机器人辅助下胰十二指肠切除术:附18例报告
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摘要
目的:初步总结DaVinci机器人辅助下的胰十二指肠切除术(RPD)的经验。方法:回顾2015年11月—2018年1月18例行RPD的患者临床资料。结果:18例患者手术时间为(450±30)min,术中出血量为(525±125)mL,术中均无输血;1例(5.6%)中转开腹;术后肠道功能恢复时间(4.0±1.0)d,术后住院时间(16±4)d;术后出现并发症者7例,其中4例(22.2%)术后并发胰瘘(均为B级胰瘘)、胆瘘1例、腹腔内出血2例;无再次手术,术后病死率5%。术后病理结果显示,胰腺高分化腺癌3例、低分化导管腺癌1例、胰腺浆液性囊腺瘤3例、胰腺黏液性囊腺瘤2例、胰腺导管内乳头状黏液瘤1例、十二指肠高分化腺癌2例、十二指肠绒毛管状腺瘤2例、胆总管下段中低分化腺癌1例、胆总管下段高分化腺癌2例、胰腺慢性炎症1例。9例恶性肿瘤中8例完成R_0切除,1例R1切除;淋巴结清扫数目为(16±4)枚。结论:RPD安全可行,并未明显增加手术相关并发症,同时可以加快患者术后恢复时间。
Objective: To preliminarily summarize the experience in robotic-assisted pancreaticoduodenectomy(RPD) by the DaVinci system.Methods: The clinical data of 18 patients undergoing RPD between November 2015 and January 2018 were retrospectively analyzed.Results: In the 8 patients, the operative time was(450±30) min, intraoperative blood loss was(525±125) mL, with no requirement of blood transfusion; 1 case(5.6%) was converted to open surgery; the time for postoperative intestinal function recovery was(4.0±1.0) d, and the length of postoperative hospital stay was(16±4) d; postoperative complications occurred in 7 cases, including pancreatic fistula in 4 cases(22.2%)(of whom all were grade B pancreatic fistula), biliary fistula in 1 case, and intra-abdominal hemorrhage in 2 cases; no reoperationwas required, and the postoperative mortality rate was 5%. Postoperative pathological results showed 3 cases of highly differentiated adenocarcinoma of the pancreas, 1 case of poorly differentiated ductal adenocarcinoma, 3 cases of pancreatic serous cystadenoma, 2 cases of pancreatic mucinous cystadenoma, and 1 case of pancreatic ductal papillary myxoma; 2 cases of well-differentiated adenocarcinoma of the duodenum, 2 cases of duodenal villus tubular adenoma; 1 case of poorly differentiated adenocarcinoma of lower common bile duct, 2 cases of well differentiated adenocarcinoma of lower common bile duct, and 1 case of chronic pancreatitis. Of the 9 patients with malignant tumors, R0 resection was achieved in 8 cases and R1 resection was obtained in 1 case; the number of dissected lymph nodes was 16±4.Conclusion: RPD is clinically safe and feasible, without increase of procedure-associated complications, and meanwhile, it can accelerate the postoperative recovery of the patients.
Objective: To preliminarily summarize the experience in robotic-assisted pancreaticoduodenectomy(RPD) by the DaVinci system.Methods: The clinical data of 18 patients undergoing RPD between November 2015 and January 2018 were retrospectively analyzed.Results: In the 8 patients, the operative time was(450±30) min, intraoperative blood loss was(525±125) mL, with no requirement of blood transfusion; 1 case(5.6%) was converted to open surgery; the time for postoperative intestinal function recovery was(4.0±1.0) d, and the length of postoperative hospital stay was(16±4) d; postoperative complications occurred in 7 cases, including pancreatic fistula in 4 cases(22.2%)(of whom all were grade B pancreatic fistula), biliary fistula in 1 case, and intra-abdominal hemorrhage in 2 cases; no reoperationwas required, and the postoperative mortality rate was 5%. Postoperative pathological results showed 3 cases of highly differentiated adenocarcinoma of the pancreas, 1 case of poorly differentiated ductal adenocarcinoma, 3 cases of pancreatic serous cystadenoma, 2 cases of pancreatic mucinous cystadenoma, and 1 case of pancreatic ductal papillary myxoma; 2 cases of well-differentiated adenocarcinoma of the duodenum, 2 cases of duodenal villus tubular adenoma; 1 case of poorly differentiated adenocarcinoma of lower common bile duct, 2 cases of well differentiated adenocarcinoma of lower common bile duct, and 1 case of chronic pancreatitis. Of the 9 patients with malignant tumors, R0 resection was achieved in 8 cases and R1 resection was obtained in 1 case; the number of dissected lymph nodes was 16±4.Conclusion: RPD is clinically safe and feasible, without increase of procedure-associated complications, and meanwhile, it can accelerate the postoperative recovery of the patients.
