胰腺囊性肿瘤19例的诊断与外科治疗

目的 探讨胰腺囊性肿瘤的诊断及外科治疗方法.方法 对我院普外科2000年1月至2009年8月诊治的19例胰腺囊性肿瘤的临床资料进行回顾性分析.结果 胰腺囊性肿瘤无特征性临床表现,B超和CT是其主要诊断手段,但均不能准确区分其病理类型,与术后病理对照的定性诊断符合率分别为57.9%(11/19)和68.4%(13/19).肿瘤位于胰头颈部5例,胰体尾部14例,最大直径3～15cm.19例均行手术治疗,切除肿瘤16例,总切除率为84.2%.术中误诊误治4例(21.0%).病理证实浆液性囊腺瘤6例,黏液性囊腺瘤6例,黏液性囊腺癌5例,导管内乳头状黏液腺瘤2例.获得随访15例(78.9%),3例囊腺癌患者中1例切除者已存活4年,无复发;2例未切除者分别于术后4个月和7个月病死.12例囊腺瘤患者目前均存活,肿瘤无复发.失访4例,囊腺癌和囊腺瘤各2例.结论 加强对胰腺囊性肿瘤的认识是减少误诊误治的关键;胰腺囊性肿瘤手术切除后疗效满意,故一经诊断即应积极行外科手术切除.     

经内镜射频消融和置入内支架联合治疗不能切除的胆胰肿瘤

目的探讨经内镜射频消融和置入内支架的联合治疗在延长不能切除的胆胰肿瘤患者胆道通畅期中的作用。方法共58例患者采用联合治疗：6例十二指肠乳头癌先作内镜下乳头局部切除，而后对残留病灶作射频消融；52例经ERCP测出肿瘤狭窄段的范围，对狭窄段作射频消融，然后置入相匹配的金属内支架。收集同期52例单放金属内支架者作为对照组。结果在联合治疗组中，3例治疗后2个月内因胆道严重感染、全身衰竭死亡，余55例胆道平均通畅期为9．2个月，平均存活期为16个月。其中48例再次梗阻后再次内镜下治疗，28例单作射频消融和20例射频消融加再置入内支架，通畅期又平均延长5．1个月。而单放内支架组胆道通畅期为6．1个月，平均存活期为13个月。结论射频消融能阻止肿瘤的局部增长，从而延长内支架的通畅期和患者的存活期。     

结核病误诊误治为恶性肿瘤8例分析

本组8例中男性6例、女性2例，年龄25～65岁，平均42岁，误诊误治时间2周～5个月，平均2个月。其中肺结核误诊误治为肺癌5例，3例手术及术后病理确诊为肺结核，2例纤维支气管镜活检病理诊断为肺结核；3例淋巴结核误诊误治为非霍奇金淋巴瘤，经淋巴结活检病理检查确诊为淋巴结核。     

原发性十二指肠癌长期误诊分析

我院消化科近五年收治延误诊断长达3个月以上原发性十二指肠癌7例，其中男4例，女3例，年龄32～73岁。误诊时间最长达16个月，平均误诊时间为8．2个月。首发症状：上腹隐痛3例，上腹痛4例，不完全肠梗阻3例，乏力消瘦3例，腹泻黑便2例，发热2例，黄疸1例。     

青年女性大肠癌61例

目的了解青年女性大肠癌的发病、病理规律及误诊原因．方法选择本院自1981-01／1995－12间收治的经手术和（或）纤维结肠镜检，并经病理证实的青年女性大肠癌共61例．对其进行发病年龄、临床症状、肿块发生部位、组织学类型及病理分期、误诊情况等进行分析．结果61例平均年龄25．7岁，20岁以下6例，21岁～25岁18例，26岁～30岁37例．临床症状为血便和粘液血便25例，腹痛17例，大便习惯改变12例，其他7例．从初发症状到确诊平均时间为7．5mo．发生部位为直肠31例，乙状结肠3例，降结肠2例，结肠脾曲1例，结肠肝曲3例，升结肠21例组织学类型腺癌33例，粘液癌12例，粘液腺癌9例，未分化癌7例，其中年龄越小，未分化癌发生率越高．Dukes分期Ⅰ期7例，Ⅱ期20例，Ⅲ期19例，Ⅳ期15例．误诊率为80．3％，平均误诊时间为8．6mo．误诊慢性菌痢、肠炎、痔疮为最多．结论青年女性大肠癌患病率较男性多，且随年龄增长而增加．肿瘤分布以直肠和升结肠为多．     

