腹腔镜胰十二指肠切除时邻近器官病变的处理策略

Strategy in management of adjacent organ lesion during laparoscopic pancreaticoduodenectomy

目的评估腹腔镜胰十二指肠切除术（LPD）联合邻近器官切除的可行性和安全性。 方法收集2013年3月至2017年9月浙江省人民医院胃肠胰外科开展的15例LPD联合邻近器官切除术的临床资料，其中男性10例，女性5例，年龄20～86岁，体重指数19.6～34.5 kg/m2。术前有腹部手术史者2例，行新辅助化疗者2例。 结果15例患者中，腹腔镜胰十二指肠切除术联合肝脏部分切除4例，联合远端胃癌根治术3例，联合结肠切除术6例，联合右肾切除＋下腔静脉取栓及整形修补1例，联合脾动脉瘤双头结扎1例。手术时间280～450 min，出血量100～450 ml，并发症发生率33.3%，无术后90 d内死亡。术后住院时间10～42 d，中位时间18 d。术后病理学检查结果：胃、十二指肠双重癌1例，胃癌累及胰头和十二指肠2例，壶腹癌伴左肝内胆管结石1例，壶腹癌伴左肝良性肿瘤1例，壶腹癌伴肝寡转移1例，胆管癌侵及右肝管1例，壶腹癌伴梗阻性黄疸1例（首次误诊为胆管结石而手术），胰腺神经内分泌癌伴结肠癌1例，十二指肠癌1例，十二指肠巨大间质瘤2例，十二指肠肉瘤1例，胰腺导管内乳头状黏液瘤伴脾动脉瘤1例，胰腺神经内分泌肿瘤侵及下腔静脉右肾静脉汇合处伴瘤栓形成1例。随访3～40个月，12例存活，3例死亡，中位生存时间17.5个月。 结论腹腔镜胰十二指肠切除术联合邻近器官切除的肿瘤治疗效果可。对拟行LPD，术前或术中发现合并肝脏、胃和结肠等邻近器官病变的患者，应根据病变的性质、部位选择手术治疗方式。

ObjectiveTo evaluate the safety and feasible of adjacent organ resection during laparoscopic pancreaticoduodenectomy（LPD）, and summary the surgical strategies. MethodsClinical data of 15 adjacent organ resections combined with LPD from March 2013 to September 2017 were reviewed.There were 10 male and 5 female patients aging from 20 to 86 years, and the body mass index ranged from 19.6 to 34.5 kg/m2.Two patients had previous abdominal surgical history.Two patients underwent preoperative chemotherapy. ResultsThe resected adjacent organs included liver（n=4）, stomach（n=3）, colon（n=6）, right kidney with embolectomy and vasoplastic of inferior vena cava（n=1）, and spleen artery aneurysms（n=1）. The operative time ranged from 280 to 450 minutes, and the blood loss ranged from 100 to 450 ml.The total complication rate was 5/15 and no one died in 90 days after surgery.The postoperative hospital stay ranged from 10 to 42 days with medium 18 days.The pathology included adenocarcinoma of stomach and duodenum（n=1）, gastric cancer invading pancreas or duodenum（n=2）, ampullary adenocarcinoma with left hepatolithiasis（n=1）, ampullary adenocarcinoma with a benign lesion in left liver（n=1）, ampullary adenocarcinoma with single liver metastasis（n=1）, ampullary adenocarcinoma（n=1）, pancreatic intraductal papillary mucinous neoplasm with splenic artery aneurysms（n=1）, pancreatic neuroendocrine neoplasm with colon cancer（n=1）, distal common bile duct adenocarcinoma involving righ hepatic duct（n=1）, pancreatic neuroendocrine neoplasm invading inferior vena cava and right renal vein（n=1）, duodenal adnocarcinoma（n=1）, duodenal ewing′s sarcoma（n=1）, duodenal intesititialoma（n=2）. The follow-up was from 3 to 40 months with the medium survival of 17.5 months. ConclusionsThe oncological outcomes of PD combined with adjacent organ resection is acceptable.Surgical treatment for those patients with periampullary neoplasma and adjacent organ lesions should be aggressive.