改进型经典胰肠吻合减少胰十二指肠切除术后胰瘘等并发症的研究

发布时间：2018-03-21 07:50

  本文选题：改进型经典胰肠吻合　切入点：连续缝合　出处：《山东大学》2017年硕士论文　论文类型：学位论文

【摘要】：研究背景:自1935年首次报道以来,标准式胰十二指肠切除术(Pancreatico-duodenectomy,PD)逐渐在各大医疗中心开展,给众多罹患胰头癌及壶腹周围肿瘤疾病患者带来了治愈的希望。经过百余年的发展和改进,其中包括众多外科学者积极参与该术式的改进和推广的过程中,现已经成为治疗胰腺肿瘤、胆管下段肿瘤、壶腹周围肿瘤、十二指肠肿瘤及该区域外伤和其他良恶性疾病的标准术式,也是唯一可根治疾病的经典术式。但该手术由于操作程序较复杂、涉及组织脏器较多、手术时间较长、以及术前患者一般情况和局部情况较差等不利因素,导致术后出现较多且程度严重的并发症,因此PD 一直是外科学界认为最具有挑战性手术之一。尽管随着辅助检查技术的不断改进、新型高科技医疗器材及药物的研发、外科手术医师手术技术的不断提高以及围手术期处理的综合水平及临床经验的不断积累,手术的安全性得到一定程度的提高,但与外科其他手术相比,依然存在着较高的手术风险。影响术后恢复因素众多,而其中胰腺消化道重建是一个可控性和操作性很强的因素,基于胰腺消化道吻合及改进的方法目前已报道了80多种,其中端侧胰肠吻合最常见,将其视为胰肠重建的经典吻合方式。虽然对胰瘘等并发症的发生率的下降起到了一定的作用,但胰肠吻合口瘘引起的相关并发症等问题始终未得到完美的解决。如何改进和提高现有的吻合方法和处理技巧,降低胰瘘等并发症的发生率,已成为外科学者研究的一个重大现实临床课题。经过多年的临床实践研究,术中胰肠吻合采用精细的缝合材料和改进型缝合技术,如Prolene线的连续缝合技术,完全可以将PD术后胰瘘等并发症及严重程度降至更低的水平。目的:比较标准式PD的传统型经典胰肠吻合法和改进型经典胰肠吻合法在临床中应用效果,探讨其改变的过程优势及其对胰瘘等并发症的影响。方法:对山东大学附属省立医院东院肝胆外科从2011年5月至2016年8月间成功实施了标准式PD的134例患者的临床资料进行了回顾性分析,术中根据胰管内经大小相对应的传统经典胰肠吻合方法是否进行改进而分组,共分4组:A组,端侧胰管-空肠粘膜吻合组,42例;B组,套入式端侧胰肠吻合组,25例,C组,改进型端侧胰管-空肠粘膜吻合组,43例;D组,改进型套入式端侧胰肠吻合组,24例。所有疾病均根据临床表现、实验室检查、影像学资料及术后病理结果证实。比较各组术前情况(年龄、性别、疾病类型构成、既往史、白蛋白、凝血酶原时间、总胆红素、血清谷丙转氨酶),术中情况(手术时间、胰肠吻合时间、出血量、胰管内径、胰腺质地、输血量)、术后并发症(总并发症及严重程度、胰瘘及其分级、腹腔出血、腹腔感染、肺部感染、胆瘘、淋巴瘘、胃排空障碍、腹泻的发生率)、术后死亡率、术后平均住院时间、再手术率和再住院率之间的差异。采用SPSS20.0软件进行统计学分析,采用Pearsonχ2检验或Fisher精确概率法;所有可能变量进行单变量分析和P值接近0.1的变量进行logistic多因素分析,如P0.05,则表示差异具有统计学意义。结果:1.术前各组情况比较:四组患者的年龄、性别、Alb、ATL、T-Bil、PT、高血压、糖尿病、脑血管疾病及疾病类型构成无显著统计学差异(P0.05)。2.术中各组情况比较:四组患者输血量、手术的时间及胰腺的质地均不存在统计学差异(P0.05),但A组的平均胰管内径大于B组的平均胰管内径0.7mm(P0.05),C组平均胰管内径大于D组平均胰管内径0.6mm(P0.05)。3.术后各组情况比较:四组患者的总体并发症与再住院率无明显差异(P0.05),但是根据Clavien-Dindo标准,A组和B组患者的并发症较C组和D组患者的并发症严重;A组和B组患者的胰瘘发生率均明显大于C组和D组患者的胰瘘发生率(P0.05);A组和B组患者比C组和D组患者术后更易出现胃排空障碍(P0.05);其他术后并发症无明显差异。A组患者的平均住院天数较C组患者延长了 7天(P0.05),B组患者的平均住院天数比D组患者延长了 6天(P0.05);相比于C组及D组患者,A组患者的再次手术风险较高(P0.05);A组患者术后死亡率比C组高(P0.05)。4.危险因素分析:性别、疾病类型、主胰管内径为胰瘘发生的独立危险因子,对于主胰管3.0mm的患者的胰瘘发生率(54.2%)明显高于主胰管3.0mm的胰瘘发生率(29.1%)(P0.05)。另外,相比与患有其他疾病的患者,胰腺肿瘤或慢性胰腺炎的患者拥有更低的胰瘘发生率(P0.01)。结论:胰肠吻合使用Prolene线的连续缝合技术替代传统外科缝线蚕丝线的间断缝合技术,并根据胰管内径的大小选择相应合适的胰肠吻合方式,可降低术后胰瘘发生率及相关并发症的严重程度,明显缩短了患者住院时间。
[Abstract]:Background: since the first report of 1935, standard pancreaticoduodenectomy (Pancreatico-duodenectomy, PD) is gradually carried out in the medical center, brings hope to cure many suffering from pancreatic head carcinoma and periampullary tumor disease. After more than 100 years of development and improvement, including many scholars actively participate in the surgical operation the improvement and promotion process, has become the treatment of pancreatic cancer, bile duct cancer, periampullary