整块切除含肠系膜上静脉—门静脉的胰十二指肠治疗Ⅱ,Ⅲ期胰头…

作者在１９８９￣１９９５年间收治的２８例Ⅱ、Ⅲ期胰头癌患者中，对肿瘤侵及肠系膜上静脉－门静脉，难以采用标准的胰十二指肠切除术的１５例施行了含ＳＭＰＶ在内的胰十二指肠整块切除。术后并发症发生率５３．３％，无围手术期死亡。随访１４例中已死亡７例，中位生存期１７．１个月，与在此以前因癌种侵及ＳＭＰＶ而放弃根治切除１７例的中位生存期３．８个月进行比较，两组生存期有显著差异（ｔ＝８．０１，Ｐ〈０．００１）。     

胰头十二指肠并受侵PV／SMV整块联合切除治疗Ⅱ,Ⅲ期胰头癌

目的 提高单纯侵犯门静脉和（或）肠系膜上静脉（ＰＶ／ＳＭＶ）之Ⅱ，Ⅲ期胰头癌的根治性切除率，方法 对６例Ⅱ，Ⅲ期胰头癌施行包括受侵ＰＶ／ＳＭＶ在内的扩大的胰头十二指肠切除术（ＰＤ）和广泛的区域淋巴结清扫。结果 平均手术时间９小时，平均术中输血１０００ｍｌ。３例获得根治性切除。术后发生切口裂开，胃动力障碍和上消化道出血各１例，但未发生胆漏，胰漏，肝肾功能衰竭等严重并发症，且无手术死亡，平均住院时间３     

区域性胰腺切除治疗胰头癌的临床实践和探索

目的：临床研究区域性胰腺切除治疗胰头癌的效果。方法：采用区域性胰腺切除（ＲＰ）治疗３９例，其中包括尖胰十二指肠切除的基础上扩大区域淋巴结廓清的Ｏ型ＲＰ２０例，同时联合切除受肿瘤侵犯的肠系膜上静脉门静脉（ＳＭＰＶ）的Ⅰ型１８例，和联合切除受侵的肠系膜上的动脉的Ⅱ型１例。结果：２０例发生了围手术期并发症（５１．３％），围手术期死亡率５．１％，获随访３６例（９２．３％），其中２１例已死亡的病例中，除２例     

含SMPV胰十二指肠切除并发症的分析

含ＳＭＰＶ胰十二指肠切除并发症的分析吴荣进罗建生郑樟栋陈凯曾天定手术切除是治疗胰头癌的首选方法。胰十二指肠切除因其手术创伤大、范围广、时间长，术后并发症发生率较高。我院１９８９年１１月至１９９５年１２月６年间共收治胰头癌５８例，采用区域性胰十二指肠切...     

胰十二指肠联合门静脉切除治疗胰头癌

目的 探讨联合门静脉和(或)肠系膜上静脉(PV/SMV)切除的胰十二指肠切除治疗胰头癌的安全性和疗效.方法 回顾分析12例胰头癌施行包括受侵PV/SMV在内的胰十二指肠切除术的临床资料,并与同期40例胰头癌行标准胰十二指肠切除术进行比较.结果 联合PV/SMV切除的12例中3例行血管段切除、人造血管移植,3例行血管段切除、血管端端吻合,6例行血管壁部分切除后修复.与同期40例行标准胰十二指肠切除术进行比较,两组在年龄、性别、手术时间、术中出血、手术并发症、手术病死率、肿瘤大小、肿瘤分化程度、淋巴结转移、切缘阳性率及中位生存期无统计学差异.结论 联合PV/SMV切除的胰十二指肠术不会增加手术病死率和手术并发症,是安全可行的术式;胰头癌单纯侵犯PV/SMV不是手术的禁忌证.联合PV/SMV切除能获得较好的疗效.     

螺旋CT血管造影在胰头癌手术中的价值

目的 探讨术前螺旋CT血管造影(SCTA)诊断局部进展期胰头癌侵犯胰周大血管在胰头癌手术中的价值.方法 92例横断面CT检查疑似局部进展期的胰头痛病人,术前均进行了sCTA检查,评价胰头癌侵犯血管的情况.根据不同的分级,采取不同的术中探查方式和术式.结果 45例胰头癌病人SMV/PV受侵2级以下,施行了经典胰十二指肠切除术.其中受侵1～2级的12例术中探查证实肿瘤与血管之间是粘连和慢性炎症表现.13例SMV/PV受侵3～4级,长度低于2 cm的,行联合血管切除(PVR)的胰十二指肠切除术,直接端端吻合重建门静脉.而SMV/PV受侵4级,长度2 cm以上的34例,5例行联合PVR的胰头癌切除术,其中胰十二指肠切除术4例,全胰切除术1例,均采用Gore-Tex人工血管植入重建门静脉.其余29例SMV/PV受侵长度3 cm以上,术中探查不可切除,行胆管空肠内引流术,其中6例同时行胃卒肠吻合术.结论 术前SCTA检查可精确诊断胰头癌侵犯胰周大血管的情况,藉此可在术中选择不同的探查方式和术式.     

