联合血管切除重建的胰十二指肠切除术治疗胰腺癌的临床意义

Clinical significance of combined vascular resection and reconstruction in pancreaticoduodenectomy forpancreatic cancer

目的探讨联合血管切除重建的胰十二指肠切除术治疗胰腺癌的临床意义。方法回顾性分析2006年1月至2011年12月第三军医大学西南医院收治的231例行胰十二指肠切除术胰腺癌患者的临床资料。根据手术方式不同将患者分为联合血管切除重建组（97例）和无血管切除重建组（134例），比较两组患者的手术情况、病理检查结果、患者预后以及淋巴结转移对两组患者预后的影响。计量资料采用两独立样本f检验，计数资料采用，检验。采用Kaplan-Meier法绘制生存曲线，生存分析采用Log-rank检验。结果联合血管切除重建组及无血管切除重建组手术时间分别为（554±136）rain和（445±106）min，术中出血量分别为（1110±939）ml和（623±349）ml，两组比较，差异有统计学意义（t=6．552，4．873，P〈0．05）。联合血管切除重建组和无血管切除重建组患者病死率分别为8．2％（8／97）和3．0％（4／134），两组比较，差异无统计学意义（，=3．164，P〉0．05）。联合血管切除重建组和无血管切除重建组患者术后并发症发生率分别为20．6％（20／97）和8．2％（11／134），两组比较，差异有统计学意义（X2=7．458，P〈0．05）。联合血管切除重建组和无血管切除重建组患者淋巴结阳性率分别为32．0％（31／97）和16．4％（22／134），两组比较，差异有统计学意义（X2=7．687，P〈0．05）。随访至2012年9月，223例患者获得随访，其中有淋巴结转移者53例，中位生存时间为8．4个月（6．9～10．0个月）；无淋巴结转移者170例，中位生存时间为18．6个月（15．8～21．5个月），两者比较，差异有统计学意义（，=17．045，P〈0．05）。53例有淋巴结转移的患者中，联合血管切除重建组31例，中位生存时间为8．5个月（6．3～10．7个月），无血管切除重建组22例，中位生存时间为8．3个月（6．1～10．5个月），两组生存情况比较，差异无统计学意义（X2=0．022，P〉0．05）。170例无淋巴结转移的患者中，联合血管切除重建组64例，中位生存时间为13．2个月（9．2～17．1个月），无血管切除重建组106例，中位生存时间为21．7个月（18．1～25．3个月），两组生存情况比较，差异有统计学意义（X2=11．908，P〈0．05）。结论联合血管切除重建的胰十二指肠切除术增加了患者术后并发症发生率，但是可以做到完整切除肿瘤，且没有明显增加患者病死率，对有淋巴结转移的胰腺癌患者术后生存时间无显著影响，对无淋巴结转移患者预后可能有一定影响。

Objective To investigate the significance of combined vascular resection and reconstruction in surgery for pancreatic cancer. Methods The clinical data of 231 patients with pancreatic cancer who received pancreaticoduodenectomy at the Southwest Hospital from January 2006 to December 2011 were retrospectively analyzed. All the patients were divided into the combined vascular resection and reconstruction group （97 patients） and non-vascular resection and reconstruction group （134 patients）. Effects of operation, results of pathological examination, prognosis and lymph node metastasis on the prognosis of the patients in the 2 groups were compared. Two independent samples t test was used to analyze the measurement data, and the count data were analyzed using the chi-square test. The survival curve was drawn by the Kaplan-Meier method, and the survival was analyzed using the Log-rank test. Results The operation time and intraoperative volume of blood loss were （ 554± 136 ） minutes and （ 1110±＋ 939 ） ml in the combined vascular resection and reconstruction group, and （445 ± 106） minutes and （623 ±349）ml in the non-vascular resection and reconstruction group, with significant differencebetween the 2 groups （t = 6. 552, 4. 873, P 〈 0.05 ）. The mortality, morbidity and positive rate of lymph node metastasis of were 8.2% （ 8/97）, 20.6% （20/97） and 32.0% （31/97 ） in the combined vascular resection and reconstruction group and 3.0% （4/134） , 8.2% （11/134） and 16.4% （22/134） in the non-vascular resection and reconstruction group. There was no significant difference in the mortality between the 2 groups （X2= 3. 164, P 〉 0.05 ） , while significant differences in the morbidity and positive rate of lymph node metastasis were detected between the 2 groups （X2 = 7. 458, 7. 687, P 〈 0.05 ）. A total of 223 patients were followed up till September 2012, 53 patients were with lymph node metastasis, and their median survival time was 8.4 months （range, 6.9- 10.0 months） ; 170 patients were with negative lymph node metastasis, and their median survival time was 18.6 months （ range, 15.8-21.5 months） , which was significantly longer than that of patients with positive lymph node metastasis （X2= 17. 045, P 〈 0.05 ）. Of the 53 patients with lymph node metastasis, 31 were in the combined vascular resection and reconstruction group, and their median survival time was 8.5 months （range, 6.3- 10.7 months） ; 22 were in the non-vascular resection and reconstruction group, and their median survival time was 8.3 months （range, 6. 1-10.5 months）, with no significant difference between the 2 groups （X2= 0. 022, P 〉 0.05 ）. Of the 178 patients with negative lymph node metastasis, 64 were in the combined vascular resection and reconstruction group, and their median survival time was 13.2 months （range, 9.2-17.1 months） ; 106 were in the non-vascular resection and reconstruction group, and their median survival time was 21.7 months （range, 18.1-25.3 months）, with significant difference between the 2 groups （X2= 11. 908, P 〈 0.05）. Conclusions Although pancreaticoduodenectomy combined with vascular resection and reconstruction increases the incidence of postoperative complications, it could achieve the complete removal of tumors without significantly increasing the mortality rate. For patients with lymph node metastasis, pancreaticodnodenectomy combined with vascular resection and reconstruction has no influence on the postoperative survival time, while it might have influence on the patients without lymph node metastasis.