摘要
近20年来,胰腺外科手术理念与技术有了巨大的更新和进步,在显著提高胰腺癌手术安全性与切除率的同时,也衍生出对手术指征、手术时机、切除范围等传统外科问题的再审视与思考。患者预后改善是判断手术指征的“金标准”,传统形态学“不可切除”的标准将不断被突破,可否切除的判断将从“能否切除”过渡到“应否切除”。在临床研究之外,提倡进行标准范围的淋巴结清扫。对于新辅助治疗后的交界可切除及局部进展期胰腺癌,可行扩大范围的淋巴结清扫。各种手术入路皆为可行之选,入路服从于解剖的需要,解剖服从于根治的需要,根治服从于预后改善的需要。对于部分局部进展期胰腺癌患者,动脉鞘剥除及“海德堡三角”清扫有助于提高切除率,降低局部复发率,但对远期预后的影响尚有待进一步临床观察。胰肠吻合质量较吻合方式对胰瘘发生率的影响更大。对于开展样本量大、临床经验丰富的术者,腹腔镜或机器人辅助手术具有微创优势,但对胰头癌行胰十二指肠切除,尚无充分证据证明其肿瘤学优势。
Over the past 20 years,the concept of pancreatic surgery has been updated and surgical skills has improved dramatically.With the significant improvement of surgical safety and increase of resection rate for pancreatic cancer,some traditional surgical issues such as surgical indications,timing and extent of resection are being re-evaluated.The improvement of patients′prognosis is the gold standard for judging the surgical indications.The traditional criteria of“unresectable”based on morphology will be constantly broken through,and the estimation of resectability will transition from“what can we resect”to“what should we resect”.Except for clinical research,standard extent of lymph node dissection is recommended.However,for borderline resectable and locally advanced pancreatic cancer after neoadjuvant treatment,extended lymph node dissection is recommended.All kinds of surgical approaches are feasible.The approach is subject to the needs of anatomy,anatomy is subject to the needs of radical treatment,and radical treatment is subject to the needs of improving prognosis.For some patients with locally advanced pancreatic cancer,sub-adventitial divestment of superior mesenteric artery and“Heidelberg triangle”cleaning are helpful to improve the resection rate and reduce the local recurrence rate,however,the impact on the long-term prognosis still needs to be further observed clinically.The quality of pancreaticojejunostomy has more influence on the incidence of pancreatic fistula than the type of pancreaticojejunostomy.For the centers with high volume patients and the surgeons with rich personal experience,laparoscopic or robot assisted surgery has the advantages of minimally invasive,but for pancreatic head carcinoma,it is not enough evidence to prove the oncological advantages of laparoscopic pancreaticoduodenectomy and robotic-assistant pancreaticoduodenectomy.
作者
杨尹默
Yang Yinmo(Department of Surgery,Peking University First Hospital,Beijing 100034,China)
出处
《中华外科杂志》
CAS
CSCD
北大核心
2023年第1期1-6,共6页
Chinese Journal of Surgery
基金
国家自然科学基金(82171722)。
关键词
胰腺肿瘤
外科手术
胰十二指肠切除术
Pancreatic neoplasms
Surgical procedures,operative
Pancreaticoduodenectomy
