联合门静脉胰腺癌切除术的安全性及疗效评价

目的对联合门静脉切除胰腺癌的可行性进行分析,为胰腺癌的治疗提供新途径。方法以行联合门静脉胰腺癌切除术的病变累及门静脉胰腺癌35例患者为观察组,20例同期行姑息旁路术的同类患者为对照1组,同期病灶未累及门静脉行标准根治手术的20例胰腺癌患者为对照2组,观察3组的手术效果及并发症情况。结果采用联合门静脉切除胰腺癌患者的手术后并发症发生率为25％,与对照2组的23．5％相比差异无统计学意义（P〉0．05）;对患者采用寿命表进行计算,观察组患者术后1、3、5年的生存率分别为78．5％,28．8％,9．58％,与对照2组的80．5％,30．9％以及10．23％的差异无统计学意义（均P〉0．05）,但显著高于对照1组的48．5％,11．5％,1．5％（均P〈0．05）。结论对于病变已累及门静脉的胰腺癌采用联合门静脉胰腺癌切除术,可有效提高胰腺癌手术切除率,有效延长患者寿命,改善患者预后。     

门静脉血循环肿瘤细胞、C反应蛋白 /清蛋白、糖类抗- 199/糖类抗- 50比值联合评估根治性胰腺癌切除术后生存情况的研究

目的:研究门静脉血循环肿瘤细胞(CTCs)、C反应蛋白/清蛋白(CAR)、糖类抗原199/糖类抗原50(CA199/CA50)比值联合评估根治性胰腺癌切除术后的生存情况。方法:选取我院2018年1月—2020年1月收治的83例接受胰腺癌根治术患者。检测患者门静脉血的CTCs、CAR、CA199/CA50水平,比较不同病理特征患者的CTCs、CAR、CA199/CA50水平。对患者随访2年,分析生存与死亡患者门静脉血CTCs、CAR、CA199/CA50水平,采用受试者工作特征曲线分析CTCs、CAR、CA199/CA50对患者术后生存的评估价值,并用Kaplan-Meier生存曲线分析CTCs、CAR、CA199CA50对肝癌患者的影响。结果;存在淋巴结转移、TNM分期III期和低分化程度患者的门静脉血CTCs、CAR、CA199/CA50水平均高于不存在淋巴结转移、TNM分期为I-II期和中高分化程度的患者(P＜0.05)。与死亡组患者相比,生存组患者门静脉血CTCs、CAR、CA199/CA50水平更低(P＜0.05)。门静脉血CTCs、CAR、CA199/CA50对于根治性胰腺癌切除术患者预后评估的灵敏度分别为78.9%、78.8%和73.7%,特异度分别为90.6%、91.0%和91.2%,三者联合对根治性胰腺癌切除术患者预后评估的灵敏度为89.5%,特异度为93.7%,三者联合对于根治性胰腺癌切除术患者预后的灵敏度和特异度均高于各项单独检测。CTCs正常组(n=50)的生存率为86.00%,高于CTCs升高组(n=33)的63.63%;CAR正常组(n=47)的生存率为82.97%,高于CAR升高组(n=36)的69.44%;CA199/CA50正常组(n=53)的生存率为88.67%,高于CA199/CA50升高组(n=30)的56.66%,差异有统计学意义(P＜0.05)。结论:门静脉血CTCs、CAR、CA199CA50比值联合评估根治性胰腺癌切除术后的生存价值较高,三者联合的灵敏度和特异性高于各项单独检测。     

Hilar cholangiocarcinoma involving the portal vein bifurcation: long-term results after resection

Abstract. Background/Purpose: Resection offers the only potential cure of hilar cholangiocarcinoma. Portal bifurcation involvement is often thought to contraindicate resection. We reviewed our experience with aggressive surgical management in 28 patients with hilar cholangiocarcinoma. Methods: All patients underwent hepatectomy and bile duct resection with hepaticojejunostomy. In 10 cases (group 1) the portal bifurcation was involved, necessitating portal resection and reconstruction; 18 (group 2) had no portal involvement. Frozen section of duct margins was routine. Survival was estimated using the Kaplan-Meier method and compared with the log-rank test. Results: Portal reconstruction in group 1 was by graft interposition (1), venoplasty using the posterior wall of the right portal vein (2), or end-end anastomosis (7). Hepatectomies included right trisegmentectomy (8), right lobectomy (4), and left lobectomy (16); 20 (71%) had concomitant caudate resection. Median survival was 18 months in group 1 and 32 months in group 2 (P, not significant [NS]). One-, 3-, and 5-year survivals were 60%, 22%, and 22%, respectively, in group 1 and 70%, 47%, and 38%, respectively, in group 2 (P = 0.319). Conclusions: Portal involvement by hilar cholangiocarcinoma does not contraindicate resection. Received: June 11, 2001 / Accepted: February 8, 2002     

