本文選題：胰腺遠端切除術 + 胰腺殘端　； 參考：《遵義醫(yī)學院》2017年碩士論文

【摘要】：目的:探討胰腺殘端捆綁式結扎對胰腺遠端切除術(Distal Pancreatectomy,DP)術后胰瘺(Postoperative Pancreatic Fistula,POPF)發(fā)生的影響,評價其安全性、有效性。方法:回顧性分析四川省人民醫(yī)院肝膽胰中心于2012年1月~2017年1月因胰腺體尾部疾病擇期開腹行胰腺遠端切除術患者的臨床資料112例。根據(jù)胰腺遠端切除術中胰腺殘端是否捆綁,分為胰腺殘端捆綁式結扎組(捆綁組)53例和胰腺殘端非捆綁式結扎組(非捆綁組)59例。以上兩組分別又根據(jù)胰腺殘端閉合方式不同分為手工縫合和閉合器兩亞組;其中在捆綁組亞組中手工縫合39例、閉合器14例,而在非捆綁組亞組中則分別為40例、19例。對以上患者術前一般資料(性別、年齡、體重指數(shù)、血紅蛋白、白蛋白、總膽紅素、合并疾病、腹部手術史),術中一般資料(胰腺殘端閉合方式、手術時間、術中出血量、術中輸血例數(shù)、脾切除例數(shù)、聯(lián)合血管切除例數(shù)、聯(lián)合其他臟器切除例數(shù)、胰腺質地)及術后病理資料,術后恢復、隨訪資料(腹腔引流管引流量、術后輸血例數(shù)、引流管留置時間、術后住院時間、住院費用、再次手術例數(shù)、出院一月內再次入院例數(shù)等資料)進行對比分析;并就患者術后并發(fā)癥的發(fā)生率,尤其是對術后胰瘺等并發(fā)癥的發(fā)生率進行統(tǒng)計分析。結果:1.捆綁組和非捆綁組患者術前一般資料(性別、年齡、體重指數(shù)、血紅蛋白、白蛋白、總膽紅素、腹部手術史、術前合并癥)比較無統(tǒng)計學差異(P0.05)。2.在捆綁組亞組和非捆綁組亞組中,手工縫合和閉合器患者術前一般資料(性別、年齡、體重指數(shù)、血紅蛋白、白蛋白、總膽紅素、腹部手術史、術前合并癥)比較亦均無統(tǒng)計學差異(P0.05)。3.捆綁組和非捆綁組患者術中一般資料及術后病理資料(胰腺殘端閉合方式、手術時間、術中出血量、術中輸血例數(shù)、脾切除例數(shù)、聯(lián)合血管切除例數(shù)、聯(lián)合其他臟器切除例數(shù)、胰腺質地、病理診斷)比較無統(tǒng)計學差異(P0.05)。4.所有患者均無圍手術期死亡,術后發(fā)生并發(fā)癥總計35例,發(fā)生率為31.3%(35/112)。其中,捆綁組發(fā)生并發(fā)癥12例,發(fā)生率為22.6%(12/53);非捆綁組發(fā)生并發(fā)癥23例,發(fā)生率為39.0%(23/59)。捆綁組術后并發(fā)癥發(fā)生率明顯低于非捆綁組,但兩組間差異無統(tǒng)計學意義(P0.05)。(1)捆綁組和非捆綁組患者在術后胰瘺(B級+C級)發(fā)生方面,捆綁組發(fā)生術后胰瘺2例,非捆綁組發(fā)生術后胰瘺10例,發(fā)生率分別為3.8%(2/53)、17.0%(10/59),兩組間比較存在統(tǒng)計學差異(P0.05)。(2)在胰瘺分級方面,捆綁組發(fā)生B級胰瘺2例,非捆綁組發(fā)生B級胰瘺9例,發(fā)生率分別為3.8%(2/53)、15.3%(9/59),兩組間比較亦存在統(tǒng)計學差異(P0.05);而在生化漏(A級)及C級胰瘺發(fā)生率方面,兩組間比較無統(tǒng)計學意義(P0.05)。(3)在捆綁組亞組和非捆綁組亞組中,手工縫合組的術后胰瘺發(fā)生率分別為2.6%(1/39)、15.0%(6/40);閉合器組的術后胰瘺發(fā)生率分別為7.1%(1/14)、21.1%(4/19)。經比較,閉合器組的術后胰瘺發(fā)生率均明顯高于手工縫合組(7.1%VS 2.6%,21.1%VS15.0%),但差異無統(tǒng)計學意義(P0.05);在胰瘺分級方面,手工縫合組與閉合器組比較亦均無統(tǒng)計學意義(P0.05)。(4)捆綁組和非捆綁組患者在術后出血(1.9%VS 0%)、胃排空障礙(1.9%VS 0%)、腹腔積液(13.2%VS 20.3%)、腹腔感染(1.9%VS 8.5%)、腸梗阻(5.7%VS 1.7%)、切口感染(3.8%VS 6.8%)等并發(fā)癥發(fā)生率上無統(tǒng)計學差異(P0.05)。5.在術后恢復及隨訪資料方面,捆綁組腹腔引流管的引流量與非捆綁組在術后前3天比較無明顯統(tǒng)計學差異(P0.05),而在第4天、第5天捆綁組的引流量明顯少于非捆綁組,差異有統(tǒng)計學意義(P0.05)。此外,捆綁組在引流管留置時間(8d VS 12d)、術后住院時間(9d VS 13d)、住院費用(46165.85±11120.29元VS 51751.14±15675.09元)方面優(yōu)于非捆綁組且有統(tǒng)計學差異(P0.05)。而在術后輸血例數(shù)、再次手術例數(shù)以及出院一月內再次入院例數(shù)等方面,兩組間比較無統(tǒng)計學意義(P0.05)。結論:1、胰腺殘端捆綁式結扎可有效降低胰腺遠端切除術術后胰瘺的發(fā)生率,尤其對B級胰漏的預防效果較為顯著。2、胰腺殘端捆綁式結扎能夠有效加強殘端封閉效果,在降低術后胰瘺發(fā)生率的同時,亦可減少術后腹腔引流管的引流量,縮短引流管留置時間,減少住院天數(shù),促進患者恢復并降低住院費用,減輕經濟負擔。3、捆綁式結扎可能通過有效降低胰腺殘端手工縫合的密度和閉合器封閉的不確定性因素,進而減少手術操作對胰腺組織的損傷,是一種簡單、安全、有效的方法。
[Abstract]:Objective: To investigate the effects of binding pancreatic ligature on the occurrence of pancreatic fistula (Postoperative Pancreatic Fistula, POPF) after Distal Pancreatectomy (DP) and evaluate its safety and effectiveness. Methods: a retrospective analysis of the liver and gallbladder center of the Sichuan Provincial People's Hospital in January January 2012 for the disease of the body and tail of the pancreas in January ~2017. The clinical data of 112 patients with distal pancreatic resection were performed. According to the binding of the pancreatic residues in the distal pancreas resection, 53 cases were divided into the bundle ligature group (bundle