【作者】 成剑；

【导师】 洪德飞； 彭淑牖；

【作者基本信息】 浙江大学 ， 外科学， 2012， 硕士

【摘要】 目的应用多中心前瞻性随机对照研究方法,对胰十二指肠切除术(Pancreaticoduodenectomy,PD)中残胰消化道的重建方式——捆绑式胰肠吻合术(Binding Pancreaticojejunostomy,BPJ)、捆绑式胰胃吻合术(Binding Pancreaticogastrostomy,BPG)进行对比研究,评价两者的临床疗效。方法参与本项研究的专家小组包括浙江大学医学院附属邵逸夫医院的蔡秀军教授和洪德飞教授医疗小组、上海交通大学附属新华医院刘颖斌教授医疗小组、华中科技大学同济医学院附属同济医院秦仁义教授医疗小组、哈尔滨医科大学附属二院崔云甫教授医疗小组、浙江大学医学院附属第二医院李江涛教授医疗小组。对2009年11月至2012年1月的多中心的136例行PD患者采用前瞻性双盲随机对照试验研究方法,随机分成BPJ组和BPG两组。通过分析比较术后胰瘘、胃排空障碍、术后出血、胆漏、腹腔感染等严重并发症发生率、死亡率、再手术率以及术后肛门排气时间、进食时间、术后住院时间等康复指标,评价BPJ和BPG的临床疗效。结果本组共136例,其中BPJ组53例,BPG组83例。两组之间患者性别及年龄,既往史(包括吸烟史、饮酒史、高血压、糖尿病、既往腹部手术史)症状(腹痛、黄疸)、术前相关指标(血清淀粉酶、空腹血糖)、术前住院时间,不存在统计学差异(P>0.05),两组具有可比性。胃十二指肠溃疡病史,两组存在统计学差异(p<0.05)。对比术中相关指标(手术时间、失血量、输血量、胰腺质地、胰腺游离长度、胰管断端直径等),不存在统计学差异(P>0.05)。BPJ组与BPG组术后肛门排气时间,拔除胃管时间,进食半流质时间,术后住院时间均无显著统计学差异(P>0.05)。BPJ组53例,术后并发胃排空障碍5例,切口感染3例,胰漏6例(胰漏发生率11.3%),胆漏2例,消化道出血1例,腹腔内脓肿1例,肺炎2例,心律失常1例；术后5d因腹腔内出血、多器官功能衰竭而死亡1例(死亡率为1.9%)；BPG组患者83例,术后并发胃排空障碍11例,切口感染1例,胰漏5例(胰漏发生率为6.0%。),胆管炎1例,胆漏5例,消化道溃疡1例,肠瘘1例,腹腔内脓肿2例,肺炎7例,心律失常1例,均保守治疗痊愈出院。BPG组术后并发上消化道出血3例(术后出血率3.6%),其中有2例术后2d上消化道出血,1例术后1w上消化道出血,再次进腹探查,均发现为胰腺残端出血,予以止血后痊愈出院。无围手术期死亡(死亡率为0%)。结论BPG组胰瘘发生率低于BPJ组,BPG组胃排空障碍、胆漏并发症高于BPJ组,但均无统计学差异(P>0.05)；术后恢复指标比较也无统计学差异。与文献报告的传统胰肠吻合和胰胃吻合术比较,BPJ与BPG均是安全有效的胰消化道重建方式。更多还原

【Abstract】 Objective Through the Pancreaticoduodenectomy(PD) with residual pancreatic and digestive tract reconstruction by the way of Binding Pancreaticojejunostomy(BPJ) or Binding Pancreaticogastrostomy(BPG) combined with multi-center prospective randomized controlled clinical trials, to discuss clinical effect by comparative study of BPJ and BPG.Methods There’er total six professional study teams including Professor Xiu-Jun Cai team and Dei-Fei Hong team in SRRS Hospital Affiliated to Medical School of Zhejiang University、Professor Ying-Bin Liu team in Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine、Professor Ren-Yi Qin team in TongJi Hospital Affiliated to TongJi Medical College of Huazhong University of Science and Technology、Professor Yun-Fu Cui team in the Second Affiliated Hospital of Harbin Medical University and Professor Jiang-Tao Li in the Second Affiliated Hospital of Medical School of Zhejiang University. In this prospective double-blind randomized controlled clinical trials,136cases who underwent PD were recruited from general surgery department of multi-center between November2009and January2012.A11the patients are randomized divided into two treatment groups:BPJ group and BPG group. To evaluate the clinical effect of these two anastomosis by analyzing post-operation incidences of complication about pancreatic fistula、delayed gastric emptying、post-operative hemorrhage、bile leakage、intra-abdominal infection、 death、re-operation. Besides, post-operative recovery situation about anus exhaust time、 feeding time and post-operative hospitalization period stay were also evaluated.Results There were total136cases,53cases were with BPJ,83cases were with BPG. The two treatment groups were comparable in multiple parameters, including demographics, medical history(smoking history、drinking history、hypertension、 diabetes、previous history of abdominal operation),symptom(abdominal pain、jaundice), pre-operative laboratory values(serum amylase、abdominal induced fluid), pre-operative hospitalization time; There is not existing significant difference (P>0.05). The two groups were comparable. But the history of gastric and duodenal ulcer is existing significant difference(P<0.05).Comparing BPJ with BPG in operative time、blood loss、 blood transfusions、pancreatic texture、pancreatic free length、pancreatic duct stump diameter, there were also not existing significant difference (P>0.05). Moreover, there were not existing significant difference in post-operative anus exhaust time, taking off gastric tube time, feeding time and post-operative hospitalization period stay etc.In BPJ group among53cases, there’er complications of5gastroparesis cases,3incision infection cases、6pancreatic fistula cases(The incidence of pancreatic fistula is11.3%)、2bile leakage cases、1peptic ulcer case、1intra abdominal abscess case、2pneumonia cases and1arrhythmia case. One died because of intra abdominal hemorrhage and MODS on post-operation day5(Death rate is1.9%).83cases were with BPG, among whom11had the complication of gastroparesis、1had incision infection、5had pancreatic fistula (The incidence of pancreatic fistula is11.3%)、1had cholangitis、5had bile leakage、1had peptic ulcer、1had intestinal fistula、1had intra abdominal abscess、7had pneumonia and1had arrhythmia, all of them were treated conservatively cured.3cases had complication of hemorrhage of upper digestive tractombining occurred on the post-operation day2、2、7respectively (The incidence is3.6%). All were founded pancreatic stump bleeding after exploration. No cases with the complication of death (Death rate is0%)Conclusion The incidence of pancreatic fistula in BPG group is lower than BPJ group, the incidence of bile leakage and delayed gastric emptying in BPG is higher than BPJ. But there is not existing significant difference (P>0.05) between them. Post-operative recovery index is also not existing significant difference. Compared with traditional pancreaticogastrostomy and pancreaticojejunostomy reported, BPJ and BPG are both safe and effective ways as pancreatic and digestive tract reconstruction way in PD.更多还原