Ann Ital Chir. 2020;91:469-477.
The rates of post-operative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) are between 5% and 30%. Nowadays, pancreaticojejunostomy (PJ) represents the most common type of reconstruction after PD, but the ideal technique is still debated. Our randomized trial was conceived with the intent to evaluate if two variants of PJ could influence the post-operative outcome in term of early complications.
Forty-eight consecutive patients treated with PD were randomized into 2 groups (Group 1 or Large Jejunal Incision or LJI group and Group 2 or Small Jejunal Incision or SJI group). Outcome measures were the operative time, postoperative complications, length of postoperative hospital stay, amylase content in drains.
wenty-two patients were enrolled in the LJI and 26 in the SJI group. Median operative times did not differ between the 2 groups. The groups were homogeneous in respect to the median age of patients, the clinical presentation of jaundice and the presence of percutaneous biliary drainage (PBD). POPF developed in 3/22 (13.6%) and 1/26 (4%) patients among the LJI and SJI group respectively (3 grade B and 1 grade C respectively) (p=0.341). PPH occurred in 8/22 (36%) and 2/26 (8%) patients among the LJI and SJI group, respectively (p=0.018). The Amylase content in the drainage fluid measured at the 5th postoperative day showed a higher value in patients who underwent LJI anastomosis compared to those with SJI anastomosis [LJI group: 26.5 (6-254) U/l vs SJI group: 7 (0-38) U/l; p=0.051]. Delayed Gastric Emptying (DGE) was not different. The multivariate logistic regression analysis demonstrated both LJI anastomosis and DGE as independent predictors for pancreatic fistula (DGE: OR=20.04, CI 95%=1.92-208.83, P=0.012; LJI anastomosis: OR=24.58, CI 95%=1.71-354.32, P=0.019) and PPH (DGE: 30.5, CI 95%=3.02-308.16, P=0.004; LJI anastomosis: OR=12.71, CI 95%=1.23-131.55, P=0.033).
Based on the present results, we suggest to adopt what a "pancreas duct-oriented" approach: if pancreas duct is large a SJI-PJ is recommended; if the duct is < than 3 mm, a LJI must be preferred. Our conclusion is that the association of some surgeons to perform always the techniques with them are more confident is a concept of the past: recent data suggest that the pancreatic surgeon must have the different techniques in his "armamentarium" and varying the technique depending on local characteristic of the pancreas to allow a tailored approach to the patient.
Pancreaticojejunostomy, Pancreatic fistula, Surgical Sutcome.
胰十二指肠切除术（PD）后胰瘘（POPF）的发生率为 5%至 30%。如今，胰肠吻合术（PJ）是 PD 后最常见的重建类型，但理想的技术仍存在争议。我们的随机试验旨在评估 PJ 的两种变体是否会影响术后早期并发症的结果。
连续 48 例接受 PD 治疗的患者被随机分为 2 组（第 1 组或大空肠切口或 LJI 组和第 2 组或小空肠切口或 SJI 组）。观察指标为手术时间、术后并发症、术后住院时间、引流液中淀粉酶含量。
22 例患者纳入 LJI 组，26 例患者纳入 SJI 组。两组的手术时间无差异。两组患者的中位年龄、黄疸的临床表现和经皮胆道引流（PBD）的存在均具有可比性。LJI 和 SJI 组分别有 3/22（13.6%）和 1/26（4%）患者发生 POPF（分别为 3 级 B 和 1 级 C）（p=0.341）。LJI 和 SJI 组分别有 8/22（36%）和 2/26（8%）患者发生 PPH（p=0.018）。第 5 天引流液中淀粉酶含量在接受 LJI 吻合术的患者中高于接受 SJI 吻合术的患者[LJI 组：26.5（6-254）U/l 与 SJI 组：7（0-38）U/l；p=0.051]。延迟性胃排空（DGE）无差异。多变量逻辑回归分析显示 LJI 吻合术和 DGE 均为胰瘘（DGE：OR=20.04，95%CI=1.92-208.83，P=0.012；LJI 吻合术：OR=24.58，95%CI=1.71-354.32，P=0.019）和 PPH（DGE：OR=30.5，95%CI=3.02-308.16，P=0.004；LJI 吻合术：OR=12.71，95%CI=1.23-131.55，P=0.033）的独立预测因子。
根据目前的结果，我们建议采用“胰管导向”方法：如果胰管较大，推荐 SJI-PJ；如果胰管小于 3mm，则必须采用 LJI。我们的结论是，一些外科医生坚持使用他们更有信心的技术的做法是过去的概念：最近的数据表明，胰腺外科医生必须在他的“武器库”中拥有不同的技术，并根据胰腺的局部特征改变技术，以便为患者提供量身定制的治疗方法。
胰肠吻合术、胰瘘、手术结果。
