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腹腔镜与开腹远端胰腺切除术的对比研究

作　者: 陈金水
导　师: 胡先贵
学　校: 第二军医大学
专　业: 外科学
关键词: 胰腺腹腔镜远端胰腺切除术开腹对比分析
分类号: R657.5
类　型: 硕士论文
年　份: 2012年
下　载: 51次
引　用: 0次
阅　读: 论文下载

内容摘要

腹腔镜是现代医学领域最先进的技术之一，具有患者创伤小、恢复快、美观、疼痛轻、对生理影响小、住院时间短等优点，已成为许多疾病（如胆石症、肝囊肿等）的金标准术式。但是，由于胰腺位于腹膜后，周围毗邻大血管、胃、十二指肠等重要脏器，显露困难，手术难度较大，学习曲线长，相对于其他腹部手术，腹腔镜手术在胰腺外科领域的发展较缓慢。近年来，随着超声刀(Harmonic Scalpel)切割闭合器(Endo-GIA Stapler)血管闭合系统(LigaSure)等新器械的出现，腹腔镜技术不断成熟，腹腔镜胰腺手术取得了长足的进步，并逐渐普及。近年来，国外几个大的胰腺外科中心报道了腹腔镜远端胰腺切除术(Laparoscopic Distal Pancreatectomy, LDP)的单中心回顾性病例对照研究，结果显示，腹腔镜远端胰腺切除术是手术治疗胰腺体尾部良性疾病或癌前病变有效的手段，与开腹手术相比，术后并发症未增加，具有住院时间短、术中出血少、术后恢复快等优势。与腹腔镜胰十二指肠切除术(Laparoscopic Pancreaticoduodenectomy,LPD)相比，腹腔镜远端胰腺切除术（LDP）不需要进行吻合，手术时间短，技术相对简单；与传统手术相比，切口明显缩小，具有明显优势。但是，在国内，目前腹腔镜胰腺手术例数仍较少，相关文献多为病例报告，并且例数较少，缺乏对比研究。长海医院普外科是国内最大的胰腺外科中心之一，平均每年完成胰腺手术近600例，其中胰十二指肠切除术400余例，远端胰腺切除术近200例，胰腺病种齐全，几乎涵盖所有胰腺良、恶性肿瘤。我们选择合适的病例，开展腹腔镜胰腺手术，既满足病人对微创手术的需求，也是我们胰腺外科发展的重点方向之一。本研究对同期进行的腹腔镜远端胰腺切除术(LDP)与开腹远端胰腺切除术(OpenDistal Pancreatectomy, ODP)的两组病例临床资料进行回顾性分析对比，排除胰腺恶性肿瘤、联合手术、术者手术技术差异等其他干扰因素，以评估LDP的可行性、安全性及与临床疗效。对象与方法2011年5月至2012年2月，第二军医大学附属长海医院普外三科连续收治的因胰腺体尾部疾病接受手术治疗的146例病人；排除恶性肿瘤的患者63例，良性疾病行胰腺节段切除+胰肠吻合患者9例，以及联合其他脏器切除者6例，共68例入选；其中男16例，女52例，年龄18～77岁。LDP组16例，ODP组共52例，收集其全部临床资料，并对两组进行回顾性对比分析。临床资料主要包括：1．一般情况：年龄、性别、体重指数、肿瘤直径、合并疾病、既往手术史；2．术中情况：手术切口长度、手术时间、手术方式、术中出血量、输血量等；3．术后情况：术后住院时间、禁食时间、卧床时间、术后疼痛指数、并发症、病理诊断；4．住院总费用；5．术后随访内容：术后近期症状及疾病复发情况。结果LDP组男5例，女11例，平均年龄42.86±13.94岁，体重指数22.25±2.58，肿瘤直径为4.34±1.47cm；ODP组男11例，女41例，平均年龄46.1±13.62岁，体重指数22.30±2.86，肿瘤直径为5.63±3.03cm；两组病例在年龄、性别比例、体重指数、肿瘤直径等差异均无统计学意义(P>0.05)；两组病例临床资料基线情况一致，具有可比性。两组病例手术切口长度分别为3.50±1.30cm和17.94±2.30cm(P <0.001)，LDP组手术切口长度明显小于ODP组；LDP组与ODP组手术时间分别为145.63±56.8min和87.21±32.06min，两组差异有统计学意义(P <0.001)，LDP组平均手术时间长于ODP组；两组术中失血量分别为318.75±227.21ml和306.35±378.36ml，两组间差异无统计学意义(P=0.898)；LDP组中有2例患者需输血，输血率12.5%(2/16)，输血量分别为1000ml和1200ml；ODP组中有6例患者需输血，输血率11.53%(6/52)，输血量800~1800ml不等，两组输血率差异无统计学意义(P=1.000)。LDP组与ODP组术后住院时间分别为5.06±1.24d和8.06±2.53d，两组差异有统计学意义(P <0.001)，LDP组术后住院时间明显缩短，平均比ODP组短3天；两组的术后卧床时间两组分别为1.31±0.68d和2.94±0.80d(P <0.001)，术后禁食时间1.31±0.57d和2.86±1.34d(P <0.001)，两组卧床时间和禁食时间差异均有统计学意义，LDP组术后下床活动与恢复饮食时间均早于ODP组，ODP组有1例发生胃排空障碍，第8天才恢复进食。LDP组术后5例患者出现术后并发症（31.25%），其中胰漏4例（25.0%），腹腔积液1例（6.25%）；ODP组术后14例患者出现术后并发症（26.92%），发生胰漏12例（23.07%），腹腔积液3例（5.77%），其中有1例同时发生胰漏和腹腔积液；两组间胰漏及腹腔积液发生率差异均无统计学意义(P>0.05)；全组均顺利恢复。两组病例住院总费用分别为3.79±0.55万元和3.50±0.65万元，两组差异无统计学意义(P=0.098)，LDP未明显增加病人治疗费用。我们采用“长海痛尺”疼痛评估量表，连续3天评估患者术后疼痛指数，分0-10级，取疼痛指数最高值，LDP组术后疼痛多分布于1～2级，而ODP组多分布于2～3级，两组术后疼痛指数差异有统计学意义(P <0.001)。本研究中，我们采用Endo-GIA和手工缝合两种方法分别处理胰腺残端，Endo-GIA法26例，手工缝合法40例，分别统计术后胰漏发生率：Endo-GIA组胰漏6例（23.08%），手工缝合组10例(23.8%)，两种方法胰漏发生率的差异无统计学意义(P=0.945)。两组术后病理结果均为良性或交界性疾病。两组临床症状消失或明显好转，均未见疾病复发，LDP组1例术后2月CT检查发现腹腔包裹性积液，无症状，未特殊处理。结论腹腔镜比传统开腹远端胰腺切除术相比，在缩短切口、降低术后疼痛指数、缩短卧床时间和禁食时间、减少术后住院日等方便均有明显意义，手术时间虽然延长，但是术中失血量、输血率、术后并发症发生率和住院总费用等并没有明显增加。因此，我们认为腹腔镜远端胰腺切除术(LDP)用于治疗胰腺体尾部良性或交界性疾病是安全可行的，与常规开腹手术相比，LDP具有创伤轻、痛苦小、恢复快等优势。postoperative parameters were analyzed to assess the feasibility, safety and efficacy of LDP.Subjects and MethodsFrom May2011to February2012,146consecutive patients with pancreatic body ortail disease admitted to General Sugery of Changhai HosPital, Second Military MedicalUniversity who uderwent LDP or ODP were retrospectively constrasted ananyzed. Surgicalprocedures were performed by1of3pancreaticobiliary surgeons at our pancreasprofessional group.We ruled out the63patients with malignant disease and9patients withbenign disease who underwent pancreatic segmental resection plus pancreatic-entericanastomosis, excluding6cases combined resection of other organs. All the68cases agedfrom18to77years old were selected finally, including16males and52females. LDP wasperformed in16cases, ODP in52cases. The clinical data include:1.general information:age, gender, body mass index, tumor diameter, concomitant diseases, previous surgicalhistory;2.intraoperative conditions: incision length, operative time, surgical approach,estimated blood loss (EBL), blood transfusion;3.postoperative conditions: hospital staytime, fasting time, time in bed after surgery, postoperative pain scores, complications, finalpathological findings;4.total hospital costs;5.follow-up contents: postoperative symptomsand recurrence.ResultsThere were5male and11female in the LDP group. The mean age of LDP group was42.86±13.94years. The body mass index (BMI) was22.25±2.58. However, there were11male and41female in the ODP group. The mean age of this group