胰头癌行根治性胰十二指肠切除术神经清扫指征与技巧

胰腺癌具有嗜神经侵袭和转移特性,神经组织内癌细胞残留是胰腺癌术后复发的重要原因。然而,传统胰腺癌根治术并未重视胰腺周围神经丛的清扫。目前,对于胰头癌病人行联合胰周神经清扫的手术指征和清扫范围仍缺乏统一标准。建议对相对早期胰头癌进行联合神经清扫的胰十二指肠切除术,重点对胰头后方神经丛、肠系膜上动脉环绕270?及腹腔干右侧180?以上进行完整清扫,并推荐采用肠系膜上动脉先行游离的手术路径。     

动脉优先入路在胰十二指肠切除术中的技术要点

目的 探讨在胰十二指肠切除术中利用动脉优先入路（artery first approach）早期探查肠系膜上动脉（SMA）和腹腔干以判断肿瘤可切除性,并完成以SMA及腹腔干为轴的右侧神经及淋巴组织的完全切除的技术要点。方法 回顾性分析笔者所在医院胰腺外科中心2010年9月至2013年12月期间27例实施动脉优先入路胰十二指肠切除术患者的临床资料。结果 27例患者术前均疑诊为“胰头癌”,且术前CT判断均为交界性可切除者。8例行内引流手术,2例行全胰切除术,17例行胰十二指肠切除术;其中5例行联合门静脉（PV）/肠系膜上静脉（SMV）切除,1例行肝总动脉切除,2例行扩大右侧胰腺切除术。手术时间（281.28±78.53） min （133～354 min）,术中出血（352±537） mL （189～1 352 mL）。无术后死亡,无因并发症再次手术者。结论 动脉优先入路适合于术前判断为交界可切除病例,具体的入路方式需根据肿瘤位置以及侵犯情况灵活采用。     

腹腔镜下动脉优先、钩突优先入路:一种提高胰头癌动脉周围廓清率的简易安全方法

胰腺癌胰十二指肠切除术（pancreaticoduodenectomy,PD）术后局部复发率高达30%~60%,反映了清扫不足的现状,其常见复发部位集中于肠系膜上动脉（superior mesenteric artery,SMA）、腹腔干（celiac artery,CA）中轴线周围。CA、SMA由于位置深在、解剖关系复杂,     

结肠下区肠系膜上动脉优先入路在交界可切除胰头癌外科治疗中的应用价值

目的探讨结肠下区肠系膜上动脉优先入路在交界可切除胰头癌外科治疗中的应用价值。方法回顾性分析2015年1月至2021年12月在首都医科大学附属北京朝阳医院肝胆外科行根治性胰十二指肠切除术的90例交界可切除胰头癌患者的临床及随访资料。结果 90例患者在结肠下区探查肠系膜上动脉判断有血管侵犯但符合交界可切除标准后, 先断血供再切除组织器官, 将受侵血管行切除重建或置换后行常规吻合。所有患者均顺利完成手术, 无围手术期死亡。所有患者术后均经病理学检查结果证实为胰腺导管腺癌。结肠下区动脉优先入路组患者术后1、2、3年无瘤生存率为68.2%、60.4%、54.3%, 常规入路组患者术后1、2、3年无瘤生存率为58.4%、26.4%、11.7%(P=0.001)。结论结肠下区肠系膜上动脉优先入路可延长交界可切除胰头癌患者术后生存时间, 减少复发。     

全胰切除术21例疗效评价

目的对全胰切除术的疗效进行评价。方法对2003年4月至2006年6月21例接受全胰切除术的患者的临床资料进行回顾性分析。结果21例行全胰切除术的患者中1例联合横结肠切除,1例联合全胃切除,9例行门静脉．肠系膜上静脉部分切除端端吻合术,9例行门静脉-肠系膜上静脉部分切除人造血管间置术,其中联合腹腔干切除8例,联合腹腔干、肝固有动脉切除4例,联合腹腔干、肝总动脉切除和肠系膜上动脉部分切除端端重建1例。12例（57．1％）发生术后并发症;5例（23．8％）术后30d内死亡。术后每日胰岛素用量18～28U,均能较好地控制血糖。生活质量较术前有明显提高。16例获得随访,中位生存期为9．2个月（1．2～13．0个月）,其中胰腺导管癌中位生存期为7个月（1．2～9．0个月）,侵袭性导管内乳头状黏液性肿瘤中位生存期为11．3个月（10．0～13．0个月）。结论全胰切除术不提高生存期,而并发症和手术死亡率增加,但可改善生活质量,可作为胰管内乳头状黏液性肿瘤的手术选择,对胰腺导管腺癌则必须考虑手术的必要性。全胰切除术后糖尿病是可控的。     

