中华消化外科杂志
中華消化外科雜誌
중화소화외과잡지
Chinese Journal of Digestive Surgery
2015年
11期
925-929
,共5页
李岩%张雷%曾兆林%孙岩
李巖%張雷%曾兆林%孫巖
리암%장뢰%증조림%손암
梗阻性黄疸%胰十二指肠切除术%封闭式胰肠吻合%胰瘘
梗阻性黃疸%胰十二指腸切除術%封閉式胰腸吻閤%胰瘺
경조성황달%이십이지장절제술%봉폐식이장문합%이루
Obstructive jaundice%Pancreaticoduodenectomy%Closed pancreaticojejunostomy%Pancreatic fistula
目的 探讨端侧封闭式原位胰肠吻合术在胰十二指肠切除术中的应用价值.方法 回顾性分析2014年1-3月哈尔滨医科大学附属第二医院收治22例梗阻性黄疸患者的临床资料.所有患者采用气管插管全身麻醉,胆囊减压后探查肿瘤是否侵犯下腔静脉、肠系膜上静脉及门静脉,并根据术中探查结果决定行标准胰十二指肠切除术还是扩大胰十二指肠切除术.胰肠吻合方法采用端侧封闭式原位胰肠(胰管与空肠浆肌层)吻合术.观察患者手术时间,术中出血量,术后胃肠功能恢复时间,术后第1、3、5天分别检测引流液淀粉酶浓度,术后并发症发生率,病理学类型,住院时间等指标.采用门诊和电话的方法进行随访,门诊随访内容为彩色多普勒超声检查胰腺残端附近是否有积液,电话随访了解患者是否有腹泻等胰腺外分泌功能不足的表现.随访时间截至2014年5月.正态分布的计量资料以-x±s(范围)表示,偏态分布的计量资料以M(范围)表示.结果 22例患者成功施行手术,其中17例患者采用标准胰十二指肠切除术,5例患者采用扩大胰十二指肠切除术,胰肠吻合方法采用端侧封闭式原位胰肠吻合术.22例患者手术时间为(313 ±37)min(228 ～360 min),端侧封闭式原位胰肠吻合手术时间为(13 ±4) min(7 ～22 min);术中出血量为(400±207) mL(100 ～ 800 mL).平均肿瘤大小为3.69 cm2(0.72 ～1.68 cm2).术后胃肠功能恢复时间为(5±2)d(4～7 d).21例患者术后第1、3、5天血清淀粉酶分别为(145±30)U/L(116～ 180 U/L)、(136±40)U/L(105 ～ 176 U/L)、(147±38)U/L(110 ～175 U/L),术后第1、3、5天引流液淀粉酶分别为(220 ±56) U/L(172 ～ 289 U/L)、(240±54) U/L(192～ 300 U/L)、(245±52) U/L(190 ～298 U/L);1例胰瘘患者术后第1、3、5天血清淀粉酶分别为156 U/L、178 U/L、177 U/L,术后第1、3、5天引流液淀粉酶分别为500 U/L、620 U/L、605 U/L.22例患者中1例放置胰管支架.本组患者无手术或住院死亡.4例患者出现术后并发症:术后胰瘘(A级)、感染、肺炎和术后应激性溃疡出血各1例.胰瘘患者经持续外引流的非手术治疗痊愈,其余3例患者经对症支持治疗痊愈.22例患者术后病理学类型:12例为导管腺癌,2例为神经内分泌肿瘤,单纯囊肿、囊腺癌、鳞癌、腺癌、壶腹癌、管状腺瘤癌变、平滑肌瘤、导管上皮非典型增生各1例.22例患者住院时间为(11±3)d(2～15 d).22例患者随访时间为2～4个月,彩色多普勒超声检查胰腺残端附近均无积液,无腹泻等胰腺外分泌功能不足的表现.结论 端侧封闭式原位胰肠吻合术安全、可行,适用于任何胰管直径大小和质地性质的胰腺手术.
