吳傳有，劉長(zhǎng)安，李生偉

(重慶醫(yī)科大學(xué)附屬第二醫(yī)院，重慶 400010)

胰十二指腸切除術(shù)由德國(guó)外科醫(yī)生Kausch在1909年首次實(shí)施[1]。Whipple等[2]于1935年報(bào)告3例胰十二指腸切除病案之后，胰十二指腸切除術(shù)就成為壺腹部腫瘤外科治療的選擇方式。而今，胰十二指腸切除術(shù)已經(jīng)作為胰頭癌和壺腹周圍癌治療的標(biāo)準(zhǔn)手術(shù)方式。隨著手術(shù)技術(shù)的改進(jìn)和術(shù)后管理的提高，已經(jīng)使胰腺切除術(shù)后死亡率減少到5%以下，然而術(shù)后并發(fā)癥的發(fā)生率卻改變很小，仍然在30%～40%范圍[3-4]。術(shù)后胰瘺、腹腔出血、腹腔膿腫形成以及胃排空障礙等并發(fā)癥時(shí)有報(bào)道。術(shù)后胰瘺依然是胰十二指腸切除術(shù)后最常見、最嚴(yán)重的并發(fā)癥[5]，其發(fā)生率從2%～40%不等[5-6]。而這些并發(fā)癥的發(fā)生往往需要藥物或再次手術(shù)干預(yù)，以致延長(zhǎng)住院時(shí)間，增加住院費(fèi)用，甚至導(dǎo)致患者死亡。胰十二指腸切除術(shù)后胰瘺的風(fēng)險(xiǎn)因素包括一般因素(年齡[7]、性別[8]、黃疸指數(shù)[9]、營(yíng)養(yǎng)狀況)、疾病因素(胰腺病理學(xué)、胰腺質(zhì)地[10-12]、胰管擴(kuò)張程度[13-14]、胰液輸出量)和手術(shù)因素(手術(shù)時(shí)間、切除類型、吻合技術(shù)/方式[15-16]、術(shù)中出血量)。此外,外科醫(yī)生的經(jīng)驗(yàn)已經(jīng)被證明是與胰腺吻合口瘺有關(guān)的因素(如消化道重建方式、胰管支撐引流與否),預(yù)防性應(yīng)用生長(zhǎng)抑素也與胰瘺相關(guān)[17]。本文從胰十二指腸切除術(shù)后消化道重建、胰管支撐引流等方面為術(shù)后胰瘺的預(yù)防作一綜述。

1 消化道重建

1.1 胰胃吻合與胰腸吻合 胰十二指腸切除術(shù)后消化道重建與術(shù)后并發(fā)癥的發(fā)生率、死亡率以及患者的生活質(zhì)量有著密切的關(guān)系。目前主要有兩種方式來完成胰十二指腸切除術(shù)后消化道重建。自1941年Hun和他的同事第一次報(bào)道胰腸套入式吻合術(shù)后，胰腸吻合就成為胰十二指腸切除術(shù)后消化道重建的主要手術(shù)方式；Waugh等[18]于1946年第一次報(bào)道了胰胃吻合術(shù)。Oida等[19]認(rèn)為胃腸吻合有3個(gè)優(yōu)點(diǎn)：①胃壁厚且血流豐富；②胰液的出口靠近胃的背側(cè)；③胃里面沒有腸激酶，胰液不易被激活。McKay等[20]認(rèn)為胰胃吻合術(shù)后胰瘺的發(fā)生，以及并發(fā)癥的發(fā)生，總的死亡率明顯比胰腸吻合術(shù)后低。Topal等[21]通過對(duì)胰胃吻合與胰腸吻合的多中心隨機(jī)對(duì)照研究顯示：胰胃吻合能夠降低術(shù)后胰瘺的發(fā)生，但不能降低術(shù)后總的并發(fā)癥，且在胰胃吻合術(shù)后一旦發(fā)生胰瘺，將明顯增加患者的死亡風(fēng)險(xiǎn)及延長(zhǎng)住院時(shí)間。Watanabe等[22]通過對(duì)81個(gè)中心、3 109例胰十二指腸切除術(shù)后病人的分析認(rèn)為：胰胃吻合與胰腸吻合術(shù)后吻合口瘺的發(fā)生率(胰胃吻合11.0%，胰腸吻合13.3%)、腹腔內(nèi)出血、腹腔膿腫形成、總的死亡率沒有明顯差別。He等[23]通過對(duì)1966—2011年胰胃吻合與胰腸吻合的隨機(jī)對(duì)照研究和臨床觀察研究的數(shù)據(jù)分析顯示，尚沒有足夠的證據(jù)證明胰胃吻合比胰腸吻合更安全，胰胃吻合與胰腸吻合術(shù)后總的死亡率相近。比起胰腸吻合，胰胃吻合可能減少術(shù)后胰瘺的發(fā)生和腹腔膿腫的形成，但卻增加術(shù)后腹腔出血的風(fēng)險(xiǎn)。Daisuke等[24]最近研究認(rèn)為：胰胃吻合與胰腸吻合術(shù)后胰瘺發(fā)生無明顯不同，甚至在胰腺質(zhì)地較軟的患者來說也是如此。

