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。     

胰头癌侵犯门静脉的外科治疗

在胰头癌行胰十二指肠切除时 ,由于癌肿侵犯门静脉 ,往往被认为是手术禁忌症放弃切除 ,使部分病人失去根治性治疗的机会。其实肿瘤单纯侵犯门静脉 ,并非一定属肿瘤晚期 ,笔者 1991年 5月 - 1999年 4月 ,对胰头癌侵犯门静脉 7例病人 ,根据肿瘤侵犯门静脉范围 ,对门静脉肠系膜上静脉分别进行修补、补片及人造血管替代性门静脉肠系膜上静脉 (SMPV)重建 ,取得良好效果 ,报告如下。1　临床资料1.1　一般资料本组 7例 ,男 4例 ,女 3例。年龄 56 - 78岁 ,平均年龄 6 1.5岁。 5例胰十二指肠切除 ,2例全胰腺切除 ,该 2例 ,一例术中探查胰头癌全胰侵…     

联合肠系膜门静脉切除的胰十二指肠切除术治疗胰头腺癌

胰腺癌侵犯门静脉被视为切除手术的禁忌证，一般认为门静脉系统孤立的肿瘤侵犯是根治性切除的最大障碍。而胰十二指肠切除术中联合肠系膜门静脉切除的价值一直存有争议。本文的主要目的是比较胰头癌病人接受单纯或联合胰十二指肠切除术两组的死亡率、发病率、长期生存率以及术后预后参数。自1989年至2003年，共45例相连续的胰头癌病人接受胰十二指肠切除术，术中发现肠系膜上静脉或（和）门静脉被肿瘤侵犯而联合施行肠系膜门静脉切除（VR＋组）。同期88例胰头部腺癌病人接受了胰十二指肠切除而未联合肠系膜门静脉联合切除术（VR-组）。     

门静脉主干低温灌注下切除侵犯门静脉的胰头癌及胆管癌

胰头癌及肝外胆管癌由于易侵犯门静脉或肠系膜上静脉主干，导致手术难度大、切除率不高。传统胰十二指肠切除率仅为20％；联合侵犯血管切除重建的胰十二指肠切除率达46％。由于肝脏对缺血、缺氧较为敏感，尤其对严重淤胆的患者，常温下阻断肝门时间更为受限。为提高胰头癌及肝外胆管癌根治性切除率，我们创用了低温灌注门静脉延长阻断门静脉主干时间，切除肿瘤侵犯的部分门静脉、肠系膜上静脉和脾静脉，并进行人造血管架桥重建获得成功。现报告如下。     

联合门静脉-肠系膜上静脉切除重建的腹腔镜胰十二指肠切除术关键技术环节

联合门静脉-肠系膜上静脉的胰十二指肠切除术可使部分血管侵犯病人可获得根治性手术机会并能从手术中获益。随着技术进步,联合门静脉-肠系膜上静脉切除重建的腹腔镜胰十二指肠切除术已在国内外少数中心开展,国内外多项回顾性研究结果证实该术式在围手术期是安全可行的。针对伴有肿瘤侵犯门静脉-肠系膜上静脉的腹腔镜胰十二指肠切除术,术前精准评估、合适的肠系膜上动脉入路、手术流程、合理的血管切除重建方式以及重建血管通畅性的术中评估是该技术的关键环节。由经验较为丰富的胰腺微创外科医师以及在较大的胰腺外科中心开展该技术能够大大提高该技术围手术期的安全性,该技术已从技术挑战阶段进入了更为规范合理的、以胰腺微创外科手术为主导的多学科综合治疗阶段。该技术对胰腺恶性肿瘤治疗的安全性与有效性,仍需要更多的随机、前瞻性的、大样本、多中心的高质量研究来证明。     

胰头癌侵犯门静脉／肠系膜上静脉行胰十二指肠并血管切除和重建术（附五例报告）

目的　探讨胰头癌侵犯门静脉／肠系膜上静脉行胰十二指肠并血管切除和重建术对进展期胰头癌施行扩大根治性切除的疗效。方法　手术操作步骤同Whipple。在处理血管时首先确认门静脉和肠系膜上静脉肿瘤累及范围,阻断门静脉血流。阻断时间30～50min,平均40min。门静脉／肠系膜上静脉节段切除3例：切除长度＞5cm2例,采用Gore-Txe人造血管移植;血管断端吻合1例。楔形切除2例,予以局部修补。消化道重建采用胰胃吻合,胆肠、胃肠吻合术。结果　本组手术时间5～7h,平均6h。术中出血800～1200ml,平均1000ml。平均输血1200ml。术后并发切口裂开1例,顽固性腹水1例,肝功能损害加重1例。临床治愈4例,因术后肝功能衰竭死亡1例。结论　胰十二指肠并血管切除和重建是超范围手术,应在有条件的医院选择适宜的病例施行。同时,必须达到肉眼根治性切除,以提高生存率。     

