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胰腺癌累及血管精准切除重建技术及评价
Precise resection and reconstruction techniques for vascular involvement in pancreatic cancer and their evaluation
胰腺癌确诊时常因血管侵犯而失去直接手术指征。在精准外科理念指导下，可切除性评估应从“解剖学”转向“生物学”，从“可切除性”转向“可重建性”。需动态评估肿瘤生物学反应以决策最佳手术时机。术前需对受累血管进行精准评估，以规划个体化切除重建策略。静脉切除重建技术已逐渐成熟。脾静脉汇合部受累者提倡积极重建，可选用脾静脉原位重建或脾静脉-左肾静脉分流术。低位静脉侵犯的处理最具挑战性，可通过血管整形技术行多支静脉束支重建；超低位广泛侵犯者可选择离体切除联合自体小肠移植。静脉重建应避免使用移植物，长节段切除者推荐采用Cattell-Braasch游离实现免移植物对端吻合。动脉切除重建虽对术者技术要求高、围手术期风险大，但可为转化治疗生物学反应良好者带来显著生存获益。动脉鞘剥除及动脉切除重建已在高容量中心成熟开展。针对合并门静脉闭塞及海绵样变的复杂病例，静脉转流优先策略可有效提升手术安全性与可控性。科学化的外科决策、精准的术前规划、精致的血管重建技术，是提升胰腺癌手术安全性与根治性的关键。未来需推动手术流程规范化与培训体系建设，以使更多血管受累的胰腺癌病人获益。
Pancreatic cancer is often ineligible for upfront surgery at diagnosis due to vascular involvement. Under the precision surgery paradigm, resectability assessment should shift from anatomical to biological criteria, and from “resectability” to “reconstructability”, with dynamic evaluation of tumor biology guiding optimal surgical timing. Preoperative precision vascular assessment is essential for individualized surgical planning. Venous reconstruction techniques are well established. Splenic vein reconstruction is recommended for involvement of the spleno-portal confluence. Low-level venous involvement remains challenging, multi-branch reconstruction of the jejunal venous trunks can be achieved via vascular plastic techniques, while extensive low-level involvement may necessitate ex vivo resection with intestinal autotransplantation. Graft interposition should be avoided whenever possible; the Cattell-Braasch maneuver enables graft-free end-to-end anastomosis for long-segment venous resection. Arterial resection and reconstruction, though technically demanding and associated with significant perioperative risks, confers a survival benefit in patients with a favorable response to conversion therapy. Arterial divestment and resection have been proven safe and feasible in high-volume centers. The venous bypass-first strategy improves safety in complex cases with portal vein occlusion and cavernous transformation. Precise preoperative planning and vascular reconstruction techniques, and standardized surgical strategies are key to improving the safety and radicality of pancreatic cancer surgery. Future efforts should focus on promoting standardized surgical protocols and training systems to benefit more patients with vascular involvement.
胰腺癌 / 血管侵犯 / 血管切除重建 / 局部进展期胰腺癌 / 精准外科
pancreatic cancer / vascular invasion / vascular resection and reconstruction / locally advanced pancreatic cancer / precision surgery
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董家鸿, 黄志强. 精准肝切除--21世纪肝脏外科新理念[J]. 中华外科杂志, 2009, 47(21): 1601-1605. DOI:10.3760/cma.j.issn.0529-5815.2009.21.001.
