恶性肿瘤病人胰十二指肠切除术后胰瘘及胆瘘的防治

目的 总结恶性肿瘤病人胰十二指肠切除术（PD）主要并发症胰瘘、胆瘘的初步处理经验和体会，并探讨其防治措施。方法 对1998年1月至2003年1月间的20例PD术后并发胰瘘、胆瘘病例进行回顾性分析。结果 全组病例手术均获得成功。术后并发胰瘘2例，死亡1例；并发胆瘘2例，死亡1例；另1例死于肝肾综合症，余17例治愈出院。远期效果在进一步随访中。结论 术后并发胰瘘应以内科治疗为主，通过减少胰液的分泌，并且保持局部引流的通畅，多数胰瘘可治愈。术后并发胆漏，通过保持支架管及局部引流通畅，多可治愈，出现肝汁性腹膜炎时应考虑手术处理。     

Cost and Utilization Impact of a Clinical Pathway for Patients Undergoing Pancreaticoduodenectomy

Background: When implemented in several common surgical procedures, clinical pathways have been reported to reduce costs and resource utilization, while maintaining or improving patient care. However, there is little data to support their use in more complex surgery. The objective of this study was to determine the effects of clinical pathway implementation in patients undergoing elective pancreaticoduodenectomy (PD) on cost and resource utilization.Methods: Outcome data from before and after the development of a clinical pathway were analyzed. The clinical pathway standardized the preoperative outpatient care, critical care, and postoperative floor care of patients who underwent PD. An independent department determined total costs for each patient, which included all hospital and physician costs, in a blinded review. Outcomes that were examined included perioperative mortality, postoperative morbidity, length of stay, readmissions, and postoperative clinic visits.Results: From January, 1996 to December, 1998, 148 consecutive patients underwent PD or total pancreatectomy; 68 before pathway development (PrePath) and 80 after pathway implementation (PostPath). There were no significant differences in patient demographics, comorbid conditions, underlying diagnosis, or use of neoadjuvant therapy between the two groups. Mean total costs were significantly reduced in PostPath patients compared with PrePath patients ($36,627 vs. $47,515; P = .003). Similarly, mean length of hospital stay was also significantly reduced in PostPath patients (13.5 vs. 16.4 days; P = .001). The total cost differences could not be attributed solely to differences in room and board costs. Cost and length-of-stay differences remained when outliers were excluded from the analysis. Despite these findings, there were no significant differences between PrePath and PostPath patients in terms of perioperative mortality (3% vs. 1%), readmissions within 1 month of discharge (15% vs. 11%), or mean number of clinic visits within 90 days of discharge (3.3 vs. 3.4 visits).Conclusions: The establishment of a clinical pathway for PD patients dramatically reduced costs and resource utilization without any apparent detrimental effect on quality of patient care. These findings support the implementation of clinical pathways for PD patients, as well as investigation into pathway care for other complex surgical procedures.     

Relationship between surgical volume and clinical outcome: should pediatric surgeons be doing pancreaticoduodenectomies?

Background

The relationship between surgical volume and clinical outcome is well established in adult pancreatic surgery. We examined whether this relationship is applicable in pediatric surgery, given that very few cases are done regularly by pediatric surgeons even at tertiary centers.

Methods

A retrospective analysis of all patients who underwent pancreaticoduodenectomies between 1993 and 2003 was done. Comparisons were made to the largest recent series of pancreaticoduodenectomies in the adult literature.

Results

With the age at presentation from 9 to 17 years, 5 patients were identified. Mean operative time was 451 minutes with a median of 363 minutes compared with the mean and median in the adult literature of 420 minutes. Clean margins were obtained in all patients compared with 71% in adults. Mean follow-up was 35 months. All patients are alive, with 1 patient who has underwent subsequent resections for local recurrence.

Conclusion

Although 5 consecutive cases of pancreaticoduodenectomies represent very low volume compared with high-volume adult centers, minimal difference in operative time, length of stay, and mortality (none) were observed in this series. Therefore, unlike adults, particular case volume in the pediatric population may not be a significant factor because of the nature of pancreatic pathology, patient characteristics, and hospital and surgical environment.     

