孫志鵬 朱昱冰 阿民布和 樊 慶 李天雄 張能維

(首都醫(yī)科大學(xué)附屬北京世紀(jì)壇醫(yī)院腫瘤外科，北京大學(xué)第九臨床醫(yī)學(xué)院， 北京 100038)

·臨床研究·

腹腔鏡保脾胰體尾整塊切除手術(shù)治療胰腺癌的技術(shù)細(xì)節(jié)及預(yù)后

孫志鵬△朱昱冰△阿民布和 樊 慶 李天雄 張能維*

(首都醫(yī)科大學(xué)附屬北京世紀(jì)壇醫(yī)院腫瘤外科，北京大學(xué)第九臨床醫(yī)學(xué)院， 北京 100038)

目的闡述腹腔鏡保脾胰體尾整塊切除手術(shù)的技術(shù)細(xì)節(jié)，并對(duì)其治療胰腺癌的短期、長(zhǎng)期腫瘤學(xué)預(yù)后及合并癥情況進(jìn)行評(píng)價(jià)。方法采用回顧性病例對(duì)照分析的方法，研究對(duì)象為北京世紀(jì)壇醫(yī)院2007年1月1日至2010年1月1日間術(shù)前診斷為I期、II期胰體尾癌，且無脾門淋巴結(jié)轉(zhuǎn)移的23例病人，其中17例接受腹腔鏡保脾胰體尾整塊切除手術(shù)，同期6例行脾切除的腹腔鏡胰體尾整塊切除手術(shù)，對(duì)兩組的手術(shù)時(shí)間、術(shù)中出血等術(shù)中情況，近期、遠(yuǎn)期腫瘤學(xué)預(yù)后及合并癥情況進(jìn)行匯總分析，并與開腹手術(shù)的同期文獻(xiàn)報(bào)道的相關(guān)指標(biāo)進(jìn)行比較。結(jié)果6例腹腔鏡保脾胰體尾整塊切除手術(shù)的平均手術(shù)時(shí)間為(203±54)min。平均出血量為(208±106)mL。1例由于嚴(yán)重的腹腔粘連中轉(zhuǎn)開腹。短期合并癥率為47%(n=8)，胰瘺的發(fā)生率為41%(n=7)。無圍術(shù)期死亡病例。腫瘤平均直徑為(32±12)mm，平均淋巴結(jié)獲得數(shù)量為(19.8±9.3)個(gè)。切緣均為陰性。病人的1、3、5年總生存率分別為64.7%、52.9%、41.2%，無復(fù)發(fā)生存率分別為58.8%、47.1%、35.3%。這些指標(biāo)與同時(shí)期行脾切除的腹腔鏡胰體尾手術(shù)及同期開腹胰體尾手術(shù)報(bào)道相比，差異無統(tǒng)計(jì)學(xué)意義。結(jié)論腹腔鏡保脾胰體尾整塊切除手術(shù)治療術(shù)前診斷為I期、II期，且無脾門淋巴結(jié)轉(zhuǎn)移的胰體尾癌，具有可接受的近期、遠(yuǎn)期腫瘤學(xué)預(yù)后及手術(shù)合并癥發(fā)生率。

腹腔鏡保脾胰體尾整塊切除手術(shù)；胰腺癌；整塊切除技術(shù)；根治性順勢(shì)胰體尾脾切除術(shù)

在過去的20年里，腹腔鏡胰體尾手術(shù)經(jīng)歷了從最初的嘗試應(yīng)用的個(gè)案報(bào)道，到逐漸地用在診斷性腹腔鏡探查、標(biāo)本活檢、胰體尾切除、胰十二指腸切除的過程[1]。由于腹腔鏡胰體尾切除的難度不大，在良性及低度惡性的疾病中，該手術(shù)方式得到了廣泛應(yīng)用[2]。

2003年，Strasberg等[3]首先提出了根治性順行胰體尾脾整塊切除的概念(radical antegrade modular pancreatosplenectomy, RAMPS)。其后Mitchem等[4]對(duì)后方離斷平面進(jìn)行了研究，將其分為離斷部分Gerota筋膜的前RAMPS平面和完全剝離Gerota筋膜的后RAMPS平面。并得出后RAMPS切除平面可獲得更好的R0切除率。獲得更好的遠(yuǎn)期生存率。然而以歐美流派為代表的RAMPS手術(shù)雖然對(duì)于后方清掃平面給予了明確界定，但對(duì)于胰體尾癌的淋巴結(jié)清掃及神經(jīng)清掃范圍的描述仍十分模糊[5]。

