Hospital Attached to Hebei Medical University from November 2013 to July 2017 was performed. According to the break-through of corresponding technical milestones，the learning curve for LPD was grouped into three phases: initial period including 19 cases from first attempt to total mesopancreases excision（TMpE），progressive period involving 99 cases between implementing TMpE and first LPD with major vascular resection and reconstruction，and professional period containing 133 cases after LPD with major vascular resection and reconstruction. The learning curve and technical milestone of LPD was analyzed according to the compare of surgical related indexes and perioperative results. Results    Out of 251 patients，TMpE was performed in 96 cases，LPD with major vascular resection and reconstruction in 8 cases，and total pancreas resection in 5 cases. Among the patients，postoperative complications occurred in 61(24.3%) patients with Grade B/C pancreatic fistula in 22（8.8%） patients. Mortality happened to 10（4.0%） patients with 4 in progressive period and 6 in professional period. In the initial period, operative time and blood loss was （565.5±43.4）min and （650.0±447.9）mL, respectively. The postoperative hospital stay was（24.2±11.5d）and 4 patients developed postoperative complications. No statistical differences were detected between patients in progressive period and professional period in age, sex and body mass index (BMI). Meanwhile，significant differences were observed from progressive to professional period in operative time [(459.3±87.4) min versus (409.5±78.4)min, P=0.003], blood loss [(451.6±329.7) mL versus (413.1±304.1) mL, P=0.006] and postoperative hospital stay[(18.4±7.8)d versus(13.9±8.5)d, P=0.001]. It also found differences but without statistical significance in laparotomy conversion (4.5% versus 7.1%, P=0.402), postoperative morbidity (27.3% versus 22.6%, P=0.409), Grade B/C pancreatic fistula (11.2% versus 7.0%, P=0.244) and perioperative mortality (4.5% versus 4.0%, P=0.861). Conclusion    Technical milestones of LPD learning curve include adaptation of laparoscopic view，suture and anastomosis skills，achievement of TMpE，major vascular resection and reconstruction experience. With extended experience in open pancreaticoduodenectomy，adaption of laparoscopic view，and certain skills in suture technique，LPD could be accomplished completely after 20 tentative cases. LPD with vascular resection and reconstruction could be attempted after 100 LPDs with breaking through the technical milestone of TMpE. It is a sign of profession to implement LPD with majorvascular resection and reconstruction.

Key words: laparoscopic pancreaticoduodenectomy, learning curve, total mesopancreases excision, major vascular resection and reconstruction