胰腺癌综合诊治中国专家共识(2014年版)

<正>1前言据世界卫生组织统计,2008年全球胰腺癌发病率和病死率分别列恶性肿瘤第13位和第7位[1]。2013年最新统计数据显示,在发达国家(美国)胰腺癌新发估计病例数列男性第10位,女性第9位,占恶性肿瘤病死率的第4位[2]。据《2012中国肿瘤登记年报》统计,2009年胰腺癌占我国恶性肿瘤发病率和病死率的第7位和第6位。在我国上海等经济发达地区,胰腺癌新发估计病例数列男性第6位,女性第7位,并且呈快     

胰腺癌临床研究的热点问题

胰腺癌是一种恶性程度极高的消化系统肿瘤,其发病率在全球范围内逐年上升.据2010年统计数据,美国胰腺癌新发病例数为43 140例,死亡病例数为36 800例,在恶性肿瘤中占第10位,死亡率却高居第4位.我国胰腺癌发病率也呈逐年增长趋势,近20年发病率增长约6倍.根据全国34个登记处上报的2006年肿瘤登记数据进行全面分析,胰腺癌发病率占各个部位恶性肿瘤的第7位,病死率位居恶性肿瘤第6位.     

EUS引导下的胰腺肿瘤治疗

l990～l992年．中国胰腺癌死亡率为1．48／10万，上海市区2000年男女胰腺癌标化发病率分别为7．9／10万和5．8／10万，居男女恶性肿瘤发病的第9位和第7位．属较高水平．近年来，我国胰腺癌发病率有增加趋势。胰十二指肠切除术治疗胰腺癌的5年存活率为3％。但胰十二指肠切除，切缘无癌细胞残存、无淋巴结癌转移则5年存活率可达25％。然而．大多数患出现临床表现时已属癌肿晚期，无法外科手术．主要靠姑息性治疗。化疗、放疗、生物治疗．或多种方法的综合治疗可改善患的存活率及生活质量。近年来-开发了肿瘤的射频消融治疗和基因治疗．这些技术正适合EUS引导的微创治疗。现对近年来EUS引导下治疗胰腺癌的一些新尝试做简要介绍。     

我国胰腺癌诊治策略的研究

胰腺癌是一种凶险的恶性肿瘤,严重危及人类的健康.近年来发病率逐年上升.美国胰腺癌发病率10年间升高了3倍,占恶性肿瘤的第十位、死亡率的第四位.我国胰腺癌的年发病率为5.1/10万人,较20年前升高了3倍.上海市男性胰腺癌发病率已经接近欧美国家.只有10%～15%的患者有手术切除的机会,其中能根治者仅为5%～7.5%.胰腺癌的预后极差,美国国家卫生研究院报告,胰腺癌1年生存率为8%,5年生存率为3%,中位生存期仅2～3月.我国外科的统计资料5年生存率在5%左右.因此,可以看出胰腺癌的诊断和治疗水平急切需要提高.     

我国胰腺癌诊治策略的研究

胰腺癌是一种凶险的恶性肿瘤,严重危及人类的健康。近年来发病率逐年上升。美国胰腺癌发病率10年间升高了3倍,占恶性肿瘤的第十位、死亡率的第四位。我国胰腺癌的年发病率为5.1/10万人,较20年前升高了3倍。上海市男性胰腺癌发病率已经接近欧美国家。只有10％～15％的患者有手术切除的机会,其中能根治者仅为5％～7.5％。胰腺癌的预后极差,美国国家卫生研究院报告,胰腺癌1年生     

小胰腺癌的诊断进展

<正>胰腺癌已经成为消化系统常见的恶性肿瘤之一,近20年来胰腺癌的发病率约增加1～5倍,病死率位居恶性肿瘤的第5～7位,5年生存率为1%～5%。目前缺乏有效的诊治手段。因此,进行深入的胰腺癌基础和临床研究,强调小胰癌的诊断,对提高胰腺癌整体治疗水平、改善患者预后十分重要。1小胰癌的诊断标准小胰腺癌迄今尚无统一的诊断标准。有学者[1,2]认为肿瘤直径4 cm,不管有无淋巴结转移     

肝癌多学科综合治疗团队建立——广东专家共识(1)

