The Department of Surgery, London Health Sciences Centre and Schulich School of Medicine and Dentistry, London, Ont., Canada.
Can J Surg. 2010 Jun;53(3):171-4.
Despite advances in preoperative staging, cancer of the pancreatic head is frequently found to be unresectable at laparotomy. We sought to identify potential areas of improvement in preoperative staging.
We performed a retrospective institutional review of patients referred for resection of cancer of the pancreatic head over a 2-year period. The primary outcome was the rate of metastasis or unresectable disease found at laparotomy in patients who were booked for pancreaticoduodenectomy with curative intent.
During the study period, 133 patients were referred with suspected cancer of the pancreatic head. All underwent preoperative computed tomography scanning. Twenty-four also underwent preoperative endoscopic ultrasonography (EUS) and 23 also underwent magnetic resonance imaging (MRI). In total, 78 patients were deemed not to be candidates for surgery, leaving 55 patients with potentially resectable cancer who were scheduled for pancreaticoduodenectomy. Of these, 32 patients (58%) underwent successful resection with curative intent, and 23 patients (42%) were found to have metastatic or locally advanced disease not identified by preoperative staging. Reasons for nonresectability were metastases (9 patients, 16%), vascular involvement (12 patients, 22%) and mesentery involvement (2 patients, 4%). One patient had a diagnostic laparoscopy immediately before planned open exploration and was found to have peritoneal seeding precluding curative resection. Of the patients who underwent EUS, 14 were not surgical candidates because of locally advanced tumours. Ten patients were offered surgery with curative intent, and 5 patients (50%) were found have unresectable tumours (4 metastatic, 1 locally advanced). Of the patients who underwent MRI, 11 were offered surgery, and 5 (45%) had unresectable tumours (2 metastatic, 3 locally advanced disease).
In our institution, preoperative staging for cancer of the pancreatic head misses a substantial number of metastatic and unresectable disease. There is clearly room for improvement, and newer technologies should be evaluated to enhance the detection of metastatic and locally advanced disease to prevent unnecessary laparotomy.
尽管术前分期有了进展，但在剖腹手术时仍经常发现胰头癌无法切除。我们试图确定术前分期中潜在的改进领域。
我们对 2 年内因胰头癌接受切除术的患者进行了回顾性机构审查。主要结果是在计划进行胰十二指肠切除术的患者中，剖腹术中发现转移或不可切除疾病的发生率。
在研究期间，有 133 例患者因疑似胰头癌被转介。所有患者均接受了术前计算机断层扫描。24 例患者还接受了术前内镜超声检查（EUS），23 例患者还接受了磁共振成像（MRI）。总共，78 例患者被认为不适合手术，留下 55 例具有潜在可切除癌症的患者接受胰十二指肠切除术。其中，32 例（58%）成功进行了治愈性切除，23 例（42%）患者发现术前分期未识别的转移性或局部晚期疾病。不可切除的原因是转移（9 例，16%）、血管受累（12 例，22%）和肠系膜受累（2 例，4%）。1 例患者在计划进行开放性探查前进行了诊断性腹腔镜检查，发现腹膜播种，无法进行治愈性切除。接受 EUS 的患者中，有 14 例因局部晚期肿瘤而不适合手术。10 例患者接受了治愈性手术治疗，其中 5 例（50%）发现肿瘤无法切除（4 例转移，1 例局部晚期）。接受 MRI 的患者中，有 11 例被提议手术，其中 5 例（45%）发现肿瘤无法切除（2 例转移，3 例局部晚期疾病）。
在我们的机构中，胰头癌的术前分期漏诊了大量的转移和不可切除的疾病。显然还有改进的空间，应该评估新技术以提高转移性和局部晚期疾病的检测率，以防止不必要的剖腹手术。
