动脉优先入路处理胰腺钩突在腹腔镜胰十二指肠切除术中的应用
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摘要
目的探讨动脉优先入路处理胰腺钩突在腹腔镜胰十二指肠切除术(LPD)中的应用价值。方法回顾性分析2015年2月至2016年1月在复旦大学附属华东医院采用动脉优先入路处理胰腺钩突的LPD治疗的10例患者临床资料。其中男6例,女4例;平均年龄(58±10)岁。患者术前CT及MRI检查诊断胰头或壶腹占位性病变;肿瘤直径<4 cm,无明显血管受侵犯表现,无远处转移。患者均签署知情同意书,符合医学伦理学规定。术中离断钩突时优先处理肠系膜上动脉(SMA),沿SMA根部右侧缘用超声刀骨骼化约3 cm,在SMA后方分离钩突系膜,然后将肠系膜上静脉推向左侧,自下向上完整游离钩突。观察患者围手术期情况及并发症。结果 10例患者均成功实施LPD,无中转开腹。手术时间(401±72)min,术中钩突系膜离断处理时间(34±9)min,术中出血量(255±183)ml。术后病理示所有标本切缘均阴性,清扫淋巴结(14±8)枚。术后4例出现并发症,其中B级胰瘘2例,胃瘫1例,均经保守治疗治愈;腹腔出血1例,经开腹手术止血治愈。本组患者无围手术期死亡。结论在LPD中,采取动脉优先入路处理胰腺钩突安全、可行,该方法可使钩突完整切除,保证了肿瘤的根治性切除。
Objective To investigate the application value of management of pancreatic uncinate process via artery first approach in laparoscopic pancreaticoduodenectomy(LPD). Methods Clinical data of 10 patients who underwent LPD with artery first approach management of pancreatic uncinate process in Huadong Hospital affiliated to Fudan University between February 2015 and January 2016 were retrospectively analyzed. There were 6 males and 4 females with a mean age of(58±10) years old. Space-occupying lesions at the head of pancreas or ampulla in the patients were detected by preoperative CT and MRI. The tumor diameter was shorter than 4 cm. Neither evident vascular invasion nor distant metastasis was observed. The informed consents of all patients were obtained and the local ethical committee approval was received. The superior mesenteric artery(SMA) was first processed during the dissection of uncinate process. The SMA was skeletonized approximately 3 cm along the right edge of SMA root by harmonic scalpel. The mesentery of uncinate process was dissected behind the SMA. And then the superior mesentericvein was pushed to the left side and the uncinate process was completely dissected from the bottom to the top. The conditions and complications during the perioperative period were observed. Results All the 10 patients underwent LPD successfully without convertion to open surgery. The operation time was(401±72) min. The dissection time of uncinate process mesentery was(34±9) min. The intraoperative hemorrhage volume was(255±183) ml. The postoperative pathological examination indicated that the incisal margin of all specimens were negative. The quantity of dissected lymph node was 14±8. Postoperative complications were observed in 4 cases, including 2 cases of grade B pancreatic fistula and 1 of delayed gastic emptying which were all cured after conservative therapy, and 1 of abdominal hemorrhage which was cured by open surgery. No death was observed during the perioperative period. Conclusions Management of pancreatic uncinate process via artery first approach is safe and feasible for LPD. It can completely resect the uncinate process and guarantee the radical resection of the tumors.
