目的探讨保留幽门的胰十二指肠切除术(PPPD)的手术适应证、捆绑式胰肠吻合术的特点及胃排空障碍的治疗。方法12例均行PPPD，消化道重建按Child法，胰肠吻合均采用捆绑式胰肠吻合。结果除1例术后第21天并发切口裂开、肺栓塞死亡外，其余11例均顺利出院，平均住院时间24 d，随访1年，1例术后8个月死亡，余均健在。结论PPPD是治疗胰头癌及壶腹周围癌的一种具有广阔应用前景的术式，捆绑式胰肠吻合有望作为胰肠吻合的标准术式。
Objective To explore the clinical value of preoperative neoadjuvant chemotherapy (NAC) combined with laparoscopic pancreatoduodenectomy (LPD) with multiple surgical approaches in the treatment of borderline resectable pancreatic head cancer. Methods The clinicopathologic data of 35 patients with critical resectable pancreatic head carcinoma admitted to the Department of Hepatobiliary and Pancreatic Surgery of Luoyang Central Hospital Affiliated to Zhengzhou University and the Department of Hepatobiliary and Pancreatic Surgery of the Fifth Affiliated Hospital of Zhengzhou University from January 2017 to June 2022 were retrospectively analyzed. All patients received NAC before operation (AG protocol). At the end of the course of treatment, according to the type of borderline resectable pancreatic cancer (BRPC) [venous invasion type (BRPC-V type) and arterial invasion type (BRPC-A type)], take the individualized surgical approach for LPD (BRPC-V type: inferior mesenteric vein approach; BRPC-A type: left posterior approach, medial uncinate process approach, anterior approach, or lower mesocolon approach). The intraoperative condition, R0/R1 resection rate, lymph node dissection, postoperative complications, average hospital stay, recovery, follow-up and survival were recorded. Results① Efficacy evaluation of NAC: 13 patients were partially relieved , 17 patients were stable and 5 patients were progressive after 4 weeks of treatment. Five progressive patients continued to receive comprehensive internal medicine treatment, and the remaining 30 patients underwent LPD. ② Intraoperative situation: LPD were successfully completed in 30 patients, 2 patients underwent extended pancreaticoduodenectomy combined with superior mesenteric vein (or) portal vein reconstruction among them. Among the 30 patients with LPD, there were 10 cases of inferior mesenteric vein approach, 10 cases of left posterior approach, 6 cases of medial uncinate process approach, 1 case of left posterior approach+medial uncinate process approach, 2 cases of anterior approach, and 1 case of inferior mesocolon approach. The mean operative time was (379.4±77.3) min, the intraoperative blood loss was (436.9±95.1) mL. ③ Postoperative situation: The incidence rate of postoperative surgery-related complications was 33.3% (10/30), including 4 cases of Clavien-Dindo grade Ⅰ [biliary fistula in 1 case (3.3%), A-grade pancreatic fistula in 1 case (3.3%), gastric draining dysfunction in 1 case (3.3%), diarrhea in 1 case (3.3%)], 5 cases of grade Ⅱ [pulmonary infection in 2 cases (6.6%), B-grade pancreatic fistula in 2 cases (6.6%), abdominal infection in 1 case (3.3%)], and 1 case of grade Ⅲ [gastroduodenal artery stump bleeding (3.3%)]. Among the 10 patients with complications, 9 cases recovered after symptomatic treatment, and 1 case died, with a fatality rate of 3.3% (1/30). The mean postoperative hospital stay was (17.3±5.5) days. ④ Excision rate and pathological results: R0 resection rate was 90.0% (9/10) in 10 patients with BR-PV type LPD, and R1 resection was performed in 1 patient. R0 resection rate was 75.0% (15/20) in 20 patients with BR-A type, and R1 resection was performed in 5 patients (2 patients with medial uncinate process approach; Left posterior approach in 2 cases; Submesocolon approach was used in 1 case). In 30 patients with LPD, the total R0 removal rate was 80.0% (24/30), the number of lymph nodes dissected was (11±5). Pathological type: There were 26 cases (86.7%) of ductal adenocarcinoma in 30 patients, 1 case of adeno-squamous carcinoma (3.3%), 1 case of mucinous carcinoma (3.3%), 2 cases of acinocytic cell carcinoma (6.7%). 23 cases (76.7%) of medium-high differentiation and 5 cases (16.6%) of low differentiation, two cases (6.7%) were undifferentiated. ⑤ Postoperative follow-up and survival: 30 patients were completely followed-up for 6-39 months, with a median follow-up time of 17 months. The median survival time of BRPC-V and BRPC-A patients was 24.0 months and 17.0 months, respectively. The overall survival rates of 30 patients at 1, 2 and 3 years after operation were 77.3%、46.5% and 13.7%, respectively. Conclusion The selection of preoperative NAC combined with individualized surgical approach for patients with borderline resectable pancreatic head cancer is beneficial to improve the radical resection rate and clinical therapeutic effect, and has good clinical application value.
