胰管空肠黏膜对黏膜双层连续吻合法在全腹腔镜胰十二指肠切除术中的应用
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摘要
目的探讨使用支撑管及胰管-空肠黏膜对黏膜双层连续缝合法行胰肠端侧吻合在全腹腔镜胰十二指肠切除术(laparoscopic pancreaticoduodenectomy,LPD)中的应用价值。方法回顾性分析2013年8月～2018年10月105例LPD中应用支撑管及胰管-空肠黏膜对黏膜双层连续缝合法行胰肠端侧吻合的临床资料。结果 105例均顺利完成LPD。手术时间360～640(465. 1±53. 8) min,术中出血量100～2800(356. 9±296. 2) ml。术后并发症发生率29. 5%(31/105):出血18例(17. 1%),其中消化道出血7例,腹腔出血11例;漏10例(9. 5%),其中胆漏2例,胰漏8例,胰漏发生于术后3～9(5. 0±2. 1) d,包括B级3例,C级5例;感染15例(14. 3%);胃排空障碍3例(2. 9%)。良性病变19例(18. 1%),恶性病变86例(81. 9%)。淋巴结清扫1～33(10. 6±7. 1)个,R0切缘率96. 5%(83/86)。围术期死亡5例(4. 8%),其余100例术后腹腔引流管放置5～46(14. 4±6. 4) d,术后住院时间6～46(18. 3±6. 4) d,总住院时间15～62(27. 1±7. 8) d。非计划再次手术6例(5. 7%)。结论 LPD中应用支撑管及胰管-空肠黏膜对黏膜双层连续缝合法行胰肠端侧吻合是安全、可行的。
Objective To explore the clinical practice of placing stenting tube and performing end-to-side pancreaticojejunostomy with pancreatic duct-jejunum mucosa-mucosal double-layer continuous suture in laparoscopic pancreaticoduodenectomy( LPD). Methods We retrospectively summarized clinical data of 105 patients who were placed a stenting tube and underwent end-to-side pancreaticojejunostomy with pancreatic duct-jejunum mucosa-mucosal double-layer continuous suture in LPD from August 2013 to October 2018 in our hospital. Results All the 105 patients underwent classical LPD successfully. The operation time was 360-640 min( mean,465. 1 ± 53. 8 min),and the intraoperative blood loss was 100-2800 ml( mean,356. 9 ± 296. 2 ml). There were 31 cases( 29. 5%) of postoperative complications,including 18 cases( 17. 1%) of hemorrhage( gastrointestinal hemorrhage in 7 cases,abdominal bleeding in 11 cases),10 cases( 9. 5%) of leakage [2 cases of biliary leakage and 8 cases of pancreatic leakage; the latter occurred on 3-9 d( mean,5. 0 ± 2. 1 d) after surgery; 3 were classified as grade B and 5 as grade C],15 cases( 14. 3%) of infection,and 3 cases( 2. 9%) of delayed gastric emptying. Pathological results showed 19 cases( 18. 1%) of benign tumors and 86 cases( 81. 9%) of malignant cancers. The number of lymph node resected was1-33( mean,10. 6 ± 7. 1),and the R0 resection rate was 96. 5%( 83/86) in patients with malignant cancers. The postoperative mortality was 4. 8%( 5/105). In the remaining 100 cases,the length of abdominal cavity drainage tube indwelling time,postoperative hospital stay and total hospital stay time was 5-46 d( mean,14. 4 ± 6. 4 d),6-46 d( mean,18. 3 ± 6. 4 d),and 15-62 d( mean,27. 1 ± 7. 8 d),respectively. The rate of overall re-operation was 5. 7%( 6/105). Conclusion It is safe,reliable,and practical to place a stenting tube and perform end-to-side pancreaticojejunostomy with pancreatic duct-jejunum mucosa-mucosal doublelayer continuous suture in LPD.