Postoperative complications and survival after pancreatoduodenectomy in patients aged over 70 years

An analysis of postoperative complications and survival was conducted in 31 patients undergoing pancreatoduodenectomy (PD) for carcinoma of the pancreas or periampullary carcinoma. Of them, 11 were over 70 years of age and 20 were under 70. Anastomotic leakage was the most common complication after PD. Definite pancreatic leakage was found in one patient in the over 70 group, and one case each of pancreatic, biliary, and gastric leakage were found in the under 70 group. All complications were treated conservatively without any further operative intervention. The overall morbidity rate was 41.9% (13/31), being 45.5% (5/11) in the over 70 group and 40.0% (8/20) in the under 70 group, and no operative deaths occurred within 30 days after surgery. The cumulative survival rate of the patients aged over 70 years with carcinoma of the pancreas or periampullary carcinoma did not differ significantly from the rate of those under 70. It was thus concluded that PD achieves an adequate prognosis and survival in patients over 70 years of age.     

Survival benefits of portal vein resection for pancreatic cancer

BACKGROUND: The efficacy of portal vein resection for pancreatic cancer is controversial. METHODS: Eighty-one consecutive patients with pancreatic cancer undergoing surgical resection were retrospectively analyzed. The clinicopathological findings and relationship between portal vein resection and survival were investigated. RESULTS: Thirty-three patients with pancreatic cancer underwent pancreatic resection with portal vein resection. Histological examination revealed that 17 patients had definite invasion to the portal vein (group 1) and 16 patients had no invasion (group 2). Forty-eight patients with pancreatic cancer underwent pancreatic resection without portal vein resection (group 3). There were no significant differences in survival rates (P = 0.437) between patients with portal vein resection and patients without portal vein resection. However, patients in group 1 had a significantly (P = 0.021) worse prognosis as compared with those in group 2. Despite aggressive surgical resection, the surgical margin was positive in 35% of patients in group 1 as compared with 13% of patients in group 2 and 21% of patients in group 3. CONCLUSIONS: Patients undergoing portal vein resection for pancreatic cancer had a prognosis similar to patients without portal vein resection. Negative microscopic invasion to the portal vein was significantly associated with improved survival.     

Durability of portal venous reconstruction following resection during pancreaticoduodenectomy

Venous resection and reconstruction is becoming more common during pancreaticoduodenectomy (PD). There are multiple options for reconstruction of the mesenteric venous system ranging from primary repair to grafting with autologous or synthetic material. Few studies report on the patency rates and long-term morbidity of these repairs. We sought to describe our experience with venous reconstruction during PD with specific attention to patency and long-term morbidity and mortality. Thrombosis rates of mesenteric venous reconstruction during PD are low, with low associated morbidity. In this retrospective cohort, clinical, operative, and pathologic data were collected from consecutive patients for 1988 through 2003. Graft patency on follow-up imaging studies was determined, and short- as well as long-term morbidity and mortality were recorded. Sixty-four patients underwent PD with venous resection/reconstruction from 1988 through 2003. Mean patient age was 63 years, with pancreatic ductal adenocarcinoma as the pathology in 88%. Reconstruction consisted of primary lateral venorrhaphy in 29 (45%), PTFE graft in 18 (28%), primary end-to-end repair in 13 (20%), and autologous vein graft in 4 (6%). There was one perioperative death (2%). Follow-up imaging to assess patency was available for a mean of 12.2 months postoperatively. Eleven thromboses were diagnosed at a mean of 11.9 months. Three thromboses (5%) were noted within 30 days and full anticoagulation was chosen. Fifty-three percent of patients received anticoagulation with aspirin, warfarin, or clopidogrel based upon surgeon preference. There was no difference in thrombosis rates between those receiving anticoagulation and those who did not (P=0.65). In those patients with thrombosis outside the acute time period, morbidity was limited to ascites in three patients and splenic vein thrombosis with uncomplicated esophageal varices in another patient. Mesenteric venous resection and reconstruction during PD has a high patency rate, and those reconstructions that do thrombose are associated with a low morbidity. The majority of reconstruction thromboses that occurred late were associated with recurrence.     

