贯穿缝合式胰肠吻合在胰十二指肠切除术中的临床应用价值

Clinical value of penetratingsuture type of pancreaticojejunostomy after pancreaticoduodenectomy

    摘要
  • 摘要: 目的:探讨贯穿缝合式胰肠吻合(PPJ)在胰十二指肠切除术中的临床应用价值。
    方法:
    回顾性分析2002年6月至2012年3月江苏省泰兴市人民医院收治的77例行根治性胰十二指肠切除术患者的临床资料。34例采用PPJ者为研究组；43例根据胰腺的质地、大小，胰管的粗细选择不同的胰肠吻合方法者(胰管直径≥4 mm，选用胰管黏膜吻合；胰腺切断≤3 mm选用胰肠端端套入式或捆绑式胰肠吻合)为对照组。术后胰瘘的诊断参照国际胰瘘研究小组(ISGPF)的诊断与分级标准进行诊断，有临床意义的胰瘘为 B级和C级胰瘘。采用门诊和电话随访，随访时间截至2012年5月。计量资料符合正态分布数据用 ±s表示，采用t检验；不符合正态分布用M (范围) 表示，统计采用Wilcoxon秩和检验。 计数资料用χ 2检 验或Fisher确切概率法。
    结果:研究组患者均在术中找到胰管，研究组和对照组胰管平均直径均为3 mm。研究组无胰管外引流，对照组为4例，两组比较，差异有统计学意义( χ=3.632，P <0.05)；研究组胰肠吻合时间为12 min(8～25 min)，对照组记录不详。研究组和对照组的手术时间均为(304±60)min，术中出血量分别为(475±75)mL和(500±97)mL，术中输血例数分别为24例(70.6%)和29例(67.4%)，术中中位输血量分别为400 mL(300～800 mL)和600 mL(300～1 200 mL)，术后中位住院时间分别为18 d(11～ 32 d)和20 d(9～44 d)，两组患者手术治疗情况比较，差异无统计学意义( t=1.293，0.619，χ=0.088，Z=0.165，0.074，P >0.05)。研究组和对照组患者B、C级胰瘘(均为胰肠吻合口瘘)发生率分别为0和27.9% (12/43)，胰瘘相关病死率分别为0和11.6%(5/43)，两组比较，差异有统计学意义( χ=11.232，4.237， P <0.05)。研究组和对照组患者术后胆汁漏、腹腔出血、胃排空延迟障碍的发生率分别为5.9%(2/34)、2.9%(1/34)、5.9%(2/34)和11.6%(5/43)、7.0%(3/43)、14.0%(6/43)，两组比较，差异无统计学意义( P >0.05)。两组共56例患者获得门诊随访，随访时间为术后9个月至5年。研究组26例患者经影像学检查未见胰管明显扩张。对照组30例患者出现不同程度的胰管扩张。
    结论:PPJ简单、可靠，在胰十二指肠切除术中应用疗效较好。

     

    Abstract: Objective:To investigate the clinical value of penetrating suture type pancreaticojejunostomy (PPJ) after pancreaticoduodenectomy (PD).
    Methods: The clinical data of 77 patients who received pancreatico duodenectomy from Taixing People′s Hospital from June 2002 to March 2012 were retrospectively analyzed. Of all the patients, 34 received PPJ after PD (PPJ group), and the other 43 patients received PJ anastomosis (control group) based on the texture and size of the pancreas, pancreatic duct diameter (duct to mucosa pancreaticojejunostomy for pancreatic duct diameter≥ 4 mm, end to end or binding pancreaticojejunostomy for pancreatic duct diameter ≤3 mm). Pancreatic fistula was diagnosed according to the criteria of the International Study Group on Pancreatic Fistula, including grade B or C pancreatic fistula with clinical value. Patients were followed up through outpatient examination and telephone interview till May 2012. Data were presented by 〖AKx-D〗 ±s or median (range) and the t test and Wilcoxon rank sum test were used to evaluate quantitative data with or without normal distribution, respectively. Qualitative data were analyzed using Pearson χ 2  test or Fisher′s exact test.
    Results:The mean diameter of the pancreatic duct was 3 mm for both the PPJ group and the control group. The external drainage via the pancreatic duct stent was not used in the PPJ group, compared with 4 cases in the control group, showing a statistically significant difference between the 2 groups ( χ 2 =3.632, P<0.05). The duration of pancreaticojejunostomy was 12 minutes (range, 8 25 minutes) in the PPJ group, while no records in the control group. The operation time and intraoperative blood loss in the PPJ group and the control group were (304±60)minutes and (475±75)mL, (304±60)minutes and (500±97)mL, respectively. Twenty four (70.6%) patients in the PPJ group and 29 (67.4%) patients in the control group received intraoperative blood transfusion, with volume of 400 mL (range, 300 800 mL) and 600 mL (range, 300 1 200 mL), respectively. The median duration of postoperative hospital stay were 18 days (range, 11 32 days) in the PPJ group and 20 days (range, 9 44 days) in the control group. None of these comparisons were statistically significant between the 2 groups ( t=1.293,  0.619, χ 2 =0.088,  Z=0.165, 0.074, P>0.05). The rate of grade B or C pancreatic fistula were 0 for the PPJ group and 27.9% (12/43) for the control group, and the mortality rate of patients who had pancreatic fistula were 0 and 11.6%(5/43) for the PPJ group and the control group, with statistical significance ( χ 2 =11.232, 4.237, P<0.05). The overall incidence of bile leakage, peritoneal bleeding and delayed gastric emptying in the PPJ group and the control group were 5.9%(2/34), 2.9%(1/34), 5.9%(2/34) and 11.6%(5/43), 7.0%(3/43), 14.0%(6/43), with no significance difference ( P>0.05). Fifty six patients were followed up after operation from 9 months to 5 years. Pancreatic duct dilation was detected by imaging examination for 26 patients in the control group.
    Conclusion:PPJ is a simple and feasible approach with better clinical efficacy after PD.

     

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