PDF(1422 KB)
PDF(1422 KB)
PDF(1422 KB)
胰肠吻合技术昨日纷争 今日所为 明日期盼
Pancreaticojejunostomy: historical controversies, current practices, and future prospects
胰肠吻合是胰十二指肠切除术中技术难度最高、并发症风险最大的关键步骤，尽管近百年来方法不断创新，但术后胰瘘仍是主要挑战。胰肠吻合相关临床并发症发生率依旧较高，B/C级胰瘘可导致严重感染、出血甚至死亡，且多因素影响其发生，其中吻合技术被视为独立危险因素。围绕降低胰瘘发生率的核心目标，胰肠吻合方法在手术操作方式、胰肠对合模式及缝合技术层面呈现多样化演进，包括端-端吻合、端-侧包埋法吻合、胰管空肠黏膜端-侧吻合及端-侧套入式吻合等，所见报道的各类技术均体现出某一方面的独特优势，但尚无公认的最佳方案。近年来，Blumgart吻合因强调U型缝合、符合“黏膜-黏膜”愈合理念及血运保护理念，被认为在稳定性与降低胰瘘发生率方面具有优势，并在多项研究中表现良好。除技术选择外，个体化评估同样关键。吻合过程中的张力控制、精准对合、缝线选择、支架管通畅及细节处理均直接影响术后愈合质量。胰肠吻合技术的发展呈多路径并行趋势，腹腔镜、机器人在胰肠吻合中的应用逐渐成熟且已得到公认，未来仍需在保证安全性的基础上，探索更简化、可复制、微创化、适用于不同手术场景的标准化技术体系，以进一步降低胰瘘发生率并提升术后恢复质量。
Pancreaticojejunostomy is the most technically demanding and complication-prone component of pancreaticoduodenectomy. Despite nearly a century of continual refinement, postoperative pancreatic fistula (POPF) remains a major challenge. The incidence of pancreaticojejunostomy-related complications remains high, and clinically relevant grade B/C POPF can lead to severe infection, hemorrhage, or even death. Multiple factors influence its occurrence, among which the anastomotic technique is considered an independent risk factor. To reduce the incidence of POPF, pancreaticojejunostomy techniques have evolved along several dimensions, including operative approach, patterns of pancreaticjejunal alignment, and specific suturing strategies. These include end-to-end anastomosis, end-to-side invagination, duct-to-mucosa end-to-side anastomosis, and end-to-side intussusception techniques, each suited to particular clinical contexts, with no universally accepted optimal method to date. In recent years, Blumgart anastomosis—characterized by U-shaped sutures, adherence to the “mucosa-to-mucosa” healing principle, and favorable vascular preservation—has gained recognition for its stability and potential to reduce POPF, with favorable outcomes reported in multiple clinical studies and Meta-analyses. Beyond technique selection, individualized assessment is equally essential. Tension control, precise alignment, suture material choice, stent patency, and meticulous technical execution directly affect postoperative healing quality. The development of pancreaticojejunostomy has followed multiple parallel pathways, the application of laparoscopic and robotic-assisted pancreaticojejunostomy has gradually matured and gained acceptance, future progress will require establishing simplified, reproducible, minimally invasive, and standardized techniques applicable across diverse surgical settings, aiming to further reduce POPF incidence and improve postoperative recovery.
pancreatojejunostomy / pancreaticoduodenectomy / pancreatic fistula
| [1] |
|
| [2] |
The most common complications after a pancreaticoduodenectomy are delayed gastric emptying, pancreatic fistulae, hemorrhage, chyle leaks, endocrine and exocrine pancreatic insufficiency, and surgical site infections. Understanding the potential complications and recognizing them are imperative to taking great care of these complex patients. Taking care of these patients postoperatively requires a team approach including experienced nursing staff combined with robust gastroenterology and interventional radiology.Copyright © 2021 Elsevier Inc. All rights reserved.
|
| [3] |
|
| [4] |
王爽, 时国东, 尹杰, 等. 胰十二指肠切除术围手术期胰腺外分泌功能不全影响因素分析[J]. 中国实用外科杂志, 2025, 45(7):819-825.DOI:10.19538/j.cjps.issn1005-2208.2025.07.17.
