摘要
目的分析腹腔镜保留幽门胰十二指肠切除术中进行腔外和腔内胃-空肠重建的临床获益情况,为胃-空肠吻合方式的选择提供循证医学证据。方法应用回顾性病例对照研究方法,收集2013年1月至2022年12月陆军军医大学第一附属医院全军肝胆外科研究所连续收治177例接受腹腔镜保留幽门胰十二指肠切除术的患者,经过纳入和排除标准后,纳入161例患者,其中进行腔内胃-空肠重建99例,腔外胃-空肠重建62例。利用累计和(cumulative sum,CUSUM)方法绘制学习曲线,将两种重建方式临床资料进一步行学习曲线前后对比,并应用倾向评分匹配分析围手术期结果。结果总体资料中腔外胃-空肠重建组手术时间和胃-空肠重建时间较腔内组显著缩短(385.8±74.6 vs 436.6±85.2 min,P<0.001;23.6±13.5 vs 37.2±19.5 min,P<0.001)。经过学习曲线制定后发现,腹腔镜保留幽门胰十二指肠切除术需完成77例病例才能度过学习曲线阶段。进一步行学习曲线前后两种重建方式的对比,利用倾向评分匹配排除组间差异发现,学习曲线阶段内腔外胃-空肠重建组在手术时间(451.29±51.16 vs 501.47±47.89 min,P=0.006)、胃空肠重建时间(15.5±11.6 vs 45.2±18.5 min,P<0.001)和术后胃管留置时间(4.0±3.0 vs 5.6±3.2 d,P=0.028)明显缩短。完成77例手术度过学习曲线后,两种重建方式在手术时间(P=0.059)、胃空肠重建时间(P=0.053)、术后胃管留置时间(P=0.521)上无明显统计学差异。并发症在总体及学习曲线阶段前后均无明显统计学差异。结论腹腔镜保留幽门胰十二指肠切除术在学习曲线阶段内,对于选择性患者,相对于腔内胃-空肠重建,行腔外胃-空肠重建具有简便、快捷优势,有利于胃肠功能恢复,是该阶段值得推荐的胃肠重建方式。
Objective To analyze the clinical benefits of laparoscopic pylorus-preserving pancreaticoduodenectomy with extraluminal and intraluminal gastro-jejunal reconstruction in order to provide evidence-based medical data for the choice of gastro-jejunal anastomosis.MethodsA retrospective case-control trial was conducted on 177 consecutive patients undergoing laparoscopic pylorus-preserving pancreaticoduodenectomy in our institute from January 2013 to December 2022,and 161 patients were finally enrolled after the inclusion and exclusion criteria,including 99 cases of endoluminal gastrointestinal reconstruction and 62 cases of extraluminal gastrointestinal reconstruction.Learning curves were drawn using cumulative sum chart(CUSUM).The clinical data of the 2 reconstruction modalities were further compared before and after the learning curves,and the perioperative outcomes were analyzed with propensity score matching.Results The overall data showed the extraluminal group had significant shorter operation time and gastro-jejunal reconstruction time than the intraluminal group(385.8±74.6 vs 436.6±85.2 min,23.6±13.5 vs 37.2±19.5 min,P<0.001).After the learning curve was developed,it was found that completion of 77 cases of laparoscopic pylorus-preserving pancreaticoduodenectomy is required to get through the learning curve phase.Further comparisons of the 2 reconstruction modalities before and after the learning curve indicated that after excluding between-group differences with propensity score matching,the endoluminal group during the learning curve phase had better intraoperative results in terms of operation time(451.29±51.16 vs 501.47±47.89 min,P=0.006),gastro-jejunostomy reconstruction time(15.5±11.6 vs 45.2±18.5 min,P<0.001),and postoperative gastric tube retention time(4.0±3.0 vs 5.6±3.2 d,P=0.028).After completing 77 surgeries through the learning curve,there were no statistically significant differences between the 2 reconstruction procedures in operation time(P=0.059),gastrojejunal reconstruction time(P=0
作者
李仁杰
林恒
李建伟
张雷达
王小军
田峰
李雪松
欧晏娇
曹利
孙天歌
廖科曦
旷钥文
郑树国
LI Renjie;LIN Heng;LI Jianwei;ZHANG Leida;WANG Xiaojun;TIAN Feng;LI Xuesong;OU Yanjiao;CAO Li;SUN Tiange;LIAO Kexi;KUANG Yaowen;ZHENG Shuguo(Institute of Hepatobiliary Surgery,First Affiliated Hospital,Army Medical University(Third Military Medical University),Chongqing,400038,China)
出处
《陆军军医大学学报》
CAS
CSCD
北大核心
2023年第22期2334-2342,共9页
Journal of Army Medical University
基金
重庆市科卫联合医学科研项目(2022MSXM152)。
关键词
保留幽门胰十二指肠切除术
腹腔镜
胃肠道重建
学习曲线
pylorus-preserving pancreaticoduodenectomy
laparoscopy
gastro-jejunal reconstruction
learning curve
