联合门静脉和(或)肠系膜上静脉切除的胰十二指肠切除术4例报告

摘要

目的 探讨联合门静脉(PV)和(或)肠系膜上静脉(SMV)切除的胰十二指肠切除术方法.方法 回顾性分析2015-12-01—2016-01-15因侵袭(>180°)门静脉和(或)肠系膜上静脉的胰颈部肿瘤在第二军医大学附属长海医院胰腺外科接受联合血管切除的胰十二指肠切除术4例病人临床资料.4例手术方式分别为保留幽门的胰十二指肠切除术(PPPD)+PV节段切除重建,先行PV+SMV节段切除重建的胰十二指肠切除术(PD),PD+SMV节段切除重建,PPPD+SMV节段切除重建.结果 手术时间206~263 min,平均242 min;血管切除长度为20~35 mm,平均27 mm,血管阻断时间20~25 min,平均22 min,均未使用人造血管;术中出血700~1700 mL,平均1025 mL,术中输血800~1800 mL,平均1100 mL,手术顺利;4例病人术后病理学检查均为胰腺导管腺癌,肿块最大径2.5~5.0 cm,平均3.9 cm;1例病人术后出现胃排空延迟,术后第15天拔除胃管;1例术后出现胆肠吻合口水肿伴不全梗阻,合并A级胰瘘,经保守治疗后恢复;总住院费用46694.3~146991.0元,平均80214.3元;术后住院时间10~27 d,平均20 d,均顺利出院.结论 联合PV和(或)SMV切除的PD的术前和术中评估非常重要.行切除前须解剖被侵犯静脉的上下端,明确静脉切除后是否能安全重建非常重要;切除癌灶前在原位完成门静脉与肠系膜上静脉的阻断、切除与重建的手术策略对此类病人安全有效.%Objective To discuss the operative strategy of pancreaticoduodenectomy combined with vascular resection of portal vein (PV) and/or superior mesenteric vein (SMV). Methods The clinical data of 4 patients with pancreatic neck tumor encasing the PV and/or SMV received pancreaticoduodenectomy (PD) combined with vascular resection between December 1, 2015 and January 15, 2016 at the Department of Pancreatic Surgery of Changhai Hospital Affiliated to the Second Military Medical University were analyzed retrospectively. The patients received pylorus-preserving pancreaticoduodenectomy(PPPD)combined with PV resection,pancreaticoduodenectomy(PD)with prior PV-SMV shunting,PD combined with SMV resection and PPPD combined with SMV resection, respectively. Results The duration of surgery ranged from 206 to 263 min,with an average of 242 min;the length of the resected vein ranged from 20 to 35 mm, with an average of 27 mm;the duration of vascular occlusion ranged from 20 to 25 min, with an average of 22 min;artificial blood vessel was not used in all of patients;intraoperative blood loss ranged from 700 to 1700 mL,with an average of 1025mL,and intraoperative blood transfusion ranged from 800 to 1800 mL,with an average of 1100 mL. The pathology diagnosis of the 4 patients was pancreatic ductal adenocarcinoma, and the maximal diameter of the tumor ranged from 2.5 to 5.0 cm, with an average of 3.9cm. One of them had delayed gastric emptying, and the gastric tube was removed at postoperative day 15. One of them had bilioenteric anastomosis edema with partial obstruction and pancreatic fistula grade A, and all of them recovered well. The total hospitalization cost ranged from 46 694.3 to 146991.0 yuan, with an average of 80214.3 yuan. The postoperative length of hospital stay ranged from 10 to 27 days,with an average of 20 days. All the patients discharged home smoothly. ConclusionThe preoperative and intraoperative evaluation is very important for PD combined with vascular resection of PV and/or SMV. It is very important to dissect the invaded blood vessels before resection to insure the blood vessels can be reconstructed safely. It is safe and effective to resect and reconstruct the PV and/or SMV in situ before the resection of the tumor.