胰管对空肠黏膜连续板层胰肠吻合术在胰十二指肠切除术中的应用

发布时间：2018-05-20 09:08

本文选题：胰十二指肠切除术 + 胰肠吻合术　；参考：《郑州大学》2017年硕士论文

【摘要】：背景和目的:胰十二指肠切除术是治疗胆管下端肿瘤、壶腹周围癌、十二指肠恶性肿瘤、胰头癌的主要手术切除方式。而胰十二指肠切除术手术之后的一些并发症如胰瘘、出血、胆瘘、胃排空障碍等会严重影响手术的效果,一些严重的并发症甚至会威胁病人的生命。最相关的并发症是胰瘘,不同研究机构其发生率也不同一般波动在2%至24%之间,胰瘘是胰十二指肠切除术中的难点问题甚至关乎着手术的成败,研究表明胰十二指肠切除术术后胰瘘相关死亡率接近10%。胰瘘的出现与否受到许多因素的影响,包括一些不可改变的内在因素如性别、年龄、体重指数等,但是其影响因素还包括一些可控因素如胰肠吻合重建的方式、围手术期的管理、外科操作技术水平、手术切除范围等,其中胰肠重建的方式是其中一个重要影响因素。胰肠吻合的方式从胰十二指肠切除术诞生以来不断演变,其方式可谓多种多样,但是截至目前,最佳的重建方式尚无定论,这个领域颇具争议。我中心致力于胰肠重建方式的研究,在传统端侧吻合方式的基础上创立了一种新的吻合方式?胰管对空肠黏膜连续板层胰肠吻合术,根据临床观察,这种吻合方式临床效果比较满意,本研究旨在验证其临床应用效果,并比较和探讨该吻合方式与胰肠端端套入吻合方式对人体应激反应的差异。材料和方法:回顾性研究分析2011年1月至2015年12月在本院因恶性肿瘤行胰十二指肠切除术的168例病人的病历资料,在所有病人中86例患者行胰管对空肠黏膜连续板层胰肠吻合术(实验组),82例患者行传统的胰腺空肠端端套入吻合术(对照组)。比较实验组、对照组两组病人手术前一般状况、手术中情况、手术后情况以及手术后并发症的发生情况,并比较这两组患者手术后第一天、手术后第三天及手术后一周的CRP、白细胞计数、中性粒细胞比例等应激检验指标。结果:胰管对空肠黏膜连续板层胰肠吻合组(实验组)与胰腺空肠端端套入吻合组(对照组)的性别、年龄、ASA分级、BMI、伴发疾病情况、既往腹部手术史、手术前胆道引流情况、手术病因类型、术前实验室检测指标、胰管直径、胰腺质地各指标差异无统计学意义(P0.05);实验组的胰肠吻合时间、手术中出血量、手术后进食时间、手术后住院时间、住院总花费明显低于对照组,差异有统计学意义(P0.05);实验组术后胰瘘的发生率显著低于对照组,差异有统计学意义(P0.05);实验组、对照组两组间腹腔出血、腹痛、高热、胃排空障碍、切口感染并发症发生率无显著性差异(P0.05);实验组与对照组两组再次手术、围手术期死亡临床结局指标比较差异无统计学意义(P0.05);实验组手术后第一天、手术后第三天、手术后一周的白细胞计数、中性粒细胞比例、CRP应激指标显著优于对照组,差异有统计学意义(P0.05)。结论:胰管对空肠黏膜连续板层式胰肠吻合方法在胰十二指肠切除术中应用的短期效果比较满意,但是该吻合方法临床应用的例数少,其治疗效果还有待进一步的随机对照试验和大宗病例分析进一步证实。
[Abstract]:Background and objective: pancreatoduodenectomy is a major surgical procedure for the treatment of lower bile duct tumors, periampullary carcinoma, malignant duodenal tumor, and pancreatic head carcinoma. The complications such as pancreatic fistula, bleeding, biliary fistula, and gastric emptying obstruction after pancreatoduodenectomy will seriously affect the effect of the operation, and some serious complications are complicated. The disease may even threaten the life of the patient. The most related complication is the pancreatic fistula, and the incidence of the different research institutions varies from 2% to 24%. The pancreatic fistula is a difficult problem in the pancreatoduodenectomy, even the success or failure of the operation. The study shows that the mortality of pancreatic fistula related to pancreatic fistula after pancreatoduodenectomy is close to the 10%. pancreatic fistula. There are many factors affecting the presence or not, including some unaltered internal factors such as sex, age, and body mass index, but the influencing factors include some controllable factors such as the way of reconstruction of the pancreas and intestines, the management of the perioperative period, the level of surgical operation and the range of hand resection, among which the way of the reconstruction of the pancreas is one of them. The mode of Pancreatoenterostomy has evolved since the birth of pancreatoduodenectomy, and its way is varied. However, the best way of reconstruction is not conclusive as of now. This field is quite controversial. My center is devoted to the study of the way of pancreas bowel reconstruction and founded a traditional way of end to side anastomosis. A new anastomosis of the pancreatic duct to the continuous lamellar pancreaticojejunostomy of the jejunum mucosa, according to clinical observation, the clinical effect of this anastomosis is satisfactory. The purpose of this study is to verify its clinical effect, and to compare and explore the difference between the anastomosis and the end of the Pancreaticoenterostomy on human stress response. Materials and methods: Retrospective From January 2011 to December 2015, 168 patients who underwent pancreatoduodenectomy due to malignant tumor were analyzed in our hospital. In all the patients, 86 patients underwent pancreatic duct to jejunum mucosa continuous lamellar pancreaticojejunostomy (experimental group), and 82 patients underwent traditional end-to-end anastomosis of the pancreas jejunum (control group). The experimental group was compared with the experimental group. The general condition of the two groups before operation, the operation situation, the postoperative situation and the occurrence of postoperative complications were compared, and the CRP, white blood count and neutrophils ratio of the two groups were compared on the first day after operation, third days after operation, and the ratio of neutrophils in the first week after operation. The sex, age, ASA classification, BMI, associated disease, previous history of abdominal surgery, preoperative biliary drainage, surgical etiological types, preoperative laboratory test indexes, pancreatic duct diameter and pancreatic texture were not statistically significant (P0.05) in the group of intestinal anastomosis group (experimental group) and the concomitant group (control group); the pancreatic duct was not statistically significant (P0.05); the pancreas of the experimental group was not significant. The time of intestinal anastomosis, the amount of bleeding in the operation, the time of eating after the operation, the time of hospitalization after the operation, the total cost of hospitalization were significantly lower than that of the control group (P0.05). The incidence of pancreatic fistula in the experimental group was significantly lower than that of the control group (P0.05); the experimental group and the control group were two groups of abdominal bleeding, abdominal pain, high fever, gastric emptying. There was no significant difference in the incidence of complications in the incision infection (P0.05). There was no significant difference between the two groups in the experimental group and the control group, and there was no significant difference in the perioperative mortality index (P0.05), the first day after the operation, the third day after the operation, the leukocyte count, the proportion of neutrophils, and the CRP stress index at one week after the operation. Compared with the control group, the difference was statistically significant (P0.05). Conclusion: the short term effect of the continuous lamellar pancreaticojejunostomy anastomosis in the jejunum mucosa in the pancreatoduodenectomy is satisfactory, but the clinical application of this anastomosis method is less, and the therapeutic effect of this method is still to be further randomized controlled trial and large case analysis. Further confirmation.
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R656

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