The “vein definition” for locally advanced pancreatic ductal adenocarcinoma (LA PDAC) assumes portal-to-superior mesenteric vein (PV/SMV) unreconstructability due to tumor involvement or occlusion. Radical pancreatectomies with SMV resection without PV/SMV reconstruction are scarcely discussed in the literature. Retrospective analysis of 19 radical pancreatectomies for “low” LA PDAC with SMV and all its tributaries resection without PV/SMV reconstruction has shown zero mortality; overall morbidity—56%; Dindo–Clavien—3–10.5%; R0—rate—82%; mean operative procedure time—355 ± 154 min; mean blood loss—330 ± 170 mL; delayed gastric emptying—25%; and clinically relevant postoperative pancreatic fistula—8%. In three cases, surgery was associated with superior mesenteric (n2) and common hepatic artery (n1) resection. Surgery was completed without vein reconstruction (n13) and with inferior mesenteric-to-splenic anastomosis (n6). There were no cases of liver, gastric, or intestinal ischemia. A specific complication of the SMV resection without reconstruction was 2–3 days-long intestinal edema (48%). Median overall survival was 25 months, and median progression-free survival was 18 months. All the relapses, except two, were distant. The possibility of successful SMV resection without PV/SMV reconstruction can be predicted before surgery by CT-based reconstructions. The mandatory anatomical conditions for the procedure were as follows: (1) preserved SMV-SV confluence; (2) occluded SMV for any reason (tumor or thrombus); (3) well-developed inferior mesenteric vein collaterals with dilated intestinal veins; (4) no right-sided vein collaterals; and (5) no varices in the upper abdomen. Conclusion: “Low” LA PDACs involving SMV with all its tributaries can be radically and safely resected in highly and specifically selected cases without PV/SMV reconstruction with an acceptable survival rate.
针对局部进展期胰腺导管腺癌（LA PDAC）的“静脉界定”标准，通常指因肿瘤侵犯或阻塞导致门静脉-肠系膜上静脉（PV/SMV）无法重建。现有文献中极少探讨在不进行PV/SMV重建的情况下，联合肠系膜上静脉切除的根治性胰腺切除术。本研究回顾性分析19例针对“低位”LA PDAC实施的根治性胰腺切除术，这些手术均切除了SMV及其所有属支且未行PV/SMV重建，结果显示：术后死亡率为零；总并发症发生率为56%；Dindo–Clavien分级≥3级并发症发生率为10.5%；R0切除率达82%；平均手术时间为355±154分钟；平均失血量330±170毫升；胃排空延迟发生率为25%；临床相关性术后胰瘘发生率为8%。其中3例手术联合切除了肠系膜上动脉（2例）和肝总动脉（1例）。手术完成方式包括直接静脉无重建（13例）及肠系膜下静脉-脾静脉吻合（6例）。未出现肝脏、胃或肠道缺血病例。未重建SMV切除的特有并发症为持续2-3天的肠道水肿（发生率48%）。中位总生存期为25个月，中位无进展生存期为18个月。除2例局部复发外，其余均为远处转移。通过CT三维重建可在术前预测成功实施不进行PV/SMV重建的SMV切除术的可能性。该术式必须满足的解剖条件包括：（1）SMV-脾静脉汇合部完整；（2）SMV因肿瘤或血栓完全阻塞；（3）肠系膜下静脉侧支循环发达伴肠系膜静脉扩张；（4）无右侧静脉侧支；（5）上腹部无静脉曲张。结论：在严格筛选的特定病例中，侵犯SMV及其所有属支的“低位”LA PDAC可在不进行PV/SMV重建的情况下实现根治性安全切除，并获得可接受的生存率。
肿瘤(癌症)患者之家