胰十二指肠切除淋巴结清扫原则及意义

The principle and significance of lymphadenectomy in pancreaticoduodenectomy

胰腺癌早期即可出现淋巴结转移,这也是胰腺癌患者整体生存期短,5年生存率不高的主要原因。完整的RO手术切除和彻底的淋巴结清扫有助于延长术后生存期。胰十二指肠切除中标准的淋巴结清扫应该尽可能包括第5,6,8a,12b1,12b2,12c,13a,13b,14a,14b,17a,以及17b组淋巴结。然而,扩大的淋巴结清扫术对于术后的生存获益一直存在争议,对于淋巴结清扫范围的严格定义也还缺乏专家共识。其中争议最多的是第8组和第16组淋巴结的清扫。有研究证实对于肠系膜上动脉(SMA)左侧方、腹腔干、脾动脉、胃左动脉周围的淋巴结清扫对于术后生存期没有明显的获益。全胰腺系膜切除术有助于胰头癌患者后方的淋巴结清扫以及胰十二指肠的R0切除。全胰腺系膜切除术包括了SMA右侧以及其血管根部的骨骼化清扫,其中包含了一部分16a2组的淋巴结。笔者认为,我们至少应该做到胰十二指肠切除的D2淋巴结清扫,从而最大程度提高腺癌患者的生存率。

Lymph node metastasis occurs in early period, which is one of the important reasons for short survival and low 5-year survival rate of patients with pancreatic cancer. The curative surgical margin(R0) and complete clearance of regional lymph nodes could contribute to the improvement of survival. Standard lymphadenectomy for pancreatoduodenectomy should include No.5, 6, 8 a, 12 b1, 12 b2, 12 c, 13 a, 13 b,14 a, 14 b, 17 a, and 17 b stations. However, the survival benefit of extended lymphadenectomy during pancreatectomy remain controversial, and there is no true definition of the optimal extent of lymphadenectomy. The controversy of extended lymphadenectomy focused on No.8 and 16 stations. There is a lot of evidence showed that no survival benefit could be achieved from lymphadenectomy of the left side of the superiormesenteric artery(SMA) and around the celiac trunk, splenic artery, and left gastric artery during pancreatoduodenectomy. Total mesopancreas excision could faciliate posterior clearance and R0 resection of pancreaticoduodenectomy in treating pancreatic head carcinoma. Total mesopancreas excision include the skeletonization on the right side of the SMA and CT at their origins,which is correspondent with partial No. 16 a2 lymphadenectomy. Therefore, D2 lymphadenectomy should be performed during pancreaticoduodenectomy to improve the survival of patients with pancreatic cancer.