Hasegawa Kiyoshi, Kokudo Norihiro, Sano Keiji, Seyama Yasuji, Aoki Taku, Ikeda Mami, Hashimoto Takuya, Beck Yoshifumi, Imamura Hiroshi, Sugawara Yasuhiko, Makuuchi Masatoshi
Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
Am J Surg. 2008 Jul;196(1):3-10. doi: 10.1016/j.amjsurg.2007.05.050.
The morbidity associated with pancreatic fistula formation after pancreaticoduodenectomy (PD) still remains high. While theoretically 2-stage pancreatojejunostomy (PJ) is effective for preventing pancreatic juice enzymes from becoming activated by enteric contents, its clinical usefulness remains unknown. The aim of this retrospective study was to evaluate the short-term results of two-stage PJ in PD.
In PD cases with a narrow main pancreatic duct and/or soft texture of the pancreas, we performed 2-stage PJ; first an external tube pancreatostomy was performed, in which the tube was not passed through the jejunal loop, followed about 3 months later by second-stage reconstruction for PJ. Between 1998 and 2005, PDs with 1-stage and 2-stage PJ were performed in 53 and 99 patients, respectively, at our institution. Among the latter 99 patients, 13 (13%) also underwent concomitant right or extended right hemi-hepatectomy. In this study, the clinical records of these 152 patients were retrospectively analyzed.
After PD, a pancreatic fistula occurred in 58% of the patients undergoing 2-stage PJ; however, the fistula healed with conservative therapy in all but 2 patients who required surgical drainage for abdominal abscess. A second-stage pancreato-enteric reconstruction by PJ could be completed about 3 months after the PD in 89 of the 99 (90%) cases. Although the incidence of pancreatic fistula was 16% after the second-stage reconstruction for PJ, completion pancreatectomy was not needed in any of the cases. There were no deaths or other catastrophic events related to the procedure.
While it is difficult to completely prevent pancreatic fistula formation after PD, a 2-stage PJ appears to be effective for minimizing pancreatic juice-related adverse events, especially in high-risk patients with a narrow pancreatic duct or undergoing highly invasive surgery, such as hepato-pancreticoduodenectomy.
胰十二指肠切除术（PD）后胰瘘形成的发病率仍然很高。虽然理论上两阶段胰空肠吻合术（PJ）对于防止胰液酶被肠内容物激活是有效的，但其临床实用性仍不明确。这项回顾性研究的目的是评估两阶段PJ在PD中的短期结果。
在主胰管狭窄和/或胰腺质地柔软的PD病例中，我们实施了两阶段PJ；首先进行外引流胰管造口术，导管不穿过空肠袢，约3个月后进行第二阶段的PJ重建。1998年至2005年期间，我们机构分别对53例和99例患者进行了一期和两阶段PJ的PD手术。在后者的99例患者中，13例（13%）还同时进行了右半肝或扩大右半肝切除术。在本研究中，对这152例患者的临床记录进行了回顾性分析。
PD术后，接受两阶段PJ的患者中有58%发生了胰瘘；然而，除2例因腹腔脓肿需要手术引流的患者外，所有患者的瘘均通过保守治疗愈合。99例中的89例（90%）在PD术后约3个月可完成第二阶段的PJ胰肠重建。虽然第二阶段PJ重建后胰瘘的发生率为16%，但所有病例均无需行全胰切除术。没有与手术相关的死亡或其他灾难性事件。
虽然难以完全防止PD术后胰瘘的形成，但两阶段PJ似乎对减少胰液相关不良事件有效，特别是在胰管狭窄的高危患者或接受高侵袭性手术（如肝胰十二指肠切除术）的患者中。