日本的胰腺癌診療指南[6-7]一直有對(duì)胰腺癌淋巴結(jié)的明確分組，第5版及第6版有對(duì)神經(jīng)叢切除范圍的明確描述。盡管這樣的手術(shù)規(guī)范仍缺乏充分的循證醫(yī)學(xué)證據(jù)支持，但這是少有的明確淋巴結(jié)分組及神經(jīng)清掃范圍的指南之一。因此根據(jù)日本胰腺癌診療指南第5版(2003年)[8]及RAMPS手術(shù)后方離斷平面，筆者設(shè)計(jì)了腹腔鏡胰腺癌整塊切除手術(shù)。標(biāo)準(zhǔn)保脾胰體尾整塊切除技術(shù)的目前術(shù)式并未確定。因此筆者的研究目的是闡述筆者所理解的保脾的腹腔鏡胰體尾整塊切除(laparoscopic distal pancreatectomy，LDP)手術(shù)的技術(shù)細(xì)節(jié)，并參考匯總既往的胰體尾腫瘤手術(shù)的近期、遠(yuǎn)期療效的研究[4，9-12]，對(duì)該手術(shù)技術(shù)的近期、遠(yuǎn)期腫瘤學(xué)預(yù)后予以評(píng)估。

1 資料與方法

1.1病例資料

從2007年1月1日至2010年1月1日，共計(jì)60名病人進(jìn)行了胰腺癌手術(shù)，其中23例病人進(jìn)行了腹腔鏡手術(shù)。17例為腹腔鏡下保脾胰體尾整塊切除手術(shù)，6例為腹腔鏡下胰體尾+脾切除手術(shù)(包含1例中轉(zhuǎn)開腹)。2002年，大量的臨床研究[12-15]顯示：腹腔鏡手術(shù)可用于胰腺癌治療。對(duì)于良性及術(shù)前根據(jù)美國(guó)癌癥聯(lián)合會(huì)(American Joint Committee on Cancer，AJCC)臨床分期為I期、Ⅱ期，術(shù)前影像學(xué)考慮無脾門淋巴結(jié)轉(zhuǎn)移的胰體尾癌，均將腹腔鏡手術(shù)作為治療方案之一。關(guān)于術(shù)后合并癥的分析，采取Clavian-Dindo的分類方法[14]。胰瘺的定義及分級(jí)標(biāo)準(zhǔn)采用國(guó)際胰瘺研究組織(International Study Group of Pancreatic fistular, ISGPF)的定義及分級(jí)標(biāo)準(zhǔn)[15]。

1.2腹腔鏡胰體尾整塊切除手術(shù)的技術(shù)細(xì)節(jié)

整塊切除的概念：1)整塊切除Gerota筋膜、Toldt筋膜、胰體尾；從左側(cè)自胰尾部開始翻起腎前筋膜至腸系膜上動(dòng)靜脈。2)切除第一站，第二站淋巴結(jié)；清掃8a、8p、10、11p、11 d、18和7、9、14p、14 d、15兩組淋巴結(jié)(表1)。3)腹腔神經(jīng)叢清掃：清掃腹腔神經(jīng)叢第一部、第二部左半周(表2)。在無脾門及胃網(wǎng)膜左血管及淋巴結(jié)侵犯的情況下，保留脾臟。手術(shù)技術(shù)細(xì)節(jié)詳見圖1、圖2，手術(shù)技術(shù)路線見圖3。

表1 胰腺淋巴結(jié)的分組(日本胰腺癌診療指南第5版,2003年)[8]Tab.1 Pancreatic lymph nodes group in General Rulesfor the Study of Pancreatic Cancer (5th edition, 2003)[8]

1.3統(tǒng)計(jì)學(xué)方法

表2 胰腺相關(guān)神經(jīng)叢編號(hào)及名稱(日本胰腺癌診療指南第5版,2003年)[8]Tab.2 Pancreatic nerve plexus group in General Rules for the Study of Pancreatic Cancer (5th edition, 2003)[8]