Objective To investigate the application value of management of pancreatic uncinate process via artery first approach in laparoscopic pancreaticoduodenectomy(LPD). Methods Clinical data of 10 patients who underwent LPD with artery first approach management of pancreatic uncinate process in Huadong Hospital affiliated to Fudan University between February 2015 and January 2016 were retrospectively analyzed. There were 6 males and 4 females with a mean age of(58±10) years old. Space-occupying lesions at the head of pancreas or ampulla in the patients were detected by preoperative CT and MRI. The tumor diameter was shorter than 4 cm. Neither evident vascular invasion nor distant metastasis was observed. The informed consents of all patients were obtained and the local ethical committee approval was received. The superior mesenteric artery(SMA) was first processed during the dissection of uncinate process. The SMA was skeletonized approximately 3 cm along the right edge of SMA root by harmonic scalpel. The mesentery of uncinate process was dissected behind the SMA. And then the superior mesentericvein was pushed to the left side and the uncinate process was completely dissected from the bottom to the top. The conditions and complications during the perioperative period were observed. Results All the 10 patients underwent LPD successfully without convertion to open surgery. The operation time was(401±72) min. The dissection time of uncinate process mesentery was(34±9) min. The intraoperative hemorrhage volume was(255±183) ml. The postoperative pathological examination indicated that the incisal margin of all specimens were negative. The quantity of dissected lymph node was 14±8. Postoperative complications were observed in 4 cases, including 2 cases of grade B pancreatic fistula and 1 of delayed gastic emptying which were all cured after conservative therapy, and 1 of abdominal hemorrhage which was cured by open surgery. No death was observed during the perioperative period. Conclusions Management of pancreatic uncinate process via artery first approach is safe and feasible for LPD. It can completely resect the uncinate process and guarantee the radical resection of the tumors.
引文
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[15]Ishizaki Y,Sugo H,Yoshimoto J,et al.Pancreatoduodenectomy with or without early ligation of the inferior pancreatoduodenal artery:comparison of intraoperative blood loss and short-term outcome[J].World J Surg,2010,34(12):2939-2944.
[16]Ogiso S,Conrad C,Araki K,et al.Posterior approach for laparoscopic pancreaticoduodenectomy to prevent replaced hepatic artery injury[J].Ann Surg,2013,20(9):3120.
[17]Weitz J,Rahbari N,Koch M,et al.The"artery first"approach for resection of pancreatic head cancer[J].J Am Coll Surg,2010,210(2):el-4.
[18]Kendrick ML,Cusati D.Total laparoscopic pancreaticoduodenectomy:feasibility and outcome in an early experience[J].Arch Surg,2010,145(1):19-23.
[19]Cho A,Yamamoto H,Kainuma O.Tips of laparoscopic pancreaticoduodenectomy:superior mesenteric artery first approach(with video)[J].J Hepatobilliary Pancreat Sci,2014,21(3):E19-21.
[20]Pandanaboyana S,Bell R,Windsor J.Artery first approach to pancreatoduodenectomy:current status[J].ANZ J Surg,2016,86(3):127-132.
[21]Puntambekar S,Kenawadekar R,Pandit A,et al.Laparoscopic supracolic pancreaticoduodenectomy:a novel technique for complete uncinate process resection[J].Hepato gastroenterology,2014,61(132):1118-1123.
[22]Hackert T,Werner J,Weitz J,et al.Uncinate process firs--a novel approach for pancreatic head resection[J].Langenbecks Arch Surg,2010,395(8):1161-1164.
[23]王敏,朱峰,田锐,等.全动脉优先离断法在n型胰头癌根治性切除中的应用价值[J/CD].中华肝脏外科手术学电子杂志,2014,3(6):341-344.
[2]O'Sullivan AW,Heaton N,Rela M.Cancer of the uncinate process of the pancreas:surgical anatomy and clinicopathological features[J].Hepatobiliary Pancreat Dis Int,2009,8(6):569-574.
[3]Corcione F,Pirozzi F,Cuccurullo D,et al.Laparoscopic pancreaticoduodenectomy:experience of 22 cases[J].Surg Endosc,2013,27(6):2131-2136.
[4]Pessaux P,Varma D,Amaud JP.Pancreaticoduodenectomy:superior mesenteric artery first approach[J].J Gastrointest Surg,2006,10(4):607-611.
[5]Sanjay P,Takaori K,Govil S,et al.'Artery-first'approaches to pancreatoduodenectomy[J].Br J Surg,2012,99(8):1027-1035.
