中国实用外科杂志

中国实用外科杂志

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胰十二指肠切除术消化道重建方式个体化选择临床研究

洪德飞1，秦仁义2，王    敏2，卢    毅1，张宇华1，张成武1，孙晓东1，吴伟顶1   

  1. 1浙江省人民医院肝胆胰外科，浙江杭州 310014；2华中科技大学同济医学院附属同济医院胆胰外科，湖北武汉 430030
  • 出版日期:2017-01-01 发布日期:2017-01-03

  • Online:2017-01-01 Published:2017-01-03

摘要：

目的    评价以胰管直径为选择标准的胰消化道重建个体化选择策略的的临床疗效。方法    选择2012年6月至2015年6月浙江省人民医院肝胆胰外科（58例）和华中科技大学同济医学院附属同济医院胆胰外科（61例）行开放胰十二指肠切除术（PD）的119例病人。根据胰腺残端胰管直径（<3 mm和≥3 mm），术中分别采用改良捆绑式胰胃吻合（BPG组，56例）和胰管空肠黏膜吻合（DM组，63例）。观察两组病人术后临床疗效。结果  BPG组和DM组胰管直径分别为（2.3±0.5）mm和（5.0±1.8）mm，手术时间为（353.4±90.5）min和（395.6±122.2）min，胰消化道重建时间为（25.7±7.9）min和（28.8±5.6）min，术中出血量分别为（457.1±377.0）mL和（520.7±218.5）mL。所有病人术后总并发症发生率为37.0%（44/119），总胰瘘发生率为11.8%（14/119），均未发生C级胰瘘。BPG组和DM组术后B级胰瘘、出血、胆瘘、胃排空延迟、胃肠吻合口瘘、腹腔感染发生率分别为3.2%（2/56）、12.5%（7/56）、3.6%（2/56）、17.9%（10/56）、3.6%（2/56）、7.1%（4/56）和3.2%（2/63）、7.9%（5/63）、3.2%（2/63）、6.3%（4/63）、1.6%（1/63）、4.8%（3/63）。BPG组和DM组再手术率为5.4%（3/56）和3.2%（2/63），再入院率为3.6%（2/56）和3.2%（2/63），Ⅲa及以上级别并发症发生率为14.3%（8/56）和9.5%（6/63），术后住院时间为（15.4±6.9）d和（13.2±6.0）d。围手术期均无死亡病例。结论    根据胰管直径大小个体化选择胰消化道重建方式，有助于减少PD后具有临床级（B、C级）胰瘘的发生。

关键词: 胰十二指肠切除术, 胰管直径, 胰消化道重建, 胰瘘

Abstract:

Applicafion of individual selection strategy for pancreatico-digestive anastomosis after pancreaticoduodenectomy        HONG De-fei*，QIN Ren-yi，WANG Min，et al. *Department of Hepatobiliary and Pancreatic Surgery，People’s Hospital of Zhejiang Province and Institute of Biliary Pancreatic Surgery，Hangzhou 310014，China
Corresponding authors：HONG De-fei Hong，E-mail：hongdefi@163.com；QIN Ren-yi，E-mail：ryqin@tjh.tjmu.edu.cn
Abstract    Objective    To evaluate an individual strategy of pancreatic duct diameter-oriented for pancreaticoenteric anastomosis in pancreaticoduodenectomy. Methods    A total of 119 patients with resectable tumour were undergone pancreaticoduodenectomy （PD） and conducted prospective randomized controlled study at the Department of Hepatobiliary and Pancreatic Surgery，People’s Hospital of Zhejiang Province and Institute of Biliary Pancreatic Surgery，Tongji Hospital，Tongji Medical College，Huazhong Scientific and Technological University. According to the size of pancreatic duct diameter (preoperative CT/MR and intraoperative measurement )，patients with duct diameter <3 mm and ≥3 mm were divided into two groups，and conducted improved binding pancreatogastrostomy (BPG group) occurred in 56 cases，and pancreatic duct to mucosa anastomosis (DM group) occurred in 63 cases，respectively. The clinical data of both groups were collected and analyzed retrospectively. Results    The size of pancreatic duct were（2.3±0.5）mm in BPG group and（5.0±1.8） mm in DM group. The intraoperative data including operation time, pancreaticojejumostomy time and estimated blood loss were （353.4±90.5）min,（25.7±7.9）min and（457.1±377.0）mL in BPG group and（395.6±122.2）min ,（28.8±5.6）min and（520.7±218.5）mL in DM group. Complication occurred in 37% of patients and incidence of pancreatic fistula was 11.8%（14/119）in all patients, however, no grade C pancreatic fistula was detected. The rate of pancreatic fistula (grade B), postoperative bleeding, bile leakage, delayed gastric empty, gastrointestinal anastomotic leakage and intra-abdominal infection were 3.2%（2/56）、12.5%（7/56）、3.6%（2/56）、17.9%（10/56）、3.6%（2/56）、7.1%（4/56）and 3.2%（2/63）、7.9%（5/63）、3.2%（2/63）、6.3%（4/63）、1.6%（1/63）、4.8%（3/63） in BPG group and DM group respectively. Re-operative and readmission rate were 5.4%（3/56）and 3.6%（2/56）in BPG group and 3.2%（2/63）and 3.2%（2/63）in DM group. Serious complications (≥IIIa) occurred in 14.3%（8/56） patients in BPG group and 9.5%（6/63） patients in DM group. The length of postoperative hospital stay were（15.4±6.9）d in BPG group and （13.2±6.0）d in DM group. No mortality was found in both groups. Conclusion  The individual strategy of pancreatic duct diameter-oriented for pancreaticoenteric anastomosis can reduce effectively the incidence of POPF and other severe complications in pancreaticoduodenectomy.

Key words: pancreaticoduodenectomy, pancreatic duct diameter, pancreatic anastomosis, pancreatic