胰头肿块的治疗策略

胰头肿块是临床常见病症,包括实性肿块（胰头癌、内分泌肿瘤、肿块型慢性胰腺炎等）和囊性病变（真性囊肿、假性囊肿、囊腺瘤和囊腺癌等）两大类。囊性病变一般通过病史、实验室检查和影像学检查能获明确诊断,处理亦较实性肿块简单。本文胰头肿块特指胰头癌和胰头肿块型慢性胰腺炎．诊断较为困难．术前常难以定性．以至于胰头癌误诊为肿块型慢性胰腺炎而延误治疗或慢性胰腺炎诊断为腺头癌而致手术扩大的情况时有发生,因此正确诊治胰头肿块是胰腺外科医师面临的重要课题。     

胰头肿块的手术治疗

胰头肿块是临床常见病症,大致可以分为实性肿块（胰头癌、肿块型慢性胰腺炎、神经内分泌肿瘤等）和囊性肿块（假性囊肿、囊腺瘤、真性囊肿等）两大类.神经内分泌肿瘤和囊性病变通过实验室、影像学检查,结合病史通常能够获得明确诊断,手术处理也相对简单.然而,即便是对于有经验的外科医师而言,胰头癌和肿块型慢性胰腺炎的诊断和治疗都较为棘手,手术方式上也存在较大争议,是胰腺外科的难点和热点.本文主要就胰头癌和胰头部肿块型慢性胰腺炎的诊断及手术治疗进行讨论.     

胰头占位性病变的诊断与治疗

目的 总结胰头占位性病变的诊断与治疗经验.方法 回顾性分析2011年1月至2014年4月中国医科大学附属第一医院收治的247例胰头占位性病变患者的临床资料.术前均行胰腺增强CT和(或)胰腺MRI等影像学检查.血清学检查包括AFP、CA19-9、CA125、CEA,对于怀疑自身免疫性胰腺炎的患者检查血清IgG4.临床诊断为胰头癌、胰头肿块、肿块型胰腺炎的患者行术中病理学检查.胰头癌根据肿瘤的分期及浸润程度选择胰十二指肠切除术、扩大的胰十二指肠切除术或胆肠吻合和(或)胃肠吻合术.肿块型慢性胰腺炎在患者及家属充分了解并同意的前提下选择行保留十二指肠的胰头切除术或胰十二指肠切除术.胰腺良性及低度恶性肿瘤应在肿瘤完整切除的基础上尽量保留肿瘤周围的组织和器官,行个体化治疗.结果 胰头实性占位性病变194例,其中胰头癌125例、胰头肿块45例、肿块型慢性胰腺炎9例、自身免疫性胰腺炎11例,胰岛素瘤4例;胰头囊性占位性病变53例,其中黏液性囊腺瘤12例、浆液性囊腺瘤8例、胰腺囊肿17例、实性假乳头状瘤12例、导管内乳头状黏液瘤4例.病理学检查确诊胰腺癌的71例患者术前肿瘤系列检查阳性率分别为:AFP为7.0％ (5/71)、CA19-9为94.4％ (67/71)、CA125为42.3％(30/71)、CEA为0.12例肿块型慢性胰腺炎肿瘤系列检查阳性率分别为:AFP为1/12、CA19-9为4/12、CA125为1/12、CEA为0.119例患者进行手术治疗获得病理学诊断,其中胰头癌71例、肿块型慢性胰腺炎7例、胰岛素瘤4例、胰腺结核1例,黏液性囊腺瘤8例、浆液性囊腺瘤4例、胰腺假性囊肿6例、巨大淋巴管瘤1例、淋巴上皮囊肿1例、实性假乳头状瘤12例、导管内乳头状黏液瘤4例.247例胰头占位性病变患者中,61例行胰十二指肠切除术,4例行保留十二指肠的胰头切除术,4例行胰头、胰颈部切除术,2例行钩突部分切除术,9例行肿瘤摘除术,38例行胆肠吻合和(或)胃肠吻合术,22例行ERCP+内支架治疗,18例行PTCD+内支架治疗,1例行剖腹探查,88例未行治疗.结论 胰头占位性病变的临床诊断及鉴别诊断主要依靠病史、临床表现、实验室检查及超声、CT、MRI检查.根据肿瘤性质、疾病种类个体化制订手术方案,对胰头良性及低度恶性的肿瘤应行个体化治疗,在肿瘤完整切除的基础上尽量保留肿瘤周围的组织和器官,术中病理学诊断有利于手术方案的选择.     

