After Distal Pancreatectomy Pancreatic Leakage from the Stump of the Pancreas May Be Due to Drain Failure or Pancreatic Ductal Back Pressure
After Distal Pancreatectomy Pancreatic Leakage from the Stump of the Pancreas May Be Due to Drain Failure or Pancreatic Ductal Back Pressure
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DOI：
10.1007/s11605-012-1849-y
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发表时间：
2012-05-01
影响因子：
3.2
通讯作者：
Traverso, L. William
中科院分区：
文献类型：
--
作者：
Hashimoto, Yasushi;Traverso, L. William
降低胰体尾切除术后胰瘘的方法包括控制胰残端漏的危险因素。本研究的目的是确定可控制的胰瘘危险因素。为了促进同质性，我们使用了一个外科医生的病例系列，然后用公共网站计算了POPF，基于国际胰腺外科研究组（ISGPS）严重程度分类系统的工具。共审查了223例连续的DP病例。DP涉及胰腺残端的相同手工缝合鱼嘴闭合。所有患者均接受术后硬膜外麻醉。Logistic回归分析确定了临床相关POPF（B/C级）的危险因素，死亡率为0。ISGPS分级为：无POPF 53%，A级= 32%，B = 13.9%，C = 0.9%。临床相关POPF（B/C）发生率为14.8%，其中24%表示由于缺乏通畅性和/或从其原始位置错位导致的手术引流失败。术前内镜下Wirsung管消融和/或支架植入术是较低级别B/C泄漏的显著风险因素（3%）。多变量分析确定了两个可控的风险因素-术中失血> 1,000 ml和术前未接受维松氏管内镜干预的患者。在假定胰腺括约肌完整的组（无内镜干预，n = 177）中，术后静脉阿片类药物的使用（硬膜外失败）是B/C漏的风险因素（34%）。这些结果表明，胰管背压的增加在促进胰腺残端漏中起作用。使用ISGPS定义及其基于网络的工具，在223例DP中，临床相关漏的发生率为14.8%。降低这一发生率的机会是改善我们的外科引流技术，限制术中失血，避免术后静脉麻醉剂与硬膜外镇痛。
The method to lower postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) involves controlling risk factors for leakage from the pancreatic stump.The aim of this study was to identify controllable risk factors for POPF.In order to promote homogeneity, we used a single surgeon case series and then calculated POPF with a public web-based tool based on the severity classification system of the International Study Group of Pancreatic Surgery (ISGPS). A total of 223 consecutive cases of DPs were reviewed. DP involved the same hand-sewn fish-mouth closure of the pancreatic stump. All received postoperative epidural anesthesia. Logistic regression analysis identified risk factors for clinically relevant POPF (grade B/C).Mortality was zero. ISGPS gradings were: no POPF 53%, grade A = 32%, B = 13.9%, and C = 0.9%. The clinical-relevant POPF (B/C) rate was 14.8% of which 24% represented surgical drain failure due to lack of patency and/or misplaced from their original location. Preoperative endoscopic ablation and/or stenting of Wirsung's duct was a significant risk factor to lower grade B/C leak (3%). Multivariate analysis identified two controllable risk factors-intraoperative blood loss > 1,000 ml and those who did not undergo preoperative endoscopic interventions of Wirsung's duct. In the group with presumed intact pancreatic sphincters (no endoscopic intervention, n = 177), the use of postoperative intravenous opioids (with epidural failure) was a risk factor for B/C leak (34%). These findings suggest that increased back pressure in the pancreatic duct has a role in promoting pancreatic stump leakage.Using the ISGPS definition and its web-based tool, the incidence of clinically relevant leakage was 14.8% in 223 cases of DP. Opportunities to lower this rate are improving our surgical drain technology, limiting intraoperative blood loss, and avoiding postoperative intravenous narcotics with epidural analgesia.