Braun吻合在胰十二指肠切除术中的应用价值

张波; 许文彦; 刘文生; 项金峰; 徐近; 虞先濬

doi:10.3760/cma.j.issn.1673-9752.2017.10.009

Braun吻合在胰十二指肠切除术中的应用价值

Application value of Braun anastomosis in pancreaticoduodenectomy

摘要

摘要: 目的:探讨Braun吻合方式在胰十二指肠切除术中的应用价值。
方法:采用回顾性队列研究方法。收集2012年3月至2014年7月复旦大学附属肿瘤医院收治的389例行胰十二指肠切除术患者的临床病理资料。389例患者中，235例行空肠空肠Braun吻合，设为Braun吻合组；154例未行空肠空肠Braun吻合，设为非Braun吻合组。患者均行开腹胰十二指肠切除术，术中消化道重建采用Child重建方法。Braun吻合组患者空肠输入段与输出段之间加行5～10 cm Braun吻合。非Braun吻合组患者在胃空肠吻合后，不再行空肠空肠Braun吻合。观察指标：(1)术中情况。(2)术后恢复情况。(3)随访情况。采用门诊和电话方式进行随访，随访内容为每个月复查血常规，肝肾功能，大小便常规，每3个月复查腹上区增强CT，检测其消化道功能恢复情况。随访时间截至2015年5月。正态分布的计量资料以±s表示，两组比较采用t检验；计数资料比较采用x²检验。
结果:(1)术中情况：389例患者均成功施行胰十二指肠切除术。Braun吻合组患者行标准的胰十二指肠切除术以及保留幽门的胰十二指肠切除术分别为205例和 30例；非 Braun吻合组分别为137例和17例，两组比较，差异无统计学意义(x²=0.259，P>0.05)。Braun吻合组和非 Braun吻合组患者胰腺残端吻合重建方式：主胰管空肠黏膜吻合分别为138、85例，乳头样主胰管嵌入式吻合分别为89、60例，胰胃吻合分别为8、9例，两组比较，差异无统计学意义(x²=1.535，P>0.05)。Braun吻合组和非Braun吻合组患者总体手术时间、胰腺空肠吻合时间、术中出血量分别为(398.9±61.9)min和(401.3±59.2)min、(20.6±3.5)min和(20.7±2.1)min、(401±59)mL和(407±159)mL，两组患者上述指标比较，差异均无统计学意义(t=-0.380，-0.562，-0.319，P>0.05)。(2)术后恢复情况：Braun吻合组和非Braun吻合组患者术后肛门首次排气时间分别为(103±28)h和(102±31)h，术后首次进食流质食物时间分别为(77±25)h和 (79±30)h，术后引流管拔除时间分别为(12±5)d和(13±6)d，两组患者上述指标比较，差异均无统计学意义(t=0.330，-0.712，-1.783，P>0.05)。Braun吻合组和非 Braun吻合组患者术后发生胃排空障碍为25、27例，消化道出血为3、4例，输入襻梗阻为0、2例，胰瘘为30、23例，两组患者上述指标比较，差异均无统计学意义(x²=3.818，0.918，3.068，0.695，P>0.05)。17例患者同时合并胃排空障碍和胰瘘，Braun吻合组和非Braun组分别为8例和9例，两组比较，差异无统计学意义(x²=1.363，P>0.05)。术后发生并发症患者经对症、支持治疗后好转。Braun吻合组和非 Braun吻合组患者术后住院时间分别为(14±7)d和(22±11)d，治疗费用分别为(73 205±4 538)元和(83 219±5 738)元，两组患者上述指标比较，差异均有统计学意义(t=-8.767，-19.139，P<0.05)。(3)随访情况：389例患者均获得术后 6个月的随访，随访期间Braun吻合组和非Braun组患者均无死亡。Braun组和非Braun组分别有6例和 9例患者发生反流性胆管炎，两组患者均未出现消化道出血，无消化道梗阻再次入院患者，无高血糖、顽固性腹泻等症状发生。
结论: Braun吻合能够缩短胰十二指肠切除术后住院时间，降低治疗费用。

