目的 根据CT检查评估胰头癌与周围血管的关系,建立一种新的胰头癌分型,探讨新型胰头癌分型在胰头癌患者手术方式选择及评估患者预后中的应用价值.方法 回顾性分析2009年1月至2012年12月华中科技大学同济医学院附属同济医院收治的127例胰头癌患者的临床资料.根据术前多排螺旋CT检查结果评估胰头癌与血管的关系,将胰头癌分为Ⅰ型、Ⅱ型、Ⅲ型和Ⅳ型4种类型.根据肿瘤部位及胰头癌新分型,采取不同的手术入路和手术方式.术后患者入住胰腺手术重症监护室,常规予以监测生命体征、禁食水、补液、营养支持、常规抗生素预防感染等支持治疗,同时保持腹腔引流通畅.术后并发症按照国际胰腺外科研究组(ISGPS)定义进行资料收集.记录并观察患者术前情况:性别、年龄、BMI、黄疸、腹痛、其他消化道症状、近期体质量下降、合并糖尿病;术中情况:手术方式、手术时间、术中出血量;术后情况:患者术后并发症和术后住院时间;术后病理学检查结果.患者术后1、3、6、12、18个月,通过电话或门诊方式进行随访.随访时间截至2014年12月.正态分布的计量资料用(x)±s表示,多组间比较采用单因素方差分析;非正态分布的计量资料用M(范围)表示,多组间比较采用Wilcoxon检验;计数资料比较采用x2检验.采用Kaplan-Meier法绘制生存曲线,生存率的比较采用Log-rank检验.结果 (1)胰头癌分型:Ⅰ、Ⅱ、Ⅲ、Ⅳ型患者分别为83例、20例、11例、13例;术前分别有31例、9例、0例、2例患者临床症状表现为黄疸,23例、8例、7例、7例表现为腹痛,4型患者比较,差异有统计学意义(x2=5.63,3.49,P＜0.05).(2)术中情况:80例患者行标准的胰十二指肠切除术(手术方式采用静脉优先入路),其中Ⅰ型74例、Ⅱ型6例.47例患者行胰十二指肠联合门静脉或肠系膜上静脉切除术,其中Ⅰ型9例、Ⅱ型14例、Ⅲ型11例、Ⅳ型13例.13例患者术中行扩大淋巴结清扫,其中Ⅰ型2例、Ⅱ型3例、Ⅲ型4例、Ⅳ型4例.消化道重建方式:74例患者行胰胃吻合,其中Ⅰ型52例、Ⅱ型10例、Ⅲ型6例、Ⅳ型6例.37例患者行胰肠吻合,其中Ⅰ型22例、Ⅱ型6例、Ⅲ型5例、Ⅳ型4例.16例患者行胰管对空肠黏膜吻合,其中Ⅰ型9例、Ⅱ型4例、Ⅳ型3例.Ⅰ、Ⅱ、Ⅲ、Ⅳ型胰头癌患者手术时间分别为(287±47) min、(354 ±64) min、(342±86) min、(380±46) min;术中出血量分别为(399±180) mL、(480±233) mL、(418±256) mL、(554±307) mL,4型患者比较,差异均有统计学意义(F =4.02,3.91,P＜0.05).(3)术后情况:Ⅰ、Ⅱ、Ⅲ、Ⅳ型胰头癌患者术后住院时间分别为(22±10)d、(29±10)d、(28±12)d、(33 ±17)d,4型患者比较,差异有统计学意义(F=4.01,P＜0.05).(4)术后病理学检查结果:Ⅰ、Ⅱ、Ⅲ、Ⅳ型胰头癌患者肿瘤直径分别为(3.3±1.1)cm、(4.1±0.9)cm、(4.1±1.0)cm、(4.6±1.1)cm,TNM分期T1～2期和T3～4期分别为59例和24例、0例和20例、0例和11例、0例和13例,神经侵犯分别为14例、8例、6例、9例,4型患者比较,差异均有统计学意义(F=5.12,x2=58.41,20.76,P＜0.05).(5)随访结果:112例患者获得随访(其中Ⅰ型74例、Ⅱ型18例、Ⅲ型9例、Ⅳ型11例),15例患者失访.Ⅰ型患者中位生存时间为24个月(2～60个月),2年生存率为42.2％;Ⅱ型患者中位生存时间为16个月(2～30个月),2年生存率为25.0％;Ⅲ型患者中位生存时间为18个月(2～ 30个月),2年生存率为27.3％;Ⅳ型患者中位生存时间为16个月(2～26个月),2年生存率为15.0％.4型胰头癌患者生存情况比较,差异有统计学意义(x2=16.85,P＜0.05).其中Ⅰ型分别与Ⅱ、Ⅲ、Ⅳ型患者生存情况比较,差异均有统计学意义(x2=12.11,5.10,10.73,P＜0.05);Ⅱ型分别与Ⅲ、Ⅳ型患者生存情况比较,差异均无统计学意义(x2=0.22,0.48,P＞0.05);Ⅲ型与Ⅳ型患者生存情况比较,差异无统计学意义(x2=1.09,P＞0.05).结论 根据胰头癌与血管的关系建立胰头癌新分型.该分型对指导临床手术方式选择和判断预后具有重要临床意义.
目的 根據CT檢查評估胰頭癌與週圍血管的關繫,建立一種新的胰頭癌分型,探討新型胰頭癌分型在胰頭癌患者手術方式選擇及評估患者預後中的應用價值.方法 迴顧性分析2009年1月至2012年12月華中科技大學同濟醫學院附屬同濟醫院收治的127例胰頭癌患者的臨床資料.根據術前多排螺鏇CT檢查結果評估胰頭癌與血管的關繫,將胰頭癌分為Ⅰ型、Ⅱ型、Ⅲ型和Ⅳ型4種類型.根據腫瘤部位及胰頭癌新分型,採取不同的手術入路和手術方式.術後患者入住胰腺手術重癥鑑護室,常規予以鑑測生命體徵、禁食水、補液、營養支持、常規抗生素預防感染等支持治療,同時保持腹腔引流通暢.術後併髮癥按照國際胰腺外科研究組(ISGPS)定義進行資料收集.