全胰腺切除术治疗胰腺癌的临床疗效

Clinical efficacy of total pancreatectomy for pancreatic cancer

目的探讨全胰腺切除术治疗胰腺癌的临床疗效。方法采用回顾性描述性研究方法。收集2009年3月至2016年1月哈尔滨医科大学附属第一医院收治的11例行全胰腺切除术胰腺癌患者的临床病理资料。患者行计划性全胰腺切除术或非计划性全胰腺切除术，消化道重建采用空肠胆管端侧吻合和胃空肠侧侧吻合。观察指标：（1）治疗情况。（2）随访情况。采用门诊和电话方式进行随访，随访内容包括患者空腹血糖水平、糖化血红蛋白、胰岛素和口服胰酶片用量、消瘦、腹泻等症状以及患者预后情况。随访时间截至2016年11月。计量资料采用x±s、平均数（范围）或肘（范围）表示。结果（1）治疗情况：11例患者均成功施行全胰腺切除术，其中4例术前影像学检查结果示胰腺多发占位性病变行计划性全胰腺切除术，7例行非计划性全胰腺切除术。2例患者因肿瘤侵犯肠系膜上静脉，行肠系膜上静脉部分切除＋人工血管置换术。2例患者因无胆管扩张，术中放置胆管支架外引流，术后1个月拔除。11例患者全胰腺切除术的平均手术时间为450min（270—640min）；平均术中出血量为564mL（200～1500mL）；其中5例术中输血，输血量为400～1600mL。11例患者术后病理学检查结果：10例为R0切除，1例为R．切除；均为胰腺导管腺癌，ⅡA期4例，ⅡB期7例。11例患者术中淋巴结清扫数目为（17．2±2．3）枚／例；7例患者发生局部淋巴结转移，转移淋巴结数目为2．1枚／例。11例患者中．术后3例采用GP方案行6个疗程的化疗。4例患者出现术后并发症，其中感染2例、胆汁漏1例、胃排空障碍1例，术后并发症均经对症支持治疗后好转；无死亡病例。11例患者平均住院时间为24d（15～56d）。（2）随访情况：11例患者均获得术后随访，随访时间为5～24个月。11例患者随访期间，平均空腹血糖为7．6mmol／L（5．0～10．0mmol／L）：平均糖化血红蛋白为7．5％（5．4％～10．4％）；平均胰岛素用量为22．7U／d（18．0～28．0U／d）;平均口服胰酶片剂量为640mg／d（450～900mg／d）。11例患者随访期间，4例患者食欲增加，5例无明显变化，2例食欲减退；体质量增）Jn3例，无明显变化4例，下降4例；2例发生腹泻，2例于门诊复查时发现脂肪肝，1例出现低血糖症状。11例患者中，2例无瘤生存；9例带瘤中位生存时间为12个月（5～23个月），其中腹腔转移或复发3例，肝脏转移2例，肺转移2例，腹膜后淋巴结转移2例。结论全胰腺切除术是一种安全可行治疗胰腺癌的手术方式，且在规范控制血糖和补充胰酶的条件下，患者可获得较好的生命质量。

Objective To investigate the clinical efficacy of total pancreatectomy （TP） for pancreatic cancer. Methods The retrospective descriptive study was conducted. The cliuicopathological data of 11 patients who underwent TP for pancreatic cancer in the First Affiliated Hospital of Harbin Medical University from March 2009 to January 2016 were collected. Patients received planned TP or unplanned TP and digestive tract reconstruction using biliojejunal end-to-side anastomosis and side-to-side gastrojejunostomy. Observation indicators included： （1） treatment situations; （2） follow-up situation. Follow-up using outpatient examination and telephone interview was performed to detect the level of fasting blood glucose, glycosylated hemoglobin, dosages of insulin and pancreatic enzymes, symptoms of emaciation and diarrhea and patients＇ prognosis up to November 2016. Measurement data were represented as x±s, average （range） and M （range）. Results （ 1 ） Treatment situations ： all the 11 patients underwent successful TP, including 4 undergoing planned TP due to pancreatic multiple space-occupying lesions by preoperative imaging examination and 7 undergoing unplanned TP. Two patients received partial resection of the superior mesenteric vein and artificial vascular replacement due to tumor invading superior mesenteric vein. Two patients without cholangiectasis received external drainage through intraoperative biliary stent placement, and drainage tube was removed at month 1 postoperatively. Operation time was 270-640 minutes, with an average of 450 minutes. Volume of intraoperative blood loss was 200-1 500 mL, with an average of 564 mL. Five patients had intraoperative blood transfusion, with volume of 400- 1 600 mL. Results of postoperative pathological examination of 11 patients： R0 and R1 resection were respectively detected in 10 and 1 patients; 4 and 7 patients were in stage Ⅱ A and Ⅱ B, showing pancreatic ductal adenocarcinoma. Number of lymph node dissected with an average of 17.2±2.3 per case. Seven patients were complicated with local lymph node metastases, with a number of 2.1 per case. Three of 11 patients received postoperative 6-cycle chemotherapy regimens of gemcitabine and cisplatin. Four patients with postoperative complications were improved by conservative treatment, including 2 with infection, 1 with bile leakage and 1 with delayed gastric emptying, without death. Duration of hospital stay was 15-56 days, with an average of 24 days. （2） Follow-up situation： 11 patients were followed up for 5-24 months. During follow-up, levels of fasting blood glucose and glycosylated hemoglobin were respectively 5.0-10.0 mmol/L and 5.4%-10.4% ,with averages of 7.6 mmol/L and 7.5%. Dosages of insulin and pancreatic enzymes were respectively 18.0-28.0 U/d and 450-900 mg/d, with averages of 22.7 U/d and 640 mg/d. During follow-up, 4, 5 and 2 patients had respectively increased, normal and decreased appetites. Three, 4 and 4 patients had respectively increased, unchanged and decreased body weights. Symptoms of diarrhea, fatty liver （ outpatient reexamination） and hypoglycemia were occurred in 2, 2 and 1 patients, respectively. Of 11 patients, 2 had tumor- free survival, and 9 had survival with tumor, with a median survival time of 12 months （range, 5-23 months）, including 3 with abdominal metastases or recurrence, 2 with liver metastases, 2 with pulmonary metastases and 2 with retroperitoneal lymphatic metastasis. Conclusion TP is safe and feasible for pancreatic cancer, it can also provide better quality of life for patients under conditions of regulating blood glucose and supplying pancreatic enzyme.