猪门静脉转流下胰十二指肠切除及肠系膜上静脉-门静脉切除重建的研究

目的 探讨门静脉转流下胰十二指肠切除(PD)及肠系膜上静脉-门静脉(SMPV)切除重建的可行性及安全性,并对其评价。方法 利用猪与人胰腺解剖的相似性,用来模拟人的胰头癌浸润SMPV后的胰十二指肠切除方式,建立门静脉转流下PD及SMPV切除重建的技术及方法。结果 (1)实验组、对照组长期存活率分别为100.0％、66.7％;(2)对照组阻断前后血流动力学参数波动较大,实验组稳定;(3)两组均有肝脏缺血再灌注损伤,但对照组病理损害比实验组重;(4)实验组肠黏膜的病理损害明显轻于对照组;(5)对照组肠黏膜通透性、肠系膜淋巴结肠道菌属培养阳性率及门静脉血内毒素均明显高于实验组。结论 在门静脉转流下,猪胰十二指肠切除联合SMPV切除及自体颈外静脉移植,其操作简便,安全性大,是研究临床手术方式比较实用的技术方法。     

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...     

Reconstruction of portal vein using a hepatic vein patch graft after combined hepatectomy and portal vein resection

BACKGROUND: Surgical resection is the only treatment modality that ensures complete tumor removal in patients with liver tumors involving a major portal vein branch or its bifurcation. Restoration of good portal blood flow is essential for recovery in the early postoperative period and for long-term survival. However, such extended resections often result in large defects at the bifurcation of the portal vein that are not amenable to suturing or end-to-end anastomosis. METHODS: A patch graft technique is very useful for reconstruction of long and elongated defects when other methods are not technically appropriate. We describe a simple technique for reconstructing the portal vein using a patch graft obtained from the hepatic vein stump of the resected specimen. CONCLUSIONS: This technique permits surgeons to reconstruct the portal vein without any need for harvesting another vein and with no need for an additional incision.     

Pancreatic function and rehabilitation after pancreaticoduodenectomy

Postoperative pancreatic function and rehabilitation were monitored in 149 patients who had had reconstruction of the digestive tract by Child's method, out of a total 151 patients who had undergone pancreaticoduodenectomy. The occurrence of peptic ulcer following Child's method may be prevented by the resection of a wider area of the stomach. Because the source of gut hormone secretion is removed by the pancreaticoduodenectomy, the secretion of this hormone is subsequently reduced and thus metabolic abnormalities also occur. If careful attention however, is paid to the maintenance of residual pancreatic function most patients who undergo pancreaticoduodenectomy can be expected to lead reasonably normal lives.     

Arguments for a selective approach of preoperative portal vein embolization before major hepatic resection

Preoperative PVE can induce hypertrophy of the future liver remnant volume resulting in a decrease of surgical risk after major hepatic resection. However, the number of patients with normal liver at risk is small and there is no arguments for inducing hypertrophy before standard right hepatectomy. Therefore, in patients with normal liver PVE is indicated in patients in whom very extended liver resection or associated major gastro-intestinal surgery is planned. In patients with chronic liver disease and in those with injuried liver (chemotherapy, major steatosis, cholestasis), PVE is indicated before major liver resection.     

Pancreaticoduodenectomy with vascular resection: margin status and survival duration

Major vascular resection performed at the time of pancreaticoduodenectomy (PD) for adenocarcinoma remains controversial. We analyzed all patients who underwent vascular resection (VR) at the time of PD for any histology at a single institution between 1990 and 2002. Preoperative imaging criteria for PD included the absence of tumor extension to the celiac axis or superior mesenteric artery (SMA). Tangential or segmental resection of the superior mesenteric or portal veins was performed when the tumor could not be separated from the vein. As a separate analysis, all patients who underwent PD with VR for pancreatic adenocarcinoma were compared to all patients who underwent standard PD for pancreatic adenocarcinoma. A total of 141 patients underwent VR with PD. Superior mesenteric-portal vein resections included tangential resection with vein patch (n = 36), segmental resection with primary anastomosis (n = 35), and segmental resection with autologous interposition graft (n = 55). Hepatic arterial resections were performed in 10 patients, and resections of the anterior surface of the inferior vena cava were performed in 5 patients. PD was performed for pancreatic adenocarcinoma in 291 patients; standard PD was performed in 181 and VR in 110. Median survival was 23.4 months in the group that required VR and 26.5 months in the group that underwent standard PD (P = 0.177). A Cox proportional hazards model was constructed to analyze the effects of potential prognostic factors (VR, tumor size, T stage, N status, margin status) on survival. The need for VR had no impact on survival duration. In conclusion, properly selected patients with adenocarcinoma of the pancreatic head who require VR have a median survival of approximately 2 years, which does not differ from those who undergo standard PD and is superior to historical patients believed to have locally advanced disease treated nonoperatively. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004 Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004 Supported by the Lockton Fund for Pancreatic Cancer Research, The University of Texas M. D. Anderson Cancer Center.     

