保留十二指肠胰头肿块切除术在儿童胰头肿瘤治疗中的应用

Application of duodenum-preserving surgery for pancreatic head tumors in children

目的 通过对比保留十二指肠的胰头肿块切除术与胰十二指肠切除术治疗儿童胰头肿瘤的术后并发症及治疗效果,探讨保留十二指肠胰头肿块切除术在儿童患者中的应用价值.方法 回顾性地分析了复旦大学附属儿科医院从2007年到2015年,收治并行保留十二指肠的胰头肿块切除术与胰十二指肠切除手术治疗的胰头部肿瘤患儿的临床资料.我们定义保留十二指肠肿块切除术为：①肿块剜除术;②保留十二指肠的胰头切除术（duodenum-preserving pancreatic head resection,DPPHR）.胰十二指肠切除术均为保留幽门胰十二指肠切除术（pylorus-preserving pancreaticoduode-nectomy,PPPD）.结果 共收集11例患儿临床资料,平均年龄（8.4±3.7）岁.其中7例行保留十二指肠手术,术后病理证实4例为实性假乳头状瘤;3例为胰母细胞瘤;4例行PPPD,3例病理结果为实性-假乳头状瘤;1例为炎性肌纤维母细胞瘤.保留十二指肠组患儿平均肿瘤最长径为：（9.4±4.5）cm,PPPD组最长径为（5.9±2.1）cm,两组肿瘤长径无统计学差异（P=0.17）.保留十二指肠组手术平均时间为（6.0±3.5）h,而PPPD组平均手术时间为（7.5±1.3）h,两组手术时间差异无统计学意义（P=0.44）.根据国际胰漏小组的定义,4例行保留十二指肠手术的患儿出现A级胰瘘,pp-PD组患儿均无术后胰瘘.根据国际胰腺外科研究小组的定义,11例患儿均未出现临床相关胃排空延迟（B级或C级）.除1例炎性肌纤维母细胞瘤失访外,余10例患儿术后经B型超声、CT等影像学检查随访时间为4个月到32个月,均未出现肿瘤复发.临床症状随访时间为6个月到4年,10例患儿均存活,且未诉与疾病相关不适.结论 针对儿童胰头肿瘤,根据术中情况,在肿瘤未侵犯十二指肠且能保证胆道及十二指肠血供的前提下,采取保留十二指肠的胰头肿块切除术,能减少手术创伤,保留胆道及胃肠道的完整性.

Objective To explore the surgical efficacy of duodenum-preserving techniques for pancreatic head tumor in children by comparing the postoperative complications and therapeutic efficacy of duodenum-preserving techniques versus pylorus-preserving pancreatic head resection （PPPHD）.Methods The clinical data of patients undergoing operations for pancreatic head tumors from 2007-2015 were analyzed retrospectively.Duodenum-preserving surgery was defined as tumor enucleation （EU） and duodenum-preserving pancreatic head resection （DPPHR）.And pancreatoduodenectomy was pylorus-preserving pancreatoduodenecotomy （PPPD）.Results There were a total of 11 patients with an average age of （8.3 ± 3.7） years.Duodenum-preserving surgery was performed in 7 patients,including solid pseuodopapillary tumor （SPT,n =4） and pancreatoblastoma （n =3）;PPPD was performed in 4 patients,including SPT （n =3） and inflammatory myofibroblastic tumor （n =1）.The longest tumor diameter was （9.4 ± 4.5） cm in duodenum-preserving group versus （5.9 ± 2.1） cm in PPPD group.There was no inter-group statistical difference in diameter （P =0.17）.The average operative duration was （6.0 ± 3.5） hours in duodenum-preserving group versus （7.5 ± 1.3）hours in PPPD group.No inter-group statistical difference existed in operative duration （P =0.44）.According to the definition of postoperative pancreatic fistula,4 patients suffered grade A pancreatic fistula post-operation in duodenum-preserving group versus none in PPPD group.None had delayed gastric emptying in neither group.During a follow-up period of 4 to 32 months,except for one patient of inflammatory myofibroblastic tumor being lost to follow-up,the other 10 patients all survived without recurrence.Conclusions Both surgical approaches are effective for pancreatic head tumors.For the advantages of duodenum-preserving surgery,including preserving endocrine and exocrine pancreatic functions,it should be considered for carefully selected eases so that blood supply may be preserved for biliary tract and duodenum.