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中华肝脏外科手术学电子杂志

中华肝脏外科手术学电子杂志 ›› 2021, Vol. 10 ›› Issue (05) : 479 -483. doi: 10.3877/cma.j.issn.2095-3232.2021.05.010

临床研究

扩大淋巴结清扫在交界可切除胰头癌术中的应用价值
许文犁1, 张欣雪1, 朱继巧1, 李先亮1, 贾亚男1, 王若麟1, 贺强1,†()   
  1. 1. 100020　首都医科大学附属北京朝阳医院肝胆外科
  • 收稿日期:2021-07-02 出版日期:2021-08-17
  • 通信作者: 贺强

Application value of extended lymph node dissection in surgical resection of borderline resectable pancreatic head cancer

Wenli Xu1, Xinxue Zhang1, Jiqiao Zhu1, Xianliang Li1, Yanan Jia1, Ruolin Wang1, Qiang He1,†()   

  1. 1. Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
  • Received:2021-07-02 Published:2021-08-17
  • Corresponding author: Qiang He
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许文犁, 张欣雪, 朱继巧, 李先亮, 贾亚男, 王若麟, 贺强. 扩大淋巴结清扫在交界可切除胰头癌术中的应用价值[J]. 中华肝脏外科手术学电子杂志, 2021, 10(05): 479-483.

Wenli Xu, Xinxue Zhang, Jiqiao Zhu, Xianliang Li, Yanan Jia, Ruolin Wang, Qiang He. Application value of extended lymph node dissection in surgical resection of borderline resectable pancreatic head cancer[J]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2021, 10(05): 479-483.

目的

探讨扩大淋巴结清扫在交界可切除胰头癌术中的应用价值。

方法

回顾性分析2015年1月至2020年12月首都医科大学附属北京朝阳医院收治的94例交界可切除胰头癌患者临床资料。患者均签署知情同意书，符合医学伦理学规定。其中男41例，女53例；年龄29~78岁，中位年龄62岁。根据手术方式将患者分为扩大淋巴结清扫组（扩大清扫组，50例）和标准淋巴结清扫组（标准清扫组，44例）。观察两组患者围手术期和生存情况。两组淋巴结清扫数比较采用秩和检验，并发症发生率、死亡率比较采用χ2检验或Fisher确切概率法，生存分析采用Kaplan-Meier法和Log-rank检验。

结果

本组94例患者均顺利完成手术。扩大清扫组术后总并发症发生率为34%（17/50），标准清扫组为30%（13/44），差异无统计学意义（χ2=0.214，P>0.05）；两组围手术期死亡分别为0、2例，差异无统计学意义（P=0.419）。扩大清扫组淋巴结清扫数为25（15）个，明显大于标准清扫组的18（15）个（Z=2.243，P<0.05）。扩大清扫组术后腹泻发生率30%（15/50），明显高于标准清扫组的7%（3/44） （χ2=8.124，P<0.05）。扩大清扫组和标准清扫组术后1、2、3年无瘤生存率分别为54.1%、44.4%、27.3%和34.9%、19.0%、19.0%，差异有统计学意义（χ2=5.571，P<0.05）。扩大清扫组和标准清扫组术后1、2、3年总体生存率分别为66.1%、49.9%、29.7%和48.8%、16.7%、16.7%，差异有统计学意义（χ2=8.350，P<0.05）。

结论

扩大淋巴结清扫术有助于改善交界可切除胰头癌患者远期预后，且不增加围手术期总并发症发生率和死亡率，但术后腹泻发生率升高。

关键词: 胰腺肿瘤, 交界可切除, 淋巴结切除术, 预后
Objective

To evaluate the application value of extended lymph node dissection in surgical resection of borderline resectable pancreatic head cancer.

Methods

Clinical data of 94 patients with borderline resectable pancreatic head cancer admitted to Beijing Chaoyang Hospital of Capital Medical University from January 2015 to December 2020 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them, 41 patients were male and 53 female, aged from 29 to 78 years, with a median age of 62 years. All patients were divided into the extended lymph node dissection group (extended dissection group, n=50) and standard lymph node dissection group (standard dissection group, n=44). The perioperative conditions and survival of patients in two groups were observed. The number of resected lymph nodes between two groups were compared by rank-sum test. The incidence of complications and mortality between two groups were statistically compared by Chi-square test or Fisher's exact test. Survival analysis was performed by Kaplan-Meier method and Log-rank test.

