误诊为胰腺肿瘤行手术切除的胰腺结核6例临床分析

目的：探讨胰腺结核的诊断和治疗方法。方法：回顾分析近3年误诊为胰腺癌的6例胰腺结核病例。结果：6例病人中有结核病史2例。临床表现为腹痛1例,腹胀5例,体重减轻1例,便血1例。6例均经剖腹探查．病理学证实;其中4例获病灶切除。全部病例均经术后抗结核治疗。6例中出现肠瘘1例,顽固性腹泻2例,区域性门静脉高压、食管下段静脉曲张各1例。结论：胰腺结核易被误诊为胰腺肿瘤而手术,故对影像学检查证实胰腺有局限性、囊性病变伴病灶周围及后腹膜淋巴结肿大,且肿瘤指标正常者,应考虑胰腺结核可能。切除胰腺结核可能发生的并发症较为严重,手术治疗应慎重考虑。     

胰腺结核临床分析13例

目的进一步深入对胰腺结核的认识,提高对临床胰腺结核诊断率及治愈率。方法回顾性分析我院截止2004年10月收治的胰腺结核13例。结果本组有结核病史2例,临床表现:发热6例、腹痛13例、腹部包块4例、黄疸3例、盗汗4例、体重减轻7例、脾大和脾亢1例等。根据临床表现及淋巴结活检诊断2例;剖腹探查12例,经病理学检查确定诊断11例,1例术后合并肺结核经抗结核治疗证实胰腺结核诊断。全部病例经抗结核治疗治愈,1例未手术患者结核控制2年后出现区域性门脉高压、食管下段静脉曲张。结论腹痛、发热、体重减轻及影像学证实胰腺局限性、节段性病变病例,应考虑胰腺结核的可能。抗结核治疗是治愈胰腺结核的主要手段,外科手术对胰腺结核特别是胰腺结核性脓肿治疗具有重要意义。     

胆胰部位结核6例分析

目的 探讨胆胰部位结核的临床和病理特征,提高对该病的诊治水平.方法 回顾性分析复旦大学附属中山医院经手术证实的6例胆胰部位结核误诊为恶性肿瘤病例的临床资料.病人均为中青年,临床表现为黄疸、发热及腹痛.术前影像学检查提示局限性胆管狭窄伴近端肝内外胆管扩张;胆胰周围淋巴结结核病人还表现为胆胰周围实质性占位;胰腺结核病人可见胰头占位伴胰周淋巴结肿大;胆管结核病人胆管周围及十二指肠圈软组织影增多.6例术前均误诊癌肿而行手术探查由病理确诊,术后均予抗结核治疗.结果 经随访所有病例胆胰周围肿块明显缩小,黄疸、发热等临床症状消失.结论 胆胰部位结核与胆胰恶性肿瘤具有相似的临床表现和影像学特征,在术前难以鉴别,常需术中或术后病理检查确诊.经手术或内镜进行有效的支撑和引流胆道,术后积极的抗结核治疗是治愈胆胰结核的关键.     

胆胰部位结核6例分析

目的 探讨胆胰部位结核的临床和病理特征,提高对该病的诊治水平.方法 回顾性分析复旦大学附属中山医院经手术证实的6例胆胰部位结核误诊为恶性肿瘤病例的临床资料.病人均为中青年,临床表现为黄疸、发热及腹痛.术前影像学检查提示局限性胆管狭窄伴近端肝内外胆管扩张;胆胰周围淋巴结结核病人还表现为胆胰周围实质性占位;胰腺结核病人可见胰头占位伴胰周淋巴结肿大;胆管结核病人胆管周围及十二指肠圈软组织影增多.6例术前均误诊癌肿而行手术探查由病理确诊,术后均予抗结核治疗.结果 经随访所有病例胆胰周围肿块明显缩小,黄疸、发热等临床症状消失.结论 胆胰部位结核与胆胰恶性肿瘤具有相似的临床表现和影像学特征,在术前难以鉴别,常需术中或术后病理检查确诊.经手术或内镜进行有效的支撑和引流胆道,术后积极的抗结核治疗是治愈胆胰结核的关键.     