|
| [5] |
田孝东, 杨尹默. 腹腔镜胰肠吻合术式选择与评价[J]. 中国实用外科杂志, 2022, 42(5):509-513.DOI:10.19538/j.cjps.issn1005-2208.2022.05.08.
|
| [6] |
|
| [7] |
中华医学会外科学分会胰腺外科学组, 中国研究型医院学会胰腺病专业委员会. 胰腺术后外科常见并发症诊治及预防的专家共识(2017)[J]. 协和医学杂志, 2017, 8(2):139-146.DOI:10.3969/j.issn.1674-9081.2017.03.012.
|
| [8] |
The surgical treatment of pancreatic cancer (PDAC) has seen sweeping changes during the past 5 decades. Up to the middle of the 20th century resection rates were below 5%, but the numbers of curative resections for PDAC are now continuously increasing due to improved neoadjuvant treatment concepts as well as progress in surgical techniques and perioperative management. During the same period, mortality rates after pancreatic surgery have decreased considerably and are now less than 5%. One of the most important cornerstones of reduced mortality has been the concentration of PDAC surgery in specialized centers. In addition, the management of postoperative complications has improved greatly as a result of optimized interdisciplinary teamwork. Adjuvant chemotherapy has become the reference treatment in resected PDAC, achieving significantly prolonged survival. Moreover, the concept of borderline resectable PDAC has emerged to characterize tumors with increased risk for tumor-positive resection margins or worse outcome. The best treatment strategy for borderline resectable PDAC is currently under debate, whereas neoadjuvant therapy has become established as a beneficial treatment option for patients with locally advanced PDAC, enabling conversion surgery in up to 60% of cases. This review article summarizes the principal changes in PDAC surgery during the past 50 years.
|
| [9] |
To evaluate surgical performance in pancreatoduodenectomy using clinically relevant postoperative pancreatic fistula (CR-POPF) occurrence as a quality indicator.Accurate assessment of surgeon and institutional performance requires (1) standardized definitions for the outcome of interest and (2) a comprehensive risk-adjustment process to control for differences in patient risk.This multinational, retrospective study of 4301 pancreatoduodenectomies involved 55 surgeons at 15 institutions. Risk for CR-POPF was assessed using the previously validated Fistula Risk Score, and pancreatic fistulas were stratified by International Study Group criteria. CR-POPF variability was evaluated and hierarchical regression analysis assessed individual surgeon and institutional performance.There was considerable variability in both CR-POPF risk and occurrence. Factors increasing the risk for CR-POPF development included increasing Fistula Risk Score (odds ratio 1.49 per point, P < 0.00001) and octreotide (odds ratio 3.30, P < 0.00001). When adjusting for risk, performance outliers were identified at the surgeon and institutional levels. Of the top 10 surgeons (≥15 cases) for nonrisk-adjusted performance, only 6 remained in this high-performing category following risk adjustment.This analysis of pancreatic fistulas following pancreatoduodenectomy demonstrates considerable variability in both the risk and occurrence of CR-POPF among surgeons and institutions. Disparities in patient risk between providers reinforce the need for comprehensive, risk-adjusted modeling when assessing performance based on procedure-specific complications. Furthermore, beyond inherent patient risk factors, surgical decision-making influences fistula outcomes.
|
| [10] |
|
| [11] |
王建奇, 范美丽, 姜洪池. 胰肠吻合效果影响因素的浅析与吻合技术的原则初探[J]. 中华外科杂志, 2022, 60(3):219-222.DOI:10.3760/cma.j.cn112139-20211123-00549.
|
| [12] |
秦仁义, 马春阳, 王敏, 等. 腹腔镜胰十二指肠切除术胰肠吻合方式的选择[J]. 外科理论与实践, 2017, 22(2):106-109.DOI:CNKI:SUN:WKLL.0.2017-02-006.
|
| [13] |
颜伟康, 刘颖斌. 胰肠吻合方式发展历史与现状[J]. 中国实用外科杂志, 2022, 42(4):464-467.DOI:10.19538/j.cjps.issn1005-2208.2022.04.21.
