端侧封闭式原位胰肠吻合术在胰十二指肠切除术中的应用价值

Application value of end-to-side closed in situ pancreaticojejunostomy in pancreaticoduodenectomy

目的探讨端侧封闭式原位胰肠吻合术在胰十二指肠切除术中的应用价值。方法回顾性分析2014年1-3月哈尔滨医科大学附属第二医院收治22例梗阻性黄疸患者的临床资料。所有患者采用气管插管全身麻醉，胆囊减压后探查肿瘤是否侵犯下腔静脉、肠系膜上静脉及门静脉，并根据术中探查结果决定行标准胰十二指肠切除术还是扩大胰十二指肠切除术。胰肠吻合方法采用端侧封闭式原位胰肠（胰管与空肠浆肌层）吻合术。观察患者手术时间，术中出血量，术后胃肠功能恢复时间，术后第1、3、5天分别检测引流液淀粉酶浓度，术后并发症发生率，病理学类型，住院时间等指标。采用门诊和电话的方法进行随访，门诊随访内容为彩色多普勒超声检查胰腺残端附近是否有积液，电话随访了解患者是否有腹泻等胰腺外分泌功能不足的表现。随访时间截至2014年5月。正态分布的计量资料以孟x±s（范围）表示，偏态分布的计量资料以M（范围）表示。结果22例患者成功施行手术，其中17例患者采用标准胰十二指肠切除术，5例患者采用扩大胰十二指肠切除术，胰肠吻合方法采用端侧封闭式原位胰肠吻合术。22例患者手术时间为（313±37）min（228—360min），端侧封闭式原位胰肠吻合手术时间为（13±4）min（7～22min）；术中出血量为（400±207）mL（100—800mL）。平均肿瘤大小为3．69em。（0．72—1．68cm2）。术后胃肠功能恢复时间为（5±2）d（4—7d）。21例患者术后第1、3、5天血清淀粉酶分别为（145±30）U／L（116～180U／L）、（136±40）U／L（105—176U／L）、（147±38）U／L（110～175U／L），术后第1、3、5天引流液淀粉酶分别为（220±56）U／L（172～289U／L）、（240±54）U／L（192—300U／L）、（245±52）U／L（190—298U／L）；1例胰瘘患者术后第1、3、5天血清淀粉酶分别为156U／L、178U／L、177U／L，术后第1、3、5天引流液淀粉酶分别为500U／L、620U／L、605U／L。22例患者中1例放置胰管支架。本组患者无手术或住院死亡。4例患者出现术后并发症：术后胰瘘（A级）、感染、肺炎和术后应激性溃疡出血各1例。胰瘘患者经持续外引流的非手术治疗痊愈，其余3例患者经对症支持治疗痊愈。22例患者术后病理学类型：12例为导管腺癌，2例为神经内分泌肿瘤，单纯囊肿、囊腺癌、鳞癌、腺癌、壶腹癌、管状腺瘤癌变、平滑肌瘤、导管上皮非典型增生各1例。22例患者住院时间为（114-3）d（2—15d）。22例患者随访时间为2—4个月，彩色多普勒超声检查胰腺残端附近均无积液，无腹泻等胰腺外分泌功能不足的表现。结论端侧封闭式原位胰肠吻合术安全、可行，适用于任何胰管直径大小和质地性质的胰腺手术。

Objective To explore the application value of end-to-side closed in situ pancreaticojejunostomy in pancreaticoduodenectomy. Methods The clinical data of 22 patients with obstructive jaundice who were admit- ted to the Second Affiliated Hospital of Harbin Medical University from January to March 2014 were retrospectively analyzed. All the patients were explored whether tumors invaded inferior vena cava, superior mesenteric vein and portal vein after gallbladder decompression under general anesthesia by tracheal intubation. The standard or extended pancreaticoduodenectomy was applied according to the intraoperative results. The method of pancreatico- jejunostomy was end-to-side closed in sltu anastomosis of pancreatic duct and jejunal seromuscular layer. The operation time, intraoperative blood loss, postoperative gastrointestinal function recovery time, amylase concentration of drainage at postoperative day 1,3, 5, postoperative complication, pathological classification and duration of hospital stay were observed. Patients were followed up by outpatient examination and telephone interview till May 2014. The out-patient follow-up included color Doppler ultrasound examination of effusion near the pancreatic stump, and the telephone interview included whether there were diarrhea of exocrine pancreatic insufficiency. Measurement data with normal distribution were presented as Yc ＋ s （ range）, and measurement data with skewed distribution as M（range）. Results All the 22 patients underwent successfully the operation, including 17 under- going standard pancreaticoduodenectomy and 5 undergoing extended pancreaticoduodenectomy, with end-to-side closed in situ anastomosis of pancreatic duct and jejuna seromuscular layer. The operation time of pancreaticoduo- denectomy and end-to-side closed in situ pancreaticojejunostomy were （ 313 - 37 ） minutes （ range, 228-360 minutes） and （ 13 ± 4） minutes （ 7- 22 minutes）, respectively. The intraoperative blood loss was （ 400 ± 207 ） mL （ range, 100-800 mL）. The mean tumor size was 3.69cm2 （range, 0.72-1.68 cm2 ）. The recovery time of gastrointestinal function was （5 ±2）days （range, 4-7 days）. The serum amylase at postoperative day 1, 3, 5 in the 21 patients was （145±30）U/L （range, 116-180 U/L）, （136 ±40）U/L （range, 105-176 U/L）, （147±38）U/L （range, 110-175 U/L）, and the drainage amylase was （220±56）U/L （range, 172-289 U/L）, （240 ±54）U/L （ range, 192-300 U/L） , （245 ± 52） U/L （ range, 190-298 U/L）, respectively. The serum amylase at postopera- tive day 1, 3, 5 in the patient with pancreatic fistula was 156 U/L, 178 U/L and 177 U/L, and the drainage fluid amylase was 500 U/L, 620 U/L and 605 U/L, respectively. There was 1 patient in the 22 patients with pancreatic duct stent and without death. Among the 4 patients with postoperative complications, 1 patient with grade A post- operative pancreatic fistula recovered after continuous external drainage, the other 3 including 1 case of infection, 1 case of pneumonia and 1 of stress ulcer bleeding also recovered after symptomatic and supportive treatment. Post- operative pathological examinations of the 22 patients showed 12 cases of ductal adenocarcinoma, 2 of neuroendocine tumors, 1 of simple cyst, 1 of cystadenocarcinoma, 1 of squamous carcinoma, 1 of adenocarcinoma, 1 of ampullary carcinoma, 1 of tubular adenoma, 1 of leiomyoma and 1 of atypical intraductal hyperplasia. The average length of hospital stay was （11 ±3）days （range, 2-15 days）. There were no effusion near the pancreatic stump showed in color Doppler uhrasound examination and diarrhea of exocrine pancreatic insufficiency. Conclusion End-to-side closed in situ pancreaticojejunostomy is safe and feasible, and can be applied to any pancreatic duct size and texture.