【Abstract】略Henan Cancer Hospital General Surgery Department Wang Gangcheng Pancreatic-intestinal anastomosis is one of the key links in pancreaticoduodenectomy, and the bleeding and pancreatic leakage of abdominal drain after pancreaticoduodenectomy are closely related to pancreatic-intestinal anastomosis, and the operation and method of pancreatic-intestinal anastomosis directly affects the time of the overall operation and the recovery of the patients after the operation. After years of discussion and clinical summarization, pancreatic mucosa-jejunum mucosa docking anastomosis has been widely used as one of the main modes of pancreatico-intestinal anastomosis in the clinic. However, the operation method of pancreatic mucosa and jejunal mucosa docking anastomosis is clinically diversified without uniform standard, and improper operation may delay the operation time or lead to local tissue bleeding and other tissues of the side damage affecting the healing of pancreatic and intestinal anastomosis, and in recent years, the author has used the separated ring continuous suture to perform the pancreatic stump embedding, and pancreatic mucosa and jejunal mucosa docking anastomosis, and he believes that this suture method exposes the surgical field sufficiently, does not easily injure other tissues, and the operation is simple and easy to perform. It is considered that this suture method has sufficient exposure of the surgical field, does not easily injure other tissues, is easy to operate, has fast suture time, and has a low incidence of postoperative anastomotic leakage and anastomotic hemorrhage. It is reported as follows. DATA AND METHODS I. GENERAL DATA From March 2010 to October 2014, there were 43 cases of pancreaticoduodenectomy with pancreatico-intestinal anastomosis, of which 24 cases were male and 19 cases were female; the age ranged from 36 to 78 years old, and the median age was 62.5 years old. Among them, there were 32 cases of simple pancreaticoduodenectomy, 6 cases of pancreaticoduodenum combined with right hemicolectomy, 4 cases of pancreaticoduodenum combined with distal gastrectomy, and 1 case of pancreaticoduodenum combined with right nephrectomy. Preoperative abdominal CT, MRI and intraoperative exploration of the tumor in 43 cases did not invade the superior mesenteric vessels and inferior vena cava, and there was no distant metastasis. All patients underwent radical R0 resection of the tumor, and digestive tract reconstruction was performed by Child’s method. Pancreatic-intestinal anastomosis was performed by docking anastomosis between pancreatic mucosa and jejunal mucosa, and the suture method was separated ring continuous suture. All patients had no absolute contraindications to surgery in preoperative blood biochemistry, blood routine, chest X-ray, electrocardiogram, and immunological examination; no recent acute onset of systemic infections, and no history of hormone-endocrine and/or immune function-affecting drugs. All of them underwent open abdominal surgery under endotracheal intubation and intravenous combined anesthesia by the same group of physicians. II. Surgical approach to pancreatico-enteric anastomosis (1). Free the jejunum. The distance from the flexor ligament is about 25 cm with a cutting occluder to dissect the jejunum, the jejunal stump is reinforced and closed, and the plasma membrane layer of the jejunum is incised longitudinally from the stump at a distance of 4.0 cm, and the plasma layer is separated from the mucous membrane layer on both sides with the use of a tissue forceps, and the width of the separation is comparable to the thickness of the pancreatic stump, and the exposed jejunal mucous membrane is opened in the middle of a hole with a diameter of about 3 mm. (2). Hemostasis of the pancreatic stump and placement of an endopancreatic duct support tube. Pancreatic stump with 2-0 absorbable thread strict suture hemostasis, will remove the needle infusion tube 10cm as the pancreatic duct support tube (according to the internal diameter of the pancreatic duct to select the support tube), the support tube cut 2-3 side holes at one end of the tube, placed into the pancreatic duct and fixed in the pancreatic stump. (3). Separate rows of suture pancreatic stump and jejunum anastomosis. Take “4-0” suture (w-8557 Puri Ling) first from the posterior wall of the pancreatic stump into the needle out of the needle (to avoid the superior mesenteric vein), and then from the jejunum anastomosis of the posterior wall of the plasma musculature into the needle out of the needle, the pancreatic stump and the jejunum interval of about 20cm (in order to do not affect the operation of suture operation for the appropriate distance), so the cycle of successive suture