腹腔镜保留脾脏胰体尾切除术后脾血管通畅性的随访研究

发布时间：2018-03-04 17:15

本文选题：腹腔镜　切入点：保留脾脏　出处：《浙江大学》2015年硕士论文　论文类型：学位论文

【摘要】：研究目的：1.评价腹腔镜保留脾脏胰体尾切除术的安全性、可行性。2.探究腹腔镜保留脾脏胰体尾切除术(Kimura法)脾血管的通畅状态和脾脏保留的必要性。研究方法：分析2004年3月到2014年12月间本中心行腹腔镜胰体尾切除术病例的临床资料,并进行随访。排除胰腺腺癌、中转开腹、Warshaw法保留脾脏的病例。根据是否保留脾脏分为腹腔镜保留脾脏胰体尾切除(Laparoscopic Spleen-Preserving Distal Pancreatectomy, LSPDP)组和腹腔镜胰体尾联合脾脏切除未(Laparoscopic Distal Pancreatosplenectomy, LDPS)组。通过对比分析两组患者的近期手术结果对LSPDP的安全性、可行性进行评价。通过对两组白细胞(White blood cell, WBC)、血红蛋白(Hemoglobin, Hgb)、血小板(Platelet, PLT)、C反应蛋白(C-reactive protein, CRP)等对比分析以及LSPDP术后脾血管通畅性来评估保留的脾脏功能。此外,根据LSPDP组脾血管通畅程度分级进而分成2组,即：A组(0级：完全通畅)与B组(1级：脾血管局部栓塞或狭窄),并对两组进行多因素对比筛选,分析脾血管通畅的影响因素。研究结果：两组共119例患者,其中LSPDP组59例,LDPS组60例。两组的性别、年龄、BMI指数、术前症状、合并症、腹部手术史、术前ASA分级均无显著性差异(P0.05)。术中相关指标：对比LDPS组,LSPDP组手术时间(174.2±61.4分钟vs191.4±49.4分钟,P=0.098)减少、术中出血量(116.4±150.9mlvs229.0±233.7ml,P=0.002)减少,两组术中输血量上差异无统计学意义(P0.05)。术后恢复方面：LSPDP组术后总体并发症率高于LDPS组(72.9%vs53.3%,P=0.021)。严重并发症(≥Grade Ⅲ)(10.2%vs10.0%, P0.05)、胰瘘(特别是≥Grade B:28.8%vs21.7%, P=0.469)、术后出血(P=0.311)、感染(P=0.445)等发生率无显著性差异。LSPDP组术后下床时间、术后肛门排气时间、术后进流质时间、术后住院天数与LDPS组均无显著性差异。术后脾脏功能：LSPDP组及LDPS组白细胞和血小板分别为术后3天和14天达到顶峰。因此,我们将两组的术后3天WBC,术后14天PLT进行分级比较：LDPS组WBC≥10*109/L的病例明显多于LSPDP组(67.8%vs23.7%,P=0.000),PLI≥300*109/L的病例明显多于LSPDP组(61.7%vs46.7%,P=0.000) 脾血管通畅性：LSPDP组中,59例患者中术前CT显示脾血管均显示完全通畅,0级。于术后早期(1～3月)复查发现脾动脉1级为15人,0级44人。在术后3～6月再次复查,发现15人中有6人转变为0级。术后早期(1～3月)复查脾静脉1级为18人,0级41人。在术后3～6月再次复查发现18人中有5人转变为0级。对比完全通畅组与不完全通畅组,性别、年龄、BMI指数、术前症状、合并症、腹部手术史、术前ASA分级、术中出血量、有无输血/病理类型、肿瘤位置、肿瘤大小、切除胰腺长度差异均无统计学意义,其中并发症分级(P=0.026)有统计学意义,手术时间(P=0.084)有差异,但未达到统计学意义。结论：1.保留血管的腹腔镜保留脾脏胰体尾切除术在技术上安全可行的,适用于胰腺良性、交界性肿瘤。2.腹腔镜保留脾脏胰体尾切除术(Kimura法)后能有效保证脾脏灌注,保留的脾脏减少了血液系统的干扰。3.术后并发症为保留的脾血管通畅的高危因素。
[Abstract]:Research purposes: 1.. Evaluate the safety and feasibility of laparoscopic splenectomy for distal pancreatectomy..2. explored the necessity of laparoscopic preservation of splenic pancreatic body and tail resection (Kimura), the patency of splenic vessels and the necessity of spleen preservation.
Methods: from March 2004 to December 2014 the analysis center for clinical data of laparoscopic distal pancreatectomy were excluded, and were followed up. Pancreatic adenocarcinoma, laparotomy, Warshaw spleen preserving cases. According to whether the preservation of the spleen were divided into laparoscopic spleen preserving distal pancreatectomy (Laparoscopic Spleen-Preserving Distal Pancreatectomy, LSPDP) and group laparoscopic distal pancreatectomy combined with splenectomy (Laparoscopic Distal Pancreatosplenectomy, not LDPS) group. Through the comparative analysis of two groups of patients with recent surgical results of the safety of LSPDP, evaluate the feasibility. The two groups of white blood cells (White blood cell, WBC), hemoglobin (Hemoglobin, Hgb), platelet (Platelet, PLT) C, C-reactive protein (C-reactive protein, CRP and LSPDP) were compared after surgery to assess the patency of spleen preserving splenic function. In addition, according to LSPDP The degree of splenic vascular patency was further divided into 2 groups: group A (level 0: complete patent) and group B (Level 1: local embolization or stenosis of splenic vessels), and two groups were screened by multiple factors to analyze the influencing factors of patency of splenic vessels.