胰十二指肠切除术治疗胰头和壶部癌230例分析

目的：了解胰十二指肠切除术治疗胰头和壶腹部癌的效果和影响病人生存的因素。方法：分析２３０例胰头和壶腹部癌的主要表现、辅助检查、手术并发症、手术死亡率，调查术后生存情况及影响病人长期生存的因素。结果：本组病人出现黄疸９０．９％，腹痛５６．１％。手术并发症７２例（３１．３％），死亡２０例（８．７％）。术后１、３、５年存活率分别为４６．７％，１７．４％和５２％。肿瘤直径、淋巴结转移和切缘状态是影响病人术     

联合门静脉和/或肠系膜上静脉切除的扩大胰十二指肠切除术

目的探讨胰头癌侵犯门静脉和／或肠系膜上静脉（PV／SMV）时的根治切除的可行性。方法回顾分析包括受侵PV／SMV在内的扩大胰头十二指肠切除术16例的临床资料。16例均行胰头十二指肠切除术，其中9例行血管壁部分切除，5例行血管节段性切除及对端吻合，2例行受侵血管切除＋自体静脉移植。结果全组患者术后均未发生血管栓塞、肠坏死、肝衰竭等并发症。除1例并发多器官衰竭于术后2d死亡外，均康复出院。15例均随访。存活超过3年者3例，超过5年者1例，存活3～26个月4例。结论对单纯侵犯PV／SMV的胰头癌施行联合PV／SMV住内的胰头癌扩大根治术是可行的。     

胰十二指肠联合门静脉切除治疗胰头癌

目的: 总结胰十二指肠联合门静脉切除治疗胰头癌的经验 。方法: 对4例肿瘤侵犯门静脉胰头癌患者行胰头十二指肠联合门静脉的切除术,门静脉阻断时间分别为20分钟、25分钟、29分钟和37分钟,手术方法和步骤独特 。结果: 术后患者顺利恢复,无并发症发生 。结论: 对于癌肿侵犯门静脉系统的胰头癌患者,施行含门静脉在内的联合切除术是必要的。     

胰十二指肠切除术治疗胰头及壶腹部癌（附97例临床分析）

为提高胰头及壶腹部癌的疗效，总结９７例胰十二指肠切除术（ＰＤ）治疗胰头及壶腹部癌的诊治经验。癌肿切除率为３４．４％，手术并发症发生率为３８．４％，手术死亡率为１１．３％，术后１、３和５年生存率分别为６８．８％、４３．１％和３０．０％。认为要提高本病早期诊断率，必须对可疑高危病人提高警惕，首选Ｂ超检查，Ｂ超和ＥＲＣＰ两项联合检查可提高本病早期诊断。     

Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group.

OBJECTIVE: Tumor invasion of the superior mesenteric-portal vein (SMPV) confluence is often considered a contraindication to pancreaticoduodenectomy for patients with malignant tumors of the pancreas or periampullary region. The authors sought to determine whether pancreaticoduodenectomy with en bloc resection of the SMPV confluence could be safely performed and whether tumors involving the SMPV confluence were associated with pathologic parameters suggesting poor prognosis. SUMMARY BACKGROUND DATA: Several centers have reported high rates of retroperitoneal margin positivity after pancreaticoduodenectomy for tumors of the pancreatic head and periampullary region. Positive-margin or incomplete resection is associated with early tumor recurrence and no survival benefit compared with palliative therapy. Tumor adherence to the lateral of posterior wall of the SMPV confluence often represents the only barrier to complete tumor resection at the time of pancreaticoduodenectomy. METHODS: Data on all patients undergoing pancreaticoduodenectomy for adenocarcinoma of the pancreas or periampullary region over a 3.5-year period were entered prospectively in a pancreatic tumor database. To be considered for surgery, patients were required to fulfill the following computed tomography criteria for resectability: 1) the absence of extrapancreatic disease, 2) no tumor encasement of the superior mesenteric artery or celiac axis, and 3) a patent SMPV confluence. Tumor adherence to the superior mesenteric vein or SMPV confluence was assessed intraoperatively, and en bloc venous resection was performed when necessary to achieve complete tumor extirpation. Data on operative characteristics, morbidity, mortality, tumor size, nodal metastases, margin positivity, perineural invasion, and tumor DNA content were compared for patients who did and did not receive venous resection. RESULTS: Fifty-nine patients underwent pancreaticoduodenectomy, 36 without venous resection and 23 with en bloc resection of the SMPV confluence. No differences in median hospital stay, morbidity, mortality, tumor size, margin positivity, nodal positivity, or tumor DNA content were observed between groups. CONCLUSIONS: When necessary, segmental resection of the SMPV confluence may be performed safely during pancreaticoduodenectomy for periampullary malignant tumors. Tumors invading the SMPV confluence are not associated with histologic parameters suggesting a poor prognosis. Our data suggest that venous involvement is a function of tumor location rather than an indicator of aggressive tumor biology.     

