Fromm David, Schwarz Karl
Department of Surgery, Wayne State University, Detroit, MI 48201, USA.
J Am Coll Surg. 2003 Dec;197(6):943-8. doi: 10.1016/S1072-7515(03)00793-2.
The current approach to managing the distal pancreas after pancreaticoduodenectomy is to anastomose the stump to either the jejunum or stomach, but pancreatic ductal occlusion without anastomosis of the pancreatic remnant remains an option during difficult operative circumstances. This article describes some situations in which distal pancreatic ductal ligation may be of use and reviews the morbidity associated with this procedure.
Review was done of a prospectively kept database of operative and pathology reports and of both immediate and 3-month to 6-year followup data of seven patients who underwent ductal occlusion during pancreaticoduodenectomy or central pancreatectomy.
Ductal occlusion was performed in three circumstances: 1. necessity for expedient termination of the operation; 2. short jejunal mesentery allowing only a tension-free biliary or pancreatic anastomosis; and 3. massive jejunal edema that would result in a tenuous anastomosis. Two patients developed a fistula. One patient had dense residual pancreatic fibrosis, which resolved after 5 days; the other patient had a normal residual pancreas and subsequently underwent a pancreaticojejunostomy. Three patients developed acute pancreatitis (two had a normal and one had mild to moderate fibrosis in the residual pancreas) and one of these developed a peripancreatic abscess and late pseudocyst. Four patients with dense fibrosis did not develop acute pancreatitis. No patient developed either overt or worsening diabetes during the limited followup. None of the patients required enzyme supplementation, but all voluntarily maintained a low-fat diet.
The development of complications after ductal ligation appears to be associated with the degree of fibrosis of the residual distal gland. Acute pancreatitis and fistula are the major complications but are associated with a low mortality. Diabetes is a potential late problem. The morbidity associated with ductal ligation is generally accepted as being greater than anastomosis, but ligation can be considered as an alternative in difficult circumstances where anastomosis of the distal pancreatic stump is believed to be unwise.
胰十二指肠切除术后处理胰腺远端的当前方法是将残端与空肠或胃进行吻合，但在手术困难的情况下，不进行胰腺残端吻合而闭塞胰管仍是一种选择。本文描述了一些远端胰管结扎可能有用的情况，并回顾了与该手术相关的发病率。
对一个前瞻性保存的手术和病理报告数据库以及7例在胰十二指肠切除术或胰体尾切除术中接受胰管闭塞的患者的即时及3个月至6年随访数据进行了回顾。
在三种情况下进行了胰管闭塞：1. 需要迅速结束手术；2. 空肠系膜短，仅允许进行无张力的胆肠或胰肠吻合；3. 空肠重度水肿会导致吻合口脆弱。2例患者发生了瘘。1例患者有致密的胰腺残余纤维化，5天后消退；另1例患者胰腺残余正常，随后进行了胰肠吻合术。3例患者发生了急性胰腺炎（2例残余胰腺正常，1例有轻度至中度纤维化），其中1例发生了胰周脓肿和晚期假性囊肿。4例有致密纤维化的患者未发生急性胰腺炎。在有限的随访期间，没有患者发生明显的糖尿病或糖尿病病情恶化。所有患者均无需补充酶，但都自觉保持低脂饮食。
胰管结扎术后并发症的发生似乎与残余胰腺远端的纤维化程度有关。急性胰腺炎和瘘是主要并发症，但死亡率较低。糖尿病是一个潜在的晚期问题。一般认为胰管结扎相关的发病率高于吻合术，但在认为远端胰腺残端吻合不明智的困难情况下，结扎可被视为一种替代方法。