was46.1±13.62years,and the BMI was22.30±2.86. Tumor diameter of the LDP group was4.34±1.42cm withthe ODP group5.63±3.00cm. General information (age, BMI, sex ratio, tumor diameter)of the patients in two groups has no significant differences (P>0.05). The baseline ofclinical data in the two groups was comparable.Incision length were3.50±1.30cm and17.94±2.30cm (P <0.001), the surgicalincision of LDP group was significantly shorter than the ODP group. The operative timewas145.63±56.8min and87.21±32.06min, there was a significant difference betweenthe two groups (P <0.001), operative time of LDP group was significantly longer than theODP group. Estimated blood loss were318.75±227.21ml and306.35±378.36ml, therewas no significant difference between the two groups (P=0.898). Two cases from LDPgroup needed blood transfusion. The amounts of blood transfusion were1000ml and1200ml. The rate of blood transfusion was12.5%(2/16). Meanwhile,6patients fromODP group needed blood transfusions, ranging from800ml to1800ml. The rate of bloodtransfusion in the ODP group was11.53%(6/52). There was no significant difference ofblood transfusion rate between the two groups (P=1.000).Postoperative hospital stay was5.06±1.24d和8.06±2.53d, there was a significantdifference between the two groups (P <0.001). Postoperative hospital stay of LDP groupwas significantly shorter than the ODP group, with an average of3days. Time in bed aftersurgery of the two groups was1.31±0.68d和2.94±0.80d, there was a significantdifference (P <0.001), Postoperative fasting time was1.31±0.57d和2.86±1.34d, therewas a significant difference (P <0.001). Both recovery activities and resuming eating timein the LDP group were earlier than the ODP group. There was1patient concurrent delayedgastric emptying (DGE), resume oral intake on the8th day after operation.There were5cases with postoperative complications (31.25%) in the LDP group,including4pancreatic fistulas (25.0%) and1peritoneal effusion (6.25%). In the ODPgroup, there were14cases (26.92%) with postoperative complications, including12pancreatic fistulas (23.07%),3peritoneal effusions (5.77%). One of them occursimultaneously pancreatic fistulas and peritoneal effusions. Both pancreatic fistulas andperitoneal effusion incidence between the two groups had no significant difference (P>0.05). All cases were successfully recovered.Hospital costs of two groups were37870.94±5535.03Yuan and35035.79±6458.66Yuan, there was no significant difference (P=0.098). LDP didn’t significantly increasepatient’s cost of treatment.We assessed postoperative pain scores in the two groups for three consecutive daysafter operation with “Changhai Pain Rating Scale”, which grading the pain degrees from0to10. We took the highest score of pain to analyze. Most of the postoperative pain scoresin the LDP group were1-2, while2-3in the ODP group. There was a significant differencebetween the two groups (P <0.001).Two methods（Endo-GIA stapler closure versus manual suture）were taken fortreating the resected pancreatic remnant in this study. Endo-GIA stapler closure wasperformed in26patients, while manual suture was conducted in40patients. Thepancreatic fistula rate in Endo-GIA group was23.08%(6cases), while23.8%(10cases)for manual suture group. There was no significant difference between the two methods (P=0.945).Final pathological findings were all benign or borderline disease. The clinicalsymptoms disappeared or improved markedly and no recurrence. One patient from theLDP group was found the wrapped fluid of the abdominal cavity by CT two months aftersurgery. She was asymptomatic without special treatment.ConclusionCompared to conventional open pancreatic body and tail resection, laparoscopy hasobvious advantages such as shorter incision, lower postoperative pain scores, shorter timein bed and fasting time and shorter postoperative hospital stay. Although, the operativetime was longer, but estimated blood loss, rate of blood transfusion， incidence ofpostoperative complications and total hospital costs have not increased significantly.Therefore, we believe that laparoscopic distal pancreatectomy (LDP) for the treatment ofpancreatic body and tail of benign or borderline disease is feasible and safe. Compared toopen distal pancreatectomy (ODP)，LDP has light trauma, less pain, quicker recovery,shorter postoperative hospital stay and other advantages, no increasing the economicburden of patients.

