Establishment And Evaluation Of Norms Of R0~+ Radical Treatment Of Pancreatic Head Ductal Adenocarcinoma

Objectives:1.Through the study and summary of pancreatic anatomy,the concept of pancreatic cancer occurrence,progression,metastasis,the evolution of pancreatic cancer surgery and the controversial issues faced,combined with the team’s clinical practice to establish a radical treatment of pancreatic head ductal adenocarcinoma R0+based on the principles of tumor resection and detailed rules.Surgical strategies and procedures of R0+radical pancreatodudenectomy(R0+-RPD).2.Through the comparison of R0+-RPD and standard pancreatodudenectomy(standard pancreatodudenectomy,SPD)in the perioperative period and prognosis-related indicators,evaluate the feasibility,safety and efficacy of R0+-RPD.Methods:1.A literature review of the current hot spots and controversial issues of pancreaticoduodenectomy for pancreatic head cancer combined with the clinical practice of this research team,to lay a theoretical and practical foundation for the strategies and procedures of R0+-RPD surgery.2.The 64 cases of pancreaticoduodenectomy and postoperative pathology confirmed by the team of Dr.Fu Bimang from the fourth ward of the Hepatobiliary and Pancreatic Surgery Department of the Second Affiliated Hospital of Kunming Medical University were admitted from January 2015 to May 2019.The clinical data of patients with pancreatic ductal adenocarcinoma(PDAC)were analyzed retrospectively.Among them,29 patients underwent standard pancreaticoduodenectomy(SPD group)from January 2015 to June 2017,and 35 patients underwent R0+radical resection of pancreatic cancer from July 2017 to May 2019(R0+-RPD group).Through statistical analysis of the medical history data of the two groups of patients to evaluate the operation method,the medical history data to be observed include:①General clinical data:gender,age,body mass index(BMI),CA199.②Intraoperative observation indicators:operation time,intraoperative blood loss,blood transfusion,whether combined with vascular resection.③Postoperative observation indicators:postoperative hospital stay,perioperative complications[pancreatic fistula,biliary fistula,bleeding,delayed gastric emptying(DGE),abdominal infection],perioperative mortality.④Pathological conditions:R0 resection rate,number of lymph nodes,lymph node positive rate(lymph nodes ratio,LNR),tumor size,TNM stage.⑤Prognostic indicators:whether postoperative chemotherapy,local recurrence,distant metastasis,median survival,1-year survival rate,2-year survival rate.3.Statistical analysis of the medical history data of the two groups of patients in order to evaluate the safety,feasibility and effectiveness of R0+radical resection of pancreatic cancer in the treatment of pancreatic cancer,and to guide clinical practice.Results:1.There is no statistically significant difference between the R0+-RPD group and the SPD group in the comparison of general clinical data such as age,gender,BMI,and CA199(P values are 0.629,0.149,0.115,0.094,respectively).2.For the intraoperative observation indicators,the R0+-RPD group has higher requirements for the breadth of the operation scope,the fineness of the operation,and the skills due to the removal of the primary lesions,including regional lymph nodes,nerves,blood vessels,mesangium and other soft tissues.To a large extent,it caused more operation time and intraoperative blood loss in the R0+-RPD group,and the difference was statistically significant(P 0.037,0.035,respectively).There was no significant difference in the amount of intraoperative blood transfusion and the proportion of cases with or without vascular resection and reconstruction in the two groups in this study(P=0.136,P=0.589).3.Postoperative observation indexes including postoperative hospital stay,pancreatic fistula,biliary fistula,postoperative bleeding,DGE,abdominal infection,total complication rate,and perioperative mortality rate are in the R0+-RPD and SPD groups.There was no statistical difference in the comparisons(P values were 0.430,0.885,0.577,0.783,0.558,0.778,0.931,0.905,0.312,0.414,0.729,1.000).4.In the comparison of postoperative pathological examination indexes,the number of lymph nodes dissected in the R0+-RPD group was 21.31±6.539,and the SPD group was 14.69±8.260,the difference was statistically significant(P=0.023).However,there was no statistically significant difference between the two groups in the R0 status of the specimen resection margin,the number of lymph node metastases,the largest tumor diameter,the T stage,the N stage,and the TNM stage(P 1.000,0.518,0.857,0.334,0.575,0.786,respectively).5.The postoperative local recurrence rates of R0+-RPD group and SPD group were 20.0%and 44.8%,respectively,which was statistically different(P=0.033).The median survival time of the R0+-RPD group and the SPD group were 19.0 months and 15.0 months,respectively;the 1-year survival rates were 77.1%and 65.5%,respectively;the 2-year survival rates were 20.0%and 13.8%,respectively.There was no statistically significant difference between the two groups of cases in the proportion of patients who received chemotherapy or not and the survival time(P 0.461 and 0.052,respectively).Conclusions:1.The R0+-RPD surgical strategy is achievable and safe in pancreaticoduodenectomy for pancreatic head ductal adenocarcinoma,but it involves regional lymph node dissection,nerve and mesangectomy except for the primary lesion,Arterial sheath stripping,so R0+-RPD surgery has a higher surgical difficulty.Therefore,it is recommended to carry out a specialized team or center based on the accumulation of a certain amount of pancreaticoduodenectomy.2.Compared with standard pancreaticoduodenal surgery,the R0+-RPD surgical strategy requires a higher number of lymph node dissections,which is conducive to the removal of positive and potentially positive lymph nodes,and nerves,blood vessels,and mesangial tissues in areas with high risk of recurrence.3.The perioperative complication rate and mortality rate of R0+-RPD surgical strategy is the same as that of standard pancreaticoduodenal surgery,and the local recurrence and metastasis rate of R0+-RPD surgical strategy is low.Therefore,the short-term effect of pancreaticoduodenectomy with R0+-RPD surgical strategy is satisfactory.