胰腺切除术的改性单循环重建
Summary
胰腺切除术后修饰的单循环重建技术将胰腺分泌从胆汁中分离出来，从而降低了POPF的严重程度，同时延长了手术时间。
Abstract
胰腺切除术中修饰的单循环重建分离胰腺分泌从胆汁。它在高风险胰腺残留物的情况下进行，以减少术后胰腺瘘的严重程度，以及术后的整体发病率。这种重建技术的特点是为胰腺肌切除术和肝切除术的超长环。这些麻醉剂和另外一个济州-杰朱诺-杰尤诺索托法之间的长距离距离，使肝胆肌切除术分离液体，防止胆汁回流到胰腺肌切除术。因此，分泌物不能相互激活，并加剧现有的麻醉漏。与传统的单回路重建相比，经改造的单回路重建后，严重术后胰腺瘘的发生率降低。与传统的双循环重建相比，该技术易于执行、安全且耗时更少。
Introduction
胰腺切除术（PD）被认为是一个复杂的外科手术。虽然死亡率在过去几十年中有所下降，但发病率仍然很高。最频繁和害怕的并发症是术后胰腺瘘（POPF），它发生在超过20%的手术2，3，4，5。POPF可导致后续并发症，如产后造血、延迟胃排空、腹腔内脓肿和败血症。住院费用增加、住院时间过长、癌症患者化疗推迟，对2、3、4的社会经济影响巨大。
在过去的几十年中，人们采用了不同的手术方法来降低POPF的频率和严重程度。其中之一是双循环重建（DLR），与孤立的Roux-en-Y循环胆道和胰腺麻醉剂。胰腺汁从胆汁中分离出来被认为可以减少相互激活的分泌物对胰腺肌切除术（PJ）的有害影响。文学的结果一直鼓舞人心6，7，8。然而，使用DLR4，9，操作时间显著延长。
这里我们介绍了在PD期间修改的单循环重建（mSLR）技术，将胰腺分泌从胆汁中分离出来，而传统的单循环重建（SLR，图1）。在这种方法中，使用单个长的小肠环来构造肝热肌切除术（HJ）和PJ。HJ 的可致和可活动肢体之间的侧对侧麻醉有助于胆汁和胰腺分泌物的分离流动。2018年10月，我们小组报告了第一个有希望的结果，证实高危胰腺患者的死亡率和发病率有所下降。
与双循环重建相比，该方法通过分离胰腺液和胆汁来降低POPF的严重程度，同时不显著延长手术持续时间。
Protocol
该协议侧重于使用 mSLR 的 PD 重建阶段，并遵循德国鲁尔大学波鸿分校道德委员会的指导方针。 注：胰腺头、大肠状或严重难治性慢性钙化胰腺炎患者接受PD。如果肿瘤与围肠动脉的接触少于50%，且没有渗透门户静脉或优越的静脉。腺癌病例的远转移也是PD的禁忌症。PD 中的切除技术是标准化的，并在其他部分11、12中详细描述。它不…
Representative Results
每个接受PD的患者都接受胰腺组织调查，以评估mSLR的指示。高风险胰腺残余物（即软胰腺组织和微小的主胰腺导管）尽可能使用经过修饰的单回路进行重建。 我们确定了50名高危胰腺组织和一个小主胰腺导管患者。他们都接受了mSLR。平均年龄为63~13岁。男女比例为17：33。手术适应症是33例患者恶性疾病（66%）和良性疾病在17个患者（34%）。平均操作时间是365~77分钟。该组与两?…
Discussion
迄今为止，POPF对PD1之后的术后发病率有显著贡献。
胆汁和胰腺汁的混合物可以导致两种分泌物的相互激活，增加对PJ或HJ9、13、14、15、16的不利影响。活性磷脂酶A2的细胞毒性活性，将胆汁卵磷脂转化为有害的利索西质，使胰腺麻醉风?…
Divulgations
The authors have nothing to disclose.
Acknowledgements
不适用。
Materials
| Alexis O XXL | Applied medical | C8405 | |
| Bauchtuch Grün 10×90 | Nobatrast | 603219 | abdominal compress |
| Bauchtuch Grün 45×45 | Nobatrast | 607544 | abdominal compress |
| GIA 60mm-3.8mm | Covidien/Medtronic | GIA6038S | |
| GIA Loading Unit | Covidien/Medtronic | GIA6038L | |
| OP-Flex Yankauer | Unomedical | 34094182 | suction device |
| Präpariertupfer-Set | Fuhrmann | 32019 | sterile swab |
| Schlinggazetupfer 30×40 | Fuhrmann | 32016 | sterile swab |
| Telescopic Smoke Pencil | LiNA Medical | SHK-TSP-CL | electro cautery |
| Thermocover ECO | PEMAX | TC43-75EC2 | bowel cover |
| Whipple-Set | Mölnlycke | 97016042-00 | |
| Drainages: | |||
| Drainagebeutel | Coloplast | ? | drainagebag |
| Silikon-Kapillardrainage | AsidBonz | 551012 | capillary drainage |
| Trichteransatz für T-Rohr | Rüsch | 333169-000025 | 2,5 mm |
| T-Rohr nach Kehr | Rüsch | 423600-000025 | t-tube 2,5 mm |
| Sutures: | |||
| Ethiloop 2mm 2x45cm | Ethicon | EH387 | loop |
| Mersilene 0 FSL | Ethicon | EH7637 | fixation of the drainage |
| PDS 1 CT | Ethicon | PDP9234 | suturing of the fascia |
| Vicryl 2-0 , 6x45cm | Ethicon | VCP1226 | for ligature |
| Vicryl 2-0 SHplus, 8×70 | Ethicon | VCP7850 | for ligature |
| Vicryl 3-0 MH-1plus | Ethicon | VCP245 | subcutaneous suture |
| Pancreatic anastomoses: | |||
| Prolene 5-0 c1 | Ethicon | 8890 | 6 x |
| PDS 5.0 RB-1plus | Ethicon | X1153 | 2 x Multipack |
| Prolene 4-0 RB-1 | Ethicon | 8871 | 2 x holding sutures |
| Hepaticojejunostomy: | |||
| Prolene 5-0 c1 | Ethicon | 8890 | 2 x holding sutures |
| PDS 5-0 c1 | Ethicon | PDP1013 | 7 x |
| PDS 6-0 c1 | Ethicon | PDP1012 | 1 x mucosa fixation sutures |
| Gastrojejunostomy: | |||
| PDS 4-0 SH-1 plus | Ethicon | X1154 | 1 x Multipack |
| Jejuno-Jejunostomy | |||
| Ligasure | Covidien | LS1520 | |
| PDS 5-0 RB-1 plus | Ethicon | X1153 | 1 x Multipack |
| Prolene 2-0 SH | Ethicon | 8833 | Vessel-suture, etc. |
| Prolene 3-0 SH | Ethicon | 8832 | Cystic duct, cystic artery |
| Prolene 4-0 RB-1 | Ethicon | 8871 | 2 mal suturing of the slit in the meso |
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Citer Cet Article
Luu, A. M., Aghalarov, I., Braumann, C., Uhl, W., Belyaev, O. Modified Single-Loop Reconstruction for Pancreaticoduodenectomy. J. Vis. Exp. (151), e59319, doi:10.3791/59319 (2019).