| Objective:Currently,there have been many studies on the risk factors of postoperative pancreatic fistula,but few studies have focused on the effect of pancreatic duct movement in the pancreas,especially it’s relative position in the pancreatic section on postoperative pancreatic fistula.In this study,preoperative crosssectional CT was used to simulate the position of pancreatic duct at pancreatic section during operation,so as to explore the relationship between the position of pancreatic duct at pancreatic section during pancreaticojejunostomy and the occurrence of postoperative pancreatic fistula,and try to apply it to clinical practice initially.Methods:Due to the anatomical characteristics of the pancreas,the neck of the pancreas and the anterior junction of the superior mesenteric vein are usually selected as the site of the disconnected pancreas in routine surgery,and their positions are relatively fixed in different patients,so this truncated surface can be selected for analysis.In this study,intraoperative pancreatic cross-sectional images and preoperative CT cross-sectional images were collected and analyzed respectively to compare the consistency between the two group.After the conclusion of the first step,the clinical data and imaging data of patients who had previously undergone pancreaticojejunostomy were retrospectively collected.Univariate analysis and multivariate analysis were performed to determine whether the relative position of the pancreatic duct on the pancreatic section during pancreaticojejunostomy caused images for the occurrence of clinically related pancreatic fistula after surgery.Finally,according to the conclusions in the second part,different pancreaticojejunostomy procedures were performed on patients with different pancreatic duct types to try to improve the incidence of postoperative clinically related pancreatic fistula and other complications.Results:Part Ⅰ: A total of 44 patients were able to obtain both intraoperative and preoperative imaging measurements,of which 42(95.5%)underwent pancreaticoduodenectomy and 2(4.5%)underwent duodenal sparing pancreatectomy.In this study,the value ranged from 2.8 mm to 11.6mm,with an average distance of 5.9±1.9mm.The ratio at the overall pancreatic section thickness ranged from 0.181 to 0.687,with an average value of 0.41±0.09.This result was close to the imaging measurement,ICC=0.916>0.75,P<0.0001.Part Ⅱ: A total of 373 patients,according to whether the clinically relevant pancreatic fistula in pancreatic fistula groups(biochemical fistula,no pancreatic fistula in total 284 cases)and pancreatic fistula of pancreatic fistula(B,C grade pancreatic fistula in total,89 cases),the overall incidence of clinically relevant postoperative pancreatic fistula was 23.9%,including 7 cases due to the severe postoperative pancreatic fistula and complications in hospital rescue,finally has announced 3 cases of clinical death and 4 cases were discharged automatically.Statistical analysis was conducted on the clinical data of the patients,and univariate analysis showed that there were no statistically significant differences between the two groups in gender,age,diabetes,preoperative serum protein level,preoperative total bilirubin level,estimated intraoperative blood loss,distance from the center of the pancreatic duct to the posterior edge of the pancreas(P>0.05).Compared with patients without pancreatic fistula,pancreatic fistula patients higher BMI(23.9±3.4 VS 21.4±2.7),have high blood pressure disease percentage was higher(25.9% vs.16.2%),surgery time larger ratio of more than 300 minutes(69.7% VS 54.2),quality of a material soft pancreas,pancreatic duct diameter and the pathological type for more than pancreatic cancer or pancreatitis,pancreatic duct center to the edge of the short distance in the pancreas thickness of less than(36.3±7.2 %VS 43.8±6.0%),the difference is statistically significant(P<0.05).When related items were included in the multivariate analysis,the patients had a higher BMI(OR=1.276,95%CI: 1.154-1.411,P<0.0001),soft pancreatic texture(OR=2.771,CI: 1.5588-4.927,P=0.001)were independent risk factors for postoperative pancreatic fistula,and the increased proportion of centre-tomarginal pancreatic duct short distance to pancreatic thickness in follow-up patients was associated with a decreased risk of postoperative pancreatic fistula(OR= 0.875CI: 0.840-0.911,P<0.0001).Receiver operating characteristic curve(ROC)was drawn for the relationship between the proportion of pancreatic duct center-to-edge short distance in pancreatic thickness(%)and postoperative pancreatic fistula,and the area under the ROC curve was 0.802(P<0.0001),the corresponding cutoff value was 40.1% when the Youden index was at its maximum,and the predictive sensitivity and specificity of this value for the occurrence of postoperative pancreatic fistula was 73.0% and 81.3%,which were compared with the current FRS scoring system.Part Ⅲ: Experimental line into the pancreatic duct of mucosal anastomosis operation of 38 patients,control group included 281 patients,there is no difference on preoperative basic situation,both the experimental group according to the location of the main pancreatic duct type adopts single layer,double pancreatic duct of mucosal anastomosis operation,the control group adopts double pancreatic duct mucosa anastomosis operation.The incidence of clinically related pancreatic fistula was relatively lower in the experimental group than in the control group(15.8% VS 23.5%),and the incidence of perioperative bleeding was also slightly lower(2.6% VS 7.1%),but there was no statistically significant difference.Conclusion:1.The three-dimensional reconstruction of preoperative CT for the position of the pancreas and pancreatic duct of patients can truly reflect the intraoperative conditions of patients,and partial parameters measured by preoperative imaging can be used to replace the intraoperative values for analysis to a certain extent.2.Patients with higher BMI and soft pancreatic texture are independent risk factors for postoperative pancreatic fistula,and the increased proportion of short distance from center to edge of pancreatic duct in pancreatic thickness is a protective factor for postoperative pancreatic fistula.The truncation value of the ratio of pancreatic duct centermargin short distance to pancreatic thickness was 40.1%,and the prediction sensitivity and specificity for postoperative pancreatic fistula was 73.0% and 81.3%.It could be used to estimate the risk of postoperative clinically related pancreatic fistula,which is better than FRS score.3.Selection of appropriate pancreaticojejunostomy according to different types of pancreatic duct location may reduce the incidence of clinically related pancreatic fistula after surgery.Compared with the traditional double-layer pancreatic catheter anastomosis,the single-layer pancreatic catheter to mucosal anastomosis adopted in this study can simplify the surgical operation and reduce the difficulty of surgery,and does not increase the risk of postoperative clinically related pancreatic fistula.However,the specific pancreaticojejunostomy is more appropriate and needs further exploration in subsequent studies. |
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