引文
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[9]Allen PJ,Kuk D,Castillo CF,et al.Multi-institutional Validation Study of the American Joint Commission on Cancer(8th Edition)Changes for T and N Staging in Patients With Pancreatic Adenocarcinoma[J].Ann Surg,2017,265(1):185-191.doi:10.1097/SLA.0000000000001763.
[10]汤朝晖,田孝东,魏妙艳,等.美国癌症联合委员会胆道恶性肿瘤分期系统(第8版)更新解读[J].中国实用外科杂志,2017,37(3):248-254.doi:10.19538/j.cjps.issn.issn1005-2208.2017.03.10.Tang ZH,Tian XD,Wei MY,et al.Updates and interpretations of the 8th edition of AJCC cancer staging system for biliary tract carcinoma[J].Chinese Journal of Practical Surgery,2017,37(3):248-254.doi:10.19538/j.cjps.issn.issn1005-2208.2017.03.10.
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[12]Giulianotti PC,Coratti A,Angelini M,et al.Robotics in general surgery:personal experience in a large community hospital[J].Arch Surg,2003,138(7):777-784.doi:10.1001/archsurg.138.7.777.
[13]刘荣,赵国栋,唐文博,等.机器人胰腺手术1010例经验与教训[J].南方医科大学学报,2018,38(2):130-134.doi:10.3969/j.issn.1673-4254.2018.02.02.Liu R,Zhao GD,Tang WB,et al.A single-team experience with robotic pancreatic surgery in 1010 cases[J].Journal of Southern Medical University,2018,38(2):130-134.doi:10.3969/j.issn.1673-4254.2018.02.02.
[14]Lai EC,Yang GP,Tang CN.Robot-assisted laparoscopic pancreaticoduodenectomy versus open pancreaticoduodenectomy--a comparative study[J].Int J Surg,2012,10(9):475-479.doi:10.1016/j.ijsu.2012.06.003.
[15]Chalikonda S,Aguilar-Saavedra JR,Walsh RM.Laparoscopic robotic-assisted pancreaticoduodenectomy:a case-matched comparison with open resection[J].Surg Endosc,2012,26(9):2397-2402.doi:10.1007/s00464-012-2207-6.
[16]Rosemurgy A,Ross S,Bordeau T,et al.Robotic Pancreaticoduodenectomy Is the Future:Here and Now[J].J Am Coll Surg,2019,pii:S1072-7515(19)30055-9.doi:10.1016/j.jamcollsurg.2018.12.040.[Epub ahead of print]
[17]Doula C,Kostakis ID,Damaskos C,et al.Comparison Between Minimally Invasive and Open Pancreaticoduodenectomy:ASystematic Review[J].Surg Laparosc Endosc Percutan Tech,2016,26(1):6-16.doi:10.1097/SLE.0000000000000228.
[18]Buchs NC,Addeo P,Bianco FM,et al.Robotic versus open pancreaticoduodenectomy:a comparative study at a single institution[J].World J Surg,2011,35(12):2739-2746.doi:10.1007/s00268-011-1276-3.
[19]Wang SE,Shyr B U,Chen SC,et al.Comparison between robotic and open pancreaticoduodenectomy with modified Blumgart pancreaticojejunostomy:A propensity score-matched study[J].Surgery,2018,164(6):1162-1167.doi:10.1016/j.surg.2018.06.031.
[20]Kim HS,Han Y,Kang JS,et al.Comparison of surgical outcomes between open and robot-assisted minimally invasive pancreaticoduodenectomy[J].J Hepatobiliary Pancreat Sci,2018,25(2):142-149.doi:10.1002/jhbp.522.
[21]Zhou NX,Chen JZ,Liu Q,et al.Outcomes of pancreatoduodenectomy with robotic surgery versus open surgery[J].Int J Med Robot,2011,7(2):131-137.doi:10.1002/rcs.380.
