小肠自体移植式扩大胰腺癌根治术的疗效与安全性分析：附2例报告

背景与目的 局部进展期胰腺癌（LAPC）的治疗方法在不断更新,且随着血管重建技术与自体器官移植技术的进步,血管侵犯的LAPC的手术根治率也极大提高。本文探讨小肠自体移植式扩大胰腺癌根治术的可行性与安全性。方法 回顾性分析中国人民解放军火箭军特色医学中心2022年5月—2023年5月收治的肠系膜根部受侵的2例LAPC患者的临床资料。2例患者均为女性,分别为66岁和58岁,术前影像学检查提示胰腺钩突恶性肿瘤,肿瘤侵犯并包绕肠系膜上动脉（SMA）及空肠动脉分支。2例患者术前一般情况可,均有十二指肠梗阻表现而未实施化疗,术前心、肺、肝、肾功能经评估患者均能耐受手术,实施小肠自体移植式扩大胰腺癌根治术。手术的关键是将小肠连同肿瘤标本一并切除至体外,再迅速移除标本,后遵循“先动脉、后静脉”的顺序进行SMA/肠系膜上静脉（SMV）重建。结果 2例患者的手术均顺利实施,患者1使用脾动脉翻转与SMA进行重建,SMV与门静脉（PV）对端吻合,小肠热缺血时间为24 min,术后病理诊断为胰腺低分化腺癌。患者2使用SMA端端吻合重建,SMV与PV对端吻合,小肠热缺血时间为18 min,术后病理诊断为胰胆管型壶腹癌。2例患者术后恢复均良好,没有出现动静脉血栓,术后住院时间分别为25 d和21 d。截至2023年8月1日,2例患者分别已在门诊随访12个月与2个月,随访期间患者一般情况良好,除患者2血糖控制尚不平稳外,2例均未见复发或转移证据。结论 从对2例病例回顾性分析结果看,对于侵犯肠系膜根部的LAPC患者采用小肠自体移植式的扩大根治术可以安全成功实现,为此类患者提供了一种可以获得解除病痛、增加生存机会的治疗选择。

Analysis of the efficacy and safety of extended radical resection of pancreatic cancer with small bowel autotransplantation: a report of two cases

Background and Aims The treatment strategies for locally advanced pancreatic cancer (LAPC) are continuously evolving, and with advancements in vascular reconstruction and autologous organ transplantation techniques, the radical resection rate for LAPC with vascular invasion has greatly improved. This study was performed to evaluate the feasibility and safety of extended radical resection of pancreatic cancer with small bowel autotransplantation.Methods The clinical data of two LAPC patients with involvement of the mesenteric root who were treated at the Rocket Force Characteristic Medical Center from May 2022 to May 2023 were retrospectively analyzed. Both patients were female, aged 66 and 58 years, and preoperative imaging indicated malignant tumors within the pancreatic uncinate process, with tumor invasion and encasement of the superior mesenteric artery (SMA) and jejunal artery branches. Both patients had a generally stable preoperative condition but had not undergone chemotherapy due to signs of duodenal obstruction. Preoperative assessments of heart, lung, liver, and kidney function showed that both patients were able to tolerate the surgery. Then, the extended radical resection of pancreatic cancer with small intestinal autotransplantation was performed. The key to the surgery was the simultaneous removal of the small intestine along with the tumor specimen, then rapidly remove the specimen, followed by sequential reconstruction of the SMA/mesenteric vein (SMV) with "artery first, then vein" approach.Results Both patients underwent successful surgeries. In case 1, reconstruction was performed using the inverted splenic artery and the SMA, and the SMV was anastomosed distally to the portal vein (PV). The warm ischemia time of the small intestine was 24 min, and postoperative pathology diagnosed it as poorly differentiated adenocarcinoma of the pancreas. In case 2, end-to-end anastomosis was used for SMA reconstruction, with distal anastomosis of SMV and PV. The warm ischemia time of the small intestine was 18 min, and postoperative pathology diagnosed it as pancreatobiliary-type ampullary carcinoma. Both patients had good postoperative recoveries, with no arterial or venous thrombosis. Their postoperative hospital stays were 25 d and 21 d, respectively. As of August 1, 2023, both patients had been followed up in the outpatient clinic for 12 and 2 months, respectively. During the follow-up period, their general conditions remained good, with no evidence of recurrence or metastasis, except for unstable blood sugar control in case 2.Conclusion Based on the retrospective analysis of these two cases, small bowel autotransplantation for LAPC patients with mesenteric root invasion can be safely and successfully performed. This approach offers a treatment option to relief pain and increase the chances of survival for such patients.