發(fā)布時(shí)間：2018-04-30 11:53

  本文選題：肝聯(lián)合胰十二指腸切除 + 胰十二指腸切除　； 參考：《浙江大學(xué)》2017年碩士論文

【摘要】：背景:對(duì)于一些常規(guī)無法切除的惡性膽道疾病包括進(jìn)展性膽管癌和晚期膽囊癌,以及局部侵犯的胃腸道惡性腫瘤,因手術(shù)無法達(dá)到R0切除,患者的生存預(yù)后往往極差。1980年Takasaki等首次報(bào)道五例肝聯(lián)合胰十二指腸切除術(shù)(hepatopancreatoduodenectomy,HPD)應(yīng)用于局部侵犯的膽囊癌患者,當(dāng)時(shí)的五例患者術(shù)后生存時(shí)間最長為16月[1],自此HPD術(shù)被越來越多臨床中心嘗試應(yīng)用于其他手術(shù)無法根治切除的惡性膽道疾病患者。然而因其高死亡率和并發(fā)癥發(fā)生率,大多數(shù)中心只能報(bào)道少數(shù)病例,對(duì)HPD的臨床應(yīng)用還需要不斷積累經(jīng)驗(yàn)總結(jié)。方法:回顧性分析浙江大學(xué)醫(yī)學(xué)院附屬第一醫(yī)院23例行肝聯(lián)合胰十二指腸切除術(shù)(HPD)的住院患者,計(jì)算機(jī)隨機(jī)抽取23例同期內(nèi)住院行單純胰十二指腸切除術(shù)(PD)患者,分別納入病例組和對(duì)照組。對(duì)比兩組間臨床特征,術(shù)后腹腔內(nèi)嚴(yán)重并發(fā)癥,生存預(yù)后等結(jié)果,分析影響HPD組生存的術(shù)前、術(shù)中及術(shù)后因素,探究HPD術(shù)后早期死亡的危險(xiǎn)因素,總結(jié)單中心經(jīng)驗(yàn)與不足。結(jié)果:HPD組主要手術(shù)適應(yīng)癥為膽道惡性腫瘤患者,而單純PD組主要為胰腺或十二指腸惡性腫瘤患者,前者術(shù)前腫瘤標(biāo)志物CA199、CEA、CA125、術(shù)中出血量等指標(biāo)均顯著高于后者(P0.05)。Kaplan生存分析顯示HPD組術(shù)后生存明顯低于單純PD組(P=0.009)。與PD組相比,HPD組術(shù)后1月內(nèi)早期死亡率較高(17.4%),院內(nèi)死亡率為25.2%,而死亡原因均為出現(xiàn)嚴(yán)重腹腔內(nèi)并發(fā)癥,主要包括胰漏、肝衰竭以及腹腔感染。單因素分析顯示,術(shù)前腹部癥狀(P=0.023)、術(shù)中門靜脈切除重建(P=0.008)是HPD組術(shù)后發(fā)生嚴(yán)重腹腔內(nèi)并發(fā)癥的危險(xiǎn)因素,后者也是早期院內(nèi)死亡的危險(xiǎn)因素(P=0.04)。分析HPD組內(nèi)的長期生存預(yù)后發(fā)現(xiàn)CA125≥35U/mL(P=0.028),門靜脈重建(P=0.01),手術(shù)時(shí)間≥478min(P=0.043),腹腔內(nèi)嚴(yán)重并發(fā)癥(P=0.004)為影響HPD組長期生存的危險(xiǎn)因素,而進(jìn)一步多因素分析顯示腹腔內(nèi)嚴(yán)重并發(fā)癥是影響患者長期生存的獨(dú)立風(fēng)險(xiǎn)因素(P=0.018)。結(jié)論:HPD術(shù)是一項(xiàng)高風(fēng)險(xiǎn)的術(shù)式,主要應(yīng)用于其他方法無法根治性切除的惡性膽道腫瘤患者。HPD術(shù)后患者生存率明顯低于單純PD術(shù)后患者,前者早期死亡率高,主要是由于腹腔內(nèi)嚴(yán)重并發(fā)癥(主要包括胰漏、肝衰竭、腹腔感染)的出現(xiàn)。術(shù)前存在腹部癥狀和術(shù)中門靜脈切除重建為HPD術(shù)后發(fā)生腹腔內(nèi)嚴(yán)重并發(fā)癥的危險(xiǎn)因素,后者也是HPD術(shù)后院內(nèi)死亡的危險(xiǎn)因素。術(shù)后發(fā)生嚴(yán)重腹腔內(nèi)并發(fā)癥是HPD術(shù)后長期生存的獨(dú)立危險(xiǎn)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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