紀(jì)偉平　邵卓　宋彬　馬洪運(yùn)　胡先貴　金鋼　畢建威

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·論著·

雙層連續(xù)縫合法行胰腺空腸吻合在胰十二指腸切除術(shù)中的應(yīng)用

紀(jì)偉平邵卓宋彬馬洪運(yùn)胡先貴金鋼畢建威

200433上海，第二軍醫(yī)大學(xué)長海醫(yī)院普外科

【摘要】目的探討胰十二指腸切除術(shù)中雙層連續(xù)縫合法行胰腺空腸吻合的應(yīng)用價(jià)值。方法回顧性分析2012年7月至2013年6月間上海長海醫(yī)院收治的114例連續(xù)行胰十二指腸切除術(shù)患者的資料,其中有79例采用雙層連續(xù)縫合法行胰空腸吻合，35例采用雙層間斷縫合法行胰空腸吻合,對比兩種方法的的手術(shù)時(shí)間、術(shù)中失血量、術(shù)后進(jìn)食時(shí)間、術(shù)后住院時(shí)間和術(shù)后胰瘺發(fā)生情況。結(jié)果雙層連續(xù)縫合組和雙層間斷縫合組的手術(shù)時(shí)間分別為(284±5)、(288±7)min，術(shù)中出血量分別為(236±29)、(282±49)ml，兩組間差異均無統(tǒng)計(jì)學(xué)意義。術(shù)后進(jìn)食時(shí)間分別為(7.8±0.5)、(9.7±0.5)d，住院天數(shù)為(14.0±1.0)、(17.2±10.0)d，術(shù)后胰瘺發(fā)生率分別為17.1%(6/35)、39.2%(31/79)，兩組間差異均有統(tǒng)計(jì)學(xué)意義(P值均<0.05)。雙層連續(xù)縫合組A級胰瘺4例(11.4%)，B級胰瘺1例(2.9%)，C級胰瘺1例(2.9%)；雙層間斷縫合組分別為5例(6.3%)、23例(29.1%)、3例(3.8%)。兩組術(shù)后30 d內(nèi)均無死亡病例。結(jié)論雙層連續(xù)縫合法可安全應(yīng)用于胰空腸吻合，術(shù)后進(jìn)食時(shí)間、住院天數(shù)、胰瘺發(fā)生率均顯著低于雙層間斷縫合法，值得在臨床推廣應(yīng)用。

【關(guān)鍵詞】胰十二指腸切除術(shù)；胰管空腸吻合術(shù)；縫合技術(shù)

Fund program: Changhai Hospital "1255" Disciphine Project(CH125542400)

胰十二指腸切除術(shù)后胰瘺一直是困擾著胰腺外科醫(yī)師的難題。大部分胰瘺發(fā)生在胰空腸吻合處，因此，多年來外科醫(yī)師在胰空腸吻合上做了大量的研究和實(shí)踐，應(yīng)用了多種不同的吻合方式以盡量減少術(shù)后胰瘺的發(fā)生[1]，但目前為止尚無發(fā)現(xiàn)“零胰瘺”的吻合方式。本研究回顧性分析2012年7月至2013年6月期間114例連續(xù)行胰十二指腸切除術(shù)的患者資料，發(fā)現(xiàn)雙層連續(xù)縫合胰空腸吻合法在預(yù)防術(shù)后胰瘺上明顯優(yōu)于雙層間斷縫合法，現(xiàn)報(bào)告如下。

資料與方法

一、一般資料

收集2012年7月至2013年6月間上海長海醫(yī)院胰腺外科連續(xù)行胰十二指腸切除術(shù)的114例患者資料，其中男性67例，女性47例，年齡33～78歲，平均59歲；腺癌112例，黏液腺癌1例，神經(jīng)內(nèi)分泌癌1例；高分化癌5例，中分化癌89例，低分化癌20例；T1期37例、T2期76例、T3期1例，N0期79例、N1期35例，M0期113例、M1期1例；ⅠA期29例，ⅠB期47例，ⅡA期1例，ⅡB期36例，Ⅳ期1例。