[6]Campbell F,Smith RA,Whelan P,et al.Classification of R1resections for pancreatic cancer:the prognostic relevance of tumour involvement within 1 mm of resection margin[J].Histopathology,2009,55(3):277-283.
[7]Jamieson NB,Foulis AK,Oien KA,et al.Positive mobilization margins alone do not influence survival following panreaticoduodenectomy for pancreatic ductal adenocarcinoma[J].Ann Surg,2010,251(6):1003-1010.
[8]Fatima J,Schnelldorfer T,Barton J,et al.Pancreatoduodenectomy for ductal adenocarcinoma:implications of positive margin on survival[J].Arch Surg,2010,145(2):167-172.
[9]Konstantinidis IT,Warshaw AL,Allen JN,et al.Pancreatic ductal adenocarcinoma:is there a survival difference for R1 resections versus locally advanced unresectable tumors?what is a"true"R0resection?[J].Ann Surg,2013,257(4):731-736.
[10]Evans DB,Farnell MB,Lillemore KD,et al.Surgical treatment of resectable and borderline resectable pancreas cancer:expert consensus statement[J].Ann Surg Oncol,2009,16(7):1736-1744.
[11]Delpero JR,Bachellier P,Regenet N,et al.Pancreaticoduodenectomy for pancreatic ductal adenocarcinoma:a French multicentre prospective evaluation of resection margins in 150 evaluable specimens[J].HPB,2014,16(1):20-33.
[12]Gaedcke J,Gunawan B,Grade M,et al.The mesopancreas is the primary site for R1 resection in pancreatic head cancer:relevance for clinical trials[J].Langenbecks Arch Surg,2010,395(4):451-458.
[13]Wenger FA,Peter F,Zieren J,et al.Prognosis factors in carcinoma of the head of the pancreas[J].Dig Surg,2000,17(1):29-35.
[14]Dumitrascu T,David L,Popescu I.Posterior versus standard approach in pancreatoduodenectomy:a case-match study[J].Langenbecks Arch Surg,2010,395(6):677-684.
[15]Ishizaki Y,Sugo H,Yoshimoto J,et al.Pancreatoduodenectomy with or without early ligation of the inferior pancreatoduodenal artery:comparison of intraoperative blood loss and short-term outcome[J].World J Surg,2010,34(12):2939-2944.
[16]Ogiso S,Conrad C,Araki K,et al.Posterior approach for laparoscopic pancreaticoduodenectomy to prevent replaced hepatic artery injury[J].Ann Surg,2013,20(9):3120.
[17]Weitz J,Rahbari N,Koch M,et al.The"artery first"approach for resection of pancreatic head cancer[J].J Am Coll Surg,2010,210(2):el-4.
[18]Kendrick ML,Cusati D.Total laparoscopic pancreaticoduodenectomy:feasibility and outcome in an early experience[J].Arch Surg,2010,145(1):19-23.
[19]Cho A,Yamamoto H,Kainuma O.Tips of laparoscopic pancreaticoduodenectomy:superior mesenteric artery first approach(with video)[J].J Hepatobilliary Pancreat Sci,2014,21(3):E19-21.
[20]Pandanaboyana S,Bell R,Windsor J.Artery first approach to pancreatoduodenectomy:current status[J].ANZ J Surg,2016,86(3):127-132.
[21]Puntambekar S,Kenawadekar R,Pandit A,et al.Laparoscopic supracolic pancreaticoduodenectomy:a novel technique for complete uncinate process resection[J].Hepato gastroenterology,2014,61(132):1118-1123.
[22]Hackert T,Werner J,Weitz J,et al.Uncinate process firs--a novel approach for pancreatic head resection[J].Langenbecks Arch Surg,2010,395(8):1161-1164.
[23]王敏,朱峰,田锐,等.全动脉优先离断法在n型胰头癌根治性切除中的应用价值[J/CD].中华肝脏外科手术学电子杂志,2014,3(6):341-344.