本文選題：改進(jìn)型經(jīng)典胰腸吻合　切入點(diǎn)：連續(xù)縫合　出處：《山東大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：研究背景:自1935年首次報(bào)道以來(lái),標(biāo)準(zhǔn)式胰十二指腸切除術(shù)(Pancreatico-duodenectomy,PD)逐漸在各大醫(yī)療中心開(kāi)展,給眾多罹患胰頭癌及壺腹周圍腫瘤疾病患者帶來(lái)了治愈的希望。經(jīng)過(guò)百余年的發(fā)展和改進(jìn),其中包括眾多外科學(xué)者積極參與該術(shù)式的改進(jìn)和推廣的過(guò)程中,現(xiàn)已經(jīng)成為治療胰腺腫瘤、膽管下段腫瘤、壺腹周圍腫瘤、十二指腸腫瘤及該區(qū)域外傷和其他良惡性疾病的標(biāo)準(zhǔn)術(shù)式,也是唯一可根治疾病的經(jīng)典術(shù)式。但該手術(shù)由于操作程序較復(fù)雜、涉及組織臟器較多、手術(shù)時(shí)間較長(zhǎng)、以及術(shù)前患者一般情況和局部情況較差等不利因素,導(dǎo)致術(shù)后出現(xiàn)較多且程度嚴(yán)重的并發(fā)癥,因此PD 一直是外科學(xué)界認(rèn)為最具有挑戰(zhàn)性手術(shù)之一。盡管隨著輔助檢查技術(shù)的不斷改進(jìn)、新型高科技醫(yī)療器材及藥物的研發(fā)、外科手術(shù)醫(yī)師手術(shù)技術(shù)的不斷提高以及圍手術(shù)期處理的綜合水平及臨床經(jīng)驗(yàn)的不斷積累,手術(shù)的安全性得到一定程度的提高,但與外科其他手術(shù)相比,依然存在著較高的手術(shù)風(fēng)險(xiǎn)。影響術(shù)后恢復(fù)因素眾多,而其中胰腺消化道重建是一個(gè)可控性和操作性很強(qiáng)的因素,基于胰腺消化道吻合及改進(jìn)的方法目前已報(bào)道了80多種,其中端側(cè)胰腸吻合最常見(jiàn),將其視為胰腸重建的經(jīng)典吻合方式。雖然對(duì)胰瘺等并發(fā)癥的發(fā)生率的下降起到了一定的作用,但胰腸吻合口瘺引起的相關(guān)并發(fā)癥等問(wèn)題始終未得到完美的解決。如何改進(jìn)和提高現(xiàn)有的吻合方法和處理技巧,降低胰瘺等并發(fā)癥的發(fā)生率,已成為外科學(xué)者研究的一個(gè)重大現(xiàn)實(shí)臨床課題。經(jīng)過(guò)多年的臨床實(shí)踐研究,術(shù)中胰腸吻合采用精細(xì)的縫合材料和改進(jìn)型縫合技術(shù),如Prolene線的連續(xù)縫合技術(shù),完全可以將PD術(shù)后胰瘺等并發(fā)癥及嚴(yán)重程度降至更低的水平。目的:比較標(biāo)準(zhǔn)式PD的傳統(tǒng)型經(jīng)典胰腸吻合法和改進(jìn)型經(jīng)典胰腸吻合法在臨床中應(yīng)用效果,探討其改變的過(guò)程優(yōu)勢(shì)及其對(duì)胰瘺等并發(fā)癥的影響。方法:對(duì)山東大學(xué)附屬省立醫(yī)院東院肝膽外科從2011年5月至2016年8月間成功實(shí)施了標(biāo)準(zhǔn)式PD的134例患者的臨床資料進(jìn)行了回顧性分析,術(shù)中根據(jù)胰管內(nèi)經(jīng)大小相對(duì)應(yīng)的傳統(tǒng)經(jīng)典胰腸吻合方法是否進(jìn)行改進(jìn)而分組,共分4組:A組,端側(cè)胰管-空腸粘膜吻合組,42例;B組,套入式端側(cè)胰腸吻合組,25例,C組,改進(jìn)型端側(cè)胰管-空腸粘膜吻合組,43例;D組,改進(jìn)型套入式端側(cè)胰腸吻合組,24例。所有疾病均根據(jù)臨床表現(xiàn)、實(shí)驗(yàn)室檢查、影像學(xué)資料及術(shù)后病理結(jié)果證實(shí)。比較各組術(shù)前情況(年齡、性別、疾病類型構(gòu)成、既往史、白蛋白、凝血酶原時(shí)間、總膽紅素、血清谷丙轉(zhuǎn)氨酶),術(shù)中情況(手術(shù)時(shí)間、胰腸吻合時(shí)間、出血量、胰管內(nèi)徑、胰腺質(zhì)地、輸血量)、術(shù)后并發(fā)癥(總并發(fā)癥及嚴(yán)重程度、胰瘺及其分級(jí)、腹腔出血、腹腔感染、肺部感染、膽瘺、淋巴瘺、胃排空障礙、腹瀉的發(fā)生率)、術(shù)后死亡率、術(shù)后平均住院時(shí)間、再手術(shù)率和再住院率之間的差異。采用SPSS20.0軟件進(jìn)行統(tǒng)計(jì)學(xué)分析,采用Pearsonχ2檢驗(yàn)或Fisher精確概率法;所有可能變量進(jìn)行單變量分析和P值接近0.1的變量進(jìn)行l(wèi)ogistic多因素分析,如P0.05,則表示差異具有統(tǒng)計(jì)學(xué)意義。結(jié)果:1.術(shù)前各組情況比較:四組患者的年齡、性別、Alb、ATL、T-Bil、PT、高血壓、糖尿病、腦血管疾病及疾病類型構(gòu)成無(wú)顯著統(tǒng)計(jì)學(xué)差異(P0.05)。2.術(shù)中各組情況比較:四組患者輸血量、手術(shù)的時(shí)間及胰腺的質(zhì)地均不存在統(tǒng)計(jì)學(xué)差異(P0.05),但A組的平均胰管內(nèi)徑大于B組的平均胰管內(nèi)徑0.7mm(P0.05),C組平均胰管內(nèi)徑大于D組平均胰管內(nèi)徑0.6mm(P0.05)。3.術(shù)后各組情況比較:四組患者的總體并發(fā)癥與再住院率無(wú)明顯差異(P0.05),但是根據(jù)Clavien-Dindo標(biāo)準(zhǔn),A組和B組患者的并發(fā)癥較C組和D組患者的并發(fā)癥嚴(yán)重;A組和B組患者的胰瘺發(fā)生率均明顯大于C組和D組患者的胰瘺發(fā)生率(P0.05);A組和B組患者比C組和D組患者術(shù)后更易出現(xiàn)胃排空障礙(P0.05);其他術(shù)后并發(fā)癥無(wú)明顯差異。A組患者的平均住院天數(shù)較C組患者延長(zhǎng)了 7天(P0.05),B組患者的平均住院天數(shù)比D組患者延長(zhǎng)了 6天(P0.05);相比于C組及D組患者,A組患者的再次手術(shù)風(fēng)險(xiǎn)較高(P0.05);A組患者術(shù)后死亡率比C組高(P0.05)。4.危險(xiǎn)因素分析:性別、疾病類型、主胰管內(nèi)徑為胰瘺發(fā)生的獨(dú)立危險(xiǎn)因子,對(duì)于主胰管3.0mm的患者的胰瘺發(fā)生率(54.2%)明顯高于主胰管3.0mm的胰瘺發(fā)生率(29.1%)(P0.05)。另外,相比與患有其他疾病的患者,胰腺腫瘤或慢性胰腺炎的患者擁有更低的胰瘺發(fā)生率(P0.01)。結(jié)論:胰腸吻合使用Prolene線的連續(xù)縫合技術(shù)替代傳統(tǒng)外科縫線蠶絲線的間斷縫合技術(shù),并根據(jù)胰管內(nèi)徑的大小選擇相應(yīng)合適的胰腸吻合方式,可降低術(shù)后胰瘺發(fā)生率及相關(guān)并發(fā)癥的嚴(yán)重程度,明顯縮短了患者住院時(shí)間。