Objective To explore the clinical practice of placing stenting tube and performing end-to-side pancreaticojejunostomy with pancreatic duct-jejunum mucosa-mucosal double-layer continuous suture in laparoscopic pancreaticoduodenectomy( LPD). Methods We retrospectively summarized clinical data of 105 patients who were placed a stenting tube and underwent end-to-side pancreaticojejunostomy with pancreatic duct-jejunum mucosa-mucosal double-layer continuous suture in LPD from August 2013 to October 2018 in our hospital. Results All the 105 patients underwent classical LPD successfully. The operation time was 360-640 min( mean,465. 1 ± 53. 8 min),and the intraoperative blood loss was 100-2800 ml( mean,356. 9 ± 296. 2 ml). There were 31 cases( 29. 5%) of postoperative complications,including 18 cases( 17. 1%) of hemorrhage( gastrointestinal hemorrhage in 7 cases,abdominal bleeding in 11 cases),10 cases( 9. 5%) of leakage [2 cases of biliary leakage and 8 cases of pancreatic leakage; the latter occurred on 3-9 d( mean,5. 0 ± 2. 1 d) after surgery; 3 were classified as grade B and 5 as grade C],15 cases( 14. 3%) of infection,and 3 cases( 2. 9%) of delayed gastric emptying. Pathological results showed 19 cases( 18. 1%) of benign tumors and 86 cases( 81. 9%) of malignant cancers. The number of lymph node resected was1-33( mean,10. 6 ± 7. 1),and the R0 resection rate was 96. 5%( 83/86) in patients with malignant cancers. The postoperative mortality was 4. 8%( 5/105). In the remaining 100 cases,the length of abdominal cavity drainage tube indwelling time,postoperative hospital stay and total hospital stay time was 5-46 d( mean,14. 4 ± 6. 4 d),6-46 d( mean,18. 3 ± 6. 4 d),and 15-62 d( mean,27. 1 ± 7. 8 d),respectively. The rate of overall re-operation was 5. 7%( 6/105). Conclusion It is safe,reliable,and practical to place a stenting tube and perform end-to-side pancreaticojejunostomy with pancreatic duct-jejunum mucosa-mucosal doublelayer continuous suture in LPD.
引文
1中华医学会外科学分会胰腺外科学组.腹腔镜胰十二指肠切除手术专家共识(附:手术流程与主要步骤).中华外科杂志,2017,55(5):335-339.
2 Wente MN,Veit JA,Bassi C,et al. Postpancreatectomy hemorrhage(PPH):an International Study Group of Pancreatic Surgery(ISGPS)definition. Surgery,2007,142(1):20-25.
3 Bassi C,Marchegiani G,Dervenis C,et al. The 2016 update of the International Study Group(ISGPS)definition and grading of postoperative pancreatic fistula:11 years after. Surgery,2017,161(3):584-591.
4 Wente MN,Bassi C,Dervenis C,et al. Delayed gastric emptying(DGE)after pancreatic surgery:a suggested definition by the International Study Group of Pancreatic Surgery(ISGPS). Surgery,2007,142(5):761-768.
5 Koch M,Garden OJ,Padbury R,et al. Bile leakage after hepatobiliary and pancreatic surgery:a definition and grading of severity by the International Study Group of Liver Surgery. Surgery,2011,149(5):680-688.
6 Pugalenthi A,Protic M,Gonen M,et al. Postoperative complications and overall survival after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. J Surg Oncol,2016,113(2):188-193.
7 Mcmillan MT,Soi S,Asbun HJ,et al. Risk-adjusted outcomes of clinicallyrelevantpancreaticfistulafollowing pancreatoduodenectomy:a model for performance evaluation. Ann Surg,2016,264(2):344.
8 Shrikhande SV,Sivasanker M,Vollmer CM,et al. Pancreatic anastomosis after pancreatoduodenectomy:a position statement by the International Study Group of Pancreatic Surgery(ISGPS). Surgery,2017,161(5):1221.
9 Cheng Y,Briarava M,Lai M,et al. Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy.Cochrane Database Syst Rev,2017,9(6):CD012257.
10 吴志明,牟一平.腹腔镜胰体尾切除术后胰漏的防治进展.中国微创外科杂志,2016,16(6):566-569.
11 Keck T,Wellner UF,Bahra M,et al. Pancreatogastrostomy Versus PancreatojejunostomyforRECOnstructionAfter PANCreatoduodenectomy(RECOPANC, DRKS 00000767):perioperative and long-term results of a multicenter randomized controlled trial. Ann Surg,2016,263(3):440-449.
12 Topal B,Fieuws S,Aerts R,et al. Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours:a multicentre randomised trial. Lancet Oncol,2013,14(7):655-662.
13 邹仲之,李继承,主编.组织学与胚胎学.第8版.北京:人民卫生出版社,2013. 148-150.
14 Bin X,Lian B,Jianping G,et al. Comparison of patient outcomes with and without stenting tube in pancreaticoduodenectomy. J Int Med Res,2018,46(1):403-410.
