[腹腔镜胰十二指肠切除术术后并发症的经验]

[Experience on postoperative complications of laparoscopic pancreaticoduodenectomy].

作者信息

Lu C, Jin W W, Mou Y P, Zhou Y C, Zhu Q C, Shao H L, Chen K, Li S D

机构信息

Department of Gastroenterology and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou 310014, China.

出版信息

Zhonghua Wai Ke Za Zhi. 2018 Nov 1;56(11):822-827. doi: 10.3760/cma.j.issn.0529-5815.2018.11.006.

Abstract

To summarize the incidence and characteristics of postoperative complications after laparoscopic pancreaticoduodenectomy(LPD), and to share our experience on management of complications. The clinical data of 320 LPD performed by a single team in Sir Run Run Shaw Hospital and Zhejiang Provincial People's Hospital between September 2012 and September 2017 were retrospectively analyzed, among which there were 196 males and 124 females with age of (60.2±11.6) years old.There were 306 patients who underwent standard LPD, and 14 patients who underwent extended LPD. The patients were divided into 2 groups of former 160 LPD and later 160 LPD according to the time order. By analyzing the differences of clinical outcomes between the two groups, especially focusing on the incidence of postoperative complications.The experience on management of complications was concluded. The prior surgical history of latter group was significantly higher than the former group(30.0%(48/160). 18.8%(30/160), χ(2)=5.49, =0.019), and the rest of baseline characteristics remained the comparable (>0.05). For resectable lesions, LPD was performed by "No back" approach, following the principle of "From distal to cephalad, from ventral to dorsal, and from left to right" . As for the borderline resectable patients, LPD was performed by "Easy first" strategy. Student test, χ(2) test or Fisher test was used to analyzed the data between the two groups respectively. Of 320 LPD patients, 306 cases underwent standard LPD, 14 cases underwent LPD with resection of other organs.There were 278 LPD cases who followed "No back" approach, and 42 cases who followed "Easy first" strategy because of difficulty in creating the retro-pancreatic tunnel. And the overall morbidity was 32.2%(103/320) with reoperation rate of 5.3%(17/320). The perioperative mortality was 0.6%(2/320). The operation time of latter group was ((346.6±48.8)minutes), which was shorter than that of former group((358.0±54.4)minutes)(=1.97, =0.048). The blood loss of former and latter group remained comparable((207.9±135.8)ml .(189.6±121.4)ml, =0.205). However, in subgroup analysis, the patients with blood loss less <200 ml of latter group decreased significantly from 59.4%(95/160) to 47.5%(76/160)(χ(2)=4.53, =0.033). The overall morbidity of latter group was 28.8%(46/160), indicated a decrease from 35.6%(57/160) of former group without significant difference(=0.188). Moreover, Grade A/B/C pancreatic fistula rate, Grade A/C bile leakage rate, Grade B/C postoperative hemorrhage rate of the later group tended to decrease, although they also didn't reach a significant difference. However, the abdominal infection rate decreased significantly(χ(2)=3.93, =0.047). The length of hospital stay remained comparable(=0.156). The most common complications after LPD were postoperative hemorrhage and pancreatic fistula. With specialized team and accumulated experience, the morbidity can decrease progressively by analyzing the leading cause and improving the technical skills.

摘要

总结腹腔镜胰十二指肠切除术(LPD)术后并发症的发生率及特点,并分享我们在并发症处理方面的经验。回顾性分析2012年9月至2017年9月在浙江大学医学院附属邵逸夫医院和浙江省人民医院由同一团队完成的320例LPD患者的临床资料,其中男性196例,女性124例,年龄(60.2±11.6)岁。行标准LPD 306例,扩大根治性LPD 14例。根据时间顺序将患者分为前160例LPD组和后160例LPD组。通过分析两组临床结局的差异,尤其关注术后并发症的发生率,总结并发症处理经验。后一组患者既往手术史显著高于前一组(30.0%(48/160)对18.8%(30/160),χ²=5.49,P=0.019),其余基线特征相当(P>0.05)。对于可切除病变,LPD采用“不翻胃”入路,遵循“从下向上、从前向后、从左向右”的原则。对于交界可切除患者,LPD采用“先易后难”策略。分别采用t检验、χ²检验或Fisher检验分析两组间数据。320例LPD患者中,306例行标准LPD,14例行联合其他器官切除的LPD。278例LPD采用“不翻胃”入路,42例因胰后隧道建立困难采用“先易后难”策略。总体并发症发生率为32.2%(103/320),再次手术率为5.3%(17/320)。围手术期死亡率为0.6%(2/320)。后一组手术时间为(346.6±48.8)分钟,短于前一组(358.0±54.4)分钟(t=1.97,P=0.048)。两组术中出血量相当((207.9±135.8)ml对(189.6±121.4)ml,t=0.205)。但在亚组分析中,后一组术中出血量<200 ml的患者比例从59.4%(95/160)显著降至47.5%(76/160)(χ²=4.53,P=0.033)。后一组总体并发症发生率为28.8%(46/160),较前一组的35.6%(57/160)有所下降,但差异无统计学意义(P=0.188)。此外,后一组A级/B级/C级胰瘘发生率、A级/C级胆漏发生率及B级/C级术后出血发生率均有下降趋势,但差异也无统计学意义。然而,腹部感染率显著下降(χ²=3.93,P=0.047)。住院时间相当(P=0.156)。LPD术后最常见的并发症是术后出血和胰瘘。通过专业团队及积累经验,分析主要原因并提高技术水平,并发症发生率可逐步降低。

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