CAJ | 학술논문

目的探讨胰头部动脉优先离断在肠系膜上静脉或门静脉受侵犯的胰头部恶性肿瘤行根治性胰十二指肠切除术中的运用价值.方法回顾性分析2012年1月至2013年5月华中科技大学同济医学院附属同济医院完成的58例胰头部恶性肿瘤行根治性胰十二指肠切除术患者的临床资料.58例患者术前薄层CT检查均显示肠系膜上静脉或门静脉受侵犯或受压,均行胰头部动脉优先离断的根治性胰十二指肠切除术,即在处理胰头部静脉血管之前优先离断胰头部的所有动脉供血,即三大动脉血管的分支,主要步骤包括:在十二指肠水平部或横结肠系膜根部暴露和悬吊肠系膜上动、静脉;解剖肝总动脉从而离断胃十二指肠动脉和胃右动脉,同时沿肝总动脉根部解剖腹腔动脉干上方;离断胰腺和脾动脉的胰头分支;沿暴露的肠系膜上动脉前方、右侧和后方解剖,完全离断胰头钩突部与肠系膜上动脉和腹腔动脉干间的神经结缔组织,与腹腔动脉干的上方贯通,此时可清楚地显示腹主动脉前方;最后通过预置的静脉血管阻断带安全剥离、切除或重建肠系膜上静脉或门静脉,完整切除肿瘤.结果术前影像学检查判断局部肿瘤可切除患者37例,可能切除患者21例.58例患者均顺利施行胰头部动脉优先离断的根治性胰十二指肠切除术,手术时间为4.5 ～8.1 h,术中出血量为200 ～900 mL,术中及术后胰腺钩突部无出血.行肠系膜上静脉侧壁部分切除修补术21例,肠系膜上静脉受累段切除端端吻合术10例,血管受压迫成功将肿瘤从血管上剥离行标准的胰十二指肠切除术27例.术后患者出血、胰液漏和胆汁漏的发生率分别为5.2％ (3/58)、6.9％(4/58)和1.7％(1/58).围手术期无患者死亡.结论胰头部动脉优先离断方式能保障肠系膜上静脉或门静脉受侵犯或受压的胰头部恶性肿瘤行根治性胰十二指肠切除术的安全性,减少术中出血. 目的探討胰頭部動脈優先離斷在腸繫膜上靜脈或門靜脈受侵犯的胰頭部噁性腫瘤行根治性胰十二指腸切除術中的運用價值.方法迴顧性分析2012年1月至2013年5月華中科技大學同濟醫學院附屬同濟醫院完成的58例胰頭部噁性腫瘤行根治性胰十二指腸切除術患者的臨床資料.58例患者術前薄層CT檢查均顯示腸繫膜上靜脈或門靜脈受侵犯或受壓,均行胰頭部動脈優先離斷的根治性胰十二指腸切除術,即在處理胰頭部靜脈血管之前優先離斷胰頭部的所有動脈供血,即三大動脈血管的分支,主要步驟包括:在十二指腸水平部或橫結腸繫膜根部暴露和懸弔腸繫膜上動、靜脈;解剖肝總動脈從而離斷胃十二指腸動脈和胃右動脈,同時沿肝總動脈根部解剖腹腔動脈榦上方;離斷胰腺和脾動脈的胰頭分支;沿暴露的腸繫膜上動脈前方、右側和後方解剖,完全離斷胰頭鉤突部與腸繫膜上動脈和腹腔動脈榦間的神經結締組織,與腹腔動脈榦的上方貫通,此時可清楚地顯示腹主動脈前方;最後通過預置的靜脈血管阻斷帶安全剝離、切除或重建腸繫膜上靜脈或門靜脈,完整切除腫瘤.結果術前影像學檢查判斷跼部腫瘤可切除患者37例,可能切除患者21例.58例患者均順利施行胰頭部動脈優先離斷的根治性胰十二指腸切除術,手術時間為4.5 ～8.1 h,術中齣血量為200 ～900 mL,術中及術後胰腺鉤突部無齣血.行腸繫膜上靜脈側壁部分切除脩補術21例,腸繫膜上靜脈受纍段切除耑耑吻閤術10例,血管受壓迫成功將腫瘤從血管上剝離行標準的胰十二指腸切除術27例.術後患者齣血、胰液漏和膽汁漏的髮生率分彆為5.2％ (3/58)、6.9％(4/58)和1.7％(1/58).圍手術期無患者死亡.結論胰頭部動脈優先離斷方式能保障腸繫膜上靜脈或門靜脈受侵犯或受壓的胰頭部噁性腫瘤行根治性胰十二指腸切除術的安全性,減少術中齣血.
