摘要目的:探讨胰头癌胰十二指肠切除术中清扫肠系膜上动脉左后侧淋巴结［第14cd组淋巴结（14cd-LN）］对肿瘤淋巴结分期和TNM分期的影响。方法:回顾性分析2022年1—12月于南京医科大学第一附属医院胰腺中心行胰十二指肠切除术的连续103例胰头癌患者的临床和病理学资料，其中男性69例，女性34例，年龄［ M（IQR）］63.0（14.0）岁（范围：48.0~86.0岁）。分类资料的组间比较采用χ 2检验或Fisher确切概率法，定量资料的组间比较采用秩和检验；影响因素分析采用单因素和多因素Logistic回归分析。 结果:103例患者均经左侧钩突和动脉入路完成胰十二指肠切除术。术后病理学检查结果显示，组织学类型均为胰腺导管腺癌，肿瘤部位为胰头部40例、胰头偏钩突部45例、胰头偏颈部18例，肿瘤最大径为3.2（0.8）cm（范围：1.7~6.5 cm），肿瘤分化程度为中分化38例、低分化65例，淋巴结清扫数量为25（10）枚（范围：11~53枚），阳性淋巴结数量为1（3）枚（范围：0~40枚），淋巴结分期为N0期35例（34.0%）、N1期43例（41.7%）、N2期25例（24.3%），TNM分期ⅠA期5例（4.9%）、ⅠB期19例（18.4%）、ⅡA期2例（1.9%）、ⅡB期38例（36.9%）、Ⅲ期38例（36.9%）、Ⅳ期1例（1.0%）。103例胰头癌患者14cd-LN总体阳性率为31.1%（32/103），其中第14c组淋巴结和第14d淋巴结阳性率分别为21.4%（22/103）和18.4%（19/103）；14cd-LN清扫增加了淋巴结清扫数量和阳性淋巴结数量（ P值均<0.01），改变了6例患者的淋巴结分期，其中5例由N0期变为N1期，1例由N1期变为N2期；同时改变了5例患者的肿瘤TNM分期，其中2例由ⅠB期变为ⅡB期，2例由ⅡA期变为ⅡB期，1例由ⅡB期变为Ⅲ期。单因素和多因素Logistic回归分析结果显示，肿瘤部位为胰头偏钩突部（ OR=3.43，95% CI：1.08~10.93， P=0.037）和第7、8、9、12组淋巴结阳性（ OR=5.45，95% CI：1.45~20.44， P=0.012）是第14c组淋巴结转移的独立危险因素；而肿瘤最大径>3 cm（ OR=3.93，95% CI：1.08~14.33， P=0.038）和 第7、8、9、12组淋巴结阳性（ OR=11.09，95% CI：2.69~45.80， P=0.001）是第14d组淋巴结转移的独立危险因素。 结论:胰头癌14cd-LN阳性率较高，建议进行清扫，有助于取得更准确的肿瘤淋巴结分期和TNM分期。

abstractsObjectives:To evaluate the positive rate of left posterior lymph nodes of the superior mesenteric artery (14cd-LN) in patients undergoing pancreaticoduodenectomy for pancreatic head carcinoma,to analyze the impact of 14cd-LN dissection on lymph node staging and tumor TNM staging.Methods:The clinical and pathological data of 103 consecutive patients with pancreatic cancer who underwent pancreaticoduodenectomy at Pancreatic Center,the First Affiliated Hospital of Nanjing Medical University from January to December 2022 were analyzed,retrospectively. There were 69 males and 34 females,with an age( M (IQR))of 63.0 (14.0) years (range:48.0 to 86.0 years). The χ2 test and Fisher′s exact probability method was used for comparison of the count data between the groups,respectively. The rank sum test was used for comparison of the measurement data between groups. Univariate and multivariate Logistic regression analyzes were used for the analysis of risk factors. Results:All 103 patients underwent pancreaticoduodenectomy successfully using the left-sided uncinate process and the artery first approach. Pathological examination showed pancreatic ductal adenocarcinoma in all cases. The location of the tumors was the pancreatic head in 40 cases,pancreatic head-uncinate in 45 cases,and pancreatic head-neck in 18 cases. Of the 103 patients,38 cases had moderately differentiated tumor and 65 cases had poorly differentiated tumor. The diameter of the lesions was 3.2 (0.8) cm (range:1.7 to 6.5 cm),the number of lymph nodes harvested was 25 (10) (range:11 to 53),and the number of positive lymph nodes was 1 (3) (range:0 to 40). The lymph node stage was stage N0 in 35 cases (34.0%),stage N1 in 43 cases (41.7%),and stage N2 in 25 cases (24.3%). TNM staging was stage ⅠA in 5 cases (4.9%),stage ⅠB in 19 cases (18.4%),stage ⅡA in 2 cases (1.9%),stage ⅡB in 38 cases (36.9%),stage Ⅲ in 38 cases (36.9%),and stage Ⅳ in 1 case (1.0%). In 103 patients with pancreatic head cancer,the overall positivity rate for 14cd-LN was 31.1% (32/103),and the positive rates for 14c-LN and 14d-LN were 21.4% (22/103) and 18.4% (19/103),respectively. 14cd-LN dissection increased the number of lymph nodes ( P<0.01) and positive lymph nodes ( P<0.01). As a result of the 14cd-LN dissection,the lymph node stage was changed in 6 patients,including 5 patients changed from N0 to N1 and 1 patient changed from N1 to N2. Similarly,the TNM stage was changed in 5 patients,including 2 patients changed from stage ⅠB to ⅡB,2 patients changed from stage ⅡA to ⅡB,and 1 patient changed from stage ⅡB to Ⅲ. Tumors located in the pancreatic head-uncinate ( OR=3.43,95% CI:1.08 to 10.93, P=0.037) and the positivity of 7,8,9,12 LN ( OR=5.45,95% CI:1.45 to 20.44, P=0.012) were independent risk factors for 14c-LN metastasis; while tumors with diameter >3 cm ( OR=3.93,95% CI:1.08 to 14.33, P=0.038) and the positivity of 7,8,9,12 LN ( OR=11.09,95% CI:2.69 to 45.80, P=0.001) were independent risk factors for 14d-LN metastasis. Conclusion:Due to its high positive rate in pancreatic head cancer,dissection of 14cd-LN during pancreaticoduodenectomy should be recommended,which can increase the number of lymph nodes harvested,provide a more accurate lymph node staging and TNM staging.