cancer, standard operation and the traumatic duodenal tumor and other benign and malignant diseases, and only can cure the disease. But the classical surgical operation because the operation procedure is more complicated, involving many organs, the operation time is longer, and the preoperative general condition of patients and the local poor and other unfavorable factors, and lead to more serious complications, so PD has been That surgery is one of the most challenging operation. Although with the improvement of auxiliary examination technology, the development of new high-tech medical equipment and drugs, the accumulation of technology surgery doctors surgery as well as the improvement of the comprehensive level of perioperative treatment and clinical experience, the safety of the operation has been improved to a certain extent, but compared to and other surgical operations, there is still a high risk operation. Postoperative recovery effect of many factors, including pancreatic digestive tract reconstruction is a controllable and strong operational factors, methods of elimination and improvement of pancreatic anastomosis based on the reported more than 80, of which the most common end to side pancreaticojejunostomy that will be regarded as pancreatic enteric reconstruction classic anastomosis of pancreatic fistula. Although the incidence rate of decline has played a certain role, but the pancreatic fistula caused by complications Such problem has not been perfectly solved. How to improve and enhance the existing method of anastomosis and processing skills, reduce the incidence of complications such as pancreatic fistula, surgery has become a major research topic. The clinical reality after years of clinical practice study, the fine suture material and improved suture anastomosis of pancreatic intestinal surgery in the continuous suture technique such as Prolene line, can be reduced to pancreatic fistula and other complications and severity of postoperative PD level. Objective: the traditional classic pancreatojejunal compared to standard PD anastomosis and improved classical pancreaticojejunostomy in clinical application, to explore the process of changing the advantages and its influence the pancreatic fistula and other complications. Methods: the Provincial Hospital Affiliated to Shandong University Hospital Department of hepatobiliary surgery from May 2011 to August 2016 the East between the successful implementation of the clinical data of 134 cases of standard type PD patients were 鍥為【鎬у垎鏋，

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