多次胆道手术后行胰十二指肠切除术的经验探讨

Pancreaticoduodenectomy performed in patients with a history of multiple biliary tract operations

目的总结多次胆道手术后患者行胰十二指肠切除术的相关外科技术和经验。方法4例曾行多次胆道相关手术的患者行PD术，其中男女性患者各2例，年龄在17～73岁。在4例患者中：2例是因先天性胆管囊肿多次手术后因残余囊肿癌变行PD术；1例是因肝内外胆管结石行多次取石及左肝外叶切除、T管引流术后，行胆道镜检查发现胆管下段肿瘤梗阻行PD术；1例是因急性胆囊炎及胆囊癌曾行多次手术，术后3年胰头区发现肿瘤局部复发致十二指肠及胆管梗阻行PD术。结果4例患者均顺利完成PD术，其中1例合并肝动脉局段切除再吻合。术后各有1例患者发生术后胆瘘、胃瘫及腹腔积液感染。所有4例患者均接受术后化疗、放疗等综合辅助治疗。在术后随访中，1例患者在术后15个月因肿瘤复发而死亡，另3例患者均存活并随访中。结论经多次胆道手术后的患者仍可安全实施PD术。术中，采取CattellandBraasch手法由外至内、由下至上，先解剖胰头十二指肠再解剖肝门及肝十二指肠韧带视为手术的关键步骤。保留原本通畅的胆肠吻合口可使手术简单且减少并发症。术后的综合辅助治疗有益于患者的预后。

Objective To summarize the surgical technique and experience of pancreaticoduodenectomy for patients with medical history of multiple biliary tract surgery. Methods Four patients who had undergone multiple biliarv tract surgeries received pancreaticoduodenectomy in China-Japan friendship hospital, including 2 male and 2 female patients, with the age of 17 - 73 years old. Two cases underwent pancreaticoduodenectomy for residual cyst canceration after repeated surgery for congenital bile duct cyst. One case was found with malignant obstruction by choledochoscope after muhiple biliary tract surgery, left hemihepatectomy and T-tube drainage due to intra- and extra-hepatic cholelithiasis. The other case unde^weent pancreaticodnodenectomy because of cancer recurrence on region of the pancreatic head, who had had a hiatory of repeated surgery for acute cholecystitis and gallbladder cancer. Results Pancreaticoduodenectomy for all these four patients were successfully completed. Among them, one case received pancreaticoduodenectomy combined with hepatic artery resection and anastomosis. Gastric paralysis ensued in one case, abdominal cavity infection in one case, and biliary fistula in one case, respectively. One case died of cancer recurrence 15 months later. The other 3 cases were still alive in the follow-up of 4 to 42 months. Conclusion Pancreaticoduodenectomy can be safely performed for patients who had received multiple biliary tract surgeries. It is crucial that the Cattell and Braasch maneuver was taken from right to left and bottom up ways. It is better to keep the unobstructed bile intestinal anastomosis in place hence reduce serious complications.