先行门-肠系膜上静脉重建的扩大胰十二指肠切除术

目的：为使一些原本由于体积较大或侵犯门静脉而无法安全切除的胰头部肿瘤病人得到手术治疗的机会,我们尝试施行先行门-肠系膜上静脉重建的胰十二指肠切除术。方法：2004年9月～2005年6月,对5例严重侵犯肠系膜上静脉或门静脉的胰头部肿瘤病人施行先行人造血管门-肠系膜上静脉重建的扩大胰十二指肠切除术。平均年龄61岁。肿瘤平均直径4.8cm。结果：5例病人均成功施行先行门-肠系膜上静脉重建的胰十二指肠切除术,无手术死亡及严重并发症发生。平均手术时间260min,平均术中出血1570ml,平均术后住院天数18天。术后随访,平均术后生存时间为11.6个月（4～15月）。结论：由于先行建立了通畅的门静脉系统血流,有效地保证了肝脏的主要血流,减少了严重肠道淤血和肝脏缺血的发生。本术式在切除肿瘤前,即在原位完成门脉的阻断与重建,理论上能够降低手术过程中对肿瘤的挤压而导致肿瘤细胞门静脉系统播散的可能性。     

胰头癌侵犯门静脉/肠系膜上静脉行胰十二指肠并血管切除和重建术(附五例报告)

目的　探讨胰头癌侵犯门静脉 /肠系膜上静脉行胰十二指肠并血管切除和重建术对进展期胰头癌施行扩大根治性切除的疗效。方法　手术操作步骤同Whipple。在处理血管时首先确认门静脉和肠系膜上静脉肿瘤累及范围 ,阻断门静脉血流。阻断时间 30～ 5 0min ,平均 40min。门静脉 /肠系膜上静脉节段切除 3例 :切除长度 >5cm2例 ,采用Gore Txe人造血管移植 ;血管断端吻合1例。楔形切除 2例 ,予以局部修补。消化道重建采用胰胃吻合 ,胆肠、胃肠吻合术。结果　本组手术时间 5～ 7h ,平均 6h。术中出血 80 0～ 12 0 0ml,平均 10 0 0ml。平均输血 12 0 0ml。术后并发切口裂开 1例 ,顽固性腹水 1例 ,肝功能损害加重 1例。临床治愈 4例 ,因术后肝功能衰竭死亡 1例。结论　胰十二指肠并血管切除和重建是超范围手术 ,应在有条件的医院选择适宜的病例施行。同时 ,必须达到肉眼根治性切除 ,以提高生存率     

胰十二指肠切除术伴肠系膜上静脉-门静脉汇合部切除治疗胰头癌的生存期

肿瘤粘着肠系膜上静脉（SMV）或肠系膜上静脉-门静脉汇合部（SMVP）的侧壁给胰十二指肠切除的技术上带来不少困难，作者分析同时整块切除SMV或SMVP的效果。作者分析Texas大学肿瘤外科胰腺肿瘤研究组等单位于1990～1995年所施行的胰头或钩突癌手术切除病例。凡无胰外病灶、无肿瘤侵犯SMV或腹腔动脉轴、SMVP汇合部通畅者，列CT影像学可切除的指标。如肿瘤粘着SMV或SMVP，则与肿瘤整块切除。结果在75例胰头癌中，44例行胰十二指肠切除，31例加作SMV或SMVP切除，用自体颈内静脉或人工血管移植修复。年龄42～81岁（中位值65岁）…     

门、脾、肠系膜上静脉控制在胰腺钩突癌的手术切除中的应用

目的探讨门静脉、肠系膜上静脉、脾静脉控制下进行胰腺钩突部肿瘤切除的可行性、作用和意义。方法对28例原发于胰腺钩突部的肿瘤行胰十二指肠切除。在手术中均预置门静脉、脾静脉、肠系膜上静脉阻断带。其中男性19例、女性9例。结果所有28例均成功切除肿瘤,平均手术时间4．6小时;平均出血量400毫升。无术中、术后严重并发症发生。术后中位生存时间22个月。其中12例联合血管切除,联合血管切除与单纯胰十二指肠切除组术后生存期无显著差异。结论门静脉、脾静脉、肠系膜上静脉控制下进行胰腺钩突部肿物手术治疗,可以提高手术的根治性。增加手术安全性。     

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.     

