套入式肝腸吻合在困難的膽道重建中的應用
發(fā)布時間：2018-09-19 09:04
【摘要】：目的研究胰十二指腸切除術中困難的膽腸吻合病人的臨床特點、病理特征,評估不同引流方式對困難的膽腸吻合術后近期并發(fā)癥的發(fā)病率,深入了解不同膽道重建方式在膽腸吻合術中的優(yōu)劣。 背景在腹部外科中,胰十二指腸切除術(PD)雖然是一種難度較大的手術。但卻是根治胰頭癌、壺腹周圍癌、十二指腸癌等的重要手術方法,由于該術式創(chuàng)傷大,術后并發(fā)胰瘺、膽漏等并發(fā)癥的機會較高,住院時間長,費用高。目前針對如何減少胰十二指腸切除術后胰瘺發(fā)病率的研究已經(jīng)很多,并且已經(jīng)有達成共識的胰瘺定義及分級方法,但針對膽漏的研究則并不多見。對于困難的膽腸吻合中膽道重建方法仍存在爭議。 方法回顧性收集我科1995年1月至2013年12月行胰十二指腸切除術并肝總管直徑小于8mm病例共51例,以膽道重建的不同方式分成三組,對照組為行傳統(tǒng)的膽腸吻合的病人(n=19),實驗組一為套入式肝腸吻合組(n=15),實驗組二為放置T管組(n=17),收集整理病人臨床資料,包括性別、年齡、BMI、術后天數(shù)、術前麻醉ASA評分、肝總管直徑、病變良惡性及部位以及術后并發(fā)癥的發(fā)病率等內容。最后行統(tǒng)計學分析比較。 結果傳統(tǒng)吻合組19例病人(男性10例/女性9例,52±10歲,BMI21.5±2.6),套入式吻合組15例(男性7/女性8例,50±9歲,BMI20.44±2.2),T管組17例(男性12/女性5例,54±9歲,BMI21.44±2.9),三組之間在人口學特征上沒有統(tǒng)計學差異(p0.05)。三組病人術前ASA評分、病變良惡性及病變部位、肝總管直徑也沒有統(tǒng)計學差異(p0.05)。三組病人術后并發(fā)癥發(fā)病率僅在術后膽漏上有差異,其中傳統(tǒng)膽腸吻合組為31%(6/19),套入式吻合組15例病人沒有病人發(fā)生膽漏,T管組為35%(6/17)[P=0.037],套入式吻合組膽漏發(fā)病率低于傳統(tǒng)吻合組(p=0.016)及T管組(p=0.011),傳統(tǒng)吻合組和T管組的膽漏發(fā)病率無差異(p=0.813)。膽漏與術后住院天數(shù)、死亡率以及術后出血、傷口感染、術后胰瘺、腹腔積液、敗血癥、膽管炎的發(fā)病率有關。7%(4/51)的病人需要再次手術(傳統(tǒng)吻合組21%[4/19]vs套入式吻合組0[0/15]vsT管組0[0/17],p=0.026)。12%(1/17)的病人出現(xiàn)T管相關并發(fā)癥。 結論胰十二指腸切除術中在膽腸吻合口無論是套入式肝腸吻合或放置T管在術后總并發(fā)癥發(fā)病率上并沒有差異,但是在Clavien-Dindo分級4a級以上的并發(fā)癥中,套入式吻合組和T管組的發(fā)病率要低于傳統(tǒng)吻合組。此外,行套入式肝腸吻合可降低術后膽漏發(fā)病率,但放置T管并不能降低膽漏發(fā)病率,因此我們認為在胰十二指腸切除術困難的膽道重建中行套入式肝腸吻合可以有效減少術后膽道并發(fā)癥的發(fā)生,有利于病人術后康復。 目的探討套入式肝腸吻合在輔助性肝移植膽道重建中的應用及體會,提高膽道重建的技術。 方法對2008年1月到2013年12月10例輔助性肝移植膽道重建病例的臨床資料進行分析。共行肝腸吻合6例(60%),均行套入式肝腸吻合并根據(jù)情況放置膽管支撐管；膽道對膽道吻合4例(40%),1例放置膽管支撐管,熱缺血時間3.6±1.6分鐘,冷缺血時間6.3±2.5小時,膽道重建時間25±5min。術后采用他克莫司+驍悉+強的松三聯(lián)免疫抑制方案,評價膽道重建的方式、膽道重建時間、術后膽道并發(fā)癥的資料。隨訪時間為術后3個月。 結果術后隨訪3月沒有病人出現(xiàn)膽道并發(fā)癥。 結論套入式肝腸吻合是輔助性肝移植術復雜膽道重建的一種有效方式,具有術后膽道并發(fā)癥少的優(yōu)點。
[Abstract]:Objective To study the clinical and pathological characteristics of patients with difficult biliary-enteric anastomosis in pancreaticoduodenectomy, and to evaluate the incidence of complications after different drainage methods for difficult biliary-enteric anastomosis.
