Hishinuma S, Ogata Y, Matsui J, Ozawa I
Department of Surgery, Tochigi Cancer Center, Utsunomiya, Japan.
J Am Coll Surg. 1998 Jan;186(1):10-6. doi: 10.1016/s1072-7515(97)00133-6.
Pylorus-preserving pancreatoduodenectomies (PPPDs) have been performed for disorders of the pancreatic head and periampullary region. The most commonly used reconstructive technique anastomoses the duodenum end-to-side to the jejunum, with pancreatic and biliary anastomoses placed proximally to the end-to-side duodenojejunostomy. In contrast, we have favored PPPD with gastrointestinal reconstruction by the Imanaga method (PPPD-Imanaga), which consists of end-to-end duodenojejunostomy, end-to-side pancreatojejunostomy, and choledochojejunostomy, performed in that order, because the PPPD-Imanaga provides a physiologic mixture of food, pancreatic juice, and bile in the upper portion of the jejunum.
To identify their postoperative complications, we retrospectively reviewed the cases of 55 patients who underwent a PPPD-Imanaga between December 1986 and December 1996. In all cases, the right gastric artery was divided and the pancreatic duct was sewn directly to a small opening in the jejunal mucosa. Twenty patients with malignancy received adjuvant radiotherapy.
Five patients died without being discharged, including one who died of cancer progression, for a postoperative mortality rate of 9%. These deaths were limited to patients who had received adjuvant radiotherapy, with only two deaths being procedure related. Delayed gastric emptying, pancreatic leak, and marginal ulcer were observed in 25 (45%), 3 (5%), and 3 (5%) patients, respectively. The delay in gastric emptying was transient and resolved spontaneously, with no patients undergoing reoperation. Only one patient required a reoperation, for the control of intraabdominal bleeding.
A PPPD-Imanaga can be performed with acceptable morbidity and mortality risks. We conclude that the Imanaga method is a favorable complement to PPPD.
保留幽门的胰十二指肠切除术（PPPD）已用于治疗胰头和壶腹周围区域的疾病。最常用的重建技术是将十二指肠端侧吻合至空肠，胰管和胆管吻合口置于十二指肠空肠端侧吻合口的近端。相比之下，我们更倾向于采用今永法进行胃肠道重建的PPPD（PPPD-今永法），该方法包括按此顺序进行的十二指肠空肠端端吻合、胰管空肠端侧吻合和胆总管空肠吻合，因为PPPD-今永法能使食物、胰液和胆汁在空肠上段实现生理性混合。
为确定其术后并发症，我们回顾性分析了1986年12月至1996年12月期间接受PPPD-今永法手术的55例患者的病例。所有病例中，均切断胃右动脉，将胰管直接缝至空肠黏膜的一个小切口处。20例恶性肿瘤患者接受了辅助放疗。
5例患者未出院即死亡，其中1例死于癌症进展，术后死亡率为9%。这些死亡仅限于接受辅助放疗的患者，仅2例死亡与手术相关。分别有25例（45%）、3例（5%）和3例（5%）患者出现胃排空延迟､胰漏和边缘性溃疡。胃排空延迟是短暂的，可自行缓解，无患者接受再次手术。仅1例患者因控制腹腔内出血需要再次手术。
PPPD-今永法手术的发病率和死亡率风险可接受。我们得出结论，今永法是PPPD的一种良好补充。
