胰管损伤和胰瘘的外科诊疗进展

摘要

胰瘘是胰管损伤和胰腺术后最常见的并发症之一，主胰管损伤是影响患者治疗结局最重要的因素，诊治延迟与较高的术后并发症发病率和病死率相关，术后胰瘘可直接或间接导致腹腔内感染、出血、败血症和多器官衰竭综合征等严重并发症。胰管损伤可通过胰瘘的临床表现发现，主要根据影像学检查确诊，包括计算机断层扫描（CT/CECT）、磁共振成像（MRI/MRCP）、内窥镜逆行胰胆管造影（ERCP）、超声内窥镜（EUS）和术中超声等。胰瘘的治疗除保守治疗外，主要有内镜介入治疗和手术治疗，通过维持通畅引流、主胰管精确处理、提高残端吻合技术和质量、改进重建吻合术式、使用生物医学材料可减少胰瘘及相关并发症发生。就胰管损伤和胰瘘的诊治及最新研究现状进行归纳总结，为进一步提高其临床诊治效果提供新的策略。

关键词

胰管损伤 / 胰瘘 / 胰管修复 / 诊断 / 治疗

参考文献

[1] Meierhofer C , Fuegger R , Biebl M , et al. Pancreatic fistulas: current evidence and strategy: a narrative review[J]. J Clin Med, 2023, 12(15): 5046. DOI: 10.3390/jcm12155046.

[2] Wang ZJ , Song YH , Li SY , et al. Endoscopic management of pancreatic fluid collections with disconnected pancreatic duct syndrome[J]. Endosc Ultrasound, 2023, 12(1): 29-37. DOI: 10.4103/EUS—D—21—00272.

[3] Ando Y , Okano K , Yasumatsu H , et al. Current status and management of pancreatic trauma with main pancreatic duct injury: a multicenter nationwide survey in Japan[J]. J Hepato—biliary—pancreat Sci, 2021, 28(2): 183-191. DOI: 10.1002/jhbp.877.

[4] Timmerhuis HC , van Dijk SM , Verdonk RC , et al. Various modalities accurate in diagnosing a disrupted or disconnected pancreatic duct in acute pancreatitis: a systematic review[J]. Dig Dis Sci, 2021, 66(5): 1415-1424. DOI: 10.1007/s10620—020—06413—0.

[5] Biffl WL , Ball CG , Moore EE , et al. Current use and utility of magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, and pancreatic duct stents: a secondary analysis from the western trauma association multicenter trials group on pancreatic injuries[J]. J Trauma Acute Care Surg, 2023, 95(5): 719-725. DOI: 10.1097/TA.0000000000003990.

[6] Toledo PF , Cárdenas G , Berger Z , et al. Neostigmine ^® improves pancreatic duct visualization in magnetic resonance cholangiopancreatography and could be a cheap alternative for secretin [J]. Turk J Gastroenterol: Off J Turk Soc Gastroenterol, 2022, 33(8): 704-709. DOI: 10.5152/tjg.2022.21864.

[7] Ball CG , Biffl WL , Moore EE , et al. Should surgeon—performed intraoperative ultrasound be the preferred test for detecting main pancreatic duct injuries in operative trauma cases?[J]. J Trauma Acute Care Surg, 2024, 96(3): 461-465. DOI: 10.1097/TA.0000000000004107.

[8] 李汶钢， 李杰， 徐宗珍， 等 . 腹腔镜下保留十二指肠全胰头切除术治疗胰头良性及低度恶性病变的近期效果分析[J]. 中国现代普通外科进展， 2025， 28（4）： 318-322. DOI: 10.3969/j. issn. 1009—9905.2025.04.014.

[9] 王金歌， 薛恒辉， 耿文茂， 等 . 腹腔镜保留十二指肠胰头切除术的安全性和手术技巧探讨[J]. 中国现代普通外科进展， 2025， 28（2）： 151-154. DOI: 10.3969/j.issn.1009—9905.2025.02.011.

[10] Hai H , Li Z , Zhang Z , et al. Duct—to—mucosa versus other types of pancreaticojejunostomy for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy[J]. Cochrane Database Syst Rev, 2022, 3(3): CD013462. DOI: 10.1002/14651858.CD013462.pub2.