記錄併觀察患者術前情況:性彆、年齡、BMI、黃疸、腹痛、其他消化道癥狀、近期體質量下降、閤併糖尿病;術中情況:手術方式、手術時間、術中齣血量;術後情況:患者術後併髮癥和術後住院時間;術後病理學檢查結果.患者術後1、3、6、12、18箇月,通過電話或門診方式進行隨訪.隨訪時間截至2014年12月.正態分佈的計量資料用(x)±s錶示,多組間比較採用單因素方差分析;非正態分佈的計量資料用M(範圍)錶示,多組間比較採用Wilcoxon檢驗;計數資料比較採用x2檢驗.採用Kaplan-Meier法繪製生存麯線,生存率的比較採用Log-rank檢驗.結果 (1)胰頭癌分型:Ⅰ、Ⅱ、Ⅲ、Ⅳ型患者分彆為83例、20例、11例、13例;術前分彆有31例、9例、0例、2例患者臨床癥狀錶現為黃疸,23例、8例、7例、7例錶現為腹痛,4型患者比較,差異有統計學意義(x2=5.63,3.49,P＜0.05).(2)術中情況:80例患者行標準的胰十二指腸切除術(手術方式採用靜脈優先入路),其中Ⅰ型74例、Ⅱ型6例.47例患者行胰十二指腸聯閤門靜脈或腸繫膜上靜脈切除術,其中Ⅰ型9例、Ⅱ型14例、Ⅲ型11例、Ⅳ型13例.13例患者術中行擴大淋巴結清掃,其中Ⅰ型2例、Ⅱ型3例、Ⅲ型4例、Ⅳ型4例.消化道重建方式:74例患者行胰胃吻閤,其中Ⅰ型52例、Ⅱ型10例、Ⅲ型6例、Ⅳ型6例.37例患者行胰腸吻閤,其中Ⅰ型22例、Ⅱ型6例、Ⅲ型5例、Ⅳ型4例.16例患者行胰管對空腸黏膜吻閤,其中Ⅰ型9例、Ⅱ型4例、Ⅳ型3例.Ⅰ、Ⅱ、Ⅲ、Ⅳ型胰頭癌患者手術時間分彆為(287±47) min、(354 ±64) min、(342±86) min、(380±46) min;術中齣血量分彆為(399±180) mL、(480±233) mL、(418±256) mL、(554±307) mL,4型患者比較,差異均有統計學意義(F =4.02,3.91,P＜0.05).(3)術後情況:Ⅰ、Ⅱ、Ⅲ、Ⅳ型胰頭癌患者術後住院時間分彆為(22±10)d、(29±10)d、(28±12)d、(33 ±17)d,4型患者比較,差異有統計學意義(F=4.01,P＜0.05).(4)術後病理學檢查結果:Ⅰ、Ⅱ、Ⅲ、Ⅳ型胰頭癌患者腫瘤直徑分彆為(3.3±1.1)cm、(4.1±0.9)cm、(4.1±1.0)cm、(4.6±1.1)cm,TNM分期T1～2期和T3～4期分彆為59例和24例、0例和20例、0例和11例、0例和13例,神經侵犯分彆為14例、8例、6例、9例,4型患者比較,差異均有統計學意義(F=5.12,x2=58.41,20.76,P＜0.05).(5)隨訪結果:112例患者穫得隨訪(其中Ⅰ型74例、Ⅱ型18例、Ⅲ型9例、Ⅳ型11例),15例患者失訪.Ⅰ型患者中位生存時間為24箇月(2～60箇月),2年生存率為42.2％;Ⅱ型患者中位生存時間為16箇月(2～30箇月),2年生存率為25.0％;Ⅲ型患者中位生存時間為18箇月(2～ 30箇月),2年生存率為27.3％;Ⅳ型患者中位生存時間為16箇月(2～26箇月),2年生存率為15.0％.4型胰頭癌患者生存情況比較,差異有統計學意義(x2=16.85,P＜0.05).其中Ⅰ型分彆與Ⅱ、Ⅲ、Ⅳ型患者生存情況比較,差異均有統計學意義(x2=12.11,5.10,10.73,P＜0.05);Ⅱ型分彆與Ⅲ、Ⅳ型患者生存情況比較,差異均無統計學意義(x2=0.22,0.48,P＞0.05);Ⅲ型與Ⅳ型患者生存情況比較,差異無統計學意義(x2=1.09,P＞0.05).結論 根據胰頭癌與血管的關繫建立胰頭癌新分型.該分型對指導臨床手術方式選擇和判斷預後具有重要臨床意義.
목적 근거CT검사평고이두암여주위혈관적관계,건립일충신적이두암분형,탐토신형이두암분형재이두암환자수술방식선택급평고환자예후중적응용개치.방법 회고성분석2009년1월지2012년12월화중과기대학동제의학원부속동제의원수치적127례이두암환자적림상자료.근거술전다배라선CT검사결과평고이두암여혈관적관계,장이두암분위Ⅰ형、Ⅱ형、Ⅲ형화Ⅳ형4충류형.근거종류부위급이두암신분형,채취불동적수술입로화수술방식.술후환자입주이선수술중증감호실,상규여이감측생명체정、금식수、보액、영양지지、상규항생소예방감염등지지치료,동시보지복강인류통창.술후병발증안조국제이선외과연구조(ISGPS)정의진행자료수집.기록병관찰환자술전정황:성별、년령、BMI、황달、복통、기타소화도증상、근기체질량하강、합병당뇨병;술중정황:수술방식、수술시간、술중출혈량;술후정황:환자술후병발증화술후주원시간;술후병이학검사결과.환자술후1、3、6、12、18개월,통과전화혹문진방식진행수방.수방시간절지2014년12월.정태분포적계량자료용(x)±s표시,다조간비교채용단인소방차분석;비정태분포적계량자료용M(범위)표시,다조간비교채용Wilcoxon검험;계수자료비교채용x2검험.채용Kaplan-Meier법회제생존곡선,생존솔적비교채용Log-rank검험.결과 (1)이두암분형:Ⅰ、Ⅱ、Ⅲ、Ⅳ형환자분별위83례、20례、11례、13례;술전분별유31례、9례、0례、2례환자림상증상표현위황달,23례、8례、7례、7례표현위복통,4형환자비교,차이유통계학의의(x2=5.63,3.49,P＜0.05).