目的 探討耑側封閉式原位胰腸吻閤術在胰十二指腸切除術中的應用價值.方法 迴顧性分析2014年1-3月哈爾濱醫科大學附屬第二醫院收治22例梗阻性黃疸患者的臨床資料.所有患者採用氣管插管全身痳醉,膽囊減壓後探查腫瘤是否侵犯下腔靜脈、腸繫膜上靜脈及門靜脈,併根據術中探查結果決定行標準胰十二指腸切除術還是擴大胰十二指腸切除術.胰腸吻閤方法採用耑側封閉式原位胰腸(胰管與空腸漿肌層)吻閤術.觀察患者手術時間,術中齣血量,術後胃腸功能恢複時間,術後第1、3、5天分彆檢測引流液澱粉酶濃度,術後併髮癥髮生率,病理學類型,住院時間等指標.採用門診和電話的方法進行隨訪,門診隨訪內容為綵色多普勒超聲檢查胰腺殘耑附近是否有積液,電話隨訪瞭解患者是否有腹瀉等胰腺外分泌功能不足的錶現.隨訪時間截至2014年5月.正態分佈的計量資料以-x±s(範圍)錶示,偏態分佈的計量資料以M(範圍)錶示.結果 22例患者成功施行手術,其中17例患者採用標準胰十二指腸切除術,5例患者採用擴大胰十二指腸切除術,胰腸吻閤方法採用耑側封閉式原位胰腸吻閤術.22例患者手術時間為(313 ±37)min(228 ～360 min),耑側封閉式原位胰腸吻閤手術時間為(13 ±4) min(7 ～22 min);術中齣血量為(400±207) mL(100 ～ 800 mL).平均腫瘤大小為3.69 cm2(0.72 ～1.68 cm2).術後胃腸功能恢複時間為(5±2)d(4～7 d).21例患者術後第1、3、5天血清澱粉酶分彆為(145±30)U/L(116～ 180 U/L)、(136±40)U/L(105 ～ 176 U/L)、(147±38)U/L(110 ～175 U/L),術後第1、3、5天引流液澱粉酶分彆為(220 ±56) U/L(172 ～ 289 U/L)、(240±54) U/L(192～ 300 U/L)、(245±52) U/L(190 ～298 U/L);1例胰瘺患者術後第1、3、5天血清澱粉酶分彆為156 U/L、178 U/L、177 U/L,術後第1、3、5天引流液澱粉酶分彆為500 U/L、620 U/L、605 U/L.22例患者中1例放置胰管支架.本組患者無手術或住院死亡.4例患者齣現術後併髮癥:術後胰瘺(A級)、感染、肺炎和術後應激性潰瘍齣血各1例.胰瘺患者經持續外引流的非手術治療痊愈,其餘3例患者經對癥支持治療痊愈.22例患者術後病理學類型:12例為導管腺癌,2例為神經內分泌腫瘤,單純囊腫、囊腺癌、鱗癌、腺癌、壺腹癌、管狀腺瘤癌變、平滑肌瘤、導管上皮非典型增生各1例.22例患者住院時間為(11±3)d(2～15 d).22例患者隨訪時間為2～4箇月,綵色多普勒超聲檢查胰腺殘耑附近均無積液,無腹瀉等胰腺外分泌功能不足的錶現.結論 耑側封閉式原位胰腸吻閤術安全、可行,適用于任何胰管直徑大小和質地性質的胰腺手術.
목적 탐토단측봉폐식원위이장문합술재이십이지장절제술중적응용개치.방법 회고성분석2014년1-3월합이빈의과대학부속제이의원수치22례경조성황달환자적림상자료.소유환자채용기관삽관전신마취,담낭감압후탐사종류시부침범하강정맥、장계막상정맥급문정맥,병근거술중탐사결과결정행표준이십이지장절제술환시확대이십이지장절제술.이장문합방법채용단측봉폐식원위이장(이관여공장장기층)문합술.관찰환자수술시간,술중출혈량,술후위장공능회복시간,술후제1、3、5천분별검측인류액정분매농도,술후병발증발생솔,병이학류형,주원시간등지표.채용문진화전화적방법진행수방,문진수방내용위채색다보륵초성검사이선잔단부근시부유적액,전화수방료해환자시부유복사등이선외분비공능불족적표현.수방시간절지2014년5월.정태분포적계량자료이-x±s(범위)표시,편태분포적계량자료이M(범위)표시.결과 22례환자성공시행수술,기중17례환자채용표준이십이지장절제술,5례환자채용확대이십이지장절제술,이장문합방법채용단측봉폐식원위이장문합술.22례환자수술시간위(313 ±37)min(228 ～360 min),단측봉폐식원위이장문합수술시간위(13 ±4) min(7 ～22 min);술중출혈량위(400±207) mL(100 ～ 800 mL).평균종류대소위3.69 cm2(0.72 ～1.68 cm2).술후위장공능회복시간위(5±2)d(4～7 d).21례환자술후제1、3、5천혈청정분매분별위(145±30)U/L(116～ 180 U/L)、(136±40)U/L(105 ～ 176 U/L)、(147±38)U/L(110 ～175 U/L),술후제1、3、5천인류액정분매분별위(220 ±56) U/L(172 ～ 289 U/L)、(240±54) U/L(192～ 300 U/L)、(245±52) U/L(190 ～298 U/L);1례이루환자술후제1、3、5천혈청정분매분별위156 U/L、178 U/L、177 U/L,술후제1、3、5천인류액정분매분별위500 U/L、620 U/L、605 U/L.22례환자중1례방치이관지가.본조환자무수술혹주원사망.4례환자출현술후병발증:술후이루(A급)、감염、폐염화술후응격성궤양출혈각1례.이루환자경지속외인류적비수술치료전유,기여3례환자경대증지지치료전유.22례환자술후병이학류형:12례위도관선암,2례위신경내분비종류,단순낭종、낭선암、린암、선암、호복암、관상선류암변、평활기류、도관상피비전형증생각1례.22례환자주원시간위(11±3)d(2～15 d).22례환자수방시간위2～4개월,채색다보륵초성검사이선잔단부근균무적액,무복사등이선외분비공능불족적표현.결론 단측봉폐식원위이장문합술안전、가행,괄용우임하이관직경대소화질지성질적이선수술.
