经肠系膜下静脉入路胰十二指肠切除联合静脉切除术治疗可能切除胰头癌的临床疗效

Clinical efficacy of pancreaticoduodenectomy combined with venous resection via inferior mesenteric vein pathway for resectable pancreatic cancer

目的探讨经肠系膜下静脉人路胰十二指肠切除联合静脉切除术治疗合并肠系膜上静脉和（或）门静脉前壁受累的可能切除胰头癌的临床疗效。方法采用回顾性横断面研究方法。收集2013年1月至2017年1月四川大学华西医院收治的38例行经肠系膜下静脉入路胰十二指肠切除联合静脉切除术治疗的可能切除胰头癌患者的临床病理资料。38例患者中，BR-PV型[单纯肠系膜上静脉和（或）门静脉受累]25例，BR-A型[肠系膜上动脉受累，腹腔干和（或）肝动脉受累]13例。经肠系膜下静脉入路胰十二指肠切除术的器官切除和淋巴结清扫范围与传统胰十二指肠切除术相同，手术不同点在于行肠系膜下静脉入路时，在肠系膜下静脉汇人脾静脉处切断胰腺。观察指标：（1）术中和术后情况。（2）术后病理学检查情况。（3）随访和生存情况。采用门诊和电话方式进行随访，了解患者术后生存情况。随访时间截至2018年1月。偏态分布的计量资料以肘（范围）表示。采用Kaplan-Meier法绘制生存曲线，Log．rank检验进行生存分析。结果（1）术中和术后情况：38例患者术中均行门静脉和（或）肠系膜上静脉节段切除，其中原位端端吻合30例，人工血管间置吻合8例；38例患者中，2例术中联合肝总动脉切除并行原位端端吻合；术中无患者切除腹腔干。38例患者手术时间为320min（280～520min），术中出血量为530mL（420-650mL）。38例患者术后总并发症（Clavien-Dindo分级Ⅲ级及以上）发生率为18．4％（7／38），部分患者合并多种并发症，其中肺部感染6例，术后胰瘘（B级和c级）4例，腹腔感染4例，胃排空障碍3例，术后出血2例，静脉血栓2例。5例患者术后行对症支持治疗后痊愈，2例术后出血患者行再手术治疗后病情进一步恶化死亡。患者术后90d病死率为5．3％（2／38），术后住院时间为12d（9～52d）。（2）术后病理学检查情况：38例患者Rn切除率为81．6％（31／38）。其中25例BR-PV型患者R。切除率为92．0％（23／25），2例非R。切除患者均为胰腺前缘切缘〈1mm；13例BR-A型患者Rn切除率为8／13，非Rn切除患者中2例胰腺前缘和4例肠系膜上动脉切缘〈1mm（1例患者合并多部位切缘〈1mm）。BR-PV型和BR-A型患者胰腺后缘、静脉切缘和胰腺断缘的切缘均≥1mm。BR-PV型和BR．A型患者静脉浸润率分别为100．0％（25／25）和9／13。（3）随访和生存情况：38例患者均获得术后随访，随访时间为6-40个月，中位随访时间为15个月。38例患者生存时间为18个月（6～40个月）。25例BR-Pv型患者生存时间为23个月（8～40个月），13例BR．A型患者生存时间为16个月（6～25个月）。BR-PV型患者和BR．A型患者1、2、3年总体生存率分别为89．5％、33．1％、22．1％和83．9％、16．8％、0。BR-PV型和BR．A型患者无瘤生存时间分别为15个月（5～30个月）和9个月（4～18个月），1、2年无瘤生存率分别为63．0％、7．5％和11．5％、0。结论对于合并肠系膜上静脉和（或）门静脉前壁受累的可能切除胰头癌，采用经肠系膜下静脉人路胰十二指肠切除联合静脉切除术中能够避免肠系膜上静脉和（或）门静脉损伤，提高静脉切缘和胰腺断缘阴性率。

