Kapoor V K
Rozhl Chir. 2016 Feb;95(2):53-9.
Pancreato-duodenectomy (PD) is the procedure of choice for management of resectable periampullary and pancreatic cancers and some patients with chronic pancreatitis. PD is one of the most major GI/ HPB surgical procedures performed involving resection of multiple organs and reconstruction with multiple anastomoses. While mortality of PD has been brought down to less than 5% morbidity still remains high.Patients undergoing PD are usually elderly with comorbidities - general complications of a major operation e.g. wound, chest, cardiac and venous thrombo-embolism, are common.The major intra-operative morbidity of PD is bleeding which can be from multiple sites viz. gall bladder bed, choledochal veins, gastro-colic trunk, pancreato-duodenal veins, jejunal veins, uncinate veins and cut surface of pancreas. An aberrant right hepatic artery (from the superior mesenteric artery) can be injured while dissecting the common bile duct.Pancreatic leak is defined as presence of amylase rich (>3x serum amylase) fluid in drain beyond 3 days. It is graded as A (no clinical impact), B (persists, infected) or C (systemic sepsis, reoperation). Investigation of choice is computed tomography; a localized collection can be drained percutaneously. Major leak requires reexploration at which lavage and drainage should be performed; no attempt should be made to repair or redo the anastomosis. Soft pancreas and undilated duct are the two most important risk factors for pancreatic anastomotic leak; role of octreotide to prevent the leak is debatable. Preoperative biliary drainage in the form of endoscopic stenting may reduce bleeding complications by controlling coagulopathy but increases the risk of infective complications.Postoperative bleed can be early or delayed and intra-luminal or intra-abdominal. Early intra-abdominal bleed is surgical - either a slipped ligature e.g. of the gastro-duodenal artery or one of the veins or from the pancreato-duodenal bed; reexploration should be done to control it if it is severe. Early intra-luminal bleed is from one of the anastomoses - commonest being the pancreatic. UGIE rules out bleed from the gastro/duodenal anastomosis (which if present, can be controlled endoscopically). Control of pancreatic stump bleed requires reoperation - taking down anterior layer of the anastomosis or a jejunotomy. Delayed intra-abdominal bleed is from a pseudo-aneurysm of an artery, usually gastro-duodenal caused by erosion by an abscess secondary to a leak; treatment of choice is angio-embolization. Delayed intra-luminal bleed is because of stress ulcers caused by systemic sepsis usually secondary to a leak and intra-abdominal sepsis.Other common complications include delayed gastric emptying and acute pancreatitis.Reoperations after PD are frequent - commonest cause is bleed, followed by leak; mortality of reexploration is high. Long term complications include anastomotic (PJ/ HJ) stricture, endocrine and exocrine insufficiency and inability to regain weight and poor quality of life.
pancreato-duodenectomy complications.
胰十二指肠切除术（PD）是可切除的壶腹周围癌、胰腺癌以及部分慢性胰腺炎患者的首选治疗方法。PD是胃肠道/肝脏胰胆外科中最主要的手术之一，需要切除多个器官并进行多个吻合口的重建。虽然PD的死亡率已降至5%以下，但发病率仍然很高。接受PD手术的患者通常为老年人且伴有多种合并症，大手术常见的一般并发症，如伤口、胸部、心脏和静脉血栓栓塞等很常见。PD术中主要的并发症是出血，出血可来自多个部位，即胆囊床、胆总管静脉、胃结肠干、胰十二指肠静脉、空肠静脉、钩突静脉和胰腺切面。在解剖胆总管时，异常的右肝动脉（发自肠系膜上动脉）可能会受到损伤。胰瘘定义为引流液中淀粉酶含量超过血清淀粉酶3倍且持续3天以上。根据严重程度分为A（无临床影响）、B（持续存在且感染）或C（全身感染、再次手术）。首选的检查方法是计算机断层扫描；局限性积液可经皮引流。严重的胰瘘需要再次手术，术中应进行冲洗和引流；不应尝试修复或重新进行吻合。胰腺质地软和胆管未扩张是胰肠吻合口漏的两个最重要危险因素；奥曲肽预防胰瘘的作用存在争议。术前内镜支架置入形式的胆道引流可通过控制凝血功能障碍减少出血并发症，但会增加感染并发症的风险。术后出血可分为早期或延迟性，可发生在腔内或腹腔内。早期腹腔内出血需要手术治疗，如胃十二指肠动脉或静脉之一的结扎线滑脱，或来自胰十二指肠床；如果出血严重，应再次手术控制出血。早期腔内出血来自其中一个吻合口，最常见的是胰肠吻合口。上消化道内镜检查可排除胃/十二指肠吻合口出血（如有出血，可在内镜下控制）。控制胰腺残端出血需要再次手术，拆除吻合口的前层或进行空肠切开术。延迟性腹腔内出血来自动脉假性动脉瘤，通常是胃十二指肠动脉，由胰瘘继发的脓肿侵蚀所致；首选的治疗方法是血管栓塞。延迟性腔内出血是由全身感染通常继发于胰瘘和腹腔内感染引起的应激性溃疡所致。其他常见并发症包括胃排空延迟和急性胰腺炎。PD术后再次手术很常见，最常见的原因是出血，其次是胰瘘；再次手术的死亡率很高。长期并发症包括吻合口（胰肠/肝肠）狭窄、内分泌和外分泌功能不全以及体重无法恢复和生活质量差。
胰十二指肠切除术；并发症