Objective To explore the application value of end-to-side closed in situ pancreaticojejunostomy in pancreaticoduodenectomy.Methods The clinical data of 22 patients with obstructive jaundice who were admitted to the Second Affiliated Hospital of Harbin Medical University from January to March 2014 were retrospectively analyzed.All the patients were explored whether tumors invaded inferior vena cava, superior mesenteric vein and portal vein after gallbladder decompression under general anesthesia by tracheal intubation.The standard or extended pancreaticoduodenectomy was applied according to the intraoperative results.The method of pancreaticojejunostomy was end-to-side closed in situ anastomosis of pancreatic duct and jejunal seromuscular layer.The operation time, intraoperative blood loss, postoperative gastrointestinal function recovery time, amylase concentration of drainage at postoperative day 1,3,5, postoperative complication, pathological classification and duration of hospital stay were observed.Patients were followed up by outpatient examination and telephone interview till May 2014.The out-patient follow-up included color Doppler ultrasound examination of effusion near the pancreatic stump, and the telephone interview included whether there were diarrhea of exocrine pancreatic insufficiency.Measurement data with normal distribution were presented as-x ± s (range) , and measurement data with skewed distribution as M(range).Results All the 22 patients underwent successfully the operation, including 17 undergoing standard pancreaticoduodenectomy and 5 undergoing extended pancreaticoduodenectomy, with end-to-side closed in situ anastomosis of pancreatic duct and jejuna seromuscular layer.The operation time of pancreaticoduodenectomy and end-to-side closed in situ pancreaticojejunostomy were (313 ± 37)minutes (range, 228-360 minutes) and(13 ± 4) minutes (7-22 minutes) , respectively.The intraoperative blood loss was (400 ± 207) mL (range, 100-800 mL).The mean tumor size was 3.69 cm2(range, 0.72-1.68 cm2).The recovery time of gastrointestinal function was (5 ±2)days (range, 4-7 days).The serum amylase at postoperative day 1, 3, 5 in the 21 patients was (145±30)U/L (range, 116-180 U/L), (136±40)U/L (range, 105-176 U/L), (147 ±38)U/L(range, 110-175 U/L), and the drainage amylase was (220 ±56)U/L (range, 172-289 U/L), (240 ±54)U/L (range, 192-300 U/L) , (245 ± 52) U/L (range, 190-298 U/L) , respectively.The serum amylase at postoperative day 1, 3, 5 in the patient with pancreatic fistula was 156 U/L, 178 U/L and 177 U/L, and the drainage fluid amylase was 500 U/L, 620 U/L and 605 U/L, respectively.There was 1 patient in the 22 patients with pancreatic duct stent and without death.Among the 4 patients with postoperative complications, 1 patient with grade A postoperative pancreatic fistula recovered after continuous external drainage, the other 3 including 1 case of infection,1 case of pneumonia and 1 of stress ulcer bleeding also recovered after symptomatic and supportive treatment.Postoperative pathological examinations of the 22 patients showed 12 cases of ductal adenoeareinoma, 2 of neuroendocine tumors, 1 of simple cyst, 1 of cystadenocarcinoma, 1 of squamous carcinoma, 1 of adenocarcinoma, 1 of ampullary carcinoma, 1 of tubular adenoma, 1 of leiomyoma and 1 of atypical intraductal hyperplasia.The average length of hospital stay was (11 ±3)days (range, 2-15 days).There were no effusion near the pancreatic stump showed in color Doppler ultrasound examination and diarrhea of exoerine pancreatic insufficiency.Conclusion End-to-side closed in situ pancreaticojejunostomy is safe and feasible, and can be applied to any pancreatic duct size and texture.