全文目录

摘要  6-9
Abstract  9-13
缩略词及中英文对照表  13-14
前言  14-16
对象与方法  16-33
  一、研究对象  16-17
    (一) 纳入标准  16
    (二) 排除标准  16
    (三) 腹腔镜组选择标准  16-17
    (四) 远端胰腺切除（Distal Pancreatectomy，DP）范围  17
  二、研究方法  17-18
    (一) 病例分组方法  17
    (二) 对比评价指标  17-18
  三、腹腔镜设备及主要器械  18-23
    (一) 摄像成像系统（Olympas EVIS EXERA Ⅱ CV180 型）  18-19
    (二) 气腹形成系统  19
    (三) 动力系统  19-20
    (四) 冲洗吸引系统：  20-21
    (五) 各种手术器械  21-23
  四、手术方法  23-30
    (一) ODP 组手术方法  23-24
    (二) LDP 技术准备及手术方法  24-30
  五、术后处理  30-32
    (一) 切口管理  30
    (二) 抗生素应用  30-31
    (三) 生长抑素及胰酶抑制剂  31
    (四) 活动  31
    (五) 腹腔引流管管理与拔管指征  31
    (六) 术后导尿管、胃管以及饮食管理  31
    (七) 实验室检查  31
    (八) 出院指征  31-32
  六、随访  32
  七、统计学分析  32-33
结果  33-39
  一、术前一般情况  34
  二、手术相关情况  34-35
  三、术后情况  35
  四、住院总费用  35
  五、术后疼痛指数  35-36
  六、两种不同离断胰腺方法  36-37
  七、术后病理结果  37
  八、术后随访情况  37-39
    (一) 术后复查胰腺增强 CT 扫描情况  37-38
    (二) 腹部切口情况  38-39
讨论  39-48
  一、关于 CT在胰腺疾病诊断中的作用  39-42
  二、关于 LDP 手术适应症  42-43
  三、关于 LDP 手术方法  43
  四、关于手术切口与 Trocar 位置选择  43-44
  五、关于术中出血和中转开腹  44-45
  六、关于手术时间  45
  七、关于联合手术  45
  八、关于术后并发症  45-46
  九、术后疼痛与处理  46-47
  十、腹腔镜胰腺手术的前景与展望  47-48
结论  48-49
参考文献  49-53
综述  53-63
  参考文献  59-63
硕士期间发表文章  63-64
致谢  64

腹腔镜与开腹远端胰腺切除术的对比研究

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