胰腺实性假乳头状肿瘤的诊断及外科治疗分析

目的 探讨胰腺实性假乳头状肿瘤(SPN)的诊治方法,以期为临床提供参考、避免误诊,并采取正确治疗SPN的措施.方法 收集2001年2月至2009年12月收治的24例手术治疗SPN患者的临床资料,回顾性分析其临床表现、实验室检查、影像学、病理学及手术治疗特征.结果 本组24例中,23例为女性,平均发病年龄31岁.SPN最常见的临床表现是腹痛和腹部肿块.影像学检查显示胰腺的实性或囊-实性占位病变,大部分肿瘤位于胰腺头部和尾部.24例均行肿瘤切除,22例获得根治性切除,术后获得长期生存,无复发征象;1例R1切除患者死于术后42个月,另1例R1切除患者术后复发,再次手术后获得长期生存.结论 SPN是一种低度恶性的肿瘤.SPN的正确诊断需要综合分析其临床特征、影像学检查及病理组织学特点.根治性切除能够阻止术后复发,减瘤切除手术对提高患者生存是有益的.     

胰腺囊腺瘤与囊腺癌的临床特点及其鉴别诊断

目的探讨胰腺囊腺瘤与囊腺癌的临床特点及鉴别点。方法回顾性分析23例胰腺囊腺瘤与囊腺癌患者的临床表现,实验室检查,影像学资料以及病理学结果。结果2000年1月至2005年12月我院共收治胰腺囊实性肿瘤23例,其中囊腺瘤16例,囊腺癌7例。本院首诊19例中术前误诊为胰腺假性囊肿3例,误诊为胰体尾癌1例,另有2例术前诊断为胰腺囊腺瘤,术中探查结合快速冰冻切片诊断为恶性,误诊率为31.6%（6/19）;另4例在外院行囊肿内引流手术后病情加重,转入我院手术证实为胰腺囊腺瘤3例,胰腺囊腺癌伴肝转移1例。本组病例主要临床表现为腹痛、腹胀,体重下降,贫血和低蛋白血症等。术前血清肿瘤标志物的敏感性仅为41.7%。CT在浆液性和黏液性囊性肿瘤的鉴别中的价值有限,其诊断正确率仅43.5%（10/23）。7例黏液性囊腺癌中3例术中冰冻切片判断为良性。结论胰腺囊腺瘤与囊腺癌的误诊率较高,影像学检查有助于诊断,最终诊断需要依赖病理学检查。     

胰腺实性假乳头状瘤诊治分析(附8例报道)

目的总结胰腺实性假乳头状瘤的临床特点及诊治体会。方法回顾性分析2000年5月至2010年5月期间在我科手术治疗并经病理检查证实的8例胰腺实性假乳头状瘤患者的临床资料。结果 3例肿瘤位于胰头部者行胰十二指肠切除术;2例肿瘤位于胰颈部者行单纯肿瘤摘除术;1例肿瘤位于胰体部者行胰腺中段切除、近端闭合、远端与空肠行吻合术;2例位于胰尾部者行胰体尾切除联合脾脏切除术。术中未见腹腔脏器转移。8例患者术后经病理检查均证实为胰腺实性假乳头状瘤。术后均未行放、化疗。本组患者随访1~10年(平均5.5年),除2例失访外,其余均健在。结论 胰腺实性假乳头状瘤临床少见,属低度恶性肿瘤,女性多见;CT及MRI是其主要的影像学检查手段;手术切除预后较好。     

异位胰腺误诊为胃肠间质瘤的临床分析

目的提高对异位胰腺与胃肠问质瘤的鉴别诊断水平。方法回顾性分析2007年1月至2013年6月于上海交通大学医学院附属仁济医院收治的14例术前诊断为胃肠间质瘤而术后病理证实为异位胰腺组织患者的临床资料及随访资料。结果本组病例男9例,女5例,年龄26,69岁。其中8例有上腹隐痛不适症状,2例为肠梗阻表现,4例为体检偶然发现。12例术前影像学检查及内镜检查均提示胃肠间质瘤。所有患者均行手术治疗,其中11例病变发生于胃,l例发生于十二指肠,2例发生于空肠;术后病理证实均为异位胰腺,其中10例以胰腺腺泡和胰腺导管混合存在为主要成分,同时含有平滑肌组织以及少量胃黏膜组织;3例以胰腺腺泡为主;1例以胰腺导管及平滑肌为主。随访时间为（26．5±5．1）月,均无复发和死亡者。结论异位胰腺缺乏特征性的临床表现和有效的术前辅助检查手段,易与胃肠间质瘤混淆。手术切除是治愈异位胰腺的唯一有效手段,而术后病理是鉴别两种疾病最可靠的诊断方法。     

