Marcus S G, Cohen H, Ranson J H
Department of Surgery, New York University School of Medicine, New York, USA.
Ann Surg. 1995 Jun;221(6):635-45; discussion 645-8. doi: 10.1097/00000658-199506000-00003.
The authors evaluated methods of operative management of the pancreatic remnant after pancreaticoduodenectomy.
Despite reductions in mortality after pancreaticoduodenectomy, leakage from the pancreatic remnant still may cause significant morbidity. Patients with small, unobstructed pancreatic ducts or soft, friable pancreata are at particularly high risk. Although numerous surgical techniques have been described to avoid such complications, no single method is suitable for all patients.
The authors retrospectively reviewed the medical records of 114 consecutive patients who underwent pancreaticoduodenectomy. Sixty-nine patients were men (61%) and 45 were women (39%), with median age 66 years. Underlying disease was malignant in 87 (76%) and benign in 27 (24%). Patients were divided into groups based on risk for postoperative pancreatic fistula and on the operative management of the pancreatic remnant. Sixty-eight patients underwent end-to-side pancreaticojejunostomy, 13 of whom were high risk (group 1A) and 55 of whom were low risk (group 1B). Thirty-seven patients, all high risk, had either pancreatic duct closure by oversewing (N = 19, group 2) or end-to-end pancreaticojejunal invagination (N = 18, group 3). Nine patients underwent total pancreatectomy (group 4). Morbidity related to prolonged pancreatic drainage (PPD) of greater than 20 days was determined.
Overall incidence of PPD was 17% and caused the only death. Patients considered high risk for postoperative pancreatic fistula had a 36% incidence of PPD compared with 2% in patients considered low risk (p < 0.0001). Prolonged pancreatic drainage frequency related to the method of pancreatic remnant management was as follows: group 1A, 15%; group 1B, 2%; group 2, 79%; and group 3, 6% (p < 0.001 for group 2 vs. other groups). No serious sequelae followed PPD in 15 patients (79%); however, 4 patients required reoperation for pseudocyst or abscess drainage; one in group 1A (who died) and three in group 2. Multivariate analysis revealed that operative technique (oversewing of the pancreatic duct) and male sex were significant factors predisposing a patient to the development of PPD.
After pancreaticoduodenectomy, pancreatic remnant management by end-to-side pancreaticojejunostomy appeared safe in low-risk patients. In high-risk patients, end-to-end pancreaticojejunal invagination was the safest option. Morbidity was greatest after pancreatic duct closure without anastomosis.
作者评估了胰十二指肠切除术后胰腺残端的手术管理方法。
尽管胰十二指肠切除术后死亡率有所降低，但胰腺残端漏仍可能导致严重的发病情况。胰管细小、通畅或胰腺质地柔软、脆弱的患者风险尤其高。虽然已描述了多种手术技术以避免此类并发症，但没有一种方法适用于所有患者。
作者回顾性分析了114例连续接受胰十二指肠切除术患者的病历。69例为男性（61%），45例为女性（39%），中位年龄66岁。基础疾病为恶性的有87例（76%），良性的有27例（24%）。根据术后胰瘘风险和胰腺残端的手术管理将患者分组。68例患者接受了端侧胰管空肠吻合术，其中13例为高风险（1A组），55例为低风险（1B组）。37例均为高风险的患者，要么采用缝合关闭胰管（19例，2组），要么采用端端胰管空肠套入术（18例，3组）。9例患者接受了全胰切除术（4组）。确定了与胰腺引流时间延长（PPD）超过20天相关的发病率。
PPD的总体发生率为17%，且导致了唯一一例死亡。术后胰瘘高风险患者的PPD发生率为36%，而低风险患者为2%（p<0.0001）。与胰腺残端管理方法相关的胰腺引流时间延长频率如下：1A组为15%；1B组为2%；2组为79%；3组为6%（2组与其他组相比，p<0.001）。15例患者（79%）发生PPD后未出现严重后遗症；然而，4例患者因假性囊肿或脓肿引流需要再次手术；1A组1例（死亡），2组3例。多因素分析显示，手术技术（胰管缝合）和男性性别是使患者易发生PPD的重要因素。
胰十二指肠切除术后，对于低风险患者，采用端侧胰管空肠吻合术管理胰腺残端似乎是安全的。对于高风险患者，端端胰管空肠套入术是最安全的选择。不进行吻合而关闭胰管后的发病率最高。