腹腔镜超声扫描在判断胰头癌切除中的价值

目的　探讨腹腔镜及其超声扫描技术 (LUS)在判断胰头癌可切除中的价值。方法　对2 2例临床已确诊为胰头癌的病人在剖腹探查手术前 ,采用腹腔镜超声进行前瞻性的肿瘤分期 ,明确肝、腹膜有无微小转移 ,有无局部的血管侵犯 (门静脉、肠系膜上动静脉、主动脉及下腔静脉 )。结果　本组发现肝表面及腹膜转移癌灶 3例 ,肝内转移灶 1例 ,超声引导穿刺证实为胰腺炎 1例 ,从而避免了开腹手术 ,余 17例中 8例发现腹腔、腹膜后及网膜有肿大淋巴结与局部血管或肿瘤本身与局部血管有侵犯 ,其中 2例发现门静脉血栓 ,余 9例提示可以手术切除。 17例病人进行剖腹探查 ,8例成功进行胰十二指肠切除术。结论　腹腔镜超声扫描可以较为准确的判断胰头癌切除的可能性 ,有望成为胰头癌剖腹探查术前有效的检查方法     

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。     

门静脉冷灌注下全胰切除术

Cold perfusion of liver can significantly alleviate the ischemia-reperfusion injury caused by hepatic blood flow occlusion. We have modified the technique of cold perfusion of liver and applied it to total pancreatectomy for patients with pancreatic head carcinoma complicated with metastasis to the body and tail of pancreas and with portal invasion. After skeletonization of the hepatoduodenal ligament, the amputation of the portal vein and blockage of the superior mesentoric vein were performed before portal perfusion. Meanwhile, pancreatic head resection, duodenectomy, subtotal gastrectomy and partial resection of the superior mesenteric vein and portal vein were carried out. Superior mesenteric vein and portal vein bypass grafting was achieved with artificial vessels. The digestive tract was reconstructed after it was freed of the spleen and resection of the body and tail of pancreas to the left side of superior mesenteric vein, greater omentum and intestine from the end of the colon to splenic flexure of colon. The patient was followed up for 3 months, and the general condition was good, although diarrhea frequently occurred. No tumor metastasis occurred.     

Adenocarcinoma of the distal pancreas presenting as an intrathoracic mass

Tumors of the pancreatic head may present with early heralding symptoms such as obstructive jaundice. Pancreatic masses within the body or tail usually have delayed diagnosis secondary to the lack of any early findings, which, in turn, leads to a higher incidence of involvement of adjacent structures, such as the superior mesenteric artery, portal vein, or superior mesenteric vein. Local involvement along with distant metastases or larger tumor size may be contraindications to surgical resection. The authors report a case of advanced pancreatic adenocarcinoma in which the anomalous thoracic location of the organ resulted in the tumor being resectable. This case adds support to an aggressive approach to surgical resection of distal pancreatic tumors.     

Borderline Resectable Pancreatic Cancer: Definitions, Management, and Role of Preoperative Therapy

With recent advances in pancreatic imaging and surgical techniques, a distinct subset of pancreatic tumors is emerging that blurs the distinction between resectable and locally advanced disease: tumors of “borderline resectability.” In our practice, patients with borderline-resectable pancreatic cancer include those whose tumors exhibit encasement of a short segment of the hepatic artery, without evidence of tumor extension to the celiac axis, that is amenable to resection and reconstruction; tumor abutment of the superior mesenteric artery involving <180° of the circumference of the artery; or short-segment occlusion of the superior mesenteric vein, portal vein, or their confluence with a suitable option available for vascular reconstruction because the veins are normal above and below the area of tumor involvement. With currently available surgical techniques, patients with borderline-resectable pancreatic head cancer are at high risk for a margin-positive resection. Therefore, our approach to these patients is to use preoperative systemic therapy and local-regional chemoradiation to maximize the potential for an R0 resection and to avoid R2 resections. In our experience, patients with favorable responses to preoperative therapy (radiographical evidence of tumor regression and improvement in serum tumor marker levels) are the subset of patients who have the best chance for an R0 resection and a favorable long-term outcome.     