(2)술중정황:80례환자행표준적이십이지장절제술(수술방식채용정맥우선입로),기중Ⅰ형74례、Ⅱ형6례.47례환자행이십이지장연합문정맥혹장계막상정맥절제술,기중Ⅰ형9례、Ⅱ형14례、Ⅲ형11례、Ⅳ형13례.13례환자술중행확대림파결청소,기중Ⅰ형2례、Ⅱ형3례、Ⅲ형4례、Ⅳ형4례.소화도중건방식:74례환자행이위문합,기중Ⅰ형52례、Ⅱ형10례、Ⅲ형6례、Ⅳ형6례.37례환자행이장문합,기중Ⅰ형22례、Ⅱ형6례、Ⅲ형5례、Ⅳ형4례.16례환자행이관대공장점막문합,기중Ⅰ형9례、Ⅱ형4례、Ⅳ형3례.Ⅰ、Ⅱ、Ⅲ、Ⅳ형이두암환자수술시간분별위(287±47) min、(354 ±64) min、(342±86) min、(380±46) min;술중출혈량분별위(399±180) mL、(480±233) mL、(418±256) mL、(554±307) mL,4형환자비교,차이균유통계학의의(F =4.02,3.91,P＜0.05).(3)술후정황:Ⅰ、Ⅱ、Ⅲ、Ⅳ형이두암환자술후주원시간분별위(22±10)d、(29±10)d、(28±12)d、(33 ±17)d,4형환자비교,차이유통계학의의(F=4.01,P＜0.05).(4)술후병이학검사결과:Ⅰ、Ⅱ、Ⅲ、Ⅳ형이두암환자종류직경분별위(3.3±1.1)cm、(4.1±0.9)cm、(4.1±1.0)cm、(4.6±1.1)cm,TNM분기T1～2기화T3～4기분별위59례화24례、0례화20례、0례화11례、0례화13례,신경침범분별위14례、8례、6례、9례,4형환자비교,차이균유통계학의의(F=5.12,x2=58.41,20.76,P＜0.05).(5)수방결과:112례환자획득수방(기중Ⅰ형74례、Ⅱ형18례、Ⅲ형9례、Ⅳ형11례),15례환자실방.Ⅰ형환자중위생존시간위24개월(2～60개월),2년생존솔위42.2％;Ⅱ형환자중위생존시간위16개월(2～30개월),2년생존솔위25.0％;Ⅲ형환자중위생존시간위18개월(2～ 30개월),2년생존솔위27.3％;Ⅳ형환자중위생존시간위16개월(2～26개월),2년생존솔위15.0％.4형이두암환자생존정황비교,차이유통계학의의(x2=16.85,P＜0.05).기중Ⅰ형분별여Ⅱ、Ⅲ、Ⅳ형환자생존정황비교,차이균유통계학의의(x2=12.11,5.10,10.73,P＜0.05);Ⅱ형분별여Ⅲ、Ⅳ형환자생존정황비교,차이균무통계학의의(x2=0.22,0.48,P＞0.05);Ⅲ형여Ⅳ형환자생존정황비교,차이무통계학의의(x2=1.09,P＞0.05).결론 근거이두암여혈관적관계건립이두암신분형.해분형대지도림상수술방식선택화판단예후구유중요림상의의.
Objective To explore the application value of a new classification of the pancreatic head cancer based on relationship between pancreatic head cancer and adjacent vessels evaluated by computed tomography in the surgical procedures and prognosis of patients.Methods The clinical data of 127 patients with pancreatic head cancer who were admitted to the Tongji Hospital of Huazhong University of Science and Technology from January 2009 to December 2012 were retrospectively analyzed.According to the relationship between tumor and blood vessels by preoperative multi-slice spiral computed tomography (MSCT),all patients were divided into four types,including type Ⅰ,type Ⅱ,type Ⅲ and type Ⅳ.The different surgical approaches and procedures were performed based on the location of tumors and a new classification of pancreatic head cancer.After operation,patients received the unobstructed peritoneal drainage and regular supporting treatment such as monitoring of vital signs,fasting and water,fluid infusion,nutritional support and antibiotics