前入路原位胰十二指肠切除术治疗胰头癌的临床疗效

目的探讨前入路原位胰十二指肠切除术(PD)治疗胰头癌的临床疗效。方法采用回顾性队列研究方法。收集2012年1月至2018年6月昆明医科大学第一附属医院收治的285例胰头癌患者的临床病理资料;男164例,女121例;平均年龄为57岁,年龄范围为40~76岁。285例患者中,196例行前入路原位PD,设为前入路组;89例行传统入路PD,设为传统入路组。观察指标:(1)手术情况。(2)术后情况。(3)随访情况。采用门诊、电话或网络方式进行随访,术后每2~3个月门诊随访1次,了解患者肿瘤复发、转移及生存情况。随访终点为患者死亡,随访次要终点为肿瘤复发或转移。随访时间截至2018年12月。正态分布的计量资料以±s表示,组间比较采用t检验。偏态分布的计量资料以M(范围)表示,组间比较采用Mann-Whitney U检验。计数资料以绝对数或百分比表示,组间比较采用χ2检验。采用Kaplan-Meier法绘制生存曲线,采用Log-rank检验进行生存分析。结果(1)手术情况:285例患者均顺利完成手术。前入路组患者保留幽门,联合门静脉-肠系膜上静脉切除重建(对端吻合、人工血管置换、侧壁切除吻合),手术时间,术中出血量分别为118例,37例(17、11、9例),(303±107)min,350 mL(100~750 mL);传统入路组患者上述指标分别为48例,9例(7、1、1例),(335±103)min,400 mL(100~900 mL),两组患者上述指标比较,差异均无统计学意义(χ2=0.990,3.474,t=0.722,Z=1.729,P>0.05)。(2)术后情况:前入路组患者R0切除率、淋巴结清扫数目、阳性淋巴结清扫数目、神经侵犯率、脉管侵犯率、严重并发症、围术期死亡、术后化疗分别为93.88%(184/196)、12枚(5~19枚)、4枚(0~15枚)、45.41%(89/196)、31.12%(61/196)、28例、3例、69例;传统入路组患者上述指标分别为85.39%(76/89)、7枚(4~17枚)、5枚(0~13枚)、32.58%(29/89)、23.60%(21/89)、11例、2例、41例,两组患者R0切除率、淋巴结清扫数目、神经侵犯率比较,差异均有统计学意义(χ2=5.506,Z=4.637,χ2=4.149,P<0.05);两组患者阳性淋巴结清扫数目、脉管侵犯率、严重并发症、围术期死亡、术后化疗比较,差异均无统计学意义(Z=0.052,χ2=1.962,0.192,0.001,3.048,P>0.05)。(3)随访情况:285例患者中,252例完成次要终点随访,228例完成终点随访,随访时间为35个月(6~58个月)。196例前入路组患者中,181例完成次要终点随访,176例完成终点随访,随访时间为38个月(6~58个月);89例传统入路组患者中,71例完成次要终点随访,52例完成终点随访,随访时间为33个月(7~53个月)。前入路组患者术后中位无瘤生存时间、中位总体生存时间分别为31个月、37个月,传统入路组患者上述指标分别为24个月、31个月,两组患者术后无瘤生存比较,差异有统计学意义(χ2=7.646,P<0.05),术后总体生存比较,差异无统计学意义(χ2=3.265,P>0.05)。结论前入路原位PD治疗胰头癌安全、可行,能提高手术R0切除率,延长患者无瘤生存时间。

Clinical efficacy of pancreaticoduodenectomy using anterior approach in situ technique for pancreatic head cancer

Objective To investigate the clinical efficacy of pancreaticodudenectomy(PD)using anterior approach in situ technique for pancreatic head cancer.Methods The retrospective cohort study was conducted.The clinicopathological data of 285 patients with pancreatic head cancer who were admitted to the First Affiliated Hospital of Kunming Medical University from January 2012 to June 2018 were collected.There were 164 males and 121 females,aged from 40 to 76 years,with an average age of 57 years.Of the 285 patients,196 patients who underwent PD using anterior approach in situ technique were set as anterior approach group,89 patients who underwent PD using traditional approach were set as traditional approach group.Observation indicators:(1)surgical situations;(2)postoperative situations;(3)follow-up.Follow-up was performed by outpatient examination,telephone or network interview once every 2 to 3 months to detect tumor recurrence,metastasis and survival of patients up to December 2018.The endpoint of follow-up was death of patients,and the secondary endpoint of follow-up was tumor recurrence or metastasis.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed by the t test.Measurement data with skewed distribution were represented as M(range),and comparison between groups was analyzed by the Mann-Whitney U test.Count data were represented as absolute numbers or percentages,and comparison between groups was analyzed by the chi-square test.Kaplan-Meier method was used to draw the survial curve and calculate the survival rates.Survival analysis was done by the Log-rank test.Results(1)Surgical situations:285 patients underwent surgery successfully.Cases with pylorus-preservaction,cases with superior mesenteric vein/portal vein(SMV/PV)resection and reconstruction(end to end anastomosis,artificial vascular replacement,lateral wall resection and anastomosis),operation time,volume of intraoperative blood loss were 118,37(17,11,9),(303±107)minutes,350 mL(range,100-750 mL)in the anterior approach group,and 48,9(7,1,1),(335±103)minutes,400 mL(range,100-900 mL)in the traditional approach group,respectively,showing no significant difference between the two groups(χ2=0.990,3.474,t=0.722,Z=1.729,P>0.05).(2)Postoperative situations:the rate of R0 resection,the number of lymph node dissected,the number of positive lymph node dissected,rate of nerve invasion,rate of vascular invasion,cases with postoperative severe complica-tions,the number of perioperative death,cases with postoperative chemotherapy were 93.88%(184/196),12(range,5-19),4(range,0-15),45.41%(89/196),31.12%(61/196),28,3,69 in the anterior approach group,and 85.39%(76/89),7(range,4-17),5(range,0-13),32.58%(29/89),23.60%(21/89),11,2,41 in the traditional approach group,respectively.There were significant differences in the rate of R0 resection,the number of lymph node dissected,rate of nerve invasion between the two groups(χ2=5.506,Z=4.637,χ2=4.149,P<0.05),while there was no significant difference in the number of positive lymph node dissected,rate of vascular invasion,cases with postoperative severe complications,the number of perioperative death,cases with postoperative chemotherapy between the two groups(Z=0.052,χ2=1.962,0.192,0.001,3.048,P>0.05).(3)Follow-up:of the 285 patients,252 and 228 achieved the secondary endpoint and the endpoint of follow-up respectively with the follow-up time of 35 months(range,6-58 months).There were 181 and 176 of 196 patients in the anterior approach group achieving the secondary endpoint and the endpoint of follow-up respectively with the follow-up time of 38 months(range,6-58 months).There were 71 and 52 of 89 patients in the traditional approach group achieving the second endpoint and the endpoint of follow-up respectively with the follow-up time of 33 months(range,7-53 months).The median tumor free survival time and median overall survival time were 31 months and 37 months in the anterior approach group,respectively,versus 24 months and 31 months in the traditional approach group.There was a significant difference in the tumor free survival between the two groups(χ2=7.646,P<0.05),while no significant difference in the overall survival between the two groups(χ2=3.265,P>0.05).Conclusion PD using anterior approach in situ technique is safe and feasible for pancreatic head cancer,which can improve the rate of R0 resection and prolong the tumor free survival time of patients.