Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, and National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC.
J Chin Med Assoc. 2021 Jul 1;84(7):698-703. doi: 10.1097/JCMA.0000000000000558.
Though nowadays a palliative pancreaticoduodenectomy (PD) can be performed safely with relatively low mortality and acceptable morbidity rates in experienced centers, there have been no studies on the routine use of a palliative PD or on the advantages of performing surgical resection as a debulking procedure. Furthermore, the impact of resection margins on survival outcomes has been a matter of controversy. Therefore, this study aimed to clarify the role of robotic PD (RPD) in pancreatic and periampullary adenocarcinomas with positive resection margins.
Patients undergoing RPDs and open PDs (OPDs) were included in this study. Based on the resection margins, the patients were divided into the R0, R1, and R2 PD groups. Surgical risks and survival outcomes were analyzed.
There were 348 PDs, including 29 (8.3%) palliative and 319 (91.7%) curative. Primary tumor origin, tumor sizes, perineural invasions, and abnormal serum carcinoembryonic antigen (CEA) levels were factors leading to palliative resection. The multivariate analysis showed that only pancreatic head adenocarcinomas and abnormal serum CEA levels (>5 ng/mL) were independent predictors. The surgical risks between curative and palliative PD were similar. There were no significant differences in the surgical risks and other surgical parameters between palliative RPDs and OPDs. For curative resection, RPDs resulted in less blood loss, greater harvested lymph nodes yield, less postoperative complications, less delayed gastric emptying, and shorter hospital stays than OPDs. The survival outcome was significantly better following R0 resection in overall periampullary adenocarcinomas, whereas a significant survival difference was shown only between the R0 and R2 resections for pancreatic head adenocarcinomas.
Compared with R0 PDs, palliative R1 PDs could benefit patients with pancreatic head adenocarcinomas when considering survival outcomes without increasing surgical risks. RPD can be considered for curative purposes and as an alternative for palliative management.
如今，在经验丰富的中心，通过安全的姑息性胰十二指肠切除术（PD）可以实现相对较低的死亡率和可接受的发病率，但目前还没有关于常规使用姑息性 PD 或手术切除作为减瘤术的优势的研究。此外，切缘对生存结果的影响一直存在争议。因此，本研究旨在阐明机器人 PD（RPD）在胰腺和壶腹周围腺癌伴阳性切缘中的作用。
本研究纳入了接受 RPD 和开放 PD（OPD）的患者。根据切缘情况，将患者分为 R0、R1 和 R2 PD 组。分析了手术风险和生存结果。
共进行了 348 例 PD，其中 29 例（8.3%）为姑息性，319 例（91.7%）为根治性。原发肿瘤来源、肿瘤大小、神经周围侵犯和异常血清癌胚抗原（CEA）水平是导致姑息性切除的因素。多因素分析显示，只有胰头腺癌和异常血清 CEA 水平（>5ng/ml）是独立预测因素。根治性和姑息性 PD 的手术风险相似。姑息性 RPD 和 OPD 之间的手术风险和其他手术参数无显著差异。对于根治性切除，RPD 组出血量较少，淋巴结采集量较多，术后并发症较少，胃排空延迟较少，住院时间较短。在总体壶腹周围腺癌中，R0 切除后的生存结果明显更好，而在胰头腺癌中，仅 R0 和 R2 切除之间显示出显著的生存差异。
与 R0 PD 相比，考虑生存结果时，R1 姑息性 PD 可能使胰头腺癌患者受益，而不会增加手术风险。RPD 可用于根治性目的，并作为姑息性治疗的替代方案。