<正>肝癌是临床上最常见的恶性肿瘤之一,世界范围内,男性的肝癌发病率和病死率分别列恶性肿瘤的第5位和第3位,每年新发肝癌病例和死亡病例中有一半以上发生在中国[1]。据2012中国肿瘤登记年报报道,肝癌已居全国肿瘤登记地区恶性肿瘤发病的第3位(发病率为28.71/10万),死亡原因的第2位(死亡率为26.04/10万)[2]。肝癌的高发性与高致死性对     

影像学引导胰腺癌不可逆电穿孔消融治疗专家共识2018版

<正>1概述当前胰腺癌已成为欧美等发达国家引起肿瘤患者死亡的第三大原因[1],在我国胰腺癌的病死率不断攀升,2017年11月中国癌症中心统计数据显示,胰腺癌已成为我国男性癌症患者死亡的第六大原因,女性癌症患者死亡的第七大原因。胰腺癌治疗困难的因素有:(1)胰腺癌侵袭性强、发展速度快,早期症状隐匿,患者就诊时多已发生转移,失去根治性手术切除机会;     

胰腺癌167例临床分析

胰腺癌是一种发生率较高的恶性肿瘤,在美国占肿瘤死亡的第五位,在我国为消化道肿瘤的第五位,而且目前有逐渐升高的趁势。由于胰腺为后腹膜脏器,胰腺癌临床症状往往不典型,因而早期诊断非常困难。现将我院1993年1月至1996年10月间收治的167例胰腺癌临床作一回顾性小结,以提高对胰腺癌的诊断水平。     

胰腺癌内科诊治进展

胰腺导管上皮细胞癌(简称胰腺癌)是一种致死性极高的疾病,其发病率/死亡率可达1/0.99.据统计,2011年全球约有27.6万例患者死于胰腺癌,且发病率逐年增加.美国2012年胰腺癌新发病例43920例,死亡病例37390例,占全部癌症死因的第4位[1].我国胰腺癌发病率占男性第9位;死亡率占男性第6位,女性第7位.因此,胰腺癌已成为一种严重危害人类健康的疾病.本文旨在回顾近期胰腺癌内科诊治的研究进展,为胰腺癌的进一步研究提供参考和思路.     

Laparoscopic pancreatic surgery: a review of present results and future prospects

Pancreatic surgery is still associated with a relatively high morbidity and mortality compared with other specialties. This is a result of the complex nature of the organ, the difficult access as a result of the retroperitoneal position and the number of technically challenging anastomoses required. Nevertheless, the past two decades have witnessed a steady improvement in morbidity and a decrease in mortality achieved through alterations of technique (particularly relating to the pancreatic anastomoses) together with hormonal manipulation to decrease pancreatic secretions.Recently minimally invasive pancreatic surgery has been attempted by several centres around the world which has stimulated considerable interest in this approach. The majority of the cases attempted have been distal pancreatectomies, because of the more straightforward nature of the resection and the lack of a pancreatic ductal anastomosis, but more recently reports of laparoscopic pancreaticoduodenectomy have started to appear.The reports of the series to date have been difficult to interpret and although the results are claimed to be equivalent or better than those associated with a traditional approach a careful examination of the literature and comparison with the best results previously reported does not presently support this. In the present review we examined all the reports of pancreatic procedures performed laparoscopically and compared the results with those previously achieved at open surgery.     

Clinical outcome of laparoscopic distal pancreatectomy

Background

Few studies have compared laparoscopic distal pancreatectomy (Lap-DP) and open distal pancreatectomy (open-DP). The aim of this study was to evaluate the clinical outcome of Lap-DP and compare it to that of open-DP.

Methods

A total of 37 patients who underwent distal pancreatectomy (Lap-DP, 21 patients; open-DP, 16 patients) between January 2000 and March 2007 were enrolled in this study. Prior to January 2004, open-DP was the standard procedure for patients with a lesion in the distal pancreas without invasive ductal cancer; thereafter, Lap-DP was also an approved procedure. All 16 open-DP procedures were performed prior to January 2004.