Results

The surgery of all 94 patients were completed successfully. The total incidence of postoperative complications in the extended dissection group was 34%(17/50) and 30%(13/44) in the standard dissection group, where no significant difference was observed (χ2=0.214, P>0.05). No death case was noted in the extended dissection group, and 2 cases died in the standard dissection group, where no significant difference was observed (P=0.419). The number of resected lymph nodes in the extended dissection group was 25(15), significantly higher than 18(15) in the standard dissection group (Z=2.243, P<0.05). The incidence of postoperative diarrhea in the extended dissection group was 30%(15/50), which was significantly higher than 7%(3/44) in the standard dissection group (χ2=8.124, P<0.05). The 1-, 2-, 3-year disease-free survival rates in the extended group were 54.1%, 44.4%, 27.3%, and 34.9%, 19.0%, 19.0% in the standard dissection group, respectively, significant difference was noted between two groups (χ2=5.571, P<0.05). The 1-, 2-, 3-year overall survival rates in the extended group were 66.1%, 49.9%, 29.7%, and 48.8%, 16.7%, 16.7% in the standard dissection group, respectively, significant difference was noted between two groups (χ2=8.350, P<0.05).

Conclusions

Extended lymph node dissection contributes to improving the long-term prognosis of patients with borderline resectable pancreatic head cancer, which does not increase the total incidence of perioperative complications or mortality, but the incidence of postoperative diarrhea may increased.