of the pancreatic stump The posterior wall of the pancreatic stump and the posterior wall of the jejunum, with a needle distance of 3mm, the posterior wall of all through the needle is completed, tighten the suture, the pancreas built-in tube penetrates the jejunum mucosa layer into the jejunum intestinal lumen, the jejunum mucosa is tightly adhered to the surface of the pancreatic stump, the pancreatic stump of the anterior wall and the anterior wall of the jejunum plasma membrane layer continuous suture such as sewing the posterior wall as the sewing pancreas one week, the first and last thread knotting and fixing. After the suture was completed, interrupted suture reinforcement was given depending on the stitch spacing. Figure 1 Separation of the jejunal plasma muscle layer from the mucosal layer Figure 2 Separation of the posterior wall of the pancreas from the jejunal plasma muscle layer with continuous suture III. Judgment criteria of pancreatic leakage According to the diagnostic criteria of pancreatic leakage after pancreatic surgery by Bassi [5] and others: 3 days or more after surgery, the amylase measurement value of abdominal drainage fluid is greater than normal, and the upper limit of serum amylase measurement value is three times; it can be divided into three grades: Grade I, with only the elevation of amylase in the abdominal drainage fluid without corresponding symptoms and signs; Grade II, with the elevation of amylase in abdominal drainage fluid, accompanied by typical clinical symptoms, and beginning to show signs of organ dysfunction, requiring the use of antitoxins, which is the most effective way of preventing the occurrence of pancreatic leakage. signs of insufficiency, requiring the use of antibiotics, nutritional support and abdominal drainage; Class III, the patient’s condition is serious. Grade III, the patient’s condition is serious, sepsis and organ dysfunction appear, and may even lead to death, often requiring surgical intervention. IV. Drainage tube drainage contents of the clinical manifestations of traits The presence of pancreatic leakage of the contents of the drainage tube, the color is usually gray-brown, thicker, no odor, as co-infected pus-like liquid, drainage laboratory bacterial culture without bacterial growth. Drainage tube contents without pancreatic leakage showed yellowish liquid, clear. Results I . Clinical recovery of postoperative perioperative patients According to the judgment standard of pancreatic leakage, in 43 patients in this group, 38 cases had no pancreatic leakage, no abnormality of regional drainage tube, and postoperative abdominal CT suggested that there was no effusion near the pancreatico-intestinal anastomosis; 4 cases had grade I pancreatic leakage, and amylase values of the drainage tube drainage fluid were higher than normal, and the drainage fluid of the regional drainage tube was pale yellow and slightly mixed, with no symptoms of pain and fever, and postoperative abdominal CT suggested that there was no obvious effusion near the pancreatico-intestinal anastomosis. 1 case showed a pale yellow liquid, clear. One case was grade II pancreatic leakage combined with bile leakage, the amylase value of pancreatic fluid in the abdominal drainage tube was 10307u/L, the drainage fluid in the regional drainage tube was yellowish-white, obviously turbid, and the drainage fluid was about 400 ml per day, and there was mild pressure pain under the right costal margin, and the postoperative abdominal CT suggested that there was accumulation of fluid in the pancreatic-enteric anastomosis and the periphery of the biliary-enteric anastomosis.In the case of grade I pancreatic leakage, the growth inhibitors were given to be applied continuously for 3-5 days to maintain the normal drainage of regional drain tube. The regional drainage tube was usually drained, and no special treatment was made for the rest. grade II pancreatic leakage was given with growth inhibitor for 12 days, enhanced off-site nutritional support, and according to the location of postoperative abdominal fluid, CT-guided drainage tube was placed to keep the abdominal cavity free of fluid, and the abdominal drainage tube was significantly reduced after 21 days postoperatively, and the patient was discharged with a tube in a good condition, with more than 100 ml of drainage per day. 43 patients were discharged with a tube in a pancreatic-intestinal anastomosis. There were 0 cases of bleeding at the mouth, and the time of pancreatic-intestinal anastomosis was 8-10 minutes (the anastomosis time was from the beginning of continuous suture to the end of anastomosis). 