根治性顺行模块化胰脾切除术和传统胰体尾切除术治疗胰体尾导管腺癌的临床效果分析

Comparison of radical antegrade modular pancreatosplenectomy with conventional distal pancreatectomy for pancreatic adenocarcinoma of the body and tail

目的探讨根治性顺行模块化胰脾切除术(RAMPS)和传统胰体尾切除术(CDP)治疗胰体尾导管腺癌的术后短期并发症及长期生存情况。方法回顾性分析2013年5月至2019年6月南京医科大学第一附属医院胰腺中心收治的304例胰体尾导管腺癌患者资料,男性176例,女性128例,平均年龄64.1岁(范围:39~85岁)。其中101例患者行RAMPS,203例行CDP。偏态分布的连续变量以[M(QR)]表示,组间比较采用Wilcoxon秩和检验。计数资料比较采用χ^2检验或Fisher确切概率法,同时运用倾向性评分匹配(PSM)平衡两组之间的差异后通过Kaplan-Meier法比较两组的生存情况。结果经PSM后,RAMPS组和CDP组各81例患者。RAMPS组总体并发症发生率为32.1%(26/81),无术后死亡。RAMPS组中位手术时间为[225(95)min],较CDP组[210(130)min]无延长(P=0.916)。RAMPS组中位肿瘤最大径[4.0(2.3)cm]与CDP组[4.5(2.2)cm]相比,差异无统计学意义(P=0.520)。RAMPS组T4期(胰腺癌AJCC分期第八版)患者占34.6%(28/81),与对照组39.5%(32/81)相比,差异无统计学意义(χ^2=0.574,P=0.902)。RAMPS组中位淋巴结获取数为[9(9)枚],较CDP组[10(11)枚]并无增加(P=0.992)。"1 mm"原则下RAMPS组后腹膜切缘阴性率为70.3%(52/74),高于对照组的53.6%(30/56)(χ^2=3.817,P=0.044);总体R0切除率为44.6%(33/74),较对照组的37.5%(21/56)并未提高(χ^2=0.663,P=0.474)。RAMPS组中位生存期为16.5个月,CDP组为25.2个月,两组差异无统计学意义(P=0.981);亚组分析结果显示,CA19-9≥300 U/ml的患者行RAMPS手术后中位生存期为16.0个月,CDP手术后为10.1个月,差异无统计学意义(P=0.082)。结论RAMPS能增加"1 mm"原则下后腹膜切缘阴性率,可能提高总体R0切除率及淋巴结获取数。当术前CA19-9≥300 U/ml时,RAMPS可能使患者生存获益。

Objective To compare the short-term outcomes and long-term survivals of radical antegrade modular pancreatosplenectomy(RAMPS)and conventional distal pancreatectomy(CDP).Methods A total of consecutive 304 patients including 176 male patients and 128 female patients who underwent RAMPS or CDP at Pancreas Center,the First Affiliated Hospital with Nanjing Medical University from May 2013 to June 2019 were retrospectively analyzed.The median age was 64.1 years old(range:39 to 85 years old).There were 101 patients underwent RAMPS and 203 patients underwent CDP.Measurement data with skewed distribution were presented as(M(QR))and comparison between groups was evaluated with the Wilcoxon rank sum test.Count data were analyzed using theχ^2 test or Fisher exact probability.Survival analyses were performed by the Kaplan-Meier method after a one to one propensity score matching(PSM)conducted to balance several variables.Results An eighty-one to eighty-one patients were enrolled after PSM.The overall morbidity was 32.1%(26/81)and there were no in-hospital mortalities in RAMPS.The median operative time was 225(95)minutes in RAMPS,not significantly longer as compared with CDP(210(130)minutes,P=0.916).The median greatest tumor diameter in RAMPS was 4.0(2.3)cm,not significantly larger as compared with CDP(4.5(2.2)cm,P=0.520).There were 34.6%(28/81)patients who presented with T4 tumors by 8th AJCC TNM staging system in RAMPS,which was not significantly different as compared with CDP(39.5%,χ^2=0.574,P=0.902).The median number of examined lymph nodes was 9(9),not significantly greater in RAMPS as compared with CDP(10(11),P=0.992).The rate of negative posterior margins using 1 mm rule in RAMPS was 70.3%(52/74),significantly higher as compared with CDP(53.6%(30/56),χ^2=3.817,P=0.044).The overall R0 resection rate was 44.6%(33/74)in RAMPS and 37.5%(21/56)in CDP,which was not significantly different(χ^2=0.663,P=0.474).The median overall survival was 16.5 months for RAMPS,25.2 months for CDP,and there was no statistical difference between two groups(P=0.981).The median overall survival was 16.0 months for patients with preoperative CA19-9≥300 U/ml who underwent RAMPS,10.1 months for patients who underwent CDP,without significant difference(P=0.082).Conclusions RAMPS can improve the rate of negative posterior margins by 1 mm rule and probably increase R0 resection rate and the harvest of lymph nodes.RAMPS may be beneficial to some patients with preoperative CA19-9≥300 U/ml.