Correlation between spiral computed tomography, endoscopic ultrasonography and findings at operation in pancreatic and ampullary tumours

BACKGROUND: Spiral computed tomography (CT) allows high-resolution examination of the pancreas, surrounding vascular structures, lymph nodes and liver. Endoscopic ultrasonography (EUS) also allows high-resolution imaging of the pancreas and adjacent structures but is an invasive procedure. With the availability of spiral CT, the role of EUS in the investigation of patients with suspected pancreatic or ampullary tumours is unclear. METHODS: Forty-eight patients with clinical suspicion of a pancreatic or ampullary tumour underwent both spiral CT and EUS. Thirty-four patients had surgical exploration, of whom 17 underwent pancreatic resection and 17 had biliary and gastric bypass. The results of spiral CT and EUS were compared with the operative findings. RESULTS: The final histological diagnosis was ductal adenocarcinoma (24 patients), ampullary carcinoma (six), serous cystadenoma (two) and chronic pancreatitis (two). EUS demonstrated 33 and spiral CT 26 of the 34 primary lesions. EUS was particularly useful in the assessment of small resectable tumours missed by spiral CT. The sensitivity and specificity of EUS and spiral CT for detecting involvement by the tumour of the superior mesenteric vein, portal vein and lymph nodes were similar, but EUS was less effective at evaluating the superior mesenteric artery. CONCLUSION: EUS is an important additional investigation after spiral CT in patients with a suspected pancreatic or ampullary tumour.     

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??Pancreaticoduodenectomy combined with vascular resection of portal vein and/or superior mesenteric vein: A report of 4 patients OUYANG Liu, YAO Jian, JIN Gang, et al. Department of Pancreatic Surgery, Changhai Hospital Affiliated to the Second Military Medical University, Shanghai 200433, China
Corresponding author: HU Xian-gui, E-mail: xianguihu@yahoo.com.cn
Abstract Objective To discuss the operative strategy of pancreaticoduodenectomy combined with vascular resection of portal vein (PV) and/or superior mesenteric vein (SMV). Methods The clinical data of 4 patients with pancreatic neck tumor encasing the PV and/or SMV received pancreaticoduodenectomy (PD) combined with vascular resection between December 1, 2015 and January 15, 2016 at the Department of Pancreatic Surgery of Changhai Hospital Affiliated to the Second Military Medical University were analyzed retrospectively. The patients received pylorus-preserving pancreaticoduodenectomy??PPPD??combined with PV resection??pancreaticoduodenectomy??PD?? with prior PV-SMV shunting??PD combined with SMV resection and PPPD combined with SMV resection, respectively. Results The duration of surgery ranged from 206 to 263 min??with an average of 242 min; the length of the resected vein ranged from 20 to 35 mm, with an average of 27 mm; the duration of vascular occlusion ranged from 20 to 25 min??with an average of 22 min; artificial blood vessel was not used in all of patients; intraoperative blood loss ranged from 700 to 1700 mL??with an average of 1025mL??and intraoperative blood transfusion ranged from 800 to 1800 mL??with an average of 1100 mL. The pathology diagnosis of the 4 patients was pancreatic ductal adenocarcinoma, and the maximal diameter of the tumor ranged from 2.5 to 5.0 cm, with an average of 3.9cm. One of them had delayed gastric emptying, and the gastric tube was removed at postoperative day 15. One of them had bilioenteric anastomosis edema with partial obstruction and pancreatic fistula grade A, and all of them recovered well. The total hospitalization cost ranged from 46 694.3 to 146 991.0 yuan, with an average of 80 214.3 yuan. The postoperative length of hospital stay ranged from 10 to 27 days??with an average of 20 days. All the patients discharged home smoothly. Conclusion The preoperative and intraoperative evaluation is very important for PD combined with vascular resection of PV and/or SMV. It is very important to dissect the invaded blood vessels before resection to insure the blood vessels can be reconstructed safely. It is safe and effective to resect and reconstruct the PV and/or SMV in situ before the resection of the tumor.     

侵犯大血管的胰腺神经内分泌肿瘤外科治疗

胰腺神经内分泌肿瘤的预后明显好于胰腺癌,局部进展期的胰腺神经内分泌肿瘤可侵犯肠系膜上静脉、门静脉、肠系膜上动脉、腹腔干等胰腺周围大血管。术前需进行全面的检查,对肿瘤的可切除性和生物学特性进行评估和判断,选择合适的术前治疗。积极的手术治疗不仅能增加肿瘤的根治性切除,还可以避免肿瘤继续进展带来的并发症。联合门静脉-肠系膜上静脉、腹腔干的切除重建手术安全可行,疗效确切。联合肠系膜上动脉切除值得进一步探索和积累经验。