保留十二指肠胰头勺式切除术治疗慢性胰腺炎合并胰管结石的前瞻性研究

目的探讨保留十二指肠的胰头勺式切除术治疗慢性胰腺炎合并Ⅰ、Ⅲ型胰管结石患者的疗效。方法前瞻性分析2008年6月至2013年6月湖南省人民医院收治的55例慢性胰腺炎合并Ⅰ、Ⅲ型胰管结石患者的临床资料，按随机数字表法将患者分为经典组27例（行胰十二指肠切除术）和勺式组28例（行保留十二指肠的胰头勺式切除术）。经典组患者中慢性胰腺炎合并Ⅰ型胰管结石18例，合并Ⅲ型胰管结石9例。勺式组患者中慢性胰腺炎合并Ⅰ型胰管结石16例，合并Ⅲ型胰管结石12例。经典组患者行传统胰十二指肠切除术，消化道重建采用Child吻合，胰肠吻合采用胰腺空肠端侧套入式吻合，放置胰管支撑管。胆肠吻合采用空肠与胆总管端侧连续吻合。勺式组患者行保留十二指肠的胰头勺式切除术，作Kocher切口，游离十二指肠，采用“四边法”向胰头方向切开胰管。距离十二指肠边缘1cm处切除胰管前方的胰腺组织，暴露胰头部的各分支胰管，取尽结石，沟通主胰管。对合并Ⅲ型胰管结石的患者，必要时可剖开胰体尾部的胰管取石。消化道重建采用胰勺面空肠Roux—en—Y吻合术。采用门诊随访，随访时间截至2013年12月。计量资料采用t检验和Mann—WhitneyU秩和检验，计数资料采用矿检验。结果术中经典组2例患者改行保留十二指肠的胰头勺式切除术，勺式组1例患者改行胰十二指肠切除术。经典组实际施行手术人数为26例，勺式组为29例。所有患者围手术期无死亡，腹痛、腹泻等消化道症状多在术后2周左右得以改善。经典组患者手术时间为（7．5±1．6）h，出血量为（460±88）mL，术后住院时问为（18．0±3．5）d，住院费用为（7．8±2．1）万元，并发症发生率为19．2％（5／26）。勺式组患者手术时间为（4．0±1．0）h，出血量为（120±36）mL，术后住院时间为（9．5±2．9）d，住院费用为（3．9±1．2）万元，并发症发生率为3．4％（1／29）。两组患者在手术时间、出血量、术后住院时间、住院费用及并发症发生率等方面比较，差异均有统计学意义（t=9．358，11．365，6．325，8．647，x2=3．976，P〈0．05）。53例患者获得随访，中位随访时间为33个月（6个月至5年），随访期间无患者死亡。经典组患者中24例获得随访，其中2例患者术后仍有轻微腹痛，1例腹痛剧烈，诊断为胰肠吻合口处胰管开口狭窄，经再次手术切除部分胰体组织后缓解；19例合并糖尿病的患者中12例病情好转或血糖恢复正常。勺式组患者均获得随访，其中2例术后轻微腹痛，疼痛时间较为短暂，未行处理；22例合并糖尿病的患者中16例血糖恢复正常。结论对慢性胰腺炎并Ⅰ、Ⅲ型胰管结石的患者，保留十二指肠的胰头勺式切除术是较为理想的术式。

Efficacy of duodenum-preserving pancreatic head resection for the treatment of chronic pancreatitis com- bined with pancreatic duct stones： a prospective analysis

Objective To investigate the efficacy of duodenum-preserving pancreatic head resection （DPPHR） for the treatment of chronic pancreatitis combined with type Ⅰ and Ⅲ pancreatic duct stones. Methods The clinical data of 55 patients with chronic pancreatitis and type Ⅰ and Ⅲ pancreatic duct stones who were admitted to the People＇s Hospital of Hunan Province from June 2008 to June 2013 were prospectively analyzed. All the patients were randomly divided into the pancreatoduodenectomy （PD） group （27 patients ） and the DPPHR group （28 patients）. There were 18 patients with chronic pancreatitis and type I pancreatic duct stones and 9 patients with chronic pancreatitis and type Ⅲ pancreatic duct stones in the PD group. There were 16 patientswith chronic pancreatitis and type I pancreatic duct stones and 12 patients with chronic pancreatitis and type m pancreatic duct stones in the DPPHR group. Patients in the PD group received PD ± Child anastomosis ± end-to- side pancreato jejunal anastomosis ± pancreatic stent placement ± end-to-side cholangiojejunostomy. Patients in the DPPHR group received free of duodenum ± pancreatic duct incision ± resection of pancreas at 1 cm ahead of the pancreatic duct ± extraction of the pancreatic duct stones ± pancreaticoduodenal Roux-en-Y anastomosis. Patients were followed up via out-patient examination till December 2013. The measurement data were analyzed using the t test or Mann-Whitney U test, and the count data were analyzed using the chi-square test. Results During the operation, 2 patients in the PD group were converted to the DPPHR group and 1 patient in the DPPHR group was converted to the PD group. No patient died during the perioperative period, and the symptoms including abdominal pain and diarrhea were alleviated at postoperative week 2. The operation time, blood loss, duration of postopera- tive hospital stay, total expenses and incidence of complications were （7.5-± 1.6）hours, （460 ± 88 ）mL, （18.0 ± 3.5）days, （7.8 ±2.1） ×104 yuan, 19.2% （5/26） in the PD group, and （4.0 ± 1.0）hours, （120 ±36）mL, （9.5 ± 2.9） days, （3.9 ± 1.2） × 104 yuan, 3.4% （1/29） in the DPPHR group, there were no significant differ- ences in the operation time, blood loss, duration of hospital stay, total expenses and incidence of complications between the 2 groups （ t = 9. 358, 11. 365, 6. 325, 8. 647, X2 = 3. 976, P 〈 0.05 ）. Fifty-three patients were followed up, with the median time of 33 months （range, 6 months to 5 years）. No patient died during the follow-up. Twenty-four patients in the PD group were followed up, 2 patients had slight abdominal pain, 1 patient had severe abdominal pain due to pancreatic duct stenosis, and the symptom was alleviated after resection of partial pancreas ; the condition of 12 patients was improved among the 19 patients with diabetes. Twenty-nine patients in the DPPHR group were followed up, 2 patients had slight pain; the condition of 16 patients were improved among the 22 patients with diabetes. Conclusion DPPHR is an ideal surgical procedure for patients with chronic pancreatitis and type Ⅰ and Ⅲ pancreatic duct stones.