动脉先行路径胰十二指肠切除治疗交界性可切除胰腺癌的临床疗效分析

Analysis on the clinical therapeutic effects of arterial first approach pancreatoduodenectomy in the treatment of borderline resectable pancreatic adenocarcinoma

目的 比较动脉先行路径胰十二指肠切除术与标准路径术式在治疗交界性可切除胰腺癌的临床疗效.方法 回顾性分析第二军医大学长海医院胰腺外科2014年1月至2015年8月收治的113例胰腺癌患者的临床资料.所有患者术前均行高分辨率胰腺薄层增强CT检查,并由高年资影像科医师和胰腺外科医师共同确诊为交界性可切除胰腺癌,其中43例行动脉先行路径胰十二指肠切除术（AFA-PD组）,70例行标准路径胰十二指肠切除术（SPD组）.AFA-PD组中男性24例,女性19例,年龄（61.6±10.2）岁;SPD组中男性47例,女性23例,年龄（62.7±9.4）岁.对两组患者手术情况、住院时间、术后并发症、术后病理及预后等指标进行分析.结果 AFA-PD组患者的手术时间为（210.7±31.5）min,术中出血量为（1007.1±566.3）min;SPD组的手术时间为（187.9±27.4）min,术中出血量为（700.0±390.0）min.与SPD组相比,AFA-PD组的手术时间和术中出血量相对较多,差异有统计学意义（P值均〈0.01）.AFA-PD组和SPD组患者术后发生腹泻的比例（9.3％比5.7％）,术后1、3 d的白细胞计数[术后1 d：（13.3±1.1）×10^9/L比（12.4±2.4）×10^9/L;术后3 d：（12.7±1.6）×10^9/L比（11.7±2.5）×10^9/L],术后1、3、5 d腹腔引流液量[术后1 d：（184±42）ml比（156±54）ml;术后3 d：（155±48）ml比（133±35）ml;术后5 d：（66±20）ml比（47±31）ml]的差异均有统计学意义（P值均〈0.05）.SPD组中1例患者因术后腹腔出血行非计划二次手术治疗,术后治愈出院.两组患者术后30 d内均无死亡.两组均无胃切缘阳性、十二指肠切缘阳性和前切缘阳性患者.AFA-PD组患者肠系膜上动脉表面切缘阳性率（7.0％）较SPD组（24.3％）低,差异有统计学意义（χ^2=4.355,P〈0.05）,其余病理指标的差异均无统计学意义（P值均〉0.05）.两组随访时间为14～30个月,AFA-PD组平均生存时间（20.4±1.2）个月,中位生存时间20个月,平均无进展生存时间（21.5±1.4）个月,发生局部复发3例（7.0％）,发生肝脏或远处转移8例（18.6％）;SPD组平均生存时间（17.1±1.1）个月,中位生存时间16个月,发生局部复发13例（18.6％）,发生肝脏或远处转移25例（35.7％）,平均无进展生存时间（16.4±1.3）个月;AFA-PD组的肿瘤局部复发和远处转移率相对较低,但两组差异无统计学意义（P值均〉0.05）,AFA-PD组的生存时间（P=0.001）和无进展生存时间（P=0.002）更长.结论动脉先行路径胰十二指肠切除处理交界性可切除胰腺癌是安全有效的,可以提高肠系膜上动脉切缘R0切除率,延长患者生存时间.

Objective To compare the clinical therapeutic effects of arterial first approach pancreaticoduodenectomy （ AFA-PD ） with standard approach pancreaticoduodenectomy （ SPD ） in the treatment of borderline resectable pancreatic cancer （ BRPC） . Methods A retrospective analysis of the clinical data of 113 cases of pancreatic cancer patients from January 2014 to August 2015 at Department of Hepato-Biliary-Pancreatic Surgery, Changhai Hospital, the Second Military Medical University, including 43 cases in AFA-PD group and 70 cases in SPD group. Every patient had gone high-resolusion computed tomography before the surgery, when BRPC was definitely diagnosed by both experienced radiologist and pancreatic surgeon. There were 24 males and 19 females in the AFA-PD group,with average age of （61. 6± 10. 2） years. And in the SPD group, there were 47 males and 23 females, with average age of （ 62. 7 ± 9. 4） years. Results The operation time was （ 210. 7 ± 31. 5 ） minutes in AFA-PD group, （ 187. 9 ± 27. 4）minutes in SPD group,and peroperative bleeding volume was （1007. 1±566. 3）ml in AFA-PD group, （700. 0±390. 0）ml in the other group. Those two indicators of AFA-PD group,compared with SPD group, were relatively higher, the difference was statistically significant （ all P〈0. 01 ） . And with regard to postoperative diarrhea（9. 3% vs. 5. 7%）,postoperative 1,3 days of white blood cells（postoperative 1 day：（13. 3±1. 1）×10^9/L vs. （12. 4±2. 4）×10^9/L;postoperative 3 days：（12. 7±1. 6）×10^9/L vs. （11. 7±2. 5）× 10^9/L）,postoperative 1,3,5 days of peritoneal drainage fluid volume（postoperative 1 day：（184±42）ml vs. （156±54）ml;postoperative 3 days：（155±48）ml vs. （133±35）ml;postoperative 5 days：（66±20）ml vs. （47±31）ml）,the differences between the two groups were statistically significant （ all P〈0. 05） . One patient in the SPD group was treated with unplanned secondary surgery for postoperative intraperitoneal hemorrhage,and the patient was cured and discharged. There was no death in the two groups within 30 days after surgical operation and no patient with positive gastric margin,duodenal margin,or anterior margin. The resection rate of superiormesenteric artery（ SMA） margin R0 in AFA-PD group was higher than that in SPD group （P=0. 019）. The two groups were followed up for 14 to 30 months. As for AFA-PD group,the average survival time,progression free survival time and median survival time was respectively （20. 4±1. 2）months, （21. 5±1. 4）months and 20 months. There were 3 cases（7. 0%） with local recurrence and 8 cases（18. 6%） with liver metastasis or distant metastasis. In the SPD group, the average survival time, progression free survival time and median survival time was （ 17. 1 ± 1. 1 ） months, （ 16. 4 ± 1. 3 ） months and 16 months, respectively. There were 13 cases（ 18. 6%） with local recurrence and 25 cases（ 35. 7%） with liver metastasis or distant metastasis.As a result,the AFA-PD group had longer survival time（P=0.001）and progression free survival time（ P=0. 002） . However,the lower local recurrence and distant metastasis rate in AFA-PD group did not reach statistical standard （ P 〉 0. 05 ） . Conclusion The arterial first approach pancreaticoduodenectomy is safe and effective in the treatment of borderline resectable pancreatic cancer, which can improve the resection rate of SMA margin R0,and prolong patient survival time.