Results: there were 119 cases in two groups, including 59 cases in group LSPDP and 60 cases in group LDPS. There was no significant difference in gender, age, BMI index, preoperative symptoms, complications, abdominal operation history and preoperative ASA grading in two groups (P0.05).
Intraoperative related indicators: compared with group LDPS, operation time in group LSPDP (174.2 + 61.4 minutes vs191.4 + 49.4 minutes, P=0.098) decreased, and intraoperative blood loss (116.4 + 150.9mlvs229.0 + 233.7ml, P=0.002) decreased. There was no significant difference in blood transfusion volume between two groups (P0.05).
Recovery of postoperative overall complications after operation in LSPDP group was higher than that of group LDPS (72.9%vs53.3%, P=0.021). Serious complications (Grade III) (10.2%vs10.0%, P0.05), pancreatic fistula (especially Grade or B:28.8%vs21.7%, P=0.469), postoperative bleeding, infection (P=0.311) (P= 0.445), there was no time to get out of bed significant differences in.LSPDP group after operation, postoperative anal exhaust time, postoperative advanced liquid time, postoperative hospital stay and LDPS group showed no significant difference.
The spleen function after operation: LSPDP group and LDPS group of white blood cells and platelets respectively peaked 3 days and 14 days after operation. Therefore, we will be in the two groups after 3 days WBC, 14 days after operation PLT classification comparison: LDPS group WBC = 10*109/L were significantly more than group LSPDP (67.8%vs23.7%, P=0.000) PLI, more than 300*109/L were significantly higher than those of group LSPDP (61.7%vs46.7%, P=0.000)
Splenic vascular patency: in group LSPDP, 59 cases of patients with preoperative CT showed splenic vessels showed complete patency, 0. In early postoperative period (1~3 months) were found 1 splenic artery for 15 people, 0 people in 44. After 3~6 months to check again, found that 15 people in 6 turn to 0. Early postoperative period (1~3 months) were 1 splenic vein for 18 people, 0 people in 41. After 3~6 months to check again found 18 people in 5 to 0.
Comparison of complete and incomplete patency group patency group, gender, age, BMI index, preoperative symptoms, complications, history of abdominal surgery, preoperative ASA classification, the amount of bleeding, blood transfusion and pathological type, tumor location, tumor size, pancreatic resection length had no significant difference, the complications (grade P=0.026) had statistical significance (P=0.084), the operation time is different, but the difference was not statistically significant.
Conclusion: Laparoscopic spleen preserving 1. arteries preserved pancreatectomy is technically feasible and safe, suitable for pancreatic benign, borderline tumor.2. laparoscopic spleen preserving distal pancreatectomy (Kimura) can effectively guarantee the splenic perfusion, risk factors of retention of spleen reduced blood disturbance.3. complications the spleen retained patency.

【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R657.5

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