改良Appleby手术和动脉鞘剥除技术治疗动脉受累胰体尾癌的临床效果分析  

Comparison of distal pancreatectomy with celiac axis resection and sub-adventitial divestment technique for locally advanced or borderline resectable pancreatic body cancer

作　　者：黄徐敏 尹杰 陆子鹏 陈建敏 蔡宝宝 吴鹏飞 蒋奎荣 苗毅 Huang Xumin;Yin Jie;Lu Zipeng;Chen Jianmin;Cai Baobao;Wu Pengfei;Jiang Kuirong;Miao Yi(Pancreas Center,First Affiliated Hospital of Nanjing Medical University,Pancreas Institute,Nanjing Medical University,Nanjing 210029,China)

机构地区：[1]南京医科大学第一附属医院胰腺中心南京医科大学胰腺研究所,南京210029

出　　处：《中华外科杂志》2022年第5期441-448,共8页Chinese Journal of Surgery

摘　　要：目的比较改良Appleby手术和动脉鞘剥除技术治疗动脉受累胰体尾癌的临床效果。方法回顾性分析2013年9月至2019年5月南京医科大学第一附属医院胰腺中心收治的58例交界可切除或局部进展期动脉受累胰体尾癌患者资料。男性33例,女性25例;年龄[M(IQR)]62(9)岁(范围:43~79岁)。其中31例行改良Appleby手术(DP-CAR组),27例行动脉鞘剥除的胰体尾癌根治术(SDT组)。收集两组患者术前、术中及术后资料。定量资料的组间比较采用Wilcoxon秩和检验,分类变量的组间比较采用χ^(2)检验或Fisher确切概率法,通过Kaplan-Meier法比较两组患者的生存情况。结果两组患者在年龄、体重指数、性别比例、腹部症状、合并症及术前血清CA19-9水平等的差异均无统计学意义(P值均>0.05)。SDT组术前3个月体重明显减轻的发生率更高[48.1%(13/27)比19.4%(6/31),χ^(2)=5.431,P=0.020];DP-CAR组手术时间更长[310(123)min比254(137)min,Z=2.277,P=0.023]、联合器官切除比例更多[41.9%(13/31)比14.8%(4/27),χ^(2)=5.123,P=0.041]、术后住院时间更长[15(10)d比11(5)d,Z=2.292,P=0.022]、总体并发症发生率更高[71.0%(22/31)比29.6%(8/27),χ^(2)=9.876,P=0.003],主要表现在B、C级胰瘘的发生率更高[61.3%(19/31)比29.6%(8/27),χ^(2)=5.814,P=0.020],其他主要并发症的发生率差异无统计学意义(P<0.05)。DP-CAR组肿瘤最大径更长[4.9(1.5)cm比4.0(1.2)cm,Z=2.343,P=0.019],DP-CAR组与SDT组的R0+R1(<1 mm)切除率[84.0%(21/25)比90.0%(18/20),P=0.678]、淋巴结阳性率[12.0(23.0)%比9.0(18.0)%,Z=1.238,P=0.216]、中位无病生存时间(11.7个月比11.4个月,Z=0.019,P=0.892)及中位总体生存时间(16.3个月比13.7个月,Z=0.172,P=0.679)的差异均无统计学意义。结论对交界可切除或局部进展期动脉受累胰体尾癌患者行改良Appleby手术或联合动脉鞘剥除胰体尾癌根治术是可行的。动脉鞘剥除技术较改良Appleby手术可降低手术总体并发症的发生率、缩短住院Objective To compare the outcomes of modified Appleby procedure and sub-adventitial divestment technique for locally advanced or borderline resectable pancreatic body cancer.Methods A total of consecutive 58 patients(33 males and 25 females)who were diagnosed as locally advanced or borderline resectable pancreatic body cancer and underwent distal pancreatectomy at Pancreas Center,First Affiliated Hospital of Nanjing Medical University between September 2013 and May 2019 were retrospectively reviewed.The age(M(IQR))was 62(9)years(range:43 to 79 years).Thirty-one patients underwent distal pancreatectomy with celiac axis resection(DP-CAR)and 27 patients underwent distal pancreatectomy with sub-adventitial divestment technique(SDT).Perioperative parameters and follow-up data of these patients were analyzed.Quantitative data were compared with Wilcoxon test while categorical variables were compared withχ^(2) test or Fisher′s exact test.Survival results were estimated by the Kaplan-Meier survival method with a Log-rank test.Results There were no differences in age,gender,body mass index,abdominal symptoms,comorbidity or preoperative serum CA19-9 between two groups(all P>0.05).Obvious preoperative weight loss was more common in the group of SDT(48.1%(13/27)vs.19.4%(6/31),χ²=5.431,P=0.020).Longer operative time(310(123)minutes vs.254(137)minutes,Z=2.277,P=0.023),higher rate of combined organ resection(41.9%(13/31)vs.14.8%(4/27),χ²=5.123,P=0.041)and longer postoperative hospital stay(15(10)days vs.11(5)days,Z=2.292,P=0.022)were observed in the group of DP-CAR.Moreover,rate of overall morbidities was also higher(71.0%(22/31)vs.29.6%(8/27),χ^(2)=9.876,P=0.003),implicated by clinically relevant postoperative pancreatic fistula(61.3%(19/31)vs.29.6%(8/27),χ^(2)=5.814,P=0.020)in the DP-CAR group.Tumor size of the DP-CAR group was bigger(4.9(1.5)cm vs.4.0(1.2)cm,Z=2.343,P=0.019)but no difference was seen between the DP-CAR group and SDT group in R0+R1(<1 mm)resection rate(84.0%(21/25)vs.90.0%(18/20),P=0.678)and LNR(12.0

关 键 词：胰腺肿瘤 外科手术 局部进展期胰腺癌 交界可切除胰腺癌 胰体尾切除术 Appleby手术 

分 类 号：R735.9[医药卫生—肿瘤]