套入式肝肠吻合在困难的胆道重建中的应用
发布时间：2018-09-19 09:04
【摘要】：目的研究胰十二指肠切除术中困难的胆肠吻合病人的临床特点、病理特征,评估不同引流方式对困难的胆肠吻合术后近期并发症的发病率,深入了解不同胆道重建方式在胆肠吻合术中的优劣。 背景在腹部外科中,胰十二指肠切除术(PD)虽然是一种难度较大的手术。但却是根治胰头癌、壶腹周围癌、十二指肠癌等的重要手术方法,由于该术式创伤大,术后并发胰瘘、胆漏等并发症的机会较高,住院时间长,费用高。目前针对如何减少胰十二指肠切除术后胰瘘发病率的研究已经很多,并且已经有达成共识的胰瘘定义及分级方法,但针对胆漏的研究则并不多见。对于困难的胆肠吻合中胆道重建方法仍存在争议。 方法回顾性收集我科1995年1月至2013年12月行胰十二指肠切除术并肝总管直径小于8mm病例共51例,以胆道重建的不同方式分成三组,对照组为行传统的胆肠吻合的病人(n=19),实验组一为套入式肝肠吻合组(n=15),实验组二为放置T管组(n=17),收集整理病人临床资料,包括性别、年龄、BMI、术后天数、术前麻醉ASA评分、肝总管直径、病变良恶性及部位以及术后并发症的发病率等内容。最后行统计学分析比较。 结果传统吻合组19例病人(男性10例/女性9例,52±10岁,BMI21.5±2.6),套入式吻合组15例(男性7/女性8例,50±9岁,BMI20.44±2.2),T管组17例(男性12/女性5例,54±9岁,BMI21.44±2.9),三组之间在人口学特征上没有统计学差异(p0.05)。三组病人术前ASA评分、病变良恶性及病变部位、肝总管直径也没有统计学差异(p0.05)。三组病人术后并发症发病率仅在术后胆漏上有差异,其中传统胆肠吻合组为31%(6/19),套入式吻合组15例病人没有病人发生胆漏,T管组为35%(6/17)[P=0.037],套入式吻合组胆漏发病率低于传统吻合组(p=0.016)及T管组(p=0.011),传统吻合组和T管组的胆漏发病率无差异(p=0.813)。胆漏与术后住院天数、死亡率以及术后出血、伤口感染、术后胰瘘、腹腔积液、败血症、胆管炎的发病率有关。7%(4/51)的病人需要再次手术(传统吻合组21%[4/19]vs套入式吻合组0[0/15]vsT管组0[0/17],p=0.026)。12%(1/17)的病人出现T管相关并发症。 结论胰十二指肠切除术中在胆肠吻合口无论是套入式肝肠吻合或放置T管在术后总并发症发病率上并没有差异,但是在Clavien-Dindo分级4a级以上的并发症中,套入式吻合组和T管组的发病率要低于传统吻合组。此外,行套入式肝肠吻合可降低术后胆漏发病率,但放置T管并不能降低胆漏发病率,因此我们认为在胰十二指肠切除术困难的胆道重建中行套入式肝肠吻合可以有效减少术后胆道并发症的发生,有利于病人术后康复。 目的探讨套入式肝肠吻合在辅助性肝移植胆道重建中的应用及体会,提高胆道重建的技术。 方法对2008年1月到2013年12月10例辅助性肝移植胆道重建病例的临床资料进行分析。共行肝肠吻合6例(60%),均行套入式肝肠吻合并根据情况放置胆管支撑管；胆道对胆道吻合4例(40%),1例放置胆管支撑管,热缺血时间3.6±1.6分钟,冷缺血时间6.3±2.5小时,胆道重建时间25±5min。术后采用他克莫司+骁悉+强的松三联免疫抑制方案,评价胆道重建的方式、胆道重建时间、术后胆道并发症的资料。随访时间为术后3个月。 结果术后随访3月没有病人出现胆道并发症。 结论套入式肝肠吻合是辅助性肝移植术复杂胆道重建的一种有效方式,具有术后胆道并发症少的优点。
[Abstract]:Objective To study the clinical and pathological characteristics of patients with difficult biliary-enteric anastomosis in pancreaticoduodenectomy, and to evaluate the incidence of complications after different drainage methods for difficult biliary-enteric anastomosis.
