Pathogenesis and treatment of neoplastic diseases of the papilla of Vater: Kausch-Whipple procedure with lymph node dissection in cancer of the papilla of Vater
Pathogenesis and treatment of neoplastic diseases of the papilla of Vater: Kausch-Whipple procedure with lymph node dissection in cancer of the papilla of Vater
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DOI：
10.1007/s00534-004-0895-6
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发表时间：
2004-01-01
期刊：
影响因子：
--
通讯作者：
Rau, BM
中科院分区：
文献类型：
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作者：
Beger, HG;Thorab, FC;Rau, BM
从临床的角度来看，乳头癌或壶腹癌似乎是十二指肠内癌或壶腹癌。腺瘤-异型增生-癌的顺序已经确立。在20%-40%的乳头腺瘤患者中，还观察到腺瘤中的癌性病变。采用Kausch-Whipple技术或保留幽门的部分胰十二指肠切除术（PPPD）的肿瘤切除术提供了45%至65%的5年生存率。在有经验的中心，肿瘤切除术后的住院死亡率低于5%。最常见的治疗相关并发症是胰瘘，约有20%的患者发生。在约10%的pT（1）癌症患者和25%至67%的pT（2）和pT（3）癌症患者中观察到淋巴结受累。胰腺头部前后的淋巴结是癌细胞扩散的主要目标。超过三分之一的患者累及下腔静脉间隙淋巴结、肠系膜上上级动脉周围淋巴结和肝十二指肠韧带胰腺段淋巴结。因此，组织切除，包括选择性地N-2淋巴结，是乳头癌根治手术的重要组成部分。标准的Kausch-Whipple切除术或PPPD没有选择性的扩大淋巴结清扫，包括门腔静脉和上级肠系膜动脉淋巴结，导致约30%的患者有R-2切除术，即，留下了癌症长期生存取决于肿瘤生物学因素：（1）没有淋巴结受累和（2）没有浸润到胰腺。外科医生对乳头癌治愈的贡献是进行低住院死亡率和低术后发病率的R-0切除术。无淋巴结受累、无胰腺浸润、无淋巴管浸润和肿瘤阴性切缘的患者在癌症的可治愈性方面从肿瘤切除术中获得主要益处。
Cancer of the papilla or the ampulla of Vater appears, from a clinical point of view, to be an intraduodenal or ampullary cancer. An adenoma-dysplasia-carcinoma sequence has been established. In 20%-40% of the patients with an adenoma of the papilla, a cancerous lesion in the adenoma is additionally observed. Oncological resection using a Kausch-Whipple technique or a pylorus-preserving partial pancreatico-duodenectomy (PPPD) offers a 5-year survival probability of between 45% and 65%. The hospital mortality after oncological resection at experienced centers is below 5%. The most frequent treatment-related complication is pancreatic fistula, which occurs in around 20% of the patients. In about 10% of the patients with a pT(1) cancer and in 25 % to 67 % with pT(2) and pT(3), cancer, lymph node involvement has been observed. Lymph nodes in front of and behind the head of the pancreas are the primary targets for cancer cell disseminations. In more than one-third of the patients, lymph nodes in the inter-aortocaval space and the lymph nodes around the superior mesenteric artery and the nodes in the pancreatic segment of the hepatoduodenal ligament are involved. Therefore, tissue dissection, including, selectively, the N-2 lymph nodes, is an essential component of radical surgery for cancer of the papilla. A standard Kausch-Whipple resection or PPPD without a selective extended lymph node dissection, including the interaortocaval and superior mesenteric artery nodes, results in about 30% of the patients having an R-2-resection, i.e., with cancer left behind. The long-term survival is determined by the tumor biological factors: (1) absence of lymph node involvement and (2) absence of infiltration into the pancreas. The surgeon's contribution to the cure of cancer of the papilla is to perform an R-0-resection with low hospital mortality and low postoperative morbidity. Patients without lymph node involvement, and with absence of infiltration into the pancreas, no lymph vessel invasion, and tumor-negative margins have major benefits from oncological resection in regard to curability of the cancer.