圖1 保脾胰體尾整塊切除技術(shù)Fig.1 The technique of standard en-bloc spleen-preserving LDP

A： Dissect the gastro-colic ligament, disconnect the transverse mesocolon from the Gerota fascia.B: At the level above the upper surface of the pancreas isolate LGEV and the communicating veins from the distal pancreas. Preserve the LGEV.C: Dissect between the communicating vessels to the distal pancreas.D: At the tail of the pancreas, dissect Gerota fascia from the lower border of left renal vein upward to the left kidney.E: Continue to dissect Gerota fascia to the left border of the SMA. Dissect the lymph nodes and celiac ganglion group Ⅱ around SMA preserving 5 mm ganglion at the right side.F: Continue to dissect upward to the splenic vein. Expose the splenic vein and IMV, ligate and cutoff the IMV.G: Penetrate the pancreas from the posterior surface at the root of splenic vessels.H: Dissect the pancreas at the root of splenic vessels with Harmonic scalpel.I: Isolate the splenic vein at the root, and dissect it.J: Isolate the splenic artery at the root, and dissect it.K: Dissect the lymph nodes and celiac ganglion group I around the celiac trunk preserving 5 mm ganglion at the right side.L: Dissect the retroperitoneum adipose tissue at the upper border of the pancreas. Expose the left adrenal vessles and adrenal gland.M: Preserve the adrenal gland if it hasn’t been invaded. Dissect the retroperitoneum adipose tissue to the origin.N: Ligate and dissect the spleen vessles at the tail of the pancreas.O: Inverting suture the stump of the pancreas.P: Leave a drainage tube in the surgical site;LDP:laparoscopic distal panceatectomy;LGEV：left gastro-epiploic vein；SMA：superior mesentery artery；IMV：inferior mesenteric vein.

圖2 取出標(biāo)本后的腹膜后組織結(jié)構(gòu)Fig.2 The posterior peritoneal structure afterdislodge the specimen

A： The stump of spleen artery, left renal vein, left adrenal vessels, and superior mesentery artery were shown in the picture after surgery.B: The stump of spleen vein was shown in the picture.

2 結(jié)果

2.1病人的一般特征

在23例胰腺癌病人中,12例為男性，11例為女性。平均年齡(65±11.4)歲。平均體質(zhì)量指數(shù)(body mass index, BMI)為(25.9±4.4)kg/m2。美國(guó)麻醉醫(yī)師協(xié)會(huì)(American Society of Anesthesiologists, ASA)評(píng)分均值：2.2。無病人行新輔助化療。

2.2短期預(yù)后評(píng)估

病人手術(shù)情況詳見表3。17例病人行保脾的LDP手術(shù)，6例病人行腹腔鏡切脾的LDP手術(shù)?？傮w平均手術(shù)時(shí)間(203 ± 54) min。平均出血量(208 ± 106)mL。1例病例由于腹腔內(nèi)嚴(yán)重粘連而中轉(zhuǎn)開腹。在手術(shù)時(shí)間上，切脾的LDP與保脾的LDP差異無統(tǒng)計(jì)學(xué)意義[(198±59) minvs(223 ± 29) min，P=0.45]。出血量差異亦無統(tǒng)計(jì)學(xué)意義[(184 ± 65)mLvs(275 ± 109)mL，P=0.49)]。

腹腔鏡胰體尾切除術(shù)總體的合并癥率為47.8%(n=11)，胰瘺的發(fā)生率為39.1%(n=9)。保脾(n=8)與切脾(n=3)兩組之間合并癥的發(fā)生率差異無統(tǒng)計(jì)學(xué)意義(48%vs50%，P=0.90)。所有的病人均在30 d內(nèi)出院。4名病人發(fā)生了Ⅲa級(jí)別的合并癥。2例病人接受了超聲引導(dǎo)下腹腔積液穿刺引流。2例病人接受了經(jīng)內(nèi)鏡逆行性胰膽管造影術(shù)(endoscopic retrograde cholangiopancreatography， ERCP)檢查以確定胰瘺。3例病人診斷為脾梗死。12例病人經(jīng)增強(qiáng)CT檢查脾血運(yùn)正常。2例病人術(shù)后未行增強(qiáng)CT檢查。中轉(zhuǎn)開腹病人為腹腔鏡胰體尾脾整塊切除組病人。因術(shù)中粘連較重，中轉(zhuǎn)開腹，術(shù)后病理為Ⅲ期(T3N1M0)。

圖3 整塊切除手術(shù)技術(shù)的示意圖Fig.3 The diagram of en-bloc resection range

A： After dissecting the spleen artery and vein, the blood flow of spleen compensated by left gastro-epiploic vessels and short gastric vessels.B: Gerota fascia, spleen artery and vein and the distal pancreas were removed with en-bloc technique.C: The posterior peritoneal structures were shown after the specimen removed.SA: spleen artery;SV: spleen vein;LGEA: left gastro-epiploic artery;SGA: short gastric artery;IVC: inferior vena cava;SMA: superior mesentery artery;SMV: superior mesentery artery.

