急性胆石性胰腺炎病因学的研究进展

急性胆石性胰腺炎(AGP)是一种由胆结石引起的急性胰腺炎, 其病因学复杂, 解剖基础和始动因素对发病具有协同作用, 需要共同研究。胆胰管汇合方式、扩张的主胰管、相对狭小的乳头开口以及小结石或微小结石可能共同参与了AGP的发病过程, 其中小结石最为重要。对AGP应做到病因诊断和临床治疗同步进行, 针对不同病因及时选择相应的治疗方式能最大程度上缓解患者病情并降低治疗成本。目前AGP的预测指标难以统一, 发病过程和相关防治方法有待研究。本文就AGP发病的解剖基础、始动因素、发病机理及自身防御等方面进行综述, 为治疗提供参考。     

胆石性胰腺炎的外科治疗

急性胰腺炎中最常见的是胆石性胰腺炎,平均占总数的75％,其发病机理及治疗原则有其独特性。100年前德国病理学家Opie提出了胆管和胰管共同通道及胆汁向胰管逆流导致胰腺炎的假说。其基本点是胰胆管末端汇合成共同通道,开口于十二指肠乳头,结石通过oddi括约肌时造成的粘膜损伤引起十二指肠乳头水肿、狭窄和胰、胆管梗阻,胆、     

胆石性胰腺炎的发病机制和诊治进展

胆石和酗酒两者占急性胰腺炎病因的60%～80%,又以胆石占优势,其他病因占10%～20%,不明原因10%～15%。1901年 Opie 在一例死于急性胰腺炎病人尸检中,发现一结石嵌塞于 Vater 壶腹,因而表明结石嵌塞于胆胰管共同通道末端使胆汁反流到胰管能引起胰腺炎。这一发观直到本世纪70年代中期才被接受,从而使胆石性胰腺炎(Gallstone pancreatitisGP)成为一个独立的疼病。此后,人们对 GP 的研究有了不少进展。发病机制现已普遍接受,GP 是由胆石嵌塞或经 Vater 壶腹移位到肠道的过程所致。1974年 Acosta 一篇具有里程陴意义的报道表明,症状发作10天内,36例 GP病人胆石随大便排出率占94%,单纯胆石病组仅为8%。Kelly 也观察到84%的 GP 病人经肠道排出胆石,而且多发结石常引起多次胰腺炎发作。这些观察能解释为什么大多数 GP 病人在行择期胆囊切除术     

急性胆石性胰腺炎发病原因和手术时机探讨

通过６０例急性胆石性胰腺炎资料分析，结合文献探讨了ＡＧＰ的发病原因与手术时机。结果显示：共同通道具备了胆汁返流的解剖学基础；胆石阻塞胆总管下端、感染胆汁返流入胰管；肠胰返流及胰管梗阻均为ＡＧＰ发病的重要因素。     

胆石性胰腺炎治疗及手术时机的选择

自本世纪初,Opie首次揭示了胆石与胰腺炎关系之后,这方面的临床资料不断积累,胆道结石作为胰腺炎的重要病因之一基本上得到确认.但对胆石性胰腺炎病理机制的了解仍较局限,胆石性胰腺炎的治疗仍存在分歧.因此,通过对近几年来收治的67例胆石性胰腺炎总结分析,探讨胆石性胰腺炎的治疗及手术时机.     

内镜技术在急性胆源性胰腺炎诊治中的合理应用

正急性胆源性胰腺炎(acute biliary pancreatitis,ABP)是指以胆道疾病为发病原因的急性胰腺炎的统称,发病原因包括胆道结石、蛔虫、出血、感染、狭窄、Oddi括约肌功能紊乱、乳头旁憩室等因素引起的胆管梗阻~([1])。胆囊内小结石进入胆总管或微小胆石下移阻塞胆管是引起ABP的最常见原因。100余年前,德国病理学家Opie提出胆管和胰管共同通道及胆汁向胰管逆流导致胰腺炎发生的假说,其基     

胆石性胰腺炎108例临床分析

急性胰腺炎的病因至今尚未明确,但胆石症是其主要病因之一已获确认。国外文献报道胆道疾患占胰腺炎病因半数左右。我国胆石症发病率较高,近年来发现胆石症引起的胰腺炎也有增加。我院1976年1月至1986年12月,收治胰腺炎224例,其中诊为胆石性胰腺炎108例,50例经手术证实。本文结合文献探讨胆石性胰腺炎的发病机理、诊断及治疗措施。临床资料一、性别:男48例,女60例,男比女为1:1.25。二、年龄:最大82岁,最小21岁,平均54.1岁。三、主要临床表现:绞痛94例(87%),发热64例(59.2%),黄疸58例(53.7%),腹膜炎25例     

