Mohammed Somala, Mendez-Reyes Jose E, McElhany Amy, Gonzales-Luna Daniel, Van Buren George, Bland Daniel S, Villafane-Ferriol Nicole, Pierzynski Jeanne A, West Charles A, Silberfein Eric J, Fisher William E
Baylor College of Medicine, The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, Houston, Texas.
Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
J Surg Res. 2018 Aug;228:271-280. doi: 10.1016/j.jss.2018.02.006. Epub 2018 Apr 13.
Addition of en bloc segmental venous reconstruction (VR) to pancreaticoduodenectomy (PD) for venous involvement of pancreatic tumors increases the complexity of the operation and may increase complications. The long-term mesenteric venous patency rate and oncologic outcome has not been well defined.
Our prospective database was reviewed to assess 90-day postoperative outcomes for patients who underwent PD or PD + VR (September 2004-June 2016). Two independent observers reviewed CT scans to determine long-term vein patency. In patients with pancreatic ductal adenocarcinoma, the impact of VR on 5-year overall survival was assessed using multivariate Cox proportional hazards regression. Student's t-test was used to evaluate continuous variables and the chi-square test for categorical variables.
Three hundred ninety-three patients underwent PD (51 PD + VR). Patients undergoing PD + VR had longer operations (561 ± 119 versus 433 ± 89 min, P < 0.00001) and greater blood loss (768 ± 812 versus 327 ± 423 cc, P < 0.00001). There was no difference in 90-day mortality, overall postoperative complication rates, complication severity grades, reoperation, readmission, or length of stay. 26.7% experienced venous thrombosis. Most thromboses occurred in the first year after surgery, but we also observed late thrombosis in 1 patient after 89-month follow-up. Among 135 patients with pancreatic ductal adenocarcinoma, survival was significantly longer in the PD-alone group (31.3 months [95% confidence interval: 22.9-40.0] versus 17.0 [95% confidence interval: 13.0-19.1], p = 0.013).
PD + VR does not increase short-term morbidity, but venous thrombosis is frequent and can occur long after surgery. Survival is inferior when VR is required especially in the absence of neoadjuvant chemotherapy.
对于伴有静脉受累的胰腺肿瘤，在胰十二指肠切除术（PD）中增加整块节段性静脉重建（VR）会增加手术复杂性，并可能增加并发症。肠系膜静脉长期通畅率和肿瘤学结局尚未明确。
回顾我们的前瞻性数据库，评估接受PD或PD + VR手术患者（2004年9月至2016年6月）的术后90天结局。两名独立观察者复查CT扫描以确定静脉长期通畅情况。在胰腺导管腺癌患者中，使用多因素Cox比例风险回归评估VR对5年总生存的影响。采用学生t检验评估连续变量，采用卡方检验评估分类变量。
393例患者接受了PD手术（51例为PD + VR）。接受PD + VR的患者手术时间更长（561±119分钟对433±89分钟，P < 0.00001），失血量更多（768±812毫升对327±423毫升，P < 0.00001）。90天死亡率、总体术后并发症发生率、并发症严重程度分级、再次手术、再次入院或住院时间无差异。26.7%的患者发生静脉血栓形成。大多数血栓形成发生在术后第一年，但在89个月随访后我们也观察到1例患者发生晚期血栓形成。在135例胰腺导管腺癌患者中，单纯PD组生存时间显著更长（31.3个月[95%置信区间：22.9 - 40.0]对17.0个月[95%置信区间：13.0 - 19.1]，P = 0.013）。
PD + VR不增加短期发病率，但静脉血栓形成很常见，且可在术后很长时间发生。尤其是在未进行新辅助化疗的情况下，需要VR时生存情况较差。