|
| [14] |
刘颖斌, 王许安, 黄丛云. 胰十二指肠切除术后胰腺残端消化道重建的历史回顾[J]. 中华消化外科杂志, 2018, 17(7):671-676.DOI:10.3760/cma.j.issn.1673-9752.2018.07.007.
|
| [15] |
|
| [16] |
This study compared the postoperative pancreatic anastomosis leakage rate of a new binding technique with the conventional technique of pancreaticojejunostomy after pancreaticoduodenectomy.Leakage from pancreatic anastomoses remains the single most important morbidity after pancreaticoduodenectomy and contributes to prolonged hospitalization and mortality. The reported incidence after conventional pancreaticojejunostomy ranged from 10% to 29%. We previously reported a new binding pancreaticojejunostomy technique with a leakage of 0%.We conducted a prospective randomized study on 217 patients who underwent pancreaticoduodenectomy for benign and malignant diseases of the pancreatic head and the periampullary region comparing the 2 techniques of pancreaticojejunostomy.Of the 111 patients randomized to the conventional group, pancreaticojejunostomy leakage occurred in 8 patients, while no patient in the 106 patients randomized to the binding group developed leakage (chi test, P = 0.014). The overall postoperative complications developed in 41 patients (36.9%) in the conventional group compared with 26 patients (24.5%) in the binding group (chi test, P = 0.048). Seven patients (6.3%) died in the perioperative period in the conventional group compared with 3 patients (2.8%) in the binding group (chi test, P = 0.37). The postoperative hospital stay (mean +/- SD) for the conventional group was 22.4 +/- 10.9 days, which was significantly longer than the binding group (18.4 +/- 4.7 days) (Mann-Whitney U test, P < 0.001).Binding pancreaticojejunostomy after panceaticoduodenectomy significantly decreased postoperative complication and pancreaticojejunostomy leakage rates and shortened hospital stay when compared with conventional pancreaticojejunostomy.
|
| [17] |
|
| [18] |
洪德飞, 刘亚辉, 张宇华, 等. 腹腔镜胰十二指肠切除术中“洪氏一针法”胰管空肠吻合的临床应用[J]. 中华外科杂志, 2017, 55(2):136-140.DOI:10.3760/cma.j.issn.0529-5815.2017.02.012.
|
| [19] |
周海华, 吴晓康, 范恒丹, 等. 双荷包桥接式胰肠吻合在完全腹腔镜胰十二指肠切除术中的应用[J]. 中华肝胆外科杂志, 2019, 25(10):759-762.DOI:10.3760/cma.j.issn.1007-8118.2019.10.010.
|
| [20] |
|
| [21] |
|
| [22] |
|
| [23] |
Postoperative pancreatic fistula (POPF) is the most serious complication after pancreaticoduodenectomy (PD). Recently, Blumgart anastomosis (BA) has been found to have some advantages in terms of decreasing POPF compared with other pancreaticojejunostomy (PJ) using either the duct-to-mucosa or invagination approach. Therefore, the aim of this study was to examine the safety and effectiveness of BA versus non-Blumgart anastomosis after PD. The PubMed, EMBASE, Web of Science and the Cochrane Central Library were systematically searched for studies published from January 2000 to March 2020. One RCT and ten retrospective comparative studies were included with 2412 patients, of whom 1155 (47.9%) underwent BA and 1257 (52.1%) underwent non-Blumgart anastomosis. BA was associated with significantly lower rates of grade B/C POPF (OR 0.38, 0.22 to 0.65; P = 0.004) than non-Blumgart anastomosis. Additionally, in the subgroup analysis, the grade B/C POPF was also reduced in BA group than the Kakita anastomosis group. There was no significant difference regarding grade B/C POPF in terms of soft pancreatic texture between the BA and non-Blumgart anastomosis groups. In conclusion, BA after PD was associated with a decreased risk of grade B/C POPF. Therefore, BA seems to be a valuable PJ to reduce POPF comparing with non-Blumgart anastomosis.
|
| [24] |
|
| [25] |
李秋生, 吴子强, 张建生, 等. 降落伞式单荷包胰肠吻合在胰十二指肠切除术中的应用[J]. 中华肝胆外科杂志, 2022, 28(4):254-258.DOI:10.3760/cma.j.cn113884-20211116-00367.
