胰头部动脉优先离断在根治性胰十二指肠切除术中的运用
Application of total arteries devascularization first technique in radical pancreaticoduodenectomy
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摘要:
目的：探讨胰头部动脉优先离断在肠系膜上静脉或门静脉受侵犯的胰头部恶性肿瘤行根治性胰十二指肠切除术中的运用价值。
方法：回顾性分析2012年1月至2013年5月华中科技大学同济医学院附属同济医院完成的58例胰头部恶性肿瘤行根治性胰十二指肠切除术患者的临床资料。58例患者术前薄层CT检查均显示肠系膜上静脉或门静脉受侵犯或受压，均行胰头部动脉优先离断的根治性胰十二指肠切除术，即在处理胰头部静脉血管之前优先离断胰头部的所有动脉供血，即三大动脉血管的分支，主要步骤包括：在十二指肠水平部或横结肠系膜根部暴露和悬吊肠系膜上动、静脉；解剖肝总动脉从而离断胃十二指肠动脉和胃右动脉，同时沿肝总动脉根部解剖腹腔动脉干上方；离断胰腺和脾动脉的胰头分支；沿暴露的肠系膜上动脉前方、右侧和后方解剖，完全离断胰头钩突部与肠系膜上动脉和腹腔动脉干间的神经结缔组织，与腹腔动脉干的上方贯通，此时可清楚地显示腹主动脉前方；最后通过预置的静脉血管阻断带安全剥离、切除或重建肠系膜上静脉或门静脉，完整切除肿瘤。
结果：术前影像学检查判断局部肿瘤可切除患者37例，可能切除患者21例。58例患者均顺利施行胰头部动脉优先离断的根治性胰十二指肠切除术，手术时间为4.5～8.1 h，术中出血量为200～900 mL，术中及术后胰腺钩突部无出血。行肠系膜上静脉侧壁部分切除修补术21例，肠系膜上静脉受累段切除端端吻合术10例，血管受压迫成功将肿瘤从血管上剥离行标准的胰十二指肠切除术27例。术后患者出血、胰液漏和胆汁漏的发生率分别为 5.2%(3/58)、6.9%(4/58)和1.7%(1/58)。围手术期无患者死亡。
结论：胰头部动脉优先离断方式能保障肠系膜上静脉或门静脉受侵犯或受压的胰头部恶性肿瘤行根治性胰十二指肠切除术的安全性，减少术中出血。Abstract:Objective:To investigate the value of total arteries devascularization first technique in radical pancreaticoduodenectomy.
Methods:The clinical data of 58 patients with malignant pancreatic head cancer who received pancreaticoduodenectomy at the Tongji Hospital from January 2012 to May 2013 were retrospectively analyzed. The results of preoperative thin-slice computed tomography scanning indicated that the portal vein and superior mesenteric vein were invaded by the tumor. During the operation, 3 arterial blood supplies of the head of the pancreas were obstructed before devascularization of vein in the head of pancreas. The key steps of the technique were: (1) The superior mesenteric artery and vein were dissected at lower parts of the duodenal mesenterium. (2) The common hepatic arteries were dissected to cut the right gastric artery and the gastroduodenal artery. (3) Dissecting the celiac trunk and transecting the branches of splenic artery in the head of the pancreas. (4) Neural and connective tissues between the superior mesenteric artery and the uncinate process of the pancreas were dissected, and then the anterior surface of the abdominal aorta was excellently exposed. (5) The superior mesenteric vein or portal vein were dissected or rebuilt with the help of presetting vascular blocking bands, and then the tumor was en-bloc resected.
Results:The operation time was 4.5-900 mL. No bleeding of the uncinate process of the pancreas was detected. Twenty-one patients underwent lateral vessel angiectomy or angiorrhaphy, 10 received resection of the superior mesenteric vein which was invaded by the tumor and end-to-end anastomosis, and 27 received detachment of tumor from the blood vessel and pancreatoduodenectomy. The incidences of hemorrhage, pancreatic fistula and biliary fistula were 6.9%(4/58) and 1.7%(1/58). No patient died perioperatively.
Conclusion:Total arteries devascularization first technique could improve the safety and reduce intraoperative bleeding in radical pancreaticoduodenectomy. -
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