腹腔镜胰十二指肠切除术临床研究
发布时间：2018-03-04 13:33
本文选题：腹腔镜 切入点：胰十二指肠切除术 出处：《浙江大学》2017年博士论文 论文类型：学位论文
【摘要】：胰十二指肠切除术(Pancreaticoduodenectomy,PD)是壶腹周围及胰头部疾病的标准手术方式。自1935年Whipple成功开展胰十二指肠切除术,历经80多年的发展,PD的院内死亡率从20世纪70年代的20%～25%降低到如今的1～5%,但其术后并发症仍有40%～60%,Ⅲ级以上并发症达20%～30%,其中手术本身引起的切口相关并发症为8.3%～13%。如何降低PD的并发症率、提高患者术后恢复成为人们关注的热点。1987年法国Mouret医生成功开展电视腹腔镜胆囊切除术以来,腹腔镜手术凭借切口小而视野清,术中出血少,术后恢复快等微创优势,深受医生和患者欢迎。随着腹腔镜技术的不断提高和腔镜器械的快速发展,腹腔镜技术在带蒂器官如胆囊、脾脏,空腔脏器如胃、空肠,实质脏器如肝脏、胰腺等器官的手术上都获得成功,其在外科的各个领域得到了广泛应用。Gawande回顾新英格兰医学杂志创刊200年外科学发展史时,将以腹腔镜技术带动的外科手术微创化评价为与麻醉具有同样意义的进步。外科微创化已成为二十一世纪外科学发展的两大方向之一。1994年,Gagner等就首次报道了腹腔镜胰十二指肠切除术(Laparoscopic Pancreaticoduodenenctomy,LPD),早于1996年报道的腹腔镜胰腺肿瘤剜除术和腹腔镜保留脾脏胰体尾切除术,以及2003年首次报道的腹腔镜胰腺中段切除术。但20多年过去了,虽然LPD被报道有出血少、疼痛轻、术后住院时间短等微创优势,但其仍只在少部分中心开展,而且手术时间较开腹手术时间长,不能进行常规开展。如何快速渡过LPD学习曲线,缩短LPD手术时间,使其能够广泛开展,让更多壶腹周围及胰头部肿瘤患者获得微创技术带来的益处,成为术者们继续解决的问题。一些术者根据腹腔镜手术特点,尝试改变LPD的手术步骤,使其适应腹腔镜视野特点,而不是完全按照开腹手术方法。但目前仍没有人提出针对不同解剖条件下的手术策略。本团队于2012年9月实施了首例LPD,并且在腹腔镜胃癌手术、腹腔镜胰腺中段/体尾切除术、腹腔镜胆管手术等腹腔镜上腹部手术的基础上,总结出了基于"五孔法"的腹腔镜胰十二指肠切除术的优化手术路径。然而,随着病例数的增加,,我们发现上述方法无法预防异位右肝动脉的损伤。鉴于此,本团队在此前基础上,结合异位右肝动脉损伤预防,总结了"No Back"策略。此外,随着技术积累,手术适应证的逐步扩大,本团队还总结了针对肿瘤与门静脉/肠系膜上静脉粘连或侵犯、胰颈后隧道无法贯通的交界可切除肿瘤等的LPD手术策略,即"Easy First"策略。本研究将详细介绍"No Back"LPD手术路径以及"Easy First"LPD手术路径,总结本团队LPD规范化操作流程,并对上述策略下开展LPD进行回顾性分析,评估其安全性、可行性、以及肿瘤治疗效果。第一部分腹腔镜胰十二指肠切除手术路径和方法研究目的:详细描述腹腔镜胰十二指肠切除术中采用的"No Back" LPD手术路径和"Easy First"LPD手术路径,总结LPD规范化操作流程。研究方法:分析总结此前的基于"五孔法"腹腔镜胰十二指肠切除术优化手术路径的缺陷,通过团队讨论、文献回顾以及会议交流,设定新的手术策略,并进行临床实践。研究结果:在"五孔法"操作平台上,针对解剖情况良好、胰后隧道能够贯通的患者,采用"No Back"LPD手术路径,即在解剖性探查后,首先解剖肝门部,游离肝总动脉、肝动脉、门静脉和胆管,确定是否存在异位右肝动脉,再根据基于腹腔镜视野特点的从左侧到右侧、从腹侧到背侧、从足端到头端的切除顺序,逐步离断空肠、胃、胰颈、钩突、胆管;此手术路径可在减少重复操作、缩短手术时间的基础上,减少了异位右肝动脉的损伤几率。针对肿瘤与血管粘连或侵犯、胰后隧道无法贯通的患者,采用"Easy First" LPD手术路径,即首先通过近端空肠侧游离肠系膜上动脉,确定肠系膜上动脉无侵犯,在将近端空肠、胃、胆管等离断后,在游离解剖胰颈和钩突,必要时及时中转小切口手;此手术路径可在保证安全的情况下,最大可能使手术在腹腔镜下完成,并可有效控制术中出血。此外,在患者经济允许范围内,对于胰管小于1mm的患者,除胃肠吻合外,采用机器人辅助的胰肠吻合和胆肠吻合,确保胰肠吻合口质量,减少胰漏发生。结论:在"五孔法"操作平台上,"No Back"LPD手术路径不仅满足使手术操作无反复,且可以有效降低异位右肝动脉的损伤,减少并发症;"Easy First"LPD手术路径则在保证手术安全的情况下,扩大了手术指征,适用于尚未完全掌握腹腔镜下大血管切除重建的术者。第二部分腹腔镜胰十二指肠切除术治疗胰头和壶腹周围病变的临床疗效研究目的:评估"No Back"LPD手术路径和"Easy First"LPD手术路径的安全性、可行性及肿瘤治疗效果。研究方法:选取2012年9月至2016年12月期间,诊断为胰头或壶腹周围病变拟行腹腔镜胰十二指肠切除术。分析其术前人口学资料,术中手术时间、出血量,术后住院时间、并发症,病理资料及生存率等临床资料。研究结果:2012年9月至2016年12月,本团队共开展245例LPD,其中协助外院59例。男性154例,女性91例,平均年龄(60.4±12.7)岁,有腹部手术史者55例。其中行标准LPD者233例,LPD联合胰体尾切除术4例,机器人辅助重建8例;采用"No Back"路径213例,"Easy First"路径32例。中转开腹5%。平均手术时间(364.9±57.4)min,术中中位失血量200ml,术后总体并发症率34.7%,B级和C级胰瘘发生率6.9%,术后出血9.4%。术后二次手术率4.9%。术后30 d内死亡2例(0.82%)。术后中位住院时间15d。肿瘤最大径平均(3.9±2.4)cm,平均淋巴结清扫数量(21.4±12.2)个,R0切除率99.2%。其中恶性肿瘤173例,包括胰腺癌94例,胆管下段癌22例,壶腹癌55例,胃癌1例,胃和十二指肠降部双重癌1例。术后共43例患者行术后化疗,术后开始化疗中位时间31天。胰腺癌患者中位随访时间16个月,其1年、2年、3年总体生存率分别为70.3%、27.1%、27.1%,无瘤生存率分别为68.3%、23.5%、23.5%。胆管癌患者中位随访时间20个月,其1年、2年、3年总体生存率分别为69.3%、49,5%、37.1%,无瘤生存率分别为68.3%、49.5%、37.1%。壶腹癌患者中位随访时间22个月,其1年、2年、3年总体生存率分别为 91.5%、79.6%、79.6%,无瘤生存率分别为 90.0%、73.7%、61.2%。"No Back"路径组平均年龄较"Easy First"路径组小(p=0.0098),术中中转率低(p0.0001),手术时间短(p=0.0490),术中输血者多(p=0.0345),但术后并发症、住院时间等无明显区别。研究结论:"No Back"路径和"Easy First"路径的LPD安全可行、肿瘤治疗效果可靠。顺利、安全开展LPD的关键在于术者熟练掌握腹腔镜下缝合止血等操作,并根据术者经验选择合适的患者,根据术中解剖情况选择合适的路径。规范的手术路径可以促进团队建设,加快术者的技术积累。
