可切除性胰腺癌外科治疗中的随机对照试验分析

ANALYSIS OF RANDOMIZED CONTROLLED TRIALS IN THE SURGICAL TREATMENT OF RESECTABLE PANCREATIC CANCER

目的 从近10年的随机对照临床试验中总结出可切除性胰腺癌外科治疗的最佳证据。方法 对1995年0 1月至2 0 0 4年4月间Medine中有关可切除性胰腺癌外科治疗的随机对照临床试验文献进行分析。结果 共检索到相关文献2 3篇代表19项不同的随机对照临床试验。结果表明:(1)标准的胰十二指肠切除术和保留幽门的胰十二肠切除术手术并发症和手术死亡率相似,术后患者生存率相当。(2 )扩大淋巴结清扫术较标准淋巴结清扫术手术并发症增多,手术死亡率相当,长期生存率和生活质量无明显改善。目前仍缺乏联合门静脉/肠系膜上静脉切除的扩大根治术可提高胰腺癌患者长期生存率的有力证据。(3)闭塞胰管而不用吻合方法者术后胰瘘和胰腺分泌不足增多,胰肠或胰胃吻合仍然是胰十二指肠切除中的主要重建方式,同时经纤维蛋白胶闭塞主胰管并不能减少术后腹腔内并发症。(4)不主张在胰切端床常规置引流管。(5 )胰切除术后常规使用生长抑素并不减少术后胰瘘的发生率。(6 )胰腺癌治愈性切除后可以得益于辅助性化疗,而辅助性放疗则有害。结论 手术治疗仍为治愈胰腺癌的唯一手段,仍需经过大样本的前瞻性随机对照临床试验和长期随访的结果来找出合理的规范化手术操作和综合治疗方案,形成临床实践指导原则。

Objective To conduct a analysis of randomized controlled clinical trials and summary the best evidence of resectable pancreatic carcinoma.Methods A literature search strategy identified randomized controlled clinical trials for pancreatic carcinoma in Medline database from January 1995 to April 2004.Result Current surgical studies have demonstrated that morbidity,mortality and survival are similar for pylorus-preserving and classic pancreaticoduodenectomy.Extended retroperitoneal lymphadenectomy can be perfomed withsimilar mortality but increased morbidity compared with standard pancreaticoduodenectomy but does not prolong survival.There still lack powered evidence to prove that pancreaticoduodenectomy combined PV/SMV resection can improve survival.Pancreatic-enteric anastomosis is associated with lower rates of pancreatic fistula and endocrine insufficiency than duct occlusion without anastomosis.Pancreaticogastrostomy and pancreaticojejunostomy appear to be comparable techniques for pancreatic duct reconstruction.Fibrin glue occlusion of the main pancreatic duct does not decrease the rate of intraabdominal complications.Intraperitoneal drainage should not be considered mandatory or standard after pancreatic resection.Routine use of prophylactic somatostatin or octreotide does not lower the rate of pancreatic fistula.Adjuvant chemotherapy has a significant survival benefit in patients with resected pancreatic cancer,whereas adjuvant chemoradiotherapy has a deterious effect on survival.Conclusion Surgical resection remains the only potentially curative therapy for adenocarcinoma of the pancreas.There still needs further prospective randomized controlled clinical trials and longer follow-up results to form clinical practice guidelines.