Results

The operating times for the Lap-DP and open-DP patients were 308.4 ± 124.6 and 281.5 ± 83.3 min, respectively, and these were not significantly different (P = 0.4635). Blood loss for the Lap-DP group (249.0 ± 239.8 ml) was significantly smaller than that for the open-DP group (714.1 ± 650.4 ml) (P = 0.0055), and none of the patients in the Lap-DP group received transfusions. The frequency of complications for the Lap-DP and open-DP groups was 0 and 18.8%, respectively, which is not significantly different (P = 0.0784). The average hospital stay for the Lap-DP group was significantly shorter than that for the open-DP group (10.0 ± 2.6 vs. 25.8 ± 8.8 days; P < 0.0001).

Conclusion

In pancreatic diseases, other than invasive ductal cancer, arising in the distal pancreas, Lap-DP might be a more feasible and safer than open-DP.     

Minimally invasive radical pancreatectomy for left-sided pancreatic cancer: Current status and future perspectives

Minimally invasive distal pancreatectomy with splenectomy has been regarded as a safe and effective treatment for benign and borderline malignant pancreatic lesions. However, its application for left-sided pancreatic cancer is still being debated. The clinical evidence for radical antegrade modular pancreatosplenectomy (RAMPS)-based minimally invasive approaches for left-sided pancreatic cancer was reviewed. Potential indications and surgical concepts for minimally invasive RAMPS were suggested. Despite the limited clinical evidence for minimally invasive distal pancreatectomy in left-sided pancreatic cancer, the currently available clinical evidence supports the use of laparoscopic distal pancreatectomy under oncologic principles in well-selected left sided pancreatic cancers. A pancreas-confined tumor with an intact fascia layer between the pancreas and left adrenal gland/kidney positioned more than 1 or 2 cm away from the celiac axis is thought to constitute a good condition for the use of margin-negative minimally invasive RAMPS. The use of minimally invasive (laparoscopic or robotic) anterior RAMPS is feasible and safe for margin-negative resection in well-selected left-sided pancreatic cancer. The oncologic feasibility of the procedure remains to be determined; however, the currently available interim results indicate that even oncologic outcomes will not be inferior to those of open radical distal pancreatosplenectomy.     

Alterations in EGF binding to acini during pancreatic regeneration in the rat

Summary The binding of¹²⁵I-labeled epidermal growth factor (EGF) was compared in acini isolated from the regenerating remnant following 90% partial pancreatectomy (ppx) and from the pancreas of sham-pancreatectomized (sham-ppx) rats. Saturation binding studies with increasing amounts of unlabeled EGF revealed that cell-associated radioactivity was decreased in acini from the regenerating remnant by comparison to acini from sham-ppx rats. Analysis of these data indicated that binding was decreased by 35% and 27% at 3 and 7 days post-ppx, respectively. This alteration in EGF binding coincides with increased exocrine cell mitotic activity. EGF binding was normalized at 14 days post-ppx, at which time the exocrine cell mitotic activity is no longer increased (Brockenbrough et al. 1987, Diabetes).¹²⁵I-insulin binding was the same in ppx and sham-ppx acini at 3 days post-ppx. Furthermore, plasma EGF concentrations were the same in ppx and sham-ppx rats. These data indicate that EGF handling by the pancreatic acinar cell is altered during the proliferative response to ppx. A portion of this work was presented at the American Pancreatic Association meeting, Chicago, IL. November 7–8, 1985.     

Spleen and gastrosplenic ligament preserving distal pancreatectomy under a minimum incision approach assisted by laparoscopy

Background

As a modification of hand-assisted laparoscopic pancreatectomy, we devised a method of spleen and gastrosplenic ligament preserving distal pancreatectomy, in which pancreatic resection is performed under direct vision extracorporeally.

Methods

The distal pancreas and spleen are pulled out of the peritoneal cavity through the minilaparotomy at the epigastrium following hand-assisted laparoscopic dissection of the distal pancreas. Spleen-preserving pancreatectomy is performed safely under direct vision. The gastrosplenic ligament is also preserved to prevent splenic volvulus after the operation. The transected main pancreatic duct is doubly ligated, and the transected pancreatic stump is sewn manually. The preserved spleen and splenic vessels are placed back in the peritoneal cavity after resection.

Results

In the current study (n = 3), overall morbidity rate, including splenic volvulus and pancreatic fistula, was 0%.

Conclusion

Preservation of the gastrosplenic ligament and extracorporeal preparation of the transected pancreatic stump under direct vision are useful measures in spleen-preserving distal pancreatectomy under a minimum incision approach assisted by laparoscopy.     