胰头部肿块定性诊断

常见的胰头部肿块包括胰头癌、慢性肿块型胰腺炎、胰腺内分泌肿瘤和囊(实)性肿块(包括囊实性假乳头状肿瘤、囊腺瘤、假性囊肿、真性囊肿).胰头部肿块的定性诊断,尤其胰头部实质性肿块的诊断十分辣手.     

胰头部肿块手术方式选择及评价

胰头部肿块解剖位置特殊,病理类型多样,治疗应采取个体化原则,对于胰头部实性包块,术前应重视肿块型胰腺炎和胰腺癌的鉴别,胰十二指肠切除术是胰头癌的经典术式,关于保留幽门的胰十二指肠切除,扩大淋巴结清扫范围及联合血管切除目前仍无共识,可酌情选用。近年来保留十二指肠的胰头切除术在治疗胰头肿块型胰腺炎中体现出一定优越性。对于术中仍无法区别良恶性者,不必过分强调病理结果,选择胰十二指肠切除术是可以接受,也是值得的。对于胰头部囊性及囊实性肿块,应根据肿瘤大小、位置、病理类型选用假性囊肿内、外引流、单纯摘除、保留十二指肠的胰头切除、胰腺节段切除及胰十二指肠切除术等,注意囊性肿块鉴别诊断,避免误将囊性肿瘤按假性囊肿行内引流术。     

胰腺癌外科治疗失败原因分析

虽然胰腺癌包括不同种类的外分泌或内分泌恶性肿瘤 (表 1) ,但胰腺癌一词主要用于导管腺癌。而导管腺癌是胰腺肿瘤中最常见的 ,约占所有胰腺肿瘤 90 %以上。表 1　胰腺肿瘤来源外分泌来源内分泌导管腺癌 >90 %胰岛素瘤巨细胞癌促胃液素瘤浆液性囊腺癌胰腺血管活性瘤粘液性囊腺癌胰高血糖素瘤导管内乳头状粘液癌生长抑素瘤腺泡细胞癌成胰细胞癌假性乳头状实性癌混合性癌一、误诊胰腺癌最常见的表现为胰腺肿块。胰头部癌较胰体、胰尾癌为常见。胰腹肿块 ,可分为实性和囊性肿块。胰腺实性肿块 ,主要鉴别胰腺癌 ,慢性胰腺炎和胰腺内分泌肿瘤。囊…     

胰腺囊性肿瘤诊治进展

目的：探讨胰腺囊性肿瘤的影像学特点和诊治方法,方法：参考目前关于胰腺囊性肿瘤的最新研究成果。结果：探讨了胰腺囊性肿瘤与胰腺假性囊肿的鉴别诊断,分别就浆液性囊性肿瘤（SCN）、粘液性囊性肿瘤(MCN)、导管内乳头状瘤(IPMN)和实性假乳头状瘤（SPN）的影像学特点和治疗方法进行了讨论,并且就内镜超声（EUS）、内镜超声引导下穿刺抽吸活检（EUS-FNA）以及囊液分析的诊断价值进行了深入探讨。结论：结论：尽管囊性病变有典型的影像学表现,但单一的影像检查的准确性还是有限的,CT、MR应与EUS相辅相成,而且还可行囊肿穿刺,分析囊液的成分,对于诊断不明确的病例,可以通过动态的影像检查来观察。     

血清肿瘤标志物在胰头部肿块鉴别诊断中的作用

目前单独依靠血清肿瘤标志物的检测还不能满足胰头肿块鉴别诊断的需要,只有结合其他多种影像学及细胞学检查,才有可能提高胰头肿块性质的确诊率。同时应对新的胰腺癌肿瘤标志物进行探索,以期进一步提高胰头肿块鉴别诊断和对预后的判断水平。     

胰头部肿块鉴别诊断和临床对策

胰头部肿块的鉴别诊断中最为困难的是胰头肿块型胰腺炎与胰腺癌的鉴别。近年来,血清肿瘤标记物检查、多排螺旋CT和内镜超声引导穿刺活检等技术的发展为临床鉴别诊断提供了很多帮助,但仍有部分病人不能通过非手术方法获得确诊。对于这些病人,在与病人及家属进行充分沟通后,可以考虑行剖腹探查,建议术中对胰头部肿块行细针多点穿刺细胞学检查,并由专业人员及时处理标本。慢性胰腺炎是胰腺癌的癌前病变,并且可以导致胰管、胆管及十二指肠梗阻,行胰十二指肠切除术或保留十二指肠的胰头切除术能切除病变,缓解疼痛症状,改善病人的生活质量。但由于该手术创伤大,术后并发症发生率较高,应严格掌握手术适应证,加强围手术期处理,由经验丰富的医师实施手术,将并发症的发生率降到最低。     

