Herter F P, Cooperman A M, Ahlborn T N, Antinori C
Ann Surg. 1982 Mar;195(3):274-81. doi: 10.1097/00000658-198203000-00006.
Between 1940 and 1978, 179 patients underwent pancreatic resection (64 total, 102 Whipple, 13 distal) at the Presbyterian Hospital, predominantly for carcinoma of the pancreas and periampullary area. With respect to operative morbidity and mortality and survival, these patients have been compared with 141 patients subjected to pancreatic biopsy only, and with 172 by-passed for palliation. Likewise, total pancreatectomy has been compared to pancreaticoduodenectomy (Whipple) in terms of safety and efficacy. The overall major postoperative complication rate for pancreatic resection was 36%, in contrast with 13.5% for biopsy only and 16.8% for by-pass. Of the resected cases with major complications postoperatively, roughly half died, a mortality of 17.9%. Patients who underwent Whipple resections fared significantly better than did those having total pancreatectomies; the postoperative mortality following 102 Whipples was 14.7%, as compared with 23.4% for total pancreatectomies. Intra-abdominal sepsis accounted for most of the postoperative deaths; nine pancreatic and four biliary leaks or fistulae followed Whipple resections. The later complications were of interest; 18 patients undergoing biliary-en-teric by-pass procedures later developed gastroduodenal obstruction, 15 of whom required reoperation, and in 18 survivors of pancreatic resection, upper gastrointestinal hemorrhage (mostly from marginal ulcers) developed, necessitating surgery in seven. Brittle diabetes was a problem in nine patients following pancreatectomy. Survival rates were discouraging in all categories. For ductal carcinoma of the pancreas, median survival for biopsy only was two months, for by-pass six months, for total pancreatectomy nine months, and for Whipple resection 14 months. There were three five-year survivors following resection, a rate of 4.5%. Five-year survival rates following resection for ampullary, common duct, duodenal, and islet cell cancer were 27.8, 33.3, 27.3, and 37.5%, respectively. It is concluded that survival after resection for ductal pancreatic cancer is so rare as to be considered more a biologic aberration than a result of radical surgery. Despite theoretical advantages of total pancreatectomy over Whipple resections, our experience would suggest that the latter can be carried out with lower morbidity and mortality, and with equal chance for cure. Resection for pancreatic cancer should not be abandoned, but rather undertaken with greater selectivity. Operative morbidity and mortality can probably be improved additionally by preoperative transhepatic biliary decompression, and later complications reduced by including vagotomy with gastric resection at the time of pancreatectomy and by performing prophylactic gastroenterostomies in conjunction with by-pass procedures.
1940年至1978年间，179例患者在长老会医院接受了胰腺切除术（全胰切除术64例，惠普尔手术102例，胰体尾切除术13例），主要用于治疗胰腺癌和壶腹周围癌。在手术发病率、死亡率和生存率方面，将这些患者与仅接受胰腺活检的141例患者以及因姑息治疗而接受旁路手术的172例患者进行了比较。同样，在安全性和有效性方面，将全胰切除术与胰十二指肠切除术（惠普尔手术）进行了比较。胰腺切除术的总体术后主要并发症发生率为36%，而仅活检的患者为13.5%，旁路手术的患者为16.8%。在术后出现主要并发症的切除病例中，约一半死亡，死亡率为17.9%。接受惠普尔切除术的患者预后明显好于接受全胰切除术的患者；102例惠普尔手术后的术后死亡率为14.7%，而全胰切除术为23.4%。腹腔内感染是术后死亡的主要原因；惠普尔切除术后有9例胰瘘和4例胆瘘。后期并发症也值得关注；18例接受胆肠旁路手术的患者后来出现胃十二指肠梗阻，其中15例需要再次手术，在18例胰腺切除术后的幸存者中，出现上消化道出血（主要来自边缘溃疡），7例需要手术治疗。胰腺切除术后9例患者出现脆性糖尿病。所有类型的生存率都令人沮丧。对于胰腺导管癌，仅活检的患者中位生存期为2个月，旁路手术为6个月，全胰切除术为9个月，惠普尔切除术为14个月。切除术后有3例患者存活5年，生存率为4.5%。壶腹癌、胆总管癌、十二指肠癌和胰岛细胞癌切除术后的5年生存率分别为27.8%、33.3%、27.3%和37.5%。结论是，胰腺导管癌切除术后的生存极为罕见，与其说是根治性手术的结果，不如说是一种生物学异常。尽管全胰切除术相对于惠普尔切除术在理论上有优势，但我们的经验表明，后者可以在更低的发病率和死亡率下进行，且治愈机会相同。胰腺癌的切除术不应被放弃，而应更有选择性地进行。术前经肝胆汁减压可能会进一步改善手术发病率和死亡率，在胰腺切除时行迷走神经切断术加胃切除术以及在旁路手术时行预防性胃肠吻合术可能会减少后期并发症。
