本文選題：腹腔鏡　切入點：胰十二指腸切除術　出處：《浙江大學》2017年博士論文　論文類型：學位論文

【摘要】：胰十二指腸切除術(Pancreaticoduodenectomy,PD)是壺腹周圍及胰頭部疾病的標準手術方式。自1935年Whipple成功開展胰十二指腸切除術,歷經(jīng)80多年的發(fā)展,PD的院內死亡率從20世紀70年代的20%～25%降低到如今的1～5%,但其術后并發(fā)癥仍有40%～60%,Ⅲ級以上并發(fā)癥達20%～30%,其中手術本身引起的切口相關并發(fā)癥為8.3%～13%。如何降低PD的并發(fā)癥率、提高患者術后恢復成為人們關注的熱點。1987年法國Mouret醫(yī)生成功開展電視腹腔鏡膽囊切除術以來,腹腔鏡手術憑借切口小而視野清,術中出血少,術后恢復快等微創(chuàng)優(yōu)勢,深受醫(yī)生和患者歡迎。隨著腹腔鏡技術的不斷提高和腔鏡器械的快速發(fā)展,腹腔鏡技術在帶蒂器官如膽囊、脾臟,空腔臟器如胃、空腸,實質臟器如肝臟、胰腺等器官的手術上都獲得成功,其在外科的各個領域得到了廣泛應用。Gawande回顧新英格蘭醫(yī)學雜志創(chuàng)刊200年外科學發(fā)展史時,將以腹腔鏡技術帶動的外科手術微創(chuàng)化評價為與麻醉具有同樣意義的進步。外科微創(chuàng)化已成為二十一世紀外科學發(fā)展的兩大方向之一。1994年,Gagner等就首次報道了腹腔鏡胰十二指腸切除術(Laparoscopic Pancreaticoduodenenctomy,LPD),早于1996年報道的腹腔鏡胰腺腫瘤剜除術和腹腔鏡保留脾臟胰體尾切除術,以及2003年首次報道的腹腔鏡胰腺中段切除術。但20多年過去了,雖然LPD被報道有出血少、疼痛輕、術后住院時間短等微創(chuàng)優(yōu)勢,但其仍只在少部分中心開展,而且手術時間較開腹手術時間長,不能進行常規(guī)開展。如何快速渡過LPD學習曲線,縮短LPD手術時間,使其能夠廣泛開展,讓更多壺腹周圍及胰頭部腫瘤患者獲得微創(chuàng)技術帶來的益處,成為術者們繼續(xù)解決的問題。一些術者根據(jù)腹腔鏡手術特點,嘗試改變LPD的手術步驟,使其適應腹腔鏡視野特點,而不是完全按照開腹手術方法。但目前仍沒有人提出針對不同解剖條件下的手術策略。本團隊于2012年9月實施了首例LPD,并且在腹腔鏡胃癌手術、腹腔鏡胰腺中段/體尾切除術、腹腔鏡膽管手術等腹腔鏡上腹部手術的基礎上,總結出了基于"五孔法"的腹腔鏡胰十二指腸切除術的優(yōu)化手術路徑。然而,隨著病例數(shù)的增加,,我們發(fā)現(xiàn)上述方法無法預防異位右肝動脈的損傷。鑒于此,本團隊在此前基礎上,結合異位右肝動脈損傷預防,總結了"No Back"策略。此外,隨著技術積累,手術適應證的逐步擴大,本團隊還總結了針對腫瘤與門靜脈/腸系膜上靜脈粘連或侵犯、胰頸后隧道無法貫通的交界可切除腫瘤等的LPD手術策略,即"Easy First"策略。本研究將詳細介紹"No Back"LPD手術路徑以及"Easy First"LPD手術路徑,總結本團隊LPD規(guī)范化操作流程,并對上述策略下開展LPD進行回顧性分析,評估其安全性、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路徑和方法研究目的:詳細描述腹腔鏡胰十二指腸切除術中采用的"No Back" LPD手術路徑和"Easy First"LPD手術路徑,總結LPD規(guī)范化操作流程。研究方法:分析總結此前的基于"五孔法"腹腔鏡胰十二指腸切除術優(yōu)化手術路徑的缺陷,通過團隊討論、文獻回顧以及會議交流,設定新的手術策略,并進行臨床實踐。研究結果:在"五孔法"操作平臺上,針對解剖情況良好、胰后隧道能夠貫通的患者,采用"No Back"LPD手術路徑,即在解剖性探查后,首先解剖肝門部,游離肝總動脈、肝動脈、門靜脈和膽管,確定是否存在異位右肝動脈,再根據(jù)基于腹腔鏡視野特點的從左側到右側、從腹側到背側、從足端到頭端的切除順序,逐步離斷空腸、胃、胰頸、鉤突、膽管;此手術路徑可在減少重復操作、縮短手術時間的基礎上,減少了異位右肝動脈的損傷幾率。