Tucker Olga N, Rela Mohamed
The Department of Hepatopancreaticobiliary and Liver Transplant Surgery, King's College Hospital, Denmark Hill, London SE5 9RS, UK.
HPB Surg. 2008;2008:839503. doi: 10.1155/2008/839503. Epub 2009 Mar 11.
Synchronous major vessel resection during pancreaticoduodenectomy (PD) for borderline resectable pancreatic adenocarcinoma remains controversial. In the 1970s, regional pancreatectomy advocated by Fortner was associated with unacceptably high morbidity and mortality rates, with no impact on long-term survival. With the establishment of a multidisciplinary approach, improvements in preoperative staging techniques, surgical expertise, and perioperative care reduced mortality rates and improved 5-year-survival rates are now achieved following resection in high-volume centres. Perioperative morbidity and mortality following PD with portal vein resection are comparable to standard PD, with reported 5-year-survival rates of up to 17%. Segmental resection and reconstruction of the common hepatic artery/proper hepatic artery (CHA/PHA) can be performed to achieve an R0 resection in selected patients with limited involvement of the CHA/PHA at the origin of the gastroduodenal artery (GDA). PD with concomitant major vessel resection for borderline resectable tumours should be performed when a margin-negative resection is anticipated at high-volume centres with expertise in complex pancreatic surgery. Where an incomplete (R1 or R2) resection is likely neoadjuvant treatment with systemic chemotherapy followed by chemoradiation as part of a clinical trial should be offered to all patients.
在胰十二指肠切除术（PD）中，对于可切除边缘的胰腺腺癌同期进行主要血管切除仍存在争议。20世纪70年代，Fortner倡导的区域性胰腺切除术与高得令人难以接受的发病率和死亡率相关，且对长期生存没有影响。随着多学科方法的建立、术前分期技术的改进、手术专业技能以及围手术期护理的提升，高容量中心在切除术后降低了死亡率并提高了5年生存率。门静脉切除术后的围手术期发病率和死亡率与标准PD相当，报道的5年生存率高达17%。对于在胃十二指肠动脉（GDA）起始处肝总动脉/肝固有动脉（CHA/PHA）受累有限的特定患者，可进行节段性切除并重建CHA/PHA以实现R0切除。对于可切除边缘的肿瘤，当在具备复杂胰腺手术专业知识的高容量中心预期能进行切缘阴性切除时，应进行PD并同期进行主要血管切除。如果可能进行不完全（R1或R2）切除，则应将所有患者纳入一项临床试验，给予全身化疗联合放化疗作为新辅助治疗。
