十二指肠乳头肿瘤局部切除术成功治疗及体会

2013-07-19 上海交通大学医学院附属仁济医院普外科 王坚 杨林华 中国医学论坛报

      疾病概述   十二指肠乳头部肿瘤发病率约占消化道肿瘤的1%。主要包括: 腺瘤、腺癌、家族性腺瘤性息肉病以及其他发病率很低的类癌、黑色素瘤、肾上腺样瘤、肉瘤、间质瘤、神经纤维瘤、淋巴瘤及平滑肌瘤等。   由于其病变部位较特殊,早

 

十二指肠乳头肿瘤局部切除术
 十二指肠乳头肿瘤局部切除术

  疾病概述

  十二指肠乳头部肿瘤发病率约占消化道肿瘤的1%。主要包括: 腺瘤、腺癌、家族性腺瘤性息肉病以及其他发病率很低的类癌、黑色素瘤、肾上腺样瘤、肉瘤、间质瘤、神经纤维瘤、淋巴瘤及平滑肌瘤等。

  由于其病变部位较特殊,早期多无特殊临床表现,偶有消化道不适症状,诊断困难。随着病程的进展,患者可逐渐出现恶心、呕吐、发热、黄疸等胆管阻塞症状,一经发现,往往病情已发展到一定程度, 治疗效果不理想。

  十二指肠乳头肿瘤的治疗以手术治疗为主,目的在于切除病灶,重建消化道。主要治疗方法有:胰十二指肠切除术、十二指肠乳头肿瘤局部切除术及内镜下十二指肠乳头肿瘤切除术。

  病例简介

  患者,男性,66岁。主因“反复右上腹痛伴恶心呕吐2月余”入院。

  患者无明显诱因出现反复右上腹隐痛2月,阵发性,能自行缓解,无明显腰背部放射;伴恶心呕吐、胃纳欠佳、明显消瘦;无发热,无皮肤黄染、尿色加深、粪便颜色变浅等。CT示:肝内胆管、胆总管、胰管扩张,不排除壶腹部肿瘤可能。磁共振胰胆管造影(MRCP)示:胆总管下段占位,肝内外胆管、肝总管及胰管扩张,胆囊肿大。内镜逆行胰胆管造影(ERCP):十二指肠乳头占位。活检病理:高级别上皮内瘤伴少量异型细胞。

  手术步骤

  ⒈开腹探查 患者取仰卧位,常规气管插管,全身麻醉。采用腹部正中绕脐切口,上至剑突,下达脐下二横指水平。入腹后常规探查肝、胆、胰、脾、胃、肠、肠系膜、盆腔及腹膜有无异常,特别应注意肝十二指肠韧带内、胰头周围、肠系膜根部及腹主动脉周围有无肿大淋巴结。

  ⒉显露病灶 作Kocher切口,游离十二指肠框部,向左翻起十二指肠降部,触诊肿瘤的位置、大小、质地及其与周围组织器官的关系。于十二指肠降部前外侧壁纵向切肠壁约3~4 cm(图1),找到十二指肠乳头,切取部分乳头肿瘤组织送术中冷冻病理检查。

  ⒊切除胆囊

  ⒋清扫第12组淋巴结 对于12组淋巴结肿大或术前病理为乳头恶性肿瘤的患者,应行肝十二指肠韧带淋巴结清扫,并送术中冰冻病理检查。

  ⒌切除肿瘤 打开胆总管前壁约1 cm,经胆总管置入胆道探条自十二指肠乳头处戳出,作为十二指肠乳头肿瘤局部切除时的指引(图2)。距十二指肠乳头肿瘤基底部1 cm处,12点方向以3-0缝线作切除标记与牵引(图3)。以此为起始点,逆时针方向切除十二指肠乳头肿瘤,边切边用4-0可吸收缝线将胆管和十二指肠后壁全层缝合(图4)。

  注意若仅将胆管黏膜和十二指肠黏膜缝合,则易导致黏膜下出血,形成血肿,发生胆漏。切开时须注意切勿一次切开过多,以免切缘处出血影响操作视野,或胆管回缩导致吻合困难、吻合不确切,发生胆汁漏。因此每切开2~3 mm就应将胆管和十二指肠肠壁全层缝合。