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目的 探讨联合切除血管和重建的胰腺癌根治术的适应征和方法。方法 对上来所放行的区域性胰腺切除术,标准胰十二指肠切除术联合肠系膜上静脉切除的７例胰腺癌作一回顾性分析。结果 ２例行区域性胰腺切除术,其中１例联合切除肝动脉,血管端－端吻合,１例联合切作肠系膜上动脉、肠系膜上静脉,行血管间置移植术;５例行标准胰十二指肠切除术,联合肠系膜上静脉切除血管同置移植术。随访８～６０个月,情况良好,无胰腺癌复发,彩     

小肠解旋转技术用于胰十二指肠切除术3例体会

目的探讨小肠解旋转技术及其在胰十二脂肠切除术中的应用。方法回顾性分析复旦大学附属中山医院2016年8月至2016年9月收治的3例接受胰十二指肠切除术病人资料,通过结合术前影像学资料、术后病理学检查结果及术后恢复情况,探讨小肠解旋转技术对术中局部解剖的改变及其在胰十二指肠切除术中的应用。结果病人解小肠旋转时间分别为30、15、15 min。消化道重建前恢复小肠旋转状态所需时间约5 min。小肠解旋转后,肠系膜上动脉自肠系膜上静脉左后侧易位到右后侧,胰十二指肠下动脉直接发自肠系膜上动脉右侧壁并水平向右走行;胰腺系膜直接发自肠系膜上动脉右侧并创造了一个水平面,从而方便胰腺系膜的完整切除。术中出血量分别在0.10、0.15、0.05L,均未输血。术后病理学检查提示后腹膜切缘阴性(1例姑息性手术除外),另2例淋巴结清扫总数均10枚。术后引流量偏大,中位值约0.3 L/d,引流管放置时间均在1周以上。结论通过小肠解旋转技术简化胰腺系膜的解剖,可获得良好的手术视野,从而使得胰腺系膜切除变得容易、精确和可控。     

可切除性胰腺癌外科治疗中的随机对照试验分析

目的 从近10年的随机对照临床试验中总结出可切除性胰腺癌外科治疗的最佳证据。方法 对1995年01月至2004年4月间Medine中有关可切除性胰腺癌外科治疗的随机对照临床试验文献进行分析。结果 共检索到相关文献23篇代表19项不同的随机对照临床试验。结果表明：(1)标准的胰十二指肠切除术和保留幽门的胰十二肠切除术手术并发症和手术死亡率相似,术后患者生存率相当。(2)扩大淋巴结清扫术较标准淋巴结清扫术手术并发症增多,手术死亡率相当。长期生存率和生活质量无明显改善。目前仍缺乏联合门静脉／肠系膜上静脉切除的扩大根治术可提高胰腺癌患者长期生存率的有力证据。(3)闭塞胰管而不用吻合方法者术后胰瘘和胰腺分泌不足增多,胰肠或胰胃吻合仍然是胰十二指肠切除中的主要重建方式,同时经纤维蛋白胶闭塞主胰管并不能减少术后腹腔内并发症。(4)不主张在胰切端床常规置引流管。(5)胰切除术后常规使用生长抑素并不减少术后胰瘘的发生率。(6)胰腺癌治愈性切除后可以得益于辅助性化疗,而辅助性放疗则有害。结论 手术治疗仍为治愈胰腺癌的唯一手段,仍需经过大样本的前瞻性随机对照临床试验和长期随访的结果来找出合理的规范化手术操作和综合治疗方案,形成临床实践指导原则。     

联合血管切除和重建的FortnerⅠ型和Ⅱ型胰腺癌区域性切除术

目的探讨联合切除血管和重建的区域性胰腺癌根治术的临床疗效.方法对行联合肠系膜上静脉-门静脉(SMPV)切除的Ⅰ型区域性胰十二指肠切除术、联合SMPV等多根血管切除的Ⅱ型区域性胰十二指肠切除术的 6例胰腺癌作一回顾性分析.结果 1例胰体癌联合切除肠系膜上动脉、肠系膜上静脉和肝动脉行人造血管间置移植术,术后存活13个月死亡; 5例行标准胰十二指肠切除术,联合肠系膜上静脉切除人工血管间置移植术,随访 5～34个月,无复发,超声和CT显示移植人造血管通畅.结论在严格选择的病例中可施行联合切除血管的胰腺癌区域根治术.     