包裹性胰腺坏死被误诊为胰腺囊实性肿瘤的原因分析:附12例报道

目的探讨包裹性胰腺坏死(walled-off pancreatic necrosis,WOPN)误诊为胰腺囊实性肿瘤(pancreatic cystic neoplasm,PCN)的原因。方法回顾性分析2009–2013期间华西医院胰腺外科收治的术前诊断为胰腺PCN而术后病理学诊断为WOPN的12例患者的临床资料。结果 12例患者术前诊断为胰腺PCN,而术后病理学诊断为WOPN。其中女2例,男10例;年龄36~68岁、(47.1±10.7)岁;病程0.5~48.0个月,中位数为1.0个月;主要临床表现:腹痛12例,体质量减轻7例;术前1例总胆红素水平增高,2例血淀粉酶水平增高,4例癌胚抗原(CEA)水平增高,4例CA19-9水平增高,4例CA-125水平增高。8例行腹部增强MRI检查,7例行腹部增强CT检查,1例行正电子发射计算机断层显像(PET-CT)检查,提示7例包块位于胰头,5例位于胰尾;肿块最大径1.8~11.0 cm、(4.9±2.9)cm,其中4例最大直径超过5 cm;3例腹腔内发现肿大淋巴结;4例肿块内部分隔;8例呈类肿瘤表现。结论 WOPN与PCN的鉴别需要根据临床、实验室检查及影像学特点进行综合判断,影像学检查是主要的鉴别方法,但同时也是误诊的主要原因。此外,男性患者可能更易误诊。     

胰腺神经内分泌肿瘤的外科诊治

目的探讨胰腺神经内分泌肿瘤的临床特点和外科诊治方法。方法回顾性分析1980年1月至2006年8月经病理确诊的12例胰腺神经内分泌肿瘤的临床资料。结果本组12例患者,男5例,女7例,年龄27～73岁。肿瘤位于胰头部10例,胰颈胰体1例,胰体部1例。临床症状以上腹部疼痛为主。术前血浆CA19-9基本正常,影像学检查易误诊为胰腺癌。12例患者中,行肿瘤切除＋节段性胰腺切除术2例（其中1例加行区域淋巴结清扫术）,行扩大胰头十二指肠切除术3例,经典胰头十二指肠切除术6例,因肝脏广泛转移行肝肿块切除活检＋胆囊切除＋胆总管空肠吻合术1例。术后病理检查：均诊断为胰腺神经内分泌癌,瘤体直径4～14 cm,均呈浸润性生长,淋巴结转移5例,侵犯十二指肠4例,侵犯胆总管3例,侵犯肠系膜上动静脉1例,侵犯下腔静脉1例,肝转移1例。随访9例,8例至今存活,1例术后第8个月死于肝转移。结论对于血清CAl9-9不高且胰腺占位体积较大的胰腺肿物,应想到本病的可能,以手术为主的治疗能改善预后。     

Laparoscopic pancreatic resection of pancreatic cancer

Laparoscopic pancreatic resection of pancreatic cancer is still not universally accepted as an alternative approach to open surgery because of technical difficulties and a lack of consensus regarding the adequacy of this approach for malignancy. Ten patients with pancreatic cancer underwent laparoscopic pancreatic resection, including pancreaticoduodenectomy and distal pancreatectomy in our institution. Eight of the 10 patients recovered without any complications and were discharged on the 10-29th postoperative day. The remaining 2 patients developed pancreatic fistula and were discharged on the 46 and 60th postoperative day, respectively. All lesions were well clear of surgical margins in 6 patients (R0). In the remaining 4 patients, microscopic neoplastic change was found at the surgical margin (R1). Those 4 patients developed tumor recurrence, including liver metastases or peritoneal dissemination, and 3 of the 4 died of the primary disease. Although experience is limited, laparoscopic pancreatic resection of pancreatic cancer can be feasible, safe, and effective in carefully selected patients. However, the benefit of this procedure has yet to be confirmed. Not only adequate experience in pancreatic surgery but also expertise in laparoscopy is mandatory, and careful selection of patients is essential for successful application of this procedure.     

Treatment of pancreatic necrosis and secondary pancreatic infections

Acute pancreatitis is a disease capable of the widest clinical expression, ranging from mild discomfort to multiorgan failure and death. Moreover, the process may remain localized in the pancreas, or spread to regional tissues, or even involve remote organs. Despite several efforts, the pathophysiology of acute pancreatitis and its complications remains obscure. In the absence of an understanding of the pathogenesis and the reasons for the variations in severity, the study and management of acute pancreatitis has necessarily been empirical. There is little doubt that the development of pancreatic necrosis in patients with acute pancreatitis results in an increase in clinical severity and an escalation of the mortality risk when compared to interstitial pancreatitis. Furthermore, the mortality risk of patients with sterile pancreatic necrosis is markedly different from that of patients developing secondary infections in pre-existing pancreatic necrosis. Infected pancreatic necrosis is uniformly fatal, if untreated. While most authorities agree that surgical debridement is required for survival in patients with secondary pancreatic infections, the precise form of the subsequent drainage has become a matter of some controversy. In this paper we discuss the most recent insights relating to the nosographical classification of pancreatic necrosis and secondary pancreatic infections, along with an analysis of the findings in the literature regarding the surgical treatment of these conditions.     