administration.The data of postoperative complications were collected according to principle of International Study Group on Pancreatic Surgery (ISGPS).The preoperative conditions of patients were observed and recorded,including sex,age,body mass index,jaundice,abdominal pain,other symptoms of digestive tract,recent weight loss and diabetes mellitus.The intraoperative and postoperative conditions were analyzed,including surgical method,operation time,volume of blood loss,postoperative complications,duration of postoperative hospital stay and pathological examination.All the patients were followed up by outpatient examination and telephone interview at postoperative month 1,3,6,12,18 up to December 2014.Measurement data with normal distribution were presented as (x) ± s.Comparisons among groups were evaluated with the one-way ANOVA and Wilcoxon rank sum test.Non-normal distribution data were described as M (range).Count data were analyzed with chi-square test.Survival curve was drawn by the Kaplan-Meier method,and survival rate was analyzed using the Log-rank test.Results (1) The classification of pancreatic head cancer:type Ⅰ,type Ⅱ,type Ⅲ and type Ⅳ were detected respectively in 83,20,11 and 13 patients.The jaundice and abdominal pain of patients with type Ⅰ,type Ⅱ,type Ⅲ and type Ⅳ were occurred in 31,9,0,2 and 23,8,7,7 patients,respectively,with a significant difference (x2=5.63,3.49,P ＜ 0.05).(2) The intraoperative situation:80 patients underwent pancreaticoduodenectomy (PD) with " vein first" approach,including 74 of type Ⅰ and 6 of type Ⅱ.Forty-seven patients underwent PD combined with resection of portal vein and superior mesenteric vein,including 9 patients with type Ⅰ,14 patients with type Ⅱ,11 patients with type Ⅲ and 13 patients with type Ⅳ.Thirteen patients received extended lymph node dissection,including 2 patients with type Ⅰ,3 patients with type Ⅱ,4 patients with type Ⅲ and 4 patients with type Ⅳ.The methods of digestive reconstruction:of 74 patients receiving pancreatic-gastric anastomosis,type Ⅰ,Ⅱ,Ⅲ and Ⅳ were detected respectively in 52,10,6 and 6 patients.Of 37 patients receiving PD,type Ⅰ,Ⅱ,Ⅲ and Ⅳ were detected respectively in 22,6,5 and 4 patients.Of 