Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China.
Surg Endosc. 2023 Dec;37(12):9326-9338. doi: 10.1007/s00464-023-10470-7. Epub 2023 Oct 27.
The use of laparoscopic pancreaticoduodenectomy (LPD) in pancreatic head cancer remains controversial, and an appropriate surgical approach can help improve perioperative safety and oncological outcomes. This study aimed to assess the short-term outcomes and long-term survival of the superior mesenteric artery first (SMA-first) approach in patients with pancreatic ductal adenocarcinoma (PDAC) undergoing LPD.
The data of 91 consecutive PDAC patients who underwent LPD from June 2014 to June 2021 were retrospectively analyzed. Patients were divided into two groups, the modified SMA-first approach group, using a combined posterior and anterior approach, and the conventional approach group. Perioperative outcomes, pathologic results, and overall survival (OS) were compared between groups, and propensity score-matched (PSM) analysis was performed.
The number of lymph nodes harvested was greater in the SMA-first approach group (19 vs. 15, P = 0.021), as did the results in the matched cohort (21 vs. 15, P = 0.046). No significant difference was observed in the R0 resection rate (93.3% vs. 82.6%, P = 0.197), but the involvement of the SMA margin was indeed lower in the SMA-first approach group (0 vs. 13%). There were no obvious variances between the two groups in terms of intraoperative bleeding, operative time, overall and major postoperative complication rates, and mortality in either the original cohort or matched cohort. The median OS was 21.8 months in the SMA-first group, whereas it was 19.8 months in the conventional group (P = 0.900). Survival also did not differ in the matched cohort (P = 0.558). TNM stage, resection margin, overall complications, and adjuvant therapy were independent risk factors affecting OS.
The modified SMA-first approach is safe and feasible for PDAC patients undergoing LPD. It had a slight advantage in specimen quality, but OS was not significantly prolonged.
腹腔镜胰十二指肠切除术（LPD）在胰头癌中的应用仍存在争议，合适的手术方式有助于提高围手术期安全性和肿瘤学结果。本研究旨在评估肠系膜上动脉优先（SMA-first）入路在接受 LPD 的胰腺导管腺癌（PDAC）患者中的短期结果和长期生存情况。
回顾性分析 2014 年 6 月至 2021 年 6 月期间连续 91 例接受 LPD 的 PDAC 患者的数据。患者分为两组：改良 SMA-first 组采用联合后前入路，常规组采用常规入路。比较两组患者的围手术期结果、病理结果和总生存期（OS），并进行倾向评分匹配（PSM）分析。
SMA-first 组的淋巴结清扫数目更多（19 个 vs. 15 个，P=0.021），匹配队列的结果也是如此（21 个 vs. 15 个，P=0.046）。R0 切除率无显著差异（93.3% vs. 82.6%，P=0.197），但 SMA 切缘受累率确实较低（0% vs. 13%）。在原始队列或匹配队列中，两组之间在术中出血量、手术时间、总并发症和主要并发症发生率以及死亡率方面均无明显差异。SMA-first 组的中位 OS 为 21.8 个月，常规组为 19.8 个月（P=0.900）。匹配队列的生存情况也无差异（P=0.558）。TNM 分期、切缘、总体并发症和辅助治疗是影响 OS 的独立危险因素。
改良 SMA-first 入路应用于接受 LPD 的 PDAC 患者是安全可行的，在标本质量方面略有优势，但 OS 无显著延长。
