联合腹腔干的胰体尾切除和血管变异的临床分析

doi:10.16139/j.1007-9610.2020.02.010

摘要/Abstract

摘要：

目的: 研究联合腹腔干的胰体尾切除（distal pancreatectomy with en bloc celiac axis resection, DP-CAR）对扩大根治局部进展期胰体尾癌的近期临床疗效,并探讨血管变异对DP-CAR术后并发症发生的影响。方法: 回顾性研究43例行DP-CAR且术后病理结果均为胰腺导管腺癌的病例,分析R0切除率和围术期手术并发症发生率、死亡率等,比较有无血管变异对术后并发症发生的影响。结果: 本研究DP-CAR的R0切除率达81.4%,围术期死亡率为7.0%,并发症发生率为46.5%。腹腔血管变异8例。血管变异组与无血管变异组术后并发症发生率为3/8（37.5%）比17/35（48.6%）,P=0.535,死亡率为1/8（12.5%）比2/35（5.7%）,P=0.224,组间差异均无统计学意义。结论: DP-CAR具有一定的优越性,安全可行。血管变异对DP-CAR术后并发症发生无显著影响。

关键词: 联合腹腔干切除的胰体尾扩大根治术, 术后并发症, 血管变异, 局部进展期胰体尾癌

Abstract:

Objective: To analyze the short-term efficacy of distal pancreatectomy with en bloc celiac axis resection (DP-CAR) in the treatment of locally advanced pancreatic body or tail cancer and the effect of vascular variation on morbidity after DP-CAR. Methods: A retrospective study was undertaken of 43 cases with pancreatic ductal adenocarcinoma diagnosed by pathological examination in the treatment of DP-CAR. R0 resection, morbidity and mortality were analyzed perioperatively with the effect of vascular variation. Results: R0 resection by DP-CAR was 81.4% in this study with mortality 7.0% and morbidity 45.6%. Eight cases were found with vascular variation. The postoperative morbidity in the group with vascular variation and in the group without vascular variation was 3/8 (37.5%) vs 17/35 (48.5%) and the mortality 1/8 (12.5%) vs 2/35 (5.7%), respectively. There was no significant difference statistically in morbidity and mortality between 2 groups. Conclusions: DP-CAR has the advantage of safety and feasibility. There would be no effect of vascular variation on morbidity after DP-CAR.

Key words: Distal pancreatectomy with en bloc celiac axis resection, Postoperative morbidity, Vascular variation, Locally advanced pancreatic body or tail cancer

中图分类号:

R735.9

陈梦闽, 赵舒霖, 金佳斌, 秦凯, 邓侠兴, 沈柏用, 彭承宏. 联合腹腔干的胰体尾切除和血管变异的临床分析[J]. 外科理论与实践, 2020, 25(02): 134-138.

CHEN Mengmin, ZHAO Shulin, JIN Jiabin, QIN Kai, DENG Xiaxing, SHEN Baiyong, PENG Chenghong. Clinical study on distal pancreatectomy with en bloc celiac axis resection with analysis of vascular variation[J]. Journal of Surgery Concepts & Practice, 2020, 25(02): 134-138.