|
| [26] |
刘荣, 刘渠, 赵之明, 等. 单针全层胰肠吻合(301式)在胰十二指肠切除术中的应用[J]. 腹腔镜外科杂志, 2018, 23(11):854-857.DOI:10.13499/j.cnki.fqjwkzz.2018.11.854.
|
| [27] |
Pancreaticojejunostomy (PJ) reconstruction is the Achilles' heel of laparoscopic pancreaticoduodenectomy (LPD). However, only a few studies have focused on the performance of this difficult procedure laparoscopically.We present a safe and feasible technique of duct-to-mucosa pancreaticojejunostomy for LPD, named Bing's anastomosis. Our study included 238 cases of LPDs that underwent Bing's anastomosis. Data on the demographic characteristics, operative outcomes (total operative time, PJ duration, and estimated blood loss), and postoperative results (length of hospital stay, recovery of bowel function, and rates of postoperative morbidity and mortality) of the cases were prospectively collected and retrospectively analyzed.Only one patient (0.4%) in our series required conversion to open surgery as a result of uncontrolled bleeding from the superior mesenteric artery. The average operative time was 358 min (220 min to 495 min). The mean duration for PJ was 23 min (19 min to 33 min). The mean estimated blood loss was 112 ml (50 ml to 800 ml). The overall incidence of pancreatic fistula was 21.4% and included 42 cases (17.6%) of biochemical leak, eight cases (3.4%) of Grade B, and one case (0.4%) of Grade C pancreatic fistulas. The 90-day mortality was 0.4%.Bing's anastomosis is a safe, reliable, and rapid PJ technique for LPD that is associated with favorable outcomes and a low risk of pancreatic fistula. However, its safety and feasibility should be verified by performing prospective randomized controlled trials at different institutions.
|
| [28] |
|
| [29] |
Leakage from the pancreaticojejunostomy is the major cause of septic complications after partial pancreaticoduodenectomy. This study evaluated a new transpancreatic U-suture technique (Blumgart anastomosis, BA), which aims to avoid shear forces during knot-tying.Using a before-after study design, BA was compared with a modified Cattell-Warren anastomosis (CWA). Two patient cohorts (CWA, 90; BA, 92), which were similar with respect to primary diagnosis, age, sex and American Society of Anesthesiologists score, were compared retrospectively. Dependent variables were surgical and overall morbidity and mortality after partial pancreaticoduodenectomy.Duration of operation (354 versus 328 min for CWA versus BA; P = 0.002), pancreatic leakage rate (13 versus 4 per cent; P = 0.032), postoperative haemorrhage (11 versus 3 per cent; P = 0.040), total surgical complications (31 versus 15 per cent; P = 0.011), general complications (36 versus 17 per cent; P = 0.005) and length of intensive care unit stay (median 5.4 versus 2.8 days; P = 0.015) were significantly reduced after BA. These effects were not related merely to an improvement over time.BA appears to be a fast, simple and safe technique for pancreaticojejunostomy. It might reduce leakage rates and surgical complications after partial pancreaticoduodenectomy.Copyright 2009 British Journal of Surgery Society Ltd.
|
| [30] |
Postoperative pancreatic fistula (POPF) is the main cause of fatal complications after pancreatoduodenectomy. There is still no universally accepted technique for pancreaticoenterostomy, especially in patients with soft pancreas.Between July 2008 and June 2013, 240 patients who underwent pancreatoduodenectomy were enrolled in this single-institution matched historical control study. To approximate the pancreatic parenchyma to the jejunal seromuscular layer, 120 patients underwent anastomosis using the Kakita method (three or four interrupted penetrating sutures) and 120 underwent anastomosis using the modified Blumgart anastomosis (m-BA) method (one to three transpancreatic/jejunal seromuscular sutures to completely cover the pancreatic stump with jejunal serosa).The rate of clinically relevant POPF formation was significantly lower in the m-BA group than that in the Kakita group (2.5 vs 36 %; p < 0.001). The duration of drain placement and the length of postoperative hospital stay were significantly shorter in the m-BA group. Multivariate analysis showed that m-BA was an independent predictor of non-formation of POPF (hazard ratio, 0.02; 95 % confidence interval, 0.01-0.08; p < 0.001).The m-BA method is safe and simple and improves postoperative outcomes. We suggest that the m-BA is suitable for use as a standard method of pancreaticojejunostomy after pancreatoduodenectomy.