[11] Mastalier B , Cauni V , Tihon C , et al. Pancreaticogastrostomy versus pancreaticojejunostomy and the proposal of a new postoperative pancreatic fistula risk score[J]. J Clin Med, 2023, 12(19): 6193. DOI: 10.3390/jcm12196193.

[12] 秦骋， 赵邦博， 王维斌 . 胰十二指肠切除术后胰瘘的处理策略及研究进展[J]. 中华外科杂志， 2025， 63（8）： 765-770. DOI: 10.3760/cma.j.cn112139—20250228—00097.

[13] 中华医学会消化内镜学分会， 中国医师协会内镜医师分会， 北京医学会消化内镜学分会 . 中国胰瘘消化内镜诊治专家共识（2020，北京）[J]. 中华消化内镜杂志， 2021， 38（4）： 276-287. DOI: 10.3760/cma.j.cn321463—20201208—00952.

[14] Ni J , Peng K , Yu L , et al. Transpapillary stenting improves treatment outcomes in patients undergoing endoscopic transmural drainage of ductal disruption—associated pancreatic fluid collections[J]. Am J Gastroenterol, 2023, 118(6): 972-982. DOI: 10.14309/ajg.0000000000002083.

[15] Karpuzcu HC , Erdoĝan Ç . The clinical efficacy and safety of ERCP in traumatic pancreatic injuries: a systematic review and meta—analysis[J]. World J Emerg Surg: WJES, 2025, 20(1): 52. DOI: 10.1186/s13017—025—00631—5.

[16] 石梦月， 沈珊珊， 朱浩， 等 . 内镜综合治疗在胰瘘治疗中的临床价值[J]. 中华消化内镜杂志， 2024， 41（4）： 292-296. DOI: 10.3760/cma.j.cn321463—20220505—00251.

[17] Takenaka M , Saito T , Hamada T , et al. Disconnected pancreatic duct syndrome: diagnostic and therapeutic challenges and future directions[J]. Expert Rev Gastroenterol Hepatol, 2024, 18(10): 631-645. DOI: 10.1080/17474124.2024.2419056.

[18] García—Alonso FJ , Peñas—Herrero I , Sanchez—Ocana R , et al. The role of endoscopic ultrasound guidance for biliary and pancreatic duct access and drainage to overcome the limitations of ERCP: a retrospective evaluation[J]. Endoscopy, 2021, 53(7): 691-699. DOI: 10.1055/a—1266—7592.

[19] Mazzaferro V , Virdis M , Sposito C , et al. Permanent pancreatic duct occlusion with neoprene—based glue injection after pancreatoduodenectomy at high risk of pancreatic fistula: a prospective clinical study[J]. Ann Surg, 2019, 270(5): 791-798. DOI: 10.1097/SLA.0000000000003514.

[20] Giuliani A , Avella P , Segreto AL , et al. Postoperative outcomes analysis after pancreatic duct occlusion: a safe option to treat the pancreatic stump after pancreaticoduodenectomy in low—volume centers[J]. Front Surg, 2021, 8: 804675. DOI: 10.3389/fsurg.2021.804675.

[21] Gagliardi M , Soldaini C , Sica M , et al. Endoscopic use of N—butyl—2—cyanoacrylate in refractory pancreatic duct leak and cystic duct leak: is it really a last resort[J]. J Clin Med, 2025, 14(10): 3362. DOI: 10.3390/jcm14103362.

[22] Li X , Paz—Fumagalli R , Wang W , et al. Percutaneous direct pancreatic duct intervention in management of pancreatic fistulas: a primary treatment or temporizing therapy to prepare for elective surgery[J]. BMC Gastroenterol, 2021, 21(1): 44. DOI: 10.1186/s12876—021—01620—z.

[23] Biffl WL , Ball CG , Moore EE , et al. A comparison of management and outcomes following blunt versus penetrating pancreatic trauma: a secondary analysis from the western trauma association multicenter trials group on pancreatic injuries[J]. J Trauma Acute Care Surg, 2022, 93(5): 620-626. DOI: 10.1097/TA.0000000000003651.

[24] Xu Y , Ai T . Emergency hybrid surgery for transection of pancreas at the head and neck after blunt abdominal trauma: a case report and review of the literature[J]. Medicine (Baltimore), 2024, 103(5): e37144. DOI: 10.1097/MD.0000000000037144.