group) and the non binding group (non binding group) of the pancreatic residue 59 cases. The above two groups were divided into manual suture according to the difference of the pancreatic stump closure. In the subgroup two, 39 were hand sutured in the bundling group, 14 were closed in the closed group, and 40 in the non binding group, and 19 in the non binding group. The general data (sex, age, body mass index, hemoglobin, albumin, total bilirubin, hemoglobin, total bilirubin, the history of abdominal surgery), and the general data of the operation (closure of the pancreatic stump closure) in the subgroup of the non binding group. Methods, operation time, intraoperative bleeding, intraoperative blood transfusion, number of splenectomy cases, number of combined splenectomy cases, number of combined resection of other organs, pancreas texture and postoperative pathological data, postoperative recovery, follow-up data (abdominal drainage tube flow, number of postoperative blood transfusion, drainage tube indwelling time, postoperative hospital stay, hospitalization expenses, reoperation) The incidence of postoperative complications, especially the incidence of postoperative complications such as pancreatic fistula, was statistically analyzed. Results: the general data (sex, age, body mass index, hemoglobin, albumin, total bilirubin, total bilirubin) in 1. bundles and unbundled groups were analyzed. The history of abdominal surgery, preoperative complication) had no statistical difference (P0.05).2. in the bundling group subgroup and the non bundle group, the general data (sex, age, body mass index, hemoglobin, albumin, total bilirubin, abdominal hand history, preoperative amalgamation) were also not statistically different (P0.05).3. bundling. The general data and postoperative pathological data in group and non binding group (pancreatic stump closure, operation time, intraoperative bleeding, number of intraoperative blood transfusions, number of splenectomy cases, combined number of excision cases, combined with other organ resection cases, pancreas texture and pathological diagnosis) had no statistical difference (P0.05) all patients of.4. had no perioperative period. The incidence of postoperative complications occurred in 35 cases, with a total incidence of 31.3% (35/112). Among them, there were 12 cases of complications in the bundling group, 22.6% (12/53), 23 cases in the non binding group and 39% (23/59). The incidence of complications in the bundle group was significantly lower than that in the non binding group, but there was no significant difference between the two groups (P0.05). (1) bundling (1) bundling. There were 2 cases of pancreatic fistula (grade B +C) in group and non bundle group, 2 cases of pancreatic fistula in binding group and 10 cases of pancreatic fistula in non binding group, 3.8% (2/53) and 17% (10/59), respectively (P0.05). (2) there were 2 cases of B grade pancreatic fistula in the bundle group and B grade pancreas in the non binding group. The incidence of fistula in 9 cases was 3.8% (2/53), 