【摘要】：目的胰十二指腸切除術(shù)(PD)是壺腹周圍癌唯一有效的治療方法。目前胰十二指腸切除術(shù)的主要問題是術(shù)后胰瘺(POPF)等并發(fā)癥發(fā)生率仍較高,嚴(yán)重影響了病人的術(shù)后康復(fù)。胰胃吻合(PG)相對(duì)于傳統(tǒng)的胰腸吻合(PJ)能否降低術(shù)后胰瘺的發(fā)生率一直是研究爭(zhēng)論的熱點(diǎn)。過(guò)去的研究所使用的術(shù)后胰瘺診斷標(biāo)準(zhǔn)存在缺陷。2016年國(guó)際胰腺外科小組對(duì)術(shù)后胰瘺診斷標(biāo)準(zhǔn)進(jìn)行了重大更新。本研究首次使用新標(biāo)準(zhǔn),比較胰腸吻合和胰胃吻合對(duì)胰十二指腸切除術(shù)后胰瘺等并發(fā)癥的影響。方法回顧了本中心2012年1月至2016年12月期間接受胰十二指腸切除術(shù)的210名病人的臨床數(shù)據(jù),其中胰腸吻合組136例,胰胃吻合組74例,主要觀察結(jié)局是術(shù)后胰瘺,次要觀察結(jié)局包括其他并發(fā)癥和再手術(shù)、圍手術(shù)期死亡等臨床結(jié)果。另外,還驗(yàn)證了術(shù)后胰瘺風(fēng)險(xiǎn)評(píng)分工具(FRS)的預(yù)測(cè)效果;并通過(guò)回歸分析探索術(shù)后胰瘺的相關(guān)風(fēng)險(xiǎn)因素。結(jié)果210例胰十二指腸切除術(shù)總體的術(shù)后胰瘺發(fā)生率為16.2%,其中胰腸吻合為16.9%,胰胃吻合為14.9%,兩者沒有顯著性差異,p=0.701;其他并發(fā)癥方面,雖然胰腸吻合和胰胃吻合的胃排空延遲總發(fā)生率沒有顯著性差異(18.4%vs 14.9%,p=0.518),但胰胃吻合的嚴(yán)重等級(jí)顯著低于胰腸吻合,p=0.012;另外,胰胃吻合的術(shù)后膽漏發(fā)生率顯著低于胰腸吻合(18.9%vs33.8%,p=0.022)。盡管如此,胰腸吻合和胰胃吻合在主要臨床結(jié)果方面沒有發(fā)現(xiàn)顯著差異,如死亡率(0.7%vs 0),總并發(fā)癥率(45.6%vs 40.5%,p=0.481),嚴(yán)重并發(fā)癥率(11.0%vs 13.5%,p=0.595)。根據(jù)術(shù)后胰瘺風(fēng)險(xiǎn)評(píng)分量表所劃分的風(fēng)險(xiǎn)等級(jí)與實(shí)際術(shù)后胰瘺發(fā)生率相匹配,無(wú)風(fēng)險(xiǎn)的術(shù)后胰瘺發(fā)生率為0,低風(fēng)險(xiǎn)為5%,中風(fēng)險(xiǎn)為12%,高風(fēng)險(xiǎn)為48%。在對(duì)15項(xiàng)可能的術(shù)后胰瘺風(fēng)險(xiǎn)因素的單因素分析中,胰管直徑與術(shù)后胰瘺的發(fā)生有顯著相關(guān)性(OR:4.31,p0.001),在對(duì)胰腺質(zhì)地、胰管直徑、病理類型、術(shù)中出血4個(gè)風(fēng)險(xiǎn)因素的多因素分析中,同樣得出胰管直徑3mm顯著增加術(shù)后胰瘺風(fēng)險(xiǎn)(OR:4.93,p0.001)。結(jié)論胰腸吻合和胰胃吻合都是胰十二指腸術(shù)后可選擇的安全可靠的胰腺-消化道重建方法。胰腸吻合與胰胃吻合的術(shù)后胰瘺發(fā)生率和嚴(yán)重程度沒有顯著性差異。盡管胰胃吻合的胃排空延遲嚴(yán)重程度更低,而且膽漏發(fā)生率更低,但兩種吻合方式的總并發(fā)癥率、嚴(yán)重并發(fā)癥率、死亡率等主要臨床結(jié)果沒有顯著差異。術(shù)后胰瘺風(fēng)險(xiǎn)評(píng)分量表是有效的術(shù)后胰瘺風(fēng)險(xiǎn)預(yù)測(cè)工具。胰管直徑3mm是術(shù)后胰瘺唯一的獨(dú)立風(fēng)險(xiǎn)因素。
[Abstract]:Objective: pancreaticoduodenectomy (PD) is the only effective treatment for periampullary carcinoma. At present, the main problem of pancreaticoduodenectomy is that the incidence of postoperative complications such as pancreatic fistula (POPF) is still high, which seriously affects the postoperative rehabilitation of patients. Compared with the traditional pancreaticojejunostomy (PG) can reduce the incidence of postoperative pancreatic fistula. The diagnostic criteria for postoperative pancreatic fistula used in the past have been flawed. The 2016 International Panel of Pancreatic surgery has significantly updated the diagnostic criteria for postoperative pancreatic fistula. To compare the effects of pancreaticojejunostomy and pancreaticogastric anastomosis on pancreatic fistula after pancreaticoduodenectomy. Methods the clinical data of 210 patients undergoing pancreaticoduodenectomy from January 2012 to December 2016 were reviewed, including 136 cases of pancreaticojejunostomy group and 74 cases of pancreaticogastric anastomosis group. The main outcome was postoperative pancreatic fistula. Secondary outcomes include other complications and re-operation, perioperative