本文選題：腹腔鏡　切入點(diǎn)：胰十二指腸切除術(shù)　出處：《浙江大學(xué)》2017年博士論文　論文類(lèi)型：學(xué)位論文

【摘要】：胰十二指腸切除術(shù)(Pancreaticoduodenectomy,PD)是壺腹周?chē)耙阮^部疾病的標(biāo)準(zhǔn)手術(shù)方式。自1935年Whipple成功開(kāi)展胰十二指腸切除術(shù),歷經(jīng)80多年的發(fā)展,PD的院內(nèi)死亡率從20世紀(jì)70年代的20%～25%降低到如今的1～5%,但其術(shù)后并發(fā)癥仍有40%～60%,Ⅲ級(jí)以上并發(fā)癥達(dá)20%～30%,其中手術(shù)本身引起的切口相關(guān)并發(fā)癥為8.3%～13%。如何降低PD的并發(fā)癥率、提高患者術(shù)后恢復(fù)成為人們關(guān)注的熱點(diǎn)。1987年法國(guó)Mouret醫(yī)生成功開(kāi)展電視腹腔鏡膽囊切除術(shù)以來(lái),腹腔鏡手術(shù)憑借切口小而視野清,術(shù)中出血少,術(shù)后恢復(fù)快等微創(chuàng)優(yōu)勢(shì),深受醫(yī)生和患者歡迎。隨著腹腔鏡技術(shù)的不斷提高和腔鏡器械的快速發(fā)展,腹腔鏡技術(shù)在帶蒂器官如膽囊、脾臟,空腔臟器如胃、空腸,實(shí)質(zhì)臟器如肝臟、胰腺等器官的手術(shù)上都獲得成功,其在外科的各個(gè)領(lǐng)域得到了廣泛應(yīng)用。Gawande回顧新英格蘭醫(yī)學(xué)雜志創(chuàng)刊200年外科學(xué)發(fā)展史時(shí),將以腹腔鏡技術(shù)帶動(dòng)的外科手術(shù)微創(chuàng)化評(píng)價(jià)為與麻醉具有同樣意義的進(jìn)步。外科微創(chuàng)化已成為二十一世紀(jì)外科學(xué)發(fā)展的兩大方向之一。1994年,Gagner等就首次報(bào)道了腹腔鏡胰十二指腸切除術(shù)(Laparoscopic Pancreaticoduodenenctomy,LPD),早于1996年報(bào)道的腹腔鏡胰腺腫瘤剜除術(shù)和腹腔鏡保留脾臟胰體尾切除術(shù),以及2003年首次報(bào)道的腹腔鏡胰腺中段切除術(shù)。但20多年過(guò)去了,雖然LPD被報(bào)道有出血少、疼痛輕、術(shù)后住院時(shí)間短等微創(chuàng)優(yōu)勢(shì),但其仍只在少部分中心開(kāi)展,而且手術(shù)時(shí)間較開(kāi)腹手術(shù)時(shí)間長(zhǎng),不能進(jìn)行常規(guī)開(kāi)展。如何快速渡過(guò)LPD學(xué)習(xí)曲線(xiàn),縮短LPD手術(shù)時(shí)間,使其能夠廣泛開(kāi)展,讓更多壺腹周?chē)耙阮^部腫瘤患者獲得微創(chuàng)技術(shù)帶來(lái)的益處,成為術(shù)者們繼續(xù)解決的問(wèn)題。一些術(shù)者根據(jù)腹腔鏡手術(shù)特點(diǎn),嘗試改變LPD的手術(shù)步驟,使其適應(yīng)腹腔鏡視野特點(diǎn),而不是完全按照開(kāi)腹手術(shù)方法。但目前仍沒(méi)有人提出針對(duì)不同解剖條件下的手術(shù)策略。本團(tuán)隊(duì)于2012年9月實(shí)施了首例LPD,并且在腹腔鏡胃癌手術(shù)、腹腔鏡胰腺中段/體尾切除術(shù)、腹腔鏡膽管手術(shù)等腹腔鏡上腹部手術(shù)的基礎(chǔ)上,總結(jié)出了基于"五孔法"的腹腔鏡胰十二指腸切除術(shù)的優(yōu)化手術(shù)路徑。然而,隨著病例數(shù)的增加,,我們發(fā)現(xiàn)上述方法無(wú)法預(yù)防異位右肝動(dòng)脈的損傷。鑒于此,本團(tuán)隊(duì)在此前基礎(chǔ)上,結(jié)合異位右肝動(dòng)脈損傷預(yù)防,總結(jié)了"No Back"策略。此外,隨著技術(shù)積累,手術(shù)適應(yīng)證的逐步擴(kuò)大,本團(tuán)隊(duì)還總結(jié)了針對(duì)腫瘤與門(mén)靜脈/腸系膜上靜脈粘連或侵犯、胰頸后隧道無(wú)法貫通的交界可切除腫瘤等的LPD手術(shù)策略,即"Easy First"策略。本研究將詳細(xì)介紹"No Back"LPD手術(shù)路徑以及"Easy First"LPD手術(shù)路徑,總結(jié)本團(tuán)隊(duì)LPD規(guī)范化操作流程,并對(duì)上述策略下開(kāi)展LPD進(jìn)行回顧性分析,評(píng)估其安全性、可行性、以及腫瘤治療效果。第一部分腹腔鏡胰十二指腸切除手術(shù)路徑和方法研究目的:詳細(xì)描述腹腔鏡胰十二指腸切除術(shù)中采用的"No Back" LPD手術(shù)路徑和"Easy First"LPD手術(shù)路徑,總結(jié)LPD規(guī)范化操作流程。研究方法:分析總結(jié)此前的基于"五孔法"腹腔鏡胰十二指腸切除術(shù)優(yōu)化手術(shù)路徑的缺陷,通過(guò)團(tuán)隊(duì)討論、文獻(xiàn)回顧以及會(huì)議交流,設(shè)定新的手術(shù)策略,并進(jìn)行臨床實(shí)踐。研究結(jié)果:在"五孔法"操作平臺(tái)上,針對(duì)解剖情況良好、胰后隧道能夠貫通的患者,采用"No Back"LPD手術(shù)路徑,即在解剖性探查后,首先解剖肝門(mén)部,游離肝總動(dòng)脈、肝動(dòng)脈、門(mén)靜脈和膽管,確定是否存在異位右肝動(dòng)脈,再根據(jù)基于腹腔鏡視野特點(diǎn)的從左側(cè)到右側(cè)、從腹側(cè)到背側(cè)、從足端到頭端的切除順序,逐步離斷空腸、胃、胰頸、鉤突、膽管;此手術(shù)路徑可在減少重復(fù)操作、縮短手術(shù)時(shí)間的基礎(chǔ)上,減少了異位右肝動(dòng)脈的損傷幾率。針對(duì)腫瘤與血管粘連或侵犯、胰后隧道無(wú)法貫通的患者,采用"Easy First" LPD手術(shù)路徑,即首先通過(guò)近端空腸側(cè)游離腸系膜上動(dòng)脈,確定腸系膜上動(dòng)脈無(wú)侵犯,在將近端空腸、胃、膽管等離斷后,在游離解剖胰頸和鉤突,必要時(shí)及時(shí)中轉(zhuǎn)小切口手;此手術(shù)路徑可在保證安全的情況下,最大可能使手術(shù)在腹腔鏡下完成,并可有效控制術(shù)中出血。此外,在患者經(jīng)濟(jì)允許范圍內(nèi),對(duì)于胰管小于1mm的患者,除胃腸吻合外,采用機(jī)器人輔助的胰腸吻合和膽腸吻合,確保胰腸吻合口質(zhì)量,減少胰漏發(fā)生。