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Continuous theoretical and technological progress in the face of increasing expectations for quality health care has transformed the surgical paradigm. The authors systematically review these historical trends and propose the novel paradigm of "precision surgery," featuring certainty-based practice to ensure the best result for each patient with multiobjective optimization of therapeutic effectiveness, surgical safety, and minimal invasiveness. The main characteristics of precision surgery may be summarized as determinacy, predictability, controllability, integration, standardization, and individualization. The strategy of precision in liver surgery is to seek a balance of maximizing the removal of the target lesion, while maximizing the functional liver remnant and minimizing surgical invasiveness. In this article, the authors demonstrate the application of precision approaches in specific settings in complex liver surgery. They propose that the concept of precision surgery should be considered for wider application in liver surgery and other fields as a step toward the ultimate goal of perfect surgery. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
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The REDISCOVER consensus conference aimed at developing and validate guidelines on the perioperative care of patients with borderline resectable (BR-) and locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC).Coupled with improvements in chemotherapy and radiation, the contemporary approach to pancreatic surgery supports resection of BR-PDAC and, to a lesser extent, LA-PDAC. Guidelines outlining the selection and perioperative care for these patients are lacking.The Scottish Intercollegiate Guidelines Network (SIGN) methodology was used to develop the REDISCOVER guidelines and create recommendations. The Delphi approach was used to reach consensus (agreement ≥80%) among experts. Recommendations were approved after a debate and vote among international experts in pancreatic surgery and pancreatic cancer management. A Validation Committee used the AGREE II-GRS tool to assess the methodological quality of the guidelines. Moreover, an independent multidisciplinary advisory group revised the statements to ensure adherence to non-surgical guidelines.Overall, 34 recommendations were created targeting centralization, training, staging, patient selection for surgery, possibility of surgery in uncommon scenarios, timing of surgery, avoidance of vascular reconstruction, details of vascular resection/reconstruction, arterial divestment, frozen section histology of perivascular tissue, extent of lymphadenectomy, anticoagulation prophylaxis and role of minimally invasive surgery. The level of evidence was however low for 29 of 34 clinical questions. Participants agreed that the most conducive mean to promptly advance our understanding in this field is to establish an international registry addressing this patient population (https://rediscover.unipi.it/).The REDISCOVER guidelines provide clinical recommendations pertaining to pancreatectomy with vascular resection for patients with BR- and LA-PDAC, and serve as the basis of a new international registry for this patient population.Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.
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To assess the relevance of resection margin status for survival outcome after resection and adjuvant therapy for pancreatic cancer.The definitions for R0 and R1 margin status after resection for pancreatic cancer are controversial. The strict definition of R0 requiring a 1 mm tumor-free margin is not commonly accepted. Reported R0/R1 rates and associated survival are highly heterogeneous.A standardized protocol with rigorous assessment of circumferential margins and the R0 definition with a 1 mm free margin were introduced into clinical routine in 2005. From a prospective database, patients undergoing pancreatoduodenectomy for pancreatic adenocarcinoma between January 1, 2006 and December 12, 2012 were identified. The rates of R0 (≥1 mm margin), R1 (<1 mm clearance), and R1 (direct margin involvement) status and associated survival were assessed by uni- and multivariable analyses.Of 561 patients included, 112 patients (20.0%) had R0 and 449 patients (80.0%) had R1 resections, including 123 (21.9%) R1 (≤1 mm) and 326 (58.1%) R1 (direct) resections. A total of 438 (85.9%) received adjuvant therapy. With R0, R1 (<1 mm), and R1 (direct) status the median survival times and 5-year survival rates were 41.6, 27.5, and 23.4 months; and 37.7%, 30.1%, and 20.3%, respectively (P < 0.0001). By multivariable analysis, margin status was confirmed to be independently associated with survival.In the context of adjuvant therapy, the resection margin status remains an important independent determinant of postresection survival. R0/R1 resection rates and associated survival vary significantly with the definitions used. An international consensus is urgently needed to achieve comparability with respect to studies and protocols on patients with adjuvant therapy.