[Abstract]:Pancreaticoduodenectomy (Pancreaticoduodenectomy, PD) is the standard surgical approach of periampullary and head of pancreas disease. Since 1935 Whipple successful pancreaticoduodenectomy, after 80 years of development, PD hospital mortality from 20% in 1970s to 25% now reduced to 1 to 5%, but the postoperative complications are still 40% to 60%, more than grade 20% to 30% complications including incision, complications related to the surgery itself by 8.3% ~ 13%. PD how to reduce the rate of complications, improve postoperative recovery of patients with.1987 has become the focus of attention in France, Dr. Mouret successfully carried out laparoscopic cholecystectomy, laparoscopic surgery with small incision and clear vision. Less bleeding, faster postoperative recovery by minimally invasive advantages, doctors and patients are welcome. With the rapid development of technology and improvement of laparoscopic endoscopic instrument, laparoscopy In the operation of pedicle organs such as gallbladder, spleen, hollow organs such as the stomach, jejunum, parenchymal organs such as liver, pancreas and other organs of the surgery successfully, it has been widely used in various fields of surgical.Gawande review of the new England Journal of Medicine published 200 years history of surgery, the surgery to minimally invasive evaluation laparoscopic technology driven to have the same meaning with the improvement of anesthesia. Minimally invasive surgery has become the development direction of the two major surgery in twenty-first Century of.1994, Gagner and so on were reported for the first time of laparoscopic pancreaticoduodenectomy (Laparoscopic Pancreaticoduodenenctomy, LPD), first reported in 1996 the laparoscopic pancreatic tumor enucleation and laparoscopic spleen preserving pancreatic body laparoscopic pancreatic tail resection, first reported in 2003 and the middle of resection. But over the past 20 years, although LPD was reported to have less bleeding, less pain, After operation, short hospitalization time and other advantages of minimally invasive, but it is still only a small part of the center to carry out, and the operation time compared with open operation for a long time, can not be routinely carried out. How fast through LPD learning curve, shorten the operation time of LPD, which can be widely carried out, so that more around the ampulla and head of pancreas cancer patients received minimally invasive technique the benefits of becoming researchers to solve the problem. Some patients according to the characteristics of laparoscopic surgery, the surgical procedure to change the LPD, which can adapt to the characteristics of laparoscopic vision, but not completely in accordance with the method of open surgery. But there is still no one puts forward the surgical strategy of different anatomical conditions. It is the first team to implement LPD in September 2012, and in the laparoscopic gastric surgery, laparoscopic pancreatic / middle pancreatectomy, laparoscopic bile duct surgery based laparoscopic abdominal surgery, summed up based on the "five The optimization of hole method of the surgical approach of laparoscopic pancreaticoduodenectomy. However, with the increase of the number of cases, we found that the method can prevent heterotopic right hepatic artery injury. In view of this, the team in the previous basis, combined with aberrant right hepatic artery injury prevention, summed up the "No Back" strategy in addition. With the accumulation of technology, and the surgical indications gradually expanded, the team also summarized for tumor and portal vein / superior mesenteric vein adhesion or invasion, pancreatic neck after the tunnel through the junction of LPD to tumor resection operation strategy, namely "Easy First" strategy. This study introduced the "No Back" LPD surgery Easy First "LPD" path and operation path, summarizes the team LPD standardized operating procedures, and to carry out the strategy of LPD were retrospectively analyzed to evaluate its safety, feasibility, and tumor treatment. The first part of the ten laparoscopic pancreatic Two refers to the bowel resection surgery path and method of objective: a detailed description of the laparoscopic pancreaticoduodenectomy use "No Back" LPD "Easy First" operation path and LPD operation path, summarize the LPD standardized operation process. Methods: to analyze and summarize the previous research based on the method of the five hole laparoscopic pancreaticoduodenectomy surgery optimization the path of defects, through team discussion, literature review and conferences, setting new surgical strategies, and clinical practice. Results: in the operating platform of five hole method ", according to the anatomical situation is good, can through the tunnel after pancreas patients, using" No Back "LPD operation path, namely in anatomy after exploration, the anatomy of hepatic portal, free hepatic artery, hepatic artery, portal vein and bile duct, determine whether there is aberrant right hepatic artery, then based on laparoscopic vision features from left to right, from the ventral to the dorsal, from The foot end at the head end resection order, gradually breaking away from the neck of pancreas, stomach, jejunum, uncinate process, bile duct; the surgical route can reduce repeated operation, shorten the operation time of the foundation, reduce the damage probability of the right hepatic artery. The ectopic tumor and vascular adhesion or invasion of pancreas after the tunnel cannot run through patients with "Easy First LPD" operation path, first through the proximal jejunum side of superior mesenteric artery, superior mesenteric artery to determine the invasion, in the proximal jejunum, gastric, bile duct transection in the dissection of pancreatic neck and uncinate process, transfer and small incision surgery when necessary; the operation path to ensure the safety of the situation, most likely make surgery performed by laparoscopy, and can effectively control the bleeding during the operation. In addition, patients in the economy range, for less than 1mm in patients with pancreatic duct, gastrointestinal anastomosis, using robot assisted pancreaticojejunostomy and biliary Together, ensure the anastomosis quality, reduce the occurrence of pancreatic leakage. Conclusion: in the operation platform of the five hole method "," No Back LPD "operation path not only meet the operation without recurrence, and can effectively reduce the ectopic right hepatic artery injury, reduce the complications;" Easy First LPD "in the path of operation to ensure the operation safety, expand the surgical indications, suitable for patients who have not yet fully mastered laparoscopic vascular resection and reconstruction. Objective to study on clinical effect of surgical treatment of pancreatic and periampullary lesions of second laparoscopic pancreatoduodenectomy: safety evaluation of" No Back LPD "and" Easy First "operation path of LPD the surgical approach, the treatment effect and feasibility of tumor. Methods: during the period from September 2012 to December 2016, diagnosed as pancreatic or periampullary diseases underwent laparoscopic pancreaticoduodenectomy. Analysis of preoperative demographic data, intraoperative hand 鏈椂闂，
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