慢性钙化性胰腺炎的分型与手术治疗

Classification and surgical management of chronic calcifying pancreatitis

目的探讨慢性钙化性胰腺炎的分型与手术治疗。方法采用回顾性描述性研究方法。收集2015年1月至2019年12月湖南省人民医院收治的121例慢性钙化性胰腺炎患者的临床资料;男99例,女22例;中位年龄为43岁,年龄范围为10~78岁。Ⅰ型慢性钙化性胰腺炎选择行胰十二指肠切除术、保留十二指肠胰头全切除术、保留十二指肠胰头勺式切除术,合并胰周假性囊肿行假性囊肿外引流术。Ⅱ型慢性钙化性胰腺炎选择行胰体尾+脾切除术、胰管切开取石+胰管空肠Roux-en-Y吻合术。Ⅲ型慢性钙化性胰腺炎选择行胰十二指肠切除术、保留十二指肠胰头勺式切除术,合并胰周假性囊肿行假性囊肿外引流术。Ⅳ型慢性钙化性胰腺炎行胰管盆式内引流术。观察指标:(1)手术情况。(2)术后情况。(3)随访情况。采用门诊和电话方式进行随访,了解患者术后疼痛复发或再发胰腺炎、血糖情况、新发糖尿病及腹泻。随访时间截至2020年1月。正态分布的计量资料以±s表示;偏态分布的计量资料以M(范围)表示。计数资料以绝对数表示。结果(1)手术情况:48例Ⅰ型慢性钙化性胰腺炎患者中,15例行胰十二指肠切除术,手术时间为(6.8±1.9)h,术中出血量为(398±110)mL;8例因胰管不扩张行保留十二指肠胰头全切除术,手术时间为(3.7±0.8)h,术中出血量为(137±62)mL;25例胰管扩张均行保留十二指肠胰头勺式切除术,手术时间为(3.9±1.5)h,术中出血量为(123±58)mL。8例Ⅱ型慢性钙化性胰腺炎患者中,2例行胰体尾+脾切除术,平均手术时间为5.1 h,平均术中出血量为200 mL;6例行胰管切开取石+胰管空肠Roux-en-Y吻合术,手术时间为(2.7±0.8)h,术中出血量为(145±39)mL。49例Ⅲ型慢性钙化性胰腺炎患者,4例行胰十二指肠切除术,手术时间为(7.2±1.4)h,术中出血量为(415±98)mL;45例因胰管扩张行保留十二指肠胰头勺式切除术,手术时间为(4.3±1.1)h,术中出血量为(135±47)mL。16例Ⅳ型慢性钙化性胰腺炎患者均行胰管盆式内引流术,手术时间为(3.3±1.3)h,术中出血量为(150±27)mL。(2)术后情况:48例Ⅰ型慢性钙化性胰腺炎患者中,15例行胰十二指肠切除术患者术后首次肛门排气时间、进食流质食物时间、住院时间分别为(2.9±1.1)d、(3.5±1.1)d、(14.8±2.7)d;术后3例发生并发症,其中2例发生消化道出血(1例胃镜下止血后痊愈,1例经介入治疗后痊愈),1例发生A级胰瘘,延迟拔管后愈合,无胆瘘发生。8例行保留十二指肠胰头全切除术患者上述指标分别为(2.0±0.5)d、(2.5±0.4)d、(9.5±2.5)d;术后1例发生A级胰瘘,延迟拔管后胰瘘愈合。25例行保留十二指肠胰头勺式切除术患者上述指标分别为(2.4±0.8)d、(2.5±1.3)d、(9.8±3.1)d;1例发生消化道出血,经介入治疗后痊愈,1例发生A级胰瘘,延迟拔管后愈合。8例Ⅱ型慢性钙化性胰腺炎患者中,2例行胰体尾+脾切除术患者术后平均首次肛门排气时间、平均进食流质食物时间、平均住院时间分别为3.0 d、3.5 d、14.0 d;围术期未出现任何并发症。6例行胰管切开取石+胰管空肠Roux-en-Y吻合术患者术后首次肛门排气时间、进食流质食物时间、住院时间分别为(2.5±0.5)d、(2.5±0.7)d、(8.5±1.5)d;术后2例发生A级胰瘘,延迟拔管后胰瘘愈合。49例Ⅲ型慢性钙化性胰腺炎患者中,4例行胰十二指肠切除术患者术后首次肛门排气时间、进食流质食物时间、住院时间分别为(3.2±0.8)d、(4.1±1.2)d、(15.3±2.4)d;术后1例发生A级胰瘘,延迟拔管后愈合,无出血、胆瘘发生。45例行保留十二指肠胰头勺式切除术患者上述指标分别为(2.5±1.6)d、(2.8±0.9)d、(10.1±2.8)d;术后1例发生胰肠吻合口出血,再次手术后愈合,1例发生A级胰瘘,延迟拔管后愈合,1例发生B级胰瘘,予以穿刺置管、反复冲洗后愈合。16例Ⅳ型慢性钙化性胰腺炎行胰管盆式内引流术患者术后首次肛门排气时间、进食流质食物时间、住院时间分别为(2.6±0.7)d、(3.3±0.5)d、(10.4±3.0)d;术后1例发生腹腔内少量出血,表现为桥襻引流管引流少量暗红色液体,予以去甲肾上腺素氯化钠溶液冲洗后愈合。(3)随访情况:121例患者中,113例(Ⅰ型44例、Ⅱ型7例、Ⅲ型46例、Ⅳ型16例)获得随访,随访时间为3~58个月,平均随访时间为34个月。随访期间13例(Ⅰ型5例、Ⅱ型1例、Ⅲ型6例、Ⅳ型1例)术后疼痛复发或再发胰腺炎,55例(Ⅰ型15例、Ⅲ型40例)腹痛明显改善,45例(Ⅰ型24例、Ⅱ型6例、Ⅳ型15例)未诉腹痛。37例(Ⅰ型13例、Ⅱ型2例、Ⅲ型17例、Ⅳ型5例)合并糖尿病患者中,20例(Ⅰ型6例、Ⅱ型2例、Ⅲ型12例)血糖恢复正常,17例(Ⅰ型7例、Ⅲ型5例、Ⅳ型5例)血糖需要药物控制;术后新增5例(Ⅰ型4例、Ⅲ型1例)糖尿病患者。3例(Ⅱ型1例、Ⅲ型2例)患者术后发生腹泻。2例Ⅲ型患者死亡,其中1例行胰十二指肠切除术后18个月因胰腺癌死亡,1例行保留胰十二指肠勺式切除术后5个月因再发重症急性胰腺炎死亡。结论慢性钙化性胰腺炎为良性病变,治疗应尽量保留胰腺功能组织;不同类型的慢性钙化性胰腺炎应选择不同的手术方式。

Objective To investigate the classification and surgical management of chronic calcifying pancreatitis.Methods The retrospective and descriptive study was conducted.The clinical data of 121 patients with chronic calcifying pancreatitis who were admitted to Hunan Provincial People′s Hospital from January 2015 to December 2019 were collected.There were 99 males and 22 females,aged from 10 to 78 years,with a median age of 43 years.The patients with typeⅠchronic calcifying pancreatitis underwent pancreaticoduodenectomy,duodenum-preserving pancreatic head total resection,or duodenum-preserving pancreatic head spoon-type resection respectively,and external drainage when combined with peripancreatic pseudocyst.Patients with typeⅡchronic calcifying pancreatitis underwent resection of pancreatic body and tail combined with splenectomy or dissection of pancreatic duct combined with pancreato-jejunum Roux-en-Y anastomosis.Patients with typeⅢchronic calcifying pancreatitis underwent pancreaticoduodenectomy or duodenum-preserving pancreatic head spoon-type resection,and external drainage when combined with peripancreatic pseudocyst.Patients with typeⅣchronic calcifying pancreatitis underwent basin-type internal