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Комплексное лечение больных местнораспространенным раком головки поджелудочной железы

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Цель. Изучить возможности лечения больных местнораспространенным раком головки поджелудочной железы. Материал и методы. С 2002 по 2011 г. радикальному лечению подвергли 105 больных с местнораспространенным раком головки ПЖ. В 50 (47,6%) наблюдениях выполнена расширенная гастропанкреатодуоденальная резекция с резекцией мезентерикопортального венозного сегмента, в 7 (6,7%) – расширенная гастропанкреатодуоденальная резекция с сегментарной резекцией верхней брыжеечной вены, в 11 (10,5%) – расширенная гастропанкреатодуоденальная резекция с краевой резекцией верхней брыжеечной вены, в 34 (32,4%) – расширенная гастропанкреатодуоденальная резекция и в 3 (2,9%) – стандартная панкреатодуоденальная резекция. В 24 наблюдениях выполнены сочетанные вмешательства на артериях. После удаления органного комплекса в 16 (15,2%) наблюдениях выполнен I вариант, в 15 (14,3%) – II вариант, в 3 (2,9%) – III вариант, в 25 (23,8%) – IV вариант и в 46 (43,8%) – V вариант реконструкции желудочно-кишечного тракта. В 44 (41,9%) наблюдениях проведено комплексное лечение (с адъювантной химиотерапией) и в 61 (58,1%) – только хирургическое вмешательство. Результаты. Послеоперационные осложнения составили 34,3%, летальность – 6,7%. В структуре послеоперационных осложнений преобладает несостоятельность панкреатико#панкреатодигестивного анастомоза (66,7%) и связанные с ней вторичные осложнения. Факторами прогноза несостоятельности анастомоза являются применение октреотида, состояние паренхимы ПЖ, вариант реконструкции желудочно#кишечного тракта и способ соединения культи железы с кишечной трубкой. Комплексное лечение позволило увеличить отдаленную выживаемость: однолетняя выживаемость составила 85,1%, трехлетняя – 39,3%, пятилетняя – 9,3%; медиана выживаемости – 9 мес. Заключение. Схема лечения больных местнораспространенным раком головки поджелудочной железы должна включать расширенную гастропанкреатодуоденальную резекцию и адъювантную химиотерапию

Ключевые слова:
рак поджелудочной железы, гастропанкреатодуоденальная резекция, верхняя брыжеечная вена, несостоятельность, адъювантное лечение.

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Complex Treatment for Locally Advanced Pancreatic Head Cancer

Aim. To study the treatment possibilities of locally advanced pancreatic head cancer. Material and methods. Over the period of 2002–2011, totally 105 patients underwent curative treatment at Irkutsk Regional Oncology Center for locally advanced pancreatic head cancer. In 50 (47.6 %) cases provided extended pan-creatoduodenectomy (PDE) accompanied with mesenterico-portal venous segment resection was carried out, in 7 (6.7%) – extended PDE with superior mesenteric vein segmental resection, in 11 (10.5 %) – extended PDE with superior mesenteric vein marginal resection, in 34 (32.4 %) – extended PDE without any vein resection, and in 3 cases (2.9%) – standard PDE. Combined surgical operations on arterial system were carried out in 24 cases. After gastro-pancreato-duodenal complex resection following options of digestive tract reconstruction were accomplished: in 16 (15.2 %) cases – option I, in 15 (14.3 %) – option II, in 3 (2.9 %) – option III, in 25 (23.8 %) – option IV and in 46 (43.8 %) – option V. Combined management carried out in 44 (41.9%) cases, while only surgical treatment was used in 61 (58.1%) cases. Combined treatment involved extended PDE plus adjuvant chemotherapy. Results. Postoperative morbidity rate came to 34.3% and postoperative mortality rate to – 6.7%. In postoperative complications dominated pancreatic#/pancreatodigestive anastomosis leakage (LPA) and secondary associated complications (66.7%). Predictors, influencing LPA were: octreotide application, pancreas parenchyma condition, digestive tract reconstruction option and type of anastomosis between the pancreatic remnant and jejunal loop. Combined management lead to the long#term survival rate increase: 1#year survival came to 85.1%, 3#year – to 39.3%, 5#year – to 9.3%, median survival duration – to 9 months. Conclusions. Treatment schedule of the locally advanced pancreas head cancer patients must include extended PDE plus adjuvant chemotherapy.

Keywords:
pancreatic cancer, extended pancreatoduodenetomy, superior mesenteric vein leakage, neoaduvant therapy