Efficacy of venous reconstruction in patients with adenocarcinoma of the pancreatic head

Pancreaticoduodenectomy is often avoided in patients with portal or superior mesenteric venous involvement due to the perception that venous resection is complex, morbid, and carries a poor longterm survival. Our recent experience using state-of-the-art imaging and strict resection criteria show that venous reconstruction increases operative time, transfusion requirements, intensive care unit stay, and total hospital length of stay, but has no significant impact on operative morbidity rates, mortality rates, or the incidence of positive histologic margins. Kalpan-Meier life table analysis shows similar survival curves when compared to a contemporary cohort of patients who do not undergo venous reconstruction. Presented as an abstract at the Americas Hepato-Pancreatico-Biliary Association Meeting, Miami Beach, Florida, February 28–March 1, 2003.     

Huge cystic lymphangioma of the pancreas: report of a case

We report herein the case of a 33-year-old woman who presented with palpable abdominal swelling found to be caused by a huge lymphangioma of the pancreas. An abdominal computed tomographic (CT) scan showed a large multilocular cystic mass with water-dense contents, which was derived from the pancreatic head. A pancreaticoduodenectomy (PD) was performed because the tumor had invaded the duodenum. The resected tumor, which was 23 × 12 × 23 cm in size with 2 l of serous fluid, was pathologically diagnosed as a cystic lymphangioma. The endothelial cells lining the internal surface of the cystic spaces were immunohistochemically positive for factor VIII-R antigen and CD31. Our review of the literature revealed 45 reports of lymphangioma of the pancreas, including this one, but to the best of our knowledge this is only the fifth case that required a PD. Nevertheless, we recommend that a complete resection be performed to reduce the risk of recurrence. Received: April 3, 2000 / Accepted: March 6, 2001     

十二指肠癌的诊治分析

目的 提高十二指肠癌的诊治水平。方法 对45例十二指肠癌的诊治方法及预后作用回顾性分析。结果 行纤维十二指肠镜检查的十二指肠癌确诊率为95%（20/21），十二指肠X线低张造影检出率为96%（22/23），腹部B超及CT的检出率分别为29%（13/45）及73%（19/26），5例行核磁共振（MRI）检查，4例显示肿瘤。手术治疗44例，肿瘤切除率为53%（24/45），根治性切除率为42%（19/45）。根治术后1、3、5年生存率分别为91%、39%、26%，肿瘤未切除组的中位生存期仅为5个月。结论 联合应用纤维十二指肠镜和十二指肠低张造影能较理想地诊断各段十二指肠肿瘤。B超、CT及MRI均能判断梗阻性黄疸者的梗阻部位，且有助于检出转移瘤。手术切除肿瘤是有效的治疗方法。     

局部进展期胃癌或结肠癌联合胰十二指肠切除术：附15例报告

目的探讨局部进展期胃癌或结肠癌行胃癌或结肠癌切除联合胰十二指肠切除术的可行性及临床价值。方法回顾性分析2004年5月—2010年12月15例侵犯胰头十二指肠区域的局部进展期胃癌或结肠癌联合胰十二指肠切除术患者的临床资料,其中原发或复发胃癌12例,结肠癌3例。结果中位手术时间6 h(4～12 h),中位术后住院时间21 d(7～63 d)。并发症发生率为46.7%(7/15),再手术率为6.7%(1/15),病死率为6.7%(1/15)。中位生存期为23个月;1,2,3年累积生存率分别为62.2%,44.4%,22.2%。结论联合胰十二指肠切除术可作为局部进展期胃癌或结肠癌侵犯胰头十二指肠区域患者的治疗选择。该术式可延长部分患者的生存期。     

Frequency With Which Surgeons Undertake Pancreaticoduodenectomy Continues to Determine Length of Stay,Hospital Charges,and In-Hospital Mortality

