本文選題：腹腔鏡　切入點：保留脾臟　出處：《浙江大學》2015年碩士論文　論文類型：學位論文

【摘要】：研究目的：1.評價腹腔鏡保留脾臟胰體尾切除術(shù)的安全性、可行性。2.探究腹腔鏡保留脾臟胰體尾切除術(shù)(Kimura法)脾血管的通暢狀態(tài)和脾臟保留的必要性。 研究方法：分析2004年3月到2014年12月間本中心行腹腔鏡胰體尾切除術(shù)病例的臨床資料,并進行隨訪。排除胰腺腺癌、中轉(zhuǎn)開腹、Warshaw法保留脾臟的病例。根據(jù)是否保留脾臟分為腹腔鏡保留脾臟胰體尾切除(Laparoscopic Spleen-Preserving Distal Pancreatectomy, LSPDP)組和腹腔鏡胰體尾聯(lián)合脾臟切除未(Laparoscopic Distal Pancreatosplenectomy, LDPS)組。通過對比分析兩組患者的近期手術(shù)結(jié)果對LSPDP的安全性、可行性進行評價。通過對兩組白細胞(White blood cell, WBC)、血紅蛋白(Hemoglobin, Hgb)、血小板(Platelet, PLT)、C反應蛋白(C-reactive protein, CRP)等對比分析以及LSPDP術(shù)后脾血管通暢性來評估保留的脾臟功能。此外,根據(jù)LSPDP組脾血管通暢程度分級進而分成2組,即：A組(0級：完全通暢)與B組(1級：脾血管局部栓塞或狹窄),并對兩組進行多因素對比篩選,分析脾血管通暢的影響因素。 研究結(jié)果：兩組共119例患者,其中LSPDP組59例,LDPS組60例。兩組的性別、年齡、BMI指數(shù)、術(shù)前癥狀、合并癥、腹部手術(shù)史、術(shù)前ASA分級均無顯著性差異(P0.05)。 術(shù)中相關指標：對比LDPS組,LSPDP組手術(shù)時間(174.2±61.4分鐘vs191.4±49.4分鐘,P=0.098)減少、術(shù)中出血量(116.4±150.9mlvs229.0±233.7ml,P=0.002)減少,兩組術(shù)中輸血量上差異無統(tǒng)計學意義(P0.05)。 術(shù)后恢復方面：LSPDP組術(shù)后總體并發(fā)癥率高于LDPS組(72.9%vs53.3%,P=0.021)。嚴重并發(fā)癥(≥Grade Ⅲ)(10.2%vs10.0%, P0.05)、胰瘺(特別是≥Grade B:28.8%vs21.7%, P=0.469)、術(shù)后出血(P=0.311)、感染(P=0.445)等發(fā)生率無顯著性差異。LSPDP組術(shù)后下床時間、術(shù)后肛門排氣時間、術(shù)后進流質(zhì)時間、術(shù)后住院天數(shù)與LDPS組均無顯著性差異。 術(shù)后脾臟功能：LSPDP組及LDPS組白細胞和血小板分別為術(shù)后3天和14天達到頂峰。因此,我們將兩組的術(shù)后3天WBC,術(shù)后14天PLT進行分級比較：LDPS組WBC≥10*109/L的病例明顯多于LSPDP組(67.8%vs23.7%,P=0.000),PLI≥300*109/L的病例明顯多于LSPDP組(61.7%vs46.7%,P=0.000) 脾血管通暢性：LSPDP組中,59例患者中術(shù)前CT顯示脾血管均顯示完全通暢,0級。于術(shù)后早期(1～3月)復查發(fā)現(xiàn)脾動脈1級為15人,0級44人。在術(shù)后3～6月再次復查,發(fā)現(xiàn)15人中有6人轉(zhuǎn)變?yōu)?級。術(shù)后早期(1～3月)復查脾靜脈1級為18人,0級41人。在術(shù)后3～6月再次復查發(fā)現(xiàn)18人中有5人轉(zhuǎn)變?yōu)?級。 對比完全通暢組與不完全通暢組,性別、年齡、BMI指數(shù)、術(shù)前癥狀、合并癥、腹部手術(shù)史、術(shù)前ASA分級、術(shù)中出血量、有無輸血/病理類型、腫瘤位置、腫瘤大小、切除胰腺長度差異均無統(tǒng)計學意義,其中并發(fā)癥分級(P=0.026)有統(tǒng)計學意義,手術(shù)時間(P=0.084)有差異,但未達到統(tǒng)計學意義。 結(jié)論：1.保留血管的腹腔鏡保留脾臟胰體尾切除術(shù)在技術(shù)上安全可行的,適用于胰腺良性、交界性腫瘤。2.腹腔鏡保留脾臟胰體尾切除術(shù)(Kimura法)后能有效保證脾臟灌注,保留的脾臟減少了血液系統(tǒng)的干擾。3.術(shù)后并發(fā)癥為保留的脾血管通暢的高危因素。
[Abstract]:Research purposes: 1.. Evaluate the safety and feasibility of laparoscopic splenectomy for distal pancreatectomy..2. explored the necessity of laparoscopic preservation of splenic pancreatic body and tail resection (Kimura), the patency of splenic vessels and the necessity of spleen preservation.
Methods: from March 2004 to December 2014 the analysis center for clinical data of laparoscopic distal pancreatectomy were excluded, and were followed up. Pancreatic adenocarcinoma, laparotomy, Warshaw spleen preserving cases. According to whether the preservation of the spleen were divided into laparoscopic spleen preserving distal pancreatectomy (Laparoscopic Spleen-Preserving Distal Pancreatectomy, LSPDP) and group laparoscopic distal pancreatectomy combined with splenectomy (Laparoscopic Distal Pancreatosplenectomy, not LDPS) group. Through the comparative analysis of two groups of patients with recent surgical results of the safety of LSPDP, evaluate the feasibility. The two groups of white blood cells (White blood cell, WBC), hemoglobin (Hemoglobin, Hgb), platelet (Platelet, PLT) C, C-reactive protein (C-reactive protein, CRP and LSPDP) were compared after surgery to assess the patency of spleen preserving splenic function. In addition, according to LSPDP The degree of splenic vascular patency was further divided into 2 groups: group A (level 0: complete patent) and group B (Level 1: local embolization or stenosis of splenic vessels), and two groups were screened by multiple factors to analyze the influencing factors of patency of splenic vessels.
