胰腺癌外科治疗的规范化

Standardized surgical management of pancreatic carcinoma

胰腺癌的外科治疗仍极具挑战性。术前影像学评估以判断肿瘤的可切除性极为重要。在淋巴结清扫范围方面,基于若干临床随机对照研究结果,以日本胰腺学会淋巴结分组为基础,建议清扫至第二站淋巴结。如能做到切缘阴性,可行联合肠系膜上静脉或门静脉的切除术式。肠系膜上动脉切缘最易有肿瘤细胞残留,应完整切除胰腺钩突。由于病理学对R0及R1切除判断标准的再评价,应重新审视R1切除对改善患者预后的价值和意义。由解剖学层面对胰腺系膜的探讨及临床应用有助于提高腹膜后切缘的阴性率。需建立和推广标准规范的治疗及评价体系,以使更多患者获益。

Pancreatic carcinoma is still a challenging disease. Assessment of resectability of the tumor is of importance in patient evaluation. The extent of lymphadeneetomy in pancreatieoduodenectomy remains controvisal. Several RCT reports recommended dissection of the 2nd group of lymphnodes according to the JPS classification. Pancreaticoduodenectomy with resection and reconstruction of the vein is a common practice for the removal of pancreatic carcinoma if a R0/R1 resection is reasonably expected. To achieve an R0 margin is the main objective of pancreaticoduodeneetomy as it is of great importance for extended survival. The clinical application of the concept of the mesopancreas will help to improve the status of retroperitoneal margins via standardized surgical procedures. The effect of a microscopically positive （ R1 ） resection on ultimate clinical outcome is uncertain. Multimodality therapy may ＂recover＂ a R1 margin and improve survival similar to R0 resection. To improve the clinical outcome of the patient underwent pancreaticoduodenectomy, a standard system should be built to guide clinical practice.