[25] Wen XD , Liu DQ , Zhang BY , et al. The bridge stenting—based internal drainage in pancreatic trauma patients with main pancreatic duct injury[J]. Updates Surg, 2020, 72(3): 717-726. DOI: 10.1007/s13304—020—00807—5.

[26] Maatman TK , Roch AM , Lewellen KA , et al. Disconnected pancreatic duct syndrome: spectrum of operative management[J]. J Surg Res, 2020, 247: 297-303. DOI: 10.1016/j.jss.2019.09.068.

[27] Biffl WL , Zhao FZ , Morse B , et al. A multicenter trial of current trends in the diagnosis and management of high—grade pancreatic injuries[J]. J Trauma Acute Care Surg, 2021, 90(5): 776-786. DOI: 10.1097/TA.0000000000003080.

[28] Moren AM , Biffl WL , Ball CG , et al. Blunt pancreatic trauma: a western trauma association critical decisions algorithm[J]. J Trauma Acute Care Surg, 2023, 94(3): 455-460. DOI: 10.1097/TA.0000000000003794.

[29] Ratnayake CBB , Wells CI , Kamarajah SK , et al. Critical appraisal of the techniques of pancreatic anastomosis following pancreaticoduodenectomy: a network meta—analysis[J]. Int J Surg (lond Engl), 2020, 73: 72-77. DOI: 10.1016/j.ijsu.2019.12.003.

[30] Bizzoca C , Fedele S , Lippolis AS , et al. Modified technique for wirsung—pancreatogastric anastomosis after pancreatoduodenectomy: a single center experience and systematic review of the literature[J]. J Clin Med, 2021, 10(14): 3064. DOI: 10.3390/jcm10143064.

[31] Salman MA , Elewa A , Elsherbiny M , et al. Postoperative pancreatic fistula after pancreaticogastrostomy versus pancreatojejunostomy after pancreatic resection, a comparative systematic review and meta—analysis[J]. World J Surg, 2024, 48(6): 1467-1480. DOI: 10.1002/wjs.12173.

[32] Andrianello S , Marchegiani G , Malleo G , et al. Pancreaticojejunostomy with externalized stent vs pancreaticogastrostomy with externalized stent for patients with high—risk pancreatic anastomosis: a single—center, phase 3, randomized clinical trial[J]. JAMA Surg, 2020, 155(4): 313-321. DOI: 10.1001/jamasurg.2019.6035.

[33] Casciani F , Bassi C , Vollmer CM . Decision points in pancreatoduodenectomy: insights from the contemporary experts on prevention, mitigation, and management of postoperative pancreatic fistula[J]. Surgery, 2021, 170(3): 889-909. DOI: 10.1016/j.surg.2021.02.064.

[34] Hao X , Li Y , Liu L , et al. Is duct—to—mucosa pancreaticojejunostomy necessary after pancreaticoduodenectomy: a meta—analysis of randomized controlled trials[J]. Heliyon, 2024, 10(13): e33156. DOI: 10.1016/j.heliyon.2024.e33156.

[35] Cao Z , Luo W , Qiu J , et al. Is invagination anastomosis more effective in reducing clinically relevant pancreatic fistula for soft pancreas after pancreaticoduodenectomy under novel fistula criteria: a systematic review and meta—analysis[J]. Front Oncol, 2020, 10: 1637. DOI: 10.3389/fonc.2020.01637.

[36] Murata Y , Maeda K , Ito T , et al. Efficacy of reinforced stapler versus hand—sewn closure of the pancreatic stump during pure laparoscopic distal pancreatectomy to reduce pancreatic fistula[J]. Surg Laparosc Endosc Percutan Tech, 2023, 33(2): 99-107. DOI: 10.1097/SLE.0000000000001151.

[37] Probst P , Hüttner FJ , Klaiber U , et al. Stapler versus scalpel resection followed by handsewn closure of the pancreatic remnant for distal pancreatectomy[J]. Cochrane Database Syst Rev, 2025, 6(6): CD008688. DOI: 10.1002/14651858.CD008688.pub3.

[38] Lai M , Zhou S , He S , et al. Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery[J]. Cochrane Database Syst Rev, 2023, 6(6): CD009621. DOI: 10.1002/14651858.CD009621.pub5.

