Bai Xueli, Zhang Qi, Gao Shunliang, Lou Jianying, Li Guogang, Zhang Yun, Ma Tao, Zhang Yibo, Xu Yuanliang, Liang Tingbo
Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Collaborative Innovation Center for Cancer Medicine, Zhejiang University, Guangzhou, China.
J Am Coll Surg. 2016 Jan;222(1):10-8. doi: 10.1016/j.jamcollsurg.2015.10.003. Epub 2015 Oct 21.
Pancreatic fistula (PF) is the most common significant complication after pancreaticoduodenectomy. Invagination and duct-to-mucosa anastomoses are anastomotic techniques that are commonly performed after pancreaticoduodenectomy. There are conflicting data on invagination vs duct-to-mucosa anastomoses about which is superior for minimizing the risk of PF. In addition, all previous studies involved multiple operating surgeons and failed to control for variation in surgeon expertise.
This was a randomized controlled study comparing the outcomes of PD between patients who underwent invagination vs those who had duct-to-mucosa anastomoses. All 132 patients were operated on between October 2012 and March 2015 by a single surgeon experienced in both procedures. Pancreatic fistula was the main end point.
Overall and clinically relevant rates of PF rate were 29.5% and 10.6%, respectively. Overall PF rates in the patients treated with invagination vs duct-to-mucosa anastomoses were 30.9% vs 28.5% (p = 0.729), respectively and the corresponding clinically relevant PF rates were 17.6% vs 3.1%, respectively (p = 0.004). Although the overall complication rates were similar in the 2 groups, severe complications were significantly more frequent in the patients treated with invagination (p = 0.013). Duct-to-mucosa anastomosis was also associated with shorter postoperative hospital stay (13 vs 15 days; p = 0.021). There was one perioperative death. Independent variables for the risk of PF were the diameter of the pancreatic duct (greater risk with smaller diameter), the underlying pathology, and male sex.
Both methods yield similar overall rates for PF, but the rate of clinically relevant PF is lower in patients treated with duct-to-mucosa anastomosis. Additional single-surgeon studies or multi-institution randomized trials controlling for comparable expertise in both procedures should be conducted to confirm these results.
胰瘘（PF）是胰十二指肠切除术后最常见的严重并发症。套入式和胰管-黏膜吻合术是胰十二指肠切除术后常用的吻合技术。关于套入式与胰管-黏膜吻合术哪种在降低胰瘘风险方面更具优势，存在相互矛盾的数据。此外，以往所有研究均涉及多名手术医生，且未能控制手术医生专业水平的差异。
这是一项随机对照研究，比较接受套入式手术与胰管-黏膜吻合术患者的胰十二指肠切除术（PD）结局。所有132例患者均在2012年10月至2015年3月期间由一位对两种手术均有经验的单一外科医生进行手术。胰瘘是主要终点。
胰瘘的总体发生率和临床相关发生率分别为29.5%和10.6%。接受套入式手术与胰管-黏膜吻合术治疗的患者胰瘘总体发生率分别为30.9%和28.5%（p = 0.729），相应的临床相关胰瘘发生率分别为17.6%和3.1%（p = 0.004）。虽然两组的总体并发症发生率相似，但接受套入式手术治疗的患者严重并发症明显更常见（p = 0.013）。胰管-黏膜吻合术还与术后住院时间缩短有关（13天对15天；p = 0.021）。有1例围手术期死亡。胰瘘风险的独立变量包括胰管直径（直径越小风险越高）、基础病理情况和男性性别。
两种方法的胰瘘总体发生率相似，但接受胰管-黏膜吻合术治疗的患者临床相关胰瘘发生率较低。应开展更多由单一外科医生进行的研究或多机构随机试验，控制两种手术的可比专业水平，以证实这些结果。