Background In abdominal surgery, pancreaticoduodenectomy (PD) is a difficult operation, but it is an important surgical method for radical treatment of pancreatic head cancer, periampullary cancer, duodenal cancer, etc. Because of its great trauma, postoperative complications such as pancreatic fistula, bile leakage have a higher chance, long hospital stay and high cost. The incidence of pancreatic fistula after pancreaticoduodenectomy has been studied extensively, and there has been a consensus on the definition and classification of pancreatic fistula, but the study of bile leakage is rare.
Methods 51 cases of pancreaticoduodenectomy with common hepatic duct diameter less than 8 mm from January 1995 to December 2013 in our department were retrospectively collected and divided into three groups according to different ways of biliary reconstruction. The control group was treated with traditional biliary-enteric anastomosis (n=19), the experimental group was treated with nested hepato-enteric anastomosis (n=15), and the experimental group was treated with T-tube placement (n=17). The clinical data of the patients were collected, including sex, age, BMI, postoperative days, preoperative ASA score, common hepatic duct diameter, benign and malignant lesions, location and incidence of postoperative complications.
Results There were 19 patients in the traditional anastomosis group (10 males / 9 females, 52 + 10 years old, BMI 21.5 + 2.6), 15 patients in the nested anastomosis group (7 males / 8 females, 50 + 9 years old, BMI 20.44 + 2.2), 17 patients in the T tube group (12 males / 5 females, 54 + 9 years old, BMI 21.44 + 2.9). There was no significant difference in demographic characteristics among the three groups (p0.05). There was no significant difference in the diameter of the common hepatic duct between benign and malignant lesions (p0.05). The incidence of postoperative complications was only different among the three groups. The incidence of biliary leakage was 31% (6/19) in the traditional bilioenterostomy group, 35% (6/17) in the T-tube group, and 35% (6/17) in the nested bilioenterostomy group. There was no significant difference in the incidence of biliary leakage between the traditional anastomosis group (p = 0.016) and the T-tube group (p = 0.011). Bile leakage was associated with postoperative hospital stay, mortality, postoperative bleeding, wound infection, postoperative pancreatic fistula, peritoneal effusion, sepsis, and cholangitis in 21% of the patients in the traditional anastomosis group (p = 0.813). T-tube-related complications occurred in 0[0/17], p=0.026.12% (1/17) of patients in the 0[0/15] vs T-tube group.
Conclusion There was no significant difference in the incidence of postoperative complications between the two groups in pancreaticoduodenectomy. However, the incidence of complications above Clavien-Dindo grade 4A was lower in the two groups than in the traditional group. To reduce the incidence of postoperative biliary leakage, but the placement of T-tube can not reduce the incidence of biliary leakage. Therefore, we believe that nested hepatoenterostomy can effectively reduce the incidence of postoperative biliary complications in difficult biliary reconstruction after pancreaticoduodenectomy and is conducive to postoperative rehabilitation.
Objective To explore the application and experience of nested hepatointestinal anastomosis in biliary tract reconstruction of auxiliary liver transplantation and to improve the technique of biliary tract reconstruction.
Methods The clinical data of 10 cases of biliary tract reconstruction after auxiliary liver transplantation from January 2008 to December 2013 were analyzed. Six cases (60%) underwent hepatointestinal anastomosis, all of them underwent hepatointestinal anastomosis and biliary duct support tube placement according to the situation; 4 cases (40%) underwent biliary tract to biliary anastomosis, 1 case underwent biliary duct support tube placement, warm ischemia time was 3.6 (+ 1.6 minutes) and cold ischemia time was 3.6 The interval was 6.3 (+ 2.5 hours) and the time of biliary reconstruction was 25 (+ 5 minutes). The method of biliary reconstruction, the time of biliary reconstruction and the complications of biliary tract reconstruction were evaluated with tacrolimus + mycophenolate + prednisone immunosuppressive regimen. The follow-up time was 3 months.
Results no biliary complications occurred in March.
Conclusion Intratheter hepatointestinal anastomosis is an effective method for complicated biliary reconstruction in liver transplantation, and it has the advantage of less postoperative biliary complications.
【學位授予單位】：華中科技大學
【學位級別】：博士
【學位授予年份】：2014
【分類號】：R657.3;R657.4
本文編號：2249675
[Abstract]:Objective To study the clinical and pathological characteristics of patients with difficult biliary-enteric anastomosis in pancreaticoduodenectomy, and to evaluate the incidence of complications after different drainage methods for difficult biliary-enteric anastomosis.
