Sohn T A, Lillemoe K D, Cameron J L, Pitt H A, Huang J J, Hruban R H, Yeo C J
Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287-4679, USA.
Ann Surg. 1999 Mar;229(3):393-400. doi: 10.1097/00000658-199903000-00013.
This single-institution experience retrospectively reviews the outcomes of patients undergoing reexploration for periampullary carcinoma at a high-volume center.
Many patients are referred to tertiary centers with periampullary carcinoma after their tumors were deemed unresectable at previous laparotomy. In carefully selected patients, tumor resection is often possible; however, the perioperative results and long-term outcome have not been well defined.
From November 1991 through December 1997, 78 patients who underwent previous exploratory laparotomy and/or palliative surgery for suspected periampullary carcinoma underwent reexploration. The operative outcome, resectability rate, pathology, and long-term survival rate were compared with 690 concurrent patients who had not undergone previous exploratory surgery.
Fifty-two of the 78 patients (67%) undergoing reexploration underwent successful resection by pancreaticoduodenectomy; the remaining 26 patients (34%) were deemed to have unresectable disease. Compared with the 690 patients who had not undergone recent related surgery, the patients in the reoperative group were similar with respect to gender, race, and resectability rate but were significantly younger. The distribution of periampullary cancers by site in the reoperative group undergoing pancreaticoduodenectomy (n = 52) was 60%, 19%, 15%, and 6% for pancreatic, ampullary, distal bile duct, and duodenal tumors, respectively. These figures were similar to the 65%, 14%, 16% and 5% for resectable periampullary cancers found in the primary surgery group (n = 460). Intraoperative blood loss and transfusion requirements did not differ between the two groups. However, the mean operative time was 7.4 hours in the reoperative group, significantly longer than in the control group. On pathologic examination, reoperative patients had smaller tumors, and the percentage of patients with positive lymph nodes in the resection specimen was significantly less. The incidence of positive margins was similar between the two groups. Postoperative lengths of stay, complication rates, and perioperative mortality rates were not higher in reoperative patients. The long-term survival rate was similar between the two resected groups, with a median survival of 24 months in the reoperative group and 20 months in those without previous exploration.
These data demonstrate that patients undergoing reoperation for periampullary carcinoma have similar resectability, perioperative morbidity and mortality, and long-term survival rates as patients undergoing initial exploration. The results suggest that selected patients considered to have unresectable disease at previous surgery should undergo restaging and reexploration at specialized high-volume centers.
本单中心经验回顾性分析了在一家大型中心接受壶腹周围癌再次探查手术患者的治疗结果。
许多壶腹周围癌患者在先前剖腹手术中被判定肿瘤无法切除后，被转诊至三级中心。在经过精心挑选的患者中，肿瘤切除往往是可行的；然而，围手术期结果和长期预后尚未得到明确界定。
从1991年11月至1997年12月，78例因疑似壶腹周围癌先前接受过探查性剖腹手术和/或姑息性手术的患者接受了再次探查。将手术结果、可切除率、病理情况和长期生存率与690例同期未接受过先前探查手术的患者进行比较。
78例接受再次探查的患者中，52例（67%）通过胰十二指肠切除术成功切除；其余26例（34%）被判定为疾病无法切除。与690例近期未接受相关手术的患者相比，再次手术组患者在性别、种族和可切除率方面相似，但年龄明显更小。在接受胰十二指肠切除术的再次手术组（n = 52）中，壶腹周围癌按部位分布分别为胰腺癌60%、壶腹癌19%、远端胆管癌15%和十二指肠癌6%。这些数字与初次手术组（n = 460）中可切除壶腹周围癌的65%、14%、16%和5%相似。两组术中失血量和输血需求无差异。然而，再次手术组的平均手术时间为7.4小时，明显长于对照组。病理检查显示，再次手术患者的肿瘤较小，切除标本中淋巴结阳性患者的百分比明显更低。两组切缘阳性发生率相似。再次手术患者的术后住院时间、并发症发生率和围手术期死亡率并不更高。两组切除患者的长期生存率相似，再次手术组的中位生存期为24个月，未接受过先前探查的患者为20个月。
这些数据表明，接受壶腹周围癌再次手术的患者与接受初次探查的患者在可切除率、围手术期发病率和死亡率以及长期生存率方面相似。结果提示，先前手术被认为疾病无法切除的部分患者应在专业大型中心进行重新分期和再次探查。
