Clinical Study On The Relationship Between Pancreatic Fistula And The Degree Of Pancreatic Fibrosis After Pancreatic And Duodenal Resection

Background:Pancreaticoduodenectomy is also known as Whipple surgery,surgical approach to the treatment of cancer around the common pancreatic head carcinoma and ampullary surgery,abdominal surgery is one of the most complex.This procedure generally choose superior abdominal incision or right upper paramedian incision,convenient,and extended,fully revealed.The extent of resection including pancreatic head(including uncinate process),distal stomach,duodenum,jejunum,gallbladder and common bile duct,and lymph node clearance related around,finally,the broken end and distal pancreatic duct remnant stomach and jejunum reconstruction.First cases of periampullary carcinoma resection is a German surgeon Kausch in 1909 of two phases.In 1935,Whipple conducted the operation in a similar way,and in 1942 for a period of improved surgery,anastomosis after resection of the order of gallbladder and pancreas and stomach and jejunum anastomosis,namely the formation of head of pancreas and duodenum resection today.In 1944 Child will end and jejunal pancreatic stump and cholangiojejunum anastomosis,end to side anastomosis and end to side anastomosis or gastrojejunostomy,bile and pancreatic,stomach and jejunum anastomosis,called Child.Child and Whipple are the most common surgical procedures.The main steps of pancreatoduodenectomy(including the exploration is to understand the nature of the lesions,to determine the need for understanding resection;surrounding tissue,to determine whether they will be removed),resection and reconstruction of digestive tract and drainage suture.At present the operation of the lowest mortality rate is less than o r equal to 2%.With the improvement of the level of anesthesia monitoring and the improvement of surgical techniques,the mortality of PD has been significantly reduced,but the incidence of postoperative complications is still not effectively avoided.Pancreatic fistula is a common serious complication after PD,the incidence rate is 5% ~ 40%.Occurred more than 5-7 days after operation.Patients with abdominal distension,abdominal pain,high fever,increased abdominal drainage fluid,such as the increase in abdominal drainage fluid amylase,can be identified as pancreatic fistula.Non surgical treatment is generally used,because the operation is difficult to repair.Different methods of reconstruction of digestive tract are important for the prevention o f pancreatic fistula.At present,the Whipple method is used to reconstruct the digestive tract.Attention should be paid to the operation of intestinal anastomosis in the operation,especially for the placement and drainage of the main pancreatic duct,and the drainage of the abdominal cavity should be sufficient.Early application of drug sustained inhibition of pancreatic secretion,such as somatostatin and its derivatives.The soft texture of the pancreas is an independent prognostic factor for the occu rrence of pancreatic fistula after PD.However,most of the studies are judged by the subjective perception of the pancreas and lack of uniform criteria.Pancreatic fibrosis is a common pathological change of pancreatic tissue,which can be caused by acute and chronic pancreatitis,pancreatic cancer,pancreatic cystic fibrosis and autoimmune diseases.But the severity of pancreatic fibrosis can only be determined by histological examination.Previous studies have shown that preoperative CT values of pancreatic Hu may predict the risk of pancreatic fistula after PD.Therefore,we hypothesized that the degree of pancreatic fibrosis is the main factor affecting the quality of pancreas and pancreatic fistula after PD,and the preoperative CT value of pancreas can reflect the degree of pancreatic fibrosis in Hu.In this study,a retrospective analysis of our hospital department of hepatobiliary surgery from January 2013 to December 2015 a total of 408 patients underwent pancreaticoduodenectomy in patients with complete clinical data and prognostic factors of pancreatic fistula after PD analysis,a preliminary study of PD postoperative pancreatic fistula and pancreatic fibrosis relationship.Objectives:1.Clear gender,age and BMI,diabetes,hypertension,abdominal surgery history,preoperative hemoglobin,albumin,preoperative total bilirubin,preoperative ALT,preoperative AST,preoperative gamma glutamyl transpeptidase,alkaline phosphatase,preoperative pancreatic duct diameter,CT Hu value,operation mode,operation time,intraoperative blood loss,pancreatic hardness(intraoperative judgment),vascular invasion,pancreatic lobular fibrosis percentage is a risk factor for pancreatic fistula after pancreatoduodenectomy.2.To investigate the relationship between pancreatic fistula and pancreatic fibrosis after pancreaticoduodenectomy.Methods:We retrospectively analyzed 408 patients with pancreaticoduodenectomy who underwent pancreaticoduodenectomy from January 2013 to December 2015 in the Department of Hepatobiliary Surgery of the first affiliated hospital of Third military medical university.There were 274 males and females,aged from 14 to 82,with an average age of 54.6 years old.Postoperative pathological diagnosis: 285 cases of pancreatic ductal adenocarcinoma,81 cases of gastrointestinal tumors,13 cases of neuroendocrine tumors,16 cases of inflammatory changes,8 cases of pancreatic papillary tumors,4 cases of serous cystadenoma,1 cases of retroperitoneal liposarcoma.Univariate analysis using pearson chi-square test,multivariate analysis using binary logistic regression analysis,correlation analysis using Spearman rank correlation analysis and the predictive value of pancreatic fibrosis in pancreatic fistula after PD was assessed using the area under the receiver operating characteristic(ROC)curve.Result:There were 123 cases(30.14%)of postoperative pancreatic fistula in 408 patients.Univariate analysis showed that body mass index(BMI)(P=0.005),preoperative gamma-glutamyltranspeptidase content(P=0.046),pancreatic duct diameter(P=0.001),CT Hu value of pancreatic tissue(P=0.049),operation time(P=0.037),pancreatic stiffness(intraoperative judgment)(P=0.001)and percentage of pancreatic fibrosis(P=0.034)were the risk factors of pancreatic fistula.Multivariate analysis showed that BMI?25,pancreatic duct diameter ? 3mm,pancreatic tissue CT Hu value <40,pancreatic hardness(intraoperative judgments)for the soft and pancreatic lobular fibrosis percentage ? 25% of postoperative pancreatic fistula occurrence of high-risk factor(P<0.05).Pancreatic fistula's CT Hu value and percentage of pancreatic fibrosis were significantly lower than non-pancreatic fistula group,the difference was statistically significant(P<0.05).There were significant differences in CT Hu and pancreatic lobular fibrosis between different grades of pancreatic fistulae(P<0.05).Pancreatic fistula severity was negatively correlated with the CT Hu value of pancreatic body and the percentage of fibrosis of the pancreas(P=0.005;0.019),and there was a significant correlation between CT Hu value of pancreatic body and the percentage of fibrosis of the pancreas(r=0.699,P=0.028).The percentage of pancreatic fibrosis and the area under CT Hu of the pancreatic body were 0.745 and 0.714,respectively.Both of them were of moderate predictive value for pancreatic fistula after PD.Conclusions:1.BMI?25 kg/m2,pancreatic duct diameter less than 3 mm,CT Hu<40 in pancreatic tissue and pancreatic soft texture(intraoperative judgement)and pancreatic lobular fibrosis percentage is less than or equal to 25% are risk factors of pancreatic fistula after pancreaticoduodenectomy.2.The degree of pancreatic fibrosis is a prognostic factor for pancreatic texture and pancreatic fistula after Pancreaticoduodenectomy,CT Hu value of pancreatic body can be used as a quantitative index of pancreatic fibrosis,and predict the risk of pancreatic fistula after PD.