Objective To investigate clinical efficacy of pancreaticoduodenectomy combined with venous resection via inferior mesenteric vein （IMV） pathway for resectable pancreatic cancer with superior mesenteric vein （SMV） and / or anterior wall of portal vein （PV） involvements. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 38 resectable pancreatic cancer patients who underwent pancreaticoduodenectomy with venous resection via IMV pathway in the West China Hospital of Sichuan University between January 2013 and January 2017 were collected. The tumors of 25 patients were BR-PV type （simplex SMV and / or PV involvements） , and tumors of 13 patients were BR-A type （ SMV, celiac trunk and / or hepatic artery involvements）. The pancreaticoduodenectomy via IMV pathway was the same as traditional surgery in organs resection and lymph node dissection, the difference was cutting off the pancreas at a junction between IMV and splenic vein when using IMV pathway. Observation indicators： （ I ） intraoperative and postoperative situations; （2） results of postoperative pathological examination; （3） follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival up to January 2018. Measurement data with skewed distribution were described as M （range）. The survival curve was drawn by the Kaplan-Meir method, and Log-rank test was used for survival analysis. Results （1）Intraoperative and postoperative situations ： 38 patients underwent intraoperative segmental resection of PV and / or SMV, including 30 with end-to-end anastomosis in situ and 8 with artificial vessel interposition anastomosis. Two of 38 patients were intraoperatively combined with common hepatic artery resection and end-to-end anastomosis in situ. There was no intraoperative celiac trunk resection. The operation time and volume of intraoperative blood loss of 38 patients were respectively 320 minutes （range, 280-520 minutes） and 530 mL （range, 420-650 mL）. The incidence of total complications （Clavien-Dindo Ⅲ and above） of 38 patients was 18.4% （7/38） , and some patients were combined with multiple complications, including 6 with pulmonary infection, 4 with pancreatic fistula （ B and C grade） , 4 with intra-abdominal infection, 3 with delayed gastric emptying, 2 with postoperative bleeding and 2 with venous thrombosis. Five patients were cured by postoperative symptomatic treatment, and 2 with postoperative bleeding died of worsened condition after reoperation. The mortality at 90 days postoperatively and duration of hospital stay were respectively 5.3% （2/38） and 12 days （ range, 9-52 days）. （2） Results of postoperative pathological examination： the R0 resection rate of 38 patients was 81.6% （31/38）. The R0 resection rate of 25 patients in BR- PV type was 92. 0% （ 23/25）, and resection margin of pancreatic leading edge 〈 1 mm was in 2 patients without R0 resection; R0 resection rate of 13 patients in BR-A type was 8/13, and resection margin of pancreatic leading edge 〈 1 mm was in 2 patients and resection margin of SMV 〈 1 mm was in 4 patients （ 1 margined with resection margin of multiple sites 〈 1 mm） of patients without R0 resection. The resection margins of pancreatic trailing edge, venous cut edge and pancreatic cut edge in patients with BR-PV type and BR-A type were more than and equal to lmm. The venous infiltration rate in patients with BR-PV type and BR-A type was respectively 100. 0% （25/25） and 9/13. （3） Follow-up and survival situations： 38 patients were followed up for 6-40 months, with a median time of 15 months, and survival time was 18 months （range, 6-40 months）. The survival time and 1-, 2- and 3-year cumulative survival rates were respectively 23 months （range, 8-40 months）, 89.5%, 33. 1%, 22. 1% in 25 patients with BR-PV type and 16 months （range, 6-25 months）, 83.9%, 16. 8%, 0 in 13 patients with BR-A type. The tumor-free survival time and 1- and 2-year cumulative tumor-free survival rates were respectively 15 months （range, 5-30 months）, 63.0%, 7.5% in patients with BR-PV type and 9 months （range, 4-18 months）, 11. 5%, 0 in patients with BR-A type. Conclusion For resectable pancreatic cancer with SMV and / or anterior wall of PV involvements, pancreaticoduodenectomy combined with venous resection via IMV pathway could avoid injury of SMV and / or PV, and increase negative rates of venous and pancreatic resection margins.