动脉优先入路在根治性胰十二指肠切除术中的应用价值

Application of the artery-first approach in the radical pancreaticoduodenectomy

目的：探讨动脉优先入路在根治性胰十二指肠切除术中的应用价值。 方法：采用回顾性队列研究方法。收集2010年2月至2013年8月厦门大学附属第一医院90例胰头导管腺癌患者的临床资料。患者均行根治性胰十二指肠切除术，40例患者行动脉优先入路根治性胰十二指肠切除术设为动脉入路组，50例患者行传统根治性胰十二指肠切除术设为传统手术组。观察指标：（1）术中情况：手术时间、术中出血量、术中联合门静脉切除重建例数、R0切除率、淋巴结清扫数目。（2）术后情况：病理学检查结果、术后并发症发生情况。（3）随访情况：术后生存情况、肿瘤复发转移情况。采用门诊和电话方式进行随访，随访患者生存情况、肿瘤复发转移情况。随访时间截至2013年8月。正态分布的计量资料以±s表示，采用t检验。偏态分布的计量资料以M（范围）表示，两组比较采用Wilcoxon秩和检验。计数资料比较采用χ2检验或Fisher确切概率法。等级资料比较采用KruskalWallis秩和检验。采用KaplanMeier法计算生存率，Logrank检验进行生存分析。 结果：（1）术中情况：两组患者均顺利完成手术，术中未发生不可控性出血。动脉入路组患者手术时间、术中出血量、术中联合门静脉切除重建患者例数分别为（4.2±0.9）h、 294 mL（100～400 mL）、3例，传统手术组分别为（4.1±0.6）h、489 mL（100～1 100 mL）、3例，两组上述指标比较，差异均无统计学意义（t=1.05，U=1.43，χ2=0.00，P〉0.05）。动脉入路组患者R0切除率为 82.5%（33/40），传统手术组为62.0%（31/50），两组比较，差异有统计学意义（χ2=4.55，P〈0.05）。动脉入路组淋巴结清扫数目为（12.2±1.5）枚，传统手术组为（11.3±1.2）枚，两组比较，差异无统计学意义（t= 1.61，P〉0.05）。（2）术后情况：术后病理学检查结果显示：90例患者均为胰头导管腺癌。动脉入路组患者TNM分期中Ⅰ、Ⅱ、Ⅲ、Ⅳ期分别为4、12、19、5例，传统手术组分别为6、17、23、4例，两组比较，差异无统计学意义（χ2=5.84，P〉0.05）。动脉入路组20例患者术后发生并发症（胆瘘1例、胰瘘4例、胃潴留6例、腹泻9例），传统手术组11例患者术后发生并发症（胰瘘 3例、胃潴留4例、腹泻4例），两组比较，差异有统计学意义 （χ2=7.72，P〈0.05）。两组患者围术期均无死亡。（3）随访情况：90例患者中，80例获得随访，10例失访（动脉入路组4例、传统手术组6例）。中位随访时间为28个月（2～40个月）。动脉入路组患者1、3年生存率为97.2%和52.8%，传统手术组患者为72.4%和18.2%，两组患者生存情况比较，差异有统计学意义（χ2=5.10，P〈0.05）。随访期间患者死亡53例，其中动脉入路组17例［肿瘤局部复发9例、肝转移11例（肿瘤局部复发合并肝转移3例）］；传统手术组36例［肿瘤局部复发20例、肝转移26例（肿瘤局部复发合并肝转移 10例）］，两组患者死亡人数比较，差异有统计学意义（χ2=8.00，P〈0.05）。动脉入路组患者腹腔转移7例，传统手术组腹腔转移10例，两组比较，差异无统计学意义（χ2=0.09，P〉0.05）。 结论：动脉优先入路方法应用于根治性胰十二指肠切除中具有提高R0切除率和减少术后近期复发，改善患者预后的优势。