[Abstract]:Background: since the first report of 1935, standard pancreaticoduodenectomy (Pancreatico-duodenectomy, PD) is gradually carried out in the medical center, brings hope to cure many suffering from pancreatic head carcinoma and periampullary tumor disease. After more than 100 years of development and improvement, including many scholars actively participate in the surgical operation the improvement and promotion process, has become the treatment of pancreatic cancer, bile duct cancer, periampullary cancer, standard operation and the traumatic duodenal tumor and other benign and malignant diseases, and only can cure the disease. But the classical surgical operation because the operation procedure is more complicated, involving many organs, the operation time is longer, and the preoperative general condition of patients and the local poor and other unfavorable factors, and lead to more serious complications, so PD has been That surgery is one of the most challenging operation. Although with the improvement of auxiliary examination technology, the development of new high-tech medical equipment and drugs, the accumulation of technology surgery doctors surgery as well as the improvement of the comprehensive level of perioperative treatment and clinical experience, the safety of the operation has been improved to a certain extent, but compared to and other surgical operations, there is still a high risk operation. Postoperative recovery effect of many factors, including pancreatic digestive tract reconstruction is a controllable and strong operational factors, methods of elimination and improvement of pancreatic anastomosis based on the reported more than 80, of which the most common end to side pancreaticojejunostomy that will be regarded as pancreatic enteric reconstruction classic anastomosis of pancreatic fistula. Although the incidence rate of decline has played a certain role, but the pancreatic fistula caused by complications Such problem has not been perfectly solved. How to improve and enhance the existing method of anastomosis and processing skills, reduce the incidence of complications such as pancreatic fistula, surgery has become a major research topic. The clinical reality after years of clinical practice study, the fine suture material and improved suture anastomosis of pancreatic intestinal surgery in the continuous suture technique such as Prolene line, can be reduced to pancreatic fistula and other complications and severity of postoperative PD level. Objective: the traditional classic pancreatojejunal compared to standard PD anastomosis and improved classical pancreaticojejunostomy in clinical application, to explore the process of changing the advantages and its influence the pancreatic fistula and other complications. Methods: the Provincial Hospital Affiliated to Shandong University Hospital Department of hepatobiliary surgery from May 2011 to August 2016 the East between the successful implementation of the clinical data of 134 cases of standard type PD patients were 鍥為【鎬у垎鏋，

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