Liang Tingbo, Zhang Qi, Wu Guosheng, Liu Chaoxu, Bai Xueli, Gao Shunliang, Ma Tao, Sun Ke, Yan Senxiang, Xiao Wenbo, Jiang Tian'an, Lu Fangyan, Zhang Yuntao, Shen Yan, Zhang Min, Zhang Xiaochen, Shan Jianzhen
Department of Hepatobiliary and Pancretic Surgery and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
Innovation Center for the Study of Pancreatic Diseases of Zhejiang Province, Hangzhou, China.
Ann Surg. 2023 Nov 1;278(5):e1055-e1062. doi: 10.1097/SLA.0000000000005797. Epub 2023 Jan 24.
To achieve radical resection of locally advanced pancreatic ductal adenocarcinoma (PDAC), and tested the safety and benefits of intestinal autotransplantation in pancreatic surgery.
PDAC has an extremely dismal prognosis. Radical resection was proved to improve the prognosis of patients with PDAC; however, the locally advanced disease had a very low resection rate currently. We explored and evaluated whether the combination of modern advances in systemic treatment and this macroinvasive surgery was feasible in clinical practice.
Patients diagnosed as PDAC with superior mesenteric artery involvement and with or without celiac trunk involvement were included. Patients were treated with modified-FOLFIRINOX chemotherapy with or without anti-PD-1 antibodies and were applied to tumor resection combined with intestinal autotransplantation. Data on operative parameters, pathologic results, mortality, morbidity, and survival were analyzed.
A total of 36 consecutive cases were applied to this strategy and underwent radical resection combined with intestinal autotransplantation. Among these patients, 24 of them received the Whipple procedure, 11 patients received total pancreatectomy, and the other 1 patient received distal pancreatectomy. The median operation time was 539 minutes. Postoperative pathology showed an R0 resection rate of 94.4%, and tumor invasion of a superior mesenteric artery or superior mesenteric vein was confirmed in 32 patients. The median number of dissected lymph nodes was 43, and 25 patients were positive for lymph node metastasis. The median time of intensive care unit stay was 4 days. Two patients died within 30 days after surgery due to multiorgan failure. The severe postoperative adverse events (equal to or higher than grade 3) were observed in 12 out of 36 patients, and diarrhea, gastroparesis, and abdominal infection were the most frequent adverse events. Postoperative hospital stay was averagely of 34 days. The recurrence-free survival is 13.6 months. The median overall survival of patients after diagnosis and after surgery was 21.4 months and 14.5 months, respectively.
Our attempt suggests the safety of this modality and may be clinically beneficial for highly selected patients with PDAC. However, the experience in multidisciplinary pancreatic cancer care and intestinal transplantation is warranted.
实现局部晚期胰腺导管腺癌（PDAC）的根治性切除，并测试肠道自体移植在胰腺手术中的安全性和益处。
PDAC的预后极差。根治性切除已被证明可改善PDAC患者的预后；然而，目前局部晚期疾病的切除率非常低。我们探索并评估了全身治疗的现代进展与这种大型侵入性手术相结合在临床实践中是否可行。
纳入诊断为伴有肠系膜上动脉受累且有或无腹腔干受累的PDAC患者。患者接受改良FOLFIRINOX化疗，联合或不联合抗PD - 1抗体，并接受肿瘤切除联合肠道自体移植。分析手术参数、病理结果、死亡率、发病率和生存率数据。
共有36例连续病例采用该策略并接受了根治性切除联合肠道自体移植。在这些患者中，24例接受了胰十二指肠切除术，11例接受了全胰切除术，另1例接受了胰体尾切除术。中位手术时间为539分钟。术后病理显示R0切除率为94.4%，32例患者证实有肠系膜上动脉或肠系膜上静脉受肿瘤侵犯。中位清扫淋巴结数为43个，25例患者有淋巴结转移阳性。重症监护病房停留的中位时间为4天。2例患者术后30天内死于多器官功能衰竭。36例患者中有12例观察到严重的术后不良事件（等于或高于3级），腹泻、胃轻瘫和腹腔感染是最常见的不良事件。术后住院时间平均为34天。无复发生存期为13.6个月。患者诊断后和手术后的中位总生存期分别为21.4个月和14.5个月。
我们的尝试表明了这种方式的安全性，可能对经过严格筛选的PDAC患者具有临床益处。然而，多学科胰腺癌护理和肠道移植方面的经验是必要的。