[39] Gaspar AF , Kemp R , Sankarankutty AK , et al. Influence on postoperative results and cost—effectiveness of using cyanoacrylate glue for pancreaticojejunal anastomosis after duodenopancreatectomy[J]. Pancreas, 2025, 54(7): e610-e617. DOI: 10.1097/MPA.0000000000002479.

[40] Baba H , Oba A , Maekawa A , et al. Polyglycolic acid mesh and fibrin glue in minimally invasive left pancreatectomy: video technique and single—center data[J]. Ann Surg Oncol, 2025, 32(7): 5102-5103. DOI: 10.1245/s10434—025—17203—1.

[41] Huang L , Jiang B , Lai J , et al. Efficacy of the two—parts wrapping technique in reducing postoperative complications in laparoscopic pancreaticoduodenectomy[J]. Surg Endosc, 2024, 38(8): 4731-4744. DOI: 10.1007/s00464—024—11028—x.

[42] Lech GE , Viana P , de Paiva Reis CM , et al. Arterial and anastomotic wrapping in pancreaticoduodenectomy as a strategy to reduce complications: a systematic review and meta—analysis[J]. HPB: Off J Int Hepato Pancreato Biliary Assoc, 2025, 27(5): 591-598. DOI: 10.1016/j.hpb.2025.02.001.

[43] Jiang K , Chen H , Wang J , et al. Laparoscopic distal pancreatectomy with pancreatic remnant—gastric coverage: a modified technique to reduce postoperative pancreatic fistula[J]. Surg Endosc, 2025, 39(1): 368-375. DOI: 10.1007/s00464—024—11386—6.

[44] Kato T , Watanabe Y , Baba Y , et al. Preoperative risk—stratified analysis: external versus internal pancreatic stents in pancreatoduodenectomy[J]. Surgery, 2025, 178: 108845. DOI: 10.1016/j.surg.2024.09.007.

[45] Guo C , Xie B , Guo D . Does pancreatic duct stent placement lead to decreased postoperative pancreatic fistula rates after pancreaticoduodenectomy? A meta—analysis[J]. Int J Surg (lond Engl), 2022, 103: 106707. DOI: 10.1016/j.ijsu.2022.106707.

[46] Sun Y , Li Y , Liu Z , et al. Stent placement for the prevention of clinically—relevant postoperative pancreatic fistula following pancreaticojejunostomy: a systematic review and meta—analysis[J]. Am J Surg, 2024, 234: 122-128. DOI: 10.1016/j.amjsurg.2024.04.002.

[47] Ulku A , Topal U , Erdogan O , et al. Effect of main pancreatic duct suture ligation on the prevention of clinically relevant pancreatic fistula after distal pancreatectomy: analysis of 82 consecutive patients[J]. Eur Rev Med Pharmacol Sci, 2023, 27(21): 10522-10530. DOI: 10.26355/eurrev_202311_34328.

[48] Chierici A , Frontali A , Granieri S , et al. Postoperative morbidity and mortality after pancreatoduodenectomy with pancreatic duct occlusion compared to pancreatic anastomosis: a systematic review and meta—analysis[J]. HPB, 2022, 24(9): 1395-1404. DOI: 10.1016/j.hpb.2022.03.015.

[49] 刘荣， 刘渠， 王子政， 等 . 胰管（修复）外科的理论及实践[J]. 科学通报， 2023， 68（18）： 2376-2387.

[50] Xu J , Li C , Wu J , et al. The short—term outcomes of laparoscopic enucleation of pancreatic tumors with exposing the wirsung duct[J]. Surg Endosc, 2025, 39(1): 212-218. DOI: 10.1007/s00464—024—11311—x.

[51] 中国研究型医院学会微创外科专业委员会， 中国研究型医院学会智能医学专业委员会 . 胰管（修复）外科专家共识[J]. 中华腔镜外科杂志（电子版）， 2025， 18（2）： 65. DOI: 10.3877/cma. j. issn.1674—6899. 2025.02.001.

[52] Li Z , Shi Y , Zhuo Q , et al. Main pancreatic duct exposure, repair or reconstruction during minimally invasive pancreatic enucleation long—term metabolic outcome from a prospective cohort study (CSPAC—MIEN—1) [J]. Int J Surg (lond Engl), 2025, 111(11): 8001-8014. DOI: 10.1097/JS9.0000000000003016.