Division of Surgery, Department of Clinical Science, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden.
Br J Surg. 2012 Jan;99(1):104-11. doi: 10.1002/bjs.7730. Epub 2011 Nov 3.
Ischaemia and local protease activation close to the pancreaticojejunal anastomosis (PJA) are potential mechanisms of postoperative pancreatic fistula (POPF) formation. To provide information on the pathophysiology of POPF, intraperitoneal microdialysis was used to monitor metabolic changes and protease activation close to the PJA after pancreaticoduodenectomy (PD).
In patients who underwent PD, intraperitoneal metabolites (glycerol, lactate, pyruvate and glucose) were measured by microdialysis, and lactate and glucose in blood were monitored, every 4 h for 5 days, starting at 12.00 hours on the day after surgery. Trypsinogen activation peptide (TAP) was measured in microdialysates as a marker of protease activation.
Intraperitoneal glycerol levels and the ratio of lactate to pyruvate were higher after PD and glucose levels were lower in seven patients who later developed symptomatic POPF than in eight patients with other surgical complications (OSC) and 33 with no surgical complications (NSC) (all P < 0·050). TAP was detected at a concentration greater than 0·1 µg/l in six of seven patients with POPF, two of eight with OSC and two of 33 with NSC. Intraperitoneal lactate concentrations were higher than systemic levels in all patients on days 1 to 5 after surgery (P < 0·001). In patients with POPF, high intraperitoneal lactate concentrations were observed without systemic hyperlactataemia.
Early in the postoperative phase, patients who later developed clinically significant POPF had higher intraperitoneal glycerol concentrations and lactate/pyruvate ratios, and lower glucose concentrations in combination with a TAP level exceeding 0·1 µg/l close to the PJA, than patients who did not develop POPF.
胰肠吻合口（PJA）附近的缺血和局部蛋白酶激活是术后胰腺瘘（POPF）形成的潜在机制。为了提供 POPF 病理生理学的信息，使用腹腔内微透析监测胰十二指肠切除术（PD）后 PJA 附近的代谢变化和蛋白酶激活。
在接受 PD 的患者中，通过微透析测量腹腔内代谢物（甘油、乳酸、丙酮酸和葡萄糖），并监测术后第 1 天 12 点开始的 5 天内每 4 小时的血液中乳酸和葡萄糖水平。以胰蛋白酶原激活肽（TAP）作为蛋白酶激活的标志物在微透析液中进行测量。
与其他手术并发症（OSC）的 8 例患者和无手术并发症（NSC）的 33 例患者相比，7 例后来出现症状性 POPF 的患者 PD 后腹腔内甘油水平更高，乳酸/丙酮酸比值更高，血糖水平更低（均 P < 0·050）。在 7 例 POPF 患者中有 6 例、8 例 OSC 患者中有 2 例和 33 例 NSC 患者中有 2 例检测到 TAP 浓度大于 0·1μg/l。所有患者在手术后第 1 至 5 天腹腔内乳酸浓度均高于全身水平（P < 0·001）。在发生 POPF 的患者中，尽管没有全身高乳酸血症，但观察到高腹腔内乳酸浓度。
在术后早期，与未发生 POPF 的患者相比，后来发生临床上显著 POPF 的患者在 PJA 附近的腹腔内甘油浓度和乳酸/丙酮酸比值较高，血糖浓度较低，同时 TAP 水平超过 0·1μg/l。