|
| [31] |
The pancreatic reconstruction technique decides the incidence of postoperative pancreatic fistulas (POPF) in pancreaticoduodenectomy (PD). This study aims to evaluate the safety of modified single-needle continuous suture (SNCS) of duct-to-mucosa and compare the efficacy with double-layer continuous suture (DLCS) of duct-mucosa pancreaticojejunostomy (PJ) in open PD (OPD).A total of 266 patients that received PD between January 2019 and May 2023 were retrospectively analyzed. Among them, 130 patients underwent DLCS, and 136 patients underwent SNCS [73 OPD and 63 laparoscopic PD (LPD)]. The primary outcome was clinically relevant POPF (CR-POPF) according to the definition of the revised 2016 International Study Group of Pancreatic Fistula (ISGPF). Propensity score matching (PSM) was conducted to reduce confounding bias.A total of 66 pairs were successfully matched using PSM in OPD. No significant difference was observed in the occurrence of CR-POPF between the two groups (9.1% 21.2%, P=0.052). However, the median duration of operation and PJ was shorter in the SNCS group. The incidence of CR-POPF in LPD was 9.5%. Furthermore, regarding the alternative fistula risk score (a-FRS), the CR-POPF rate were 2.1%, 10.5%, and 15.6% in low-, intermediate-, and high-risk groups (P=0.067).The SNCS is a facile, safe, and effective PJ technique and does not increase the incidence of POPF, regardless of a-FRS stratification, pancreatic texture, and main pancreatic duct (MPD) size.2023 Gland Surgery. All rights reserved.
|
| [32] |
| [33] |
华杰, 施思, 孟庆才, 等. 改良“双U法胰肠吻合”在胰十二指肠切除术的运用及效果评估[J]. 外科理论与实践, 2024, 29(1):34-39.
|
| [34] |
梁月祥, 高松, 王秀超, 等. 胰十二指肠切除术“双线四针法”胰肠吻合安全性与有效性分析[J]. 中国实用外科杂志, 2025, 45(5):564-569.DOI:10.19538/j.cjps.issn1005-2208.2025.05.16.
|
| [35] |
陈孝平. 贯穿胰腺纵向“U”形缝合法行空肠内翻套入式胰肠吻合术[J]. 腹部外科, 2017, 30(3):153-154.DOI:10.3969/j.issn.1003-5591.2017.03.001.
|
| [36] |
尹新民, 李云峰, 成伟, 等. 贯穿胰腺纵向“U”形缝合法空肠内翻套入式胰肠吻合技术在腹腔镜胰十二指肠切除术应用(附116例报告)[J]. 中华外科杂志, 2020, 58(2):114-118.DOI:10.3760/cma.j.issn.0529-5815.2020.02.008.
|
| [37] |
Pancreatic fistula following pancreatic resections is still a relevant complication. The present work shows the efforts of a single institute to decrease this problem.
|
| [38] |
柴伟, 雷豹, 孟宇, 等. 荷包套入式胰肠端侧吻合法对术后胰瘘发生率的影响——单中心581例临床经验总结[J]. 中华内分泌外科杂志, 2019, 13(6):492-496.DOI:10.3760/cma.j.issn.1674-6090.2019.06.011.
|
| [39] |
Although recent technological developments and improved endoscopic procedures have further spread the application of laparoscopic pancreatic resection, laparoscopic pancreaticoduodenectomy still presents major technical difficulties, such as when performing pancreatic-enteric anastomosis.Laparoscopic dunking pancreaticojejunostomy using mattress sutures was performed in 15 consecutive patients with a soft pancreas and a nondilated pancreatic duct between October 2011 and December 2012.According to the International Study Group on Pancreatic Fistula criteria, 3 patients developed PF (grade A), whereas the remaining 12 patients did not.Dunking pancreaticojejunostomy using mattress sutures is considered to be a feasible and safe method for performing pure laparoscopic pancreaticoduodenectomy.
