微创（MI） fellowship 培训（FT）的肝胰和肝胆（HPB）外科医生的经验：经 MI 胰十二指肠切除术治疗壶腹周围肿瘤的结果是否优于开放手术？
The experience of the minimally invasive (MI) fellowship-trained (FT) hepatic-pancreatic and biliary (HPB) surgeon: could the outcome of MI pancreatoduodenectomy for peri-ampullary tumors be better than open?
机构信息
Département de Chirurgie Digestive, Centre Hospitalier Intercommunal de POISSY/SAINT-GERMAIN-EN-LAYE, 10, Rue du Champ Gaillard, 78300, Poissy, France.
Unità Chirurgia Epatobiliopancreatica, Robotica e Mininvasiva, Fondazione Poliambulanza Istituto Ospedaliero, via Bissolati, 57, Brescia, 25124, Italia.
出版信息
Surg Endosc. 2021 Sep;35(9):5256-5267. doi: 10.1007/s00464-020-08118-x. Epub 2020 Nov 4.
BACKGROUND
Although early series focused on benign disease, minimally invasive pancreatoduodenectomy (MIPD) might be particularly suited for malignancy. Unlike their predecessors, fellowship-trained (FT) Hepatic-Pancreatic and Biliary (HPB) surgeons usually have equal skills in approaching peri-ampullary tumors (PT) either openly or via minimally invasive (MI) techniques.
METHOD
We retrospectively reviewed a MI-HPB-FT surgeon's 10-year experience with PD. A sub-analysis of malignant PT was also done (MIPD-PT vs. OPD-PT). The primary endpoint was to assess postoperative mortality and morbidity. Secondary endpoints included operative parameters, length of hospital stay, and survival analysis. Moreover, we addressed practice pattern changes for a surgeon straight out of training with no previous experience of independent surgery.
RESULTS
From December 2007-February 2018, one MI-HPB-FT performed a total of 100 PDs, including 57 MIPDs and 43 open PDs (OPDs). In both groups, over 70% of PDs were undertaken for malignancy. Eight patients with borderline resectable pancreatic ductal cancer (PDC) were in the OPD-PT group (as compared to only 2 in the MIPD-PT group) (p = 0.07). Estimated mean blood loss and length of stay were less in the MIPD-PT group (345 mL and 12 days) as compared to the OPD-PT group (971 mL and 16 days), p < 0.001 and p = 0.007, respectively. However, the mean operative time was longer for the MIPD-PT (456 min) as compared to the OPD-PT (371 min), p < 0.001. Thirty and 90-day mortality was 2.6%/5.1% after MIPD-PT compared to 0%/3.2% after OPD-PT, respectively, p = 1. Overall 30-/90-day morbidity rates were similar at 41.0%/43.6% after MIPD-PT and 35.5%/41.9% after OPD-PT, respectively, p = 0.8 and 1. Complete resection (R0) rates were not statistically different, 97.4% after MIPD-PT compared to 87.0% after OPD-PT (p = 0.2). After MIPD and OPD for malignant PT, overall 1, 3 and 5-year survival rates, and median survival were 82.5%, 59.6% and 46.3% and 38 months as compared to 52.5%, 15.7% and 10.5% and 13 months, respectively (p = 0.01). In the MIDP-PT group, recurrence free survival (RFS) at 1, 3 and 5 years and median RFS were 69.1%, 41.9% and 33.5% and 26 months as compared to 50.4%, 6.3% and 6.3% and 13 months, in the OPD-PT group, respectively (p = 0.03).
CONCLUSION
FT HPB Surgeons who begin their practice with the ability to do both MI and OPD may preferentially approach resectable peri-ampullary tumors minimally invasively. This may result in decreased blood loss decreased length of hospital stays. Despite longer operative time, the improved visualization of MI techniques may enable superior R0 rates when compared to historical open controls. Moreover, combined with quicker initiation of adjuvant chemotherapeutic treatments, this may eventually result in improved survival.
背景
虽然早期的研究集中在良性疾病上，但微创胰十二指肠切除术（MIPD）可能特别适用于恶性肿瘤。与他们的前辈不同，接受过 fellowship培训的（FT）肝胰和胆道（HPB）外科医生通常在开放性手术或微创（MI）技术方面都具有同等的接近壶腹周围肿瘤（PT）的技能。
方法
我们回顾性分析了一位 MI-HPB-FT 外科医生 10 年来的 PD 经验。还对恶性 PT 进行了亚分析（MIPD-PT 与 OPD-PT）。主要终点是评估术后死亡率和发病率。次要终点包括手术参数、住院时间和生存分析。此外，我们还探讨了一位刚从培训中出来的外科医生的手术模式变化，他没有独立手术的经验。
结果
从 2007 年 12 月至 2018 年 2 月，一位 MI-HPB-FT 总共进行了 100 例 PD，其中 57 例为 MIPD，43 例为开放 PD（OPD）。在这两组中，超过 70%的 PD 是为恶性肿瘤而进行的。有 8 例边界可切除的胰管腺癌（PDC）患者在 OPD-PT 组（而 MIPD-PT 组只有 2 例）（p=0.07）。与 OPD-PT 组相比，MIPD-PT 组的平均估计出血量和住院时间分别为 345 毫升和 12 天，分别为 971 毫升和 16 天（p<0.001 和 p=0.007）。然而，MIPD-PT 的平均手术时间较长（456 分钟），而 OPD-PT 为 371 分钟（p<0.001）。MIPD-PT 术后 30 天和 90 天死亡率分别为 2.6%/5.1%，而 OPD-PT 术后分别为 0%/3.2%（p=1）。总体而言，MIPD-PT 术后 30 天/90 天发病率分别为 41.0%/43.6%，OPD-PT 术后分别为 35.5%/41.9%（p=0.8 和 1）。R0 切除率无统计学差异，MIPD-PT 后为 97.4%，OPD-PT 后为 87.0%（p=0.2）。对于恶性 PT 的 MIPD 和 OPD，总体 1 年、3 年和 5 年生存率和中位生存时间分别为 82.5%、59.6%和 46.3%和 38 个月，而 OPD 分别为 52.5%、15.7%和 10.5%和 13 个月（p=0.01）。在 MIDP-PT 组中，1 年、3 年和 5 年的无复发生存率（RFS）和中位 RFS 分别为 69.1%、41.9%和 33.5%和 26 个月，而在 OPD-PT 组中，分别为 50.4%、6.3%和 6.3%和 13 个月（p=0.03）。
结论
从一开始就能够进行 MI 和 OPD 的 FT HPB 外科医生可能更倾向于微创地处理可切除的壶腹周围肿瘤。这可能会导致出血量减少，住院时间缩短。尽管手术时间较长，但 MI 技术的更好可视化可能会导致与历史上的开放性对照相比，更高的 R0 率。此外，结合辅助化疗治疗的更快启动，这最终可能会导致生存的改善。
Zotero 插件