表3 保脾與切脾手術(shù)組的病人特征比較 Tab.3 Patient character of the spleen preserving and resecting group

所有脾梗死的病人均接受了保守觀察，并獲得了自行治愈。病人的平均住院時(shí)間(17±8) d。在住院時(shí)間上，保脾與切脾組差異無統(tǒng)計(jì)學(xué)意義[(18±8)dvs(15±7)d，P=0.36]。腫瘤的平均直徑為(32±12)mm。平均的淋巴結(jié)獲得數(shù)量為(19.8±9.3)個(gè)。14例病人的淋巴結(jié)轉(zhuǎn)移陽(yáng)性個(gè)數(shù)≥1 個(gè)。病理結(jié)果為18例導(dǎo)管腺癌，4例導(dǎo)管內(nèi)乳頭狀癌，1例黏液腺癌。所有的手術(shù)切緣均為陰性。病理分期為：2例 IA期，5例 IB期，2例 ⅡA期，13例 ⅡB期， 1例 Ⅲ期(表4)。從保脾組和切脾組病理結(jié)果分層對(duì)比來看。兩組無論大小、病理類型、切緣、分期情況，差異均無統(tǒng)計(jì)學(xué)意義。

2.3長(zhǎng)期預(yù)后評(píng)估

在5年的觀察期內(nèi)，平均的生存時(shí)間是19個(gè)月。1、3、5年的生存率分別是64.7%、52.9%和41.2%。6例病人出現(xiàn)了術(shù)后復(fù)發(fā)。1例病人同時(shí)出現(xiàn)原位復(fù)發(fā)和肝轉(zhuǎn)移。2例病人為腹膜后復(fù)發(fā)。平均的復(fù)發(fā)時(shí)間是14個(gè)月。1、3、5年的無復(fù)發(fā)生存率分別是58.8%、47.1%、35.3%(圖4)。

表4 保脾與切脾手術(shù)組的病理分期結(jié)果 (國(guó)際抗癌聯(lián)盟第六版，2006年)[16]Tab.4 Pathology outcomes (Union for International Cancer Control Classification, 6th edition)[16]

3 討論

在最近的研究報(bào)道[14-15，17]中顯示，關(guān)于腹腔鏡胰體尾整塊切除手術(shù)治療胰腺癌的長(zhǎng)期預(yù)后是比較滿意的(5年的總生存率約為33%)。筆者的臨床數(shù)據(jù)來源于單中心。腹腔鏡胰體尾整塊切除概念，依賴于胰腺腫瘤的R0切除，N2淋巴結(jié)清掃及左半周神經(jīng)叢清掃。以RAMPS手術(shù)為整塊切除范圍，結(jié)合日本胰腺癌診療指南的淋巴結(jié)及神經(jīng)清掃范圍。

筆者的研究與最近的研究[4，9-12]表明(表5)：腹腔鏡胰體尾切除淋巴結(jié)獲取的數(shù)量與開腹胰體尾切除手術(shù)相似(19.8vs15.5個(gè))。筆者最滿意的是100%的R0切除率。切除的腫瘤直徑也與開腹胰體尾脾切除術(shù)(open distal pancreatectomy， ODP)相似。腹腔鏡手術(shù)與開腹手術(shù)相比，出血量明顯減少(208 mLvs747 mL)。其主要原因是腹腔鏡的放大作用與氣腹作用下腹壓的增大。

圖4 17例腹腔鏡胰體尾整塊切除手術(shù)的生存曲線Fig.4 The overall survival (OS) and recurrencefree survival (RFS) curve

The observation period was 5 years after surgery.The survival rate of 1, 3, 5 years after surgery was 64.7%, 52.9% and 41.2% respectively. The recurrence free survival rate of 1, 3, 5 years after surgery was 58.8%, 47.1% and 35.3% respectively.

表5 既往研究報(bào)告中所報(bào)道的開腹胰體尾切除手術(shù)預(yù)后Tab.5 The prognosis reported by previous studies about open distal pancreatectomy

NS:not stated.

