小肠解旋转技术用于胰十二指肠切除术3例体会

Intestinal derotation procedure applied in pancreatoduodenectomy:A report of 3 patients

目的探讨小肠解旋转技术及其在胰十二脂肠切除术中的应用。方法回顾性分析复旦大学附属中山医院2016年8月至2016年9月收治的3例接受胰十二指肠切除术病人资料,通过结合术前影像学资料、术后病理学检查结果及术后恢复情况,探讨小肠解旋转技术对术中局部解剖的改变及其在胰十二指肠切除术中的应用。结果病人解小肠旋转时间分别为30、15、15 min。消化道重建前恢复小肠旋转状态所需时间约5 min。小肠解旋转后,肠系膜上动脉自肠系膜上静脉左后侧易位到右后侧,胰十二指肠下动脉直接发自肠系膜上动脉右侧壁并水平向右走行;胰腺系膜直接发自肠系膜上动脉右侧并创造了一个水平面,从而方便胰腺系膜的完整切除。术中出血量分别在0.10、0.15、0.05L,均未输血。术后病理学检查提示后腹膜切缘阴性(1例姑息性手术除外),另2例淋巴结清扫总数均>10枚。术后引流量偏大,中位值约0.3 L/d,引流管放置时间均在1周以上。结论通过小肠解旋转技术简化胰腺系膜的解剖,可获得良好的手术视野,从而使得胰腺系膜切除变得容易、精确和可控。

Objective To introduce the preliminary experience of intestinal derotation procedure and its applications in pancreatoduodenectomy.Methods From August 2016 to September 2016, 3 patients received pancreatoduodenectomy were analysed with preoperative imaging data, postoperative pathology and postoperative recovery or complications to introduce the changes of local anatomy with intestinal derotation procedure in the operation and its applications in pancreatoduodenectomy. Results The time of intestinal derotation in three cases was 30min,15min and 15min respectively and the time to recover from the intestinal rotation before the digestive tract reconstruction was about 5min. After intestinal derotation,the superior mesenteric artery was located from the left-rear corner of the superior mesenteric vein to the right-rear corner. The inferior pancreatoduodenal artery originated directly from the right of the superior mesenteric artery and moved towards right horizontally. The mesopancreas originated directly from the right of the superior mesenteric artery and created a horizontal plane, which was convenient for the total excision of mesopancreas. The blood loss in the operation was 0.1L,0.15 L and 0.05L respectively without blood transfusion. The postoperative pathology prompted negative in the incisal edge of retroperitoneum（with the exception of case 1 palliative surgery） and the total number of lymph node cleaning in another two cases was all more than ten. The postoperative drainage flow was relative high that the median value was about 0.3L per day and the drainage tube was placed more than one week. Conclusion The intestinal derotation procedure simplifies the anatomy of mesopancreas and obtains a good surgical field, which makes it easier, more accurate and controllable to excise the mesopancreas.