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Pancreaticoduodenectomy (PD) is a complex procedure involving the dissection of the superior mesenteric artery and vein. However, a safe and standardized technique for dissecting the jejunal veins (JVs) in the mesojejunum during PD remains elusive.We retrospectively analyzed 198 patients who underwent open PD with mesojejunum dissection using an anterior artery-first approach and evaluated anatomical variations in the first JV trunk (FJVT) and its tributaries. This study introduces the concept of a "dangerous crossover vein" (DCV) to describe tributaries that cross the transection line of the mesojejunum. Surgical techniques and perioperative outcomes were assessed.The FJVT drained the territory supplied by the first to second jejunal arteries in 144 patients (75%) and the first to third or more in 50 patients (25%). The FJVT was preserved in 100 patients (50.5%) and sacrificed in 98 (49.5%). Dangerous crossover veins were encountered in 117 patients (59%) and safely managed with standardized mesojejunal dissection. There were no significant differences in blood loss or operative time between patients with or without DCVs.Understanding the anatomy of JVs and the concept of DCVs is critical for safe mesojejunal dissection during PD. Our approach facilitates secure dissection of JVs regardless of their anatomical variations.© 2024. Society of Surgical Oncology.
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Pancreatectomies with superior mesenteric artery (SMA) resection are technically challenging. With the advent of FOLFIRNOX chemotherapy, resection of the SMA is performed in selected patients with locally advanced pancreatic cancer (LAPC), in centers of excellence by highly skilled pancreatic-vascular surgeons treating a large volume of LAPCs. METHODS: The patient was a 64-year-old female with an LAPC treated with 11 cycles of FOLFIRINOX induction chemotherapy. The SMA, the superior mesenteric vein (SMV), and a replaced right hepatic artery (r-RHA) were encased. A temporary mesenterico-portal shunt (TMPS), using a 25 cm Goretex tube between the origin of the SMV and the right side of the portal vein, was used. This TMPS (1) lessens portal hypertension in case of SMV obstruction; (2) maintains adequate liver venous perfusion during dissection; (3) gives the mesentery enough mobility to avoid graft for SMA resection; and (4) avoids simultaneous venous and arterial clamping. A mesenteric approach was performed to isolate the SMA. Upon heparin bolus, the r-RHA was re-implanted on the gastroduodenal artery stump, the SMA on the aorta, the SMV on the portal vein, and the splenic vein on the left renal vein.Postoperative course was uneventful. Pathology showed pT4N0R1 pancreatic adenocarcinomas. Three years later, the patient recurred on the left adrenal gland and was treated by external radiotherapy. Five years later, the patients is alive under chemotherapy.Pancreaticoduodenectomy with SMA and SMV using a transitory mesentericoportal shunt (The Strasbourg technique) is a standardized technique used to manage patients with LAPC at our unit.© 2025. Society of Surgical Oncology.
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This statement was developed to promote international consensus on the definition of borderline resectable pancreatic ductal adenocarcinoma (BR-PDAC) which was adopted by the National Comprehensive Cancer Network (NCCN) in 2006, but which has changed yearly and become more complicated. Based on a symposium held during the 20th meeting of the International Association of Pancreatology (IAP) in Sendai, Japan, in 2016, the presenters sought consensus on issues related to BR-PDAC. We defined patients with BR-PDAC according to the three distinct dimensions: anatomical (A), biological (B), and conditional (C). Anatomic factors include tumor contact with the superior mesenteric artery and/or celiac artery of less than 180° without showing stenosis or deformity, tumor contact with the common hepatic artery without showing tumor contact with the proper hepatic artery and/or celiac artery, and tumor contact with the superior mesenteric vein and/or portal vein including bilateral narrowing or occlusion without extending beyond the inferior border of the duodenum. Biological factors include potentially resectable disease based on anatomic criteria but with clinical findings suspicious for (but unproven) distant metastases or regional lymph nodes metastases diagnosed by biopsy or positron emission tomography-computed tomography. This also includes a serum carbohydrate antigen (CA) 19-9 level more than 500 units/ml. Conditional factors include the patients with potentially resectable disease based on anatomic and biologic criteria and with Eastern Cooperative Oncology Group (ECOG) performance status of 2 or more. The definition of BR-PDAC requires one or more positive dimensions (e.g. A, B, C, AB, AC, BC or ABC). The present definition acknowledges that resectability is not just about the anatomic relationship between the tumor and vessels, but that biological and conditional dimensions are also important. The aim in presenting this consensus definition is also to highlight issues which remain controversial and require further research.Copyright © 2017 IAP and EPC. Published by Elsevier B.V. All rights reserved.
