海德堡三角清扫在胰腺癌根治术中的应用价值

Application value of TRIANGLE operation in radical resection of pancreatic cancer

目的探讨海德堡三角清扫在胰腺癌根治术中的应用价值。方法采用回顾性描述性研究方法。收集2020年3―7月南京医科大学第一附属医院收治的30例行海德堡三角清扫胰腺癌病人的临床病理资料;男12例,女18例;中位年龄为65岁,年龄范围为41~79岁。病人完成肿瘤可切除性评估和肝十二指肠韧带廓清后,显露肠系膜上动脉、腹腔干、肝总动脉、门静脉及肠系膜上静脉,根据肿瘤部位行胰十二指肠切除术、胰体尾切除术或者全胰腺切除术,并完成海德堡三角区域内神经纤维及淋巴结组织清扫。胰十二指肠切除术至少完成肠系膜上动脉和腹腔干右半周骨骼化,胰体尾切除术时至少完成肠系膜上动脉和腹腔干左半周骨骼化,全胰腺切除术时原则上需完成肠系膜上动脉和腹腔干全周骨骼化,手术均彻底清除肠系膜上动脉和腹腔干夹角处的神经纤维及淋巴结组织。观察指标:(1)手术情况与术后组织病理学检查。(2)术后恢复情况。(3)随访情况。采用电话或门诊方式进行定期随访,了解病人肿瘤复发转移情况,随访时间截至2021年1月。偏态分布的计量资料以M(范围)表示。计数资料以绝对数或百分比表示,组间比较采用Fisher确切概率法。结果(1)手术情况与术后组织病理学检查:30例病人均行开腹手术,其中21例行胰十二指肠切除术,6例行胰体尾切除术,2例行全胰腺切除术,1例行保留中段的胰腺切除术;16例病人联合门静脉-肠系膜上静脉切除术;3例联合左侧肾上腺切除术。30例病人中,5例术中肠系膜上动脉-腹腔干周围组织清扫范围为1.00周,8例为1.25周,8例为1.50周,9例为1.75~2.00周。16例病人离断胃左静脉,14例保留胃左静脉。30例病人手术时间为287 min(165~495 min),术中出血量为275 mL(50~800 mL)。9例病人术中输注红细胞或冰冻血浆。术后组织病理学检查结果示肿瘤长径为3.4 cm(1.2~7.3 cm),淋巴结检出数目为20枚(9~35枚),阳性淋巴结数目为2枚(0~19枚)。30例病人中,20例肿瘤分化程度为中分化,10例为低分化。9例病人环周切缘为R0切除,17例为切缘1 mm R1切除,4例为R1切除。术后病理学T分期:30例病人中,3例为T1期,18例为T2期,5例为T3期,4例为T4期。术后病理学N分期:30例病人中,9例为N0期,13例为N1期,8例为N2期。术后病理学TNM分期:30例病人中,2例为Ⅰa期,2例为Ⅰb期,3例为Ⅱa期,11例为Ⅱb期,12例为Ⅲ期。(2)术后恢复情况:30例病人中,20例发生术后并发症,其中Clavien-DindoⅠ级并发症6例,Ⅱ级并发症9例,Ⅲa级并发症3例,Ⅴ级并发症2例。术中肠系膜上动脉-腹腔干周围组织清扫1.00周的病人术后腹泻发生情况为0,清扫1.25周的病人术后腹泻发生情况为1/8,清扫1.50周的病人术后腹泻发生情况为4/8,清扫1.75~2.00周的病人术后腹泻发生情况为9/9,4者比较,差异有统计学意义(P<0.05)。术中离断胃左静脉病人术后胃排空延迟发生情况为5/16,保留胃左静脉病人术后胃排空延迟发生情况为1/14,两者比较,差异无统计学意义(P>0.05)。30例病人中,19例行术后辅助化疗;28例顺利出院,术后住院时间为15 d(8~68 d);2例病人死亡。3例病人术后90 d内非计划性再入院。(3)随访情况:28例出院病人均获得随访,随访时间为1.0~9.0个月,中位随访时间为6.5个月。随访期间,1例局部进展期病人发生局部复发,9例病人发生肝转移(4例可切除胰腺癌、4例边界可切除胰腺癌、1例局部进展期胰腺癌),1例边界可切除胰腺癌病人发生腹膜转移。17例病人无瘤生存。结论海德堡三角清扫应用于胰腺癌根治术肿瘤根治程度较高,术后局部复发率较低,术后并发症发生率及病死率稍高,其远期疗效需进一步评估,建议对选择性病例行新辅助治疗后在高流量胰腺外科中心进行。