二、手術(shù)方法

114例均行保留幽門胰十二指腸切除術(shù)，采用Child消化道重建方式。術(shù)中在門靜脈左側(cè)2 cm處切斷胰腺并完整切除鉤突，胃幽門下2 cm和Treitz韌帶遠(yuǎn)端離斷十二指腸，切除肝總管以下的膽管、膽囊，骨骼化清除肝動(dòng)脈、門靜脈、腹腔動(dòng)脈周圍軟組織及淋巴結(jié)，置入適當(dāng)大小的硅膠引流管于主胰管空腸吻合處。

胰管空腸吻合分為雙層連續(xù)縫合組和雙層間斷縫合組。雙層連續(xù)縫合35例，用3-0的Prolene線連續(xù)縫合胰腺后壁和空腸漿膜層、肌層，將兩者緩慢靠攏，縫合時(shí)腸邊距和胰腺邊距各為1 cm，針間距為0.5 cm，胰腺后壁和空腸收攏后放置3-0的Prolene線于胰腸吻合口上下方；在近主胰管空腸戳孔，以3-0的Prolene線連續(xù)縫合主胰管后壁和空腸入孔處近主胰管半邊黏膜，縫合時(shí)腸黏膜邊距和胰管邊距各為0.2 cm，針間距為0.2 cm，注意縫合空腸壁全層和帶入主胰管旁0.2 cm胰腺組織，置入適當(dāng)?shù)墓枘z引流管支撐胰液入腸，再將3-0的Prolene線連續(xù)縫合主胰管前壁和空腸入孔處近前半邊黏膜，做到主胰管和空腸黏膜對黏膜吻合，最后提起3-0的Prolene線完成胰腺前壁和空腸漿膜層、肌層的連續(xù)縫合(圖1)。雙層間斷縫合79例，用3-0的Prolene線間斷縫合做胰空腸吻合，其他操作如連續(xù)縫合(圖2)。

圖1雙層連續(xù)縫合示意圖1A: 胰腺斷端與空腸吻合處的連續(xù)端側(cè)縫合(后壁)；1B: 術(shù)中實(shí)際操作圖:①胰腺殘端，②空腸，③胰管和空腸間的支撐管，④胰腺上下緣牽引線，⑤胰腺后壁與空腸漿膜層連續(xù)縫合后縫合線的兩頭，⑥胰管與空腸黏膜層連續(xù)縫合后縫合線的兩頭(后壁)；1C:連續(xù)端側(cè)縫合完成后效果圖；1D:1C實(shí)際的操作圖：①胰腺殘端，②空腸，③胰腺上下緣的牽引線，④胰腺與空腸漿膜層連續(xù)縫合后的線頭，縫合針數(shù)按照手術(shù)中實(shí)際需求，⑤胰腺與空腸的緊密吻合

圖2雙層間斷縫合示意圖2A: 胰腺斷端與空腸吻合處的間斷端側(cè)縫合(后壁)；2B: 術(shù)中實(shí)際操作圖：①胰腺殘端，②空腸，③胰腺上下緣的牽引線，④胰腺后壁與空腸漿膜層的間斷縫合，⑤胰管后壁和空腸黏膜的間斷縫合；2C: 縫合完成后效果圖；2D: 2C實(shí)際操作圖：①胰腺殘端，②空腸，③胰腺與空腸漿膜層的間斷縫合，縫合針數(shù)按照手術(shù)中實(shí)際需求，④肝總動(dòng)脈，⑤門靜脈

三、觀察指標(biāo)

記錄患者的手術(shù)時(shí)間、術(shù)中失血量、術(shù)后進(jìn)食時(shí)間、術(shù)后住院時(shí)間和術(shù)后胰瘺發(fā)生情況。術(shù)后胰瘺的診斷采用國際外科專家胰瘺定義小組(ISGPF)提出的胰瘺診斷標(biāo)準(zhǔn)[2]，即術(shù)后3 d起引流管引出的引流液淀粉酶活性大于正常上限3倍，引流量大于50 ml，或造影證實(shí)有胰液外滲者。并根據(jù)ISGPF標(biāo)準(zhǔn)將術(shù)后胰瘺分為A、B、C三級,A級最輕，C級最重。

