Objective To investigate the clinical efficacy of pancreaticoduodenectomy (PD) and duodenumpreserving pancreatic head resection (DPPHR,including Beger,Frey and Berne procedures)for the treatment of chronic pancreatitis (CP) with mass in the head of the pancreas.Methods The clinical data of 48 patients with CP who were admitted to the Armed Police Corps Hospital of Hunan province(13) and the Third Xiangya Hospital of Central South University (35) between January 2007 and December 2013 were retrospectively analyzed.The operation methods were selected according to clinical symptoms,imaging findings and intraoperative pathological examinations.Twenty-three patients receiving PD (Whipple procedure or pylorus-preserving PD) were allocated into PD group and 25 receiving DPPHR (Beger,Frey and Berne procedures) were allocated into DPPHR group.The operation time,volume of intraoperative blood loss,rate of postoperative pain relief,changes of pancreatic endocrine and exocrine function,complications,duration of hospital stay and hospital expenses in the 2 groups were analyzed.Patients were followed up by telephone interview and outpatient examination up to September 2014.Measurement data with normal distribution were presented as (x) ± s.Comparison between groups was analyzed using the t test.Count data were analyzed using chi-square test or Fisher exact probability.Results Of the 23 patients in the PD group,15 patients received Whipple procedure and 8 patients received pylorus preserving PD.Of 25 patients in the DPPHR group,8 patients received Beger procedure,13 patients received Frey procedure and 4 patients received Berne procedure.The operation time and volume of intraoperative blood loss were (5.5 ± 0.4) hours,(372 ± 174) mL in the PD group,and (4.2 ± 0.6) hours,(272 ± 114) mL in the DPPHR group,showing significant differences between the 2 groups (t =8.712,2.375,P ＜ 0.05).Three patients had massive hemorrhage in the PD group and 2 patients receiving Beger procedure had massive hemorrhage due to portal vein injury,with no significant difference (x2=0.010,P ＞ 0.05).The intraoperative pathologic examinations of frozen section showed chronic inflammation in all pancreatic tissue samples with fibrous tissue proliferations.Overall pain relief rate was 95.7％ (22/23) in the PD group,including 20 complete remissions and 2 partial remissions,and overall pain relief rate was 92.0％ (23/25) in the PD group,including 18 complete remissions and 5 partial remissions,which were no different in overall pain relief rate (x2 =0.000,P ＞ 0.05).The morbidity of postoperative diabetes mellitus and dyspepsia with fatty diarrhea were 38.9％ (7/18) and 35.7％ (5/14) in the PD group,which were no different from 9.5％ (2/21) and 20.0％ (3/15) in the DPPHR group (x2=3.200,0.281,P ＞0.05).The incidence of postoperative complication was 30.4％ (7/23) in the PD group,including 1 case of intra-abdominal hemorrhage,pancreatic fistula and localized peritonitis,1 case of pancreatic fistula,2 cases of biliary fistula,3 cases of delayed gastric emptying.Patients