联合血管切除重建的胰腺癌根治术:附12例报告

Radical pancreatic resection combined with vascular resection and reconstruction: a report of 12 cases

目的：探讨侵犯血管的胰腺癌根治手术中联合血管切除重建的可行性、手术适应证和术中注意事项。方法：回顾性分析2014年3月—2015年12月收治的12例行根治手术的胰腺癌并侵犯门静脉（PV）/肠系膜上静脉（SMV）患者资料，其中胰十二指肠切除术10例，联合PV除者3例、SMV节段切除者1例、P V/S M V同时切除6例，脾静脉均予结扎未重建，5例保留脾脏，1例因脾脏淤血严重行联合脾脏切除；胰体尾部切除术2例，均联合PV/SMV切除，同时行脾脏切除。门静脉阻断时间为16~30 min；血管对端吻合10例，人造血管移植2例。结果：12例患者术后均恢复顺利，无围手术期死亡，无胆瘘、胰瘘、出血、血栓、人工血管感染、肝功能衰竭等并发症发生，无近期区域性门静脉高压表现。结论：在有条件的医院选择合适的病例施行联合血管切除的胰十二指肠切除术或胰体尾切除术是可行的，可提高切除率，改善患者生存质量，并不增加手术死亡率和并发症发生率。但要求术中仔细解剖、细致操作，且达到肉眼根治性切除，以提高手术安全性和远期生存率。

Objective： To investigate the feasibility, indications and intraoperative precautions of radical surgery with vascular resection and reconstruction for pancreatic cancer with vascular invasion. Methods： The clinical data of 12 patients with pancreatic cancer invading the portal vein （PV）/superior mesenteric vein （SMV） undergoing radical surgery from March 2014 to December 2015 were retrospectively analyzed. Ten patients underwent pancreaticoduodenectomy, and of them synchronously, 3 cases had PV resection, one case had SMV resection, and 6 cases had PV plus SMV resection with splenic vein ligation without reconstruction, of whom, 5 cases had spleen preservation and one case had splenectomy due to severe splenic congestion; two patients underwent resection of the body and tail of the pancreas, and both cases had synchronous PV plus SMV resection and splenectomy. Portal vein occlusion time ranged from 16 to 30 min; end to end vascular anastomosis was performed in 10 cases and vascular prosthesis was used in 2 cases. Results： All 12 patients recovered uneventfully, and no perioperative death or complications such as biliary ifstula, pancreatic ifstula, bleeding, thrombosis, prosthetic gratf infection and liver function failure occurred, and no manifestations of regional portal hypertension were found in the short-term atfer operation. Conclusion： Pancreaticoduodenectomy or resection of the body and tail of the pancreas in combination with vascular resection is feasible for selected cases in qualiifed hospital, and can increase the resectability rate, improve patients’ quality of life, with no increase in operative mortality and incidence of complications. However, it requires careful intraoperative anatomic dissection and meticulous operation as well as achievement of radical resection visible to the naked eye, for improving the safety of the operation and long-term survival rates.