胰十二指肠切除术(pancreaticoduodenectomy, PD)手术难度大,操作过程复杂,是普外科手术中最具挑战性的手术之一。术后并发症发生率高,胰瘘是最常见且最为严重的并发症,并且往往能诱发其他并发症,被认为是PD术后患者死亡的最常见的并发症,明确胰瘘诊断,研究胰瘘发生的相关危险因素,减少胰瘘的发生以及对有效的预防措施,对胰十二指肠术疗效的提高有重要作用,本文通过对胰十二指肠术后胰瘘相关文献复习,综述如下。
The pancreaticoduodenectomy (hereinafter referred to as PD) is difficult and complicated to op-erate, so it is one of the most challenging operations in general surgery. Moreover, the incidence of its postoperative complications is high, and pancreatic fistula is the most common and most serious complication which often can induce other complications, hence, it is deemed as the most common complication to cause the death of PD patients. In our opinion, the pancreatic fistula should be clearly diagnosed and the related risk factors for the occurrence of pancreatic fistula should be studied so as to reduce occurrence of pancreatic fistula and further take effective prevention measures, which is of important significance to improve the curative effect of pancreati-coduodenectomy. In this paper, the literature on pancreatic fistula after pancreaticoduodenectomy is reviewed, and it is summarized as follows.
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1. 胰瘘的定义及诊断
随着近年来科学技术的进步,生长抑素等药物的应用,胰瘘的发生率已经明显降低,但是胰瘘仍是最常见的并发症,发生率约5%~20%,相关病死率为20%~40% [1] [2] 。当机体的胰管上皮和非胰管上皮之间形成了异常的通道就称为胰瘘,其中有大量胰腺分泌的液体,含有各种酶类 [3] 。在生理状态下,胰腺分泌的胰蛋白酶原是没有活性的酶,肠内的肠激酶作用于胰蛋白酶原,使其成为有活性的胰蛋白酶,胰蛋白酶又能激活其他类型的酶原,使其成为有活力的酶,使胰液更具侵袭性。在胰十二指肠切除术中,胰酶的漏出多在吻合口,处于激活状态,侵袭能力强。淀粉酶是诊断胰瘘的便捷指标,但不能反映胰酶的激活程度、侵袭能力以及炎症程度,其他酶学指标如脂肪酶、蛋白酶及其激活肽是值得研究的对象 [4] 。根据2016年国际胰腺外科协作组(International Study Group of Pancreat is Surgery Definition,ISGPS) [5] 指定的标准,并且国内专家对其进行解读。将胰瘘分为A级胰瘘(生化瘘)、B级胰瘘、C级胰瘘。A级瘘是指术后3天流液淀粉酶浓度>血淀粉酶浓度正常上限3倍以上,一般不会影响出院时间,2016年的标准中认为A级胰瘘是胰瘘前状态,被定义为生化瘘。B级胰瘘在生化瘘诊断基础上出现以下任何一点则可以明确诊断,1) 持续性的引流大于等于3周;2) 胰瘘相关的临床决策改变,包括住院时间的延长,针对胰瘘所采取的生长抑素、抗生素、输血、营养支持等药物的使用,3) 积液需经皮穿刺或内镜针对性干预,在2005年的标准中,对于进行穿刺引流可以归为B级胰瘘,也可以归为C胰瘘,2016年的标准中明确了该观点,3) 胰瘘相关性出血行血管造影。胰瘘导致行二次手术治疗或者出血相关的死亡为C级胰瘘。
2. 胰瘘的危险预测
胰瘘的发生是多因素的,包括胰腺质地、胰管直径、年龄、性别、术前营养状况、手术时间、术中出血量、吻合方式等,基于这些危险因素建立术后胰瘘的危险预测评分体系 是目前研究的热点,主要的预测体系包括引流液中淀粉酶、胰瘘风险评分(Fistula risk socre,FRS)以及日本国立癌症中心医院(Nation Cancer Center Hospital,NCCH)评分系统。在胰十二指肠切除术中,漏出的酶多处于激活状态,引流液中淀粉酶可能是预测胰瘘严重程度的指标,更高的引流液淀粉酶可能代表更多的胰酶漏出、更严重的吻合口不良、更强的胰酶侵袭能力、更高的B级和C级胰瘘的风险 [6] 。有相关文献报道,术后第1天引流液中淀粉酶超过6000 U/L [7] ,第三天引流液淀粉酶超过2820U/L [8] 是B级和C级胰瘘的高危因素。FRS是术中评分系统,包括胰腺质地、病理类型、主胰管直径、术中失血量,可以预测胰十二指肠切除术中胰瘘的风险 [9] 。FRS是使用最广泛的预测评分体系,但是FRS是术中预测体系,而且胰腺质地是一个主观标准,取决于术者的经验,这是FRS的主要缺陷。NCCH标准是术前预测标准,包括主胰管指数、性别、门静脉受侵、腹腔脂肪厚度、胰腺癌(临床诊断)。NCCH评分系统较为繁琐,使用不如FRS广泛 [10] 。基于这些预测评分系统,指导术中放置引流、术后胰瘘处理(拔管时机、生长抑素类似物使用、饮食恢复等)有重要意义。如何尽早将生化漏和B、C级胰瘘区分出来,避免对生化漏采取过度治疗,又能对B、C级胰瘘进行积极处理,是未来研究的重点。
刘宝志,陈永林,司铮先,李传文,张升宁. 胰十二指肠切除术后胰瘘的研究进展 Progress in Study on Pancreatic Fistula after Pancreaticoduodenectomy[J]. 临床医学进展, 2018, 08(02): 199-205. https://doi.org/10.12677/ACM.2018.82034
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