腹腔镜胰十二指肠切除不同手术入路的治疗效果
张成 安琳 王羊 安东均 王金涛 杨林 韩立 赵宝国
摘 要
目的：探讨传统入路或动脉优先入路开展腹腔镜胰十二指肠切除（LPD）的治疗效果。
方法：回顾性分析2016年2月～2018年8月，西安交通大学医学部附属咸阳市中心医院施行LPD术个体化选择入路58例患者的临床资料。
结果：58例患者均在完全腹腔镜下成功完成预定Whipple手术，全部采用Child消化道重建吻合。无中转开腹手术。传统静脉入路组手术时间为（302.0±20.0）min，消化道重建时间（36.0±15.0）min。术中出血量（365.0±150.0）mL。术中快速冰冻切片病理学检查切缘阴性33例。术后发生早期并发症6例，其中A级胰瘘3例（1例合并胆瘘，1例合并胃排空障碍），B级胰瘘2例均合并腹腔出血，经药物治疗痊愈。术后病理学检查R0切除例数32例（91.4%，32/35），R1切除3例（8.6%，3/35） 淋巴结清扫数目（7.5±5.5）枚。动脉优先入路组平均手术时间为（355.0±25.0）min，消化道重建时间（41.0±12.0）min。术中出血量（410.0±200.0）mL。术中快速冰冻切片病理学检查切缘阴性22例。术后发生早期并发症3例，其中A级胰瘘1例合并胃排空障碍，B级胰瘘2例均合并腹腔出血.经药物治疗痊愈。术后病理学检查R0切除例数22例（95.7%，22/23），R1切除1例（4.3%，1/22）。淋巴结清扫数目（6.8±4.2）枚。
结论：依据患者的一般状况、肿瘤来源及位置、血管关系、术者技术等情况综合考虑进行个体化选择LPD手术入路，从而做到精准的病灶清除、脏器保护、损伤控制，达到安全、高效、微创治疗的目的。
关键词
胰腺肿瘤；胰十二指肠切除术，腹腔镜；壶腹周围肿瘤；手术入路；精准外科
Impact of different operative approaches for laparoscopic pancreatoduodenectomy on shortterm treatment outcomes
Zhang Cheng，An Lin，Wang Yang，An Dongjun，Yang Lin，Wang Jintao，Han Li，Zhao Baoguo.Department of hepatobiliary surgery，the Center Hospital of Xinyang City，Xi'an Jiaotong University Health Science Center，Xianyang，Shanxi 712000，China
Corresponding author:An Lin，Email:3079027819@qq.com
ABSTRACT
Objective:To study the impact of traditional versus artery first approach in laparoscopic pancreatoduodenectomy（LPD）.
Methods:The clinical data of 58 patients who underwent laparoscopic pancreaticoduodenectomy through individualized selective approach from February 2016 to August 2018 in Xianyang Central Hospital affiliated to Xi'an Jiaotong University Medical Department were retrospectively analyzed.
Results:All 58 patients successfully completed the scheduled Whipple operation under complete laparoscopy，and all underwent Child digestive tract reconstruction and anastomosis.There was no conversion to laparotomy.The average operation time conventional venous approach group was（302.0±20.0）min and the digestive tract reconstruction time was（36.0±15.0）min.The intraoperative blood loss was（365.0±150.0）mL.33 cases were negative in pathological examination of intraoperative frozen section.Early postoperative complications occurred in 6 cases，including grade A pancreatic fistula in 3 cases（1 case complicated with biliary fistula and 1 case complicated with gastric emptying disorder），and grade B pancreatic fistula in 2 cases complicated with abdominal hemorrhage，which were cured by drug treatment.Postoperative pathological examination showed that 32 cases（91.4%，32/35）had R 0 resection and 3 cases（8.6%，3/35）had R 1 resection.The number of lymph node dissection was（7.5±5.5）.The average operation time of the artery first access group was（355.0±25.0）min，and the reconstruction time of digestive tract was（41.0±12.0）min.The amount of bleeding was（410.0±200.0）mL.During the operation，22 cases were negative in pathological examination of quick frozen sections.Early postoperative complications occurred in 3 cases，including 1 case of grade A pancreatic fistula complicated with gastric emptying disorder and 2 cases of grade B pancreatic fistula complicated with abdominal hemorrhage.The patients were cured by drug therapy.Postoperative pathological examination showed that there were 22 cases（95.7%，22/23）of R0 resection and 1 case（4.3%，1/22）of R 1 resection.The number of lymph node dissection was（6.8±4.2）.
Conclusion:The LPD surgical approach is selected according to the general condition of the patient，the origin and location of the tumor，the relationship between blood vessels，the technique of the operator and other conditions，so as to achieve accurate lesion clearance，organ protection and damage control，and achieve the goal of safe，efficient and minimally invasive treatment.
KEY WORDS
Pancreatic neoplasm；Pancreaticoduodenectomy，laparoscopic；Tumor around ampulla；Operative approach；Precision surgery
腹腔镜胰十二指肠切除术（Laparoscopic pancreatoduodenectomy，LPD）已经在一些胰腺外科中心作为常规开展［1］。手术经验的积累，精准切除概念的提出，为LPD注入了更多的新技术和优化的路径。西安交通大学医学部附属咸阳市中心医院2016年2月～2018年8月施行LPD 58例，现就LPD入路的临床选择报道如下。