肠系膜上静脉右侧间隙入路在保留十二指肠的胰头切除术治疗慢性胰腺炎合并胰头结石中的应用价值

Application value of superior mesenteric vascular right approach in duodenum-preserving pancreatic head resection for chronic pancreatitis with pancreatic head stones

目的:探讨肠系膜上静脉右侧间隙入路在保留十二指肠的胰头切除术(又称Beger术)治疗慢性胰腺炎合并胰头结石中的应用价值。方法:采用回顾性描述性研究方法。收集2015年1月至2017年5月上海交通大学医学院附属仁济医院收治的3例慢性胰腺炎合并胰头结石患者的临床资料。3例患者均施行经肠系膜上静脉右侧间隙入路Beger术,即紧贴肠系膜上静脉右侧缘解剖胰颈后隧道,逐步离断胰颈。观察指标:(1)手术情况。(2)术后情况。(3)术后病理学检查情况。(4)随访情况。采用门诊方式进行随访,随访内容为患者腹痛、腹泻、畏寒、发热、黄疸等临床表现,血糖、肝功能和肿瘤标志物检查,腹部超声、MRI或CT检查判断有无结石残留和复发。随访时间截至2017年12月。正态分布的计量资料以平均数(范围)表示。结果:(1)手术情况:3例患者均成功采用肠系膜上静脉右侧间隙入路行保留十二指肠的胰头切除术,其中1例联合胆总管囊肿切除术,无围术期死亡患者。3例患者手术时间为400min(360~480min),胰腺颈部离断时间为20min(15~25min),术中出血量为117mL(50~200mL)。(2)术后情况:3例患者术后首次下床活动时间为4d(3~5d),术后首次肛门排气时间为3d(2~3d),术后恢复饮水时间为3d(2~4d)。1例患者出现胰腺生化漏和胃瘫,经腹腔引流和对症治疗好转,术后30d带管出院,术后47d来院拔除腹腔引流管。1例患者出现胰腺生化漏,经腹腔引流和对症治疗好转,术后28d带管出院,术后48d来院拔除腹腔引流管。1例患者术后恢复平稳,未出现胰液漏、胃瘫等并发症,术后13d拔除腹腔引流管出院。(3)术后病理学检查情况。3例患者术后病理学检查结果显示:均为慢性胰腺炎、胰腺导管扩张伴结石形成,其中1例合并胆总管囊肿伴上皮轻度不典型增生。(4)随访情况:3例患者均获得术后随访,随访时间为17~27个月。随访期间,3例患者饮食情况良好,生存良好,均未出现腹痛、腹泻、畏寒、发热、黄疸等临床表现,血糖控制良好,肝功能和肿瘤标志物正常,均无胰管结石残留和复发。结论:肠系膜上静脉右侧间隙入路离断胰颈的Beger术治疗慢性胰腺炎合并胰头结石安全有效。

Objective:To investigate the application value of superior mesenteric vascular right approach in duodenumpreserving pancreatic head resection for chronic pancreatitis with pancreatic head stones.Methods: The retrospective descriptive study was conducted. The clinical data of 3 chronic pancreatitis patients with pancreatic head stones who were admitted to the Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine from January 2015 to May 2017 were analyzed. All the 3 patients underwent Beger procedure via superior mesenteric vascular right approach, dissecting the posterior tunnel of pancreatic neck and gradually cutting off the pancreatic neck close to the right side of superior mesenteric vein. Observation indicators: (1) surgical situations; (2) postoperative situations; (3) postoperative pathological examination situations; (4) follow-up situations. follow-up was performed by outpatient examination up to December 2017, including abdominal pain, diarrhea, chills, fever, jaundice, blood glucose, liver function and tumor marker examination, and residual or recurrent stones by ultrasound, CT or MRI examination. Measurement data were represented as average (range).Results: (1) Surgical situations: all the 3 patients underwent successful Beger procedure via superior mesenteric vascular right approach, including 1 combined with choledochal cyst resection, without perioperative death. The operation time, time of cutting off pancreatic neck and volume of intraoperative blood loss of 3 patients were 400 minutes (range, 360-480 minutes), 20 minutes (range, 15-25 minutes) and 117 mL (range, 50-200 mL) respectively. (2) Postoperative situations: time of initial out-of-bed activity, time to anal exsufflation and time for drinking intake were 4 days (range, 3-5 days), 3 days (range, 2-3 days) and 3 days (range, 2-4 days). One patient complicated with pancreatic fistula and gastroplegia was improved by abdominal drainage and symptomatic treatment and discharged with drainage-tube at 30 days postoperatively and removed drainage-tube at 47 days postoperatively. One patient with pancreatic fistula was improved by abdominal drainage and symptomatic treatment and discharged with drainage-tube at 28 days postoperatively and removed drainage-tube at 48 days postoperatively. One patient recovered steadily without complications and discharged at 13 days postoperatively after removal of drainage-tube. (3) Postoperative pathological examination showed that 3 patients were diagnosed as chronic pancreatitis complicated with stones of pancreatic head, including 1 along with choledochal cyst and mild atypical hyperplasia. (4) Follow-up situations: 3 patients were followed up for 17-27 months with good general conditions and without abdominal pain, diarrhea, chills, fever or jaundice. Blood glucose was controlled well, and liver function and tumor marker were normal. There was no sign of residual and recurrent stones.Conclusion:Beger procedure via superior mesenteric vascular right approach for chronic pancreatitis complicated with pancreatic head stones is safe and effective.