  ⒍寻找胰管 逆时针切除肿瘤至5点方向时,须注意解剖胰管,避免将胰管缝闭,尤其是胰管未见明显扩张的患者。一般在2~5点方向切除乳头时,可见清亮胰液涌出,即可明确胰管位置。如未见明显胰液涌出,可轻轻挤压胰腺体部后仔细观察有无胰液渗出,以此判断胰管位置。若仍未找到胰管,可使用头皮针上的硅胶管,将其剪成45°斜面,在疑似胰管处轻柔地试插探查,如可顺利插入较深并伴有胰液流出,可确认为胰管。试插时一定要轻柔,避免形成假道。对于胆胰管汇合部较长的患者,切除十二指肠乳头肿瘤后仅可见胆总管开口,此类患者大多在术前ERCP造影或MRCP成像时即可发现。

  切除的十二指肠乳头肿瘤必须做术中冷冻病理检查,确定切缘为阴性。

  ⒎胰管与十二指肠吻合 切除肿瘤后即显露完整的胆总管及胰管开口,取5-0 缝线分别间断缝合胆总管与胰管相邻的侧壁、胰管与十二指肠的后壁,整形重建胆管胰管在十二指肠的开口(图5)。 在胆总管、胰管及十二指肠后壁交汇处加作U形缝合,防止胰漏或胆漏。胰管内置一细硅胶管作支撑及引流,远端置入十二指肠水平部(图6),这样可分流胰液,减少胰漏的几率。

  ⒏十二指肠前壁的缝合 沿十二指肠降部切开处间断全层缝合十二指肠肠壁,一般不需浆肌层加固缝合,避免十二指肠狭窄(图7)。我们不建议将十二指肠肠壁纵切横缝,这只会增加缝合时肠壁的张力,增加十二指肠漏的概率。

  ⒐引流管放置 胆总管留置T管引流,用4-0可吸收缝线间断缝合胆总管(图8)。十二指肠降部背侧腹膜后置入两根负压引流管。

  病例简介及手术操作

  相关注意事项

  适应证 该术式适用于以下患者:十二指肠乳头良性肿瘤或良性肿瘤伴局部癌变,无淋巴结转移;早期恶性肿瘤(T1N0M0,肿瘤直径<2 cm,分化程度较高,无周围组织浸润,无淋巴结转移);老年患者不能耐受胰十二指肠切除术者。

  术前评估 十二指肠乳头肿瘤患者术前均进行心、肝、肾、呼吸功能、凝血及营养状况的评估,并行CT、磁共振成像(MRI)明确肿瘤位置、大小、有无淋巴结、远处转移,ERCP确认肿块大小,活检明确病理。

  术中操作要点 十二指肠乳头肿瘤局部切除术的技术要点,是通过精细操作、精准吻合,保证足够切缘,达到根治性切除肿瘤的目的,同时防止胆汁漏、胰液漏及十二指肠液漏发生。

  我们的体会

  ⒈十二指肠降部前外侧壁纵形切开3~4 cm即可,由于十二指肠浆膜下血供丰富,需要严格电凝止血或结扎止血,以防血肿形成影响愈合。切开部位缝合应沿肠壁切口纵向间断全层缝合肠壁,一般不需要浆肌层加固缝合,避免十二指肠狭窄。如切口过长不提倡纵切横缝,避免吻合口张力大,引起十二指肠漏。

  ⒉显露十二指肠乳头时可用胆道探条指引。

  ⒊术中应注意切缘距离肿瘤边缘至少1 cm,切除的肿瘤必须送术中冷冻病理,如切缘阳性,应改行胰十二指肠切除术。

  ⒋切除肿瘤后,胆总管、胰管与十二指肠肠壁全层缝合。吻合要精准,针距、间距与深度应一致,胆管与肠壁吻合用4-0可吸收线,胰管与肠壁吻合选用5-0 线。应注意三者交汇处,可采用U形缝合加固。

  ⒌胰管内放置硅胶管支撑引流,硅胶管放至十二指肠水平部。胆总管切开处应放置T管引流减压,手术结束前将带有空肠营养管的双腔胃管置入十二指肠降部减压,营养管应置于空肠曲水平。



    

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    2013-07-21 chg122