Introduction This study was undertaken to determine changes in the frequency of, volume of, and outcomes after pancreaticoduodenectomy 6 years after a study denoted that, in Florida, the frequency and volume of pancreaticoduodenectomy impacted outcome. Methods Using the State of Florida Agency for Health Care Administration database, the frequency and volume of pancreaticoduodenectomy was correlated with average length of hospital stay (ALOS), in-hospital mortality, and hospital charges for identical periods in 1995–1997 and 2003–2005. Results Compared to 1995–1997, 88% more pancreaticoduodenectomy was performed in 2003–2005 by 6% fewer surgeons; the majority of pancreaticoduodenectomies were conducted by surgeons doing <1 pancreaticoduodenectomy every 2 months. In-hospital mortality rate did not decrease from 1995–1997 to 2003–2005 (5.1 to 5.9%); in-hospital mortality rate increased for surgeons undertaking <1 pancreaticoduodenectomy every 2 months (5.5 to 12.3%, p < 0.01). For 2003–2005, frequency with which pancreaticoduodenectomy is conducted inversely correlates with ALOS (p = 0.001), hospital charges (p = 0.001), and in-hospital mortality (p = 0.001). Conclusions In Florida, more pancreaticoduodenectomies are carried out by fewer surgeons. Mortality has not decreased because of surgeons infrequently performing pancreaticoduodenectomy. Most pancreaticoduodenectomies are still undertaken by surgeons who conduct pancreaticoduodenectomy infrequently with greater lengths of stay, hospital costs, and in-hospital mortality rates. To an even greater extent than previously documented, patients are best served by surgeons frequently performing pancreaticoduodenectomy. Presented at the 2007 Annual Meeting of the American Hepato-Pancreato-Biliary Association, April 19–22, 2007, Las Vegas, Nevada.     

Survival Rates and Cause of Death in 174 Patients with Chronic Pancreatitis

Background  The natural history after surgery for chronic pancreatitis is rarely reported. Methods  Between 1970 and 1999, 174 patients underwent surgery for chronic pancreatitis and were followed until December 2006. They were divided in four groups: (1) resection 62; (2) drainage 82; (3) external drainage 7; (4) non-pancreas-directed surgery 23. A second procedure was required by 25 patients and a third by four: group 1 = 6 + 0, group 2 = 10 + 2, group 3 = 3 + 1, group 4 = 6 + 1. Results  Hospital mortality was four of 174 (2.3%). Fifty-seven patients are alive; 49 of 170 developed cancer, and 38 died: lung (22), oral, pharynx, larynx (eight), esophagus, kidney, pancreas, colon, liver (two each), breast, stomach, mediastinum, prostate, melanoma, chronic myelogenous leukemia, squamous cancer of the auricle (one each), liver metastasis from unknown primary (two). Fifteen patients died of liver cirrhosis, 13 of myocardial infarction/decompensation, six of vascular problems, five each of acute renal insufficiency or cerebral diseases, four each of acute pancreatitis, accidental trauma, complications of diabetes, bronchopneumonia, and 19 of other causes. The overall 5-, 10-, 15-, 20-, 25-, and 30-year survival rate was 84.7, 65.6, 51.6, 38.0, 28.1, and 23.5. Conclusions  Incidence of pancreatic cancer was 1.2%. The high incidence of smoking cancers (18.8%) is explained by the smoking habits of almost 100% of our patients. Eliminating smoking and increasing tests on organs at risk may prolong survival. Grant support: This study has been supported by the Ministero dell’Università e Ricerca Scientifica (Cofin 2005060715_001), Rome, Italy.     

胰十二指肠切除术治疗壶腹周围癌疗效分析

目的：探讨壶腹周围癌的手术方式，方法：对１０５例壶腹周围癌患者行胰十二指肠切除术。结果：１、３、５年生存率分别为６６．６７％，４０．８５％，２５．００％。影响术后过 铲的主要因素有病程长短，肿瘤部位、大小；病理性质及组织来源，局部浸润和淋巴结转移状况。与患者的性别、年龄等因素无明显关系。结论：在进一步探讨手术方式的基础上，深入了解壶腹周围癌分子生物学行为，提高早期诊断水平，加强辅助治疗，有望提高