Key words: Pancreatic neoplasms, Borderline resectable, Lymph node excision, Prognosis
表1 扩大清扫组和标准清扫组交界可切除胰头癌患者围手术期情况比较
指标 扩大清扫组 标准清扫组 统计值 P值
性别（例，男/女） 21/29 20/24 χ2=0.114 0.736
年龄（岁，±s） 61±10 62±11 t=-0.630 0.530
糖尿病（例） 20 16 χ2=0.131 0.717
术前减黄（例） 9 6 χ2=0.332 0.564
TB[μmol/L，M（QR）] 28（126） 20（86） Z=0.148 0.883
CEA[μg/L，M（QR）] 2.3（2.9） 3.9（3.9） Z=-2.133 0.133
CA19-9[kU/L，M（QR）] 125（491） 216（75） Z=-1.201 0.230
肿瘤直径（cm，±s） 3.6±1.2 4.1±1.5 t=-1.691 0.094
肿瘤分化（例，低/中/高） 13/34/3 15/28/1 χ2=1.346 0.510
新辅助化疗（例） 12 8 χ2=0.473 0.492
术中出血量[ml，M（QR）] 500（400） 600（600） Z=-1.080 0.280
术中输血（例） 20 26 χ2=3.414 0.065
手术时间（h，±s） 11.4±2.7 12.1±2.6 t=-1.221 0.225
淋巴结转移（例） 35 28 χ2=0.429 0.513
淋巴结清扫数[个，M（QR）] 25（15） 18（15） Z=2.243 0.025
切除分类（例，R0/R1） 45/5 39/5 χ2=0.015 0.904
术后化疗（例） 22 20 χ2=0.020 0.887
术后住院时间[d，M（QR）] 21（15） 21（14） Z=0.019 0.985
表2 扩大清扫组和标准清扫组交界可切除胰头癌患者术后并发症比较（例）
指标 扩大清扫组 标准清扫组 χ2值 P值
术后总并发症 17 13 0.214 0.644
生化瘘 5 1 - 0.269
B级胰瘘 0 3 - 0.198
C级胰瘘 1 2 - 0.910
胃排空障碍 3 4 0.031 0.860
腹泻 15 3 8.124 0.004
腹腔感染 4 4 0.033 0.856
腹腔出血 2 2 0.145 0.703
胆漏 1 2 - 0.910
图1 扩大清扫组和标准清扫组交界可切除胰头癌患者Kaplan-Meier生存曲线
[1]
Mizrahi JD, Surana R, Valle JW, et al. Pancreatic cancer[J]. Lancet, 2020, 395(10242):2008-2020.
[2]
O'Reilly EM, Ferrone C. Neoadjuvant or adjuvant therapy for resectable or borderline resectable pancreatic cancer: which is preferred?[J]. J Clin Oncol, 2020, 38(16):1757-1759.
[3]
Nevala-Plagemann C, Hidalgo M, Garrido-Laguna I. From state-of-the-art treatments to novel therapies for advanced-stage pancreatic cancer[J]. Nat Rev Clin Oncol, 2020, 17(2):108-123.
[4]
Ghaneh P, Kleeff J, Halloran CM, et al. The impact of positive resection margins on survival and recurrence following resection and adjuvant chemotherapy for pancreatic ductal adenocarcinoma[J]. Ann Surg, 2019, 269(3):520-529.
[5]
Ishikawa O, Ohhigashi H, Sasaki Y, et al. Practical usefulness of lymphatic and connective tissue clearance for the carcinoma of the pancreas head[J]. Ann Surg, 1988, 208(2):215-220.
[6]
Jang JY, Kang MJ, Heo JS, et al. A prospective randomized controlled study comparing outcomes of standard resection and extended resection, including dissection of the nerve plexus and various lymph nodes, in patients with pancreatic head cancer[J]. Ann Surg, 2014, 259(4):656-664.
[7]
Klaiber U, Schnaidt ES, Hinz U, et al. Prognostic factors of survival after neoadjuvant treatment and resection for initially unresectable pancreatic cancer[J]. Ann Surg, 2021, 273(1):154-162.
[8]
He J, Blair AB, Groot VP, et al. Is a pathological complete response following neoadjuvant chemoradiation associated with prolonged survival in patients with pancreatic cancer?[J]. Ann Surg, 2018, 268(1):1-8.
[9]
Michalski CW, Kleeff J, Wente MN, et al. Systematic review and meta-analysis of standard and extended lymphadenectomy in pancreaticoduodenectomy for pancreatic cancer[J]. Br J Surg, 2007, 94(3):265-273.
[10]
陈汝福, 周泉波. 胰腺癌淋巴结扩大清扫的价值[J]. 中国普外基础与临床杂志, 2018, 25(6):653-656.
[11]
Zhu J, Li X, Kou J, et al. Proposed Chaoyang vascular classification for superior mesenteric-portal vein invasion, resection, and reconstruction in patients with pancreatic head cancer during pancreaticoduodenectomy-a retrospective cohort study[J]. Int J Surg, 2018(53):292-297.
[12]
Malleo G, Maggino L, Marchegiani G, et al. Pancreatectomy with venous resection for pT3 head adenocarcinoma: perioperative outcomes, recurrence pattern and prognostic implications of histologically confirmed vascular infiltration[J]. Pancreatology, 2017, 17(5):847-857.
[13]
Ravikumar R, Sabin C, Abu Hilal M, et al. Portal vein resection in borderline resectable pancreatic cancer: a United Kingdom multicenter study[J]. J Am Coll Surg, 2014, 218(3):401-411.
[14]
Song A, Liu F, Wu L, et al. Histopathologic tumor invasion of superior mesenteric vein/portal vein is a poor prognostic indicator in patients with pancreatic ductal adenocarcinoma: results froma systematic review and meta-analysis[J]. Oncotarget, 2017, 8(20): 32600-32607.
[15]
Fancellu A, Petrucciani N, Porcu A, et al. The impact on survival and morbidity of portal-mesenteric resection during pancreaticoduodenectomy for pancreatic head adenocarcinoma: a systematic review and meta-analysis of comparative studies[J]. Cancers, 2020, 12(7):1976.
[16]
Ohgi K, Yamamoto Y, Sugiura T, et al. Is pancreatic head cancer with portal venous involvement really borderline resectable? appraisal of an upfront surgery series[J]. Ann Surg Oncol, 2017, 24(9):2752-2761.
[17]
Aimoto T, Mizutani S, Kawano Y, et al. Left posterior approach pancreaticoduodenectomy with total mesopancreas excision and circumferential lymphadenectomy around the superior mesenteric artery for pancreatic head carcinoma[J]. J Nippon Med Sch, 2013, 80(6):438-445.
[18]
Orci LA, Meyer J, Combescure C, et al. A meta-analysis of extended versus standard lymphadenectomy in patients undergoing pancreatoduodenectomy for pancreatic adenocarcinoma[J]. HPB, 2015, 17(7):565-572.
[19]
弓毅, 许学军, 王槐志. 扩大淋巴结清扫的胰十二指肠切除术治疗胰腺癌的临床意义[J]. 肿瘤学杂志, 2015, 21(10):816-818.
[20]
Ke K, Chen W, Chen Y. Standard and extended lymphadenectomy for adenocarcinoma of the pancreatic head: a meta-analysis and systematic review[J]. J Gastroenterol Hepatol, 2014, 29(3):453-462.
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