drainage.Observation indicators:(1)surgical situations;(2)postoperative situations;(3)follow-up.Follow-up using outpatient examination and telephone interview was performed to detect the recurrence of pain or chronic pancreatitis,the data of blood glucose,the morbidity of diabetes and diarrhea after surgery up to January 2020.Measurement data with normal distribution were represented as Mean±SD and measurement data with skewed distribution were described as M(range).Count data were represented as absolute numbers.Results(1)Surgical situations:of the 48 patients with typeⅠchronic calcifying pancreatitis,15 patients underwent pancreaticoduodenectomy with the operation time of(6.8±1.9)hours and volume of intraoperative blood loss of(398±110)mL,8 patients underwent duodenum-preserving pancreatic head total resection due to no dilation of pancreatic duct with the operation time of(3.7±0.8)hours and volume of intraoperative blood loss of(137±62)mL,25 patients underwent duodenum-preserving pancreatic head spoon-type resection due to dilation of pancreatic duct with the operation time of(3.9±1.5)hours and volume of intraoperative blood loss of(123±58)mL.Of the 8 patients with typeⅡchronic calcifying pancreatitis,2 patients underwent resection of pancreatic body and tail combined with splenectomy with an average operation time of 5.1 hours and an average volume of intraoperative blood loss of 200 mL,6 patients underwent dissection of pancreatic duct combined with pancreato-jejunum Roux-en-Y anastomosis with the operation time of(2.7±0.8)hours and volume of intraoperative blood loss of(145±39)mL.Of the 49 patients with typeⅢchronic calcifying pancreatitis,4 patients were underwent pancreaticoduodenectomy with the operation time of(7.2±1.4)hours and volume of intraoperative blood loss of(415±98)mL,45 patients underwent duodenum-preserving pancreatic head spoon-type resection due to dilation of pancreatic duct with the operation time of(4.3±1.1)hours and volume of intraoperative blood loss of(135±47)mL.Sixteen patients with typeⅣchronic calcifying pancreatitis underwent basin-type internal drainage with the operation time of(3.3±1.3)hours and volume of intraoperative blood loss of(150±27)mL.(2)Postoperative situations:15 of the 48 patients with typeⅠchronic calcifying pancreatitis who underwent pancreaticoduodenectomy had the time to first anal flatus of(2.9±1.1)days,time to initial fluid diet intake of(3.5±1.1)days,and duration of hospital stay of(14.8±2.7)days,respectively.Of the 3 patients who had postoperative complications,2 had gastrointestinal hemorrhage(1 case was cured after hemostasis under gastroscope and the other was cured after interventional therapy),1 with grade A pancreatic fistula was cured after delaying the time of extubation,no biliary fistula occurred.Eight patients undergoing duodenum-preserving pancreatic head total resection had the time to first anal flatus of(2.0±0.5)days,time to initial fluid diet intake of(2.5±0.4)days,and duration of hospital stay of(9.5±2.5)days,respectively.One case with postoperative grade A pancreatic fistula was cured after delaying the time of extubation.Twenty-five patients undergoing duodenum-preserving pancreatic head spoon-type resection had the time to first anal flatus of(2.4±0.8)days,time to initial fluid diet intake of(2.5±1.3)days,and duration of hospital stay of(9.8±3.1)days,respectively.One case with postoperative gastrointestinal hemorrhage was cured after interventional therapy and 1 case with grade A pancreatic fistula was cured after