結(jié)論:在"五孔法"操作平臺(tái)上,"No Back"LPD手術(shù)路徑不僅滿(mǎn)足使手術(shù)操作無(wú)反復(fù),且可以有效降低異位右肝動(dòng)脈的損傷,減少并發(fā)癥;"Easy First"LPD手術(shù)路徑則在保證手術(shù)安全的情況下,擴(kuò)大了手術(shù)指征,適用于尚未完全掌握腹腔鏡下大血管切除重建的術(shù)者。第二部分腹腔鏡胰十二指腸切除術(shù)治療胰頭和壺腹周?chē)∽兊呐R床療效研究目的:評(píng)估"No Back"LPD手術(shù)路徑和"Easy First"LPD手術(shù)路徑的安全性、可行性及腫瘤治療效果。研究方法:選取2012年9月至2016年12月期間,診斷為胰頭或壺腹周?chē)∽償M行腹腔鏡胰十二指腸切除術(shù)。分析其術(shù)前人口學(xué)資料,術(shù)中手術(shù)時(shí)間、出血量,術(shù)后住院時(shí)間、并發(fā)癥,病理資料及生存率等臨床資料。研究結(jié)果:2012年9月至2016年12月,本團(tuán)隊(duì)共開(kāi)展245例LPD,其中協(xié)助外院59例。男性154例,女性91例,平均年齡(60.4±12.7)歲,有腹部手術(shù)史者55例。其中行標(biāo)準(zhǔn)LPD者233例,LPD聯(lián)合胰體尾切除術(shù)4例,機(jī)器人輔助重建8例;采用"No Back"路徑213例,"Easy First"路徑32例。中轉(zhuǎn)開(kāi)腹5%。平均手術(shù)時(shí)間(364.9±57.4)min,術(shù)中中位失血量200ml,術(shù)后總體并發(fā)癥率34.7%,B級(jí)和C級(jí)胰瘺發(fā)生率6.9%,術(shù)后出血9.4%。術(shù)后二次手術(shù)率4.9%。術(shù)后30 d內(nèi)死亡2例(0.82%)。術(shù)后中位住院時(shí)間15d。腫瘤最大徑平均(3.9±2.4)cm,平均淋巴結(jié)清掃數(shù)量(21.4±12.2)個(gè),R0切除率99.2%。其中惡性腫瘤173例,包括胰腺癌94例,膽管下段癌22例,壺腹癌55例,胃癌1例,胃和十二指腸降部雙重癌1例。術(shù)后共43例患者行術(shù)后化療,術(shù)后開(kāi)始化療中位時(shí)間31天。胰腺癌患者中位隨訪(fǎng)時(shí)間16個(gè)月,其1年、2年、3年總體生存率分別為70.3%、27.1%、27.1%,無(wú)瘤生存率分別為68.3%、23.5%、23.5%。膽管癌患者中位隨訪(fǎng)時(shí)間20個(gè)月,其1年、2年、3年總體生存率分別為69.3%、49,5%、37.1%,無(wú)瘤生存率分別為68.3%、49.5%、37.1%。壺腹癌患者中位隨訪(fǎng)時(shí)間22個(gè)月,其1年、2年、3年總體生存率分別為 91.5%、79.6%、79.6%,無(wú)瘤生存率分別為 90.0%、73.7%、61.2%。"No Back"路徑組平均年齡較"Easy First"路徑組小(p=0.0098),術(shù)中中轉(zhuǎn)率低(p0.0001),手術(shù)時(shí)間短(p=0.0490),術(shù)中輸血者多(p=0.0345),但術(shù)后并發(fā)癥、住院時(shí)間等無(wú)明顯區(qū)別。研究結(jié)論:"No Back"路徑和"Easy First"路徑的LPD安全可行、腫瘤治療效果可靠。順利、安全開(kāi)展LPD的關(guān)鍵在于術(shù)者熟練掌握腹腔鏡下縫合止血等操作,并根據(jù)術(shù)者經(jīng)驗(yàn)選擇合適的患者,根據(jù)術(shù)中解剖情況選擇合適的路徑。規(guī)范的手術(shù)路徑可以促進(jìn)團(tuán)隊(duì)建設(shè),加快術(shù)者的技術(shù)積累。
[Abstract]:Pancreaticoduodenectomy (Pancreaticoduodenectomy, PD) is the standard surgical approach of periampullary and head of pancreas disease. Since 1935 Whipple successful pancreaticoduodenectomy, after 80 years of development, PD hospital mortality from 20% in 1970s to 25% now reduced to 1 to 5%, but the postoperative complications are still 40% to 60%, more than grade 20% to 30% complications including incision, complications related to the surgery itself by 8.3% ~ 13%. PD how to reduce the rate of complications, improve postoperative recovery of patients with.1987 has become the focus of attention in France, Dr. Mouret successfully carried out laparoscopic cholecystectomy, laparoscopic surgery with small incision and clear vision. Less bleeding, faster postoperative recovery by minimally invasive advantages, doctors and patients are welcome. With the rapid development of technology and improvement of laparoscopic endoscopic instrument, laparoscopy In the operation of pedicle organs such as gallbladder, spleen, hollow organs such as the stomach, jejunum, parenchymal organs such as liver, pancreas and other organs of the surgery successfully, it has been widely used in various fields of surgical.Gawande review of the new England Journal of Medicine published 200 years history of surgery, the