急性胆源性胰腺炎62例临床分析

急性胆源性胰腺炎(Acute Biliary Pancreatitis,ABP)是胰腺炎中最常见的类型,而胆结石是最常见的急性胰腺炎的病因,文献报道在我国占急性胰腺炎发病因素的55％～65%,究其原因主要是由胆石引起壶腹部阻塞或胆石迁移过程中造成的Oddi括约肌水肿痉挛。引起胆汁胰液排泌不畅,造成高压     

胆石性胰腺炎

胆石症和饮酒都是急性胰腺炎最常见的诱因。胆石性胰腺炎的发病机制、实验室检查和处理原则均与非胆石性胰腺炎不同。在我国胆石症的发病率较高,因此对胆石性胰腺炎的早期诊断和处理更需进一步引起重视。发病机制1901年Opie通过解剖一例死于出血性胰腺炎的户体发现胆石嵌顿在Vater壶腹部,因而和Halstod共同提出了胆石嵌顿,共同通路和胆汁返流是引起胰腺炎的假说。但是Trapell等则对该假说中所提出的     

急性胰腺炎的外科治疗

四十年来,急性胰腺炎的发病率在英国有明显上升.最常见的诱发原因是胆石及酗酒.但如何引起腺泡破裂使已激活的胰酶溢入胰实质的机制,目前尚不清楚.有三种可能应加考虑:①十二指肠胰管反流,②胰管出口处(乳头)梗阻,③胰液分泌过盛.任何一种推测都不能圆满地解释其病理机制,且三者常互有连系.此外,还可能有另一种物质能直接损害胰腺.有几个问题仍有待解答:急性出血性胰腺炎是否都是继发于水肿型胰腺炎?胆石性胰腺炎与酒精性胰腺炎的发病机制是否相同,例如都与乳头部炎症有关?如病人原有因酒精引起的胰腺损害,以后有腹痛及血淀粉酶升高时,是否即可诊断为酒精性胰腺炎?由于引起急性胰腺炎的真实原因不十分清楚,治疗也只能是以经验为主的支持疗法.     

Surgical therapy of inflammatory and malignant strictures of the common bile duct

Although there are growing possibilities of interventional endoscopic treatment of benign and malignant stenosis of the distal common bile duct the definitive operative drainage by terminolateral hepaticojejunostomy is in many cases the therapy of choice. In patients with chronic pancreatitis and bile duct stricture the modified duodenum preserving pancreatic head resection ("Beger operation") enables a resection of the inflammatory mass together with a drainage of the bile. Of 391 patients from our clinic being operated due to a bile duct stricture 337 underwent a biliary drainage together with a pancreatic head resection. Early postoperative biliary complications were in 0.3 % strictures of the duct and 1.5 % bile fistulas. Half of those complications could be managed conservatively. In high volume centers the operative therapy of distal common bile duct stenosis is a safe procedure with high patency rate.     

A new technique to assist in difficult bile duct cannulation at the time of endoscopic retrograde cholangiopancreatography.

BACKGROUND AND OBJECTIVES: At the time of endoscopic retrograde cholangiopancreatography, deep cannulation of the bile duct is a prerequisite to be able to provide endoscopic therapy. We describe a simple technique to assist in difficult bile duct cannulation. METHODS: If the pancreatic duct is easily entered but the bile duct cannot be accessed, a guidewire is advanced into the pancreatic duct, and the cannulating catheter is removed leaving the tip of the wire in the mid pancreatic duct. Alongside the pancreatic wire, a catheter, preloaded with a second wire, is advanced via the channel of the endoscope. With the first wire in the pancreatic duct, the second wire is advanced above it in the anticipated bile duct axis. RESULTS: We have used this technique in 12 cases and succeeded in 10. No complications occurred. DISCUSSION: Inserting a pancreatic wire can assist in bile duct cannulation, by straightening and stabilizing the papilla. The use of this new technique can reduce the need for precut sphincterotomy, with its inherent increased risks of pancreatitis, bleeding, and perforation. The approach proposed by us can assist in any difficult bile duct cannulation, but it can be particularly useful when dealing with a papilla that is very prominent with a tortuous intraduodenal segment or a papilla located in a duodenal diverticulum.     

