动脉优先入路在腹腔镜胰十二指肠切除术中的临床价值

Clinical value of arterial first approach in laparoscopic pancreaticoduodenectomy

目的：探讨动脉优先入路在腹腔镜胰十二指肠切除术（LPD）中的应用价值。方法：采用回顾性队列研究方法。收集2014年10月至2016年12月华中科技大学同济医学院附属同济医院收治的181例行LPD的胰头颈部癌和壶腹周围癌患者的临床病理资料。181例患者中，96例行动脉优先入路的LPD，设为实验组；85例行传统入路的LPD，设为对照组。两组患者手术均由同一手术团队完成，手术切除范围、淋巴结清扫范围及消化道重建方式均相同。观察指标：（1）术中情况。（2）术后情况。（3）随访及生存情况。采用门诊和电话方式进行随访，随访内容为患者无瘤生存情况。随访时间截至2017年2月。正态分布的计量资料以±s表示，组间比较采用t检验；偏态分布的计量资料采用M（范围）表示。计数资料比较采用X2检验。结果：（1）术中情况：两组患者均顺利完成LPD。实验组和对照组患者总手术时间分别为（268±20）min和（285±25）min，消化道重建时间分别为（33±10）min和（30±17）min，两组患者上述指标比较，差异均无统计学意义（t=8.529，2.741，P〉0.05）。实验组和对照组患者肿瘤切除时间，有肠系膜上静脉侵犯分别为（216±13）min和（264±22）min，两组比较，差异有统计学意义（t=41.826，P〈0.05）；无肠系膜上静脉侵犯分别为（224±14）min和（215±21）min，两组比较，差异无统计学意义（t=7.423，P〉0.05）。实验组和对照组患者术中出血量分别为（99±16）mL和（131±27）mL，术中输血量分别为（1.3±0.8）U和（2.8±1.2）U，两组患者上述指标比较，差异均有统计学意义（t=3.670，0.562，P〈0.05）；术中输血例数分别为5、8例，两组比较，差异无统计学意义（X2=1.195，P〉0.05）。（2）术后情况：实验组和对照组患者术后引流管拔除时间分别为（5.8±2.4）d和（6.3±3.6）d，术后住院时间分别为（18.3±6.3）d和（19.6±7.1）d，两组患者上述指标比较，差异均无统计学意义（t=0.498，1.305，P〉0.05）。实验组11例患者术后发生早期并发症，A级胰瘘8例（4例合并腹泻、2例合并胆瘘、1例合并胃排空障碍、1例单纯胰瘘）；B级胰瘘3例（2例合并腹腔出血、1例合并腹腔感染），其中1例合并腹腔出血患者经治疗无效后死亡。对照组12例患者术后发生早期并发症，A级胰瘘6例（2例合并胆瘘、2例合并胃排空障碍、1例合并腹泻、1例合并消化道出血）；B级胰瘘3例均合并腹腔出血 （2例合并感染），其中1例合并感染患者死亡；3例腹泻。其他并发症患者经积极对症支持治疗后均痊愈。实验组和对照组患者总并发症比较，差异无统计学意义（χ^2=0.287，P〉0.05）。术后病理学检查结果显示：实验组和对照组患者R0切除例数分别为93、76例，两组比较，差异有统计学意义 （χ^2=4.057，P〈0.05）。（3）随访及生存情况：179例患者均获得术后随访，随访时间为2-28个月，中位随访时间为14个月。实验组和对照组患者术后6个月无瘤生存率分别为92.7%（89/96）和88.2%（75/85），两组比较，差异无统计学意义（χ^2=1.060，P〉0.05）。结论：动脉优先入路LPD能够明显缩短有肠系膜上静脉侵犯胰头颈部癌和壶腹周围癌患者的肿瘤切除时间，明显减少术中出血量及输血量，提高其R0切除率。

