成人胰腺段胆总管囊肿手术技巧及术后胰瘘的预防

Surgical technique and prevention of postoperative pancreatic fistula in treatment of intrapancreatic choledochal cyst in adults

目的:探讨成人胰腺段胆总管囊肿的手术技巧及并发症的预防措施。方法:回顾2006年1月—2013年12月收治的41例胰腺段胆总管囊肿患者的临床资料,分析手术方法与技巧以及主要并发症胰瘘产生的原因。结果:手术采用Kocher切口游离胰头及十二指肠第二、三段充分暴露胰腺段胆总管囊肿,38例行囊肿切除、囊肿内黏膜剥除或囊肿黏膜烧灼法处理胰腺段胆总管囊肿,3例行胰十二指肠切除,均康复出院,无手术死亡病例。1例(2.4%)术中门静脉损伤,术后1例(2.4%)胆瘘,4例(9.8%)胰瘘(均为胆总管残端连续缝合残端瘘),5例(12.2%)切口感染。随访6个月至8年,3例术后3个月内有畏寒发热,1例死于肿瘤复发,2例死于脑出血,其余患者术后无腹痛、发热、黄疸复发。病理结果显示,41例胆总管囊肿中,合并胆管黏液乳突状腺瘤1例,胆管黏液腺癌3例,腺癌2例。结论:胰腺段胆总管囊肿手术相对复杂,应在充分游离胰头及十二指肠第二、三段,合理选择囊肿切除、黏膜剥离或黏膜烧灼的方法。处理好胆总管残端、避免胰管损伤是胰瘘的有效预防措施。

Objective：To investigate the surgical technique and measures for prevention of postoperative pancreatic fistula in dealing with intrapancreatic choledochal cyst in adults.Methods：The clinical data of 41 patients with intrapancreatic choledochal cyst admitted from January 2006 to December 2013 were reviewed.The surgical method and technique as well as the causes for pancreatic fistula were analyzed.Results：With complete exposure of the intrapancreatic choledochal cyst after isolation of the head of the pancreas and the second and third portion of the duodenum through Kocher＇s incision,38 patients underwent cyst excision or treatment by mucosal stripping or cauterization of the cyst,and 3 patients were subjected to pancreaticoduodenectomy.All patients were discharged from hospital after recovery and no surgical death occurred.Portal vein injury occurred in one patient（2.4%） during surgery,and bile leakage occurred in one patient（2.4%）,pancreatic fistula occurred in 4 patients（9.8%） following continuous suture of the bile duct stump and wound infection occurred in 5 patients（12.2%） after surgery.During follow-up for 6 months to 8 years,fever and chills occurred in 3 cases within 3 months postoperatively,one case died of tumor recurrence and two cases died of cerebral hemorrhage,while no postoperative abdominal pain,fever or recurrence of jaundice was noted in any of the other patients.The postoperative pathology revealed that in the 41 cases of intrapancreatic choledochal cyst,one case was complicated with myxopapilloma,3 cases with mucinous adenocarcinoma,and 2 cases with adenocarcinoma.Conclusion：The procedure for intrapancreatic choledochal cyst is relatively complicated,so cyst excision or treatment by mucosal stripping or cauterization should be properly selected under the condition of adequate isolation of the head of the pancreas and the second and third portion of the duodenum.Appropriate closure of the common bile duct stump and avoidance of injury of the pancreatic duct are effective measures for prevention of pancreatic fistula.