目的 探讨捆绑式胰肠吻合术的改良方法。方法 对8例胰十二指肠切除术患者行捆绑式胰肠吻合术时采用带血管蒂的大网膜包绕空肠浆肌鞘，以达捆绑之目的。8例中行桥袢空肠造瘘5例，胆总管造口T管引流3例，并观察其术后5 d内每天平均引流液量。结果 8例患者均治愈出院，无胰瘘、胆瘘发生； 5 d内每天平均引流液量除第1天胆总管造口低于空肠造瘘外，其余4 d每天平均引流液量均明显高于空肠造瘘； 1例空肠造瘘者术后第8天继发胰腺残端出血，经电灼后止血。结论 带血管蒂的大网膜包绕空肠浆肌鞘完全可以代替粗线环绕空肠结扎，并使整个空肠浆肌鞘与胰腺紧贴，更利于胰肠间愈合； 空肠造瘘或胆总管造口对桥袢空肠均有减压引流的作用，但T管引流更简单、有效、省时。
目的 探讨胰十二指肠切除术胰与消化道重建方法的选择。方法 对我院1989～1999年施行的胰十二指肠切除术后胰胃吻合83例行回顾性总结，其中行经典的胰十二指肠切除术76例，保留幽门的胰十二指肠切除术7例。胰胃吻合是残余胰腺与胃后壁间断单层植入式吻合。结果 住院病死率为2.4%（2/83）； 并发症发生率为25.3%（21/83），其中胰瘘3例，胆瘘2例，吻合口出血3例，切口裂开5例，胃排空迟缓5例，腹腔感染1例，胸腔积液1例，肠梗阻1例。结论 胰胃吻合术简便、安全，是降低术后胰瘘的胰肠重建方法。
ObjectiveTo compare the short- and long-term efficacy of artery-first approach pancreatico-duodenectomy (AF-PD) and standard approach pancreaticoduodenectomy (S-PD).MethodsThe PubMed, EMbase, The Cochrane Library, Web of Science, CBM, WanFang, and CNKI databases were searched, relevant literatures were included, and relevant data were extracted for meta-analysis.ResultsA total of 30 articles were included, including 2 750 cases underwent pancreaticoduodenectomy. The results of meta-analysis showed that in terms of short-term efficacy when compared with S-PD group, the AF-PD group had less intraoperative blood loss (WMD=–175.87, P<0.001), lower intraoperative blood transfusion rate (OR=0.36, P=0.002), higher R0 resection rate (OR=1.83, P<0.001), lower postoperative pancreatic leakage rate (OR=0.71, P=0.005), and shorter postoperative hospital stay (WMD=–2.69, P=0.007). However, there were no statistically significant differences in the operation time and overall postoperative complication rate between the two groups (P>0.05). In terms of long-term efficacy when compared with S-PD group, the AF-PD group had lower tumor local recurrence rate (OR=0.43, P=0.004) and tumor liver metastasis rate (OR=0.60, P=0.010), but had higher 1-year (OR=1.95, P=0.007), 2-year (OR=2.04, P<0.001), 3-year (OR=2.09, P=0.001), and 5-year (OR=2.06, P=0.003) overall survival rates, and there were no significant differences in the rates of lung metastasis and peritoneal metastasis between the two groups (P>0.05).ConclusionsAF-PD is better than S-PD in some short-term and long-term outcome indicators such as R0 resection rate, pancreatic leakage rate, overall survival rate, and so on. However, due to the limited quality of the included literatures, more high-quality studies are still needed to verify in the future.
ObjectiveTo investigate the advantage of superior mesenteric artery approach in laparoscopic pancreaticoduodenectomy (LPD) combined with superior mesenteric vein (SMV)-portal vein (PV) resection and reconstruction. MethodThe operation process of a pancreatic head cancer patient with SMV-PV invasion admitted to the Second Affiliated Hospital of Chongqing Medical University in April 2022 was summarized. ResultsThe resection and reconstruction of SMV-PV during the LPD through the right posterior approach and anterior approach of superior mesenteric artery was completed successfully. The operation time was 7.5 h, the intraoperative blood loss was 200 mL, and the SMV-PV resection and reconstruction time was 20 min. The patient was discharged with a better health condition on the 9th day after operation. ConclusionFrom the operation process of this patient, the arterial priority approache is a safe and effective approach in the resection and reconstruction of SMV-PV during the LPD.
目的探讨保留幽门胰胃吻合式胰十二指肠切除术的临床应用价值。方法对36例壶腹周围癌患者在证实胃幽门、幽门上、下淋巴结及十二指肠球部未受侵犯的情况下，施行保留幽门胰胃吻合的胰十二指肠切除术，术后观察治疗效果，并进行随访。结果本组无手术死亡、胆胰瘘、出血等并发症发生。5例术后短期内有胃排空延迟症状，经处理后缓解，无吻合口溃疡和胆道返流症状。1、3、5年累计生存率分别为61.1%、25.0%和13.9%。结论本术式可降低胰十二指肠切除术的死亡率和并发症，1、3、5年生存率与Whipple手术相比无差异。
目的 研究胰腺-胃吻合术在胰十二指肠切除术消化道重建中的合理性。方法 对2002年3月至2004年10月期间实施胰十二指肠切除和胰腺-胃吻合术重建消化道的24例壶腹周围癌患者的临床资料进行回顾性分析。结果 所有患者均顺利完成胰腺-胃吻合手术，胰瘘的发生率为8.3%（2/24），通过保守治疗均痊愈。结论 胰腺-胃吻合术是胰十二指肠切除术后一种安全的消化道重建方法。
Forty-five pancreatoduodenectomies had been performed in our hospital from 1981 to 1994, of which 35 cases were diagnosed as carcinomas of Vater’s ampulla or pancreatic head, and 10 (cases) as benign lesions. Through analysis of misdiagnosed cases, the authors emphasize that it is important to take correct history of jaundiced patients in detail according to the character of the jaundice and associated symptoms before any operation done. Secondly, all clinical materials must be thoroughly collected and special examinations for diagnosis should be chosen scientifically to avoid relying only on one sort of examination result as diagnostic standard. Thirdly, during operation the area of pancreatic head should be explored carefully and any lesions in doubt should be examined pathologically by puncture biopsy and frozen section to avoid misdiagnosis and thus performing pancreatoduodenectomy.