15 Suzuki S,Kaji S,Koike N,et al. Pancreaticoduodenectomies with a duct-to-mucosa pancreaticojejunostomy anastomosis with and without a stenting tube showed no differences in long-term follow-up. J Hepatobiliary Pancreat Sci,2011,18(2):258-262.
16 Mari G,Costanzi A,Monzio N,et al. Small bowel perforation caused by pancreaticojejunal anastomotic stent migration after pancreaticoduodenectomy for periampullary carcinoma. JOP,2015,16(2):185-188.
17 Park SH, Kim JH, Noh SY, et al. Migration of internal pancreaticojejunostomy stents into the bile ducts in patients undergoing pancreatoduodenectomy. J Gastrointest Surg,2015,19(11):1995-2002.
18 王振勇,刘汝海,李凤山,等.腹腔镜胰十二指肠切除术后胰漏的相关因素分析.中国微创外科杂志,2019,19(2):106-110.
2 Wente MN,Veit JA,Bassi C,et al. Postpancreatectomy hemorrhage(PPH):an International Study Group of Pancreatic Surgery(ISGPS)definition. Surgery,2007,142(1):20-25.
3 Bassi C,Marchegiani G,Dervenis C,et al. The 2016 update of the International Study Group(ISGPS)definition and grading of postoperative pancreatic fistula:11 years after. Surgery,2017,161(3):584-591.
4 Wente MN,Bassi C,Dervenis C,et al. Delayed gastric emptying(DGE)after pancreatic surgery:a suggested definition by the International Study Group of Pancreatic Surgery(ISGPS). Surgery,2007,142(5):761-768.
5 Koch M,Garden OJ,Padbury R,et al. Bile leakage after hepatobiliary and pancreatic surgery:a definition and grading of severity by the International Study Group of Liver Surgery. Surgery,2011,149(5):680-688.
6 Pugalenthi A,Protic M,Gonen M,et al. Postoperative complications and overall survival after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. J Surg Oncol,2016,113(2):188-193.
7 Mcmillan MT,Soi S,Asbun HJ,et al. Risk-adjusted outcomes of clinicallyrelevantpancreaticfistulafollowing pancreatoduodenectomy:a model for performance evaluation. Ann Surg,2016,264(2):344.
8 Shrikhande SV,Sivasanker M,Vollmer CM,et al. Pancreatic anastomosis after pancreatoduodenectomy:a position statement by the International Study Group of Pancreatic Surgery(ISGPS). Surgery,2017,161(5):1221.
9 Cheng Y,Briarava M,Lai M,et al. Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy.Cochrane Database Syst Rev,2017,9(6):CD012257.
10 吴志明,牟一平.腹腔镜胰体尾切除术后胰漏的防治进展.中国微创外科杂志,2016,16(6):566-569.
11 Keck T,Wellner UF,Bahra M,et al. Pancreatogastrostomy Versus PancreatojejunostomyforRECOnstructionAfter PANCreatoduodenectomy(RECOPANC, DRKS 00000767):perioperative and long-term results of a multicenter randomized controlled trial. Ann Surg,2016,263(3):440-449.
12 Topal B,Fieuws S,Aerts R,et al. Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours:a multicentre randomised trial. Lancet Oncol,2013,14(7):655-662.
13 邹仲之,李继承,主编.组织学与胚胎学.第8版.北京:人民卫生出版社,2013. 148-150.
14 Bin X,Lian B,Jianping G,et al. Comparison of patient outcomes with and without stenting tube in pancreaticoduodenectomy. J Int Med Res,2018,46(1):403-410.
15 Suzuki S,Kaji S,Koike N,et al. Pancreaticoduodenectomies with a duct-to-mucosa pancreaticojejunostomy anastomosis with and without a stenting tube showed no differences in long-term follow-up. J Hepatobiliary Pancreat Sci,2011,18(2):258-262.
16 Mari G,Costanzi A,Monzio N,et al. Small bowel perforation caused by pancreaticojejunal anastomotic stent migration after pancreaticoduodenectomy for periampullary carcinoma. JOP,2015,16(2):185-188.
17 Park SH, Kim JH, Noh SY, et al. Migration of internal pancreaticojejunostomy stents into the bile ducts in patients undergoing pancreatoduodenectomy. J Gastrointest Surg,2015,19(11):1995-2002.
18 王振勇,刘汝海,李凤山,等.腹腔镜胰十二指肠切除术后胰漏的相关因素分析.中国微创外科杂志,2019,19(2):106-110.