保留十二指肠的胰头切除术的手术要点

1972年Beger首先实施保留十二指肠的胰头切除术(DPRHP)治疗慢性胰腺炎以来[1],由于该术式在切除胰头病变的同时,保留了消化道的完整性,更加符合生理,且创伤较小,提高了术后的生存质量,目前已经成为欧洲国家及日本治疗胰头部良性占位病变的标准术式之一.保留十二指肠的胰头切除术适用于慢性胰腺炎(肿块型)和胰腺的良性疾病(浆液性或黏液性囊性肿瘤、实性假乳头状瘤、胰腺导管内乳头黏液性肿瘤、胰岛细胞瘤靠近胰管无法局部切除者、神经内分泌肿瘤和淋巴上皮囊肿)[2],低度恶性肿瘤不需要淋巴结廓清,也可行保留十二指肠胰头切除,然而囊腺癌是否适合此手术还存在争议.     

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??Value of endoscopic ultrasonography in diagnozing the pancreatic head mass LI Zhao-shen, ZHAN Xian-bao.Department of Gastroenterology,Changhai Hospital, the Second Military Medical University,Shanghai 200433??China Corresponding author: LI Zhao-Shen, E-mail??zhsli1956@hotmail.com Abstract Common etiologies of pancreatic head mass include carcinoma,cystic lesions,inflammatory lesions and neuroendocrine tumours,etc. The value of traditional imaging modalities in diagnozing pancreatic head mass is limited. Using high frequency and short distance scanning techniqes, endoscopic ultrasound (EUS) can show the details of the mass. And also EUS-guided fine needle aspirations can acquire the specimen and establish pathological and cytologic diagnosis. Presently,EUS is prior to other imaging modalities in early diagnosis and preoperative evaluation of pancreatic carcinoma. There are special EUS features for chronic pancreatitis mass, autoimmune pancreatitis mass and cystic mass. EUS can also localize the pancreatic endocrine tumours accurately and acquire specimen preoperatively. A large amount of evidence confirmed that EUS had high accuracy and specificity in diagnozing pancreatic head mass.     

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??Application of endoscopic ultrasenography in the diagnosis and treatment of pancreatic cystic neoplasms WU Xi, YANG Ai-ming. Department of Gastroenterology,Peking Union Medical College Hospital, Peking Union Medical College, Beijing 100730,China
Corresponding author: YANG Ai-ming, E-mail??yangaiming@medmail.com.cn
Abstract Pancreatic cystic lesions consist of inflammatory pseudoscysts and neoplastic lesions. Most pancreatic cystic lesions are asymptomatic and discovered incidentally through the routine use of crosssectional imaging tests. The differential diagnoses for cystic neoplasms include serous cystadenoma, mucinous cystic neoplasm and intraductal papillary mucinous neoplasm. The mucinous cystic lesions pose a risk of malignant degeneration. The imaging modalities, such as CT, MRCP or EUS, offer diagnostic strengths. EUS imaging play a vital role for pancreatic lesion diagnoses. The use of high frequencey imaging with EUS may provide detailed information regarding the morphology of cystic lesions, as well as the relation of the lesion and the pancreatic duct. EUS guided fine needle aspiration may improve the accuracy of EUS through the use of cystic fluid analysis. The major therapy for the mucinous neoplasms with high risk for malignancy has been surgical resection. Ethanol ablation therapy guided by EUS offers the alternative option.     

Endoscopic ultrasonography in pancreatitis

Endoscopic ultrasonography (EUS) is a useful imaging modality in the investigation of pancreatitis which provides a high‐resolution image of the pancreas and adjacent structures. In patients with ‘idiopathic’ pancreatitis diagnosed by conventional radiologic methods, EUS may help to identify the aetiology by detecting occult pancreatic neoplasm, biliary sludge and microlithiasis. In patients with biliary pancreatitis, EUS was found to be highly sensitive in detecting choledocholithiasis. Therefore, EUS can be used to select patients with choledocholithiasis for therapeutic endoscopic retrograde cholangiopancreatography (ERCP), thus avoiding unnecessary diagnostic endoscopic intervention and the morbidity associated with ERCP in more than one‐half of patients. In addition, EUS can reliably distinguish oedematous from necrotizing acute pancreatitis, and an EUS score appears to have prognostic significance in patients with acute pancreatitis. Clinical studies also suggest that EUS is at least as sensitive as ERCP for diagnosis of chronic pancreatitis, without the risk of causing or worsening pancreatitis as in ERCP. An EUS‐guided, fine‐needle aspiration may be useful in differentiating pancreatic pseudocysts from neoplastic cystic lesions of the pancreas. Also, EUS‐guided or assisted endoscopic drainage of a pseudocyst resulting from pancreatitis is an accepted alternative to surgery in selected patients.      