[22]陈章彬,白锦峰,陈见中,等.胰管支撑外引流与非引流在胰十二指肠切除术后疗效对比的Meta分析[J].中国普通外科杂志,2018,27(9):1083-1094.doi:10.7659/j.issn.1005-6947.2018.09.002.Chen ZB,Bai JF,Chen JZ,et al.Efficacy comparison between external drainage of pancreatic duct with a stent and non-drainage after pancreaticoduodenectomy:a Meta-analysis[J].Chinese Journal of General Surgery,2018,27(9):1083-1094.doi:10j.issn.1005-6947.2018.09.002.
[23]夏华,陆晔斌,周军,等.十二指肠乳头癌临床分析:附80例报告[J].中国普通外科杂志,2018,27(4):468-473.doi:10.3978/j.issn.1005-6947.2018.04.012.Xia H,Lu YB,Zhou J,et al.Clinical analysis of cancer of the duodenal papilla:a report of 80 cases[J].Chinese Journal of General Surgery,2018,27(4):468-473.doi:10.3978/j.issn.1005-6947.2018.04.012.
[24]Boone BA,Zenati M,Hogg ME,et al.Assessment of quality outcomes for robotic pancreaticoduodenectomy:identification of the learning curve[J].JAMA Surg,2015,150(5):416-422.doi:10.1001/jamasurg.2015.17.
[25]Marino M,Gulotta G,Komorowski AL.Robotic Pancreaticoduodenectomy:Technical Considerations[J].Indian JSurg,2018,80(2):118-122.doi:10.1007/s12262-017-1628-9.
[26]Baker EH,Ross SW,Seshadri R,et al.Robotic pancreaticoduodenectomy:comparison of complications and cost to the open approach[J].Int J Med Robot,2016,12(3):554-560.doi:10.1002/rcs.1688.
[27]Marino MV,Shabat G,Potapov O,et al.Robotic pancreatic surgery:old concerns,new perspectives[J].Acta Chir Belg,2019,119(1):16-23.doi:10.1080/00015458.2018.1444550.
[28]张宇华,洪德飞.微创胰十二指肠切除术:从腹腔镜到达芬奇机器人手术系统[J].中华消化外科杂志,2015,14(11):980-982.doi:10.3760/cma.j.issn.1673-9752.2015.11.020.Zhang YH,Hong DF.Minimally invasive pancreaticoduodenectomy:from laparoscopic surgery to Da Vinci robotic surgical system[J].Chinese Journal of Digestive Surgery,2015,14(11):980-982.doi:10.3760/cma.j.issn.1673-9752.2015.11.020.
[29]段小辉,周力学,田秉璋,等.3D腹腔镜胰十二指肠切除在壶腹周围癌治疗中的应用:单团队经验[J].中国普通外科杂志,2017,26(9):1127-1132.doi:10.3978/j.issn.1005-6947.2017.09.008.Duan XH,Zhou LX,Tian BZ,et al.Three-dimensional laparoscopic pancreaticoduodenectomy for periampullary carcinoma:a single surgical team's experience[J].Chinese Journal of General Surgery,2017,26(9):1127-1132.doi:10.3978/j.issn.1005-6947.2017.09.008.
[30]Kornaropoulos M,Moris D,Beal EW,et al.Total robotic pancreaticoduodenectomy:a systematic review of the literature[J].Surg Endosc,2017,31(11):4382-4392.doi:10.1007/s00464-017-5523-z.
[2]张柯迪,刘荣,唐文博.机器人胰十二指肠切除术临床应用的初步探索[J].腹部外科,2016,29(1):23-25.doi:10.3969/j.issn.1003-5591.2016.01.006.Zhang KD,Liu R,Tang WB.The preliminary study of clinical application of robotic pancreaticoduodenectomy[J].Journal of Abdominal Surgery,2016,29(1):23-25.doi:10.3969/j.issn.1003-5591
[3]Joyce D,Morris-Stiff G,Falk GA,et al.Robotic surgery of the pancreas[J].World J Gastroenterol,2014,20(40):14726-14732.doi:10.3748/wjg.v20.i40.14726.
[4]嵇武,李宁,黎介寿.我国手术机器人外科面临的机遇和挑战[J].中国微创外科杂志,2012,12(7):577-579.doi:10.3969/j.issn.1009-6604.2012.07.001.Ji W,Li N,Li JS.Opportunities and challenges faced by robotic surgery in China[J].Chinese Journal of Minimally Invasive Surgery,2012,12(7):577-579.doi:10.3969/j.issn.1009-6604.2012.07.001.
