基于膜解剖理念的腹腔镜胰十二指肠切除术:附17例报告

Application of laparoscopic pancreaticoduodenectomy guided by membrane anatomy:a report of 17 cases

背景与目的:近年来腹腔镜胰十二指肠切除术(LPD)发展迅速,但因该手术所涉及的解剖分离与吻合等关键技术的复杂性,限制了其广泛应用。笔者团队借鉴膜解剖理念在胃肠外科领域的成功应用,初步探讨膜解剖理念在LPD中的临床应用价值。方法:回顾性收集2021年3月—9月广西医科大学附属柳州市人民医院17例胰头及壶腹部肿瘤术中行基于膜解剖理念的LPD的患者的临床病理资料,分析患者围手术期情况及近期预后。结果:17例患者中男10例,女7例;中位年龄58 (42~76)岁。术前平均体质量指数(22.95±2.73) kg/m~2、 CA19-9 (147.59±23.04) U/mL、总胆红素(124.50±26.26)μmol/L。17例患者均顺利完成LPD,平均手术时间为(324±58) min;中位消化道重建前手术时间160 (120~320) min;平均出血量为(353±192) mL;病灶大小(2.75±0.21) cm。术后病理十二指肠乳头癌4例,胰腺癌7例,胆道壶腹癌5例,十二指肠神经内分泌瘤1例;淋巴结清扫数目12 (5~17)枚,淋巴结阳性7 (0~11)枚。术后2例发生生化漏,无B、C级胰瘘;1例发生胃排空延迟,经再置胃管并对症处理后,于术后10 d内恢复固体饮食;术后均无腹腔感染及腹腔出血发生;17例患者术后住院时间为11 (9~21) d;无术后30 d内死亡病例。17例患者均获得完整的术后随访,随访时间为3.0~9.0个月,中位随访时间为5.7个月,无死亡、复发病例。结论:基于膜解剖理念的LPD术式,术中出血少,有利于保持术野解剖清晰,遵守外科手术“无瘤原则”,减少手术并发症的发生和患者的住院时间,使得手术安全可行,近期效果满意,远期效果有待进一步观察,一定程度上值得应用与推广。

Background and Aims:Laparoscopic pancreaticoduodenectomy(LPD) has developed rapidly in recent years.However,the complexity of the essential techniques such as dissection,separation,and anastomosis involved in this operation limits its widespread application.Based on the successful application of the membrane anatomy concept in the field of gastrointestinal surgery,the author’s team preliminarily explored the clinical application value of the membrane anatomy concept in LPD.Methods:The clinicopathologic data of 17 patients with pancreatic head and ampullary tumors who underwent LPD based on the concept of membrane anatomy from March to September 2021 in Liuzhou People’s Hospital Affiliated with Guangxi Medical University were retrospectively collected.The perioperative conditions and short-term outcomes of the patients were analyzed.Results:Among the 17 patients,10 cases were males and 7 cases were females,with a median age of 58(42-76) years;the preoperative body mass index was(22.95±2.73) kg/m~2,CA19-9 value was(147.59±23.04) U/m L,and total bilirubin level was(124.50±26.26) μmol/L.LPD was successfully completed in all 17 patients.The average total operative time was(324±58) min,the median operative time before digestive tract reconstruction was 160(120-320) min,the average bleeding volume was(353±192) m L,and the size of the lesion was(2.75±0.21) cm.There were 4 cases of duodenal papillary carcinoma,7 cases of pancreatic cancer,5 cases of ampullary cancer of the pancreaticobiliary subtype,and 1 case of duodenal neuroendocrine tumor;the number of harvested lymph nodes was 12(5-17),and the number of positive lymph nodes was 7(0-11).After the operation,biochemical leakage occurred in 2 cases,and no grade B or C pancreatic fistula occurred;delayed gastric emptying occurred in one case who resumed a solid diet within postoperative 10 d after replacing the gastric tube and symptomatic treatment;no abdominal infection and bleeding occurred;The postoperative hospitalization time of 17 patients was 11(9-21) d;No death occurred within 30 d after operation.All the 17 patients were followed up for 3.0-9.0 months with a median follow-up time of 5.7 months.No death and recurrence occurred.Conclusion:The LPD based on the concept of membrane anatomy has less bleeding during the operation,and is helpful for keeping the clear vision of the surgical field,following the "tumor free principle" of surgery,reducing the occurrence of surgical complications,and shortening the length of hospitalization of patients,which makes the operation safe and feasible.Its short-term effect is satisfactory,and the long-term effect needs to be further observed.To a certain extent,it is worth to be widely applied and popularized.