胰十二指肠切除术328例临床分析

Clinical analysis of 328 cases of pancreaticoduodenectomy

目的总结胰十二指肠切除术(pancreaticoduodenectomy,PD)的手术经验,分析并发症和远期疗效。方法回顾性分析2001年1月—2011年1月间施行的328例PD的临床资料,包括标准PD281例,保留幽门的PD 8例,扩大PD 39例。结果全组手术并发症发生率为34.1%(112/328)。前5位并发症依次为胃排空延迟(16.5%),胰瘘(11.9%),出血(7.0%),腹腔感染(5.2%),肺部感染(4.9%)。再手术率为6.1%(20/328)。病死率为3.0%(10/328)。壶腹周围癌202例中1,3,5年生存率分别为79.1%,51.5%,33.8%,中位生存期为38个月;淋巴结阴性患者(144例)的1,3,5年生存率分别为81.7%,57.6%,40.6%,中位生存期为47个月;淋巴结阳性患者(58例)的1,3,5年生存率分别为72.1%,36.4%,16.8%,中位生存期为24个月;淋巴结阴性患者的长期生存率显著高于淋巴结阳性患者(P=0.003)。胰头癌42例中1,3,5年生存率分别为67.6%,29.1%,9.7%,中位生存期为16个月,其中淋巴结阳性患者(11例)的3年以上生存率为0。非壶腹周围癌16例中1,2,3年生存率分别为71.4%,39.6%,19.8%,中位生存期为21个月。结论严格掌握扩大切除的手术指征、提高手术技巧和加强围手术期处理是减少PD术后并发症和病死率的关键。淋巴结有无转移是壶腹周围癌和胰头癌的重要预后因素。联合胰十二指肠切除术可作为非壶腹周围癌如局部进展期胃肠癌的治疗选择,可延长部分患者的生存期。

Objective To summarize the operative complications,fatality and the long-term outcome of pancreaticoduodenectomy（PD）.Methods The clinical data of 328 consecutive patients undergoing PD between Janunary 2001 and Janunary 2011 were retrospectively analyzed,which included 281 cases of standard PD,8 cases of pylorus-preserving PD and 39 cases of extended PD.Results The incidence of operative complications in the whole group was 34.1%（112/328）,of which the five major complications were delayed gastric emptying（16.5%）,pancreatic fistula（11.9%）,hemorrhage（7.0%）,intra-abdominal infection（5.2%） and pulmonary infection（4.9%）.The reoperation rate was 6.1% and fatality rate was 3.0%.The 1-,3-and 5-year survival rate of the patients with periampullary carcinoma（n=202） was 79.1%,51.5% and 33.8%,respectively,and the median survival time was 38 months,of which the 1-,3-,and 5-year survival rate of the lymph node negative cases（n=144） was 81.7%,57.6% and 40.6%,respectively,with a median survival time of 47 months,and the 1-,3-,and 5-year survival rate of the lymph node positive cases（n=58） was 72.1%,36.4% and 16.8%,respectively,with a median survival time of 24 months.The long-term survival time of lymph node negative patients was significantly higher than that of lymph node positive patients（P=0.003）.The 1-,3-,5-year survival rate of the patients with pancreatic head cancer（n=42） was 67.6%,29.1% and 9.7%,respectively,and the median survival time was 16 months,but the 3-year survival rate of the lymph node positive cases（n=11） was 0.The 1-,2-,3-year survival rate of the patients with nonperiampullary primary tumors（n=16） was 71.4%,39.6% and 19.8%,respectively,and the median survival time was 21 months.Conclusions The keys to reducing the postoperative complications and fatality of PD are strictly adhering to the indications for extended PD,improving the operative technique and strengthening the perioperative management.The lymph node status is the important factor of prognosis for periampullary and pancreatic head cancer.En bloc PD can be considered as a treatment option for nonperiampullary tumors such as locally advanced gastrointestinal cancers,because it may prolong the survival in some of these patients.