胰头部动脉优先离断在根治性胰十二指肠切除术中的运用

目的探讨胰头部动脉优先离断在肠系膜上静脉或门静脉受侵犯的胰头部恶性肿瘤行根治性胰十二指肠切除术中的运用价值。方法回顾性分析2012年1月至2013年5月华中科技大学同济医学院附属同济医院完成的58例胰头部恶性肿瘤行根治性胰十二指肠切除术患者的临床资料。58例患者术前薄层CT检查均显示肠系膜上静脉或门静脉受侵犯或受压,均行胰头部动脉优先离断的根治性胰十二指肠切除术,即在处理胰头部静脉血管之前优先离断胰头部的所有动脉供血,即三大动脉血管的分支,主要步骤包括：在十二指肠水平部或横结肠系膜根部暴露和悬吊肠系膜上动、静脉;解剖肝总动脉从而离断胃十二指肠动脉和胃右动脉,同时沿肝总动脉根部解剖腹腔动脉干上方;离断胰腺和脾动脉的胰头分支;沿暴露的肠系膜上动脉前方、右侧和后方解剖,完全离断胰头钩突部与肠系膜上动脉和腹腔动脉干间的神经结缔组织,与腹腔动脉干的上方贯通,此时可清楚地显示腹主动脉前方;最后通过预置的静脉血管阻断带安全剥离、切除或重建肠系膜上静脉或门静脉,完整切除肿瘤。结果术前影像学检查判断局部肿瘤可切除患者37例,可能切除患者21例。58例患者均顺利施行胰头部动脉优先离断的根治性胰十二指肠切除术,手术时间为4．5～8．1h,术中出血量为200—900mL,术中及术后胰腺钩突部无出血。行肠系膜上静脉侧壁部分切除修补术21例,肠系膜上静脉受累段切除端端吻合术10例,血管受压迫成功将肿瘤从血管上剥离行标准的胰十二指肠切除术27例。术后患者出血、胰液漏和胆汁漏的发生率分别为5．2％（3／58）、6．9％（4／58）和1．7％（1／58）。围手术期无患者死亡。结论胰头部动脉优先离断方式能保障肠系膜上静脉或门静脉受侵犯或受压的胰头部恶性肿瘤行根治性胰十二指肠切除术的安全性,减少术中出血。     

Does Portal-Superior Mesenteric Vein Invasion Still Indicate Irresectability for Pancreatic Carcinoma?

Background  Pancreatic carcinoma frequently infiltrates the portal vein or the superior mesenteric vein; pancreatectomy combined with portal vein/superior mesenteric vein resection represents a potentially curative treatment in these cases but is still a controversial procedure. Methods  After performing a computerized Medline search, 12 series published during the last 8 years were selected, enrolling 399 patients who underwent pancreatectomy combined with portal vein/superior mesenteric vein resection for pancreatic carcinoma. Data were examined for information about indications, operation, adjuvant therapies, histopathology of resected specimens, perioperative results, and survival. Also, previous literature regarding the issue was extensively reviewed. Results  Operative mortality and postoperative complication rates ranged from 0 to 7.7% and 16.7% to 54%, respectively. Median survival varied from 13 to 22 months; 5-year survival rate ranged from 9% to 18%. Conclusions  The current literature suggests that portal vein/superior mesenteric vein resection combined with pancreatectomy is a safe and feasible procedure that increases the number of patients who undergo curative resection and, therefore, provides important survival benefits to selected groups of patients. This procedure should always be considered in case of suspected tumor infiltration of portal/superior mesenteric vein to achieve clear resection margins, in the absence of other contraindications for resection.     

