腹腔镜胰十二指肠切除不同手术入路的近期疗效

Impact of different operative approaches for laparoscopic pancreaticoduodenectomy on short-term treatment outcomes

目的探讨传统入路或动脉优先入路开展腹腔镜胰十二指肠切除(LPD)的治疗效果。方法回顾性分析2016年2月至2018年8月,西安交通大学医学部附属咸阳市中心医院施行LPD术个体化选择入路58例患者的临床资料。结果58例患者均在完全腹腔镜下成功完成预定Whipple手术,全部采用Child消化道重建吻合,无中转开腹手术。传统静脉入路组(35例)手术时间为(302.0±20.0)min,消化道重建时间(36.0±15.0)min,术中出血量(365.0±150.0)ml。术中快速冰冻切片病理学检查切缘阴性33例。术后发生早期并发症6例,其中A级胰瘘3例(1例合并胆瘘,1例合并胃排空障碍),B级胰瘘2例均合并腹腔出血,经药物治疗痊愈。术后病理学检查R0切除例数32例(91.4%),R1切除3例(8.6%)。淋巴结清扫数目(7.5±5.5)枚。动脉优先入路组(23例)手术时间为(355.0±25.0)min,消化道重建时间(41.0±12.0)min,术中出血量(410.0±200.0)ml。术中快速冰冻切片病理学检查切缘阴性22例。术后发生早期并发症3例,其中A级胰瘘1例合并胃排空障碍,B级胰瘘2例均合并腹腔出血,经药物治疗痊愈。术后病理学检查R0切除例数22例(95.7%),R1切除1例(4.3%)。淋巴结清扫数目(6.8±4.2)枚。结论依据患者的一般状况、肿瘤来源及位置、血管关系、术者技术等情况综合考虑进行个体化选择LPD手术入路,从而做到精准的病灶清除、脏器保护、损伤控制,达到安全、高效、微创治疗的目的。

Objective To study the impact of traditional versus artery first approach in laparoscopic pancreaticoduodenectomy(LPD).Methods The clinical data of 58 patients who underwent laparoscopic pancreaticoduodenectomy using the two different approaches from February 2016 to August 2018 at the Xianyang Central Hospital affiliated to Xi'an Jiaotong University Medical Department were retrospectively analyzed.Results All 58 patients successfully underwent the complete laparoscopic Whipple operation using the Child digestive tract reconstruction and anastomosis.There was no conversion to laparotomy.The average operation times for the conventional approach group(35 cases)was(302.0±20.0)min and the digestive tract reconstruction time was(36.0±15.0)min.The intraoperative blood loss was(365.0±150.0)ml.Negative pathological resection margins on intraoperative frozen section examination were achieved in 33 patients.Early postoperative complications happened in 6 patients which included grade A pancreatic fistula in 3 patients(1 patient complicated with biliary fistula and 1 patient complicated with gastric emptying disorder),and grade B pancreatic fistula in 2 patients who were complicated with abdominal hemorrhage,successfully treated by conservative treatment.Postoperative pathological examination showed that 32 patients(91.4%)had R0 resection and 3 patients(8.6%)had R1 resection.The number of lymph node dissection was(7.5±5.5).On the other hand,the average operation time of the artery first access group(23 cases)was(355.0±25.0)min,and the reconstruction time of digestive tract was(41.0±12.0)min.The amount of bleeding was(410.0±200.0)ml.During the operation,22 patients had negative resection margins shown on pathological frozen sections.Early postoperative complications occurred in 3 patients,including 1 patient with grade A pancreatic fistula which was complicated with gastric emptying disorder,and 2 patients with grade B pancreatic fistulas which were complicated with abdominal hemorrhage.The patients were successfully managed by conservative treatment.Postoperative pathological examination showed that 22 patients(95.7%)had R0 resection and 1 patient(4.3%)R1 resection.The number of lymph node dissection was(6.8±4.2).Conclusion The LPD surgical approach was selected according to the general conditions of patients,locations of tumors,relationship of tumors with blood vessels,and technical skills of surgeons with the aims to achieve adequate lesion clearance,organ protection,damage control,and safety and efficiency of minimally invasive surgery.