肝胆胰恶性肿瘤术中联合门静脉—肠系膜上静脉切除重建围术期安全性研究
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摘要
目的：中晚期肝癌、肝门部胆管癌和胰腺癌常侵犯门静脉、肠系膜上静脉。肿瘤血管侵犯曾经被视为手术的禁忌征,但随着血管切除研究的逐渐增多,尤其是对其围术期安全性的初步确认,如今越来越多的外科医生在尝试门静脉-肠系膜上静脉切除重建来治疗中晚期肝胆胰恶性肿瘤,以达到根治性切除最终使患者生存获益。根据肿瘤血管侵犯的不同特点,血管切除重建可有多种方案,至今尚无公认的标准。本论文旨在报道肝胆胰恶性肿瘤行血管切除重建的安全性评估结果,并尝试提出一种血管切除重建方案的分型系统。
方法：选取2008年7月至2012年9月在浙江大学医学院附属第一医院和第二医院诊断为肝胆胰恶性肿瘤并行手术切除联合门静脉-肠系膜上静脉切除重建的所有患者,同时选取同样数量的同期单纯行肿瘤切除术而未行血管切除的患者作为对照,两组患者术者均为梁廷波教授。并对不同手术方案根据解剖和病变特点分为三个类型五个亚型(IM、IL、IR、Ⅱ、Ⅲ型)。从围术期死亡率、并发症发生率、并发症严重程度和术后住院日等指标评价肝胆胰肿瘤血管切除重建的安全性,以及不同血管切除重建方案对围术期安全性的影响。
结果：研究共纳入44例门静脉-肠系膜上静脉切除重建病例和44例对照组病例,血管切除重建组均为端端吻合重建,无桥接血管。其中IM、IL、IR、Ⅱ、Ⅲ型切除分别为4、6、10、16、8例。血管切除重建组和对照组各有1例围术期死亡病例(P=0.33),并发症发生率分别为65.9%和59.1%(P=0.46)。血管切除类型和重建时间可在一定程度上预测围术期风险,长重建时间导致更多(P=0.034)和更严重的并发症(P=0.013)。血管切除重建类型与重建时间无明显相关(P=0.39)。不同切除重建类型对并发症无明显影响(P=0.64),但IR型并发症更严重(P=0.0012)。
结论：肝胆胰恶性肿瘤血管侵犯患者行血管切除重建围术期安全性与对照组相当。新的分型系统有助于指导肝胆胰肿瘤外科手术和并发症预测。
Background and aims Advanced cholangiocellular liver cancer, perihilar cholangiocarcinoma and pancreatic cancer can invade the portal vein (PV) and superior mesenteric vein (SMV), which was previously considered as a contraindication to operation. Accumulating yet limiting evidence has shown a relative security of portal-superior mesenteric vein (PV-SMV) resection and reconstruction (PSRR). Currently a growing number of PSRR is performed worldwide. Strategy of PSRR varies with resection locations and to date no reports have focused on a clinically effective classification system for PSRR. Here, we propose a classification system for PSRR and report the preliminary clinical significance of perioperative security.
Methods All patients who had cholangiocellular liver cancer, perihilar cholangiocarcinoma or pancreatic cancer underwent PSRR from July2008to September2012in First or Second Affiliated Hospital, Zhejiang University School of Medicine were collected, together with the same amount of patients underwent tumor resection without PSRR as case controls. All the operations were conducted by Prof. Liang Tingbo. We classified the PSRR into three types and five subtypes (IM, IL, IR, Ⅱ and Ⅲ) based on our clinical experience and anatomy of the PV-SMV. The associations among PSRR type, post-operative mortality, morbidity, hospital stay, pre-and intra-operation traits as well as demographic characteristics were analyzed.
Results Totally44patients in both groups was included. One patient died in each group (P=0.33), and the morbidity was65.9%and59.1%in case and control group, respectively (P=0.46). PSRR type and anastomotic time are both associated with perioperative morbidity. Long anastomotic time attributes to higher morbidity (P=0.034) and higher grade of complications (P=0.013). PSRR types were not significant associated with anastomotic time (P=0.39), though subtype IR seemed extremely tricky and time-consuming in some cases. Different PSRR types do not have significant difference in morbidity (P=0.64) but subtype IR has higher grade of complications (P=0.0012).
