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  • Title: [Application of left-sided uncinate process first approach in pancreaticoduodenectomy].
    Author: Wu PF, Huang XM, Zhang K, Lu ZP, Chen JM, Xi CH, Wei JS, Guo F, Cai BB, Yin J, Jiang KR, Miao Y.
    Journal: Zhonghua Wai Ke Za Zhi; 2021 Jul 01; 59(7):624-630. PubMed ID: 34256464.
    Abstract:
    Objective: To evaluate the value of left-sided uncinate process first approach in pancreaticoduodenectomy. Methods: The clinical data of 152 patients who underwent the left-sided uncinate process first approach during pancreaticoduodenectomy at Pancreas Center, the First Affiliated Hospital of Nanjing Medical University from January 2020 to December 2020 were analyzed retrospectively. There were 64 females and 88 males,with age(M(QR)) of 62.0(14.7)years(range:16.0 to 84.0 years). The clinical date of 117 patients who underwent pancreaticoduodenectomy without using left-sided uncinate process first approach in the same period was selected as the control group,including 65 females and 52 males,with age of 64.0(13.0) years(range:13.0 to 84.0 years). Fisher exact probability method and t test were used to compare the data between the two groups,rank sum test was used for comparison of continuous variables between the two groups. Results: Pancreaticoduodenectomy was successfully performed in 152 patients in left-sided uncinate process first approach group. The operation time was 222.5(77.0) minutes(range:117.0 to 480.0 minutes),the time of uncinate process resection from left-side(the time from jejunum dissection to complete dissociation of the uncinate process) was 11.0(4.5) minutes(range:7.5 to 20.0 minutes),the time of pancreatic head resection (the time from jejunum dissection to pancreaticoduodenal specimen removal) was 26.0(8.5) minutes(range:20.0 to 41.0 minutes),the intraoperative blood loss was 200(150) ml(range:50 to 800 ml),and the intraoperative blood transfusion rate was 9.2% (14/152). Postoperative conditions:The postoperative hospital stay was 12 (9) d(range:6 to 55 d),the overall incidence of postoperative complications was 59.9%(91/152),and there was no perioperative death. Pathological results:The R0 resection rate of periampullary malignant tumor was 64.3%(77/112),with negative rate of uncinate process margin was 91.1%(102/112). The R0 resection rate of pancreatic ductal adenocarcinoma was 46.9%,with negative rate of uncinate process margin was 89.1%(57/64). Compared with the non-left-sided uncinate process first approach group(222.5(77.0) minutes, 9.2%(14/152)),the left-sided uncinate process first approach group had shorter operation time(246.0(94.0) minutes) (Z=3.964,P<0.01),less intraoperative blood loss (18.8%(22/117))(Z=4.843,P<0.01),and lower intraoperative blood transfusion rate(χ²=5.248,P=0.029). However,there were no significant differences between two groups in postoperative hospital stay(Z=1.682,P=0.093),postoperative overall complications(P=0.549),R0 resection rate of periampullary malignant tumor(χ²=2.012,P=0.156),and negative rate of uncinate process margin(χ²=2.108,P=0.147). Conclusions: The "left-sided uncinate process first approach" could completely resect uncinate process under a direct vision,especially when the uncinate process was behind the superior mesenteric artery or beyond the left lateral margin of the superior mesenteric artery. The "left-sided uncinate process first approach" might increase the negative rate of uncinate process margin and R0 resection rate for periampullary malignant tumor. 目的： 探讨左侧钩突优先入路在胰十二指肠切除术中的应用效果。 方法： 回顾性分析2020年1―12月在南京医科大学第一附属医院胰腺中心施行的152例胰十二指肠切除术中采用左侧钩突优先入路的病例资料，其中男性88例，女性64例，中位年龄［M（QR）］62.0（14.7）岁（范围：16.0~84.0岁）；选取同期接受非左侧钩突优先入路的胰十二指肠切除术的117例患者作为对照组，其中男性65例，女性52例，中位年龄64.0（13.0）岁（范围：13.0~84.0岁）。计数资料的组间比较采用χ²检验或Fisher确切概率法，计量资料的组间比较采用秩和检验。 结果： 左侧钩突优先入路组中152例患者均成功完成胰十二指肠切除术。左侧钩突优先入路组的手术时间为222.5（77.0）min（范围：117.0~480.0 min），左侧钩突优先切除时间（从空肠离断至钩突部完全游离的时间）为11.0（4.5）min（范围：7.5~20.0 min），胰头切除时间（从空肠离断至胰十二指肠标本移除的时间）为26.0（8.5）min（范围：20.0~41.0 min），术中出血量200（150）ml（范围：50~800 ml），术中输血率为9.2%（14/152）。左侧钩突优先入路组的术后住院时间为12（9）d（范围：6~55 d），术后总体并发症发生率为59.9%（91/152），无围手术期死亡。左侧钩突优先入路组中壶腹周围恶性肿瘤R0切除率为64.3%（72/112），其中钩突切缘阴性率为91.1%（102/112）；胰腺导管腺癌R0切除率为46.9%（30/64），其中钩突切缘阴性率为89.1%（57/64）。与同期非左侧钩突优先入路组［222.5（77.0）min］和9.2%（14/152）比较，左侧钩突优先入路组手术时间［246.0（94.0） min］短（Z=3.964，P<0.01）、术中出血量少（Z=4.843，P<0.01）、术中输血率［18.8%（22/117）］低（χ²=5.248，P=0.029），但两组在术后住院时间（Z=1.682，P=0.093）、术后各级总体并发症发生率（P=0.549）、壶腹周围恶性肿瘤R0切除率（χ²=2.012，P=0.156）和钩突切缘阴性率（χ²=2.108，P=0.147）的差异均无统计学意义。 结论： 左侧钩突优先入路可在直视下于肠系膜左侧完全切除胰腺钩突部，尤其是钩突尖端位于肠系膜上动脉后侧及左侧时，可提高壶腹周围恶性肿瘤胰腺钩突切缘阴性率及总体R0切除率。.
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