目的

探讨新辅助治疗后“二步法”改良Appleby 术治疗局部进展期胰体癌的应用价值。

方法

回顾总结2021 年6 月至2022 年6 月重庆市人民医院收治的2 例局部进展期胰体癌患者临床资料。患者均签署知情同意书，符合医学伦理学规定。患者均为男性，年龄分别为56、64 岁。CA19-9 分别为901、613 kU/L，肿瘤直径分别为8.9、3.6 cm。2 例患者经超声内镜引导下胰腺穿刺活检确诊为胰腺导管腺癌，MDT 讨论后行3 个周期的新辅助化疗，方案为吉西他滨联合白蛋白结合型紫杉醇，未联用靶免治疗。新辅助治疗后1～3 周内行“二步法”改良Appleby 手术。分析2 例患者新辅助治疗后肿瘤变化情况、手术完成情况、术后并发症以及生存情况等。

结果

新辅助治疗后2 例患者CA19-9 明显下降，下降幅度超过50%，肿瘤明显缩小伴血管侵犯减小，手术指征明确。手术方案：第一步肝总动脉预处理，腹腔镜下肝总动脉结扎术，术后肝功能轻度异常，2 周内恢复正常，影像学提示肝脏、胃肠道血供良好；第二步充分术前准备后行改良Appleby 手术。术后出现转氨酶一过性升高，予以保肝治疗后好转；CA19-9 水平进一步下降，影像学提示肝脏、胃肠道血供良好，未出现缺血性病变，顺利康复出院。2 例患者术后均继续行辅助化疗，方案为吉西他滨联合白蛋白结合型紫杉醇。例1 术后13 个月出现全身多处转移，例2 术后15 个月出现肝转移，截止投稿日期仍存活。

结论

局部进展期胰体癌新辅助治疗后行改良Appleby 术可提高手术R0 切除率，“二步法”的手术设计可减少术后相关缺血性病变发生，降低围手术期并发症发生率，临床应用安全、可行。

Objective

To evaluate the application value of modified “two-step” Appleby operation after neoadjuvant therapy in the treatment of locally advanced pancreatic body cancer.

Methods

Clinical data of two patients with locally advanced pancreatic body cancer admitted to Chongqing People’s Hospital from June 2021 to June 2022 were retrospectively analyzed.The informed consents of all patients were obtained and the local ethical committee approval was received.Both two patients were male， aged 56 and 64 years， respectively.CA19-9 level was 901 and 613 kU/L， and tumor diameter was 8.9 and 3.6 cm，respectively.Two patients were diagnosed with pancreatic ductal adenocarcinoma by endoscopic ultrasoundguided pancreatic biopsy.After MDT consultation， three cycles of neoadjuvant chemotherapy were performed.The regimen consisted of gemcitabine combined with albumin-bound paclitaxel， without targeted immunotherapy.Modified “two-step” Appleby operation was performed within 1-3 weeks after neoadjuvant therapy.The tumor changes， surgical completion， postoperative complications and survival of two patients after neoadjuvant therapy were analyzed.

Results

After neoadjuvant therapy， CA19-9 level was decreased significantly by over 50% in two patients.The tumor size was evidently reduced accompanied with decrease of vascular invasion， and surgical indications were evident.Surgical regimen： at the first step， common hepatic artery pretreatment， laparoscopic ligation of common hepatic artery were performed.Postoperatively，liver function was slightly abnormal and restored to normal within 2 weeks.Imaging examination indicated that the blood supply of liver and gastrointestinal tract was normal.At the second step， modified Appleby operation was performed after comprehensive preoperative preparation.Transient elevation of transaminase level occurred after operation， which was improved after liver-protection treatment.CA19-9 level was further decreased.Imaging examination showed that the blood supply of liver and gastrointestinal tract was normal，and no ischemic lesion was found.Two patients were discharged after recovery.Postoperatively， two patients continued to receive adjuvant chemotherapy of gemcitabine combined with albumin-bound paclitaxel.One patient developed multiple systemic metastases at 13 months after operation， and the other patient had liver metastases at postoperative 15 months.Both two patients survived as of the paper submission date.

Conclusions

Modified Appleby operation after neoadjuvant therapy can improve the R0 resection rate for locally advanced pancreatic body cancer.“Two-step” surgical design can reduce the incidence of postoperative ischemic lesions and perioperative complications， which is safe and feasible in clinical application.