Objective To investigate the application value of TRIANGLE operation in radical resection of pancreatic cancer.Methods The retrospective and descriptive study was conducted.The clinicopathological data of 30 patients with pancreatic cancer who underwent TRIANGLE operation in the First Affiliated Hospital of Nanjing Medical University from March 2020 to July 2020 were collected.There were 18 females and 12 males,aged from 41 to 79 years,with a median age of 65 years.After assessment of the resectability and dissection of the hepatoduodenal ligament,the superior mesenteric artery,celiac axis,common hepatic artery,portal vein and superior mesenteric vein of patients were exposed.According to the location of tumor,patients were performed pancreaticoduodenectomy,distal pancreatectomy or total pancreatectomy combined with dissection of putatively tumor-infiltrated lymphatic and neural tissue from the triangular space.During the TRIANGLE operation,it required to at least finish the skeletonization of right semi-circumference of the superior mesenteric artery and celiac axis in cases of pancreatico-duodenectomy,whereas the left semi-circumference in cases of distal pancreatectomy.In principle,both of the superior mesenteric artery and celiac axis were circumferentially skeletonized for cases of total pancreatectomy.Lymphatic,neural and fibrous tissues between the superior mesenteric artery and the celiac artery were completely dissected in all patients.Observation indicators:(1)surgical conditions and postoperative histopathological examination;(2)postoperative recovery situations;(3)follow-up.Regular follow-up was conducted by telephone interview or outpatient examinations to understand tumor recurrence and metastasis of patients up to January 2021.Measurement data with skewed distribution were represented as M(range).Count data were described as absolute numbers or percentages,Fisher exact probability method was used for comparison between groups.Results(1)Surgical conditions and postoperative histopathological examination:all patients underwent open operation,including 21 cases of pancreaticoduodenec-tomy,6 cases of distal pancreatectomy,2 cases of total pancreatectomy,1 case of mid-segment preserving pancreatectomy.There were 16 cases combined with portal vein-superior mesenteric vein resection and 3 cases combined with left adrenal resection.For the dissection area of superior mesenteric artery-celiac axis,one cycle was conducted in 5 of 30 patients,one and a quarter cycle in 8 patients,one and a half cycle in 8 patients,one and three quarters‒two cycles in 9 patients.There were 16 cases with left gastric vein dissection and 14 cases with left gastric vein preservation.The operative time of 30 patients was 287 minutes(range,165‒495 minutes)and the volume of intraoperative blood loss was 275 mL(range,50‒800 mL).Nine patients received intraoperative transfusion of red blood cells or frozen plasma.Postoperative histopathological examination showed that the tumor diameter was 3.4 cm(range,1.2‒7.3 cm),the number of harvested lymph nodes was 20(range,9‒35),the number of positive lymph nodes was 2(0‒19).Of the 30 patients,20 cases had moderately differentiated tumor and 10 cases had poorly differentiated tumor.R0 resection was achieved in 9 patients,1 mm R1 resection in 17 patients,and R1 resection in 4 patients.Postoperative pathological T stages:3 of 30 patents were in stage T1,18 cases were in stage T2,5 cases were in stage T3,and 4 cases were in stage T4.Postoperative pathological N stages:9 of 30 patents were in stage N0,13 cases were in stage N1,and 8 cases were in stage N2.Postoperative pathological TNM stages:2 of 30 patents were in stageⅠa,2 cases were in stageⅠb,3 case were in stageⅡa,11 cases were in stageⅡb,12 cases were in stageⅢ.(2)Postoperative recovery situations:20 of 30 patients had postoperative complications,including 6 cases of Clavien-Dindo grade I complications,9 cases of gradeⅡcomplications,3 cases of gradeⅢa complications,2 cases of grade V complications.The incidence of postoperative diarrhea was 0 in cases with one cycle dissection of tissues around superior mesenteric artery-celiac axis,1/8 in cases with one and a quarter cycle dissection,4/8 in cases with one and a half cycle dissection,9/9 in cases in with one and three quarters-two cycles dissection,showing a significant difference between the four groups(P<0.05).The incidence of delayed gastric emptying was 5/16 in patients with left gastric vein dissection,versus 1/14 in patients with left gastric vein preservation,showing no significant difference between the two groups(P>0.05).Nineteen of 30 patients received adjuvant chemotherapy.Twenty-eight of 30 patients were successfully discharged from hospital,with the duration of postoperative hospital stay of 15 days(range,8‒68 days)and the rest of 2 patients died.Three patients had unplanned readmission within postoperative 90 days.(3)Follow-up:all the 28 patients discharged from hospital were followed up for 1.0‒9.0 months,with the median follow-up time of 6.5 months.During the follow-up,one patient with locally advanced pancreatic cancer had local recurrence,9 patients had liver metastasis(including 4 cases with resectable pancreatic cancer,4 cases with borderline resectable pancreatic cancer,1 case with borderline resectable pancreatic cancer),and 1 patient with borderline resectable pancreatic cancer had peritoneal metastasis.The rest of 17 patients survived without tumor recurrence.Conclusions TRIANGLE operation in the radical resection of pancreatic cancer has high radicality and low postoperative local recurrence,but a slightly high morbidity and mortality rate.Its long-term efficacy needs to be further evaluated.It is recommend that this procedure should be performed for selected patients after neoadjuvant chemotherapy in high-volume pancreatic surgery centers.