[5]Wente MN,Veit J A,Bassi C,et al.Postpancreatectomy hemorrhage(PPH):an International Study Group of Pancreatic Surgery(ISGPS)definition[J].Surgery,2007,142(1):20-25.doi:10.1016/j.surg.2007.02.001.
[6]Koch M,Garden O J,Padbury R,et al.Bile leakage after hepatobiliary and pancreatic surgery:a definition and grading of severity by the International Study Group of Liver Surgery[J].Surgery,2011,149(5):680-688.doi:10.1016/j.surg.2010.12.002.
[7]Wente MN,Bassi C,Dervenis C,et al.Delayed gastric emptying(DGE)after pancreatic surgery:a suggested definition by the International Study Group of Pancreatic Surgery(ISGPS)[J].Surgery,2007,142(5):761-768.doi:10.1016/j.surg.2007.05.005.
[8]Bassi C,Marchegiani G,Dervenis C,et al.The 2016 update of the International Study Group(ISGPS)definition and grading of postoperative pancreatic fistula:11 Years After[J].Surgery,2017,161(3):584-591.doi:10.1016/j.surg.2016.11.014.
[9]Allen PJ,Kuk D,Castillo CF,et al.Multi-institutional Validation Study of the American Joint Commission on Cancer(8th Edition)Changes for T and N Staging in Patients With Pancreatic Adenocarcinoma[J].Ann Surg,2017,265(1):185-191.doi:10.1097/SLA.0000000000001763.
[10]汤朝晖,田孝东,魏妙艳,等.美国癌症联合委员会胆道恶性肿瘤分期系统(第8版)更新解读[J].中国实用外科杂志,2017,37(3):248-254.doi:10.19538/j.cjps.issn.issn1005-2208.2017.03.10.Tang ZH,Tian XD,Wei MY,et al.Updates and interpretations of the 8th edition of AJCC cancer staging system for biliary tract carcinoma[J].Chinese Journal of Practical Surgery,2017,37(3):248-254.doi:10.19538/j.cjps.issn.issn1005-2208.2017.03.10.
[11]Amin MB,Edge S,Greene F,et al.AJCC cancer staging manual[M].New York,NY:Springer,2017:1024.
[12]Giulianotti PC,Coratti A,Angelini M,et al.Robotics in general surgery:personal experience in a large community hospital[J].Arch Surg,2003,138(7):777-784.doi:10.1001/archsurg.138.7.777.
[13]刘荣,赵国栋,唐文博,等.机器人胰腺手术1010例经验与教训[J].南方医科大学学报,2018,38(2):130-134.doi:10.3969/j.issn.1673-4254.2018.02.02.Liu R,Zhao GD,Tang WB,et al.A single-team experience with robotic pancreatic surgery in 1010 cases[J].Journal of Southern Medical University,2018,38(2):130-134.doi:10.3969/j.issn.1673-4254.2018.02.02.
[14]Lai EC,Yang GP,Tang CN.Robot-assisted laparoscopic pancreaticoduodenectomy versus open pancreaticoduodenectomy--a comparative study[J].Int J Surg,2012,10(9):475-479.doi:10.1016/j.ijsu.2012.06.003.
[15]Chalikonda S,Aguilar-Saavedra JR,Walsh RM.Laparoscopic robotic-assisted pancreaticoduodenectomy:a case-matched comparison with open resection[J].Surg Endosc,2012,26(9):2397-2402.doi:10.1007/s00464-012-2207-6.
[16]Rosemurgy A,Ross S,Bordeau T,et al.Robotic Pancreaticoduodenectomy Is the Future:Here and Now[J].J Am Coll Surg,2019,pii:S1072-7515(19)30055-9.doi:10.1016/j.jamcollsurg.2018.12.040.[Epub ahead of print]
[17]Doula C,Kostakis ID,Damaskos C,et al.Comparison Between Minimally Invasive and Open Pancreaticoduodenectomy:ASystematic Review[J].Surg Laparosc Endosc Percutan Tech,2016,26(1):6-16.doi:10.1097/SLE.0000000000000228.
