【作者】 马岩；

【导师】 李乐平；

【作者基本信息】 山东大学 ， 外科学， 2012， 硕士

【摘要】 背景和目的胃癌是我国常见的恶性肿瘤,根治性手术切除是主要的治疗方法。胃癌根治术后胰瘘发生率虽低,但却是胃癌根治术后严重的并发症之一,一旦发生,不仅大大增加医疗费用,更易引起出血、感染、吻合口瘘等并发症的发生,严重者导致死亡。本研究的目的在于探讨胃癌根治术后并发胰瘘的危险因素及合理的诊疗方法。研究方法1.对象2006年1月到2010年12月在山东大学附属省立医院682例行胃癌根治术病例,除外胃癌姑息性切除病例。2.观察因素一般因素：年龄,性别,内脏脂肪面积(Visceral Fat Area, VFA),合并疾病(糖尿病,高血压,高脂血症),血清营养水平(血红蛋白,白蛋白),腹部二次手术等。手术因素：手术时间,术中出血量,胰腺被膜剥离及胰腺损伤,胰后淋巴结清扫,联合脾脏切除,联合脾脏及胰腺切除等。病理因素：肿瘤大小,病理类型,TNM分期。术后因素：术后第1天引流液淀粉酶值,胰瘘治疗方法及预后。3.统计分析用spss15.0统计软件进行统计分析,计数资料采用x2检验,计量资料采用独立样本t检验,用均数±标准差表示,P<0.05为具有统计学意义。结果682例患者中共发生胰瘘59例,其中有1例因并发腹腔内大出血死亡,45例通过调整引流管使引流充分,同时给予禁饮食、胃肠减压、使用抑制胰酶分泌药物、抗感染及补液支持等非手术治疗后引流物逐渐减少而痊愈。6例行B超引导下穿刺置管引流术,3例行胰床引流加空肠造瘘术,4例行腹腔置管胰床引流术后并给予以上非手术治疗措施后均痊愈。胃癌根治术后胰瘘的发生与VFA、高脂血症、手术时间、胰腺被摸剥离及胰腺损伤、胰后淋巴结清扫、联合脾脏切除、脾脏及部分胰腺联合切除及肿瘤TNM分期有关,术后第一天引流液淀粉酶含量是有效的预测胰瘘的指标。结论内脏脂肪面积大、高脂血症、肿瘤侵及胰腺、手术时间长及引起胰腺或胰管损伤的手术操作皆可增加胃癌根治术后胰瘘的发生风险。术后引流液淀粉酶监测有利于早期预测并诊断胰瘘,而通畅引流、禁饮食、胃肠减压、应用抑制胰酶分泌药物(如奥曲肽)、抗感染及合理补液营养支持治疗是有效的治疗措施。更多还原

【Abstract】 Objective Gastric cancer is one of the most common cancers in china, and surgical resection is still its main therapy. Although the incidence of postoperative pancreatic fistula with radical resection of gastric cancer is low, it can lead to serious complications, such as bleeding, abdominal infection, anastomotic leakage and so on, which would not only increase hospitalization expenses but even result in death. Our study aims to find out risk factors of postoperative pancreatic fistula with radical resection of gastric cancer and its proper therapeutic measures.Methods1.Object:682cases with radical resection of gastric cancer in Provincial Hospital Affiliated to Shandong University from2006.1to2010.12were included in this study, except cases of palliative gastrectomy.2.Observation indexGeneral index:age, gender, VFA(Visceral Fat Area), diabetes mellitus, hyperlipidaemia, hypertension, nutrition status(hemoglobin, albumin) and abdominal reoperation.Surgical index:operation time, amount of bleeding in operation, pancreas capsule stripping, pancreas injury, lymph nodes dissection around pancreas, radical gastrectomy with spleen dissection and radical gastrectomy with spleen and partial pancreas dissection.Pathological index:tumor size, pathological category and pathological classification(pTNM).Postoperative index:the amylase value of drainage fluid on the first postoperative day. 3.Statistical analysis:statistical software SPSS15.0was used for data analysis. P<0.05presents significant difference.Results There are59postoperative pancreatic fistula cases, in which1case died of intraperitoneal hemorrhage and others recovered after proper therapies. Keeping abdominal drainage unobstructed, fasting, gastrointestinal decompression, inhibiting pancreatic enzyme secretion, using the antibiotics reasonably, nutrition, fluid replacement and other supportive treatments were primary treatments for the recoveries.6cases were punctured and placed a tube guided by B ultrasound, and7cases were treated with reoperation. We found that VFA, hyperlipidaemia, operation time, pancreas capsule stripping, pancreas injury, lymph nodes dissection around pancreas, radical gastrectomy with spleen dissection, radical gastrectomy with spleen and partial pancreas dissection and tumor pathological classification(pTNM) were risk factors of postoperative pancreatic fistula. The amylase value of drainage fluid on the first postoperative day was effective to forecast postoperative pancreatic fistula.Conclusion Large VFA, hyperlipidaemia, cancer invasion of the pancreas, long operating time and all the operative procedures that could injure pancreas or pancreiatic duct can increase the risk of postoperative pancreatic fistula. Monitoring the amylase value of drainage fluid is effective for forecast and diagnosis of postoperative pancreatic fistula. Keeping abdominal drainage unobstructed, fasting, gastrointestinal decompression, inhibiting pancreatic enzyme secretion(using Octreotide and so on), using the antibiotics reasonably, nutrition, fluid replacement and other supportive treatments are effective treatment measures.更多还原