摘要：
Objective To investigate the clinical efficacy of laparoscopic spleen-preserving distal pancreatectomy (Kimura method and Warshaw method) for benign lesions of pancreatic body and tail.Methods The retrospective cohort study was conducted.The clinicopathological data of 39 patients with benign lesions of pancreatic body and tail who underwent laparoscopic spleen-preserving distal pancreatectomy in the Second Affiliated Hospital of Nanchang University between March 2008 and January 2018 were collected.Of 39 patients,28 undergoing Kimura method (splenic artery and vein-preserving distal pancreatectomy) were allocated into the Kimura group,and 11 undergoing Warshaw method (cutting splenic vessels and preserving short gastric vessels)due to serious adhesion between pancreatic body and tail and splenic hilum were allocated into the Warshaw group.Observation indicators:(1) operation situations;(2) postoperative situations;(3) follow-up situations.Followup using outpatient examination and telephone interview was performed to detect blood glucose level and tumor recurrence of patients up to March 2018.Measurement data with normal distribution were represented as (x)±s and comparison between groups was analyzed using the t test.Measurement data with skewed distribution were described as M (range) and comparison between groups was done using nonparametric rank-sum test.Comparisons of count data were analyzed using chi-square test or Fisher exact probability.Results (1) Operation situations:39 patients received laparoscopic spleen-preserving distal pancreatectomy,operation time and volume of intraoperative blood loss of 39 patients were respectively (194 ±58)minutes and 100 mL (range,30-800 mL).The operation time and volume of intraoperative blood loss were respectively (197±56)minutes,100 mL (range,30-800 mL) in the Kimura group and (186±63)minutes,150 mL (range,30-450 mL) in the Warshaw group,with no statistically significant difference between groups (t =0.494,Z =-0.597,P＞ 0.05).(2) Postoperative situations:time to anal exsufflation and duration of hospital stay were respectively (2.6±0.8)days,(9.2±7.3)days in 39 patients and (2.4±0.6)days,(7.5±4.2)days in the Kimura group and (2.8±1.3)days,(13.5±11.1)days in the Warshaw group,with no statistically significant difference between groups (t=-0.720,-1.736,P＞0.05).Seven patients had postoperative complications.The incidence of complication was 2/28 in the Kimura group,1 patient with pancreatic leakage at 5 days postoperatively was cured by 15-day B ultrasound guided catheter drainage,and 1 who was diagnosed as pulmonary infection by chest CT examination at 5 days postoperatively was discharged from hospital after 8-day anti-infection and sputum-inductive treatments.The incidence of complication was 5/11 in the Warshaw group,3 patients with sustained fever at 5 and 7 days postoperatively who were diagnosed as grade 1 splenic infarction by epigastric enhanced CT examination were improved and discharged from hospital by antibiotic and low molecular weight heparin treatments,and then epigastric enhanced CT re-examination at 3 months postoperatively showed recovery of splenic perfusion;1 with pancreatic leakage at 7 days postoperatively was cured by 18-day conservative treatment;1 who was diagnosed as delayed gastric emptying by upper gastrointestinal contrast at 16 days postoperatively was improved and then discharged from hospital by 15-day placement of intestinal feeding tube and nutrition support therapy.There were statistically significant differences in the incidences of overall complication and splenic infarction between groups (x2 =5.485,4.878,P＜0.05) and no statistically significant difference in the incidence of other complications between groups (P＞0.05).(3) Follow-up situations:39 patients were followed up for 12 months (range,2-64 months).During the follow-up,six patients had normal blood glucose level,and all patients had good quality of life,without recurrence.Conclusions Laparoscopic spleen-preserving distal pancreatectomy for the benign lesions of pancreatic body and tail is satisfactory in short-and long-term curative effects.The incidences of complication and splenic infarction of Kimura method are lower than that of Warshaw method.%目的 探讨腹腔镜保脾胰体尾切除术(Kimura法和Warshaw法)治疗胰体尾良性病变的临床疗效.方法 采用回顾性队列研究方法.收集2008年3月至2018年1月南昌大学第二附属医院收治的39例胰体尾良性病变行腹腔镜保脾胰体尾切除术患者的临床病理资料,其中28例行Kimura法(保留脾动、静脉的胰体尾切除术)保脾,设为Kimura组;11例因胰体尾部与脾门间粘连严重无法分离行Warshaw法(离断脾血管而保留胃短血管的胰体尾切除术)保脾,设为Warshaw组.观察指标:(1)手术情况.(2)术后情况.(3)随访情况.采用门诊或电话方式进行随访,随访内容包括患者血糖情况、肿瘤复发情况,随访时间截至2018年3月.正态分布计量资料以(x)±s表示,组间比较采用t检验.偏态分布计量资料采用M(范围)表示,组间比较采用非参数秩和检验.计数资料组间比较采用x2检验或Fisher确切概率法.结果 (1)手术情况:39例患者均完成腹腔镜保脾胰体尾切除术,手术时间为(194 ±58) min,术中出血量为100 mL(30～800 mL).Kimura组与Warshaw组患者的手术时间分别为(197±56) min和(186±63) min、术中出血量分别为100 mL(30～ 800 mL)和150 mL(30～450 mL),两组患者上述指标比较,差异均无统计学意义(t=0.494,Z=-0.597,P＞0.05).(2)术后情况:39例患者术后肛门排气时间为(2.6±0.8)d,术后住院时间为(9.2±7.3)d.Kimura组与Warshaw组患者术后肛门排气时间分别为(2.4±0.6)d和(2.8±1.3)d,术后住院时间分别为(7.5±4.2)d和(13.5±11.1)d,两组患者上述指标比较,差异均无统计学意义(t=-0.720,-1.736,P＞0.05).39例患者中术后共有7例发生并发症.Kimura组患者并发症发生率为2/28,其中1例于术后第5天出现胰液漏,经B超引导下置管引流后15 d后治愈;1例于术后第5天行胸部CT检查提示肺部感染,经积极抗感染、促进排痰等治疗8d后顺利出院.Warshaw组患者并发症发生率为5/11,其中3例分别于术后第5天、第7天开始出现持续发热,行腹上区增强CT检查均提示脾梗死1级,经使用抗生素、低分子肝素等药物治疗,症状缓解后出院,术后3个月复查腹上区增强CT提示恢复脾灌注;1例子术后第7天发现胰液漏,经保守治疗18d后治愈;1例于术后16d行上消化道造影检查提示胃排空障碍,经留置空肠营养管、加强营养支持治疗半月后胃功能逐渐恢复并顺利出院.两组患者总体并发症发生率和脾梗死发生率比较,差异均有统计学意义(x2=5.485,4.878,P＜0.05),其余并发症发生率比较,差异无统计学意义(P＞0.05).(3)随访情况:39例患者均获得术后随访,随访时间为2～64个月,中位随访时间为12个月.随访期间,6例胰岛细胞瘤患者血糖基本正常,所有患者生命质量良好,无一例复发.结论 对胰体尾部局限性良性病变行腹腔镜保脾胰体尾切除术近、远期疗效满意.Kimura法患者术后并发症和脾梗死发生率较Warshaw法更低.
