保留幽门的胰十二指肠切除术与标准胰十二指肠切除术治疗壶腹周围癌的疗效比较

Efficacy comparison between pyloruspreserving pancreaticoduodenectomy and standard pancreaticoduodenectomy for periampullary carcinoma

    摘要
  • 摘要: 目的:比较保留幽门的胰十二指肠切除术(PPPD)与标准胰十二指肠切除术(SPD)治疗壶腹周围癌的近期效果。
    方法:回顾性分析2010年10月至2012年10月复旦大学附属中山医院收治的85例壶腹周围癌患者的临床资料。44例患者行PPPD设为PPPD组，41例患者行SPD设为SPD组。观察2组患者术中情况，分析胰瘘(B级及以上)、胆瘘、出血、腹腔感染、胃排空障碍和患者预后情况。采用电话和门诊方式随访，术后第1年每3个月随访1次，术后第2～3年每6个月随访1次，随访时间截至2014年 10月。计数资料比较采用χ2检验，计量资料用M(Qn)表示，比较采用MannWhitney U检验。KaplanMeier法绘制生存曲线，生存分析采用Logrank检验。
    结果:PPPD组患者的手术时间为195 min(180 min, 240 min)，SPD组患者为210 min(180 min,300 min)，两组比较，差异有统计学意义(Z=-2.090，P<0.05)。PPPD组患者的术中出血量、术中输血量及术后住院时间分别为200 mL(113 mL,288 mL)、0 mL(0 mL, 0 mL)和17 d(12 d,24 d)，SPD组患者上述指标分别为200 mL(150 mL，325 mL)、0 mL(0 mL,400 mL)和16 d(12 d,30 d)，两组比较，差异均无统计学意义(Z=-1.185，-1.780，-0.533，P>0.05)。两组均无围术期死亡患者，总体并发症发生率42.4%(36/85)，以胰瘘、腹腔感染及胃排空障碍多见。PPPD组患者术后胃排空障碍的发生率为20.5%(9/44)，高于SPD组的4.9%(2/41)，两组比较，差异有统计学意义(χ2=4.571，P<0.05)；PPPD组患者术后胰瘘、胆瘘、腹腔感染及术后出血发生率和2个及以上并发症发生率分别为20.5%(9/44)、2.3%(1/44)、15.9%(7/44)、4.5%(2/44)、25.0%(11/44)，SPD组患者上述指标分别为14.6%(6/41)、4.9%(2/41)、19.5%(8/41)、7.3%(3/41)、14.6%(6/41)，两组比较，差异均无统计学意义(χ2=0.495，0.423，0.295，0.190，1.425，P>0.05)。85例患者均获随访，随访时间为6～47个月，中位随访时间为31个月。85例患者的术后1、3年总体生存率分别为95.3%、75.5%；PPPD组患者的术后1、3年总体生存率分别为97.7%和78.9%，SPD组患者术后1、3年生存率为92.7%和71.7%，两组患者术后3年生存率比较，差异无统计学意义(χ2=0.690，P> 0.05)。无淋巴结转移患者与有淋巴结转移患者的术后3年生存率分别为80.5%、54.9%，两者比较，差异有统计学意义(χ2=4.290，P<0.05)。
    结论:治疗壶腹周围癌，PPPD与SPD均能获得良好的近期疗效；PPPD手术时间短于SPD，但术后胃排空障碍的发生率高于SPD；淋巴结转移是影响壶腹周围癌术后短期生存率的重要因素，对有淋巴结转移的壶腹周围癌患者不建议行PPPD。

     

    Abstract: Objective:To compare the shortterm efficacy of pyloruspreserving pancreaticoduodenectomy (PPPD) and standard pancreaticoduodenectomy (SPD) for the treatment of periampullary carcinoma.Methods :The clinical data of 85 patients with periampullary carcinoma who were admitted to the Zhongshan Hospital of Fudan University from October 2010 to October 2012 were retrospectively analyzed. Fortyfour patients who underwent PPPD were divided into the PPPD group and 41 patients who underwent SPD were divided into the SPD group. The pancreatic fistula(Grade B and above), biliary fistula, blood loss, intraabdominal infection, delayed gastric emptying (DGE) and prognosis were analyzed. Patients were followed up by telephone interview and outpatient examination once every 3 months within postoperative 1 year and once every 6 months within postoperative 2- 3 years till October 2014. Count data were analyzed using the chisquare test, measurement data with normal distribution were presented as M(Qn) and comparison was analyzed using the MannWhitney U test. The survival curve was drawn by the KaplanMeier method, and survival rate was analyzed using the Log rank test.
    Results :The operation time was 195 minutes (180 minutes, 240 minutes) in the PPPD group and 210 minutes (180 minutes,300 minutes) in the SPD group, with a significant difference (Z=-2.090, P<0.05). The volume of intraoperative blood loss, intraoperative blood transfusion and duration of postoperative hospital stay were 200 mL(113 mL, 288 mL), 0 mL(0 mL, 0 mL) and 17 days(12 days, 24 days) in the PPPD group, and 200 mL(150 mL, 325 mL), 0 mL(0 mL, 400 mL) and 16 days(12 days, 30 days) in the SPD group respectively, with no significant differences between the 2 groups (Z=-1.185,-1.780,-0.533, P>0.05). There was no perioperative death and incidence of overall complication was 42.4%(36/85) with pancreatic fistula, intraabdominal infection and DGE as the top 3 common postoperative complications. The incidence of DGE was 20.5%(9/44) in the PPPD group，which was significantly different from 4.9%(2/41) in the SPD group (χ2=4.571, P<0.05). The incidence of pancreatic fistula, biliary fistula, intraabdominal infection, postoperative bleeding and 2 or more complications were 20.5%(9/44), 2.3%(1/44), 15.9%(7/44), 4.5%(2/44), 25.0%(11/44) in the PPPD group, and 14.6%(6/41), 4.9%(2/41), 19.5%(8/41), 7.3%(3/41), 14.6%(6/41) in the SPD group, respectively, showing no significant difference between the 2 groups (χ2=0.495, 0.423, 0.295, 0.190, 1.425, P>0.05). Eightyfive patients were followed up for 6-47 months with a median time of 31 months, and postoperative overall 1 and 3year survival rates were 95.3% and 75.5%, respectively. The 1 and 3year survival rates were 97.7% and 78.9% in the PPPD group, and 92.7% and 71.7% in the SPD group, respectively, with no significant difference in 3year survival rate (χ2=0.690, P>0.05). The 3year overall survival rate was 80.5% in patients without lymph node involvement (LNI) compared with 54.9% in patients with LNI, showing a significant difference (χ2=4.290, P< 0.05).
    Conclusions:Both PPPD and SPD have good shortterm efficacy for periampullary carcinoma. There is no significant difference between PPPD and SPD concerning shortterm survival rate of periampullary carcinoma. PPPD has shorter operation time, but has a higher postoperative DGE incidence. LNI is a significant prognostic factor for shortterm survival of periampullary carcinoma. PPPD is not recommended while the lymph nodes are involved.

     

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