Endovascular pseudoaneurysm repair after distal pancreatectomy with celiac axis resection

Erosive hemorrhage due to pseudoaneurysm is one of the most life-threatening complications after pancreatectomy.Here,we report an extremely rare case of rupture of a pseudoaneurysm of the common hepatic artery(CHA)stump that developed after distal pancreatectomy with en block celiac axis resection(DP-CAR),and was successfully treated through covered stent placement.The patient is a 66-year-old woman who underwent DP-CAR after adjuvant chemoradiotherapy for locally advanced pancreatic body cancer.She developed an intra-abdominal abscess around the remnant pancreas head 31 d after the surgery,and computed tomography(CT)showed an occluded portal vein due to the spreading inflammation around the abscess.Her general condition improved after CT-guided drainage of the abscess.However,19 d later,she presented with melena,and CT showed a pseudoaneurysm arising from the CHA stump.Because the CHA had been resected during the DP-CAR,this artery could not be used as the access route for endovascular treatment,and instead,we placed a covered stent via the inferior pancreaticoduodenal artery originating from the superior mesenteric artery.After stent placement,cessation of bleeding and anterograde hepatic artery flow were confirmed,and the patient recovered well without any further complications.CT angiography at the 6-mo follow-up indicated the patency of the covered stent with sustained hepatic artery flow.To our knowledge,this is the first reported case of endovascular repair of a pseudoaneurysm that developed after DP-CAR.

胰腺体尾部癌外科治疗的几个焦点问题

胰腺体尾部癌症状隐匿,恶性程度高,切除率低,预后差,整体治疗有待提高.外科手术是唯一可能治愈的手段,手术治疗为核心的多学科协作的个体化治疗策略应该成为标准模式."可能切除"患者先接受新辅助治疗,再判断是否手术有助于提高R0切除率,改善预后.根治性顺行胰腺体尾部癌整体切除术(radical antegrade modular pancreatosplenectomy,RAMPS)手术符合肿瘤切除原则,有望成为标准的根治手术方式.腹腔镜探查术能够发现肝转移和腹腔播散,避免不必要的开腹手术.腹腔镜下胰腺体尾部癌根治术与开腹手术相比有诸多优势,但仅限于肿瘤体积较小的早期患者,肿瘤学方面的远期效果仍需验证,建议有选择地开展.联合腹腔干切除的根治性远端胰腺癌切除术(radical distal or left pancreatectomy with resection of the celiac axis,DP-CAR)适合于肝总动脉或腹腔干受侵犯但仍有条件切除的患者,需谨慎开展.胰腺体尾部癌在早期诊断、分子水平个体化治疗方面需要突破,新辅助治疗和腹腔镜手术的开展需要进一步多中心联合前瞻实验研究提供循证证据支持.

联合腹腔干的胰体尾切除和血管变异的临床分析

目的 :研究联合腹腔干的胰体尾切除(distal pancreatectomy with en bloc celiac axis resection, DP-CAR)对扩大根治局部进展期胰体尾癌的近期临床疗效,并探讨血管变异对DP-CAR术后并发症发生的影响。方法:回顾性研究43例行DP-CAR且术后病理结果均为胰腺导管腺癌的病例,分析R0切除率和围术期手术并发症发生率、死亡率等,比较有无血管变异对术后并发症发生的影响。结果:本研究DP-CAR的R0切除率达81.4%,围术期死亡率为7.0%,并发症发生率为46.5%。腹腔血管变异8例。血管变异组与无血管变异组术后并发症发生率为3/8(37.5%)比17/35(48.6%),P=0.535,死亡率为1/8(12.5%)比2/35(5.7%),P=0.224,组间差异均无统计学意义。结论:DP-CAR具有一定的优越性,安全可行。血管变异对DP-CAR术后并发症发生无显著影响。

Preoperative microcoil embolization of the common hepatic artery for pancreatic body cancer

AIM:To evaluate safety and feasibility of microcoil embolization of the common hepatic artery under proper or distal balloon inflation in preoperative preparation for en bloc celiac axis resection for pancreatic body cancer.METHODS:Fifteen patients(11 males,4 females;median age,67 years) with pancreatic body cancer involving the nerve plexus surrounding the celiac artery underwent microcoil embolization.To alter the total hepatic blood flow from superior mesenteric artery(SMA),microcoil embolization of the common hepatic artery(CHA) was conducted in 2 cases under balloon inflation at the proximal end of the CHA and in 13 cases under distal microballoon inflation at the distal end of the CHA.RESULTS:Of the first two cases of microcoil embolization with proximal balloon inflation,the first was successful,but there was microcoil migration to the proper hepatic artery in the second.The migrated microcoil was withdrawn to the CHA by an inflated microballoon catheter.Microcoil embolization was successful in the other 13 cases with distal microballoon inflation,with no microcoil migration.Compact microcoil embolization under distal microballoon inflation created sufficient resistance against the vascular wall to prevent migration.Distal balloon inflation achieved the requisite 1 cm patency at the CHA end for vascular clamping.All patients underwent en bloc celiac axis resection without arterial reconstruction or liver ischemia.CONCLUSION:To impede microcoil migration to the proper hepatic artery during CHA microcoil embolization,distal microballoon inflation is preferable to proximal balloon inflation.