Background In abdominal surgery, pancreaticoduodenectomy (PD) is a difficult operation, but it is an important surgical method for radical treatment of pancreatic head cancer, periampullary cancer, duodenal cancer, etc. Because of its great trauma, postoperative complications such as pancreatic fistula, bile leakage have a higher chance, long hospital stay and high cost. The incidence of pancreatic fistula after pancreaticoduodenectomy has been studied extensively, and there has been a consensus on the definition and classification of pancreatic fistula, but the study of bile leakage is rare.
Methods 51 cases of pancreaticoduodenectomy with common hepatic duct diameter less than 8 mm from January 1995 to December 2013 in our department were retrospectively collected and divided into three groups according to different ways of biliary reconstruction. The control group was treated with traditional biliary-enteric anastomosis (n=19), the experimental group was treated with nested hepato-enteric anastomosis (n=15), and the experimental group was treated with T-tube placement (n=17). The clinical data of the patients were collected, including sex, age, BMI, postoperative days, preoperative ASA score, common hepatic duct diameter, benign and malignant lesions, location and incidence of postoperative complications.
Results There were 19 patients in the traditional anastomosis group (10 males / 9 females, 52 + 10 years old, BMI 21.5 + 2.6), 15 patients in the nested anastomosis group (7 males / 8 females, 50 + 9 years old, BMI 20.44 + 2.2), 17 patients in the T tube group (12 males / 5 females, 54 + 9 years old, BMI 21.44 + 2.9). There was no significant difference in demographic characteristics among the three groups (p0.05). There was no significant difference in the diameter of the common hepatic duct between benign and malignant lesions (p0.05). The incidence of postoperative complications was only different among the three groups. The incidence of biliary leakage was 31% (6/19) in the traditional bilioenterostomy group, 35% (6/17) in the T-tube group, and 35% (6/17) in the nested bilioenterostomy group. There was no significant difference in the incidence of biliary leakage between the traditional anastomosis group (p = 0.016) and the T-tube group (p = 0.011). Bile leakage was associated with postoperative hospital stay, mortality, postoperative bleeding, wound infection, postoperative pancreatic fistula, peritoneal effusion, sepsis, and cholangitis in 21% of the patients in the traditional anastomosis group (p = 0.813). T-tube-related complications occurred in 0[0/17], p=0.026.12% (1/17) of patients in the 0[0/15] vs T-tube group.
Conclusion There was no significant difference in the incidence of postoperative complications between the two groups in pancreaticoduodenectomy. However, the incidence of complications above Clavien-Dindo grade 4A was lower in the two groups than in the traditional group. To reduce the incidence of postoperative biliary leakage, but the placement of T-tube can not reduce the incidence of biliary leakage. Therefore, we believe that nested hepatoenterostomy can effectively reduce the incidence of postoperative biliary complications in difficult biliary reconstruction after pancreaticoduodenectomy and is conducive to postoperative rehabilitation.
Objective To explore the application and experience of nested hepatointestinal anastomosis in biliary tract reconstruction of auxiliary liver transplantation and to improve the technique of biliary tract reconstruction.
Methods The clinical data of 10 cases of biliary tract reconstruction after auxiliary liver transplantation from January 2008 to December 2013 were analyzed. Six cases (60%) underwent hepatointestinal anastomosis, all of them underwent hepatointestinal anastomosis and biliary duct support tube placement according to the situation; 4 cases (40%) underwent biliary tract to biliary anastomosis, 1 case underwent biliary duct support tube placement, warm ischemia time was 3.6 (+ 1.6 minutes) and cold ischemia time was 3.6 The interval was 6.3 (+ 2.5 hours) and the time of biliary reconstruction was 25 (+ 5 minutes). The method of biliary reconstruction, the time of biliary reconstruction and the complications of biliary tract reconstruction were evaluated with tacrolimus + mycophenolate + prednisone immunosuppressive regimen. The follow-up time was 3 months.
Results no biliary complications occurred in March.
Conclusion Intratheter hepatointestinal anastomosis is an effective method for complicated biliary reconstruction in liver transplantation, and it has the advantage of less postoperative biliary complications.
【学位授予单位】：华中科技大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R657.3;R657.4
本文编号：2249675
[Abstract]:Objective To study the clinical and pathological characteristics of patients with difficult biliary-enteric anastomosis in pancreaticoduodenectomy, and to evaluate the incidence of complications after different drainage methods for difficult biliary-enteric anastomosis.
