Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic College of Medicine, Rochester, MN.
Division of Vascular Surgery, Mayo Clinic College of Medicine, Rochester, MN.
J Am Coll Surg. 2020 Jul;231(1):8-29. doi: 10.1016/j.jamcollsurg.2020.05.005. Epub 2020 May 15.
En bloc celiac axis resection (CAR) for pancreatic cancer is considered increasingly after modern neoadjuvant chemotherapy (NAC). Appleby and distal pancreatectomy with CAR are anatomically inaccurate terms, as tumors can extend beyond celiac axis proper, requiring concurrent resection of the proper hepatic artery and/or superior mesenteric artery.
A 3-level classification for CAR (class 1, 2, or 3) was developed after retrospective review of an arterial resection database describing anatomical variants that dictate pancreatectomy-type, formal arterial revascularization, and gastric preservation. Perioperative and oncologic outcomes were assessed.
Of 90 CARs for pancreatic cancer, 89% patients received NAC, 35% requiring chemotherapeutic switch. There were 41 class 1, 33 class 2, and 16 class 3 CARs, with arterial and venous revascularization performed 62% and 66%, respectively. Ninety-day mortality decreased to 4% in the last 50 cases (p = 0.035); major morbidity was unchanged (55%). Any hepatic or gastric ischemia occurred in 20% and 10% patients, respectively, and arterial revascularization was protective. R0 resection rate (88%) was associated with chemoradiation (p = 0.004). Median overall survival was 36.2 months, superior with NAC (8.0 vs. 43.5 months). Predictors of survival after NAC included chemotherapy duration, carbohydrate antigen 19-9 response, pathologic response, and lymph node status. Major pathologic response (p = 0.036) and extended duration NAC (p = 0.007) were independent predictors on multivariate analysis.
Current terminology for CAR inadequately describes all operative variants. Our classification, based on the largest single-center series, allows complex operative planning and standardized reporting across institutions. Extent of arterial involvement determines pancreatectomy type, need for arterial revascularization, and likelihood of gastric preservation. Operative mortality has improved, morbidity remains significant, and survival favorable after extended NAC with associated pathologic responses; given these factors, CAR should only be considered in fit patients with objective NAC responses at specialized centers.
在现代新辅助化疗（NAC）之后，越来越多的人考虑整块腹腔动脉切除（CAR）治疗胰腺癌。Appleby 和胰体尾切除术加 CAR 的解剖学术语并不准确，因为肿瘤可能超出腹腔动脉本身的范围，需要同时切除肝固有动脉和/或肠系膜上动脉。
通过回顾描述决定胰切除术类型、正式动脉重建和胃保留的解剖变异的动脉切除术数据库，开发了 CAR 的 3 级分类（1 级、2 级或 3 级）。评估了围手术期和肿瘤学结果。
90 例胰腺癌 CAR 患者中，89%接受了 NAC，35%需要化疗药物转换。有 41 例 1 级、33 例 2 级和 16 例 3 级 CAR，分别有 62%和 66%进行了动脉和静脉重建。90 天死亡率在最后 50 例中降至 4%（p=0.035）；主要发病率无变化（55%）。分别有 20%和 10%的患者出现任何肝或胃缺血，动脉重建具有保护作用。R0 切除率（88%）与放化疗相关（p=0.004）。中位总生存期为 36.2 个月，NAC 组（8.0 个月 vs. 43.5 个月）更好。NAC 后生存的预测因素包括化疗持续时间、碳水化合物抗原 19-9 反应、病理反应和淋巴结状态。主要病理反应（p=0.036）和延长 NAC 持续时间（p=0.007）是多因素分析的独立预测因素。
目前用于 CAR 的术语不能充分描述所有手术变异。我们的分类基于最大的单中心系列，允许在机构间进行复杂的手术规划和标准化报告。动脉受累程度决定了胰切除术类型、是否需要动脉重建以及胃保留的可能性。手术死亡率有所改善，但发病率仍然很高，在接受延长的 NAC 并伴有相关病理反应后，生存情况良好；鉴于这些因素，只有在有客观 NAC 反应的合适患者中，并且在专门中心进行，才能考虑 CAR。
