腹腔镜胰腺远端切除术中Warshaw保脾技术的应用体会

Application of laparoscopic Warshaw technique for spleen preservation in distal pancreatectomy

目的?探讨腹腔镜Warshaw技术(laparoscopic Warshaw technique,lap-WT)在胰腺远端切除术保脾中的安全性。研究对于脾脏血管上附有大肿瘤患者预先计划lap-WT或尽早转换为lap-WT治疗的有效性。方法 2008年1月至2019年8月在周口市中心医院行腹腔镜下胰腺远端切除术的171例患者中,42例(24.6%)行lap-WT。42例患者按时间分为早期组(2008年1月至2016年12月,n=22)和晚期组(2017年1月至2019年8月,n=20)。其中早期组为保留脾血管失败后最后才转换为lap-WT的患者;晚期组为预先计划或尽早转换为lap-WT的患者。结果 42例患者中位手术时间181.1 min(141~223 min),中位出血量318.7 mL(125~498 mL),术后平均住院9.0 d(7~11 d)。术后发生并发症9例(21.4%),其中4例(9.5%)伴有胰瘘(ISGPF分级B、C);术后因出血再次手术1例。中位随访时间35个月,42例均没有出现明显的脾脏梗死或胃静脉曲张;所有患者均保守观察。在晚期组与早期组的比较中,晚期组平均手术时间(161.0 min vs 225.0 min,P=0.001)和平均手术出血量(230.1 mL vs 380.0 mL,P=0.016)均显著低于早期组。而两组的总并发症发生率无明显差异(P=0.468),胰瘘发生率无明显差异(P=0.667)。两组间的脾脏梗死(P=0.745)和胃静脉曲张(P=0.468)的发生率无明显差异。结论在胰腺远端切除术中作为保存脾脏的一种方法,严格控制适应证,lap-WT技术在某些病例中是一种安全的治疗策略。预先计划或尽早转换为lap-WT能够缩短手术时间,减少出血量,且不增加相应并发症。

Objective To explore the safety of laparoscopic Warshaw technique(lap-WT)in spleen preservation in distal pancreatectomy,and to investigate the effectiveness of a planned lap-WT procedure or early conversion to lap-WT in selected patients with a large tumor attached to the splenic vessels.Methods Among 171 patients who underwent laparoscopic distal pancreatectomy between Jan.2008 and Aug.2019 at Zhoukou Central Hospital,42 patients(24.6%)who underwent lap-WT were analyzed.The 42 patients were categorized into two groups chronologically(early group:Jan.2008 to Dec.2016,late group:Jan.2017 to Aug.2019).The early group represented patients who were converted to lap-WT after splenic vessel retention failure,and the late group were patients who had been previously scheduled lap-WT or who had been converted to lap-WT as early as possible.Results Of the 42 patients,the median operation time was 181.1 min(range from 141 to 223 min),the median blood loss was 318.7 mL(range from 125 to 498 mL),and the median postoperative hospitaization time was 9.0 d(range from 7 to 11 d).Postoperative complications occurred in 9 patients(21.4%),including 4 patients(9.5%)with major pancreatic fistula(ISGPF grade B,and C).One patient got reoperation due to postoperative bleeding.During a median follow-up of 35 months,there were no significant splenic infarctions or gastric varices in any case.All patients were observed conservatively.For patients in the late group,the mean operating time(161.0 min vs 225.0 min,P=0.001)and mean blood loss(230.1 mL vs 380.0 mL,P=0.016)were significantly less than those in the early group.There was no difference in the incidence of total complications(P=0.468),pancreatic fistula(P=0.667),splenic infarction(P=0.745)or perigastric varicose veins(P=0.468)between the two groups.Conclusion As a method of spleen preservation during distal pancreatectomy,lap-WT technique is a safe treatment strategy.A planned lap-WT procedure or early conversion to lap-WT can shorten the operation time,as well as reduce blood loss,without increasing complications.