联合腹腔干切除胰体尾癌根治术疗效及安全性分析

目的探讨联合腹腔干切除的胰体尾癌根治术(DP-CAR)的疗效、安全性及应用价值。方法回顾性分析2010—2014年第二军医大学附属长海医院胰腺外科同一手术组收治的R0切除的126例胰体尾癌病人的临床资料,均无远处转移,其中行DP-CAR 31例,行传统胰体尾癌根治术(DP)95例。结果 DP-CAR组病人T3~T4期比例(85.7%vs.43.9%,P<0.001)和可能切除胰腺癌比例(87.1%vs.5.3%,P<0.001)均明显高于DP组。DP-CAR组手术时间[(134.4±28.6)min vs.(111.8±38.1)min,P=0.004]及术后住院时间[(16.2±11.0)d vs.(8.4±2.7)d,P<0.001]较DP组明显延长。DP-CAR组病人术后C级胰瘘(19.4%vs.2.1%,P=0.003)及术后出血(19.4%vs.3.2%,P=0.007)发生率明显高于DP组,且有2例病人因胰瘘继发腹腔出血死亡。DP-CAR组与DP组病人术后中位生存时间分别为19个月和20个月,两组差异无统计学意义(P=0.652)。结论 DP-CAR可提高可能切除胰体尾癌手术切除率,手术疗效满意,可使部分病人获益,但术后并发症发生率及病死率高于DP,手术风险相对较高。

联合腹腔干的胰体尾切除术研究进展

胰体尾癌侵袭性强,手术切除率低,以往认为肿瘤侵及腹腔干时不可切除。联合腹腔干的胰体尾切除术(DP—CAR)是治疗这种疾病的新手段。近年来,越来越多的文献报道该手术方式,但均为个案报道或小样本回顾性研究。其研究结果根据各医疗中心不同的治疗方案和围术期管理而不同。该手术方式的优势和缺点仍存在争议,本文就DP—CAR的研究进展进行综述。

联合腹腔干切除的胰体尾切除术40例疗效分析

目的评估联合腹腔干切除的胰体尾切除术(DP-CAR)安全性及治疗效果。方法回顾性分析2012年1月至2016年12月海军军医大学附属长海医院收治的40例行DP-CAR的胰腺癌病人的临床病理学资料,分析术后并发症发生率、病死率及中位生存期。结果40例病人在院并发症发生率(Clavien-Dindo评分≥2级)为13例(32.5%),其中因肝缺血导致肝衰竭术后90 d内死亡1例(2.5%),B级以上胰瘘6例(15.0%),胃排空障碍7例(17.5%),严重腹腔感染6例(15.0%),乳糜漏4例(10.0%),术后出血4例(10.0%);总中位生存时间19.1个月(IQR8.9,30.8个月),1、3、5年存活率分别为62.5%、17.5%、5.0%,T4期较T1-3期病人的中位生存期(14.2个月vs.24.1个月,P=0.0225)、有淋巴结转移N1-2期较N0期病人的中位生存期(8.8个月vs.23.2个月,P=0.00967)更差。结论在高选择的胰体尾病人中,DP-CAR的术后并发症发生率和病死率、中位生存期是可接受的,对T4期和术前影像学评估有区域淋巴结肿大的病人建议行新辅助治疗后再评估手术的可行性。

联合腹腔干切除的胰体尾癌根治术治疗胰颈体癌的单中心回顾性分析

目的探讨联合腹腔干切除的胰体尾癌根治术(DP-CAR)治疗胰腺颈体癌的临床效果。方法回顾性分析2013年9月至2022年6月南京医科大学第一附属医院胰腺中心连续收治的89例因胰腺颈体癌行DP-CAR治疗的患者资料。男性50例, 女性39例;年龄[M(IQR)]63(12)岁(范围:43~81岁)。分类资料采用χ^(2)检验或Fisher确切概率法分析, 定量资料以秩和检验分析, 以Kaplan-Meier法绘制生存曲线并估计中位生存时间。结果 89例DP-CAR中, 联合门静脉-肠系膜上静脉切除重建20例(22.5%)、联合器官切除38例(42.7%);手术时间270(110)min(范围:143~530 min), 术中出血量300(300)ml(范围:50~2 500 ml), 术后住院时间13(10)d(范围:7~101 d)。总体并发症发生率为67.4%(60/89), 其中Clavien-Dindo并发症分级系统≥Ⅲ级10例(11.2%), 术后出现一过性肝脏转氨酶升高38例(42.7%)、肝功能衰竭3例(3.4%)、B级和C级胰瘘48例(53.9%)、胆瘘1例(1.1%)、B级和C级乳糜瘘3例(3.4%)、腹腔感染10例(11.2%)、B级和C级术后出血8例(9.0%)、胃排空延迟4例(4.5%)、深静脉血栓形成6例(6.7%), 再手术3例(3.4%)。住院期间死亡4例(4.5%), 术后90 d内死亡7例(7.9%)。89例均为胰腺癌, 其中胰腺导管腺癌占92.1%(82/89);肿瘤最大径4.8(2.0)cm(范围:1.5~12.0 cm), 共清扫淋巴结14(13)枚(范围:2~33枚), 淋巴结阳性率为13.0%(24.0%);R0切除率为30.0%(24/80)、R1(<1 mm)切除率为58.8%(47/80);术后中位生存时间为21.3个月(95%CI:15.6~24.3个月), 中位无病生存时间为19.1个月(95%CI:11.7~25.1个月), 术后1年总体生存率为69.60%, 术后2年总体生存率为39.52%。58例术后行辅助化疗者的中位生存时间为24.3个月(95%CI:17.8~32.3个月), 13例术后未行化疗或其他辅助治疗者的中位生存时间为8.4个月(95%CI:7.3~22.3个月);7例患者于术前行新辅助化疗, 无Clavien-Dindo并发症分级系统Ⅲ级以上并发症发生, R0切除率为5/7。结论对选择性的胰腺颈体癌病例, 联合腹腔干切除的胰体尾癌根治术是可行的, (新)辅助治疗可能可以改善患者的术后生存。