Background In abdominal surgery, pancreaticoduodenectomy (PD) is a difficult operation, but it is an important surgical method for radical treatment of pancreatic head cancer, periampullary cancer, duodenal cancer, etc. Because of its great trauma, postoperative complications such as pancreatic fistula, bile leakage have a higher chance, long hospital stay and high cost. The incidence of pancreatic fistula after pancreaticoduodenectomy has been studied extensively, and there has been a consensus on the definition and classification of pancreatic fistula, but the study of bile leakage is rare.
Methods 51 cases of pancreaticoduodenectomy with common hepatic duct diameter less than 8 mm from January 1995 to December 2013 in our department were retrospectively collected and divided into three groups according to different ways of biliary reconstruction. The control group was treated with traditional biliary-enteric anastomosis (n=19), the experimental group was treated with nested hepato-enteric anastomosis (n=15), and the experimental group was treated with T-tube placement (n=17). The clinical data of the patients were collected, including sex, age, BMI, postoperative days, preoperative ASA score, common hepatic duct diameter, benign and malignant lesions, location and incidence of postoperative complications.
Results There were 19 patients in the traditional anastomosis group (10 males / 9 females, 52 + 10 years old, BMI 21.5 + 2.6), 15 patients in the nested anastomosis group (7 males / 8 females, 50 + 9 years old, BMI 20.44 + 2.2), 17 patients in the T tube group (12 males / 5 females, 54 + 9 years old, BMI 21.44 + 2.9). There was no significant difference in demographic characteristics among the three groups (p0.05). There was no significant difference in the diameter of the common hepatic duct between benign and malignant lesions (p0.05). The incidence of postoperative complications was only different among the three groups. The incidence of biliary leakage was 31% (6/19) in the traditional bilioenterostomy group, 35% (6/17) in the T-tube group, and 35% (6/17) in the nested bilioenterostomy group. There was no significant difference in the incidence of biliary leakage between the traditional anastomosis group (p = 0.016) and the T-tube group (p = 0.011). Bile leakage was associated with postoperative hospital stay, mortality, postoperative bleeding, wound infection, postoperative pancreatic fistula, peritoneal effusion, sepsis, and cholangitis in 21% of the patients in the traditional anastomosis group (p = 0.813). T-tube-related complications occurred in 0[0/17], p=0.026.12% (1/17) of patients in the 0[0/15] vs T-tube group.
Conclusion There was no significant difference in the incidence of postoperative complications between the two groups in pancreaticoduodenectomy. However, the incidence of complications above Clavien-Dindo grade 4A was lower in the two groups than in the traditional group. To reduce the incidence of postoperative biliary leakage, but the placement of T-tube can not reduce the incidence of biliary leakage. Therefore, we believe that nested hepatoenterostomy can effectively reduce the incidence of postoperative biliary complications in difficult biliary reconstruction after pancreaticoduodenectomy and is conducive to postoperative rehabilitation.
Objective To explore the application and experience of nested hepatointestinal anastomosis in biliary tract reconstruction of auxiliary liver transplantation and to improve the technique of biliary tract reconstruction.
Methods The clinical data of 10 cases of biliary tract reconstruction after auxiliary liver transplantation from January 2008 to December 2013 were analyzed. Six cases (60%) underwent hepatointestinal anastomosis, all of them underwent hepatointestinal anastomosis and biliary duct support tube placement according to the situation; 4 cases (40%) underwent biliary tract to biliary anastomosis, 1 case underwent biliary duct support tube placement, warm ischemia time was 3.6 (+ 1.6 minutes) and cold ischemia time was 3.6 The interval was 6.3 (+ 2.5 hours) and the time of biliary reconstruction was 25 (+ 5 minutes). The method of biliary reconstruction, the time of biliary reconstruction and the complications of biliary tract reconstruction were evaluated with tacrolimus + mycophenolate + prednisone immunosuppressive regimen. The follow-up time was 3 months.
Results no biliary complications occurred in March.
Conclusion Intratheter hepatointestinal anastomosis is an effective method for complicated biliary reconstruction in liver transplantation, and it has the advantage of less postoperative biliary complications.
【学位授予单位】：华中科技大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R657.3;R657.4
【参考文献】
相关期刊论文 前2条
1 ;A ten-year study on non-surgical treatment of postoperative bile leakage[J];World Journal of Gastroenterology;2002年05期
2 Maria C Londo泺o;Domingo Balderramo;Andrés Cárdenas;;Management of biliary complications after orthotopic liver transplantation:The role of endoscopy[J];World Journal of Gastroenterology;2008年04期
，本文编号：2249675
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