Background In abdominal surgery, pancreaticoduodenectomy (PD) is a difficult operation, but it is an important surgical method for radical treatment of pancreatic head cancer, periampullary cancer, duodenal cancer, etc. Because of its great trauma, postoperative complications such as pancreatic fistula, bile leakage have a higher chance, long hospital stay and high cost. The incidence of pancreatic fistula after pancreaticoduodenectomy has been studied extensively, and there has been a consensus on the definition and classification of pancreatic fistula, but the study of bile leakage is rare.
Methods 51 cases of pancreaticoduodenectomy with common hepatic duct diameter less than 8 mm from January 1995 to December 2013 in our department were retrospectively collected and divided into three groups according to different ways of biliary reconstruction. The control group was treated with traditional biliary-enteric anastomosis (n=19), the experimental group was treated with nested hepato-enteric anastomosis (n=15), and the experimental group was treated with T-tube placement (n=17). The clinical data of the patients were collected, including sex, age, BMI, postoperative days, preoperative ASA score, common hepatic duct diameter, benign and malignant lesions, location and incidence of postoperative complications.
Results There were 19 patients in the traditional anastomosis group (10 males / 9 females, 52 + 10 years old, BMI 21.5 + 2.6), 15 patients in the nested anastomosis group (7 males / 8 females, 50 + 9 years old, BMI 20.44 + 2.2), 17 patients in the T tube group (12 males / 5 females, 54 + 9 years old, BMI 21.44 + 2.9). There was no significant difference in demographic characteristics among the three groups (p0.05). There was no significant difference in the diameter of the common hepatic duct between benign and malignant lesions (p0.05). The incidence of postoperative complications was only different among the three groups. The incidence of biliary leakage was 31% (6/19) in the traditional bilioenterostomy group, 35% (6/17) in the T-tube group, and 35% (6/17) in the nested bilioenterostomy group. There was no significant difference in the incidence of biliary leakage between the traditional anastomosis group (p = 0.016) and the T-tube group (p = 0.011). Bile leakage was associated with postoperative hospital stay, mortality, postoperative bleeding, wound infection, postoperative pancreatic fistula, peritoneal effusion, sepsis, and cholangitis in 21% of the patients in the traditional anastomosis group (p = 0.813). T-tube-related complications occurred in 0[0/17], p=0.026.12% (1/17) of patients in the 0[0/15] vs T-tube group.
Conclusion There was no significant difference in the incidence of postoperative complications between the two groups in pancreaticoduodenectomy. However, the incidence of complications above Clavien-Dindo grade 4A was lower in the two groups than in the traditional group. To reduce the incidence of postoperative biliary leakage, but the placement of T-tube can not reduce the incidence of biliary leakage. Therefore, we believe that nested hepatoenterostomy can effectively reduce the incidence of postoperative biliary complications in difficult biliary reconstruction after pancreaticoduodenectomy and is conducive to postoperative rehabilitation.
Objective To explore the application and experience of nested hepatointestinal anastomosis in biliary tract reconstruction of auxiliary liver transplantation and to improve the technique of biliary tract reconstruction.
Methods The clinical data of 10 cases of biliary tract reconstruction after auxiliary liver transplantation from January 2008 to December 2013 were analyzed. Six cases (60%) underwent hepatointestinal anastomosis, all of them underwent hepatointestinal anastomosis and biliary duct support tube placement according to the situation; 4 cases (40%) underwent biliary tract to biliary anastomosis, 1 case underwent biliary duct support tube placement, warm ischemia time was 3.6 (+ 1.6 minutes) and cold ischemia time was 3.6 The interval was 6.3 (+ 2.5 hours) and the time of biliary reconstruction was 25 (+ 5 minutes). The method of biliary reconstruction, the time of biliary reconstruction and the complications of biliary tract reconstruction were evaluated with tacrolimus + mycophenolate + prednisone immunosuppressive regimen. The follow-up time was 3 months.
Results no biliary complications occurred in March.
Conclusion Intratheter hepatointestinal anastomosis is an effective method for complicated biliary reconstruction in liver transplantation, and it has the advantage of less postoperative biliary complications.
【學位授予單位】：華中科技大學
【學位級別】：博士
【學位授予年份】：2014
【分類號】：R657.3;R657.4
【參考文獻】
相關期刊論文 前2條
1 ;A ten-year study on non-surgical treatment of postoperative bile leakage[J];World Journal of Gastroenterology;2002年05期
2 Maria C Londo濼o;Domingo Balderramo;Andrés Cárdenas;;Management of biliary complications after orthotopic liver transplantation:The role of endoscopy[J];World Journal of Gastroenterology;2008年04期
，本文編號：2249675
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