surgery to minimally invasive evaluation laparoscopic technology driven to have the same meaning with the improvement of anesthesia. Minimally invasive surgery has become the development direction of the two major surgery in twenty-first Century of.1994, Gagner and so on were reported for the first time of laparoscopic pancreaticoduodenectomy (Laparoscopic Pancreaticoduodenenctomy, LPD), first reported in 1996 the laparoscopic pancreatic tumor enucleation and laparoscopic spleen preserving pancreatic body laparoscopic pancreatic tail resection, first reported in 2003 and the middle of resection. But over the past 20 years, although LPD was reported to have less bleeding, less pain, After operation, short hospitalization time and other advantages of minimally invasive, but it is still only a small part of the center to carry out, and the operation time compared with open operation for a long time, can not be routinely carried out. How fast through LPD learning curve, shorten the operation time of LPD, which can be widely carried out, so that more around the ampulla and head of pancreas cancer patients received minimally invasive technique the benefits of becoming researchers to solve the problem. Some patients according to the characteristics of laparoscopic surgery, the surgical procedure to change the LPD, which can adapt to the characteristics of laparoscopic vision, but not completely in accordance with the method of open surgery. But there is still no one puts forward the surgical strategy of different anatomical conditions. It is the first team to implement LPD in September 2012, and in the laparoscopic gastric surgery, laparoscopic pancreatic / middle pancreatectomy, laparoscopic bile duct surgery based laparoscopic abdominal surgery, summed up based on the "five The optimization of hole method of the surgical approach of laparoscopic pancreaticoduodenectomy. However, with the increase of the number of cases, we found that the method can prevent heterotopic right hepatic artery injury. In view of this, the team in the previous basis, combined with aberrant right hepatic artery injury prevention, summed up the "No Back" strategy in addition. With the accumulation of technology, and the surgical indications gradually expanded, the team also summarized for tumor and portal vein / superior mesenteric vein adhesion or invasion, pancreatic neck after the tunnel through the junction of LPD to tumor resection operation strategy, namely "Easy First" strategy. This study introduced the "No Back" LPD surgery Easy First "LPD" path and operation path, summarizes the team LPD standardized operating procedures, and to carry out the strategy of LPD were retrospectively analyzed to evaluate its safety, feasibility, and tumor treatment. The first part of the ten laparoscopic pancreatic Two refers to the bowel resection surgery path and method of objective: a detailed description of the laparoscopic pancreaticoduodenectomy use "No Back" LPD "Easy First" operation path and LPD operation