Results: there were 119 cases in two groups, including 59 cases in group LSPDP and 60 cases in group LDPS. There was no significant difference in gender, age, BMI index, preoperative symptoms, complications, abdominal operation history and preoperative ASA grading in two groups (P0.05).
Intraoperative related indicators: compared with group LDPS, operation time in group LSPDP (174.2 + 61.4 minutes vs191.4 + 49.4 minutes, P=0.098) decreased, and intraoperative blood loss (116.4 + 150.9mlvs229.0 + 233.7ml, P=0.002) decreased. There was no significant difference in blood transfusion volume between two groups (P0.05).
Recovery of postoperative overall complications after operation in LSPDP group was higher than that of group LDPS (72.9%vs53.3%, P=0.021). Serious complications (Grade III) (10.2%vs10.0%, P0.05), pancreatic fistula (especially Grade or B:28.8%vs21.7%, P=0.469), postoperative bleeding, infection (P=0.311) (P= 0.445), there was no time to get out of bed significant differences in.LSPDP group after operation, postoperative anal exhaust time, postoperative advanced liquid time, postoperative hospital stay and LDPS group showed no significant difference.
The spleen function after operation: LSPDP group and LDPS group of white blood cells and platelets respectively peaked 3 days and 14 days after operation. Therefore, we will be in the two groups after 3 days WBC, 14 days after operation PLT classification comparison: LDPS group WBC = 10*109/L were significantly more than group LSPDP (67.8%vs23.7%, P=0.000) PLI, more than 300*109/L were significantly higher than those of group LSPDP (61.7%vs46.7%, P=0.000)
Splenic vascular patency: in group LSPDP, 59 cases of patients with preoperative CT showed splenic vessels showed complete patency, 0. In early postoperative period (1~3 months) were found 1 splenic artery for 15 people, 0 people in 44. After 3~6 months to check again, found that 15 people in 6 turn to 0. Early postoperative period (1~3 months) were 1 splenic vein for 18 people, 0 people in 41. After 3~6 months to check again found 18 people in 5 to 0.
Comparison of complete and incomplete patency group patency group, gender, age, BMI index, preoperative symptoms, complications, history of abdominal surgery, preoperative ASA classification, the amount of bleeding, blood transfusion and pathological type, tumor location, tumor size, pancreatic resection length had no significant difference, the complications (grade P=0.026) had statistical significance (P=0.084), the operation time is different, but the difference was not statistically significant.
Conclusion: Laparoscopic spleen preserving 1. arteries preserved pancreatectomy is technically feasible and safe, suitable for pancreatic benign, borderline tumor.2. laparoscopic spleen preserving distal pancreatectomy (Kimura) can effectively guarantee the splenic perfusion, risk factors of retention of spleen reduced blood disturbance.3. complications the spleen retained patency.

【學位授予單位】：浙江大學
【學位級別】：碩士
【學位授予年份】：2015
【分類號】：R657.5

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本文編號：1566571