Laparoscopic pancreatectomy: Indications and outcomes

The application of minimally invasive approaches to pancreatic resection for benign and malignant diseases has been growing in the last two decades. Studies have demonstrated that laparoscopic distal pancreatectomy(LDP) is feasible and safe, and many of them show that compared to open distal pancreatectomy, LDP has decreased blood loss and length of hospital stay, and equivalent post-operative complication rates and shortterm oncologic outcomes. LDP is becoming the procedure of choice for benign or small low-grade malignant lesions in the distal pancreas. Minimally invasive pancreaticoduodenectomy(MIPD) has not yet been widely adopted. There is no clear evidence in favor of MIPD over open pancreaticoduodenectomy in operative time, blood loss, length of stay or rate of complications. Robotic surgery has recently been applied to pancreatectomy, and many of the advantages of laparoscopy over open surgery have been observed in robotic surgery. Laparoscopic enucleation is considered safe for patients with small, benign or low-grade malignant lesions of the pancreas that is amenable to parenchyma-preserving procedure. As surgeons’ experience with advanced laparoscopic and robotic skills has been growing around the world, new innovations and breakthrough in minimally invasive pancreatic procedures will evolve.     

Central pancreatectomy: The Dagradi Serio Iacono operation. Evolution of a surgical technique from the pioneers to the robotic approach

Central pancreatectomy (CP) is a parenchyma-sparing surgical procedure. The aims are to clarify the history and the development of CP and to give credits to those from whom it came. Ehrhardt, in 1908, described segmental neck resection (SNR) followed, in 1910, by Finney without reconstructive part. In 1950 Honjyo described two cases of SNR combined with gastrectomy for gastric cancer infiltrating the neck of the pancreas. Guillemin and Bessot (1957) and Letton and Wilson (1959) dealt only with the reconstructive aspect of CP. Dagradi and Serio, in 1982, performed the first CP including the resective and reconstructive aspects. Subsequently Iacono has validated it with functional endocrine and exocrine tests and popularized it worldwide. In 2003, Baca and Bokan performed laparoscopic CP and, In 2004, Giulianotti et al performed a robotic assisted CP. CP is performed worldwide either by open surgery or by using minimally-invasive or robotic approaches. This confirms that the operation does not belong to whom introduced it but to everyone who carries out it; however credit must be given to those from whom it came.     

Laparoscopic distal pancreatectomy: Up-to-date and literature review

Pancreatic surgery represents one of the most challenging areas in digestive surgery. In recent years, an increasing number of laparoscopic pancreatic procedures have been performed and laparoscopic distal pancreatectomy (LDP) has gained world-wide acceptance because it does not require anastomosis or other reconstruction. To date, English literature reports more than 300 papers focusing on LDP, but only 6% included more than 30 patients. Literature review confirms that LDP is a feasible and safe procedure in patients with benign or low grade malignancies. Decreased blood loss and morbidity, early recovery and shorter hospital stay may be the main advantages. Several concerns still exist for laparoscopic pancreatic adenocarcinoma excision. The individual surgeon determines the technical conduction of LDP, with or without spleen preservation; currently robotic pancreatic surgery has gained diffusion. Additional researches are necessary to determine the best technique to improve the procedure results.     

Laparoscopic left pancreatectomy: Current concepts

The minimally invasive approach has been slow to gain acceptance in the field of pancreatic surgery even though its advantages over the open approach have been extensively documented in the medical literature. The reasons for the reluctant use of the technique are manifold.Laparoscopic distal or left sided pancreatic resections have slowly become the standard approach to lesions of the pancreatic body and tail as a result of evolution in technology and experience. A number of studies have shown the potential advantages of the technique in terms of safety, blood loss, oncological and economic feasibility, hospital stay and time to recovery from surgery. This review aims to provide an overview of the recent advances in the field of laparoscopic left pancreatectomy (LLP) and discuss potential future developments.     

精准胰腺外科手术的演进历史

随着精准外科、精准肝切除技术在外科领域的渗透和应用,结合近年来数字外科和影像学技术的发展及对胰腺局部解剖和血供关系的深入研究和再认识,各种符合精准外科理念的、保留功能的、区域性精准胰腺切除术逐渐在国内兴起。本文回顾性分析了精准胰腺手术的演进历史,旨在将精准胰腺外科理念和技术进一步推广应用。