Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital and North Shore Private Hospital, St Leonards, New South Wales, Australia.
J Am Coll Surg. 2012 Oct;215(4):569-79. doi: 10.1016/j.jamcollsurg.2012.05.034. Epub 2012 Jul 3.
The aim of this study was to assess whether pancreatoduodenectomy (PD) and en bloc mesenterico-portal resection (PD+VR) could be performed with primary venous reconstruction, avoiding a vascular graft. In addition, the short-term surgical outcomes of this approach were compared with a standard PD (PD-VR).
Two hundred twelve patients underwent PD between January 2004 and June 2011. Clinical data, operative results, pathologic findings, and postoperative outcomes were collected prospectively and analyzed.
One hundred fifty patients (71%) had PD-VR and 62 patients underwent PD+VR. The majority (82%) of the venous reconstructions were performed with primary end-to-end anastomosis. Only 1 patient had synthetic interposition graft repair. The volume of intraoperative blood loss and the perioperative blood transfusion requirements were significantly greater, and the duration of the operation was significantly longer in the PD+VR group compared with the PD-VR group. There were no significant differences in the length of hospitalization, postoperative morbidity, or grades of complications between the 2 groups. Multivariate logistic regression identified American Society of Anesthesiologists score as the only predictor of postoperative morbidity. Fifty percent of patients with pancreatic adenocarcinoma (n = 101) required VR. A significantly higher rate of positive resection margins (p < 0.001) was noted in the PD+VR subgroup compared with PD-VR subgroup. Furthermore, high intraoperative blood loss and neural invasion were predictive of a positive resection margin.
Pancreatoduodenectomy with VR and primary venous anastomosis avoids the need for a graft and has comparable postoperative morbidity with PD-VR. However, it is associated with an increased operative time, higher intraoperative blood loss, and, for pancreatic ductal adenocarcinoma, a higher rate of positive resection margins compared with PD-VR.
本研究旨在评估胰十二指肠切除术（PD）和整块肠系膜门静脉切除术（PD+VR）是否可以进行原发性静脉重建，避免使用血管移植物。此外，还将比较这种方法与标准 PD（PD-VR）的短期手术结果。
2004 年 1 月至 2011 年 6 月期间，212 例患者接受了 PD。前瞻性收集临床数据、手术结果、病理发现和术后结果，并进行分析。
150 例（71%）患者行 PD-VR，62 例患者行 PD+VR。大多数（82%）静脉重建采用端对端吻合术。仅 1 例患者采用合成间置移植物修复。PD+VR 组术中出血量和围手术期输血需求明显较大，手术时间明显较长。两组间住院时间、术后发病率或并发症严重程度无显著差异。多变量逻辑回归确定美国麻醉医师协会评分是术后发病率的唯一预测因素。50%的胰腺腺癌患者（n=101）需要 VR。PD+VR 亚组的阳性切缘率明显高于 PD-VR 亚组（p<0.001）。此外，术中出血量高和神经侵犯是阳性切缘的预测因素。
带 VR 的 PD 并进行原发性静脉吻合术可避免使用移植物，与 PD-VR 相比，术后发病率相当。然而，与 PD-VR 相比，它与手术时间延长、术中出血量增加以及胰腺导管腺癌的阳性切缘率较高相关。