胰腺囊性病变的诊断与治疗(附40例报告)

目的探讨胰腺囊性病变诊断与治疗的有效方法。方法总结我科１９９２～１９９７年收治的经手术和病理证实的４０例胰腺囊性病变的诊治经验。结果患者主要临床表现为上腹部胀痛、腹部包块,Ｂ超、ＣＴ扫描见胰腺囊性肿块。但定性诊断仅靠临床表现、影像学检查较困难,特别难以鉴别假性囊肿与囊性肿瘤。结论胰腺囊性病变的确诊需病理诊断,正确的诊断决定治疗方式的选择。     

Utility of preoperative dynamic magnetic resonance imaging of the pancreas in diagnosing tumor-forming pancreatitis that mimics pancreatic cancer: Report of a case

The differential diagnosis of pancreatic carcinoma and tumor-forming pancreatitis remains difficult, and this situation can cause serious problems because the management and prognosis of these two focal pancreatic masses are entirely different. We herein report a case of tumor-forming pancreatitis that mimics pancreatic carcinoma in an 80-year-old woman. Computed tomography showed a solid mass in the head of the pancreas, and endoscopic retrograde cholangiopancreatography showed a complete obstruction of the main pancreatic duct in the head of the pancreas. Dynamic contrastenhanced magnetic resonance imaging (MRI) demonstrated a time-signal intensity curve (TIC) with a slow rise to a peak (1 min after the administration of the contrast material), followed by a slow decline at the pancreatic mass, indicating a fibrotic pancreas. Under the diagnosis of tumor-forming pancreatitis, the patient underwent a segmental pancreatectomy instead of a pancreaticoduodenectomy. The histopathology of the pancreatic mass was chronic pancreatitis without malignancy. The pancreatic TIC obtained from dynamiccontrast MRI can be helpful to differentiate tumor-forming pancreatitis from pancreatic carcinoma and to avoid any unnecessary major pancreatic surgery.     

Endoscopic ultrasound of pancreatic cystic lesions

Background: The impact of endoscopic ultrasonography (EUS) on the management of pancreatic cystic lesions remains unclear, and there are no published studies of the Australian experience in this area. The aim of this study was to review the experience of EUS for such lesions within our institution. Methods: A retrospective review was undertaken of data collected prospectively over a two‐year period within the EUS database of St. Vincent's Hospital. Patients who underwent EUS for suspected pancreatic cystic lesions were identified. Data were collected on demographic variables, EUS findings, the results of EUS‐guided fine‐needle aspiration (FNA) and the findings on clinical and radiological follow‐up. Results: Fifty‐nine patients were identified. Two thirds were female. Most lesions were located at the pancreatic head. Median diameter was 25 mm. FNA was performed in 36 cases (61%). On cytology, six (17%) showed features of mucinous tumours and five (14%) showed adenocarcinoma. The remainder contained either non‐specific benign cells or insufficient epithelial tissue. Follow‐up data on 48 cases (83%), after a median duration of 15 months, revealed that 15 lesions (31%) had been resected, including six serous and six mucinous tumours. The level of carcinoembryonic antigen in FNA specimens appeared to be higher in mucinous than in serous neoplasms. Twenty‐four lesions had undergone repeat radiological imaging: only three had grown in size. Conclusions: EUS and FNA are useful procedures for assessing pancreatic cystic lesions. Malignant features are demonstrated in only a small minority. The majority of the remainder show no signs of progression during follow‐up.     

Ectopic Pancreas in the Duodenojejunal Flexure—Computed Tomographic and Endoscopic Ultrasonographic Images

Ectopic pancreas is a rare entity where the pancreatic tissue has no anatomic and vascular contact with the main body of the pancreas and has its own duct system and vascular supply. A detailed clinical report with contrast-enhanced computed tomography (CT) and endoscopic ultrasonography (EUS) imaging findings of a 40-year-old male came with vague symptoms. CT showed a well-defined homogeneously enhancing mass lesion in the duodenojejunal (DJ) flexure. EUS revealed a well-defined hypoechoic mass lesion in the submucosal layer of the DJ flexure. Surgical resection of the mass was performed, and histopathological examination of specimen confirmed the pancreatic tissues. Here, we have described the CT and EUS imaging features which can help to differentiate the ectopic pancreas from the gastrointestinal submucosal tumours.     

