三种胆肠吻合术在晚期壶腹周围癌姑息性治疗的对比性研究

目的 对比胆囊空肠Roux-Y吻合、胆囊空肠襻式吻合与胆管空肠Roux-Y吻合三种不同的手术方式在晚期壶腹周围癌姑息性治疗中的疗效。方法 回顾性分析包头医学院第一附属医院2009年1月-2015年6月确诊的63例壶腹周围癌晚期,由于各种原因造成梗阻性黄疸不能行根治术患者,分为3组,一组行胆囊空肠Roux-Y吻合（胆囊空肠组）,一组行胆囊空肠襻式吻合（襻式吻合组）,一组行胆管空肠Roux-Y吻合（胆管空肠组）。观察其相应指标。结果 63例患者均手术顺利完成。3组患者术后住院时间[胆囊空肠组：（17.85±4.75）d,胆管空肠组：（20.64±4.71）d,襻式吻合组：（20.07±3.90）d]、术后下地时间[胆囊空肠组：（23.92±5.53）h,胆管空肠组：（23.41±7.27）h,襻式吻合组：（26.47±8.59）h]、术后胃肠功能恢复时间[胆囊空肠组：（71.12±9.81）h,襻式吻合组：（67.00±9.89）h,胆管空肠组：（67.32±8.99）h]、术后减黄效果[胆囊空肠组术前、术后1、3、7 d胆红素水平为（227.18±40.10）μmol/L、（178.13±27.40）μmol/L、（116.88±20.49）μmol/L、（72.26±12.10）μmol/L;襻式吻合组分别为（220.87±49.62）μmol/L、（173.28±32.03）μmol/L、（121.89±34.92）μmol/L、（74.31±13.01）μmol/L;胆管空肠组分别为：（233.49±53.93）μmol/L、（172.64±31.61）μmol/L、（123.81±22.73）μmol/L、（73.00±9.51）μmol/L]、及术后生存率差异（胆囊空肠组中位生存期8.05 m、襻式吻合组中位生存期8.9 m、胆管空肠组中位生存期7.9 m）无统计学意义。手术时间[胆囊空肠组（124.12±11.35）h、襻式吻合组（125.53±10.51）h、胆管空肠组（134.55±9.54）h],术中出血量[（胆囊空肠组（244.62±28.74）m L、胆管空肠组（269.55±28.70）m L、襻式吻合组（234.00±23.54）m L]胆囊空肠组与襻式吻合组均低于胆管空肠组,差异有统计学意义（P〈0.05）。胆囊空肠组术后并发症发生率（3.8%）均低于襻式吻合组（33.3%）及胆管空肠组（45.5%）,差异有统计学意义（P〈0.05）。结论 胆囊空肠Roux-Y吻合手术时间短、手术操作相对简单、术后并发症低、减黄效果好,对于一般情况较差,胆囊管通畅,无胆道结石、胆道畸形患者可作为其首选术式,对于基层医院及经济欠发达城市的医院具有很大的推广价值。

Objective the curative effects of gallbladder jejunum Roux-Y anastomosis, gallbladder jejunum loop-type anatomosis and bile duct jejunum Roux-Y anastomosis, three kinds of various operation methods, in palliative treatment of advanced periampullary carcinoma were compared. Methods 63 cases of patients with advanced periampullary carcinoma who diagnosed in NO.1 Hospital of Baotou Medical College from January 2009 to June 2015 were retrospectively analyzed. There were some patients with obstructive jaundice who was not able to carry out radical operation due to various reasons. They were divided into 3 groups, gallbladder jejeunum Roux-Y anastomosis （gallbladder jejunum group）, gallbladder jejunum loop-type anatomosis （loop-type anatomosis group） and bile duct jejunum Roux-Y anastomosis （bile duct jejunum group）. The corresponding indicators were observed. Results operations of 63 cases of patients were all completed successfully. The hospital stay of patients in 3 groups [gallbladder jejunum group： （17.85±4.76）d, bile duct jejunum group： （20.64±4.71）d, loop-type anatomosis group： （20.07±3.90）d], postoperative ambulation time [gallbladder jejunum group： （23.92±5.53）h, bile duct jejunum group： （23.41±7.27）h, loop-type anatomosis group： （26.47±8.59）h], postoperative gastrointestinal function recovery time [gallbladder jejunum group： （71.12±9.8）h, loop-type anatomosis group： （67.00±9.89）h, bile duct jejunum group： （67.32±8.99）h], postoperative effect of reducing jaundice [bilirubin levels of gallbladder jejunum group at 1, 3, 7 days before and after operation were （227.18±40.10）μmol/L, （178.13±27.40）μmol/L, （116.88±20.49）μmol/L, （72.26±12.10）μmol/L; levels of loop-type anatomosis group were （220.87±49.62）μmol/L, （173.28±32.03）μmol/L, （121.89±34.92）μmol/L, （74.31±13.01）μmol/L, respectively; levels of bile duct jejunum group were （233.49±53.93）μmol/L, （172.64± 31.61）μmol/L, （123.81±22.73）μmol/L, （73.00±9.510）μmol/L], and differences of postoperative survival rates （median survival time of gallbladder jejunum group was 8.05m, loop-type anatomosis group7.9m, bile duct jejunum 8.9m） were not statistically signifcant. Operation time [gallbladder jejunum group： （124.1±11.35）h, loop-type anatomosis group： （125.53±10.51）h, bile duct jejunum group： （134.55±9.54）h）, intraoperative blood loss [gallbladder jejunum group： （244.62±28.74）mL, bile duct jejunum group： （269.55±28.70）mL, loop-type anatomosis group： （234.00±23.54）mL）; gallbladder jejunum group and loop-type anatomosis group were both lower than bile duct jejunum group（P〈0.05）, and the differences were statistically signifcant. Postoperative complication occurrence rates of allbladder jejunum group （3.8%） were lower than those of loop-type anatomosis group（33.3%） and bile duct anatomosis group （45.5%） （P〈0.05）, and the differences were statistically signifcant. Conclusion the operation time of gallbladder jejunum Roux-Y anatomosis is short, with relatively easy operative procedures, low postoperative complication occurrence and good effect of reducing jaundice. For patients whose general situation is poor, with smooth gallbladder duct and bile duct malformation, without calculus of bile duct, it can be regarded as preferred operative method, which is of great promotional value for grassroots hospitals and hospitals in underdeveloped cities.