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??Surgical treatment for pancreatic duct calculi: a report of 18 cases WANG Kai, WANG Gang, ZOU Shu-bing??et al. Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Nanchang University??Nanchang 330006??China Corresponding author??SHAO Jiang-hua??E-mail: shao5022@163.com Abstract Objective To explore the method of surgical treatment for pancreatic duct calculi. Methods The clinical data of 18 cases of pancreatic duct calculi performed surgery from 2002 to 2007 in the Department of Hepatobiliary Surgery of the Second Affiliated Hospital of Nanchang University were analyzed retrospectively. Results Eleven cases were performed with lateral pancreaticojejunostomy. Five cases were performed pancreaticoduodenectomy. One case was performed with duodenum-preserving pancreatic head resection. One case was performed with distal pancreatectomy and splenectomy. All the cases were cured successfully. No pancreatic or bile fistula was occurred. Improvement of clinical symptoms after surgery was achieved in all cases. All the cases were followed up from 1 month to 5 years. Except one case died of pancreatic carcinoma twenty-eight months after the operation, all other cases were survived. Conclusion Surgical intervention is recommended for pancreatic duct calculi cases. The principle of individualized therapy should be followed.     

胰管结石外科手术治疗18例分析

目的 探讨胰管结石的手术治疗方式。方法 对南昌大学第二附属医院肝胆外科2002-2007年手术治疗的18例胰管结石进行回顾性分析。 结果 11例行胰管切开取石、胰管空肠Roux-en-Y 吻合术,5例行胰十二指肠切除术,1例行保留十二指肠的胰头次全切除加头、尾侧胰腺断端空肠吻合术,1例行胰体尾切除加脾切除术。无手术死亡,无胰瘘、胆瘘病例发生。术后腹痛、腹泻等症状均明显缓解。随访时间1个月至5年, 除1例伴胰腺癌病人于术后28个月死亡外,其余病人均健在。结论 外科手术是治疗胰管结石的有效方法,应遵循个体化的原则选择手术方式。     

64层螺旋CT胆道三维重建技术协助胆道梗阻的术前评估

目的 研究64层CT胆道三维重建(spiral CT cholangiograply,SCTC)在胆道梗阻中的运用价值和优缺点.方法 对20例胆道梗阻患者,包括肝门部胆管癌8例,肝内外胆管结石6例,胰头肿物4例,胆管狭窄2例进行SCTC检查,了解胆道树成像的图像质量以及对梗阻性质判断的准确率.结果 8例肝门部胆管癌中6例患者得到较完美的胆道树成像,2例患者胆道树部分显影.7例患者的Bismuth-Corlette分型与手术探查一致.4例胰头肿物、2例胆管狭窄、1例胆总管结石的患者术前SCTC均能得到较完美的胆道树成像,能准确提示梗阻的部位和病因.5例复杂的左右肝内胆管结石患者,虽能正确提示肝内外胆管结石的分布和位置,但难以得到较完美的胆道树成像.结论 SCTC可作为除复杂左右肝内结石外的胆道梗阻患者的术前评估的常规方法,其运用价值值得进一步的研究和分析.     

中下段胆管癌的诊断和鉴别诊断

目的　探讨中下段胆管癌的诊断和鉴别诊断。方法　对 18例术前误诊为中下段胆管癌资料进行回顾性分析。结果　本组 9例经ERCP、6例MRCP、以及PTC、T管胆道造影、CT各 1例确定胆管狭窄部位。 16例经手术探查确定诊断 ,分别为 :胆总管损伤 3例 ,胆囊管与胆总管汇合点过低伴结石嵌顿 2例 ,胆囊癌转移灶 2例 ,胰腺癌 2例 ,胰腺结核 2例 ,慢性胰腺炎、胆总管结石、壶腹癌、十二指肠癌和腹腔结核各 1例 ;2例经随访治疗分别确定为腹腔结核和硬化性胆管炎。结论　单凭胆管狭窄的影像学资料难以将中下段胆管癌与许多病变相鉴别。应研究其术前和术中的诊断方法 ,提高诊断准确率 ,以便选择最适当的治疗方案     

慢性肿块型胰腺炎的18F-FDG PET/CT影像学表现

目的探讨慢性肿块型胰腺炎18F-FDG PET/CT影像学表现。方法回顾性分析6例经手术病理证实的慢性肿块型胰腺炎的18F-FDG PET/CT影像资料和临床资料。结果 6例共检出6个病灶,3个位于胰头,3个位于胰尾;平均大小3.0cm×2.7cm。CT平扫6个病灶呈均匀等密度,未见钙化灶,平均CT值约为36HU;增强扫描全部病灶呈延迟期强化。全部病灶18F-FDG摄取呈局灶性增高,最大标准摄取值（SUVmax）1.6～5.3,平均SUVmax3.92±1.49,高于正常胰腺组织的2.05±0.39（t=-3.648,P=0.015）。3例病灶累及胰头,胆总管及胰管不同程度扩张,呈双管征,胰体尾部轻度萎缩;3例病灶累及胰尾,胆总管及胰管未见扩张,胰体尾部未见萎缩。病灶邻近的主要血管均未受侵。全部病例胰周及腹膜后淋巴结未见18F-FDG局灶性摄取增高,未见远处脏器或（和）组织转移。结论 18 F-FDG PET/CT对诊断慢性肿块型胰腺炎具有一定价值。     