四、統(tǒng)計(jì)學(xué)處理

結(jié)果

雙層連續(xù)縫合組和雙層間斷縫合組的手術(shù)時(shí)間分別為(284±5)、(288±7)min，術(shù)中出血量分別為(236±29)、(282±49)ml。兩組間差異均無統(tǒng)計(jì)學(xué)意義(t=0.4206，P=0.6749;t=0.8384，P=0.4036)。

兩組術(shù)后進(jìn)食時(shí)間分別為5～20 d、5～28 d，平均為(7.8±0.5)、(9.7±0.5)d；術(shù)后住院天數(shù)為10～45 d、10～65 d，平均為(14.0±1.0)、(17.2±10.0)d。兩組間差異均有統(tǒng)計(jì)學(xué)意義(t=2.285，P=0.0242；t=1.987，P=0.0493)。

術(shù)后共37例發(fā)生胰瘺，發(fā)生率為32.5%。雙層連續(xù)縫合組和雙層間斷縫合組術(shù)后胰瘺發(fā)生率分別為17.1%(6/35)、39.2%(31/79)，差異有統(tǒng)計(jì)學(xué)意義(χ2=5.403，P= 0.006)。雙層連續(xù)縫合組術(shù)后發(fā)生A級胰瘺4例(11.4%)，B級胰瘺1例(2.9%)，C級胰瘺1例(2.9%)；雙層間斷縫合組分別為5例(6.3%)、23例(29.1%)、3例(3.8%)。雙層間斷縫合組術(shù)后發(fā)生B、C級胰瘺患者例數(shù)高于雙層連續(xù)縫合組。兩組術(shù)后30 d內(nèi)均無死亡病例。

討 論

胰十二指腸切除術(shù)又稱Whipple術(shù)，1935年由Whipple首先提出。它常用于胰頭或者壺腹部疾病的治療，是外科最復(fù)雜的手術(shù)之一[3]，其術(shù)后并發(fā)癥發(fā)生率高達(dá)30%～60%[4-7]。隨著技術(shù)的發(fā)展與進(jìn)步，目前該手術(shù)死亡率已低至4%[8-9]，而術(shù)后胰瘺是致死的主要原因。文獻(xiàn)報(bào)道術(shù)后胰瘺發(fā)生率可高達(dá)25%[10]。胰瘺發(fā)生的危險(xiǎn)因素有：(1)患者的一般情況，包括高齡、性別、黃疸或者營養(yǎng)不良等；(2)疾病相關(guān)的因素，包括胰腺實(shí)質(zhì)質(zhì)地軟、胰管細(xì)等；(3)手術(shù)相關(guān)的因素，包括術(shù)中出血多、手術(shù)時(shí)間長、切除方式和吻合技術(shù)等[11]。手術(shù)方式是最重要的因素之一[12]。一旦完成了胰十二指腸切除，就要開始做3個(gè)吻合來重建消化道，分別是胰空腸吻合、膽道空腸吻合和胃空腸吻合[13]。胰空腸吻合存在的爭議最多。有報(bào)道稱20%的胰瘺歸因于胰空腸吻合[14]。胰空腸吻合的方式很多，有的主張胰管對空腸黏膜吻合，有的主張?zhí)兹胧轿呛希渲幸裙軐漳c黏膜吻合比較符合解剖原理和組織生理結(jié)構(gòu)，得到較多學(xué)者的支持[3]。在胰管對空腸黏膜吻合時(shí)縫合方法包括連續(xù)縫合、間斷縫合和捆綁式縫合，以前兩者居多。但這些縫合方法的效果仍然褒貶不一[15]。Watanobe等[16]報(bào)道，連續(xù)縫合行胰管對空腸黏膜吻合是安全的，能有效減少術(shù)后胰瘺的發(fā)生。Herrle等[17]報(bào)道，雙層連續(xù)縫合胰空腸可以縮短手術(shù)時(shí)間、住院時(shí)間和減少胰瘺發(fā)生。