图/表 1

参考文献 20

[1]	Hartwig W, Gluth A, Hinz U, et al. Outcomes after extended pancreatectomy in patients with borderline resectable and locally advanced pancreatic cancer[J]. Br J Surg, 2016, 103(12):1683-1694. doi: 10.1002/bjs.10221 pmid: 27686238
[2]	Gong H, Ma R, Gong J, et al. Distal pancreatectomy with en bloc celiac axis resection for locally advanced pancrea-tic cancer: a systematic review and meta-analysis[J]. Medicine(Baltimore), 2016, 95(10):e3061.
[3]	Christein JD, Kendrick ML, Iqbal CW, et al. Distal pancreatectomy for resectable adenocarcinoma of the body and tail of the pancreas[J]. J Gastrointest Surg, 2005, 9(7):922-927. pmid: 16137585
[4]	Barreto SG, Shukla PJ, Shrikhande SV. Tumors of the pancreatic body and tail[J]. World J Oncol, 2010, 1(2):52-65. doi: 10.4021/wjon2010.04.200w pmid: 29147182
[5]	Amano H, Miura F, Toyota N, et al. Is pancreatectomy with arterial reconstruction a safe and useful procedure for locally advanced pancreatic cancer?[J]. J Hepatobi-liarypancreat Surg, 2009, 16(6):850-857.
[6]	Vainshtein JM, Schipper M, Zalupski MM, et al. Prognostic significance of carbohydrate antigen 19-9 in unresectable locally advanced pancreatic cancer treated with dose-escalated intensity modulated radiation therapy and concurrent full-dose gemcitabine: analysis of a prospective phase 1/2 dose escalation study[J]. Int J Radiat Oncol Biol Phys, 2013, 86(1):96-101. doi: 10.1016/j.ijrobp.2012.11.020 URL
[7]	Tempero MA, Malafa MP, Al-Hawary M, et al. Pancreatic Adenocarcinoma, Version 2 2017, NCCN Clinical Practice Guidelines in Oncology[J]. J Natl Compr Canc Netw, 2017, 15(8):1028-1061 doi: 10.6004/jnccn.2017.0131 URL
[8]	Tanaka E, Hirona S, Tsuchikawa T, et al. Important technical remarks on distal pancreatectomy with en-bloc ce-liac axis resection for locally advanced pancreatic body cancer[J]. J Hepatobiliary Pancreat Sci, 2012, 19(2):141-147. doi: 10.1007/s00534-011-0473-7 URL
[9]	Nakamura T, Hirano S, Noji T, et al. Distal pancreatectomy with en bloc celiac axis resection (modified appleby procedure) for locally advanced pancreatic body cancer: a single-center review of 80 consecutive patients[J]. Ann Surg Oncol, 2016, 23(Suppl 5):969-975. pmid: 27495282
[10]	Hirano S, Kondo S, Hara T, et al. Distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic body cancer: long-term results[J]. Ann Surg, 2007, 246(1):46-51. doi: 10.1097/01.sla.0000258608.52615.5a URL
[11]	Takahashi Y, Kaneoka Y, Maeda A, et al. Distal pancreatectomy with celiac axis resection for carcinoma of the body and tail of the pancreas[J]. World J Surg, 2011, 35(11):2535-2542. doi: 10.1007/s00268-011-1245-x pmid: 21901326
[12]	Beane JD, House MG, Pitt SC, et al. Distal pancreatectomy with celiac axis resection: what are the added risks?[J]. HPB(Oxford), 2015, 17(9):777-784.
[13]	戚峰, 邰升. 联合腹腔干切除的胰体尾癌根治术[J]. 中华肝脏外科手术学电子杂志, 2017, 6(3):168-171.
[14]	Yamagami T, Yoshimatsu R, Kajiwara K, et al. Arterio-graphy after embolization before distal pancreatectomy with en bloc celiac axis resection[J]. Minim Invasive Ther Allied Technol, 2015, 24(6):350-355. doi: 10.3109/13645706.2015.1034729 URL
[15]	Christians KK, Pilgrim CH, Tsai S, et al. Arterial resection at the time of pancreatectomy for cancer[J]. Surgery, 2014, 155(5):919-926. doi: 10.1016/j.surg.2014.01.003 URL
[16]	Mittal A, de Reuver PR, Shanbhag S, et al. Distal pancreatectomy, splenectomy, and celiac axis resection (DPS-CAR): common hepatic arterial stump pressure should determine the need for arterial reconstruction[J]. Surgery, 2015, 157(4):811-817. doi: 10.1016/j.surg.2014.10.006 URL
[17]	Okada K, Kawai M, Tani M, et al. Preservation of the left gastric artery on the basis of anatomical features in patients undergoing distal pancreatectomy with celiac axis en-bloc resection(DP-CAR)[J]. World J Surg, 2014, 38(11):2980-2985. doi: 10.1007/s00268-014-2702-0 URL
[18]	Sato T, Saiura A, Inoue Y, et al. Distal pancreatectomy with en bloc resection of the celiac axis with preservation or reconstruction of the left gastric artery in patients with pancreatic body cancer[J]. World J Surg, 2016, 40(9):2245-2253. doi: 10.1007/s00268-016-3550-x URL
[19]	Hiatt JR, Gabbay J, Busuttil RW. Surgical anatomy of the hepatic arteries in 1000 cases[J]. Ann Surg, 1994, 220(1):50-52. pmid: 8024358
[20]	Egorov VI, Petrov RV, Lozhkin MV, et al. Liver blood supply after a modified Appleby procedure in classical and aberrant arterial anatomy[J]. World J Gastrointesti Surg, 2013, 5(3):51-61. doi: 10.4240/wjgs.v5.i3.51 URL

项目	血管变异组（n=8）	无血管变异组（n=35）	P值
男性	5	22	0.642
年龄（岁）	64.6±11.9	59.2±7.4	0.109
BMI	20.8±7.3	22.2±2.8	0.399
ASA评分≥Ⅱ级	4	20	0.507
吸烟史	0	7	0.209
饮酒史	0	3	0.530
术前血清总胆红素（μmol/L）	14.5±3.1	16.2±7.5	0.542
术前血清前白蛋白（mg/L）	244.6±35.6	247.0±65.4	0.322
术前血清白蛋白（g/L）	39.8±2.6	40.0±4.1	0.887
CA19-9>37 kU/L	4	18	0.624
CEA>5 μg/L	3	14	0.612
CA125>35 kU/L	2	5	0.388
肿瘤最大径（cm）	5.3±2.2	4.3±1.8	0.201
阻塞性胰腺炎	7	24	0.272
胰源性门静脉高压	6	26	0.672
DP-CAR方式
开腹	7	32	0.576
机器人辅助	1	3	0.576
手术时间（min）	231.8±61.6	237.8±77.8	0.284
术中出血量（mL）	525±345	608±573	0.695
术中输血量（mL）	800±534	868±894	0.781
术中联合放疗	0	4	0.424
血管特殊处理联合SMV-PV切除重建	0	6	0.266
保留胃左动脉	2	2	0.151
联合CA-CHA重建	2	2	0.151
围术期死亡	1	2	0.224
术后并发症	3	17	0.535
二次手术	0	4	0.637
胰漏B/C级	2	13	0.417
B级	1	9	0.390
C级	1	4	0.663
腹腔出血	0	4	0.424
胃/肠漏	0	3	0.530
胃排空延迟	0	4	0.663
乳糜漏	1	2	0.224
腹腔感染	3	7	0.266
一过性肝缺血致转氨酶升高	0	4	0.424
术后住院时间（d）	28.8±17.5	31.8±20.0	0.695