Vicente E, Quijano Y, Ielpo B, Duran H
Madrid Norte Sanchinarro San Pablo University Hospital, General Surgery Department, Calle Oña 10, 28050 Madrid, Spain.
Madrid Norte Sanchinarro San Pablo University Hospital, General Surgery Department, Calle Oña 10, 28050 Madrid, Spain.
Surg Oncol. 2017 Sep;26(3):276-277. doi: 10.1016/j.suronc.2017.05.002. Epub 2017 May 22.
Pancreatectomy for locally advanced adenocarcinoma affecting the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) is still under discussion [1]. However, in selected cases, in light of the advancement of recent neoadjuvant treatments, it must be taken into account [2,3]. This video demonstrates some of the technical aspects of SMA and SMV resection as well as some tips of vascular reconstruction.
A 48-year-old man with a large adenocarcinoma of the uncinated process affecting the SMA and SMV underwent 3 cycles of gemcitabine and nab-paclitaxel neoadjuvancy. Post chemotherapy studies showed no disease progression with a normalization of CA 19.9 and SUV of FDG PET CT scan and a downsizing of the tumor, as well. Therefore, an en bloc total spleno-pancreato-duodenectomy with resection of SMA and SMV was planned.
Through a bilateral subcostal incision, an "arterial first approach" [3] was performed. Considering the large length of the vascular resection, the replacement of the resected SMA and SMV was performed using two PTFE grafts, as showed in the video. Postoperative pathology showed margins free from disease with an important pathological response (grade 2 of Ryan classification adapted from rectal cancer) [4]. The post-operative course was uneventful and the patient is still free from disease at 31 months from surgery.
This case is part of a large experience our group have acquired since we started neoadjuvancy in 2010. In our experience, we gathered 25 cases of locally advanced pancreatic tumors, of which 12 underwent to pancreatic resection after good response to the neoadjuvant treatment. In 5 of them concomitant SMA and SMV resection was required and post-operative mortality occurred in 1 of them. Morbidities and mortalities are higher compared with standard pancreatectomies, specially related to the vascular reconstruction (bleeding, graft thrombosis) [5]. However, in some circumstances like young age, great radiological and biological response to neoadjuvancy (such as the case herein presented), surgery might be considered the best option of care providing the only possibility to increase survival for these types of locally advanced tumors. However, further studies are needed to know which patients might benefit from this approach. En bloc total spleno-pancreato-duodenectomy with resection of SMA and SMV might be considered as an effective procedure in selected cases of pancreatic adenocarcinoma with good response to preoperative treatment.
对于侵犯肠系膜上动脉（SMA）和肠系膜上静脉（SMV）的局部晚期腺癌行胰腺切除术仍存在争议[1]。然而，在某些特定情况下，鉴于近期新辅助治疗的进展，必须予以考虑[2,3]。本视频展示了SMA和SMV切除的一些技术要点以及血管重建的一些技巧。
一名48岁男性，胰头钩突部的大腺癌侵犯SMA和SMV，接受了3个周期的吉西他滨和白蛋白结合型紫杉醇新辅助治疗。化疗后检查显示疾病无进展，CA 19.9正常，FDG PET CT扫描的SUV正常，肿瘤也缩小。因此，计划行整块全脾胰十二指肠切除术，同时切除SMA和SMV。
通过双侧肋下切口，采用“动脉优先入路”[3]。考虑到血管切除长度较长，如视频所示，使用两根聚四氟乙烯移植物替代切除的SMA和SMV。术后病理显示切缘无肿瘤，有重要的病理反应（参照直肠癌的Ryan分类为2级）[4]。术后过程顺利，患者术后31个月仍无疾病。
该病例是我们团队自2010年开始新辅助治疗以来积累的丰富经验的一部分。根据我们的经验，我们收集了25例局部晚期胰腺肿瘤病例，其中12例在对新辅助治疗有良好反应后接受了胰腺切除术。其中5例需要同时切除SMA和SMV，1例发生术后死亡。与标准胰腺切除术相比，发病率和死亡率更高，特别是与血管重建相关（出血、移植物血栓形成）[5]。然而，在某些情况下，如患者年轻、对新辅助治疗有良好的影像学和生物学反应（如本病例），手术可能被认为是最佳的治疗选择，因为这是提高这类局部晚期肿瘤生存率的唯一可能。然而，需要进一步研究以确定哪些患者可能从这种方法中获益。对于术前治疗反应良好的胰腺腺癌特定病例，整块全脾胰十二指肠切除术联合SMA和SMV切除可被视为一种有效的手术方法。