腹腔鏡胰體尾整塊切除技術(shù)強(qiáng)調(diào)整塊切除Gerota筋膜、Toldt筋膜、脾血管及胰體尾，來確保陰性切緣。相對(duì)而言，標(biāo)準(zhǔn)的ODP并不需要常規(guī)切除Gerota筋膜和Toldt筋膜。對(duì)于是否要切除脾臟是一個(gè)有爭(zhēng)議的話題。一些研究[18]表明這種手術(shù)發(fā)生脾梗死的概率為11%到29%。直到目前仍未有任何指南或?qū)＜夜沧R(shí)指出行胰體尾切除手術(shù)必須要切除脾臟。

胰體尾癌有時(shí)會(huì)伴有淋巴結(jié)轉(zhuǎn)移，胰頭神經(jīng)叢、腹腔干神經(jīng)叢、腸系膜上動(dòng)脈神經(jīng)叢侵犯[19-20]。但是全部切除神經(jīng)會(huì)有嚴(yán)重的腹瀉和嘔吐。因此筆者保留上述神經(jīng)叢神經(jīng)的右半周，切除左半周。這也符合日本胰腺癌診療指南的要求，與部分學(xué)者的臨床實(shí)踐[21]相同。

在本研究中，腹腔鏡胰體尾整塊切除的預(yù)后與之前的報(bào)道[1-2，10，15]相似，在這些報(bào)道中病人平均的生存時(shí)間13到26個(gè)月不等。5年生存率19%～36%不等。截至目前，依據(jù)筆者所檢索到的文獻(xiàn)。這是第一份關(guān)于腹腔鏡胰體尾整塊切除手術(shù)長(zhǎng)期預(yù)后的報(bào)告。本研究的局限性在于：首先這是一項(xiàng)回顧性病例對(duì)照研究。并且標(biāo)本的病例類型也只有3種，對(duì)照組僅有6例病例。前瞻性隨機(jī)對(duì)照實(shí)驗(yàn)和大樣本量的研究，可以避免相關(guān)統(tǒng)計(jì)偏移，長(zhǎng)期的腫瘤學(xué)預(yù)后還有待于進(jìn)一步評(píng)估。但由于胰體尾腫瘤的發(fā)病率較低，這樣的實(shí)驗(yàn)也很難于開展。

總之，腹腔鏡保脾胰體尾切除手術(shù)是一項(xiàng)安全、有效的手術(shù)技術(shù)。近期和遠(yuǎn)期預(yù)后均可以接受，可以作為胰體尾腫瘤的治療方案。

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Detailoftheen-bloctechniqueandprognosisofspleen-preservinglaparoscopicdistalpancreatectomyforpancreaticcancer

Sun Zhipeng△, Zhu Yubing△, Aminbuhe, Fan Qing, Li Tianxiong, Zhang Nengwei*

(DepartmentofOncologySurgery,BeijingShijitanHospital,CapitalMedicalUniversity,PekingUniversityNinthSchoolofClinicalMedicine,Beijing100038,China)

ObjectiveThe aim of our study was to illustrate the detail of the spleen-preserving en-bloc technique as while as the short-term, long-term outcomes.MethodsDescribe the detail of the en-bloc technique with pictures. Evaluate the prognosis of successive 23 cases who underwent the laparoscopic distal pancreatectomy (LDP) surgery. There were 17 cases that underwent spleen-preserving LDP while 6 cases underwent spleen-resecting LDP.ResultsThe average surgery time was (203 ± 54)minutes, the average blood loss volume was (208 ± 106)mL. One case was transferred to open surgery because of severe adhesion. The complication rate was 47% (n=8) in short-term after surgery. Pancreatic fistula rate was 41% (n=7). No lethal case occurred. The average diameter of the tumor was (32 ± 12)mm. Average number of the lymph nodes obtained was (19.8 ± 9.3). All the cutting edges were negative. Survival rate of the patient after 1, 3, 5 years were 64.7%, 52.9% and 41.2%. These records showed no statistical significance compared with spleen-resecting LDP and open distal pancreatectomy (ODP) surgeries.ConclusionThe en-bloc spleen-preserving LDP can be performed by experienced surgeons. This surgery has good short-term and long-term outcome.

spleen-preserving laparoscopic distal pancreatectomy; pancreatic cancer; en-bloc technique; radical antegrade modular pancreaticosplenectomy

北京市醫(yī)院管理局揚(yáng)帆重點(diǎn)課題基金資助(ZYLX201512)。This study was supported by Beijing Municipal Administration of Hospitals Clinical Medicine Development of Special Funding Support(ZYLX201512).

*Corresponding author， E-mail：zhangnw1@sohu.com

時(shí)間：2017-10-14 16∶29

http://kns.cnki.net/kcms/detail/11.3662.R.20171014.1629.054.html

10.3969/j.issn.1006-7795.2017.05.019]

R735.9

2017-02-28)

編輯 陳瑞芳

△共同第一作者