本研究結(jié)果顯示，雙層連續(xù)縫合組術(shù)后胰瘺發(fā)生率顯著低于雙層間斷縫合組，其中B、C級胰瘺發(fā)生率也低于后者。此外，雙層連續(xù)縫合組的術(shù)后進(jìn)食時(shí)間和術(shù)后住院時(shí)間均顯著短于雙層間斷縫合組，提示雙層連續(xù)縫合優(yōu)于雙層間斷縫合。其原因可能是：(1)黏膜再生和愈合功能強(qiáng)，黏膜對黏膜的吻合，吻合口愈合較快。(2)內(nèi)層的胰管和空腸黏膜連續(xù)縫合依靠支撐管，做到了黏膜之間的無縫對合。(3)外層胰腺斷面與空腸壁的連續(xù)縫合能均勻收緊，確保了整個(gè)縫合層相同的對合強(qiáng)度，保證了胰腺斷面與空腸壁緊密不留死腔，胰液無處潴留。(4)空腸壁完全覆蓋胰腺斷面，保護(hù)了胰腺的創(chuàng)傷面，最大限度地阻止了胰液滲漏。(5)3-0的聚丙烯縫線具有光滑、無創(chuàng)的特點(diǎn)，避免了絲線縫合對組織的銳利切割作用。(6)腸邊距和胰腺邊距1 cm、針間距0.5 cm的連續(xù)縫合既保證吻合的連續(xù)性、完整性，又避免了吻合口血運(yùn)異常。因此，采用雙層連續(xù)縫合法行胰管空腸黏膜吻合可以有效降低胰十二指腸切除術(shù)后胰瘺的發(fā)生，是胰十二指腸切除術(shù)的一種胰腸吻合的有效改進(jìn)。

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(本文編輯：呂芳萍)

The application of double layer continuous suture in pancreatic-jejunum anastomosis underwent pancreatoduodenectomy

JiWeiping,ShaoZhuo,SongBin,MaHongyun,HuXiangui,JinGang,BiJianwei.

DepartmentofGeneralSurgery,ChanghaiHospital,SecondMilitaryMedicalUniversity,Shanghai200433,China

【Abstract】ObjectiveTo investigate the application value of double-layer continuous suture in pancreatic jejunum anastomosis of pancreatoduodenectomy (PD). MethodsA retrospective analysis of 114 consecutive patients (67 men and 47 women) who underwent PD from June 2012 to July 2013 were conducted. There were 79 patients who were treated by double-layer continuous suture technique and 35 patients by double-layer interrupted suture technique. The incidence of pancreatic fistula and other complications after PD with two different suture techniques were compared. ResultsThe operation time of double-layer continuous suture group and double-layer interrupted suture group is respectively (284±5) and (288±7) mins, the intraoperative bleeding volume is respectively (236±29) and (282±49) ml, the differences between two groups were no statistical significance. The postoperative fasting time in two group was respectively (7.8±0.5) and (9.7± 0.5) days, the length of hospital stay time was respectively (14.0±1.0) and (17.2±10.0) days, the incidence of postoperative pancreatic fistula (POPF) was respectively 17.1%(6/35) and 39.2%(31/79), the differences between two groups were statistically significant(all P<0.05). Grade A POPF was found in 4 patients (11.4%) from the double-layer continuous suture group and in 5 patients (6.3%) from the double-layer interrupted suture group. Grade B POPF was identified only in 1 patients (2.9%) from the double-layer continuous suture group and in 23 patients (29.1%) from the double-layer interrupted suture group. The presence of Grade C POPF was only documented in 1 patient from the double-layer continuous suture group and in 3 patients from the interrupted suture group. ConclusionsContinuous suture can be safely used in the duct-to-mucosa pancreatojejunostomy. The double-layer continuous suture can be more effective in reducing pancreatic fistula, improving the feeding time, and reducing the length of hospital stay, and it is worthy of clinical popularization and application.

【Key words】Pancreatoduodenectomy;Pancreaticojejunostomy;Suture techniques

DOI:10.3760/cma.j.issn.1674-1935.2016.03.001

通信作者：畢建威，Email: bijianwei98@163.com

基金項(xiàng)目：長海醫(yī)院“1255”學(xué)科建設(shè)項(xiàng)目(CH125542400)

Corresponding author:Bi Jianwei, Email: bijianwei98@163.com

(收稿日期：2016-03-15)