胰腺断裂合并主胰管损伤的外科治疗分析

Surgical treatment for pancreatic disrupture with major duct injury

目的探讨胰腺断裂合并主胰管损伤的手术方式选择和疗效。方法回顾性分析1995年1月～2009年2月经我院手术治疗的21例胰腺断裂伤患者的临床资料。本组男14例，女7例；平均年龄26岁（9～53岁）；开放性损伤8例，闭合性损伤13例；按美国创伤外科医师学会的损伤分级：Ⅲ级8例，Ⅳ级8例，V级5例。18例损伤后12小时内手术治疗，3例延期手术治疗。其中10例行远侧胰腺空肠Roux—en—Y吻合术；3例行胰头十二指肠切除术；2例行改良十二指肠憩室化手术；3例行胰腺尾部切除术；2例行主胰管吻合内置管引流、胰腺断面缝合；1例行胰腺两侧断端缝扎，后2期手术行远端胰腺空肠Roux—en—Y吻合术。结果治愈20例，死亡1例（胰头十二指肠切除术后）。发生胰瘘并发症3例，经充分引流、药物治疗治愈。结论早期手术探查并贯彻损伤控制性外科理念是提高胰腺断裂伤治疗效果的关键，手术方式要根据分级采取个体化方案。

Objective To investigate the selection and efficacy of operative modality for pancreatic transection with major duct injury. Methods The clinical data were retrospectively analyzed in 21 patients with pancreatic disruption. They were treated in our hospital from Jan. 1995 to Feb. 2009. There were 14 males and 7 females in these eases with a mean age of 26 years （ range 9-53 years ）. The trauma causes of them were blunt injuries in 13 and patent injuries in 8 cases. The injury grade （according to American Association for the Surgery of Trauma） distribution for these patients was grade Ⅲ in 8 cases, grade Ⅳ in 8 cases, and grade Ⅴ in 3. The early emergency operation was performed in eighteen within 12 hours, and delayed opera- tion was in three cases. Of these operative modalities, Roux-en-Y distal pancreatojejunostomy was in 10 cases, pancreatoduodenectomy was in 3, modified duodenal diverticulization was in 2, distal pancreateetomy was in 3, tube installing in major duct and external drainage, and suture of pancreatic section was in 2, suture of two broken sides in 1 （Roux-en-Y distal pancreatojejunostomy in second time）. Results Twenty patients were cured, and one was died after a procedure of pancreatoduodenectomy. The postoperative pancreatic fistula happened in 3 cases and recovered well with conservative line of management. Conclusions For improving the outcome of pancreatic transection, the earlier exploratory laparotomy and carrying out concept of ＂Damage Control Surgery＂ are critical. The individual operative modality based on the grade should be adopted in the surgical procedure.