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《中华消化外科杂志》2019年7月第18卷第7期论著

优化套入式胰肠吻合在胰十二指肠切除术中的临床应用价值

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引用本文:
周江,杨景瑞,肖瑞,等.优化套入式胰肠吻合在胰十二指肠切除术中的临床应用价值[J].中华消化外科杂志,2019,18(7):668-674.DOI:10.3760/cma.j.issn.1673-9752.2019.07.011.
【摘要】

目的:探讨优化套入式胰肠吻合在胰十二指肠切除术(PD)中的临床应用价值。
方法:采用回顾性队列研究方法。收集2014年1月至2017年12月内蒙古医科大学附属医院收治的39例行PD患者的临床病理资料;男26例,女13例;年龄为(60±7)岁,年龄范围为41~75岁。39例患者均行PD,术中采用Child法重建消化道,其中19例行优化套入式胰肠吻合,设为创新组;20例行黏膜对黏膜胰肠端侧吻合,设为传统组。观察指标:(1)手术情况。(2)术后并发症情况。(3)随访情况。采用门诊、电话方式进行术后随访。随访内容为术后肿瘤复发、主胰管扩张、患者生存情况,以及患者不适症状(腹痛、腹胀、消化不良等)。随访时间截至2018年10月。正态分布的计量资料以Mean±SD表示,组间比较采用t检验;偏态分布的计量资料以M(P25,P75)或M(范围)表示,组间比较采用Mann Whitney U检验。计数资料以绝对数表示,组间比较采用x2检验或Fisher确切概率法。
结果:(1)手术情况:创新组患者手术时间,术中出血量,胰腺质地(软、硬),胰管直径,胰管拔除时间,使用生长抑素,术后住院时间分别为(342±47)min, 400 mL(300 mL,400 mL),10、9例,3.1 cm(2.9 cm,3.4 cm),37 d(32 d,63 d),17例,18 d(15 d,22 d);传统组上述指标分别为(392±95)min,400 mL(300 mL,525 mL),6、14例,3.6 cm(2.6 cm,4.2 cm),43 d(34 d,49 d),18例,24 d(15 d,27 d)。两组患者术中出血量,胰腺质地(软、硬),胰管直径,胰管拔除时间,使用生长抑素,术后住院时间比较,差异均无统计学意义(Z=-0.775, x2=2.063,Z=-1.155,Z=-0.295, x2=0.003,Z=-1.286,P>0.05);两组患者手术时间比较,差异有统计学意义(t=-2.114,P<0.05)。(2)术后并发症情况:创新组6例患者发生术后并发症,其中胃排空延迟1例、切口感染1例、肺部感染1例、急性呼吸衰竭1例、肝周积液1例、A级胰瘘3例、无B级和C级胰瘘发生;传统组11例患者发生术后并发症,其中胆汁漏1例、胃排空延迟2例、腹腔感染4例、切口感染4例、肺部感染2例、腹腔积液1例、腹部出血 1例、胸腔积液1例、A级胰瘘2例、B级和C级胰瘘5例。同1例患者可合并多种并发症。两组患者术后并发症比较,差异无统计学意义(x2=2.174,P>0.05);两组患者术后B级与C级胰瘘比较,差异有统计学意义(P<0.05)。术后发生并发症患者均经对症支持治疗后好转,围术期无患者死亡。(3)随访情况:39例患者中,33例获得术后随访(创新组18例、传统组15例),随访时间为3~57个月,中位随访时间为17个月。创新组18例获得术后随访的患者中,因肿瘤复发转移死亡5例(生存时间为5~24个月),术后34个月 肿瘤复发1例,主胰管扩张且间断腹痛、腹胀1例,消化不良5例,后背疼痛1例,恢复良好5例。传统组 15例获得术后随访的患者中,因肿瘤复发转移死亡10例(生存时间为3~57个月),主胰管扩张且间断腹痛、腹胀2例,消化不良2例,恢复良好1例。
结论:PD术中采用优化套入式胰肠吻合行消化道重建安全可行,与黏膜对黏膜胰肠端侧吻合术比较,前者可简化手术操作,降低对术者操作技术的要求,缩短手术时间,降低术后B级和C级胰瘘并发症发生率。

