Tyler D S, Evans D B
Department of Surgical Oncology, University of Texas M. D. Anderson Cancer Center, Houston.
Ann Surg. 1994 Feb;219(2):211-21. doi: 10.1097/00000658-199402000-00014.
The preoperative diagnostic strategy and operative technique for reoperative pancreaticoduodenectomy were outlined and operative mortality, perioperative morbidity, and early survival data in carefully selected patients undergoing reoperation for pancreatic cancer were analyzed.
Many patients with localized, nonmetastatic cancer of the pancreas undergo exploratory surgery with limited preoperative assessment of resectability. Frequently, pancreaticoduodenectomy is not performed because cytologic or histologic proof of diagnosis is lacking, or tumor resectability is questioned. Many patients are denied reoperation and a potentially curative resection because of the unacceptable morbidity and mortality believed to accompany pancreaticoduodenectomy in the reoperative setting.
Twenty-three patients who had undergone previous surgery for palliation or diagnosis of a pancreatic head mass were reoperated on after a standardized preoperative imaging evaluation consisting of chest radiography, computed tomography, and visceral angiography. A standardized operative technique was used on all patients, but was modified based on altered anatomy from the initial operation.
Based on preoperative imaging studies, 19 of the 23 patients believed to have resectable tumors underwent laparotomy for planned pancreaticoduodenectomy; resection was accomplished in 14 patients. Seven of the fourteen patients required extended resections that included the superior mesenteric vein, right colon, or both. There was no perioperative mortality, and early complications occurred in 3 of the 14 resected patients. Four patients underwent planned palliative procedures. Four of ten patients who underwent resection for adenocarcinoma are without evidence of disease at a median follow-up of 26 months.
Reoperative pancreaticoduodenectomy can be performed safely and may result in prolonged survival in carefully selected patients with resectable, localized pancreatic cancer.
概述再次行胰十二指肠切除术的术前诊断策略和手术技术，并分析精心挑选的因胰腺癌接受再次手术患者的手术死亡率、围手术期发病率和早期生存数据。
许多局限性、非转移性胰腺癌患者在术前对可切除性评估有限的情况下接受了探查手术。通常，由于缺乏细胞学或组织学诊断证据，或对肿瘤可切除性存在疑问，未进行胰十二指肠切除术。许多患者因认为再次手术时胰十二指肠切除术会带来不可接受的发病率和死亡率而被拒绝再次手术及可能的根治性切除。
23例曾因胰头肿块行姑息性手术或诊断性手术的患者，在经过包括胸部X线摄影、计算机断层扫描和内脏血管造影的标准化术前影像评估后接受了再次手术。所有患者均采用标准化手术技术，但根据初次手术导致的解剖结构改变进行了调整。
根据术前影像研究，23例被认为肿瘤可切除的患者中有19例行剖腹术计划行胰十二指肠切除术；14例患者完成了切除。14例患者中有7例需要扩大切除，包括肠系膜上静脉、右半结肠或两者。围手术期无死亡病例，14例切除患者中有3例发生早期并发症。4例患者接受了计划性姑息手术。10例因腺癌接受切除的患者中有4例在中位随访26个月时无疾病证据。
对于精心挑选的可切除、局限性胰腺癌患者，再次行胰十二指肠切除术可安全实施，并可能延长生存期。
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