腹腔镜胰十二指肠切除术后并发症处理经验

摘要

目的 探讨腹腔镜胰十二指肠切除术(LPD)术后并发症的发生情况及防治经验.方法 回顾性分析2012年9月至2017年9月同一团队在浙江省人民医院和浙江大学医学院附属邵逸夫医院实施的320例LPD患者的临床资料,男性196例,女性124例,年龄(60.2±11.6)岁.行标准LPD306例,扩大LPD 14例.按照手术时间的先后顺序,分为前期组(160例)和后期组(160例).后期组患者术前有腹部手术史的比例为30.0％ (48/160),高于前期组的18.8％ (30/160)(x2=5.49,P=0.019),两组其余一般资料的差异均无统计学意义(P值均＞0.05).对可切除病变,采用“No Back”策略行LPD,遵循“从足端到头端、从前到后、从左到右”的原则进行手术;对于门静脉前的胰后隧道无法贯通者,即交界可切除病变患者,采用“Easy First”策略行LPD.两组患者计量资料的组间比较采用Studentt检验,计数资料的比较采用x2检验或Fisher确切概率法.结果 320例患者中,306例行标准LPD,14例联合其他器官切除;278例采用“No Back”策略完成,42例因胰后隧道难以贯通而采用“Easy First”策略完成.后期组手术时间[(346.6±48.8)min]少于前期组[(358.0±54.4) min](t=1.97,P=0.048).前期组和后期组的术中出血量分别为(207.9±135.8)ml和(189.6±121.4)ml,差异无统计学意义(P=0.205);但后期组术中出血量＜200 ml的患者比例(47.5％,76/160)少于前期组(59.4％,95/160)(x2=4.53,P=0.033).后期组术后总体并发症发生率为28.8％ (46/160),较前期组的35.6％(57/160)有下降趋势,但差异无统计学意义(P=0.188).后期组腹腔感染率为1.9％(3/160),低于前期组的6.3％(10/160)(x2=3.93,P=0.047).两组术后住院时间的差异亦无统计学意义(P=0.156).结论 LPD术后常见并发症为胰瘘和出血.组建攻关团队,逐渐积累手术经验,严密监测,认真分析并发症发生的原因,进行技术改进,LPD术后并发症发生率可进一步降低.%Objective To summarize the incidence and characteristics of postoperative complications after laparoscopic pancreaticoduodenectomy (LPD),and to share our experience on management of complications.Methods The clinical data of 320 LPD performed by a single team in Sir Run Run Shaw Hospital and Zhejiang Provincial People's Hospital between September 2012 and September 2017 were retrospectively analyzed,among which there were 196 males and 124 females with age of (60.2± 11.6) years old.There were 306 patients who underwent standard LPD,and 14 patients who underwent extended LPD.The patients were divided into 2 groups of former 160 LPD and later 160 LPD according to the time order.By analyzing the differences of clinical outcomes between the two groups,especially focusing on the incidence of postoperative complications.The experience on management of complications was concluded.The prior surgical history of latter group was significantly higher than the former group (30.0％ (48/160)vs.18.8％(30/160),x2 =5.49,P=0.019),and the rest of baseline characteristics remained the comparable (P＞0.05).For resectable lesions,LPD was performed by "No back" approach,following the principle of "From distal to cephalad,from ventral to dorsal,and from left to right".As for the borderline resectable patients,LPD was performed by "Easy first" strategy.Student t test,x2 test or Fisher test was used to analyzed the data between thetwo groups respectively.Results Of 320 LPD patients,306 cases underwent standard LPD,14 cases underwent LPD with resection of other organs.There were 278 LPD cases who followed "No back" approach,and 42 cases who followed "Easy first" strategy because of difficulty in creating the retro-pancreatic tunnel.And the overall morbidity was 32.2％ (103/320) with reoperation rate of 5.3％(17/320).The perioperative mortality was 0.6％(2/320).The operation time of latter group was ((346.6±48.8)minutes),which was shorter than that of former group((358.0±54.4)minutes) (t=1.97,P=0.048).The blood loss of former and latter group remained comparable((207.9±135.8)ml vs.(189.6± 121.4)ml,P=0.205).However,in subgroup analysis,the patients with blood loss less ＜200 ml of latter group decreased significantly from 59.4％ (95/160) to 47.5％ (76/160) (x2 =4.53,P =0.033).The overall morbidity of latter group was 28.8％ (46/160),indicated a decrease from 35.6％ (57/160) of former group without significant difference (P =0.188).Moreover,Grade A/B/C pancreatic fistula rate,Grade A/C bile leakage rate,Grade B/C postoperative hemorrhage rate of the later group tended to decrease,although they also didn't reach a significant difference.However,the abdominal infection rate decreased significantly (x2 =3.93,P =0.047).The length of hospital stay remained comparable (P =0.156).Conclusions The most common complications after LPD were postoperative hemorrhage and pancreatic fistula.With specialized team and accumulated experience,the morbidity can decrease progressively by analyzing the leading cause and improving the technical skills.