【Abstract】

Objective:To explore the clinical application value of modified invagination for pancreaticojejunostomy in pancreaticoduodenectomy (PD).
Methods:The retrospective cohort study was conducted. The clinicopathological data of 39 patients who underwent PD in the Affiliated Hospital o
f Inner Mongolia Medical University from January 2014 to December 2017 were collected. There were 26 males and 13 females, aged (60±7)years, with a range of 41-75 years. All the 39 patients underwent PD, using Child method to reconstruct digestive tract. Of 39 patients, 19 undergoing modified invagination for pancreaticojejunostomy and 20 undergoing mucosatomucosa end-to-side pancreaticojejunostomy were allocated to innovative group and traditional group, respectively. Observation indicators: (1) surgical situations; (2) postoperative complications; (3) followup. Follow-up was performed by outpatient examination and telephone interview to detect postoperative tumor recurrence, main pancreatic duct dilatation, survival, and discomfort (abdominal pain, bloating, indigestion, etc.) of patients up to October 2018. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed by t test. Measurement data with skewed distribution were represented as M (P25, P75) or M (range), and comparison between groups was analyzed by Mann Whitney U test. Count data were expressed as absolute numbers, and comparison between groups was analyzed by chisquare test or Fisher exact probability.
Results:(1) Surgical situations: operation time, volume of intraoperative blood loss, cases with soft pancreas or hard pancreas (pancreatic texture), pancreatic duct diameter, time of pancreatic duct removal, cases using somatostatin, and duration of postoperative hospital stay of the innovative group were (342±47)minutes, 400 mL (300 mL, 400 mL), 10, 9, 3.1 cm (2.9 cm, 3.4 cm), 37 days (32 days, 63 days), 17, 18 days (15 days, 22 days), respectively, versus (392±95)minutes, 400 mL (300 mL, 525 mL), 6, 14, 3.6 cm (2.6 cm, 4.2 cm), 43 days (34 days, 49 days), 18, and 24 days (15 days, 27days) of the traditional group; there was no significant difference in the volume of intraoperative blood loss, cases with soft pancreas or hard pancreas (pancreatic texture), pancreatic duct diameter, time of pancreatic duct removal, cases using somatostatin, and duration of postoperative hospital stay between the two groups (Z=-0.775, x2=2.063, Z=-1.155, Z=-0.295, x2=0.003, Z=-1.286, P>0.05); but a significant difference in operation time between the two groups (t=-2.114, P<0.05). (2) Postoperative complications: 6 patients in the innovative group had complications, including 1 of delayed gastric emptying, 1 of wound infection, 1 of pulmonary infection, 1 of acute respiratory failure, 1 of perihepatic effusion, and 3 of grade A pancreatic leakage; 11 patients in the traditional group had postoperative complications, including 1 of bile leakage, 2 of delayed gastric emptying, 4 of abdominal infection, 4 of wound infection, 2 of pulmonary infection, 1 of ascites, 1 of abdominal hemorrhage, 1 of pleural effusion, 2 of grade A pancreatic leakage, 5 of grade B and C pancreatic leakage; the same patient had multiple complications. There was no significant difference in postoperative complications between the two groups (x2=2.174, P>0.05), but there was a significant difference in postoperative grade B and C pancreatic leakage between the two groups (P<0.05). Patients with postoperative complications were improved after symptomatic support treatment, and no patient died during the perioperative period. (3) Follow-up: of the 39 patients, 33 (18 in the innovation group and 15 in the traditional group) were followed up for 3-57 months, with a median followup time of 17 months. Of the 18 patients receiving followup in the innovative group, 5 died of tumor recurrence and metastasis, with a survival time of 5-24 months, 1 had tumor recurrence at 34 months after operation, 1 had main pancreatic duct dilatation and intermittent abdominal pain and abdominal distension, 5 had indigestion, 1 had back pain, and 5 had good recovery. Of 15 patients receiving followup in the traditional group, 10 died of tumor recurrence and metastasis, with a survival time of 3-57 months, 2 had main pancreatic duct dilatation and intermittent abdominal pain and abdominal distension, 2 had indigestion, 1 had good recovery.
Conclusion:Compared with the traditional mucosatomucosa end-to-side pancreaticojejunostomy, modified invagination for pancreaticojejunostomy in the PD is safe and feasible, which can simplify the operation, reduce the requirements for the operator′s operation skills, shorten the operation time, and reduce incidence of postoperative grade B and C pancreatic leakage.

DOI:10.3760/cma.j.issn.1673-9752.2019.07.011
基金项目:内蒙古自治区自然科学基金(2017MS0834);内蒙古自治区科技计划项目(2017年);内蒙古自治区教育厅研究生教育教学改革研究与实践项目(YJG20181013202);内蒙古医科大学2018年度教育教学改革立项项目(NYJXGG2018011);“草原英才”称号;草原英才创新人才团队;内蒙古医科大学附属医院重大科研项目(NYFY ZD003)
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