path, summarize the LPD standardized operation process. Methods: to analyze and summarize the previous research based on the method of the five hole laparoscopic pancreaticoduodenectomy surgery optimization the path of defects, through team discussion, literature review and conferences, setting new surgical strategies, and clinical practice. Results: in the operating platform of five hole method ", according to the anatomical situation is good, can through the tunnel after pancreas patients, using" No Back "LPD operation path, namely in anatomy after exploration, the anatomy of hepatic portal, free hepatic artery, hepatic artery, portal vein and bile duct, determine whether there is aberrant right hepatic artery, then based on laparoscopic vision features from left to right, from the ventral to the dorsal, from The foot end at the head end resection order, gradually breaking away from the neck of pancreas, stomach, jejunum, uncinate process, bile duct; the surgical route can reduce repeated operation, shorten the operation time of the foundation, reduce the damage probability of the right hepatic artery. The ectopic tumor and vascular adhesion or invasion of pancreas after the tunnel cannot run through patients with "Easy First LPD" operation path, first through the proximal jejunum side of superior mesenteric artery, superior mesenteric artery to determine the invasion, in the proximal jejunum, gastric, bile duct transection in the dissection of pancreatic neck and uncinate process, transfer and small incision surgery when necessary; the operation path to ensure the safety of the situation, most likely make surgery performed by laparoscopy, and can effectively control the bleeding during the operation. In addition, patients in the economy range, for less than 1mm in patients with pancreatic duct, gastrointestinal anastomosis, using robot assisted pancreaticojejunostomy and biliary Together, ensure the anastomosis quality, reduce the occurrence of pancreatic leakage. Conclusion: in the operation platform of the five hole method "," No Back LPD "operation path not only meet the operation without recurrence, and can effectively reduce the ectopic right hepatic artery injury, reduce the complications;" Easy First LPD "in the path of operation to ensure the operation safety, expand the surgical indications, suitable for patients who have not yet fully mastered laparoscopic vascular resection and reconstruction. Objective to study on clinical effect of surgical treatment of pancreatic and periampullary lesions of second laparoscopic pancreatoduodenectomy: safety evaluation of" No Back LPD "and" Easy First "operation path of LPD the surgical approach, the treatment effect and feasibility of tumor. Methods: during the period from September 2012 to December 2016, diagnosed as pancreatic or periampullary diseases underwent laparoscopic pancreaticoduodenectomy. Analysis of preoperative demographic data, intraoperative hand 鏈椂闂，

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