death and other clinical outcomes. In addition, the predictive effect of postoperative pancreatic fistula risk scoring tool (FRS) was verified, and the risk factors of postoperative pancreatic fistula were explored by regression analysis. Results the overall incidence of pancreatic fistula in 210 cases of pancreaticoduodenectomy was 16.2.The pancreaticojejunostomy was 16.9 and pancreaticogastric anastomosis was 14.9. there was no significant difference between the two groups. Although there was no significant difference in the total incidence of delayed gastric emptying between pancreaticojejunostomy and pancreaticogastric anastomosis (18.4%vs 14.9), the severity of pancreaticogastric anastomosis was significantly lower than that of pancreaticojejunostomy (0.012), and the incidence of biliary leakage after pancreaticogastric anastomosis was significantly lower than that of pancreaticojejunostomy (18.9vs33.8p0.022). Nevertheless, there were no significant differences in the main clinical outcomes between pancreaticojejunostomy and pancreaticogastric anastomosis, such as mortality rate (0.7%vs 0), total complication rate (45.6%vs 40.5%) and severe complication rate (11.0%vs 13.5p 0.59%). According to the risk rating scale of postoperative pancreatic fistula, the incidence rate of postoperative pancreatic fistula was 0, low risk was 5, middle risk was 12, and high risk was 48. In the univariate analysis of 15 possible risk factors for postoperative pancreatic fistula, the diameter of pancreatic duct was significantly correlated with the occurrence of postoperative pancreatic fistula (OR:4.31,p0.001). In the multivariate analysis of four risk factors, pancreatic texture, diameter of pancreatic duct, pathological type and intraoperative hemorrhage, there was a significant correlation between the diameter of pancreatic duct and the occurrence of postoperative pancreatic fistula. It was also found that pancreatic duct diameter 3mm significantly increased postoperative pancreatic fistula risk (OR:4.93,p0.001). Conclusion both pancreaticojejunostomy and pancreaticoduodenostomy are safe and reliable methods for pancreaticoduodenal reconstruction. There was no significant difference in the incidence and severity of pancreatic fistula between pancreaticojejunostomy and pancreaticogastric anastomosis. Although the severity of gastric emptying delay was lower and the incidence of bile leakage was lower in pancreaticogastric anastomosis, there was no significant difference in total complication rate, severe complication rate and mortality rate between the two anastomoses. Postoperative pancreatic fistula risk scale is an effective tool for predicting postoperative pancreatic fistula risk. Pancreatic duct diameter 3mm is the only independent risk factor for postoperative pancreatic fistula.
【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R656

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