Department of Surgical Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India.
Hepatobiliary Pancreat Dis Int. 2013 Apr;12(2):196-203. doi: 10.1016/s1499-3872(13)60031-4.
Pancreaticoduodenectomy (PD) is the standard procedure for resecting tumors arising from the periampullary area and the pancreatic head. Nevertheless this procedure is inherently difficult and associated with high morbidity and mortality. Besides, the technique applied for exposing the portal and superior mesenteric veins is time-consuming, difficult and associated with the risk of major venous injury. Recently we have introduced a modified approach for making this part of the procedure quick, safe and bloodless, which constitutes the subject of this study.
Patients who underwent pylorus preserving pancreaticoduodenectomy (PPPD) either by superior approach technique (group 1) or by classical Whipple's technique (group 2) were retrospectively identified. Age-sex composition, body mass index (BMI), total operative time, operative blood loss, intraoperative blood transfusion requirement, morbidity, mortality and length of hospital stay were compared between the two groups.
Between January 1997 and December 2011, 72 patients underwent PPPD by the superior approach technique (group 1) and 38 underwent PPPD by the classical Whipple's technique (group 2) at our institution. Statistically significant differences were observed in operative time (208.1+/-46.3 minutes in group 1 vs 322.0+/-33.8 minutes in group 2), operative blood loss (601.0+/-250.3 mL in group 1 vs 1371.5+/-471.8 mL in group 2), and intraoperative blood transfusion requirement [10 (13.9%) patients in group 1 and 24 (63.2%) in group 2]. Among 18 (16.4%) obese patients, significant differences in operative time, operative blood loss and intraoperative blood transfusion requirement were observed between groups 1 and 2. There was no significant inter-group difference in complication rate among obese patients, but comparing obese patients with normal weight patients revealed higher rates of complications like pancreatic fistula (27.8% vs 6.5%), delayed gastric emptying (16.7% vs 5.4%), and infective complications like wound infection and intra abdominal collection (44.4% vs 5.4%).
On the basis of analytical data, we conclude that the superior approach technique is effective for PD compared with the classical Whipple's technique. It allows fast, safe and virtually bloodless dissection for exposure of the superior mesenteric and portal veins during early steps of PD. PD is normally a difficult and tedious procedure carrying a remote risk of major venous injury leading to substantial blood loss.
胰十二指肠切除术（PD）是切除胰头和壶腹周围区域肿瘤的标准方法。然而，该手术本身具有难度，并且与高发病率和死亡率相关。此外，用于暴露门静脉和肠系膜上静脉的技术耗时、困难，并且存在主要静脉损伤的风险。最近，我们引入了一种改良的方法，使这部分手术快速、安全、无血，这是本研究的主题。
回顾性分析了接受保留幽门的胰十二指肠切除术（PPPD）的患者，分别采用上入路技术（第 1 组）或经典的 Whipple 技术（第 2 组）。比较两组患者的年龄、性别构成、体重指数（BMI）、总手术时间、术中出血量、术中输血需求、发病率、死亡率和住院时间。
1997 年 1 月至 2011 年 12 月，本机构采用上入路技术（第 1 组）进行 PPPD 的患者有 72 例，采用经典 Whipple 技术（第 2 组）进行 PPPD 的患者有 38 例。第 1 组的手术时间（208.1±46.3 分钟）明显短于第 2 组（322.0±33.8 分钟），术中出血量（601.0±250.3 毫升）明显少于第 2 组（1371.5±471.8 毫升），术中输血需求（第 1 组 10 例[13.9%]，第 2 组 24 例[63.2%]）也明显减少。在 18 例肥胖患者中，第 1 组和第 2 组在手术时间、术中出血量和术中输血需求方面存在显著差异。肥胖患者中两组并发症发生率无显著差异，但与体重正常患者相比，肥胖患者的并发症发生率更高，如胰瘘（27.8%比 6.5%）、胃排空延迟（16.7%比 5.4%）和感染性并发症，如伤口感染和腹腔积脓（44.4%比 5.4%）。
基于分析数据，我们得出结论，与经典的 Whipple 技术相比，上入路技术在 PD 中是有效的。它允许在 PD 的早期步骤中快速、安全、几乎无血地解剖肠系膜上静脉和门静脉。PD 通常是一种困难和繁琐的手术，存在主要静脉损伤导致大量出血的潜在风险。