Objective：To investigate the application value and clinical effect of the arteryfirst approach in radical pancreaticoduodenectomy. Methods：The retrospective cohort study was adopted. The clinical data of 90 patients with ductal adenocarcinoma of the pancreatic head who were admitted to the First Affiliated Hospital of Xiamen University from February 2010 to August 2013 were collected. All the patients underwent radical pancreaticoduodenectomy, 40 undergoing arteryfirst approach were allocated into the arteryfirst approach group and 50 undergoing routine radical pancreaticoduodenectomy were allocated into the operation group. Observation indicators included （1） intraoperative situations： operation time, volume of blood loss, number of patients combined with portal vein （PV） resection and reconstruction, R0 resection and number of lymph node dissected, （2） postoperative situations： pathological examinations and complications, （3） results of followup： postoperative survival, tumor recurrence and metastasis. The patients were followed up by outpatient examination and telephone interview till August 2013. Measurement data with normal distribution were presented as ±s and analyzed using t test. Measurement data with skewed distribution were presented as M （range）, and comparison between groups was analyzed by the Wilcoxon rank sum test. Count data were analyzed using the chisquare test or Fisher exact probability. Comparison of ranked data was done using the KruskalWallis rank sum test. The survival rate was calculated using KaplanMeier method and survival analysis was done using the Logrank test. Results： （1） Intraoperative situations： all the patients underwent successful operation, without the occurrence of uncontrollable intraoperative bleeding. The operation time, volume of intraoperative blood loss and number of patients combined with intraoperative portal vein resection and reconstruction were （4.2±0.9）hours, 294 mL （range, 100-400 mL）, 3 in the arteryfirst approach group and （4.1±0.6）hours, 489 mL （range, 100-1 100 mL）, 3 in the operation group, respectively, with no statistically significant difference between the 2 groups （t=1.05, U= 1.43, χ2=0.00, P〉0.05）. The rate of R0 resection was 82.5% （33/40） in the arteryfirst approach group and 62.0% （31/50） in the operation group, showing a statistically significant difference between the 2 groups （χ2=4.55, P〈0.05）. The number of lymph node dissected was 12.2±1.5 in the arteryfirst approach group and 11.3±1.2 in the operation group, showing no statistically significant difference between the 2 groups （t=1.61, P〉0.05）. （2） Postoperative situations： the results of pathological examinations showed that all the 90 patients were confirmed as with ductal adenocarcinoma of the pancreatic head. The stage Ⅰ, Ⅱ, Ⅲ and Ⅳ of TNM stage were detected in 4, 12, 19, 5 patients in the arteryfirst approach group and 6, 17, 23, 4 in the operation group, respectively, showing no statistically significant difference between the 2 groups （χ2=5.84, P〉0.05）. Twenty patients （1 with biliary fistula, 4 with pancreatic fistula, 6 with gastric retention and 9 with diarrhea）in the arteryfirst approach group and 11 （3 with pancreatic fistula, 4 with gastric retention and 4 with diarrhea） in the operation group had postoperative complications, showing a statistically significant difference between the 2 groups （χ2=7.72, P〈0.05）. No perioperative death was occurred. （3） The results of followup： of 90 patients, 80 patients were followed up for a median time of 28 months （range, 2-40 months） and 10 patients lost to followup （4 in the arteryfirst approach group and 6 in the operation group）. The 1 and 3 year survival rates were 97.2% and 52.8% in the arteryfirst approach group and 72.4% and 18.2% in the operation group, respectively, showing a statistically significant difference between the 2 groups （χ2=5.10, P〈0.05）. Fiftythree patients were dead during the followup, including 17 [9 with local tumor recurrence and 11 with liver transplantation （3 with local tumor recurrence combined with liver transplantation）] in the arteryfirst approach group and 36 [20 with local tumor recurrence and 26 with liver transplantation （10 with local tumor recurrence combined with liver transplantation）] in the operation group, with a statistically significant difference in the death between the 2 groups （χ2=8.00, P〈0.05）. Seven patients in the arteryfirst approach group and 10 patients in the operation group were complicated with intraabdominal metastasis, with no statistically significant difference （χ2=0.09, P〉0.05）. Conclusion：The arteryfirst approach in radical pancreaticoduodenectomy can increase the R0 resection rate and reduce shortterm postoperative recurrence, meanwhile, improve the prognosis of patients.