Jain Sundeep, Sacchi M, Vrachnos P, Lygidakis N J
Department of Surgical Oncology, Henry Dunant Hospital, Athens, Greece.
Hepatogastroenterology. 2005 Sep-Oct;52(65):1596-600.
BACKGROUND/AIMS: Up to 40% of the patients with pancreatic carcinoma are not fit for curative resection due to the locally advanced nature of the disease in the form of vascular involvement. In recent years a more aggressive approach of vascular resection with pancreaticoduodenectomy (PD) has resulted in the increase in resectability rate and survival in this group of patients. The most important determinant of survival in these patients is negative resection margins. The aim of the present study is to present our experience of vascular resection using a modified technique, in patients with pancreatic cancer.
This is a retrospective study of 48 patients who underwent portal vein/superior mesenteric vein (PV/SMV) resection along with PD using the modified technique of resection, during 1982-2004. The principle modification is the initial extensive retroperitoneal dissection for the assessment of the extent of tumor involvement of the superior mesenteric vessels and division of retroperitoneal margin before the division of the pancreas. All patients also underwent extended lymphadenectomy.
The subtotal PD was done in 26 and total PD in 22 patients, with resection of the PV/SMV in all of them. The end-to-end anastomosis was possible after adequate mobilization of the PV and SMV in 40 patients. In 4 patients reconstruction was able to be done with the use of a graft. The portal vein occlusion time was 8-15 minutes. Histopathological examination showed negative margins in all the resected specimens. Postoperative complications occurred in 16.66% with reoperation rate of 8.33%, and mortality of 6.25%. After a mean follow-up of 110 months, mean survival was 40 months with the range of 18-250 months. The five-year and 10-year survival was 18% and 10% respectively. The venous patency rate was 100% at three years.
In conclusion, PD with en bloc resection of the PV/SMV confluence can safely be done with morbidity and mortality similar to that of standard PD. The survival advantage is directly related to the attainment of negative resection margins. The modified technique is a useful way of doing vascular resection with the least amount of bowel congestion and securing negative resection margins.
背景/目的：高达40%的胰腺癌患者因疾病局部进展累及血管而不适合进行根治性切除。近年来，采用更积极的血管切除联合胰十二指肠切除术（PD）的方法，使这组患者的可切除率和生存率有所提高。这些患者生存的最重要决定因素是切缘阴性。本研究的目的是介绍我们采用改良技术对胰腺癌患者进行血管切除的经验。
这是一项回顾性研究，对1982年至2004年间48例行门静脉/肠系膜上静脉（PV/SMV）切除联合PD并采用改良切除技术的患者进行分析。主要改良之处在于最初进行广泛的腹膜后解剖，以评估肠系膜上血管受肿瘤累及的范围，并在胰腺离断前先离断腹膜后切缘。所有患者均行扩大淋巴结清扫术。
26例行保留幽门的胰十二指肠切除术，22例行经典胰十二指肠切除术，所有患者均切除PV/SMV。40例患者在充分游离PV和SMV后可行端端吻合。4例患者需用移植物进行重建。门静脉阻断时间为8 - 15分钟。组织病理学检查显示所有切除标本切缘阴性。术后并发症发生率为16.66%，再次手术率为8.33%，死亡率为6.25%。平均随访110个月，平均生存期为40个月，范围为18 - 250个月。5年和10年生存率分别为18%和10%。三年时静脉通畅率为100%。
总之，联合PV/SMV汇合部整块切除的PD可以安全进行，其发病率和死亡率与标准PD相似。生存优势直接与获得阴性切缘相关。改良技术是进行血管切除的一种有用方法，可使肠管充血最少并确保切缘阴性。
