扩大胰十二指肠切除术中联合肝动脉、肝固有动脉与髂内静脉切除重建应用的可行性研究

目的探讨在行扩大胰十二指肠切除联合血管切除术中应用肝动脉(HA)或肝固有动脉(PHA)与肠系膜上动脉(SMA)吻合、髂内静脉(IIV)与肠系膜上静脉(SMV)或门静脉(PV)吻合应用的可行性。方法解剖20具成人尸体的HA、PHA、SMA、SMV、PV、左IIV及右IIV,测量各血管长度、血管壁厚度和血管直径;用多层螺旋CT扫描、磁共振血管成像、彩色多普勒、选择性动脉造影检测20例胰头癌患者和本组5例患者的上述血管,并进行比对。根据比对结果,对5例已经发生血管浸润的胰头癌行扩大胰十二指肠切除术,行HA或PHA与SMA、IIV与SMV或PV吻合重建。结果尸体的HA-PHA长度为(5.50±1.50)cm,血管壁厚度为(0.20±0.01)mm,血管直径为(5.02±1.32)mm;SMA长度为(4.00±1.00)cm,血管壁厚度为(0.21±0.01)mm,血管直径为(6.05±1.06)mm。左IIV、右IIV及PV主干或SMV血管直径分别为(11.06±0.16)mm、(11.10±0.13)mm及(11.56±0.20)mm;左IIV、右IIV及PV主干或SMV的管壁厚度分别为(0.10±0.01)mm、(0.10±0.02)mm和(0.10±0.02)mm。活体多层螺旋CT扫描、磁共振血管成像、彩色多普勒、选择性动脉造影显示HA或PHA和SMA管壁厚度及血管直径分别稍比尸体解剖大0.1 mm和0.3 mm,差异均无统计学意义(P>0.05),而HA-PHA的长度比SMA长1～2 cm(P<0.05)。5例行扩大胰十二指肠切除术同时联合HA或PHA和SMA、IIV和PV或SMV切除重建患者的生存期均长于同期姑息性或放弃手术者,无一例发生远期并发症。结论有血管侵犯的胰头癌不是根治术的绝对禁忌证;就本组5例扩大胰十二指肠切除联合血管切除重建的患者比同期发生血管浸润的胰头癌仅施行探查或姑息性手术的33例患者生存时间而言,前者生存时间明显延长;HA或PHA和IIV是最好的自体血管代用材料,没有明显增加术后并发症;熟识尸体局部解剖结构对手术医生有一定的指导性意义。

Feasibility Study on Clinical Application of Hepatic Artery,Proper Hepatic Artery,and Internal Iliac Vein Resection and Reconstruction in Extended Pancreaticoduodenectomy

Objective To explore the feasibility of clinical application of hepatic artery(HA) or proper hepatic artery(PHA) anastomosing with superior mesenteric artery(SMA) and internal iliac vein(IIV) anastomosing with superior mesenteric vein(SMV) or portal vein(PV) in the extended pancreaticoduodenectomy combined with vascular resection.Methods The HA,PHA,SMA,SMV,PV,and IIV were dissected on 20 adult corpses,and the length,thickness,and lumen diameter of blood vessels were measured and compared with the results of multislice spiral CT scan,magnetic resonance angiography,or color Doppler in 25 patients with pancreatic head carcinoma.The extended pancreaticoduodenectomy was carried out on 5 patients of pancreatic head carcinoma with vascular invasion according to the mathcing results,and the reconstructions of HA or PHA with SMA and IIV with SMV or PV were performed.Results According to autopsy,HA-PHA was(5.50±1.50) cm in length,(0.20±0.01) mm in thickness,(5.02±1.32) mm in lumen diameter;and SMA was(4.00±1.00) cm in length,(0.21±0.01) mm in thickness,(6.05±1.06) mm in lumen diameter.The lumen diameter of left IIV,right IIV,and PV or SMV was(11.06±0.16) mm,(11.10±0.13) mm,and(11.56±0.20) mm,respectively.The thickness of left IIV,right IIV,and PV or SMV was(0.10±0.01) mm,(0.10±0.02) mm,and(0.10±0.02) mm,respectively.The multislice spiral CT scan,magnetic resonance angiography,color Doppler,and selective arteriography in vivo showed that the thickness and lumen diameter of HA-PHA and SMA were wider(0.1 mm and 0.3 mm) than those of the autopsy results,and there were no statistic significances(P>0.05),but the length of HA-PHA was longer(1-2 cm) than that of SMA,and there was statistic significance(P<0.05).The survival of 5 patients with extended pancreaticoduodenectomy combined with PHA or SMA and IIV-PV/SMV resection and reconstruction was longer than that of palliative surgery patients or giving-up patients at the same period,and no long-term complications occurred.ConclusionsThe vascular invasion of pancreatic head carcinoma is not an absolute contraindication of radical pancreaticoduodenectomy.The survival of 5 patients with vascular invasion of pancreatic head carcinoma in this group is prolonged by extended pancreaticoduodenectomy combined with vascular resection and reconstruction as compared with palliative surgery group at the same period.HA,PHA,and IIV are the best autologous vascular alternative materials without more complications.Being familiar with regional anatomy will guide the surgeons in extended pancreaticoduodenectomy.