16 patients receiving pancreaticojejunal anastomosis,type Ⅰ,Ⅱ and Ⅳ were detected respectively in 9,4 and 3 patients.The operation time and volume of blood loss in patients with type Ⅰ,Ⅱ,Ⅲ and Ⅳ were (287 ±47)minutes,(354 ±64)minutes,(342 ±86)minutes,(380 ± 46) minutes and (399 ± 180) mL,(480 ± 233) mL,(418 ± 256) mL,(554 ± 307) mL,respectively,with significant differences (F =4.02,3.91,P ＜ 0.05).(3) The postoperative situation:the duration of hospital stay in patients with type Ⅰ,Ⅱ,Ⅲ and Ⅳ were (22 ± 10) days,(29 ± 10) days,(28 ± 12) days and (33 ± 17) days,respectively,showing significant differences (F =4.01,P ＜ 0.05).(4)The results of pathological examination:tumor diameter in patients with type Ⅰ,Ⅱ,Ⅲ and Ⅳ were respectively (3.3 ± 1.1) cm,(4.1 ± 0.9) cm,(4.1 ± 1.0)cm and (4.6 ± 1.1)cm,T1-2 stage,T3-4 stage and nerve invasion were detected in 59,24 and 14 cases with type Ⅰ,0,20 and 8 cases with type Ⅱ,0,11 and 6 cases with type Ⅲ,0,13 and 9 cases with type Ⅳ,respectively,showing significant differences (F =5.12,x2 =58.41,20.76,P ＜ 0.05).(5) The results of follow-up:112 patients were followed up (74 with type Ⅰ,18 with type Ⅱ,9 with type Ⅲ and 11 with type Ⅳ) and 15 patients lost to follow-up.The mean survival time and 2-year survival rate were 24 months (range,2-60 months) and 42.2％ in patients with type Ⅰ,16 months (range,2-30 months) and 25.0％ in patients with type Ⅱ,18 months (range,2-30 months) and 27.3％ in patients with type Ⅲ and 16 months (range,2-26 months) and 15.0％ in patients with type Ⅳ,showing a significant difference in the survival of patients (x2=16.85,P ＜0.05).The survival of patients with type Ⅰ was significantly different from that of patients with type Ⅱ,Ⅲ and Ⅳ (x2=12.11,5.10,10.73,P ＜0.05).There were no significant differences in the survival between patients with type Ⅱ and type Ⅲ,type Ⅳ (x2 =0.22,0.48,P ＞ 0.05).There was no significant difference in the survival of patients between type Ⅲ and type Ⅳ (x2 =1.09,P ＞ 0.05).Conclusion A new classification of pancreatic head cancer based on the relationship between tumor and adjacent vessels may play an important role in selecting appropriate surgical procedure and predicting the prognosis.
