摘要
目的探讨局部进展期胰腺癌(LAPC)转化治疗后行海德堡三角清扫的安全性和有效性。方法本研究为回顾性病例系列研究。回顾性收集2020年1月至2022年12月于南京医科大学第一附属医院胰腺中心接受转化治疗的103例LAPC患者资料,将其中26例(25.2%)行海德堡三角清扫胰腺癌切除术的患者纳入研究。男性15例,女性11例,年龄(59±7)岁(范围:49~74岁)。治疗前CA19-9[M(IQR)]为248.8(391.6)U/ml(范围:0~1428 U/ml),癌胚抗原为4.1(3.8)μg/L(范围:1.4~13.4μg/L)。转化治疗方案包括mFOLFIRINOX方案(6例,23.1%)、GnP方案(14例,53.8%)、mFOLFIRINOX+GnP方案(6例,23.1%)。随访时间截至2023年6月或患者死亡、失访。采用Kaplan-Meier法估算患者1年和3年总体生存率。结果转化治疗后疗效评估,血清CA19-9下降92.3(40.1)%(范围:2.1%~97.7%)。疾病稳定13例(50.0%),部分缓解11例(42.3%),完全缓解2例(7.7%)。手术方式包括胰十二指肠切除术(12例,46.2%)、胰体尾切除术(12例,46.2%)、全胰切除术(2例,7.7%)。遵循标准化病理流程和"1 mm原则",R0切除率为61.5%(16/26),R1(1 mm)切除率为38.5%(10/26)。各切缘R1(1 mm)切除率如下:前切缘23.1%(6/26),后切缘19.2%(5/26),断端切缘12.5%(3/24),门静脉沟切缘2/14,钩突切缘1/12。术后总体并发症发生率为57.7%(15/26),其中B、C级胰瘘发生率为25.0%(6/24),胃排空延迟发生率为23.1%(6/26),切口并发症发生率为11.5%(3/26),术后出血发生率为7.7%(2/26),乳糜瘘发生率为7.7%(2/26),胆瘘发生率为3.8%(1/26)。围手术期(术后90 d内)无二次手术,1例患者术后第32天因胃十二指肠动脉残端假性动脉瘤破裂死亡。余25例患者获得随访,随访时间为21(24)个月(范围:8~42个月)。随访期间,8例(32.0%)患者因肿瘤复发转移死亡,17例(68.0%)存活,包括无瘤生存11例、远处转移5例、局部复发1例。开始转化治疗后1、3年总体生存率分别为95.8%、58.9%,术后1、3年总体生存率分别为77.7%、57.8%。结论LAPC转化治疗后行联合海德堡三角清扫胰腺癌切除术的R0切除率较高,围手术期病死率及术后主要并发症发生率未见明显升高,可能改善患者的远期生存。
Objective To investigate the safety and efficacy of the TRIANGLE operation after neoadjuvant chemotherapy in locally advanced pancreatic cancer(LAPC).Methods This study is a retrospective case series analysis.Between January 2020 and December 2022,a total of 103 patients were diagnosed as LAPC who underwent neoadjuvant chemotherapy at the Pancreas Center,the First Affiliated Hospital of Nanjing Medical University.Among them,26 patients(25.2%)underwent the TRIANGLE operation.There were 15 males and 11 females,with a age of(59±7)years(range:49 to 74 years).The pre-treatment serum CA19-9(M(IQR))was 248.8(391.6)U/ml(range:0 to 1428 U/ml),and the serum carcinoembryonic antigen was 4.1(3.8)μg/L(range:1.4 to 13.4μg/L).The neoadjuvant chemotherapy regimens included:mFOLFIRINOX regimen in 6 cases(23.1%),GnP regimen in 14 cases(53.8%),and mFOLFIRINOX+GnP regimen in 6 cases(23.1%).The follow-up duration extended until June 2023 or until the occurrence of the patient′s death or loss to follow-up.The Kaplan-Meier method was employed to estimate the 1-year and 3-year overall survival rates.Results After neoadjuvant chemotherapy,CA19-9 levels decreased by 92.3(40.1)%(range:2.1%to 97.7%).Evaluation of the response to treatment revealed 13 cases(50.0%)of stable disease,11 cases(42.3%)of partial response,and 2 cases(7.7%)of complete response.The surgical operation consisted of 12 cases(46.2%)of pancreaticoduodenectomy,12 cases(46.2%)of distal pancreatectomy,and 2 cases(7.7%)of total pancreatectomy.Margin determination was based on the“standardised pathology protocol”and the“1 mm”principle.No R2 and R1(direct)resections were observed,while the R0 resection rate was 61.5%(16/26),and the R1(1 mm)resection rate was 38.5%(10/26).The R1(1 mm)resection rates for the anterior margin,posterior margin,transected margin,portal vein groove margin,and uncinate margin were 23.1%(6/26),19.2%(5/26),12.5%(3/24),2/14,and 1/12,respectively.The overall postoperative complication rate was 57.8%(15/26),with major complications including grade B/C pancreatic fistula 25.0%(6/24,excluding 2 cases of total pancreatectomy),delayed gastric emptying in 23.1%(6/26),wound complications 11.5%(3/26),postoperative hemorrhage 7.7%(2/26),chylous fistula 7.7%(2/26)and bile fistula 3.8%(1/26).No reoperation was performed during the perioperative period(<90 days).One patient died on the 32nd day postoperatively due to a ruptured pseudoaneurysm.A total of 25 patients were followed up,with a follow-up time of 21(24)months(range:8 to 42 months).During the follow-up period,8 cases(32.0%)died due to tumor recurrence and metastasis,while 17 patients(68.0%)remained alive,including 11 cases of disease-free survival,5 cases of distant metastasis,and 1 case of local recurrence.The overall survival rates at 1-and 3-year after the initiation of neoadjuvant chemotherapy were 95.8%and 58.9%,respectively.The overall survival rates at 1-and 3-year after surgery were 77.7%and 57.8%,respectively.Conclusion Performing pancreatoduodenectomy according to the Heidelberg triangle protocol in LAPC patients after neoadjuvant chemotherapy might increase the R0 resection rate without increasing perioperative mortality or the incidence of major postoperative complications.
作者
徐冬
涂敏
张凯
吴鹏飞
吕楠
王倩倩
尹杰
吴飏
陆子鹏
陈建敏
奚春华
卫积书
郭峰
苗毅
蒋奎荣
Xu Dong;Tu Min;Zhang Kai;Wu Pengfei;Lyu Nan;Wang Qianqian;Yin Jie;Wu Yang;Lu Zipeng;Chen Jianmin;Xi Chunhua;Wei Jishu;Guo Feng;Miao Yi;Jiang Kuirong(Pancreas Center,the First Affiliated Hospital of Nanjing Medical University,Nanjing 210029,China)
出处
《中华外科杂志》
CAS
CSCD
北大核心
2024年第2期147-154,共8页
Chinese Journal of Surgery
基金
国家自然科学基金(82072706)。
关键词
胰腺肿瘤
外科手术
新辅助化疗
根治性切除
海德堡三角清扫
Pancreatic neoplasms
Surgical procedures,operative
Neoadjuvant chemotherapy
Radical resection
The Heidelberg triangle operation
