Pryor A, Means J R, Pappas T N
Department of Surgery, Duke University Medical Center, 3116 North Duke Street, Durham, NC, USA.
Surg Endosc. 2007 Dec;21(12):2326-30. doi: 10.1007/s00464-007-9403-9. Epub 2007 Jun 26.
The technique of distal pancreatectomy has been well described, both with en bloc resection of the spleen and with splenic preservation. Splenic preservation during pancreatic tail resection is desirable when oncologically appropriate, yet it is technically challenging, particularly with laparoscopic approaches. Skeletonization of the splenic artery and vein is associated with longer operative times and greater potential for bleeding. The authors report their experience with splenic preservation during laparoscopic pancreatic resection using ligation of the splenic vessels and preservation of the short gastric vessels.
A retrospective chart review was performed for all patients who underwent attempted laparoscopic pancreatic resection at Duke University Medical Center from July 2002 to October 2005. Charts were analyzed for demographic information, length of hospital stay, conversion, splenic preservation, and postoperative complications.
A total of 12 laparoscopic distal pancreatic resections were attempted for three men and nine women with a mean age was 55.8 years (range, 33-74 years). All 12 patients underwent distal pancreatectomy, 8 with splenic preservation. The spleen was removed from three patients using splenic hilar lesions that prevented splenic salvage. One patient required splenectomy secondary to more than 50% ischemia of the spleen. No patients with preoperatively diagnosed malignancy underwent splenic salvage. The final pathologic diagnosis included neuroendocrine tumors (n = 2), cystic serous (n = 4) and mucinous (n = 2) neoplasms, intraductal papillary mucinous neoplasm (IPMN) (n = 1), pancreatitis (n = 2), and adenocarcinoma (n = 1). Two patients underwent conversion to open surgery for thickened parenchyma secondary to chronic pancreatitis (17%). There were no other conversions. There were three chemical leaks (25%) diagnosed by elevated drain amylase and low volume output, which were managed with intraoperatively placed drains removed at the initial postoperative clinic visit. There were three higher volume leaks (25%) that required extended or percutaneous drainage, with eventual removal. The average blood loss was 215 ml (range, 50-700 ml). The average operative time was 3 h and 41 min (range, 2 h 15 min to 5 h 58 min). The average length of hospital stay was 4 days (range, 2-7 days).
Splenic preservation should be performed when technically possible to decrease the morbidity of laparoscopic distal pancreatectomy. The choice to ligate the splenic vessels allows for shorter operative times with minimal perioperative morbidity and blood loss while maintaining the spleen.
胰体尾切除术技术已得到充分描述，包括整块切除脾脏和保留脾脏两种方式。在肿瘤学上合适的情况下，胰尾切除术中保留脾脏是可取的，但这在技术上具有挑战性，尤其是采用腹腔镜手术时。脾动静脉骨骼化与手术时间延长及出血风险增加相关。作者报告了他们在腹腔镜胰腺切除术中采用结扎脾血管并保留胃短血管来保留脾脏的经验。
对2002年7月至2005年10月在杜克大学医学中心尝试进行腹腔镜胰腺切除术的所有患者进行回顾性病历审查。分析病历以获取人口统计学信息、住院时间、中转情况、脾脏保留情况及术后并发症。
共对3名男性和9名女性尝试进行了12例腹腔镜胰体尾切除术，平均年龄为55.8岁（范围33 - 74岁）。所有12例患者均接受了胰体尾切除术，其中8例保留了脾脏。3例患者因脾门病变无法保留脾脏而切除了脾脏。1例患者因脾脏缺血超过50%而需要行脾切除术。术前诊断为恶性肿瘤的患者均未保留脾脏。最终病理诊断包括神经内分泌肿瘤（n = 2）、囊性浆液性（n = 4）和黏液性（n = 2）肿瘤、导管内乳头状黏液性肿瘤（IPMN）（n = 1）、胰腺炎（n = 2）和腺癌（n = 1）。2例患者因慢性胰腺炎导致实质增厚而中转开腹手术（17%）。无其他中转情况。通过引流液淀粉酶升高和引流量少诊断出3例化学性渗漏（25%），在术后首次门诊就诊时拔除术中放置的引流管进行处理。有3例高流量渗漏（25%）需要延长或经皮引流，最终拔除引流管。平均失血量为215 ml（范围50 - 700 ml）。平均手术时间为3小时41分钟（范围2小时15分钟至5小时58分钟）。平均住院时间为4天（范围2 - 7天）。
在技术可行时应进行脾脏保留，以降低腹腔镜胰体尾切除术的发病率。结扎脾血管的选择可缩短手术时间，围手术期发病率和失血量最小，同时保留脾脏。