|
| [40] |
Laparoscopic pancreaticoduodenectomy is advantageous as a minimally invasive surgery, but performing the complicated anastomosis is technically difficult. Herein, we present our experiences with total laparoscopic pancreaticoduodenectomy (TLPD) using a unique anastomosis technique, that is, pancreaticojejunostomy using only two transpancreatic sutures with buttresses method (PJt).From September 2013 to March 2015, 12 TLPDs using PJt for periampullary tumors were performed. In each case, the pancreaticoenteric anastomosis was performed using the PJt technique, a modification of invaginated, end-to-end pancreaticojejunostomy. A pair of transpancreatic sutures were placed on the upper and lower borders of the implanted pancreas through the jejunal limb covering the pancreas stump, and four buttresses were used to reinforce the anastomosis. All medical records and follow-up data were reviewed and analyzed with regard to surgical outcomes, and the results were compared with previously published reports on TLPD.The mean age of the patients was 64.3 ± 12.3 years, and all were diagnosed with pancreas head cancer except 5 patients (4 patients had ampulla of Vater cancer, and the other had chronic pancreatitis). The mean estimated blood loss was 118 ± 57 mL, and the mean hospital stay was 12.5 ± 4.5 days. The mean operative time was 411.6 ± 59.2 minutes, and the pancreas anastomosis time was 20.1 ± 4.8 minutes without any evidence of anastomosis-related complications.Our novel technique of PJt is a simple, easy, and feasible method for TLPD with the possibility of reducing the burden to the operator and acquiring secure anastomosis.
|
| [41] |
白雪莉, 陈伟, 梁廷波. 中国腹腔镜胰十二指肠切除术20年胰肠重建术式变迁与未来发展[J]. 中华普外科手术学杂志(电子版), 2021, 15(3):250-254.DOI:10.3877/cma.j.issn.1674-3946.2021.03.004.
|
| [42] |
| [43] |
|
| [44] |
李坚, 阿木金刚, 魏恒明, 等. 胰肠端侧套入“U8”型缝合吻合法在胰十二指肠切除术中的应用[J]. 中华肝胆外科杂志, 2023, 29(6):462-464.DOI:10.3760/cma.j.cn113884-20221218-00469.
|
| [45] |
中华医学会外科学分会. 腹腔镜胰腺外科手术缝合技术与缝合材料选择中国专家共识(2021版)[J]. 中国实用外科杂志, 2021, 41(5):489-494.DOI:10.19538/j.cjps.issn1005-2208.2021.05.02.
|
| [46] |
| [47] |
|
| [48] |
杨明, 王春友. 我国胰腺外科发展历史回顾与展望:从跟跑、并跑到领跑[J]. 中华实验外科杂志, 2025, 42(6):993-996.DOI:10.3760/cma.j.cn421213-20250408-01293.
|
| [49] |
郑鑫, 孙备. 《关于机器人肝胆胰手术的建议:巴黎专家会议共识》解读[J]. 中国实用外科杂志, 2025, 45(6):618-624.DOI:10.19538/j.cjps.issn1005-2208.2025.06.03.
|
| [50] |
刘文生, 李征, 卓奇峰, 等. 进一步提高腹腔镜胰十二指肠切除术安全性的关键技术环节[J]. 中国实用外科杂志, 2025, 45(1):80-83.DOI:10.19538/j.cjps.issn1005-2208.2025.01.13.
|
| [51] |
林文俊, 陶海粟, 方驰华, 等. 数智赋能胰腺外科:技术创新及临床实践[J]. 中国普通外科杂志, 2025, 34(9):1882-1891.DOI:10.7659/j.issn.1005-6947.250523.
|
| [52] |
陈昊民, 戴梦华. 胰腺肿瘤微创手术学习曲线过程中病人安全保障对策[J]. 中国实用外科杂志, 2023, 43(7):753-757.DOI:10.19538/j.cjps.issn1005-2208.2023.07.07.
|
/
| 〈 |
|
〉 |