Centrifugal pump-assisted venous bypass between the superior mesenteric vein and the umbilical vein during portal vein resection

We describe herein our method of performing centrifugal pump-assisted venous bypass between the superior mesenteric vein and the umbilical vein, developed with the aim of preventing congestion of the small intestine and promoting strong and constant hepatic blood flow during portal vein resection. By using this bypass method, portal vein resection and reconstruction was able to be carried out with ease and safety in six patients undergoing surgery for a pancreatic mass or cancer. No coagulation abnormalities, thrombocytopenia, leukocytopenia, severe liver dysfunction, or portal vein thrombosis developed in any of the patients postoperatively. Thus, we highly recommend this simple and reliable method of bypass when portal vein resection is being performed.     

肠系膜上静脉、脾动静脉和门静脉联合阻断在胰十二指肠切除术中的应用

应用联合阻断肠系膜上静脉、脾动静脉和门静脉方法成功分离了胰颈与其后门静脉间存在的难以分离的粘连８例。分离粘连过程中，门静脉破损２～５处，裂口长约２～６ｍｍ，但出血量少且速度慢，均从容地予以直视下修补。作者认为采用这种联合阻断方法分离胰颈与其后门静脉粘连是安全有效的，有助于提高胰头肿瘤切除率。常温下一次阻断２０～２５分钟是安全的。     

术后肝动脉栓塞化疗对肝癌合并门脉癌栓患者手术疗效的影响及预后因素分析

目的 探讨术后肝动脉栓塞化疗(TACE)对肝癌(HCC)合并门脉癌栓手术切除疗效的影响并分析其预后因素.方法 2005年至2009年共358例患者接受了HCC切除术,其中55例合并门脉主干和(或)一级分支癌栓.收集该组病例的临床和随访资料.按术后是否接受TACE治疗分为A组(术后TACE组)和B组(术后非TACE组).统计分析两组可能影响预后的临床资料差异,重点考察术后TACE对手术疗效的影响及其可能影响预后的因素.结果 55例患者中术后接受TACE治疗者29例,未接受26例,二组临床资料比较差异无统计学意义.55例总1、2、3年生存率分别为63.3％、51.4％和43.5％,中位生存时间为26.0个月.其中A组1、2和3年生存率分别为71.4％、60.1％和50.1％,B组为56.7％、21.7％和10.4％ (P＜0.001).术后TACE无论在单因素分析还是在多因素分析中均为显著影响术后生存的因素.此外,肿瘤多发、肝静脉癌栓、肝内转移、浸润型癌栓在单因素分析中是预后差的显著相关因素.多因素分析中,浸润型癌栓、肝静脉癌栓及肝内转移是预后不佳的独立相关因素.结论 部分HCC合并门脉一级分支和主干癌栓患者手术切除后可获得较长的术后生存期.术后TACE可显著改善此类患者的预后,其他影响预后的因素有浸润型癌栓、肝静脉癌栓及肝内转移.     

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.     

