“Easy First”策略行腹腔镜胰十二指肠切除术治疗可能切除胰腺癌的临床疗效

Clinical efficacy of ＂Easy First＂ strategy in laparoscopic pancreaticoduodenectomy for borderline resect-able pancreatic cancer

目的探讨“EasyFirst”策略行腹腔镜胰十二指肠切除术治疗可能切除胰腺癌的临床疗效。方法回顾性分析2013年6月至2015年3月浙江大学医学院附属邵逸夫医院收治的8例和浙江省人民医院收治的l例可能切除胰腺癌患者的临床资料。患者依据“EasyFirst”策略（即依次解剖、离断患者空肠、胃、肝十二指肠韧带、胆总管、门静脉主干、胰头部、十二指肠二段和三段、胰腺钩突和胰颈部），行腹腔镜胰十二指肠切除术。记录患者手术时间、术中出血量、术后并发症、术后住院时问以及术后病理学检查结果。患者术后每3个月行门诊复查或电话随访，随访时间截至2015年6月。结果9例患者中，4例患者行完全腹腔镜胰十二指肠切除术（其中2例行门静脉壁部分切除修补术）；1例患者在腹腔镜下完成切除，再在小切口下完成消化道重建；4例患者仅在腹腔镜下离断空肠、胆管和胃，中转开腹完成切除并重建（1例因肿瘤与门静脉粘连严重，3例因分离胰颈或钩突部时出血）。9例患者手术时间为（404±49）min，其中4例行完全腹腔镜患者为（395±61）min；术中出血量为（456±348）mL，其中4例行完全腹腔镜患者为（188±25）mL。术后5例患者发生并发症，其中B级胰瘘2例，胆汁漏1例，术后7d胃残端出血再次手术治疗1例，腹腔感染1例，均治愈。无围术期死亡患者。术后右侧引流管拔管时间为（9±5）d，左侧引流管拔管时间为（11±4）d10术后住院时间为（24±10）d10术后病理学检查均证实为胰腺癌，肿瘤直径为（3．2±0．8）cm。平均检出淋巴结16．8枚（6．0～25．0枚），其中4例行完全腹腔镜患者平均为19．8枚（15．0～25．0枚）。9例患者均获得随访，平均随访时间为12个月（4～24个月），1例患者术后3个月死亡，1例患者带瘤生存20个月，其余7例患者均无瘤生存。截至随访时间已有4例患者术后生存时间〉18个月。结论对于可能切除胰腺癌，应用“Easy First”策略行腹腔镜胰十二指肠切除术安全可行。

Objective To investigate clinical efficacy of ＂Easy First＂ strategy in laparoscopic pancreatico- duodenectomy （PD） for borderline resectable pancreatic cancer. Methods The clinical data of 9 patients with borderline reseetable pancreatic cancer who were admitted to the Sir Run Run Shaw Hospital of Zhejiang University （8 patients） and Zhejiang Provincial People＇s Hospital （ 1 patient） from June 2013 to March 2015 were retrospec- tively analyzed. Nine patients underwent laparoseopie pancreaticoduodeneetomy based on the ＂Easy First＂ strategy （ to sequentially dissect and amputate jejunum, stomach, hepatoduodenal ligament, common bile duct, main portal vein, head of pancreas, second segment and third segment of the duodenum, uncinate process and neck of pancre- as）. The operation time, volume of intraoperative blood loss, postoperative pathological examination, complica- tions and duration of hospital stay were recorded. Patients were followed up once every 3 months by outpatient examination and telephone interview up to June 2015. Results Of 9 patients, 4 received totally laparoscopic PD （2 received partial resection and repair of portal venous wall） , 1 received laparoscopic assisted resection and digestive tract reconstruction, and 4 received laparoscopie transection of jejunum, bile tract and stomach and conversion to open surgery for resection and digestive tract reconstruction （ 1 with severe adhesion between tumor and portal vein, 3 with bleeding due to dissection of neck and unciform process of pancreas）. The operation time and volume of intraoperative blood loss in all patients and in 4 patients with totally laparoscopic PD were （404 ±49） minutes and （456 ±348 ） mL, （ 395 ± 61 ） minutes and （ 188± 25 ） mL, respectively. Of 9 patients, 5 with postoperative complications were cured without perioperative death, including 2 with Grade B pancreatic fistula, 1 with biliary leakage, 1 receiving reoperation due to gastric stump bleeding at postoperative day 7 and 1 with abdominal infection. The extubation time of right drainage tube and left drainage tube was （9 ± 5 ） days and （ 11 ± 4）days, respectively. The duration of hospital stay was （24± 10）days. All patients were diagnosed as with pancreatic cancer by pathological examinations with the tumor diameter of （3.2 ± 0.8 ） em. The number of harvested lymph nodes in all patients and in 4 patients with totally laparoscopic PD were 16.8 （range, 6.0-25.0） and 19.8 （range, 15.0-25.0）. All the patients were followed up for mean time of 12 months （range, 4-24 months）, including 1 death at postoperative month 3, 1 with tumor survival of 20 months and others with tumor-free survival. The postoperative survival time of 4 patients was more than 18 months at the end of follow-up. Conclusion ＂Easy First＂ strategy in laparoscopic PD is safe, feasible and practical for borderline resectable pancreatic cancer.