15.3% (9/59), and there was a statistical difference between the two groups (P0.05), but there was no significant difference between the two groups (3) in the biochemical leakage (a grade) and the C grade pancreatic fistula (3) the incidence of pancreatic fistula after the manual suture group was 2.6% (1/39), 15% (6) in the bundle subgroup and the non bundle group. /40): the incidence of pancreatic fistula in the closed group was 7.1% (1/14) and 21.1% (4/19). After comparison, the incidence of pancreatic fistula in the closure group was significantly higher than that in the manual suture group (7.1%VS 2.6%, 21.1%VS15.0%), but the difference was not statistically significant (P0.05), and there was no significant difference between the manual suture group and the closure group in the classification of the pancreatic fistula (P0.05 (4) the incidence of postoperative bleeding (1.9%VS 0%), gastric emptying disorder (1.9%VS 0%), peritoneal effusion (13.2%VS 20.3%), abdominal infection (1.9%VS 8.5%), intestinal obstruction (5.7%VS 1.7%), incision infection (3.8%VS 6.8%) and other complications in binding group and non bundle group (P0.05).5. in postoperative recovery and follow-up data, binding group intraperitoneal There was no significant difference between the drainage volume of the flow tube and the non binding group in the first 3 days after the operation (P0.05), but on the fourth day, the drainage volume in the fifth day bundle group was significantly less than that in the non binding group (P0.05). In addition, the binding group was in the drainage tube retention time (8D VS 12D), the postoperative hospital stay (9D VS 13D), and the hospitalization expenses (46165.85 + 11120.29). VS 51751.14 + 15675.09 yuan) was superior to that of non binding group and had statistical difference (P0.05), but there was no significant difference between the two groups in the number of blood transfusion, the number of reoperation cases and the number of hospitalized cases again within one month (P0.05). Conclusion: 1, the bundle ligature of the pancreatic stump can effectively reduce the pancreatic fistula after the distal excision of the pancreas. The incidence of the pancreatic leakage, especially for the B leaks, is.2. The binding of the pancreatic stump can effectively strengthen the effect of the residual end closure. It can reduce the incidence of postoperative pancreatic fistula, reduce the drainage volume of the postoperative abdominal drainage tube, shorten the retention time of the drainage tube, reduce the number of days of hospitalization, promote the recovery of the patients and reduce the cost of hospitalization. To reduce the economic burden of.3, binding type ligation may be a simple, safe and effective way to reduce the surgical operation on pancreatic tissue damage by effectively reducing the density of the manual suture of the pancreatic stump and the uncertainty of closure of the closure of the closet.

【學位授予單位】：遵義醫(yī)學院
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R657.5

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