目的

研究改良后腹膜优先原位腹腔镜胰十二指肠切除术（LPD）对区域淋巴结清扫及术后并发症的临床影响。

方法

前瞻性选取2021年1月至2023年12月收治的66例壶腹部周围癌患者作为研究对象，所有患者均行LPD。应用随机数字表法分为改良组和参照组，每组各33例。改良组采用改良后腹膜优先原位LPD（MPPLPD），参照组采取常规静脉入路LPD。应用SPSS24.0统计学软件分析数据，手术时间、清扫淋巴结总数等计量资料用（）表示，行独立样本t检验；等级资料如ASA分级采取秩和检验；计数资料以百分数表示，行χ²检验。Kaplan-Meier法绘制生存曲线，Log-Rank检验患者生存情况。

结果

所有患者均行R0切除，无中转开腹手术病例。两组阳性淋巴结清扫数目，进食时间、排气时间、住院时间比较，差异无统计学意义（P>0.05）；与参照组对比，改良组手术时间更短，术中出血量更少，淋巴结清扫总数更多（P<0.05）；改良组Clavien-Dindo分级Ⅰ级3例、Ⅱ级3例、Ⅲ级以上2例，低于参照组Ⅰ级7例、Ⅱ级10例、Ⅲ级以上5例（P<0.05），且改良组术后出血发生率明显低于参照组（6.1% vs. 24.2%，P<0.05）；术后3～45个月，两组患者总生存率对比，差异无统计学意义（P>0.05），改良组患者无病生存率高于参照组（84.8% vs. 63.6%，Log-Rank χ²=9.643，P<0.05）。

结论

与标准静脉先行入路LPD相比，改良腹膜优先原位LPD能提高清扫淋巴结总数，降低术后并发症和出血风险，增强手术安全性，并减少疾病复发的可能性。

Objective

To study the clinical influence of the modified retroperitoneal-priority in situ laparoscopic pancreatoduodenectomy (LPD) on regional lymph node dissection and postoperative complications.

Methods

A total of 66 patients with periampullary carcinoma admitted from January 2021 to December 2023 were prospectively selected as the research subjects, and all patients underwent LPD. They were divided into a modified group and a reference group by the random number table method, with 33 cases in each group. The modified group adopted the modified retroperitoneal-priority in situ LPD (MPPLPD), and the reference group adopted the conventional venous approach LPD. The statistical software SPSS24.0 was used for data analysis.Measurement data such as the operation time and the total number of dissected lymph nodes were expressed as(), and an independent sample t test was performed; Rank sum test was adopted for rank data such as ASA classification; Count data were expressed as percentages, and a chi-square test was performed. The survival curve was drawn by the Kaplan-Meier method, and the survival status of the patients was examined by the Log-Rank test.

Results

All patients underwent R0 resection, and there was no case converted to open surgery.There were no statistically significant differences in the number of positive lymph nodes dissected, the time to start eating, the time to exhaust, and the length of hospital stay between the two groups (P>0.05). Compared with the reference group, the operation time in the modified group was shorter, the intraoperative blood loss was less, and the total number of dissected lymph nodes was larger (P<0.05). In the modified group, there were 3 cases of Clavien-Dindo grade I, 3 cases of grade II, and 2 cases above grade III, which were lower than 7 cases of grade I, 10 cases of grade II, and 5 cases above grade III in the reference group (P<0.05), and the incidence of postoperative bleeding in the modified group was significantly lower than that in the reference group (6.1%vs. 24.2%, P<0.05). From 3 to 45 months after surgery, there was no statistically significant difference in the overall survival rate between the two groups (P>0.05), and the disease-free survival rate of the modified group was higher than that of the reference group (84.8% vs. 63.6%, Log-Rank χ²=9.643, P<0.05).

Conclusion

Compared with the standard venous-first approach LPD, the modified retroperitoneal-priority in situ LPD can increase the total number of dissected lymph nodes, reduce the risk of postoperative complications and bleeding,enhance the surgical safety, and reduce the possibility of disease recurrence.