Robinson E K, Lee J E, Lowy A M, Fenoglio C J, Pisters P W, Evans D B
Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center, Houston 77030, USA.
Am J Surg. 1996 Nov;172(5):432-7; discussion 437-8. doi: 10.1016/S0002-9610(96)00218-8.
We have noted a continued increase in the number of patients referred to our institution for presumed or biopsy-proven periampullary carcinoma following an "exploratory" laparotomy during which tumor resection was not performed. Although previous work has demonstrated the safety of reoperative pancreaticoduodenectomy (PD), the need to avoid nontherapeutic laparotomy in these patients is obvious. In the current study, we sought to determine why PD was not performed at the initial operation.
Using the prospective pancreatic cancer database, we identified all patients who underwent reoperative PD at our institution between June 1990 and October 1995. Radiologic imaging prior to reoperation was standardized and based on thin-section, contrast-enhanced computed tomography (CT); helical CT was used in more recent cases. Pathologic data were obtained, and initial outside operative reports were reviewed to determine why a PD was not performed at the initial procedure.
Twenty-nine patients underwent reoperative PD. Resection was not performed at the initial laparotomy because of the surgeon's assessment of local unresectability (17 patients), lack of a tissue diagnosis of malignancy (9), misdiagnoses (2), and error in intraoperative management (1). In the 17 patients deemed to have unresectable disease, successful reoperative PD required vascular resection in 10. All 10 of these patients had resection with negative microscopic margins of excision. Of the 9 patients who did not have resection owing to diagnostic uncertainty, all 9 had undergone multiple intraoperative biopsies interpreted as negative for malignancy; 6 of 9 had carcinoma confirmed on permanent-section analysis of the biopsy specimens. Four patients suffered major complications from intraoperative large-needle biopsy.
Detailed preoperative imaging and a clearly defined operative plan would have allowed successful resection at the initial operation in 27 of 29 patients who underwent reoperative PD. Avoidable patient morbidity and the cost of unnecessary surgery argue strongly against "exploratory" surgery in patients with presumed periampullary neoplasms.
我们注意到，在接受了“探查性”剖腹手术但未进行肿瘤切除的患者中，转诊至我院疑似或经活检证实为壶腹周围癌的患者数量持续增加。尽管先前的研究已证明再次手术行胰十二指肠切除术（PD）的安全性，但避免对这些患者进行非治疗性剖腹手术的必要性显而易见。在本研究中，我们试图确定初次手术时未行PD的原因。
利用前瞻性胰腺癌数据库，我们确定了1990年6月至1995年10月期间在我院接受再次手术PD的所有患者。再次手术前的放射学影像检查进行了标准化，基于薄层、增强计算机断层扫描（CT）；近期病例使用螺旋CT。获取病理数据，并回顾初次外部手术报告，以确定初次手术时未行PD的原因。
29例患者接受了再次手术PD。初次剖腹手术时未进行切除是因为外科医生评估局部不可切除（17例患者）、缺乏恶性肿瘤的组织学诊断（9例）、误诊（2例）以及术中管理失误（1例）。在17例被认为患有不可切除疾病的患者中，成功的再次手术PD需要10例行血管切除。所有这10例患者切除术后显微镜下切缘阴性。在9例因诊断不确定而未进行切除的患者中，所有9例均接受了多次术中活检，结果均被解释为无恶性肿瘤；9例中有6例在活检标本的永久切片分析中确诊为癌。4例患者因术中大针活检出现严重并发症。
详细的术前影像检查和明确的手术计划本可使29例接受再次手术PD的患者中的27例在初次手术时成功切除。可避免的患者发病率和不必要手术的费用强烈反对对疑似壶腹周围肿瘤的患者进行“探查性”手术。