Technique of pancreatic procurement for pancreatic islet isolation

AIM OF THE STUDY: The allograft of pancreatic islets represents a potential alternative to insulin therapy in patients suffering from the most severe forms of Type 1 diabetes. Here we report our experience of pancreatic procurement for isolation and islet allograft. MATERIALS AND METHODS: Pancreata were procured in brain-dead donors. The islets were isolated using techniques developed and validated in pigs and men. Injection of a given preparation was decided after quantitative and qualitative controls. Islets were transplanted in Type 1 diabetic patients already grafted with a kidney or suffering from severe and/or unstable diabetes, after percutaneous or surgical settlement of an intra-portal catheter. Patients received an "Edmonton-like" immunosuppressive protocol. Grafts were repeated once or twice until a total quantity of 10,000 transplanted islet-equivalents was obtained. RESULTS: Twenty-nine pancreata were procured and 14 preparations were grafted to 7 patients. Eleven graftings were done percutaneously and three were surgical. The initial function of the 14 transplants was confirmed by secretion of C-peptide and decrease of insulin doses. Insulin therapy was completely interrupted in the 5 patients having received at least two grafts. CONCLUSION: These preliminary clinical results confirmed that the isolation technique of human islets and the technique of pancreas procurement are mastered by our team. If the results of this assay (assessment one year after graft) confirm our hopes, we will be able to offer islet allografts to an increasing number of patients with severe Type 1 diabetes.     

Peroperative pancreatic aspiration for evaluating pancreatic disease

Nineteen patients who underwent peroperative pancreatic aspiration during 1976 to 1978 were retrospectively compared with 19 other consecutively chosen patients who underwent pancreatic surgery without this procedure in 1973 and 1974. In 18 of the 19 patients who had pancreatic aspiration, an accurate diagnosis was obtained. Three patients in the 1973 to 1974 series had serious postoperative complications attributable to incorrect intraoperative diagnosis and subsequent operative therapy. Peroperative pancreatic aspiration cytology provides a definitive diagnosis that may result in the most efficacious therapy for pancreatic disease.     

Solitary pancreatic tuberculosis mimicking advanced pancreatic carcinoma

A 40-year-old woman was referred for pancreatic head carcinoma invading the portal vein. The dichotomy between the radiological findings and the general condition of the patient, as well as the laboratory results (no evidence of cholestasis), cast doubt on the diagnosis. There was no history of tuberculosis. The chest radiograph revealed no pathological findings. The anatomic relationships of the lesion entailed a high risk of vascular injury if tissue biopsy were to be done; therefore, diagnostic laparotomy was performed. Biopsy revealed granulomas with caseous necrosis, consistent with tuberculosis. After 6 months of antituberculosis treatment, the lesions had completely resolved. Tuberculosis should be considered in the differential diagnosis of pancreatic masses, particularly in regions where the disease is endemic. The condition usually resembles an advanced pancreatic tumor. Performing a biopsy of inoperable lesions and maintaining a reasonable skepticism in regard to the evaluation of operable lesions (attention to nonexclusive but helpful clues, such as young patient age, history of tuberculosis, absence of jaundice) will lead to the diagnosis in most patients. Diagnostic laparotomy may be required in a small subset of patients. The response to antituberculosis treatment is very favorable. The role of resection (e.g., pancreatoduodenectomy) is very limited. Received: December 1, 2000 / Accepted: January 25, 2001     

胰管修复外科在胰腺囊腺瘤手术的临床应用

目的探讨胰管修复外科的术式在治疗胰腺囊腺瘤的临床疗效。 方法回顾性分析2016年9月至2021年9月期间解放军总医院第一医学中心采用胰管修复外科术式治疗的胰腺囊腺瘤52例患者临床资料。 结果21例为局部切除＋主胰管修复术,其手术时间、术中出血量、肿瘤最大直径、术后住院时间中位数分别为135 min、20 ml、2.6 cm、9.0 d,B级胰瘘率33.3%;31例胰腺端端吻合术,其手术时间、术中出血量、肿瘤最大直径、术后住院时间中位数分别为132 min、50 ml、2.5 cm、6.0 d,B级胰瘘率41.9%;术后严重并发症1例,术后出血1例,两种术式均无二次手术、死亡病例。 结论胰管修复外科在胰腺囊腺瘤手术的临床应用是安全、可行的,能最大程度地保留胰腺组织结构和其生理功能,避免了胃肠道的损伤与骚扰。