Michelassi F, Erroi F, Dawson P J, Pietrabissa A, Noda S, Handcock M, Block G E
Department of Surgery, University of Chicago, Illinois.
Ann Surg. 1989 Oct;210(4):544-54; discussion 554-6. doi: 10.1097/00000658-198910000-00015.
Between 1946 and 1987, 647 patients with periampullary tumors were diagnosed at the University of Chicago Medical Center. These included 549 tumors located in the head of the pancreas, 40 in the distal common bile duct, 29 in the duodenum, and 29 at the ampulla of Vater. Ninety-eight per cent of all tumors were adenocarcinoma, with 93% of the remaining being duodenal carcinoid or sarcoma. Operability rate ranged from 81% to 97%, according to the tumor location and histologic type. A combination of laparotomy, biopsy, and bypass was performed in 433 patients and only one survived 5 years (0.2%). Resectability rate ranged from 16.5% for pancreatic adenocarcinoma to 89.3% for ampullary tumors. Of the 133 resections, 80 were pancreatoduodenectomies, 29 total pancreatectomies, 7 duodenectomies, 2 gastrectomies, 8 common bile duct resections, and 7 local excisions. Overall 19% of patients who underwent radical resection died in the immediate postoperative period, although mortality has decreased to 5% since 1981. Mortality was 20% after a standard pancreatoduodenectomy and 24.1% after a total pancreatectomy. Five-year actuarial survival rates, including perioperative deaths, were 8.8%, 20%, and 32% for pancreatic, duodenal, and ampullary adenocarcinoma, respectively. One half of patients with sarcoma and two-thirds with carcinoid of the duodenum survived 5 years. No patient with distal common bile duct adenocarcinoma achieved a 5-year survival rate. Multivariate analysis on all patients operated on (n = 566) revealed that the 5-year survival rate was significantly related to intent of operation (palliative 0.2%, curative 12%; p less than 0.001), histologic type (adenocarcinoma 2%, carcinoid and sarcoma 31%; p less than 0.0001), and site (ampullary and duodenal 21%, biliary and pancreatic 0.9%; p less than 0.001). A second multivariate analysis, evaluating only those patients with adenocarcinoma who survived the perioperative period of the radical resection (n = 97) analyzed the influence of tumor size and differentiation, lymphatic, capillary, and perineural microinvasion, lymph node status, and type of procedure (pancreatoduodenectomy vs. total pancreatectomy) on 5-year survival. None of these additional variables was significantly associated with long-term survival rates. In addition we evaluated the presence of local or distant recurrence after resection by analyzing the findings from all autopsies performed on these patients (n = 49): 29.4% of patients died with local recurrence alone, 23.5% with distant recurrence alone, and 47.1% had both local and distant recurrences.(ABSTRACT TRUNCATED AT 400 WORDS)
1946年至1987年间，芝加哥大学医学中心诊断出647例壶腹周围肿瘤患者。其中包括549例位于胰头的肿瘤，40例位于胆总管远端，29例位于十二指肠，29例位于 Vater壶腹。所有肿瘤的98%为腺癌，其余93%为十二指肠类癌或肉瘤。根据肿瘤位置和组织学类型，可手术率在81%至97%之间。433例患者接受了剖腹手术、活检和旁路手术，只有1例存活5年（0.2%）。可切除率从胰腺腺癌的16.5%到壶腹肿瘤的89.3%不等。在133例切除术中，80例为胰十二指肠切除术，29例为全胰切除术，7例为十二指肠切除术，2例为胃切除术，8例为胆总管切除术，7例为局部切除术。总体而言，接受根治性切除的患者中有19%在术后即刻死亡，不过自1981年以来死亡率已降至5%。标准胰十二指肠切除术后死亡率为20%，全胰切除术后死亡率为24.1%。包括围手术期死亡患者在内，胰腺、十二指肠和壶腹腺癌的5年精算生存率分别为8.8%、20%和32%。十二指肠肉瘤患者中有一半存活5年，十二指肠类癌患者中有三分之二存活5年。胆总管远端腺癌患者无1例达到5年生存率。对所有接受手术的患者（n = 566）进行多变量分析显示，5年生存率与手术意图（姑息性手术0.2%，根治性手术12%；p < 0.001）、组织学类型（腺癌2%，类癌和肉瘤31%；p < 0.0001）以及部位（壶腹和十二指肠21%，胆管和胰腺0.9%；p < 0.001）显著相关。第二项多变量分析仅评估了那些在根治性切除围手术期存活的腺癌患者（n = 97），分析肿瘤大小和分化、淋巴管、毛细血管和神经周围微侵袭、淋巴结状态以及手术类型（胰十二指肠切除术与全胰切除术）对5年生存率的影响。这些额外变量均与长期生存率无显著关联。此外，我们通过分析对这些患者（n = 49）进行的所有尸检结果，评估了切除术后局部或远处复发的情况：29.4%的患者仅死于局部复发，23.5%的患者仅死于远处复发，47.1%的患者同时有局部和远处复发。（摘要截短至400字）
