联合应用多种动脉优先入路胰十二指肠切除术的经验总结

Combined multiple artery-first approach to pancreatoduodenectomy

目的 探讨联合应用多种动脉优先入路施行胰十二指肠切除术的体会及其临床应用价值.方法 回顾性分析2013年6月至2015年6月哈尔滨医科大学附属第二医院胆胰外科收治的53例胰头区肿瘤患者的临床资料.所有患者术前均行胰腺增强CT、磁共振胰胆管造影、超声检查及肿瘤标志物测定.53例胰头区肿瘤患者均按照个体化的原则采用多种动脉优先入路相结合的方法（上入路＋后入路、上入路＋下入路、后入路＋下入路、上入路＋后入路＋下入路）,其中42例患者行根治性胰十二指肠切除术,9例患者行姑息性手术,2例患者终止手术.结果 联合应用动脉优先入路对42例胰头区肿瘤患者行胰十二指肠切除术.平均手术时间（5.4±3.1）h,术中出血量（366±297） ml,淋巴结清扫数量（19±5）枚,平均住院时间（14.0±5.6）d.行胰腺全系膜切除9例.术后胰瘘发生率为38.1％,术中发现肝右动脉变异1例.R0切除率88.1％,术后30 d内无患者死亡.结论 根据肿瘤部位和患者特点个体化联合应用动脉优先入路可以明显减少术中出血量、及时终止手术和发现保护变异动脉,有利于安全彻底的切除肿瘤,使胰十二指肠切除术更加安全可控.

Objective To investigate the clinical application of combined multiple artery-first approach to pancreatoduodenectomy.Methods The clinical data of 53 patients who were diagnosed with peripancreatic head tumor at Department of Biliary-Pancreatic Surgery of Second Affiliated Hospital of Harbin Medical University between June 2013 and June 2015 was retrospectively analyzed.Pancreatic enhanced CT scan,magnetic resonance cholangiopancreatography,ultrasonography and tumor marker detection were applied for all the patients preoperatively.The 53 patients were operated by combined multiple artery-first approach （superior ＋ posterior approach,superior ＋ inferior approach,posterior ＋ inferior approach,superior ＋ posterior＋ inferior approach） according to individualized therapeutic concept.And 42 patients underwent pancreatoduodenectomy,9 patients underwent palliative operation and 2 patients just received exploratory operation.Results Forty-two peripancreatic head tumor patients underwent pancreatoduodenectomy by applying combined multiple artery-first approach.The median operation time and intraoperative blood loss were （5.4±3.1）hours and （366±297）ml and the harvested lymph node and duration of hospital stay were 19±5 and （14.0 ± 5.6）days.Nine patients underwent ＂ total mesopancreas excision＂ and the rate of postoperative pancreatic fistula and R0 resection were 38.1% and 88.1%.Anomalous origin hepatic right artery was detected in one patients during the operation and no death occurred within 30 days postoperatively.Conclusion According to the tumor location and patient＇s condition,individualistically applying combined multiple artery-first approach can reduce intraoperative blood loss,terminate unnecessary surgery,detect anomalous origin artery,make the tumor resection more radical and pancreatoduodenectomy more safety.