指导在急性或慢性胰腺炎后行分离式左胰残端（DLPR）手术时的临床决策框架。

Clinical framework to guide operative decision making in disconnected left pancreatic remnant (DLPR) following acute or chronic pancreatitis.

机构信息

Departments of Surgery and Radiology, Indiana University School of Medicine, Indianapolis, IN, USA.

出版信息

Surgery. 2010 Oct;148(4):847-56; discussion 856-7. doi: 10.1016/j.surg.2010.07.039. Epub 2010 Aug 24.

DOI:10.1016/j.surg.2010.07.039

PMID:20797747

Abstract

BACKGROUND

Disconnected left pancreatic remnant (DLPR) presents clinically as a pancreatic fistula, pseudocyst, or obstructive pancreatitis. Optimal operative treatment, either distal pancreatectomy (DP) or internal drainage (ID), remains unknown. This paper critically evaluates our operative experience in patients with DLPR.

METHODS

A retrospective analysis of a consecutive case series from a single, high-volume institution was carried out. A total of 76 patients with radiographic-confirmed DLPR (computed tomography + endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography) who had operations between November 1995 and September 2008 were included. Pancreas preservation (the use of ID) was our default unless anatomic, physiologic, or technical factors precluded it. Follow-up to July 2009 was done (median follow-up, 22 months). Standard statistical methodology was used (P < .05 = statistical significance).

RESULTS

The mean age of this cohort was 52 years (range, 18-85); 57% of the patients were male. A total of 59 (73%) had acute pancreatitis, whereas 17 (22%) had chronic pancreatitis. Presentation was pseudocyst in 53%, pancreatic fistula in 34%, and obstructive pancreatitis in 13%. Resection (DP) and drainage (ID) options were utilized equally for each clinical presentation as follows: pseudocyst, 60/40; pancreatic fistula, 50/50; or obstructive pancreatitis, 50/50. The strongest driver for DP (92%) was a small pancreatic remnant and splenic vein thrombosis. In contrast, large pancreatic remnants had ID 70% of the time. No differences in short- or long-term outcomes between DP or ID options were identified.

CONCLUSION

Using anatomic, physiologic, and technical factors to guide operative choice in DLPR, we report a 74% success rate with DP and an 82% success rate with ID at a median follow-up of 22 months. A pancreatic remnant size >6 cm favored ID options over resection.

摘要

背景

断离的左胰腺残端（DLPR）临床上表现为胰瘘、假性囊肿或阻塞性胰腺炎。最佳手术治疗方法，无论是远端胰腺切除术（DP）还是内引流（ID），仍不清楚。本文批判性地评估了我们在 DLPR 患者中的手术经验。

方法

对一家高容量机构的连续病例系列进行回顾性分析。1995 年 11 月至 2008 年 9 月期间，共有 76 例经影像学证实的 DLPR（计算机断层扫描+内镜逆行胰胆管造影或磁共振胰胆管造影）患者接受了手术，纳入本研究。除非解剖、生理或技术因素排除，否则保留胰腺（使用 ID）是我们的首选。截至 2009 年 7 月进行随访（中位随访时间 22 个月）。使用标准统计学方法（P<.05=统计学意义）。

结果

该队列的平均年龄为 52 岁（范围 18-85 岁）；57%的患者为男性。共有 59 例（73%）为急性胰腺炎，17 例（22%）为慢性胰腺炎。表现为假性囊肿占 53%，胰瘘占 34%，阻塞性胰腺炎占 13%。每种临床表现均采用同样的手术治疗方式，即切除（DP）或引流（ID），具体如下：假性囊肿，60/40；胰瘘，50/50；或阻塞性胰腺炎，50/50。DP 的主要驱动因素是胰腺残端小和脾静脉血栓形成（92%）。相比之下，当胰腺残端较大时，ID 占 70%。DP 或 ID 之间在短期和长期结果上无差异。