联合肠系膜上静脉-门静脉切除在胰腺癌根治术中的作用

目的 研究胰十二指肠合并肠系膜上静脉-门静脉切除的手术安全性及术后生存率,评估它在胰腺癌根治术中的作用.方法 回顾性分析32例因胰腺癌行胰十二指肠合并肠系膜上静脉-门静脉切除患者,根据病理有无真正的血管侵犯分为无血管侵犯组和肠系膜上静脉-门静脉侵犯组.结果 32例胰十二指肠合并肠系膜上静脉-门静脉切除并发症发生率为31%,无手术死亡,术后1、3年生存率分别为59%、22%,切缘阴性组平均生存时间20个月,而切缘阳性组平均生存时间仅5.6个月;无肿瘤血管侵犯组和肠系膜上静脉-门静脉侵犯两组并发症发生率、术后3年生存率无明显差别.结论 肠系膜上静脉-门静脉侵犯并非胰腺癌根治术的禁忌证,肠系膜上静脉-门静脉侵犯并非提示不良预后的组织学指标.     

Use of the left renal vein as a practical conduit in superior mesenteric vein reconstruction

PURPOSE: Invasion of the superior mesenteric vein (SMV) or superior mesenteric-portal vein (SMPV) confluence, in pancreatic adenocarcinoma of the head and uncinate process, is the most common unexpected finding at the time of pancreaticoduodenectomy. Resection of the SMV or SMPV with reconstruction using autologous and synthetic conduits is well established. We describe the use of the left renal vein as a practical, easy, and durable alternative as an interposition graft after pancreaticoduodenectomy with en bloc segmental resection of the SMV. METHODS AND RESULTS: Involvement of the SMV by a pancreatic mass is resected en bloc with a standard pancreaticoduodenectomy. The left renal vein is then harvested from the junction with the IVC and proximal to the adrenal vein. This is then used as a vein graft for the resected portion of the SMV. DISCUSSION: Complete pancreatic cancer resection with grossly tumor-free margins provides the only chance for long-term cure. Isolated tumor involvement of the SMV or SMPV confluence is not associated with histopathological variables predictive of a poor prognosis and appears to be a function of tumor location rather than an indicator of biological aggressiveness. Recurrence and long-term survival following pancreaticoduodenectomy with and without vein resection are equivalent, provided grossly negative margins are achieved. We describe the use of the left renal vein as a technically feasible, easy, and durable conduit for SMV reconstruction in pancreaticoduodenectomy. After resection of the left renal vein, significant increase in postoperative serum creatinine has not been reported; collateral flow has been confirmed by radiological methods and severe renal dysfunction perioperatively, postoperatively, and during long-term follow-up has not been observed.     

Pancreatic resection for locally advanced primary and metastatic nonpancreatic neoplasms

