小口径吻合器胆肠吻合临床研究(1)
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[摘要] 目的：探讨小口径吻合器胆肠吻合在合并胆总管扩张壶腹部肿瘤胰十二指肠切除术中的应用。方法：2007年5月～2009年10月共30例伴胆总管扩张壶腹部肿瘤患者接受胰十二指肠切除术，其中16例行小口径吻合器胆肠吻合，其余14例采用常规方法吻合，分析其临床资料和病理结果，比较两组手术前后血清电解质、肝功能变化，手术时间，两组吻合口大小、吻合时间、吻合口狭窄发生率及胆道感染情况，手术后进食时间、住院时间和并发症发生情况。结果：全组无手术死亡及严重并发症发生。与常规术式组相比，观察组的胆肠吻合手术时间短，P=0.036，术后进食时间早，术后住院时间短，P=0.047，术后3个月胆管直径、胆漏发生率、吻合口狭窄发生率相当，两组间手术前后血钠、血钾、肝功能变化差异无统计学意义(P>0.05)。结论：有胆管扩张的患者以小口径吻合器胆肠吻合同时不放置T管是安全可行的。
[关键词] 胆肠吻合；胆管；吻合器；胰十二指肠切除术；胰瘘；胆瘘
[中图分类号] R735 [文献标识码]A[文章编号]1674-4721(2011)05(c)-005-03
Choledochojejunostomy using a mechanical stapler in pancreaticoduodenectomy
LI Zhi, REN Yingkun, ZHAO Yuzhou, HAN Guangsen*
Surgery Department of Tumor Hospital in Henan Province, Zhengzhou 450003, China
[Abstract] Objective: To discuss the validity of choledochojejunostomy performed with mechanical stapler in pancreaticoduodenectomy. Methods: 30 patients with cancer of pancreatic head, periampullary adenocarcinoma companied with biliary obstruction underwent pancreaticoduodenectomy in which choledochojejunostomywas donewith stapler without T tube drainage in 16 cases. The other patients underwent operation with routine way. Results: All cases were evaluated perioperatively period and followed up. The choledochojejunostomy was finished quickly in observed group than contrast group, and had early time for eat and less hospital stay. The complication was no more than contrast group. No biliary fistula and pancreatic fistula occurred. A good demonstration of both biliary tract and bilio-digestive anastomosis was obtained by follow-up with B ultrosound scan and no jaundice was found. Conclusion: Stapler device can be used in choledochojejunostomy safely if a common biliary tract is dilate enough large.
[Key words] Choledochojejunostomy; Bile duct; Stapler; Pancreaticoduodenectomy; Pancreatic fistula; Biliary fistula
胆肠吻合广泛用于胆道重建，是胰十二指肠重建胆道引流的主要术式[1]。传统的吻合多采用黏膜对黏膜的端端、端侧和侧侧间断缝合的吻合，近年来笔者使用吻合器行胆肠吻合，取得了满意的临床效果。
1 资料与方法
1.1 一般资料
2007年5月～2009年10月对收治的30例合并胆总管扩张的胰头癌壶腹周围癌实施胰十二指肠切除术，术中随机分组为手工吻合组16例和小口径吻合器吻合器吻合组14例，胆肠吻合采用强生管型吻合器21 mm，共16 例，其中，男9 例，女7 例，年龄38～70 岁，平均56 岁。两组患者的一般资料见表1。
1.2 使用吻合器行胆肠吻合的方法
胰十二指肠切除术采用常规的Whipple 术式，消化道重建顺序为胆肠、胰肠和胃肠吻合顺序。吻合前测量胆总管或肝总管的直径，即直径≥2.0 cm，常规选用21 号ILS 吻合器。用荷包钳完成肝总管断端的荷包缝合，将抵钉座头放入胆总管或收紧荷包线并结扎固定在抵钉座头的荷包结槽上。从空肠断端插入吻合器，距断端5～6 cm 用钉仓套抵住对膜缘肠壁让穿刺头从肠壁穿出，将穿刺头套入抵钉座头的中心杆，收紧抵钉座头使拟吻合的胆管断端和肠管壁贴紧，激发吻合器后退出整个吻合器 ......
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