Objective：To investigate the clinical value of arterial first approach in laparoscopic pancreaticoduodenectomy （LPD）. Methods：The retrospective cohort study was conducted. The clinicopathological data of 181 patients with pancreatic head and periampullay tumors who underwent LPD in the Affiliated Tongji Hospital of Huazhong University of Science and Technology between October 2014 and December 2016 were collected. Among 181 patients, 96 using arterial first approach and 85 using traditional approach were respectively allocated into the experimental group and the control group. Surgery was applied to patients in the same doctors′ team, and there were the same extent of surgical resection, range of lymph node dissection and digestive tract reconstruction. Observation indicators： （1） intraoperative situation; （2） postoperative situation; （3） followup and survival situations. Followup using outpatient examination and telephone interview was performed to detect the tumorfree survival up to February 2017. Measurement data with normal distribution were represented as ±s, and comparison between groups was analyzed using the t test. Measurement data with skewed distribution were described as M （range）. Comparison of count data were analyzed using the chisquare test or Fisher exact probability. Results： （1） Intraoperative situation： all the patients underwent successful LPD. Overall operation time and time of digestive tract reconstruction were respectively （268±20）minutes, （33±10）minutes in the experimental group and （285±25）minutes, （30±17）minutes in the control group, with no statistically significant difference between 2 groups （t=8.529, 2.741, P〉0.05）. Time of tumor resection with superior mesenteric venous invasion were respectively （216±13）minutes and （264±22）minutes in the experimental and control groups, with a statistically significant difference between the 2 groups （t=41.826, P〈0.05）. Time of tumor resection without superior mesenteric venous invasion were respectively （224±14）minutes and （215±21）minutes in the experimental and control groups, with no statistically significant difference between the 2 groups （t=7.423, P〉0.05）. Volumes of intraoperative blood loss and blood transfusion were respectively （99±16）mL, （1.3±0.8）U in the experimental group and （131±27）mL, （2.8±1.2）U in the control group, with statistically significant differences between the 2 groups （t=3.670, 0.562, P〈0.05）. Five and 8 patients had intraoperative blood transfusion in the experimental and control groups, showing no statistically significant difference between the 2 groups （X2=1.195, P〉0.05）. （2） Postoperative situation： time of drainage tube removal and duration of hospital stay were respectively （5.8±2.4）days, （18.3±6.3）days in the experimental group and （6.3±3.6）days, （19.6±7.1）days in the control group, with no statistically significant difference between the 2 groups （t=0.498, 1.305, P〉0.05）. Eleven patients in the experimental group had postoperative early complications, including 8 with grade A pancreatic fistula （4 combined with diarrhea, 2 combined with biliary fistula, 1 combined with delayed gastric emptying and 1 with single pancreatic fistula）, 3 with grade B pancreatic fistula （2 combined with intraabdominal hemorrhage and 1 combined with intraabdominal infection）. One patient with intraabdominal hemorrhage in the experimental group died after treatment failure. Twelve patients in the control group had postoperative early complications, including 6 with grade A pancreatic fistula （2 combined with biliary fistula, 2 combined with delayed gastric emptying, 1 combined with diarrhea, 1 combined with digestive tract hemorrhage）, 3 with grade B pancreatic fistula and intraabdominal hemorrhage （2 combined with infection, including 1 death） and 3 with diarrhea. Other patients with complications were cured by symptomatic and supportive treatment. There was no statistically significant difference in overall complications between the 2 groups （χ^2=0.287, P〉0.05）. Results of postoperative pathological examination showed that case with R0 resection was 93 and 76 in the experimental and control groups, with a statistically significant difference between the 2 groups （χ^2=4.057, P〈0.05）. （3） Followup and survival situations： 179 patients were followed up for 2-28 months, with a median time of 14 months. Postoperative 6month tumorfree survival rate was 92.7%（89/96） and 88.2%（75/85） in the experimental and control groups, with no statistically significant difference between the 2 groups （χ^2=1.060, P〉0.05）.Conclusion：Arterial first approach in LPD could significantly shorten the time of tumor resection of patients with superior mesenteric artery invading pancreatic head and periampullay region, significantly reduce the volumes of intraoperative blood loss and blood transfusion, and increase the rate of R0 resection.