肝联合胰十二指肠切除术（HPD）的单中心经验分析

发布时间：2018-04-30 11:53

  本文选题：肝联合胰十二指肠切除 + 胰十二指肠切除　； 参考：《浙江大学》2017年硕士论文

【摘要】：背景:对于一些常规无法切除的恶性胆道疾病包括进展性胆管癌和晚期胆囊癌,以及局部侵犯的胃肠道恶性肿瘤,因手术无法达到R0切除,患者的生存预后往往极差。1980年Takasaki等首次报道五例肝联合胰十二指肠切除术(hepatopancreatoduodenectomy,HPD)应用于局部侵犯的胆囊癌患者,当时的五例患者术后生存时间最长为16月[1],自此HPD术被越来越多临床中心尝试应用于其他手术无法根治切除的恶性胆道疾病患者。然而因其高死亡率和并发症发生率,大多数中心只能报道少数病例,对HPD的临床应用还需要不断积累经验总结。方法:回顾性分析浙江大学医学院附属第一医院23例行肝联合胰十二指肠切除术(HPD)的住院患者,计算机随机抽取23例同期内住院行单纯胰十二指肠切除术(PD)患者,分别纳入病例组和对照组。对比两组间临床特征,术后腹腔内严重并发症,生存预后等结果,分析影响HPD组生存的术前、术中及术后因素,探究HPD术后早期死亡的危险因素,总结单中心经验与不足。结果:HPD组主要手术适应症为胆道恶性肿瘤患者,而单纯PD组主要为胰腺或十二指肠恶性肿瘤患者,前者术前肿瘤标志物CA199、CEA、CA125、术中出血量等指标均显著高于后者(P0.05)。Kaplan生存分析显示HPD组术后生存明显低于单纯PD组(P=0.009)。与PD组相比,HPD组术后1月内早期死亡率较高(17.4%),院内死亡率为25.2%,而死亡原因均为出现严重腹腔内并发症,主要包括胰漏、肝衰竭以及腹腔感染。单因素分析显示,术前腹部症状(P=0.023)、术中门静脉切除重建(P=0.008)是HPD组术后发生严重腹腔内并发症的危险因素,后者也是早期院内死亡的危险因素(P=0.04)。分析HPD组内的长期生存预后发现CA125≥35U/mL(P=0.028),门静脉重建(P=0.01),手术时间≥478min(P=0.043),腹腔内严重并发症(P=0.004)为影响HPD组长期生存的危险因素,而进一步多因素分析显示腹腔内严重并发症是影响患者长期生存的独立风险因素(P=0.018)。结论:HPD术是一项高风险的术式,主要应用于其他方法无法根治性切除的恶性胆道肿瘤患者。HPD术后患者生存率明显低于单纯PD术后患者,前者早期死亡率高,主要是由于腹腔内严重并发症(主要包括胰漏、肝衰竭、腹腔感染)的出现。术前存在腹部症状和术中门静脉切除重建为HPD术后发生腹腔内严重并发症的危险因素,后者也是HPD术后院内死亡的危险因素。术后发生严重腹腔内并发症是HPD术后长期生存的独立危险因素。
[Abstract]:Background: for some malignant biliary diseases that are not normally resectable, including progressive cholangiocarcinoma and advanced gallbladder cancer, and locally invasive gastrointestinal malignancies, R0 resection is not possible. In 1980, Takasaki et al reported for the first time five patients with locally invasive gallbladder carcinoma treated by hepatectomy combined with pancreatoduodenectomy. The survival time of the five patients was up to 16 months. Since then, more and more clinical centers have tried to apply HPD to patients with malignant biliary diseases which can not be cured by other operations. However, because of its high mortality rate and complication rate, most centers can only report a few cases, and the clinical application of HPD needs to accumulate experience. Methods: a retrospective analysis was made on 23 inpatients who underwent hepatectomy combined with pancreaticoduodenectomy (HPD) in the first affiliated Hospital of Zhejiang University Medical College. 23 patients were randomly selected by computer for simple pancreaticoduodenectomy during the same period. The patients were included in the case group and the control group respectively. By comparing the clinical features, severe intraperitoneal complications and survival prognosis between the two groups, the factors affecting the survival of HPD group were analyzed, the risk factors of early death after HPD were explored, and the experience and deficiency of single center were summarized. Results the main indications of operation were biliary tract malignant tumor, while simple PD group was mainly pancreatic or duodenal malignant tumor. The preoperative tumor marker CA199CEA CA125 and intraoperative bleeding volume were significantly higher in the former than those in the latter (P0.05U. Kaplan survival analysis). The postoperative survival of HPD group was significantly lower than that of PD group (0.009%). Compared with PD group, the early mortality of HPD group was 17.4% and the hospital mortality was 25.20.The causes of death were severe intraperitoneal complications, including pancreatic leakage, liver failure and abdominal infection. Univariate analysis showed that preoperative abdominal symptoms and intraoperative portal vein resection and reconstruction (P0. 008) were the risk factors for severe intraperitoneal complications in HPD group, and the latter was also a risk factor for early hospital death. The long-term survival prognosis in HPD group was analyzed. The risk factors for long-term survival of HPD group were CA125 鈮，

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