Conclusions The new classification system for PSRR may be valuable for hepato-pancreato-biliary surgeon training, and along with anastomotic time offers a predictable factor for morbidity after operation. Care should be taken when subtype IR is used or/and long anastomotic time is expected in surgical treatment of liver cancer and perihilar cholangiocarcinoma.
方法：选取2008年7月至2012年9月在浙江大学医学院附属第一医院和第二医院诊断为肝胆胰恶性肿瘤并行手术切除联合门静脉-肠系膜上静脉切除重建的所有患者,同时选取同样数量的同期单纯行肿瘤切除术而未行血管切除的患者作为对照,两组患者术者均为梁廷波教授。并对不同手术方案根据解剖和病变特点分为三个类型五个亚型(IM、IL、IR、Ⅱ、Ⅲ型)。从围术期死亡率、并发症发生率、并发症严重程度和术后住院日等指标评价肝胆胰肿瘤血管切除重建的安全性,以及不同血管切除重建方案对围术期安全性的影响。
结果：研究共纳入44例门静脉-肠系膜上静脉切除重建病例和44例对照组病例,血管切除重建组均为端端吻合重建,无桥接血管。其中IM、IL、IR、Ⅱ、Ⅲ型切除分别为4、6、10、16、8例。血管切除重建组和对照组各有1例围术期死亡病例(P=0.33),并发症发生率分别为65.9%和59.1%(P=0.46)。血管切除类型和重建时间可在一定程度上预测围术期风险,长重建时间导致更多(P=0.034)和更严重的并发症(P=0.013)。血管切除重建类型与重建时间无明显相关(P=0.39)。不同切除重建类型对并发症无明显影响(P=0.64),但IR型并发症更严重(P=0.0012)。
结论：肝胆胰恶性肿瘤血管侵犯患者行血管切除重建围术期安全性与对照组相当。新的分型系统有助于指导肝胆胰肿瘤外科手术和并发症预测。
Background and aims Advanced cholangiocellular liver cancer, perihilar cholangiocarcinoma and pancreatic cancer can invade the portal vein (PV) and superior mesenteric vein (SMV), which was previously considered as a contraindication to operation. Accumulating yet limiting evidence has shown a relative security of portal-superior mesenteric vein (PV-SMV) resection and reconstruction (PSRR). Currently a growing number of PSRR is performed worldwide. Strategy of PSRR varies with resection locations and to date no reports have focused on a clinically effective classification system for PSRR. Here, we propose a classification system for PSRR and report the preliminary clinical significance of perioperative security.
Methods All patients who had cholangiocellular liver cancer, perihilar cholangiocarcinoma or pancreatic cancer underwent PSRR from July2008to September2012in First or Second Affiliated Hospital, Zhejiang University School of Medicine were collected, together with the same amount of patients underwent tumor resection without PSRR as case controls. All the operations were conducted by Prof. Liang Tingbo. We classified the PSRR into three types and five subtypes (IM, IL, IR, Ⅱ and Ⅲ) based on our clinical experience and anatomy of the PV-SMV. The associations among PSRR type, post-operative mortality, morbidity, hospital stay, pre-and intra-operation traits as well as demographic characteristics were analyzed.
Results Totally44patients in both groups was included. One patient died in each group (P=0.33), and the morbidity was65.9%and59.1%in case and control group, respectively (P=0.46). PSRR type and anastomotic time are both associated with perioperative morbidity. Long anastomotic time attributes to higher morbidity (P=0.034) and higher grade of complications (P=0.013). PSRR types were not significant associated with anastomotic time (P=0.39), though subtype IR seemed extremely tricky and time-consuming in some cases. Different PSRR types do not have significant difference in morbidity (P=0.64) but subtype IR has higher grade of complications (P=0.0012).
Conclusions The new classification system for PSRR may be valuable for hepato-pancreato-biliary surgeon training, and along with anastomotic time offers a predictable factor for morbidity after operation. Care should be taken when subtype IR is used or/and long anastomotic time is expected in surgical treatment of liver cancer and perihilar cholangiocarcinoma.
引文
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[3]Kawada, M., et al., Reevaluation of the indications for radical pancreatectomy to treat pancreatic carcinoma:is portal vein infiltration a contraindication? Surg Today,2002.32(7):p.598-601.
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