Schwarz Lilian, Votanopoulos Konstantinos, Morris David, Yonemura Yutaka, Deraco Marcello, Piso Pompiliu, Moran Brendan, Levine Edward A, Tuech Jean-Jacques
*Department of Digestive Surgery, Hôpital Charles Nicolle, Rouen, France †Department of General Surgery, Wake Forest University, Winston-Salem, NC ‡Department of Surgery, St George Hospital, Kogarah, Sydney, Australia §Department of General Surgery, Kusatsu General Hospital, Yabase, Japan ¶Department of Surgery, National Cancer Institute of Milan, Milan, Italy ||Department of Surgery, Hospital Barmherzige Brueder Regensburg, Germany **Peritoneal Malignancy Department, Basingstoke and North Hampshire Hospitals, Basingstoke, UK.
Ann Surg. 2016 Feb;263(2):369-75. doi: 10.1097/SLA.0000000000001225.
To report the morbidity and risk factors for overall complications and for pancreatic fistula (PF) after distal pancreatic resection (DP) during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC).
The safety of DP in patients with peritoneal surface malignancies treated by CRS and HIPEC has been debated. The risk of PF and its impact on surgical outcomes are not well defined.
Between 2001 and 2012, 118 patients with peritoneal surface malignancy undergoing CRS/HIPEC required DP at 7 oncological surgical centers. The incidence, clinical impact, and risk factors of PF were analyzed.
The indications for DP were tumoral invasion of the pancreatic gland with (n = 24; 20%) or without splenic extension (n = 76; 64%), invasion of the pancreatic capsule (n = 10; 9%), or iatrogenic lesions during CRS (n = 8; 7%). The rate of 90 days postoperative mortality was 7.6%, and the rate of severe morbidity (Clavien-Dindo ≥III) was 44%. Pancreatic fistula was observed in 39 cases (33%), with the majority grade B (48.7%) or C (28.2%). In multivariate analysis, the risk factors for PF were a peritoneal cancer index more than 20 (risk ratio: 3.01; P = 0.022) and an operative time more than 550 min (risk ratio: 2.74; P = 0.038). The occurrence of PF was not associated with a higher risk of 90-day mortality (5.1% vs 8.8%, not significant).
With regard to reported morbi-mortality rates, DP associated with CRS/HIPEC may be a reasonable procedure in highly selected patients when done in high-volume centers. Therefore, distal pancreatic involvement should not be considered as a definitive contraindication for CRS/HIPEC in patients with resectable peritoneal surface disease.
报告细胞减灭术及术中腹腔内热灌注化疗（CRS/HIPEC）期间行胰体尾切除术（DP）后总体并发症及胰瘘（PF）的发病率和危险因素。
CRS联合HIPEC治疗腹膜表面恶性肿瘤患者时，DP的安全性一直存在争议。PF的风险及其对手术结局的影响尚不明确。
2001年至2012年期间，7家肿瘤外科中心的118例接受CRS/HIPEC的腹膜表面恶性肿瘤患者需要行DP。分析PF的发生率、临床影响及危险因素。
DP的指征包括胰腺受肿瘤侵犯伴（n = 24；20%）或不伴脾脏受累（n = 76；64%）、胰腺被膜侵犯（n = 10；9%）或CRS期间的医源性损伤（n = 8；7%）。术后90天死亡率为7.6%，严重并发症发生率（Clavien-Dindo≥III级）为44%。39例（33%）观察到胰瘘，大多数为B级（48.7%）或C级（28.2%）。多因素分析显示，PF的危险因素为腹膜癌指数大于20（风险比：3.01；P = 0.022）和手术时间超过550分钟（风险比：2.74；P = 0.038）。PF的发生与90天死亡率较高无关（5.1%对8.8%，无显著性差异）。
就所报告的发病率和死亡率而言，在大型中心对经过严格挑选的患者进行DP联合CRS/HIPEC可能是一种合理的手术方式。因此，对于可切除的腹膜表面疾病患者，胰体尾受累不应被视为CRS/HIPEC的绝对禁忌证。