2. Postoperative pathology: 10 cases of carcinoma of the lower part of common bile duct, 6 cases of carcinoma of the pancreatic head, 12 cases of carcinoma of the jugular abdomen, 5 cases of duodenal mesenchymal tumor, 4 cases of gastric carcinoma, and 6 cases of carcinoma of the hepatic flexure of the colon. DISCUSSION 1. Importance of pancreatico-intestinal anastomosis modality and operation. Pancreatic-intestinal digestive tract anastomosis has always been the focus and key point of discussion in the surgical field. The operation speed of pancreatic-intestinal digestive tract anastomosis directly affects the whole operation time, and the quality of pancreatic-intestinal digestive tract anastomosis is directly related to pancreatic leakage, which is often the initiation point of abdominal hemorrhage after duodenal resection. After years of discussion and clinical summary of surgical scholars, pancreatic intestinal mucosal docking anastomosis as one of the main pancreatic intestinal anastomosis, widely used in the clinic, but the pancreatic mucosal and jejunal mucosal docking anastomosis operation method clinically diverse, there is no uniform standard, improper operation, may delay the operation time, lead to local tissue bleeding and other tissue side damage affecting the pancreatic and intestinal anastomosis healing, mild pancreatic leakage delayed Mild pancreatic leakage prolongs the time for patients to be discharged from the hospital, while severe pancreatic leakage results in repeated abdominal bleeding, which is life-threatening in severe cases. Some literature reports that the lethality of pancreatic leakage is as high as 20-50% [1]. 2.The main factors affecting the operation of docking anastomosis between pancreatic mucosa and jejunal mucosa and the problems that are likely to occur. ① Exposure of surgical field. Pancreatic organs belong to the retroperitoneal organs, the position is relatively low and fixed, if the beginning of the anastomosis will pull the pancreas, the jejunum together suture knot, any suture method in the limited field of view will be difficult, the operator feels overwhelmed, not only the sewing speed is slow, the quality of pancreatic and intestinal anastomosis is not very satisfactory. If the patient is obese and has a deep anterior-posterior body diameter, exposure of the local surgical field will be even more difficult. Poor quality of pancreatico-enteric anastomosis and pancreatic leakage may occur. (ii) Exposure of the posterior wall of the pancreatic stump to the superior mesenteric venous vasculature. No matter which way of pancreatic-intestinal anastomosis is used, the exposure of the posterior wall of the pancreatic stump and the superior mesenteric vein is crucial. When the posterior wall of the pancreas is sutured with the bowel, the superior mesenteric vein or the branch veins may be easily injured if the exposure is not clear, which will cause local hemorrhage and blurring of the local field of view, which will increase the difficulty of the anastomosis, and the worse thing is that the local hemorrhage is not handled correctly, and it may lead to more severe hemorrhage because of the tearing of the superior mesenteric vein. Repeated local hemostatic suture may appear local tissue ischemia, erosion, lack of vitality. (iii) Pancreatic tissue texture. The soft and hard texture of the pancreas and the degree of edema are also important factors affecting pancreatico-enteric anastomosis. Soft or edematous pancreas is prone to cut pancreatic tissue during suturing and knotting, resulting in bleeding or difficulty in suturing [2]. ④ Suture method. If the surgical field is not sufficiently exposed, the pancreatic tissue is brittle, and the suture method is improper, it is easy to cut and tear the pancreatic tissue or local blood vessels. ⑤ Type of suture. As the pancreas and surrounding tissues are prone to bleeding, relatively rough sutures are prone to rubbing the pancreatic tissues, damaging the pancreatic tissues, and are not conducive to pancreatic-intestinal anastomosis. 4. Advantages of separate circular continuous suture for pancreatico-enteric anastomosis. ①. The anastomosis field is clearly exposed. This suture method is a separated suture, when the anastomosis is started, the pancreatic stump and jejunal suture are separated by a certain distance, and the posterior wall of the pancreas, peripheral blood vessels, stitch spacing, and the suture site are all exposed very clearly. The uneven suturing and damage to the surrounding blood vessels caused by the limited field of vision and unclear exposure of the posterior wall of the pancreas were avoided. There are also scholars in China who thread the suture before tying the knot, which is also an embodiment of separated suture [3]. ②. It is not easy to cut the pancreatic tissue. As the method is continuous