应用胆胰管内窥镜经胆囊管胆道探查21例临床分析

目的探讨应用胆胰管内窥镜经胆囊管行胆道探查的临床应用价值。方法 2011年1月～2012年1月,对21例急、慢性结石性胆囊炎合并或可疑合并肝内外胆管结石者,在开腹胆囊切除术中应用德国PolyDiagnost公司组合式、软性、可旋转纤维内窥镜（外径F8）经胆囊管行胆道探查、取石。结果 2例肝内胆管结石,用套石篮顺利取出。胆总管结石14例,其中6例经胆囊管顺利取出,4例钬激光击碎结石取出,2例行胆囊管汇入胆总管处微切开取石,未成功2例,行传统胆总管切开取石T管引流。5例未见明显结石及十二指肠乳头狭窄。术后胆漏1例,无胆道残余结石等并发症发生。术后随访6～18个月,平均13个月,无结石复发。结论应用胆胰管内窥镜经胆囊管进行肝内外胆管探查,避免了胆总管切开和放置T管,提高了胆道结石诊断的准确率,是一种安全简便、创伤小、恢复快的方法。     

Recurrent disease after microscopically radical (r0) resection of periampullary adenocarcinoma in patients without adjuvant therapy

The survival rate after microscopically radical resection of pancreatic duct adenocarcinoma is still poor. Patients with ampulla of Vater and distal common bile duct adenocarcinoma indicate a much more favorable prognosis. Controversy exists as to whether adjuvant therapy could improve the outcome in these patients after resection. The aim of the present study was to analyze the pattern of recurrence in patients with periampullary adenocarcinoma after pancreatoduodenectomy. Between January 1992 and December 2002, all patients with an R0 resection were identified and used for this analysis. A total of 190 patients underwent a microscopically radical resection and received no adjuvant therapy. Of those, 72 patients were diagnosed with pancreatic duct adenocarcinoma, 86 patients were diagnosed with ampulla of Vater adenocarcinoma, and 31 patients were diagnosed with distal common bile duct adenocarcinoma. Recurrent disease was indicated in 81% of the patients with pancreatic duct adenocarcinoma, 50% of the patients with ampulla of Vater adenocarcinoma, and in 74% of the patients with bile duct adenocarcinoma. Multivariate analysis revealed that lymph node metastases were prognostic for recurrent disease in patients with pancreatic duct adenocarcinoma (P = 0.038). The depth of invasion (T4, P < 0.032) and lymph node metastases (P < 0.001) were prognostic in patients with ampulla of Vater adenocarcinoma. Poor tumor differentiation (P < 0.001) was prognostic in patients with distal bile duct adenocarcinoma. Selected patients with periampullary malignancies exhibited a high recurrence rate and should be encouraged to enroll in clinical trials for adjuvant treatment including local therapy (radiotherapy) according to the identified prognostic factors. Presented at the Forty-Fifth Annual Meeting of the Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004 (oral presentation).     

ERCP findings and the role of endoscopic sphincterotomy in acute gallstone pancreatitis

A total of 131 patients with acute pancreatitis (of whom 100 had gallstones) underwent endoscopic retrograde cholangiopancreatography (ERCP) during the same hospital admission. Urgent ERCP (less than 72 h) was performed in 68 cases and early ERCP (3-30 days) in 63 cases; 47 had predicted severe attacks and 84 had predicted mild attacks (modified Glasgow criteria). The highest incidence of common bile duct stones occurred in those with predicted severe attacks and those who had urgent ERCP. Highly significant correlations were found between age and common bile duct and pancreatic duct diameters. Significant correlations were also found between the common bile duct and pancreatic duct (correcting for age) and between these and the admission serum bilirubin. The common bile duct diameter was greatest in those with common bile duct stones and predicted severe attacks. A considerably lower incidence of pancreatic duct filling occurred in those with predicted severe attacks and common bile duct stones; in predicted mild attacks the pancreatic duct diameter was greater in those with common bile duct stones. In gallstone patients complications were highest in those with predicted severe attacks but more significantly in those with common bile duct stones. Endoscopic sphincterotomy was undertaken in 37 patients with common bile duct stones without mortality. The overall complication rate in gallstone patients was 19 per cent and the mortality rate was 2 per cent. These findings suggest that common bile duct stones cause acute common bile duct and pancreatic duct obstruction and are closely associated with complications. Urgent ERCP for detection of common bile duct stones, and endoscopic sphincterotomy for treatment, is strongly recommended for patients with predicted severe attacks due to gallstones and should also be considered for others who fail to show clinical improvement.