CAJ | 학술논문

目的探讨胰十二指肠切除术后外科相关并发症发生的原因与处理措施.方法回顾性研究1995年1月至2010年4月共412例行胰十二指肠切除术患者的临床资料,男性232例,女性180例,分析其术后并发症发生的影响因素与治疗方法.结果本组中共有153例患者出现并发症214例次,总发生率为37.1%.术后30 d内死亡19例,总病死率4.6%.统计学分析显示,胰腺钩突全切除与否(P=0.022)、胰肠吻合方式(P=0.005)、胰管直径(P=0.007)及残余胰腺质地(P=0.000)与胰瘘的发生具有相关性;未进行胰腺钩突全切除(P=0.002)、术中失血量≥600ml(P=0.000)及合并胰瘘者(P=0.000)术后出血发生率显著增高;保留幽门的胰十二指肠切除术组术后胃排空障碍的发生率显著高于传统胰十二指肠切除术组(P=0.000).多因素Logistic回归分析表明,胰管直径及胰腺质地是影响胰瘘发生的独立危险因素;未进行胰腺钩突全切除、术中失血量≥600ml及胰瘘为影响术后出血的独立危险因素;联合血管切除或腹膜后淋巴清扫的患者与未行血管切除或腹膜后淋巴清扫的患者相比,并发症发生率的差异无统计学意义(P＜0.05).结论合并慢性胰腺炎及胰管扩张的患者可行胰肠端侧黏膜对黏膜吻合,而端端或端侧套入式吻合更适于胰管不扩张或胰腺质软者;完整切除钩突、术中仔细止血是预防术后出血的重要因素;胰瘘是并发术后出血的重要原因之一.联合肠系膜上静脉或门静脉切除及腹膜后淋巴结清扫不会增加术后并发症的发生率.
목적 탐토이십이지장절제술후외과상관병발증발생적원인여처리조시.방법 회고성연구1995년1월지2010년4월공412례행이십이지장절제술환자적림상자료,남성232례,녀성180례,분석기술후병발증발생적영향인소여치료방법.결과 본조중공유153례환자출현병발증214례차,총발생솔위37.1%.술후30 d내사망19례,총병사솔4.6%.통계학분석현시,이선구돌전절제여부(P=0.022)、이장문합방식(P=0.005)、이관직경(P=0.007)급잔여이선질지(P=0.000)여이루적발생구유상관성;미진행이선구돌전절제(P=0.002)、술중실혈량≥600ml(P=0.000)급합병이루자(P=0.000)술후출혈발생솔현저증고;보류유문적이십이지장절제술조술후위배공장애적발생솔현저고우전통이십이지장절제술조(P=0.000).다인소Logistic회귀분석표명,이관직경급이선질지시영향이루발생적독립위험인소;미진행이선구돌전절제、술중실혈량≥600ml급이루위영향술후출혈적독립위험인소;연합혈관절제혹복막후림파청소적환자여미행혈관절제혹복막후림파청소적환자상비,병발증발생솔적차이무통계학의의(P＜0.05).결론 합병만성이선염급이관확장적환자가행이장단측점막대점막문합,이단단혹단측투입식문합경괄우이관불확장혹이선질연자;완정절제구돌、술중자세지혈시예방술후출혈적중요인소;이루시병발술후출혈적중요원인지일.연합장계막상정맥혹문정맥절제급복막후림파결청소불회증가술후병발증적발생솔.
Objective To explore the impact factors and treatment of postpancreatoduodenectomy complications. Methods The clinical data of 412 cases between January 1995 and April 2010 underwent pancreatoduodenectomy were analyzed retrospectively. There were 232 male, 180 female. Univariate and multivariate logistic regression model were used to identify the risk factors related to occurrence of postoperative complications. Results The overall postoperative morbidity rate was 37.1% ( 153/412 ), and mortality rate was 4. 6% (19/412). Total uncinate process resection, type of pancreatic-enteric anastomosis,duct diameter and pancreatic texture had effects on postoperative pancreatic fistula statistically. Total uncinate process resection, the amount of intra-operative blood loss ≥600 ml and pancreatic fistula were identified as significant risk factors for postpancreatoduodenectomy hemorrhage by means of univariate analysis. Delayed gastric empting occurrence in the patients with pylorus-preserving pancreaticoduodenectomy was higher than those with standard pancreaticoduodenectomy significantly. The multivariate Logistic regression analysis revealed that duct diameter and pancreatic texture were the independent risk factors of pancreatic fistula. Total uncinate process resection, the amount of intra-operative blood loss ≥ 600 ml and pancreatic fistula were independent risk factors of bleeding. There were no statistically significant differences between the radical group and the standard group when postoperative complication rates were analyzed ( P ＜ 0. 05 ).Conclusions Pancreaticojejunal anastomoses by means of duct-to-mucosa is fit for the patients with dilated pancreatic duct and end-to-end invaginated pancreaticojejunostomy is fit for the patients with undilated pancreatic duct. The prevention of postoperative bleeding depends on total uncinate process resection and meticulous hemostatic technique during operation. The pancreatic fistula is one of the most important factors which can result in postoperative bleeding. Pancreaticoduodenectomy combines with SMV/PV resection and extended lymphadenectomy do not significantly increase the morbidity rates.