原发性肝癌术后超声引导下经皮经肝门静脉穿刺化疗安全性分析

目的 研究原发性肝癌术后超声引导下经皮经肝门静脉穿刺化疗安全性.方法 总结2004年1～10月实施的原发性肝癌术后行超声引导下经皮经肝门静脉穿刺化疗病例,分析其术后常见并发症及其预防及处理措施.结果 共有524例原发性肝癌病人在肝切除手术后接受了超声引导下经皮经肝门静脉穿刺化疗,累及实施1865例次.共发生穿刺操作相关性并发症149例次,并发症发生率为79.89‰(149/1865),其中包括术后穿刺点疼痛118例次(118/1865,63.27％0),肝包膜下出血3例次(3/1865,1.61‰),腹腔出血2例次(2/1865,1.07‰),胆汁漏6例次(6/1865,2.54‰),门静脉血栓形成8例次(8/1865,4.29％0),导管相关性感染4例次(4/1865,2.14‰),气胸3例次(3/1865,1.61％0),导管脱落5例次(5/1865,2.68‰).化疗相关并发症587例次(587/1865,31.47％),其中包括胃肠道不良反应385例次(385/1865,20.64％),白细胞减少121例次(385/1865,20.64％),转氨酶升高62例次(62/1865,3.32％),皮疹11例次(11/1865,5.90％),其他8例次(8/1865,4.29％).所有并发症经保守治疗后均痊愈,未有致死性并发症.结论 肝癌术后超声引导下经皮经肝门静脉穿刺化疗操作简单、安全,术后并发症发生率在可接受范围.     

腹腔镜与开腹胰十二指肠切除术的安全性和疗效对比研究

目的 比较腹腔镜胰十二指肠切除术（LPD）和开腹胰十二指肠切除术（OPD）的安全性和疗效。方法 回顾性分析2016年1月至2021年8月期间施行胰十二指肠切除术患者的临床资料,将符合标准的49例患者分成LPD组（n=23）和OPD组（n=26）,比较两组患者的手术时间、术中出血量、术后并发症、术后住院时间、术后肿瘤学结果及预后等方面的差异。结果 LPD和OPD两种术式的术中输血率和术后胰瘘、胆瘘、术后出血、胃排空延迟、腹腔感染、并发症发生率等手术安全性指标相近（P>0.05）;LPD组较OPD组手术时间延长,但术中出血量减少（P<0.05）。两种术式术后入住ICU人数、非计划再次手术人数、标本肿瘤长径、术中淋巴结清扫数目、淋巴结阳性患者例数、R0切除率、肿瘤分化程度、术后病理分期、肿瘤来源、出院30 d内再次入院率、术后复发率、术后90 d死亡率及术后1年、2年、3年生存率等手术疗效指标相近（P>0.05）。与OPD相比,LPD术后首次下床活动时间和肛门排气时间提早,术后住院日缩短,术后疼痛评分降低和基本日常生活活动能力评分提高（P<0.05）。结论 与OPD相比,LPD安全可靠,可获得同样的肿瘤学根治效果,手术疗效值得肯定,在临床上是可行的。     

胰十二指肠切除术中静脉切除重建的研究现状

胰腺癌是一种恶性肿瘤,可接受治愈性手术的患者较少,静脉切除是获取切缘阴性与扩大手术人群的有效方式。外科医师主要通过术前影像学检查与患者特征决定是否在胰十二指肠切除术(pancreaticoduodenectomy,PD)中同时行相关静脉的切除及重建。切除肿瘤侵犯的静脉重建方式有多种选择,主要由肿瘤与静脉间的关系与手术医师的选择有关。PD合并静脉切除重建后可能会带来切缘阳性增多、并发症发生率升高等新的问题。辅助治疗已经成为胰腺癌的标准治疗方案,新辅助治疗在静脉受侵犯时的作用也受到认可。基因组学与信息化技术可能会为未来的手术及术后综合治疗提供新的诊疗方式。     

肝移植中门静脉-内脏曲张静脉吻合在门静脉机化血栓患者的应用

目的:探讨门静脉-内脏曲张静脉吻合在门静脉机化血栓患者肝移植中的应用。方法:对门静脉和肠系膜上静脉均完全被机化血栓阻塞的7例患者实施肝移植,其中3例供体门静脉-曲张冠状静脉吻合;2例髂静脉搭桥供体门静脉和脾门旁曲张的静脉吻合;1例采用供体门静脉-胆总管前曲张静脉吻合;1例供体门静脉—曲张的胃网膜右静脉吻合。结果:7例手术全部成功。1例术后7d死于多脏器功能衰竭,但是门静脉血流一直通畅。1例术后6个月发现吻合口狭窄,术后9个月采用经皮肝穿刺门静脉支架置入治愈;其余患者分别随访12～22个月,门静脉血流均通畅,无狭窄或血栓形成,肝、肾功能正常。结论:肝移植中对门静脉和肠系膜上静脉均完全被机化血栓阻塞的患者,行供体门静脉-曲张内脏静脉吻合可取得良好疗效。