JAMA Surgery:脾静脉联合切除和单独切除在胰腺远端切除术患者中的安全性比较

2021-03-04 MedSci原创 MedSci原创

一般情况下,远端胰腺切除术(DP)不仅包括胰腺的强制性剥离,也包括脾动静脉的剥离。在这种手术过程中,脾静脉通常在分离结扎之前与胰腺实质分离。

一般情况下,远端胰腺切除术(DP)不仅包括胰腺的强制性剥离,也包括脾动静脉的剥离。在这种手术过程中,脾静脉通常在分离结扎之前与胰腺实质分离。目的是防止胰脏瘘(PF)引起的脾静脉残端腹腔出血(8.6% ~ 42.3%)。另一方面,有报道称在进行远端胰腺切除术的患者中,有1%至8%的患者因胰脏瘘或其他原因引起腹腔内出血。

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最近,腹腔镜在胰脏病变中的广泛应用导致了机械吻合器在胰腺解剖中的应用增加。在这种情况下,由于技术上的简单性,脾静脉与胰腺实质一起解剖通常是首选的方法,这种方法实际上已经成为一些机构的标准。然而,这种类型的切除后发生PF是外科医生密切关注的。

迄今为止,没有科学证据表明这种有用但有潜在危险的手术方法是安全的。因此,有研究者开展了一项多中心、随机、3期的试验,探讨了远端胰腺切除术中脾静脉联合切除与分离切除(COSMOS-DP)的安全性。该研究结果近日发表在JAMA Surgery期刊上。

本研究设计为多中心前瞻性随机3期试验。所有结果均采用改良的意向治疗集进行分析。接受胰体尾肿瘤DP治疗的患者符合入选条件。患者在2016年8月10日至2019年7月30日之间随机分配。主要终点为B/C级PF的发生率,腹内出血的发生率作为次要终点之一。

共有318名患者被随机分配,2名患者被排除为不合格。在剩下的316名患者中,150名(50.3%)为男性。改良意向治疗人群中,单独组159例(50.3%),联合组157例(49.7%)。在改良的意向治疗组中,单独切除组的B/C级PF比例为27.1%(155例中的42例),联合切除组的28.6%(154例中的44例)(校正后的比值比为1.108;95%CI为0.847-1.225;P=0.047),表明脾静脉联合切除与单独切除相比并不差。两组术后腹腔内出血的发生率相同,为1.3%。

改良意向治疗(ITT)集和每个方案集的主要终点数据

关于次要终点,联合切除组胰腺切除术后需要钉线止血的患者比例高于单独切除组(分别为9.8%和5.9%)。胰腺损伤的发生率在联合手术组比单独手术组更为频繁(分别为5.9%和2.0%)。虽然这两个结果没有达到统计上的显著差异,但结果表明,在DP中采用机械吻合器联合分割时,应特别小心,并应考虑必须对胰腺残端进行密切的围手术期观察。

总之,多中心COSMOS-DP试验成功地证明了在B/C级PF的发生率方面,脾静脉联合切除与脾静脉单独切除的非劣性。因此,确定了该程序的安全性。

参考文献:Yamada S, Fujii T, Sonohara F, et al. Safety of Combined Division vs Separate Division of the Splenic Vein in Patients Undergoing Distal PancreatectomyA Noninferiority Randomized Clinical TrialJAMA Surg. Published online March 03, 2021. doi:10.1001/jamasurg.2021.0108

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    2021-04-23 chg121
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    2021-08-15 fusion
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    2021-03-04 旺医

    顶刊就是顶刊,谢谢梅斯带来这么高水平的研究报道,我们科里同事经常看梅斯,分享梅斯上的信息

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=1877752, encodeId=5bd318e7752bf, content=<a href='/topic/show?id=b013169237f' target=_blank style='color:#2F92EE;'>#surgery#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=16923, encryptionId=b013169237f, topicName=surgery)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d7db99, createdName=chg121, createdTime=Fri Apr 23 02:44:35 CST 2021, time=2021-04-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1698201, encodeId=a3541698201d9, content=<a href='/topic/show?id=f2399910109' target=_blank style='color:#2F92EE;'>#静脉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99101, encryptionId=f2399910109, topicName=静脉)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0bc129907796, createdName=fusion, createdTime=Sun Aug 15 21:44:35 CST 2021, time=2021-08-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2021700, encodeId=eb662021e006e, content=<a href='/topic/show?id=31e8e9669d' target=_blank style='color:#2F92EE;'>#GER#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=7966, encryptionId=31e8e9669d, topicName=GER)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=48732500158, createdName=12498c32m68暂无昵称, createdTime=Sat Nov 20 18:44:35 CST 2021, time=2021-11-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1877389, encodeId=6cc918e738916, content=<a href='/topic/show?id=67c5319121e' target=_blank style='color:#2F92EE;'>#切除术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=31912, encryptionId=67c5319121e, topicName=切除术)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=9d8a96, createdName=doctorzheng, createdTime=Fri Mar 12 18:44:35 CST 2021, time=2021-03-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1036493, encodeId=c32a103649351, content=顶刊就是顶刊,谢谢梅斯带来这么高水平的研究报道,我们科里同事经常看梅斯,分享梅斯上的信息, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=旺医, createdTime=Thu Mar 04 23:44:35 CST 2021, time=2021-03-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=945547, encodeId=831994554e14, content=了解, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6KcicAVC1MwuOgo3iaicb1Imgk1yIfnvr6oXzibcAFB6puAyNJXbzWhNuLqaFYBVRWjh7rghkvFLPxMAfD5ib3nXwVD/0, createdBy=bed21972958, createdName=wxl882001, createdTime=Thu Mar 04 22:07:21 CST 2021, time=2021-03-04, status=1, ipAttribution=)]
    2021-03-04 wxl882001

    了解

    0

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