根治性顺行模块化胰脾切除术治疗胰体尾癌的临床疗效

Clinical effect of radical antegrade modular pancreatosplenectomy for carcinoma of pancreatic body and tail

    摘要
  • 摘要: 目的:探讨根治性顺行模块化胰脾切除术(RAMPS)治疗胰体尾癌的安全性和可行性。
    方法:采用回顾性队列研究方法。收集2013年1月至2015年10月南京医科大学第一附属医院收治的 99例胰体尾癌患者的临床资料，其中21例患者行RAMPS，设为RAMPS组；78例行经典胰体尾+脾切除术，设为经典手术组。观察指标：(1)手术情况：手术时间，术中出血量，术中输血量，联合脏器切除，联合血管切除，切缘状态。(2)术后情况：总体并发症，术后重要并发症(胰瘘、乳糜瘘、腹腔出血、消化道出血、胃排空障碍、胸腔积液、肺部感染、腹腔积液、腹腔感染、切口感染、下肢深静脉血栓、MODS)，再次手术，术后住院时间，住院费用。(3)随访情况：患者术后生存及肿瘤复发、转移情况。采用门诊或电话方式进行随访，随访患者生存，肿瘤复发、转移情况。随访时间截至2016年3月。正态分布的计量资料以±s表示，组间比较采用Student t检验。偏态分布的计量资料以M(Qn)表示，组间比较采用Wilcoxon秩和检验。计数资料比较采用χ2检验或Fisher确切概率法。采用KaplanMeier法计算患者生存时间。
    结果:(1)手术情况：RAMPS组和经典手术组患者手术时间分别为235 min(180 min，278 min)、180 min(130 min，210 min)，术中出血量分别为400 mL(350 mL，650 mL)、225 mL(200 mL，400 mL)，术中输血量分别为3.1 U (2.5 U，5.6 U )、0 U(0 U，2.0 U)，联合脏器切除分别为13例、10例，两组上述指标比较，差异均有统计学意义(Z= 3.529,2.675,3.389,P<0.05)。RAMPS组和经典手术组患者切缘状态为R0切除分别为19例、71例，R1切除分别为2例、7例，两组比较，差异无统计学意义(P>0.05)。(2)术后情况：RAMPS组和经典手术组患者术后总体并发症分别为16例、48例，胰瘘A级分别为6例、15例，B级分别为5例、19例，C级分别为2例、2例，乳糜瘘分别为1例、5例，腹腔出血分别为1例、4例，消化道出血分别为0例、2例，胃排空障碍分别为1例、 1例，胸腔积液分别为7例、18例，肺部感染分别为0例、4例，腹腔积液分别为6例、15例，腹腔感染分别为 4例、5例，切口感染分别为1例、1例，下肢深静脉血栓分别为0例、2例，MODS分别为0例、1例，再次手术分别为0例、1例，两组上述指标比较，差异均无统计学意义(χ2=1.554，1.642，P>0.05)。RAMPS组和经典手术组患者术后住院时间分别为15 d(13 d，23 d)、12 d(10 d，16 d)，住院费用分别为74 632元(67 041元， 92 445元)、64 410元(54 709元，80 842元)，两组比较，差异均有统计学意义(Z=3.529,2.675,P<0.05)。(3)随访情况：99例患者中，86例获得术后随访，其中RAMPS组18例，经典手术组68例。中位随访时间为18个月(5～37个月)。RAMPS组患者中位生存时间为19个月，复发转移率为33.3%(6/18)；经典手术组患者中位生存时间为14个月，复发转移率为45.6%(31/68)；两组上述指标比较，差异均无统计学意义(χ2= 0.060，0.366，P>0.05)。
    结论:    采用RAMPS治疗胰体尾癌安全、可行，与经典胰体尾+脾切除术比较，不增加手术并发症发生率，可能提高R0切除率。

     

