胰十二指肠切除术后外科相关并发症的分析与处理

摘要:目的 探讨胰十二指肠切除术后外科相关并发症发生的原因与处理措施.方法 回顾性研究1995年1月至2010年4月共412例行胰十二指肠切除术患者的临床资料,男性232例,女性180例,分析其术后并发症发生的影响因素与治疗方法.结果 本组中共有153例患者出现并发症214例次,总发生率为37.1%.术后30 d内死亡19例,总病死率4.6%.统计学分析显示,胰腺钩突全切除与否(P=0.022)、胰肠吻合方式(P=0.005)、胰管直径(P=0.007)及残余胰腺质地(P=0.000)与胰瘘的发生具有相关性;未进行胰腺钩突全切除(P=0.002)、术中失血量≥600ml(P=0.000)及合并胰瘘者(P=0.000)术后出血发生率显著增高;保留幽门的胰十二指肠切除术组术后胃排空障碍的发生率显著高于传统胰十二指肠切除术组(P=0.000).多因素Logistic回归分析表明,胰管直径及胰腺质地是影响胰瘘发生的独立危险因素;未进行胰腺钩突全切除、术中失血量≥600ml及胰瘘为影响术后出血的独立危险因素;联合血管切除或腹膜后淋巴清扫的患者与未行血管切除或腹膜后淋巴清扫的患者相比,并发症发生率的差异无统计学意义(P<0.05).结论 合并慢性胰腺炎及胰管扩张的患者可行胰肠端侧黏膜对黏膜吻合,而端端或端侧套入式吻合更适于胰管不扩张或胰腺质软者;完整切除钩突、术中仔细止血是预防术后出血的重要因素;胰瘘是并发术后出血的重要原因之一.联合肠系膜上静脉或门静脉切除及腹膜后淋巴结清扫不会增加术后并发症的发生率.
Objective To explore the impact factors and treatment of postpancreatoduodenectomy complications. Methods The clinical data of 412 cases between January 1995 and April 2010 underwent pancreatoduodenectomy were analyzed retrospectively. There were 232 male, 180 female. Univariate and multivariate logistic regression model were used to identify the risk factors related to occurrence of postoperative complications. Results The overall postoperative morbidity rate was 37.1% ( 153/412 ), and mortality rate was 4. 6% (19/412). Total uncinate process resection, type of pancreatic-enteric anastomosis,duct diameter and pancreatic texture had effects on postoperative pancreatic fistula statistically. Total uncinate process resection, the amount of intra-operative blood loss ≥600 ml and pancreatic fistula were identified as significant risk factors for postpancreatoduodenectomy hemorrhage by means of univariate analysis. Delayed gastric empting occurrence in the patients with pylorus-preserving pancreaticoduodenectomy was higher than those with standard pancreaticoduodenectomy significantly. The multivariate Logistic regression analysis revealed that duct diameter and pancreatic texture were the independent risk factors of pancreatic fistula. Total uncinate process resection, the amount of intra-operative blood loss ≥ 600 ml and pancreatic fistula were independent risk factors of bleeding. There were no statistically significant differences between the radical group and the standard group when postoperative complication rates were analyzed ( P < 0. 05 ).Conclusions Pancreaticojejunal anastomoses by means of duct-to-mucosa is fit for the patients with dilated pancreatic duct and end-to-end invaginated pancreaticojejunostomy is fit for the patients with undilated pancreatic duct. The prevention of postoperative bleeding depends on total uncinate process resection and meticulous hemostatic technique during operation. The pancreatic fistula is one of the most important factors which can result in postoperative bleeding. Pancreaticoduodenectomy combines with SMV/PV resection and extended lymphadenectomy do not significantly increase the morbidity rates.

英文标题Surgical complications after pancreatoduodenectomy: risk factors and treatments
关键字胰十二指肠切除术,手术后并发症,胰瘘,出血,胃排空障碍
作者刘占兵,杨尹默,高嵩,庄岩,高红桥,田孝东,谢学海,万远廉
所属期刊栏目
刊名中华外科杂志,CHINESE JOURNAL OF SURGERY
作者单位杨尹默:北京大学第一医院,谢学海:北京大学第一医院,高嵩:北京大学第一医院,刘占兵:北京大学第一医院,高红桥:北京大学第一医院,田孝东:北京大学第一医院,庄岩:北京大学第一医院,万远廉:北京大学第一医院
DOI10.3760/cma.j.issn.0529-5815.2010.18.009
SSSN0529-5815

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