Metreveli Ramaz E, Sahm Katherine, Abdel-Misih Raafat, Petrelli Nicholas J
Department of Surgery Christiana Care Health Services, Helen F. Graham Cancer Center, Newark, Delaware, USA.
J Surg Oncol. 2007 Mar 1;95(3):201-6. doi: 10.1002/jso.20662.
The literature reports 4-10% mortality rate, 30-60% morbidity rate, and 9-29% anastomotic leak rate after pancreaticoduodenectomy (PD) performed for periampullary tumors. These data demonstrate a linear relationship between surgical volume and outcome.
The objective of this study was to evaluate the experience of a high-volume hospital with low-volume pancreatoduodenectomy for suspected cancer. The study was designed as a retrospective review of medical records of all patients who underwent pancreatoduodenal resection or total pancreatectomy for a suspected periampullary carcinoma between January 1994 and December 2003. The setting of the study was a community-based teaching hospital with a general surgery residency training program.
A total of 63 patients underwent pancreatoduodenal resection or total pancreatectomy. All procedures were performed by a total of 15 different surgeons; however, 27 operations were performed by one surgeon. Pre-operative diagnosis in most cases was either a known malignancy-27 cases (43%) or a tumor of the head of the pancreas, suspicious for malignancy-36 cases (57%). One patient underwent a total pancreatectomy. In 62 patients a pancreatoduodenal resection (Whipple procedure) was performed. Post-operative 30-day mortality was 4.7% (three patients). Overall in-hospital mortality was 9.5% (six patients). Ten (16.1%) had a leak of the pancreato-jejunal anastomosis, six of which resolved with non-operative management. Of the remaining four patients, three died from peritonitis or consequences of erosive hemorrhage.
Post-operative leak of the pancreatic anastomosis represents a technical challenge. Although most of the leaks can be treated non-operatively, those that lead to peritonitis or erosive hemorrhage warrant operative intervention. Major pancreatic resections can be performed safely with low rates of morbidity and operative mortality with careful selection of patients at a low-volume community-based teaching hospital.
文献报道，针对壶腹周围肿瘤行胰十二指肠切除术（PD）后，死亡率为4%-10%，发病率为30%-60%，吻合口漏发生率为9%-29%。这些数据表明手术量与手术结果之间存在线性关系。
本研究的目的是评估一家高容量医院开展低容量疑似癌症胰十二指肠切除术的经验。本研究设计为对1994年1月至2003年12月期间因疑似壶腹周围癌接受胰十二指肠切除术或全胰切除术的所有患者的病历进行回顾性分析。研究地点为一家设有普通外科住院医师培训项目的社区教学医院。
共有63例患者接受了胰十二指肠切除术或全胰切除术。所有手术由15位不同的外科医生完成；然而，其中27例手术由一位外科医生完成。大多数病例的术前诊断为已知恶性肿瘤——27例（43%），或胰腺头部肿瘤，怀疑为恶性肿瘤——36例（57%）。1例患者接受了全胰切除术。62例患者接受了胰十二指肠切除术（惠普尔手术）。术后30天死亡率为4.7%（3例患者）。总体院内死亡率为9.5%（6例患者）。10例（16.1%）出现胰肠吻合口漏，其中6例通过非手术治疗得以解决。其余4例患者中，3例死于腹膜炎或糜烂性出血的后果。
胰腺吻合口术后漏是一项技术挑战。虽然大多数漏口可通过非手术治疗，但那些导致腹膜炎或糜烂性出血的漏口需要手术干预。在低容量的社区教学医院，通过仔细选择患者，可安全地进行大型胰腺切除术，发病率和手术死亡率较低。