Results of a pancreatectomy with a limited venous resection for pancreatic cancer

PURPOSE: The indications for a pancreatectomy with a partial resection of the portal or superior mesenteric vein for pancreatic cancer, when the vein is involved by the tumor, remain controversial. It can be assumed that when such involvement is not extensive, resection of the tumor and the involved venous segment, followed by venous reconstruction will extend the potential benefits of this resection to a larger number of patients. The further hypothesis of this study is that whenever involvement of the vein by the tumor does not exceed 2 cm in length, this involvement is more likely due to the location of the tumor being close to the vein rather than because of its aggressive biological behavior. Consequently, in these instances a pancreatectomy with a resection of the involved segment of portal or superior mesenteric vein for pancreatic cancer is indicated, as it will yield results that are superposable to those of a pancreatectomy for cancer without vascular involvement. METHODS: Twenty-nine patients with carcinoma of the pancreas involving the portal or superior mesenteric vein over a length of 2 cm or less underwent a macroscopically curative resection of the pancreas en bloc with the involved segment of the vein. The venous reconstruction procedures included a tangential resection/lateral suture in 15 cases, a resection/end-to-end anastomosis in 11, and a resection/patch closure in 3. RESULTS: Postoperative mortality was 3.4%; morbidity was 21%. Local recurrence was 14%. Cumulative (standard error) survival rate was 17% (9%) at 3 years. CONCLUSION: A pancreatectomy combined with a resection of the portal or superior mesenteric vein for cancer with venous involvement not exceeding 2 cm is indicated in order to extend the potential benefits of a curative resection.     

联合门静脉-肠系膜上静脉切除的胰腺癌根治术:现状、争议与展望

由于胰头与门静脉系统解剖上的毗邻关系和胰腺癌侵袭性的生物学特性,胰腺癌极易侵犯门静脉系统.联合门静脉-肠系膜上静脉(PV/SMV)切除的胰腺癌根治术也许能为门脉受侵犯的胰腺癌患者带来潜在的益处,但这一手术的预后仍存在争议.目前尚无明确证据显示,联合PV/SMV切除的胰腺癌根治术能提高患者的生存率.为形成临床指导原则,仍...     

门静脉节段切除治疗进展期胰腺癌

目的 研究侵犯门静脉（PV）的胰腺癌的切除方法及治疗效果。方法 对22例胰腺癌患者在施行胰十二指肠切除或胰体尾部切除时清扫区域淋巴结，并联合切除受侵犯的一段PV或肠系膜上静脉（SMV）。结果 行PV或SMV楔形切除修补者6例，节段切除者8例，其中5例行端端吻合，2例行自体大隐静脉移植，1例行肠系膜上静脉下腔静脉转流。平均手术时间7.，平均术中输血600ml，无围手术期死亡。22例患者全部得到随访，存活6个月1例，12个月3例，18个月6例，24个月8例，36个月4例。结信纸 侵犯PV和（或）SMV的胰腺癌切除加广泛淋巴清扫是安全可行的，且能延长患者的生存期。     

Preoperative indications for extended pancreatectomy for locally advanced pancreas cancer involving the portal vein.

This retrospective study attempted to determine the indications for extended pancreatectomy for locally advanced carcinoma of the pancreas, in terms of postoperative prognosis. An extended pancreatectomy with portal vein or superior mesenteric vein (PV/SMV) resection and regional lymphadenectomy was performed in 35 of 50 consecutive cancers that extended into the retroperitoneal spaces and involved the PV or SMV. Among the many background factors in the 35 resected specimens, the degree of PV/SMV invasion by the cancer was most closely associated with prognosis, despite resection of all involved PV/SMV. This factor generally correlated with the preoperative findings on the portal phase of superior mesenteric arteriograph. In 17 selected patients in whom PV/SMV invasion had been angiographically both semicircular or less and 1.2 cm (1.4 cm on the film) or less in length, the 3-year survival rate was 59%. This survival rate was significantly higher than the 29% 3-year survival rate in all 35 patients (p less than 0.05). Conversely, among the 18 patients in whom invasion was angiographically either beyond semicircular or more than 1.2 cm (1.4 cm on the film) in length, there were no 1.5-year survivors, and this result was even worse than that of 15 nonresectable cases. Based on postoperative survival, the degrees of PV/SMV invasion on preoperative angiography (narrowing pattern and length) are good indicators for aggressive pancreatectomy for locally advanced pancreatic cancer.     

