全胰腺系膜切除理念应用于胰头癌根治术的初步体会  

Total mesopancreas excision in radical resection of pancreatic head carcinoma

作　　者：洪德飞[1] 彭淑牖[1] 沈国樑[1] 成剑[1] 王知非[1] 张军港[1] 黄东胜[1] 

机构地区：[1]浙江省人民医院肝胆胰外科和微创外科,杭州310014

出　　处：《中华普通外科杂志》2014年第5期344-347,共4页Chinese Journal of General Surgery

基　　金：浙江省科技厅重大专项计划（2013C03046）

摘　　要：目的探讨全胰腺系膜切除理念以及基于动脉优先技术实施胰头癌全胰腺系膜切除的手术技巧和规范。方法在根治性胰十二指肠切除术中应用前后联合入路的动脉优先技术实施全胰腺系膜切除，切除标本后标记胰腺系膜切缘送快速切片联合常规切片病理检查。结果2012年4月至2013年6月，15例患者经探查行根治性胰十二指肠切除术11例，其中2例联合肠系膜上静脉切除重建。胰消化道重建采用捆绑胰胃吻合术4例，胰管空肠黏膜端侧吻合7例。手术时间（297．7±57．2）min，术中出血（356±207．8）ml。术后并发胃排空障碍1例、胆漏2例，均经保守治疗痊愈出院。无出血、胰瘘、腹泻等并发症。无死亡病例。术后病理报告：腺癌9例，未分化癌1例、鳞癌1例。累及十二指肠及胆管下段4例，仅累及十二指肠者6例；未侵犯周围组织者1例。神经侵犯（7／11），脉管侵犯（10／11），淋巴结转移（2．5±3．8／12．9±4．9），胰腺系膜切缘全部阴性。结论基于动脉优先技术的全胰腺系膜切除策略应用于胰头癌根治性胰十二指肠切除术，不仅有助于提高腹膜后切缘阴性率，而且有助于规范胰头癌根治性切除。Objective To evaluate the concept of artery first and total mesopancreatic excision in radical resection of pancreatic head carcinoma through both anterior and posterior approaches. Method The anterior approach was to identify the superior mesenteric artery （SMA） and the posterior approach to confirm the possibility of negative margin at the origin of SMA, on the posterio-lateral vascular wall of superior mesenteric vein（SMV） and the supposed posterior of the mesopancreas. The resection scope were with the celiac trunk and common hepatic artery as the upper boarder, the SMA as the left boarder, the inferior mesenteric vein （IMA） level as the lower boarder, to achieve a complete mesopanereatic excision, namely the en bloc resection of all the involved nerve, the lymph tissue and vascular tissue along the right side of the axial composed by SMA and celiac trunk. Results Of the 15 patients, 11 had radical Whipple procedure, among which 2 had a combining SMV resection and reconstruction. 1 case suffered from delayed gastric emptying and 2 cases from bile leakage. There was no mortality＇. The postoperative pathology reported carcinoma in all 11 cases, with duodenum and low bile duct involved in 4 cases, with the duodenum involved in 6 cases, no surrounding tissue involvement was identified in 1 case. Nerve involvement was found in 7 （7/11） ,vascular involvement in 10 （ 10/11 ）, and lymphnode metastasis was （ 2. 5 ± 3.8/12. 9 ± 4. 9 ）. Conclusions The radical resection of pancreatic head carcinoma using the concept of artery first and the total mesopancreatic excision is helpful for an early evaluation of the possibility of radical resection and guarantees negative margins.

关 键 词：胰腺肿瘤 胰十二指肠切除术 胰腺系膜 全胰腺系膜切除 

分 类 号：R735.9[医药卫生—肿瘤]