목적 탐토이두부동맥우선리단재장계막상정맥혹문정맥수침범적이두부악성종류행근치성이십이지장절제술중적운용개치.방법 회고성분석2012년1월지2013년5월화중과기대학동제의학원부속동제의원완성적58례이두부악성종류행근치성이십이지장절제술환자적림상자료.58례환자술전박층CT검사균현시장계막상정맥혹문정맥수침범혹수압,균행이두부동맥우선리단적근치성이십이지장절제술,즉재처리이두부정맥혈관지전우선리단이두부적소유동맥공혈,즉삼대동맥혈관적분지,주요보취포괄:재십이지장수평부혹횡결장계막근부폭로화현조장계막상동、정맥;해부간총동맥종이리단위십이지장동맥화위우동맥,동시연간총동맥근부해부복강동맥간상방;리단이선화비동맥적이두분지;연폭로적장계막상동맥전방、우측화후방해부,완전리단이두구돌부여장계막상동맥화복강동맥간간적신경결체조직,여복강동맥간적상방관통,차시가청초지현시복주동맥전방;최후통과예치적정맥혈관조단대안전박리、절제혹중건장계막상정맥혹문정맥,완정절제종류.결과 술전영상학검사판단국부종류가절제환자37례,가능절제환자21례.58례환자균순리시행이두부동맥우선리단적근치성이십이지장절제술,수술시간위4.5 ～8.1 h,술중출혈량위200 ～900 mL,술중급술후이선구돌부무출혈.행장계막상정맥측벽부분절제수보술21례,장계막상정맥수루단절제단단문합술10례,혈관수압박성공장종류종혈관상박리행표준적이십이지장절제술27례.술후환자출혈、이액루화담즙루적발생솔분별위5.2％ (3/58)、6.9％(4/58)화1.7％(1/58).위수술기무환자사망.결론 이두부동맥우선리단방식능보장장계막상정맥혹문정맥수침범혹수압적이두부악성종류행근치성이십이지장절제술적안전성,감소술중출혈.
Objective To investigate the value of total arteries devascularization first technique in radical pancreaticoduodenectomy.Methods The clinical data of 58 patients with malignant pancreatic head cancer who received pancreaticoduodenectomy at the Tongji Hospital from January 2012 to May 2013 were retrospectively analyzed.The results of preoperative thin-slice computed tomography scanning indicated that the portal vein and superior mesenteric vein were invaded by the tumor.During the operation,3 arterial blood supplies of the head of the pancreas were obstructed before devascularization of vein in the head of pancreas.The key steps of the technique were:(1) The superior mesenteric artery and vein were dissected at lower parts of the duodenal mesenterium.(2) The common hepatic arteries were dissected to cut the right gastric artery and the gastroduodenal artery.(3) Dissecting the celiac trunk and transecting the branches of splenic artery in the head of the pancreas.(4) Neural and connective tissues between the superior mesenteric artery and the uncinate process of the pancreas were dissected,and then the anterior surface of the abdominal aorta was excellently exposed.(5) The superior mesenteric vein or portal vein were dissected or rebuilt with the help of presetting vascular blocking bands,and then the tumor was en-bloc resected.Results The operation time was 4.5-8.1 hours,and the volume of intraoperative blood loss was 200-900 mL.No bleeding of the uncinate process of the pancreas was detected.Twenty-one patients underwent lateral vessel angiectomy or angiorrhaphy,10 received resection of the superior mesenteric vein which was invaded by the tumor and end-to-end anastomosis,and 27 received detachment of tumor from the blood vessel and pancreatoduodenectomy.The incidences of hemorrhage,pancreatic fistula and biliary fistula were 5.2％ (3/58),6.9％ (4/58) and 1.7％ (1/58).No patient died perioperatively.Conclusion Total arteries devascularization first technique could improve the safety and reduce intraoperative bleeding in radical pancreaticoduodenectomy.