联合血管切除的胰头癌手术安全性分析及18例手术报道

目的探讨联合血管切除在胰头癌根治术中的作用及其安全性。方法回顾性分析2006年1月-2010年4月我科施行18例联合血管切除的胰十二指肠切除术病例的临床资料。结果门静脉(PV)/肠系膜上静脉(SMV)楔形切除5例,门静脉(PV)/肠系膜上静脉(SMV)部分切除、端端吻合9例,门静脉(SMV)/肠系膜上静脉(PV)部分切除自体血管移植2例,SMV/PV部分切除+肠系膜上动脉(SMA)部分切除2例。手术时间5～9小时;术中出血量50～2000ml;门静脉阻断时间20-45分钟。肿瘤切除类型:R0切除10例、R1切除6例、R2切除2例;术后病理证实有6例血管未受侵犯、6例仅侵犯血管外膜、3例侵犯血管中膜、3例侵犯血管内膜;术后并发症发生率22.2%(4/18),主要并发症有胃潴留(2/18)、胆汁瘘(1/18)、胰瘘(1/18)等,无围手术期死亡。结论与传统的胰十二指肠联合切除术相比,联合血管切除并不会增加术后并发症发生率及死亡率,相反会有助于提高局部较晚期肿瘤的切除率特别是R0切除率,改善病人的生存质量。     

Outcomes from mesenteric-portal axis resection during pancreatectomy

Background

Due to their complexity and risks, mesenteric-portal axis resection and reconstruction during the pancreatectomy procedure were not recommended back in the early nineties. However, as per technical improvements and the reduction in morbidity and mortality rates, they have been routinely indicated in large medical centers.

Aim

To show results from cases of patients subjected to mesenteric-portal axis resection during pancreatectomy.

Method

Patients subjected to mesenteric-portal axis resection during pancreatectomy were prospectively and consecutively assessed. The procedure was indicated according to anatomical criteria defined by imaging exams or intraoperative assessment.

Results

Ten patients, half of them were male, with mean age of 55.7 years (40-76) were included. The most frequent underlying diseases were pancreatic adenocarcinoma and Frantz tumor. The circumferential resection of the portal vein associated with the superior mesenteric vein with splenic vein ligature (4 cases=40%) and the primary anastomosis of the vascular stumps (5 cases=50%) were, respectively, the most performed types of vascular resection and reconstruction. Surgery time ranged from 480 to 600 minutes (average=556 minutes) and postoperative hospitalization time ranged from 9 to 114 days (average=34.8 days). Morbidity rate was 60%, and clinical pancreatic fistula (grade B and C) was the most common complication (3 cases=30%). Mortality rate was 10% (1 case).

Conclusion

Mesenteric-portal axis resection is a valid technical procedure. It should be taken into account after a clinical assessment that included not only the patients'' clinical condition but also the technical and anatomical conditions of the mesenteric-portal axis tumor infiltration as well as life expectancy based on the patient''s cancer prognosis.     

Management of Type 9 Hepatic Arterial Anatomy at the time of Pancreaticoduodenectomy: Considerations for Preservation and Reconstruction of a Completely Replaced Common Hepatic Artery

Recognition and management of aberrant hepatic arterial anatomy for patients undergoing pancreaticoduodenectomy (PD) are critical to ensure safe completion of the operation. When the common hepatic artery (CHA) is noted to emanate from the superior mesenteric artery (Michels’ type 9 variant), it is vulnerable to injury during the dissection required for PD. While this anatomy does not preclude an operation, care must be taken to avoid injury, often by identifying the CHA throughout its entire course before beginning the dissection of the portal venous structures. The oncologic principle that cautions against resection of a pancreatic cancer when it involves the CHA in its standard position may not universally apply to tumors that focally involve the CHA in the type 9 anatomic variant. In highly selected patients, surgical resection may be entertained as disease biology may be analogous to local involvement of the gastroduodenal artery in a patient with standard anatomy. Here, we review the indications, techniques, and outcomes associated with arterial resection and reconstruction during pancreatectomy among patients with a pancreatic tumor involving a common hepatic artery arising from the superior mesenteric artery.