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??Relationships between chronic pancreatitis with mass in the head and pancreatic carcinoma ZHANG Bo ,NI Quan-xing. Pancreatic Disease Institution, Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China Corresponding author: NI Quan-xing, E-mail??tomchang 202@yahoo.com.cn Abstract It is difficult to identify chronic pancreatitis with mass in the head with pancreatic carcinoma. It has the potential for malignant change. In the progress of hyperblastosis and atrophy based on chronic pancreatitis, cancer gene stimulated and anti-cancer gene inactivation may be the causes of canceration. In spite of more clinical examinations including CT??MRI??ERCP??EUS??FNA?? and PET-CT can help to make differential diagnosis between the both, it is still difficult in making diagnosis because of their disadvantages. So the surgery is the only method of making final diagnosis of pancreatic cancer or chronic pancreatitis with mass in the head.     

胰头部肿块型胰腺炎与胰腺癌的关系

胰头部肿块型慢性胰腺炎与胰头癌难以鉴别,虽然其属于良性病变,但有一定的恶变率。慢性胰腺炎基础上的组织增生、萎缩以及癌变过程中,癌基因激活和抑癌基因失活可以导致胰腺癌的发生。影像医学的发展为两者的鉴别诊断提供了直观的影像学证据,但是,目前的诊断方法包括CT、MRI、ERCP、EUS（FNA）和PET-CT都存有一定的不足,导致诊断困难。因此,手术是最终诊断胰腺癌和肿块型慢性胰腺炎的惟一手段。     

Pancreatic cancer—EUS and early diagnosis

BACKGROUND: Over the last decades, the incidence of pancreatic cancer has increased. Prognosis remains poor despite rapid improvements in imaging technologies and therapeutic modalities. Curative treatment is dependant on early diagnosis. MATERIAL AND METHODS: One of the most promising techniques for early detection of pancreatic lesions seems to be endoscopic ultrasound (EUS). With or without fine needle aspiration (FNA), it has been described as highly sensitive and accurate in staging. Superior to other imaging modalities in early studies, results in later publications declined. There are three fundamental different techniques of EUS available at present: radial scanning scopes, linear scanning scopes and radial or linear scanning probes, each with different pros and cons. Indications for EUS are persistent epigastric and/or back pain, acute onset of diabetes in the elderly, unclairified weight loss and suspect results in ultrasonography, especially in individuals over 45 years of age and in high-risk subpopulations. RESULTS: In early studies, EUS was superior or at least equal to other imaging modalities regarding sensitivity, determining tumour size and extent, lymph node involvement and vascular infiltration. With rapid advances in technology, first of all, computed tomography (CT) and magnetic resonance imaging have reached better results. The highest accuracy in assessing extent of primary tumour, locoregional extension, vascular invasion, distant metastasis, tumour TNM stage and tumour resectability seems to have helical CT, whereas EUS has the highest accuracy in assessing tumour size and lymph node involvement. For assessment of tumour resectability, a combination of CT and EUS seems to be the procedure with the highest accuracy. Some new techniques promise improvement of the diagnostic yield of EUS. In differentiation to focal inflammation, contrast-enhanced EUS has shown to increase sensitivity and specificity for pancreatic cancer. Another major problem is the assessment of vascular invasion. 3D reconstructions additional to conventional EUS seemed to improve the evaluation of vessel-tumour-relationships. Endoscopic ultrasound is not a foolproof method; there are several reasons for failure, and it shows a high interobserver variety even among experienced endosonographers. Nevertheless, EUS proved to have a high negative predictive value. Poor overall survival rates and some reports of high survival rates among small resected stage 1 ductal adenocarcinomas suggest a high benefit for screening and early detection of pancreatic neoplasia, and treatment of precursor lesions might prevent their progression to invasive cancer. Because of low incidence and the lack of accurate, inexpensive and non-invasive diagnostic tests for early disease, screening for pancreatic cancer and its precursor lesions in the entire population is not reasonable. But a EUS- and CT-based screening among high-risk individuals discovered pancreatic neoplasms in eight of 78 patients, in contrast to no pancreatic neoplasia among 149 control subjects. CONCLUSION: Screening for pancreatic cancer and its precursor lesions in the general population is not feasible, but high-risk subpopulations seem to be suitable targets for screening programs. EUS is an essential tool for diagnosis and assessment of extension and resectability of pancreatic tumours.