腹腔镜根治性顺行屈行模块化胰腺脾切除术经背尾动脉 入路治疗 胰腺颈体癌
Summary
随着腹腔镜技术的进步，腹腔镜根治性顺行模块化胰腺脾切除术（L-RAMPS）已得到广泛认可。然而，由于该手术中的一些技术困难，L-RAMPS 中的动脉优先入路仍然不常见。在这里，我们开发了L-RAMPS的背尾动脉方法，这可能是安全和有益的胰腺颈部肿瘤。
Abstract
腹腔镜胰颈根治性切除术是胰腺癌最复杂的根治性手术之一，尤其是对于接受过新辅助化疗的患者。在这里，我们提出了一种充分利用腹腔镜的高清视觉和手术模式，使用背尾动脉方法进行腹腔镜根治性顺行模块化胰腺脾切除术（L-RAMPS）的技术。
协议中提供了此操作的创新和优化。应优先考虑背切除面，包括肠系膜上动脉（SMA）背侧、胰头背侧、乳糜泻动脉根部（CeA）、左肾血管腹侧和肾门。在胰腺颈体癌手术可行、安全的前提下，第二步是从尾侧到头侧围绕SMA和CeA 进行肿瘤 整体切除，以提高R0（根治零）切除率和进一步预后。
Introduction
根治性顺行模块化胰腺脾切除术（RAMPS）是一种针对位于胰体或胰尾的恶性肿瘤的精细手术，由Strasberg于2003年首次描述。该手术策略基于胰腺的血液和淋巴结引流而设计，以实现无肿瘤解剖平面和区域淋巴结根治性切除1。RAMPS越来越受到外科医生的重视，因为它可能有利于获得无肿瘤边缘和相对有利的生存结果2，3，4。随着微创手术器械和技术的进步，腹腔镜斜坡（L-RAMPS）因其几个优点而逐渐普及，包括术中失血少、输血需求减少以及疼痛和感染等切口事件减少1。对于精心挑选的远端胰腺导管腺癌（PDAC）患者，最近的研究表明，L-RAMPS可能是一种有效且安全的方法1，5，6。
在胰头区域恶性肿瘤的胰十二指肠切除术 （PD） 中，动脉优先方法是一种被广泛接受的策略，具有多个优点。该方法的核心原理是在手术早期探索肠系膜上动脉（SMA），以确定胰腺横断或结扎大血管之前根治性切除的可行性7，8，9。最近的研究表明，这种动脉优先的方法可以缓解远端胰腺和脾脏静脉充血的形成，并有助于有效控制手术区域的出血;此外，它使SMA周围的淋巴结清扫更充分7，10，11。由于这些原因，动脉优先策略正在成为PD的重要组成部分，并提供了对左侧胰腺癌的洞察。
到目前为止，只有一些用于 L-RAMPS 手术的动脉优先方法被报道5，6。这些方法的核心概念是，在胰腺癌手术期间，应在执行不可逆的手术步骤之前检测肿瘤对SMA的浸润，例如胰实质的横断或大血管的结扎和切除12，13。
在这里，我们开发了L-RAMPS的背尾动脉方法，这可能是安全且有益的胰腺颈肿瘤。我们的程序进一步优化了L-RAMPS程序的常规动脉优先方法，由Yamamoto和Kawabata12，14报告。换句话说，我们首先通过背尾方法 探索 并分离了SMA，这种方法以前从未报道过。该手术的目的和优点是保证胰腺颈体癌手术的可行性和安全性，可能提高R0切除率和进一步预后。
然而，打算使用这种手术的外科医生必须在腹腔镜胰腺手术方面具有丰富的经验。即使他们通过了学习曲线，评估患者的状况（包括肿瘤类型、血管状况和其他参数）也至关重要，因为该过程需要复杂的切除技术。
在本文中，我们介绍了一名 50 岁的 PDAC 男性患者的病例，该患者经内镜超声引导下细针穿刺 （EUS-FNA） 活检确诊，他在术前新辅助化疗后接受了 L-RAMPS。我们的目标是证明使用背尾动脉入路的L-RAMPS的临床安全性和可行性，以及其在胰颈、身体或胰尾PDAC患者中的肿瘤学结果。
Protocol
Representative Results
Discussion
尽管PDAC的生存率为5年，但对于有机会进行根治性切除术的患者来说，这仍然不令人满意;到目前为止，手术一直是唯一的治疗方法22.可切除性状态主要通过区域关键血管的状况来评估，包括 SMA、CeA、CHA 和 SMV24，25。虽然术前 X 线检查可以提供有关血管疾病的充分信息，但对于评估不明确的患者，尤其是对于既往接受过新辅助化疗的患?…
Disclosures
The authors have nothing to disclose.
Acknowledgements
没有。
Materials
| 3D Laparoscope | STORZ | TC200,TC302 | |
| Echelon Flex Powered Plus Articulating Endoscopic Linear Cutter and Endopath Echelon Endoscopic Linear Cutter Reloads with Gripping Surface Technology | Ethicon Endo-Surgery | ECR60G/GST60G | |
| HARMONIC ACE Ultrasonic Surgical Devices | Ethicon Endo-Surgery | HAR36 | |
| Ligating Clips | Teleflex Medical | 5,44,22,05,44,23,05,44,000 | |
| Ultrasonic Surgical & Electrosurgical Generator | Ethicon Endo-Surgery | GEN11CN |
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