Abstract: Objective:To investigate the application value of Braun anastomosis in pancreaticoduodenectomy.
Methods:The retrospective cohort study was conducted. The clinicopathological data of 389 patients who underwent pancreaticoduodenectomy in the Fudan University Shanghai Cancer Center from March 2012 to July 2014 were collected. Of 389 patients, 235 receiving Braun anastomosis and 154 receiving nonBraun anastomosis were respectively allocated into Braun anastomosis group and nonBraun anastomosis group. All the patients underwent pancreaticoduodenectomy with digestive tract reconstruction using Child method. Patients in the Braun anastomosis group received 5-10 cm Braun anastomosis between input and output end of jejunum, and patients in the nonBraun anastomosis group didn′t receive jejunumjejunum Braun anastomosis after gastrojejunostomy. Observation indicators included: (1) intraoperative situations; (2) postoperative recovery; (3) followup. Patients were followed up using outpatient examination and telephone interview up to May 2015. Followup included monthly routine blood retest, hepatorenal function retest and urine and stool routine retest, and enhanced CT scan in the epigastric region for every three months to detect recovery of digestive tract function. Measurement data with normal distribution were represented as ±s. Comparison between groups was analyzed using t test, and count data were analyzed using chisquare test.
Results:(1) Intraoperative situations: 389 patients underwent successful pancreaticoduodenectomy. Standard pancreaticoduodenectomy and pyloricpreserving pancreaticoduodenectomy were respectively applied to 205 and 30 patients in the Braun anastomosis group and 137 and 17 patients in the nonBraun anastomosis group, with no statistically significant difference (x²=0.259, P>0.05). Anastomosis and reconstruction of pancreatic stump: anastomosis of main pancreatic duct and jejunal mucosa, embedded anastomosis of papillary main pancreatic duct and pancreasstomach anastomosis were detected in 138, 89, 8 patients in the Braun anastomosis group and 85, 60, 9 patients in the nonBraun anastomosis group, respectively, with no statistically significant difference (x²=1.535, P>0.05). Total operation time, pancreasjejunum anastomosis time and volume of intraoperative blood loss were (398.9±61.9)minutes, (20.6± 3.5)minutes, (401±59)mL in the Braun anastomosis group and (401.3±59.2)minutes, (20.7±2.1)minutes, (407±159)mL in the nonBraun anastomosis group, respectively, with no statistically significant difference (t= -0.380,-0.562,-0.319, P>0.05). (2) Postoperative recovery: time to initial anal exsufflation, time for fluid diet intake and time of drainage tube removal were (103±28)hours, (77±25)hours, (12±5)days in the Braun anastomosis group and (102±31)hours, (79±30)hours, (13±6)days in the nonBraun anastomosis group, respectively, with no statistically significant difference (t=0.330,-0.712,-1.783, P>0.05). Delayed gastric emptying, gastrointestinal hemorrhage, obstruction of afferent loop and pancreatic fistula were detected in 25, 3, 0, 30 patients in the Braun anastomosis group and 27, 4, 2, 23 patients in the nonBraun anastomosis group, respectively, with no statistically significant difference (x²=3.818, 0.918, 3.068, 0.695, P>0.05). Seventeen patients were combined with delayed gastric emptying and pancreatic fistula, including 8 in the Braun anastomosis group and 9 in the nonBraun anastomosis group, with no statistically significant difference between the 2 groups (x²=1.363, P>0.05). Patients with postoperative complications were improved by symptomatic and supporting treatment. Duration of hospital stay and treatment expenses were (14±7)days, (73 205±4 538)yuan in the Braun anastomosis group and (22±11)days, (83 219±5 738)yuan in the nonBraun anastomosis group, with statistically significant differences between the 2 groups (t=-8.767,-19.139, P<0.05). (3) Followup: 389 patients were followed up for 6 months, without death. Six and 9 patients in the Braun anastomosis group and nonBraun anastomosis group had regurgitation cholangitis. There was no readmission due to gastrointestinal hemorrhage and digestive tract obstruction, and no signs of hyperglycaemia and intractable diarrhea occurred.
Conclusion:Braun anastomosis can reduce duration of postoperative hospital stay and treatment expenses.

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