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杨尹默, 刘光年, 田孝东. 胰腺癌外科治疗若干热点问题[J]. 中国实用外科杂志, 2023, 43(7): 729-734. DOI:10.19538/j.cjps.issn1005-2208.2023.07.02.
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Contemporary practice for superior mesenteric/portal vein (SMV-PV) reconstruction during pancreatectomy with vein resection involves biological (autograft, allograft, xenograft) or synthetic grafts as a conduit or patch. The aim of this study was to systematically review the safety and feasibility of the different grafts used for SMV-PV reconstruction.A systematic search was performed in PubMed and Embase according to the PRISMA guidelines (January 2000-March 2020). Studies reporting on ≥ 5 patients undergoing reconstruction of the SMV-PV with grafts during pancreatectomy were included. Primary outcome was rate of graft thrombosis.Thirty-four studies with 603 patients were included. Four graft types were identified (autologous vein, autologous parietal peritoneum/falciform ligament, allogeneic cadaveric vein/artery, synthetic grafts). Early and overall graft thrombosis rate was 7.5% and 22.2% for synthetic graft, 5.6% and 11.7% for autologous vein graft, 6.7% and 8.9% for autologous parietal peritoneum/falciform ligament, and 2.5% and 6.2% for allograft. Donor site complications were reported for harvesting of the femoral, saphenous, and external iliac vein. No cases of graft infection were reported for synthetic grafts.In selected patients, autologous, allogenic or synthetic grafts for SMV-PV reconstruction are safe and feasible. Synthetic grafts seems to have a higher incidence of graft thrombosis.Copyright © 2020 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.
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To determine perioperative and oncologic outcomes after distal pancreatectomy with en bloc resection of the celiac axis (DP-CAR).
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Distal pancreatectomy with en bloc coeliac axis resection (DP-CAR) for pancreatic body cancer has been reported increasingly. However, its large-scale outcomes remain undocumented. This study aimed to evaluate DP-CAR volume and mortality, preoperative arterial embolization for ischaemic gastropathy, the oncological benefit for resectable tumours close to the bifurcation of the splenic artery and coeliac artery using propensity score matching, and prognostic factors in DP-CAR.In a multi-institutional analysis, 626 DP-CARs were analysed retrospectively and compared with 1325 distal pancreatectomies undertaken in the same interval.Ninety-day mortality was observed in 7 of 21 high-volume centres (1 or more DP-CARs per year) and 1 of 41 low-volume centres (OR 20.00, 95 per cent c.i. 2.26 to 177.26). The incidence of ischaemic gastropathy was 19.2 per cent in the embolization group and 7.9 per cent in the no-embolization group (OR 2.77, 1.48 to 5.19). Propensity score matching analysis showed that median overall survival was 33.5 (95 per cent c.i. 27.4 to 42.0) months in the DP-CAR and 37.9 (32.8 to 53.3) months in the DP group. Multivariable analysis identified age at least 67 years (HR 1.40, 95 per cent c.i. 1.12 to 1.75), preoperative tumour size 30 mm or more (HR 1.42, 1.12 to 1.80), and preoperative carbohydrate antigen 19-9 level over 37 units/ml (HR 1.43, 1.11 to 1.83) as adverse prognostic factors.DP-CAR can be performed safely in centres for general pancreatic surgery regardless of DP-CAR volume, and preoperative embolization may not be required. This procedure has no oncological advantage for resectable tumour close to the bifurcation of the splenic artery, and should be performed after appropriate patient selection.© The Author(s) 2023. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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尹杰, 蒋奎荣. 局部晚期胰腺癌转化治疗后手术策略与要点[J]. 中国实用外科杂志, 2025, 45(6): 640-645. DOI:10.19538/j.cjps.issn1005-2208.2025.06.07.
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利益冲突 所有作者均声明不存在利益冲突
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