with pancreatic fistula and biliary fistula recovered after 1-week sufficient drainage.The incidence of postoperative complication was 4.0％ (1/25) in the DPPHR group,including 1 case of pancreatic fistula,showing significant difference in incidence of postoperative complication (x2=4.274,P ＜ 0.05).The duration of postoperative stay and hospital expense were (12.4 ± 2.5) days and (57 751 ± 6 772) yuan in the PD group,which were significantly different from (8.2 ± 1.8) days and (49 109 ± 6 168)yuan in the DPPHR group (t =6.576,4.645,P ＜ 0.05).Forty-eight patients were followed up with a median time of 51.6 months (9.0-92.0 months).Of the 2 patients died,1 patient who underwent Frey procedure died 3 months after diagnosis of pancreatic cancer due to epigastric pain at postoperative month 6,the other died 2 years later due to cardiovascular disease.Among 48 patients with follow-up,1 received biliary-intestine drainage 6 months later and other patients had no recurrence or canceration.Conclusions DPPHR is safe and effective for chronic pancreatitis with mass in the head of the pancreas,having advantages such as shorter duration of operation,less intraoperative hemorrhage,faster postoperative recover,shorter duration of hospital stay and delayed hypofunction of pancreatic endocrine and exocrine function.But DPPHR cannot completely replace PD,It is necessary to master indications for all kinds of operations and choose proper operative approaches based on lesion characteristics.%目的 探讨胰十二指肠切除术(PD)和保留十二指肠胰头次全切除术(DPPHR,包括Beger术、Frey术、Berne术)治疗胰头肿块型慢性胰腺炎的临床疗效.方法 回顾性分析2007年1月至2013年12月武警湖南省总队医院收治的13例和中南大学湘雅三医院收治的35例慢性胰腺炎患者的临床资料.根据患者临床症状、影像学表现和术中病理学检查结果选择手术方式.其中23例行PD(经典Whipple术或保留幽门的PD)患者为PD组,25例行DPPHR术(Beger术、Frey术或Berne术)患者为DPPHR组.分析两组患者的手术时间、术中出血量、术后疼痛缓解率、胰腺内外分泌功能改变、手术并发症、术后住院时间、住院费用等指标.通过电话和门诊复查等方式随访,随访时间截至2014年9月.正态分布的计量资料以x±s表示,两组比较采用t检验;计数资料采用x2检验及其校正公式或Fisher确切概率法.结果 PD组23例患者中,行Whipple术15例,行保留幽门PD 8例;DPPHR组25例患者中,行Beger术8例,Frey术13例,Berne术4例.PD组和DPPHR组患者的手术时间、术中出血量分别为(5.5±0.4)h和(4.2±0.6)h,(372±174) mL和(272±114) mL,两组比较,差异均有统计学意义(t=8.712,2.375,P＜0.05).PD组有3例患者术中出现大出血,DPPHR组2例行Beger术患者术中损伤门静脉出现大出血;两组比较,差异无统计学意义(x2=0.010,P＞0.05).两组患者术中快速冷冻切片病理学检查结果均为胰腺慢性炎症改变,伴纤维组织增生.PD组患者术后疼痛总缓解率为95.7％(22/23),其中疼痛完全缓解20例,疼痛缓解2例;DPPHR组患者术后疼痛总缓解率为92.0％ (23/25),其中疼痛完全缓解18例,疼痛缓解5例;两组患者术后疼痛总缓解率比较,差异无统计学意义(x2=0.000,P＞0.05).PD组患者术后糖尿病发病率为38.9％(7/18),消化不良和脂肪泻发生率为35.7％(5/14);DPPHR组分别为9.5％ (2/21)和20.0％ (3/15),两组患者比较,差异均无统计学意义(x2=3.200,0.281,P＞0.05).PD组患者术后并发症发生率为30.4％(7/23),其中合并腹腔出血、胰液漏及局限性腹膜炎患者1例,胰液漏1例,胆瘘2例,胃排空延迟3例.胰液漏和胆瘘患者经充分引流约1周后痊愈.DPPHR组患者术后1例患者发生胰液漏,并发症发生率为4.0％ (1/25).两组患者术后并发症发生率比较,差异有统计学意义(x2=4.274,P＜0.05).PD组患者术后住院时间和住院费用分别为(12.4±2.5)d和(57 751±6772)元,DPPHR组分别为(8.2±1.8)d和(49 109±6 168)元,两组比较,差异均有统计学意义(t=6.576,4.645,P＜0.05).48例患者获得随访,平均随访时间为51.6个月(9.0 ～92.0个月).随访期间2例患者死亡,1例行Frey术,术后半年再次出现腹上区疼痛并确诊为胰腺癌,确诊后3个月死亡;1例行PD,术后2年因心血管系统疾病死亡.随访患者中1例半年后再行胆肠引流术,其余患者随访期间未出现复发和癌变.结论 DPPHR用于治疗胰头肿块型慢性胰腺炎安全有效,具有手术时间短、术中出血量少、术后恢复快、住院时间短并延迟胰腺内外分泌功能减退等优势.但DPPHR不能完全替代PD,因此,需把握各类手术的适应证,结合病变特点选择合适的手术方式.
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