suture, the suture is finished with the ventral surface of the pancreatic intestines and then closed, the suture force is dispersed, the local single-needle force is small, and it is not easy to cut the pancreatic tissue. ③. The cross-section of the pancreatic stump is completely encapsulated by the intestinal canal. Most of the abdominal bleeding after pancreaticoduodenectomy is due to pancreatic fluid or infection corrosion leading to bleeding of the pancreatic stump surface [4], the method of circular continuous suture, jejunum intestinal wall is tightly adhered to the pancreatic section and the pancreatic section is completely and tightly embedded, avoiding the local pancreatic leakage or infection leading to bleeding of the pancreatic stump. There was no anastomotic bleeding in any of the 23 cases in this case. ④. Anastomosis without pancreatic-intestinal mucosal sutures. Typical pancreatic-intestinal mucosal anastomosis requires a four-point suture anastomosis between the main pancreatic duct and the jejunal mucosa [5], but the method described in this study does not require a separate suture anastomosis between the main pancreatic duct and the jejunal mucosa because the pancreatic stump and jejunal mucosa butt closely together and the mucosa of the pancreatic duct is actually in close contact with the jejunal mucosa. In this case, 43 cases did not have simple anastomosis between jejunal mucosa and pancreatic duct mucosa, and there was only one case of grade II pancreatic leakage, and the cause of pancreatic leakage could not be ruled out to be closely related to the patient’s advanced age (78 years old), surgical trauma (right hemicolectomy combined with pancreaticoduodenectomy), relatively poor physical condition, and edema of the tissues, etc. The four cases of grade I pancreatic leakage were mostly considered to be associated with pancreatic fluid exudation from the eye of the stitches. Therefore, as long as the pancreatic duct can be placed into the support tube (the diameter of the support tube can be selected according to the pancreatic duct), the anastomosis can be utilized, and there is no need to worry about the diameter of the pancreatic duct is less than 3mm, the pancreatic duct mucosa and jejunum mucosa anastomosis effect is poor [6]. The clinical concept of poor quality anastomosis between jejunal mucosa and pancreatic duct mucosa due to the thinness of pancreatic duct (diameter less than 3 mm) was broken. ⑤. Fast suturing speed. At present, there is no fixed suture method for clinical pancreatic-intestinal anastomosis, and there is no standard starting time for pancreatic-intestinal anastomosis, so there is no way to compare the length of pancreatic-intestinal anastomosis in the present study. However, due to the clear field of vision exposed by this method, the local hemorrhage is small, the quality of suture is certain, the repetitive suture operation is small, and there is no need to anastomose jejunum and pancreatic duct mucosa individually, so theoretically, this method of anastomosis shortens the operation time significantly. 5. Separate ring continuous suture row pancreatic and intestinal anastomosis need to pay attention to. ①. Whenever possible, the posterior wall of the pancreatic bowel should be sutured first. The posterior wall of the pancreas should be anastomosed first, and the anterior wall should be anastomosed after tightening the sutures to avoid messy sutures. ②. Keep the suture under tension as much as possible during continuous suturing to avoid messy sutures. ③. Use a thin, non-invasive sliding suture whenever possible. The non-invasive sliding thread is easy to tighten the thread, which is less traumatic to the tissues. In conclusion, with the continuous understanding of surgical scholars of pancreaticoduodenectomy, pancreatic-intestinal anastomosis and operation methods are also constantly improving, each operator will have the corresponding feelings and experience of different pancreatic-intestinal anastomosis and operation methods, choose different pancreatic-intestinal anastomosis methods and operation methods, although the case of separating the ring of continuous suture line pancreatic-intestinal anastomosis method is applied to a relatively small number of cases, and the effect of the anastomosis is to be further clinically verified in a large number of cases, but this method is theoretically a good solution. Although there are relatively few cases of pancreaticoduodenectomy and the effect of anastomosis needs to be further verified in a large number of cases, the theoretical advantages of this method provide a new way of thinking for the majority of operators to perform pancreaticoduodenectomy and pancreatico-enteric anastomosis. References