1.2 幾種常用的胰腸吻合 幾種常見的胰腺空腸吻合術(shù)包括：套入式胰腺空腸端端吻合、胰管空腸黏膜端端吻合、胰腺空腸端側(cè)吻合、胰管空腸黏膜端側(cè)吻合、胰管栓塞結(jié)扎法、捆綁式胰腸吻合術(shù)。胰管空腸黏膜吻合術(shù)由Cattle于1943年第一次使用，它允許胰管與空腸黏膜直接接觸，防止胰液與胰腺殘端直接接觸，促進(jìn)黏膜愈合，保護(hù)嵌入空腸黏膜下吻合口，所以胰管空腸黏膜吻合理論上能夠防止術(shù)后胰瘺的發(fā)生。Poon等[25]發(fā)現(xiàn)胰管空腸黏膜吻合是一種安全的吻合方式。Marcus等[26]發(fā)現(xiàn)胰管空腸吻合用于胰腺質(zhì)地較硬、胰管擴(kuò)張的低?；颊撸g(shù)后胰瘺的發(fā)生率低；而端端吻合用于胰腺質(zhì)地較軟、胰管不擴(kuò)張的高?；颊咻^安全。胰管栓塞結(jié)扎術(shù)因?yàn)閺U除胰腺的外分泌功能，且術(shù)后胰瘺發(fā)生率也很高而不常用[27]。捆綁式胰腸吻合近來常被報(bào)道[28-31]。Hashimoto等[31]對(duì)傳統(tǒng)胰腸吻合與捆綁式胰腸吻合系統(tǒng)性分析認(rèn)為：胰胃吻合與胰腸吻合術(shù)后胰瘺發(fā)生無明顯不同，甚至在胰腺質(zhì)地較軟的患者來說也是如此。

2 胰管支撐引流

一些研究[32-34]認(rèn)為胰十二指腸切除術(shù)后暫時(shí)性的胰管支撐引流能減少術(shù)后胰瘺的發(fā)生。Poon等[32]通過對(duì)120例胰腸吻合術(shù)后胰管支撐外引流與不引流的研究認(rèn)為：胰管支撐外引流組術(shù)后胰瘺的發(fā)生率明顯低于非引流組(6.7%比20%，P=0.032)，且引流組的住院時(shí)間明顯短于非引流組(平均17 d比23 d，P=0.039)，但總的術(shù)后并發(fā)癥的發(fā)生率(31.7%比38.3%，P=0.444)和死亡率(1.7%比5%，P=0.309)沒有明顯的差別。Pessaux等[34]認(rèn)為胰管支撐外引流可減少術(shù)后胰瘺的發(fā)生，尤其適用于那些胰腺質(zhì)地較軟、胰管無明顯擴(kuò)張的胰十二指腸切除。Winter等[35]通過對(duì)234例接受胰十二指腸切除、胰腸吻合、胰管支撐內(nèi)引流與非引流的前瞻性隨機(jī)對(duì)照研究顯示：胰管支撐內(nèi)引流組對(duì)比非引流組在預(yù)防胰瘺方面無明顯優(yōu)勢(shì)，而且對(duì)于那些胰腺質(zhì)地較軟、胰管無明顯擴(kuò)張的患者來說，胰管支撐內(nèi)引流增加術(shù)后胰瘺的發(fā)生率(21.0%比10.7%，P=0.13)。Tani等[36]研究認(rèn)為胰十二指腸切除術(shù)后胰管支撐內(nèi)引流與外引流比較，術(shù)后胰瘺的發(fā)生率無明顯差別，引流方式也不受胰腺質(zhì)地影響，且簡(jiǎn)化了術(shù)后管理，縮短住院時(shí)間。Zhou等[37]對(duì)胰十二指腸切除術(shù)胰管支撐內(nèi)/外引流與不引流的Meta分析認(rèn)為：胰管支撐外引流能減少術(shù)后胰瘺的發(fā)生，而胰管支撐內(nèi)引流則不能減少胰瘺的發(fā)生，尤其是對(duì)胰腺質(zhì)地較軟，胰管無明顯擴(kuò)張的患者；最近的研究還認(rèn)為，胰管支撐內(nèi)引流不但不能減少術(shù)后胰瘺的發(fā)生，而且還有可能增加軟胰術(shù)后胰瘺的發(fā)生。

3 其他方式

此外，一些文獻(xiàn)已經(jīng)報(bào)道了用大網(wǎng)膜、鐮狀韌帶包裹吻合口亦可有效地預(yù)防術(shù)后胰瘺的發(fā)生[38-39]，但是因?yàn)橐纫褐兄久傅淖饔茫舭l(fā)生胰瘺，則易形成腹腔膿腫。生長(zhǎng)抑素及其類似物可以抑制胰腺的內(nèi)分泌和外分泌，從而降低術(shù)后胰瘺的發(fā)生[40]。

4 結(jié) 論

總結(jié)胰十二指腸切除術(shù)后消化道重建的各種手術(shù)方式及術(shù)后的管理，我們認(rèn)為：胰胃吻合與胰腸吻合術(shù)后胰瘺發(fā)生無明顯不同，兩種重建消化道方式各有利弊；文獻(xiàn)報(bào)道和外科醫(yī)生習(xí)慣更傾向于選擇胰腸吻合行胰十二指腸切除術(shù)后消化道重建；胰管空腸黏膜端側(cè)吻合，胰管支撐外引流能減輕胰液對(duì)吻合口的腐蝕，防止吻合口的梗阻，明顯降低術(shù)后胰瘺的發(fā)生率；用大網(wǎng)膜行胰腸吻合口包裹，術(shù)后常規(guī)使用生長(zhǎng)抑素抑制胰腺分泌功能等，均能降低術(shù)后胰瘺及并發(fā)癥的發(fā)生率，我們推薦使用。

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