[18]Buchs NC,Addeo P,Bianco FM,et al.Robotic versus open pancreaticoduodenectomy:a comparative study at a single institution[J].World J Surg,2011,35(12):2739-2746.doi:10.1007/s00268-011-1276-3.
[19]Wang SE,Shyr B U,Chen SC,et al.Comparison between robotic and open pancreaticoduodenectomy with modified Blumgart pancreaticojejunostomy:A propensity score-matched study[J].Surgery,2018,164(6):1162-1167.doi:10.1016/j.surg.2018.06.031.
[20]Kim HS,Han Y,Kang JS,et al.Comparison of surgical outcomes between open and robot-assisted minimally invasive pancreaticoduodenectomy[J].J Hepatobiliary Pancreat Sci,2018,25(2):142-149.doi:10.1002/jhbp.522.
[21]Zhou NX,Chen JZ,Liu Q,et al.Outcomes of pancreatoduodenectomy with robotic surgery versus open surgery[J].Int J Med Robot,2011,7(2):131-137.doi:10.1002/rcs.380.
[22]陈章彬,白锦峰,陈见中,等.胰管支撑外引流与非引流在胰十二指肠切除术后疗效对比的Meta分析[J].中国普通外科杂志,2018,27(9):1083-1094.doi:10.7659/j.issn.1005-6947.2018.09.002.Chen ZB,Bai JF,Chen JZ,et al.Efficacy comparison between external drainage of pancreatic duct with a stent and non-drainage after pancreaticoduodenectomy:a Meta-analysis[J].Chinese Journal of General Surgery,2018,27(9):1083-1094.doi:10j.issn.1005-6947.2018.09.002.
[23]夏华,陆晔斌,周军,等.十二指肠乳头癌临床分析:附80例报告[J].中国普通外科杂志,2018,27(4):468-473.doi:10.3978/j.issn.1005-6947.2018.04.012.Xia H,Lu YB,Zhou J,et al.Clinical analysis of cancer of the duodenal papilla:a report of 80 cases[J].Chinese Journal of General Surgery,2018,27(4):468-473.doi:10.3978/j.issn.1005-6947.2018.04.012.
[24]Boone BA,Zenati M,Hogg ME,et al.Assessment of quality outcomes for robotic pancreaticoduodenectomy:identification of the learning curve[J].JAMA Surg,2015,150(5):416-422.doi:10.1001/jamasurg.2015.17.
[25]Marino M,Gulotta G,Komorowski AL.Robotic Pancreaticoduodenectomy:Technical Considerations[J].Indian JSurg,2018,80(2):118-122.doi:10.1007/s12262-017-1628-9.
[26]Baker EH,Ross SW,Seshadri R,et al.Robotic pancreaticoduodenectomy:comparison of complications and cost to the open approach[J].Int J Med Robot,2016,12(3):554-560.doi:10.1002/rcs.1688.
[27]Marino MV,Shabat G,Potapov O,et al.Robotic pancreatic surgery:old concerns,new perspectives[J].Acta Chir Belg,2019,119(1):16-23.doi:10.1080/00015458.2018.1444550.
[28]张宇华,洪德飞.微创胰十二指肠切除术:从腹腔镜到达芬奇机器人手术系统[J].中华消化外科杂志,2015,14(11):980-982.doi:10.3760/cma.j.issn.1673-9752.2015.11.020.Zhang YH,Hong DF.Minimally invasive pancreaticoduodenectomy:from laparoscopic surgery to Da Vinci robotic surgical system[J].Chinese Journal of Digestive Surgery,2015,14(11):980-982.doi:10.3760/cma.j.issn.1673-9752.2015.11.020.
[29]段小辉,周力学,田秉璋,等.3D腹腔镜胰十二指肠切除在壶腹周围癌治疗中的应用:单团队经验[J].中国普通外科杂志,2017,26(9):1127-1132.doi:10.3978/j.issn.1005-6947.2017.09.008.Duan XH,Zhou LX,Tian BZ,et al.Three-dimensional laparoscopic pancreaticoduodenectomy for periampullary carcinoma:a single surgical team's experience[J].Chinese Journal of General Surgery,2017,26(9):1127-1132.doi:10.3978/j.issn.1005-6947.2017.09.008.
[30]Kornaropoulos M,Moris D,Beal EW,et al.Total robotic pancreaticoduodenectomy:a systematic review of the literature[J].Surg Endosc,2017,31(11):4382-4392.doi:10.1007/s00464-017-5523-z.