Turley Ryan S, Peterson Kirk, Barbas Andrew S, Ceppa Eugene P, Paulson Erik K, Blazer Dan G, Clary Bryan M, Pappas Theodore N, Tyler Douglas S, McCann Richard L, White Rebekah R
Department of Surgery, Duke University, Durham, NC 27710, USA.
Ann Vasc Surg. 2012 Jul;26(5):685-92. doi: 10.1016/j.avsg.2011.11.009. Epub 2012 Feb 4.
Once thought to have unresectable disease, pancreatic cancer patients with portal venous involvement are now reported to have comparable survival after pancreaticoduodenectomy (PD) with vascular reconstruction (VR) as compared with patients without vascular involvement. We hypothesize that a multidisciplinary approach involving a vascular surgeon will minimize morbidity and improve patency of VRs.
We identified 204 patients who underwent PD for pancreatic adenocarcinoma from 1997 to 2008. Patients who underwent PD with VR (N = 42) were compared with those who underwent standard PD (N = 162). VRs were performed by a vascular surgeon and involved primary repair (N = 8), vein patch (N = 25), or interposition grafting (N = 9) with femoral or other venous conduit.
Patients undergoing PD with VR had larger tumors (3.0 cm vs. 2.5 cm, P < 0.01) but did not have different rates of tumor-free margins (73% vs. 72%, P = 0.84) or lymph nodes metastases (50% vs. 38%, P = 0.14). The VR group had higher median blood loss (875 mL vs. 550 mL, P = 0<0.01), but no differences in mortality, complication rates, length of stay, or readmission rates were found in a median follow-up of 29 months. Overall survival rates were similar. Predictors of mortality on multivariate analysis included increasing histological grade (P = 0.01), positive lymph nodes (P = 0.01), and increasing tumor size (P = 0.01), but not VR (P = 0.28). When evaluated by computed tomography scans within 6 months postoperatively, 97% of reconstructions remained patent.
The need for VR is not a contraindication to potentially curative resection in patients with pancreatic adenocarcinoma. Assistance of a vascular surgeon during VR may allow moderate-volume centers to achieve outcomes comparable with high-volume centers.
曾经被认为患有不可切除疾病的门静脉受累胰腺癌患者，现在有报道称，与无血管受累的患者相比，在接受胰十二指肠切除术（PD）并进行血管重建（VR）后，其生存率相当。我们假设，由血管外科医生参与的多学科方法将使发病率降至最低，并提高血管重建的通畅率。
我们确定了1997年至2008年期间因胰腺腺癌接受PD的204例患者。将接受PD并进行VR的患者（N = 42）与接受标准PD的患者（N = 162）进行比较。VR由血管外科医生进行，包括一期修复（N = 8）、静脉补片（N = 25）或使用股静脉或其他静脉导管进行间置移植（N = 9）。
接受PD并进行VR的患者肿瘤较大（3.0 cm对2.5 cm，P < 0.01），但切缘无肿瘤率（73%对72%，P = 0.84）或淋巴结转移率（50%对38%，P = 0.14）没有差异。VR组术中失血量中位数较高（875 mL对550 mL，P = 0<0.01），但在中位随访29个月时，死亡率、并发症发生率、住院时间或再入院率没有差异。总体生存率相似。多因素分析中死亡率的预测因素包括组织学分级增加（P = 0.01）、淋巴结阳性（P = 0.01）和肿瘤大小增加（P = 0.01），但不包括VR（P = 0.28）。术后6个月内通过计算机断层扫描评估时，97%的重建血管保持通畅。
对于胰腺腺癌患者，VR的需求并非潜在根治性切除的禁忌证。血管外科医生在VR过程中的协助可能使中等规模的中心获得与大规模中心相当的治疗效果。
