Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma - Comparison of morbidity and mortality and short-term outcome
Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma - Comparison of morbidity and mortality and short-term outcome
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DOI：
10.1097/00000658-199905000-00003
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发表时间：
1999-05-01
影响因子：
9
通讯作者：
Lillemoe, KD
中科院分区：
文献类型：
--
作者：
Yeo, CJ;Cameron, JL;Lillemoe, KD
目的 这项前瞻性、随机、单机构试验旨在评估接受标准与根治性（扩大）胰十二指肠切除术（包括远端胃切除术和腹膜后淋巴结切除术）的患者的死亡率、发病率和生存终点。背景数据摘要大量回顾性报告和一项前瞻性随机试验表明，扩大淋巴结切除术与胰十二指肠切除术联合进行可能会改善一些胰腺和其他疾病患者的长期生存率。壶腹周围腺癌。许多先前发表的研究都因其回顾性和非随机设计、纳入非同步对照组以及数量较少而受到批评。 方法 1996 年 4 月至 1997 年 12 月期间，114 名壶腹周围腺癌患者参加了约翰·霍普金斯医院正在进行的一项前瞻性随机试验。术中证实壶腹周围腺癌完全切除后，患者被随机分配接受标准胰十二指肠切除术（仅切除与标本一起的胰周淋巴结）或根治性胰十二指肠切除术（标准切除加远端胃切除术和腹膜后淋巴结切除术）。所有病理标本均经过审查和分类。对术后发病率、死亡率和短期结果进行了检查。结果 在随机分组的 114 名患者中，56 名接受了标准胰十二指肠切除术，58 名接受了根治性胰十二指肠切除术。两组在年龄和性别方面统计相似，但激进组中白人患者的比例较高。根治组所有患者均接受远端胃切除术，标准组86%患者接受幽门保留。根治组的平均手术时间为 6.8 小时，而标准组为 6.2 小时。两组在术中失血量、输血需求、原发肿瘤位置、平均肿瘤大小、阳性淋巴结状态或阳性切缘状态方面没有显着差异。标准组有 3 例死亡，激进组有 2 例死亡。标准组的并发症发生率为34%，根治组的并发症发生率为40%。接受根治性切除的患者早期胃排空延迟的发生率较高，但其他并发症（如胰瘘、伤口感染、腹内脓肿和需要再次手术）的发生率相似。根治组切除的淋巴结平均总数较高。根治组的58例患者中，仅10%在切除的腹膜后淋巴结中出现转移癌，并且这些患者中没有腹膜后淋巴结是唯一淋巴结受累的部位。标准切除组术后即刻存活的患者的 1 年精算生存率为 77%，根治性切除组为 83%。 结论 这些数据表明，根治性胰十二指肠切除术（在标准胰十二指肠切除术的基础上增加远端胃切除术和扩大腹膜后淋巴结切除术）的发病率和死亡率与标准胰十二指肠切除术相似。然而，生存数据还不够成熟，入组患者数量也不足以得出关于生存获益的确切结论。
Objective This prospective, randomized, single-institution trial was designed to evaluate the end points of mortality, morbidity, and survival in patients undergoing standard versus radical (extended) pancreaticoduodenectomy (including distal gastrectomy and retroperitoneal lymphadenectomy).Summary Background Data Numerous retrospective reports and one prospective randomized trial have suggested that the performance of an extended lymphadenectomy in association with a pancreaticoduodenal resection may improve long-term survival for some patients with pancreatic and other periampullary adenocarcinomas. Many of these previously published studies can be criticized for their retrospective and nonrandomized designs, for the inclusion of nonconcurrent control groups, and for their small numbers.Methods Between April 1996 and December 1997, 114 patients with periampullary adenocarcinoma were enrolled in an ongoing, prospective, randomized trial at The Johns Hopkins Hospital. After intraoperative verification of completely resected periampullery adenocarcinoma, the patients were randomized to receive either a standard pancreaticoduodenectomy (removing only the peripancreatic lymph nodes en bloc with the specimen) or a radical pancreaticoduodenectomy (standard resection plus distal gastrectomy and retroperitoneal lymphadenectomy). All pathology specimens were reviewed and categorized. The postoperative morbidity, mortality, and short-term outcomes were examined.Results Of the 114 patients randomized, 56 underwent a standard pancreaticoduodenectomy and 58 a radical pancreaticoduo-denectomy. The two groups were statistically similar with regard to age and gender, but there was a higher percentage of white patients in the radical group. All the patients in the radical group underwent distal gastric resection, whereas 86% of the patients in the standard group underwent pylorus preservation. The mean operative time in the radical group was 6.8 hours, compared with 6.2 hours in the standard group. There were no significant differences between the two groups with respect to the intraoperative blood loss, transfusion requirements, location of primary tumor, mean tumor size, positive lymph node status, or positive margin status. There were three deaths in the standard group and two in the radical group. The complication rates were 34% for the standard group and 40% for the radical group. Patients undergoing radical resection had a higher incidence of early delayed gas tric emptying but had similar rates of other complications, such as pancreatic fistula, wound infection, intraabdominal abscess, and need for reoperation. The mean total number of lymph nodes resected was higher in the radical group. Of the 58 patients in the radical group, only 10% had metastatic carcinoma in the resected retroperitoneal lymph nodes, and none of those patients had the retroperitoneal nodes as the only site of lymph node involvement. The 1-year actuarial survival rate for patients surviving the immediate postoperative periods was 77% for the standard resection group and 83% for the radical resection group.Conclusions These data demonstrate that radical pancreaticoduodenectomy (with the addition of a distal gastrectomy and extended retroperitoneal lymphadenectomy to a standard pancreaticoduodenectomy) can be performed with similar morbidity and mortality to standard pancreaticoduodenectomy. However, the survival data are not sufficiently mature and the numbers of patients enrolled are not adequate to allow firm conclusions to be drawn regarding survival benefit.