delaying the time of extubation.Two of the 8 patients with typeⅡchronic calcifying pancreatitis who underwent resection of pancreatic body and tail combined with splenectomy had an average time to first anal flatus of 3.0 days,an average time to initial fluid diet intake of 3.5 days,and an average duration of hospital stay of 14.0 days,respectively.There was no complication during perioperative period.Six of the 8 patients with typeⅡchronic calcifying pancreatitis who underwent dissection of the pancreatic duct combined with pancerato-jejunum Roux-en-Y anastomosis had the time to first anal flatus of(2.5±0.5)days,time to initial fluid diet intake of(2.5±0.7)days,and duration of hospital stay of(8.5±1.5)days,respectively.Two cases with postoperative grade A pancreatic fistula were cured after delaying the time of extubation.Four of the 49 patients with typeⅢpancreatic duct stone who underwent pancreaticoduodenectomy had the time to first anal flatus of(3.2±0.8)days,time to initial fluid diet intake of(4.1±1.2)days,and duration of hospital stay of(15.3±2.4)days,respectively.One case with postoperative grade A pancreatic fistula was cured after delaying the time of extubation without hemorrhage or biliary fistula.Forty-five of the 49 patients with typeⅢchronic calcifying pancreatitis who underwent duodenum-preserving pancreatic head spoon-type resection had the time to first anal flatus of(2.5±1.6)days,time to initial fluid diet intake of(2.8±0.9)days,and duration of hospital stay of(10.1±2.8)days,respectively.One case with postoperative anastomotic bleeding was cured after reoperation.One case with grade A pancreatic fistula was cured after delaying the time of extubation and 1 case with postoperative grade B pancreatic fistula was cured after puncture-duct-douch treatment.Sixteen patients with typeⅣchronic calcifying pancreatitis who underwent basin-type internal drainage had the time to first anal flatus of(2.6±0.7)days,time to initial fluid diet intake of(3.3±0.5)days,and duration of hospital stay of(10.4±3.0)days respectively.One case with intraperitoneal hemorrhage which represented as small amount of dark red liquid in the drainage tube of jejunum loop was cured after puncture-duct-douch treatment with noradrenaline sodium chloride solution.(3)Follow-up:Of the 121 patients,113(44 of typeⅠ,7 of typeⅡ,46 of typeⅢ,16 of typeⅣ)were followed up for 3-58 months,with an average time of 34 months.During the follow-up,13 patients(5 of typeⅠ,1 of typeⅡ,6 of typeⅢ,1 of typeⅣ)had the recurrence of pain or pancreatitis,55 patients(15 of typeⅠ,40 of typeⅢ)with abdominal pain were improved significantly,and 45 patients(24 of typeⅠ,6 of typeⅡ,15 of typeⅣ)did not have abdominal pain.Of the 37 patients(13 of typeⅠ,2 of typeⅡ,17 of typeⅢ,5 of typeⅣ)with diabetes,20(6 of typeⅠ,2 of typeⅡ,12 of typeⅢ)had blood glucose returned to normal and 17(7 of typeⅠ,5 of typeⅢ,5 of typeⅣ)needed controlling blood sugar with medicine.There were 5 patients(4 of typeⅠ,1 of typeⅢ)diagnosed with diabetes and 3 patients(1 of typeⅡ,2 of typeⅢ)with diarrhea postoperatively.Two patients of typeⅢchronic calcifying pancreatitis died,including 1 died of pancreatic cancer at 18 months after pancreaticoduodenectomy and 1 died of severe acute pancreatitis at 5 months after duodenum-preserving pancreatic head spoon-type resection.Conclusions Chronic calcifying pancreatitis is a benign disease and should be treated to preserve functional tissues.Different surgical procedures should be adopted to treat different types of calcifying pancreatitis.