    Abstract: Objective:To explore the safety and feasibility of radical antegrade modular pancreatosplenectomy (RAMPS) for carcinoma of pancreatic body and tail (CPBT).
    Methods:The retrospective cohort study was adopted. The clinical data of 99 patients with CPBT who were admitted to the First Affiliated Hospital of Nanjing Medical University from January 2013 to October 2015 were collected. Among the 99 patients, 21 receiving RAMPS were allocated into the RAMPS group and 78 receiving traditional resection of body and tail of pancreas and splenectomy were allocated into the operation group. Observation indexes included (1) surgical situation: operation time, volume of intraoperative blood loss, volume of blood transfusion, combined organ resection, combined vascular resection, status of the resection margin, (2) postoperative situation: overall complications, major postoperative complications ［pancreatic fistula, chyle leakage, abdominal bleeding, hemorrhage of digestive tract, delayed gastric emptying, pleural effusion, pulmonary infection, peritoneal effusion, abdominal infection, wound infection, deep venous thrombosis in the lower limbs, multiple organ dysfunction syndrome (MODS)］, reoperation, duration of hospital stay, hospital expenses, (3) followup: the postoperative survival of patients, tumor recurrence and metastasis. The followup using outpatient examination and telephone interview was performed to detect the patients′ survival and tumor recurrence and metastasis up to March 2016. Measurement data with normal distribution were presented as ±s and comparison between groups was evaluated with the Student t test. Measurement data with skewed distribution were presented as M(Qn) and comparison between groups was evaluated with the Wilcoxon rank sum test. Count data were analyzed using the chisquare test or Fisher exact probability. The survival time was calculated by the KaplanMeier method.
    Results:(1) Surgical situation: operation time, volume of intraoperative blood loss, volume of blood transfusion and number of patients combined with organ resection were 235 minutes (180 minutes, 278 minutes), 400 mL (350 mL, 650 mL), 3.1 U (2.5 U , 5.6 U), 13 in the RAMPS group and 180 minutes (130 minutes, 210 minutes), 225 mL (200 mL, 400 mL), 0 (0, 2.0 U), 10 in the operation group, respectively, with statistically significant differences between the 2 groups (Z=3.529, 2.675, 3.389, P<0.05). The number of patients with R0 resection and R1 resection were 19, 2 in the RAMPS group and 71, 7 in the operation group, showing no statistically significant difference (P>0.05). (2) Postoperative situation: number of patients with overall complications, pancreatic fistula in grade A, pancreatic fistula in grade B, pancreatic fistula in grade C, chyle leakage, abdominal bleeding, hemorrhage of digestive tract, delayed gastric emptying, pleural effusion, pulmonary infection, peritoneal effusion, abdominal infection, wound infection, deep venous thrombosis in the lower limbs, MODS and reoperation were 16, 6, 5, 2, 1, 1, 0, 1, 7, 0, 6, 4, 1, 0, 0, 0 in the RAMPS group and 48, 15, 19, 2, 5, 4, 2, 1, 18, 4, 15, 5, 1, 2, 1, 1 in the operation group, respectively, with no statistically significant differences between the 2 groups (χ2=1.554, 1.642, P>0.05). The duration of hospital stay and hospital expenses were 15 days (13 days, 23 days), 74 632 Yuan (67 041 Yuan , 92 445 Yuan) in the RAMPS group and 12 days (10 days, 16 days), 64 410 Yuan (54 709 Yuan, 80 842 Yuan) in the operation group, respectively, showing statistically significant differences between the 2 groups (Z=3.529, 2.675, P<0.05). (3) Followup: among 99 patients, 86 were followed up for a median time of 18 months (range, 5-37 months), including 18 patients in the RAMPS group and 68 patients in the operation group. The median survival time and rate of recurrence and metastasis were 19 months, 33.3%(6/18) in the RAMPS group and 14 months, 45.6%(31/68) in the operation group, respectively, with no statistically significant difference between the 2 groups (χ2=0.060, 0.366, P>0.05).
    Conclusion:RAMPS in the treatment of CPBT is safe and feasible, and it could not increase the incidence of complications, however, enhance the R0resection rate compared with traditional resection of body and tail of pancreas and splenectomy.

     

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