針對腫瘤與血管粘連或侵犯、胰后隧道無法貫通的患者,采用"Easy First" LPD手術路徑,即首先通過近端空腸側游離腸系膜上動脈,確定腸系膜上動脈無侵犯,在將近端空腸、胃、膽管等離斷后,在游離解剖胰頸和鉤突,必要時及時中轉小切口手;此手術路徑可在保證安全的情況下,最大可能使手術在腹腔鏡下完成,并可有效控制術中出血。此外,在患者經(jīng)濟允許范圍內,對于胰管小于1mm的患者,除胃腸吻合外,采用機器人輔助的胰腸吻合和膽腸吻合,確保胰腸吻合口質量,減少胰漏發(fā)生。結論:在"五孔法"操作平臺上,"No Back"LPD手術路徑不僅滿足使手術操作無反復,且可以有效降低異位右肝動脈的損傷,減少并發(fā)癥;"Easy First"LPD手術路徑則在保證手術安全的情況下,擴大了手術指征,適用于尚未完全掌握腹腔鏡下大血管切除重建的術者。第二部分腹腔鏡胰十二指腸切除術治療胰頭和壺腹周圍病變的臨床療效研究目的:評估"No Back"LPD手術路徑和"Easy First"LPD手術路徑的安全性、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圍病變擬行腹腔鏡胰十二指腸切除術。分析其術前人口學資料,術中手術時間、出血量,術后住院時間、并發(fā)癥,病理資料及生存率等臨床資料。研究結果:2012年9月至2016年12月,本團隊共開展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,有腹部手術史者55例。其中行標準LPD者233例,LPD聯(lián)合胰體尾切除術4例,機器人輔助重建8例;采用"No Back"路徑213例,"Easy First"路徑32例。中轉開腹5%。平均手術時間(364.9±57.4)min,術中中位失血量200ml,術后總體并發(fā)癥率34.7%,B級和C級胰瘺發(fā)生率6.9%,術后出血9.4%。術后二次手術率4.9%。術后30 d內死亡2例(0.82%)。術后中位住院時間15d。腫瘤最大徑平均(3.9±2.4)cm,平均淋巴結清掃數(shù)量(21.4±12.2)個,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。術后共43例患者行術后化療,術后開始化療中位時間31天。胰腺癌患者中位隨訪時間16個月,其1年、2年、3年總體生存率分別為70.3%、27.1%、27.1%,無瘤生存率分別為68.3%、23.5%、23.5%。膽管癌患者中位隨訪時間20個月,其1年、2年、3年總體生存率分別為69.3%、49,5%、37.1%,無瘤生存率分別為68.3%、49.5%、37.1%。壺腹癌患者中位隨訪時間22個月,其1年、2年、3年總體生存率分別為 91.5%、79.6%、79.6%,無瘤生存率分別為 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),術中中轉率低(p0.0001),手術時間短(p=0.0490),術中輸血者多(p=0.0345),但術后并發(fā)癥、住院時間等無明顯區(qū)別。研究結論:"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、安全開展LPD的關鍵在于術者熟練掌握腹腔鏡下縫合止血等操作,并根據(jù)術者經(jīng)驗選擇合適的患者,根據(jù)術中解剖情況選擇合適的路徑。規(guī)范的手術路徑可以促進團隊建設,加快術者的技術積累。
[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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