We conducted a retrospective review of our single-institution experience with pancreas resection for locally advanced primary malignancy or metastases from other organs. From January 1989 through April 2001 35 patients underwent pancreatic resection for locally advanced primary (17) and recurrent nonpancreatic (18) tumors. Patient records were examined for recurrence and survival. Seventeen patients with locally advanced primary tumors presented with pancreatic extension either into the head/body (six) or tail (11). Pancreatic resections were completed as en bloc procedures with the primary disease of stomach (five), colon (four), sarcoma (five), adrenal gland (one), or spleen (one). Procedures performed included pancreaticoduodenectomy for proximal lesions and distal pancreatectomy for disease limited to the pancreatic tail. Median overall survival was 56 months. Fourteen of 17 patients remain alive: three with disease and 11 without evidence of recurrence. Eighteen patients presented with recurrent tumor from a previously resected right upper quadrant tumor (nine) or metastases from an intra-abdominal source (nine). The primary source was colon (eight), biliary (three), sarcoma (three), melanoma (two), ovary (one), and unknown primary (one). Patients underwent pancreaticoduodenectomy, distal pancreatectomy, or resection of residual pancreas. Overall median survival was 46 months. In this group of 18 patients there was no increased survival in those patients with a time to recurrence from their primary tumor resection greater than 2 years. We conclude that pancreatic resection for locally advanced nonpancreatic or recurrent intra-abdominal malignancies is possible in properly selected patients. The ability to obtain disease-free margins through en bloc resection is a key component of therapy.     

胰十二指肠合并肠系膜上静脉-门静脉切除(附25例报告)

目的研究胰十二指肠合并肠系膜上静脉-门静脉切除的手术安全性及术后生存率。方法回顾性分析25例因胰腺癌行胰十二指肠合并肠系膜上静脉-门静脉切除病人，根据病理有无真正的血管侵犯分为A、B两组，A组：无真正的血管侵犯，B组：肠系膜上静脉-门静脉侵犯。结果25例胰十二指肠合并肠系膜上静脉-门静脉切除并发症发生率为32．0％，无一例手术死亡，术后1、2年生存率分别为56．0％、28．0％，A、B两组并发症发生率、术后2年生存率无明显差别。结论肠系膜上静脉-门静脉侵犯并非胰腺癌根治术的禁忌证，只要仔细选择病例，合并肠系膜上静脉-门静脉切除可安全施行，并不增加手术并发症和死亡率。     

胰头癌联合门静脉区域切除的临床价值

目的探讨胰腺癌联合门静脉区域切除的临床价值,及评价区域切除术中肿瘤侵犯门静脉后以颈内静脉替代门静脉的效果。方法回顾性分析2000年1月-2003年1月间天津医科大学附属肿瘤医院6例行胰头癌联合门静脉切除并用颈内静脉替代门静脉修复的患者的临床资料。结果本组6例行胰头癌联合门静脉切除并用颈内静脉替代门静脉修复,术后病理均证实肿瘤侵犯累及门静脉和／或肠系膜上静脉,术后生存时间17～49个月,平均23．2个月,其中2例存活超过3年,最长的1例术后无瘤生存达4年1个月。结论对于胰头癌局部浸润肠系膜上静脉和／或门静脉,但无远处转移的患者,应积极行手术切除。胰腺癌联合门静脉切除后,行颈内静脉替代门静脉修复是一种有效的方法,可以提高手术切除率,减少术后并发症,延长患者生存期。     

门静脉切除重建联合胰十二指肠切除术在胰腺癌治疗中的应用

目的：探讨门静脉切除重建联合胰十二指肠切除术治疗胰头癌的临床意义。方法：回顾性分析21例行联合门静脉(PV) 和/或肠系膜上静脉(SMV)、胰十二指肠切除术患者的临床资料,分析手术并发症及其预后。结果：全组围手术期并发症发生率为19.04%(4/21),其中2例胃潴留,1例上消化道出血,1例切口裂开,无胆胰瘘并发症。围手术期（术后1个月内）病死率4.76%（1/21）。20例患者生存期为6～67个月,平均(20.38±9.36) 个月。患者术后1,3,5年生存率分别是65.9%,16.0%和10.2%。结论：有选择的施行血管切除有助于提高局部较晚期胰头癌的切除率,能明显改善患者的生存质量,在一定程度上延长了生存期。     

局部进展期胃癌或结肠癌联合胰十二指肠切除术：附15例报告

目的探讨局部进展期胃癌或结肠癌行胃癌或结肠癌切除联合胰十二指肠切除术的可行性及临床价值。方法回顾性分析2004年5月—2010年12月15例侵犯胰头十二指肠区域的局部进展期胃癌或结肠癌联合胰十二指肠切除术患者的临床资料,其中原发或复发胃癌12例,结肠癌3例。结果中位手术时间6 h(4～12 h),中位术后住院时间21 d(7～63 d)。并发症发生率为46.7%(7/15),再手术率为6.7%(1/15),病死率为6.7%(1/15)。中位生存期为23个月;1,2,3年累积生存率分别为62.2%,44.4%,22.2%。结论联合胰十二指肠切除术可作为局部进展期胃癌或结肠癌侵犯胰头十二指肠区域患者的治疗选择。该术式可延长部分患者的生存期。