19例肺癌误诊分析

1986年1月至1993年12月,我院收治肺癌48例,其中19例曾被误诊,误诊率为39.5％。误诊时间最短2个月,最长9个月,平均为3个半月。 1.误诊为肺结核6例。误诊原因:①均有咳嗽、咯血及胸痛乏力等肺结核症状。②有结核病史。③3例肺部X线片有陈旧性结核灶和边缘粗糙的块状阴影,误诊为肺结核复发,经积极抗痨治疗无效,多次查痰结核菌(一),找到癌细胞。另2例为菌阳肺结核住院期内,咳嗽频繁,持续咯血及发热,复查胸片病变迅速恶化,多次查痰结核菌(一),经纤支镜及刷检发现癌细胞。④癌性空洞易误诊为结核空洞。     

原发性气管癌5例误诊分析

原发性气管癌并非罕见,但却常易误诊而失去早期治疗的时机。现将我们近年来遇到的5例分析并讨论如下。 临床资料:5例原发性气管癌中,男3例,女2例;年龄36～64岁,平均51岁。其中3例误诊为慢性喘息型支气管炎,2例误诊为支气管哮喘;误诊时间为3个月～3年。经纤支镜取活检确诊为气管上端囊性癌、粘液表皮样癌、气管下端鳞状细胞癌各1例,未分化癌2例。2例住院期间因呼吸衰竭死亡;1例于手术时发现有淋巴结转移,术后6个月死亡;2例术后配合化疗、放疗至今仍健在     

原发性十二指肠癌诊断措施探讨—附41例分析

原发性十二指肠癌患病率低，由于早期症状元特异性，极易误诊，多数报道术前诊断率很低‘’‘。我们总结了1980年～1994年间经手术及病理证实的原发性十二指肠癌41例，本文结合临床、胃镜、X线钡餐检查对照分析，探讨误诊原冈从而为早期诊断提供依据。临床资料41例患者中男27例，女14例，平均年龄为56．2岁（32～72岁），其中40岁以上34例（82．9％），平均病程12．8个月（2个月～3年）。41例中腺癌39例，类癌1例，鳞状上皮细胞癌1例。病变位于球部10例，降段24例，水平段7例。内镜检查：术前经胃镜或十二指肠镜检查33例，27例得以确诊（8…     

55例青年人胃癌临床病理分析

我院自！985年1月至1995年1月的10年间，共收治青年同范55例，占同期确诊胃癌（2417例）的2．27％．临床资料一、一般资料本组患者年龄最小19岁，24～30岁者42例（76．3％）．平均年龄为28．5岁．其中男20例，女35例，男女之比为1：且．75．自出现症状6个月以内就诊者3O例（54．5％）；6个月～1年者16例（29％）；超过1年者9例（16％）．二、临床症状除早癌1例外，依次为：上腹部疼痛43例（7％），其中节律性疼痛14例，治疗后缓解者8例；呕吐27例（4％）；反酸24例（44％）；食欲减退13例（236％）；体重减轻12例（21．8％）；黑便13例（2…     

胃肠道类癌的内镜诊断与治疗

内镜下诊治胃肠道类癌。经内镜检出胃肠道类癌１１例，内镜结合活检确诊８例，占７３％；误诊为直肠癌、横结肠癌、回肠息肉各１例，占２７．３％。本组１１例中经内镜高频电摘除病变者８例，３例病变小于１．０ｃｍ者定期内镜随访８～１６个月，未见复发；其余５例，３例补行局部楔形切除，２例行局部扩大切除术，术后标本均未发现残留类癌灶。３例误诊病例２例行局部扩大切除术，１例行胃次全切除术，术后病理确诊为类癌。经８个月～１３年追踪，全部患者均存活。表明消化道内镜检查配合活检是诊断和治疗胃肠道类癌的有效方法。     

影响消化道肿瘤肝转移介入治疗疗效的因素

目的探讨影响消化道肿瘤肝转移介人治疗疗效的因素,并评价介入治疗的价值。方法９２例消化道肿瘤肝转移患者经肝动脉介人治疗３１６次,其中２９例行单纯灌注化疗,６３例行灌注化疗加栓塞治疗。化疗药物选用表阿霉素（ＥＡＤＭ）、或／和顺铂（ＰＤＤ）、丝裂霉素（ＭＭＣ）、５－一氟尿嘧啶（５—ＦＵ）＋甲酰四氢叶酸钙（ＣＦ）联台方案,栓塞剂为超液化碘油和／或明胶海绵。对可能影响介人治疗疗效的因素行ＣＯＸ模型多因素分析。结果近期疗效以ＣＴ征象作为评价依据,总有效率（ＣＲ＋ＰＲ）为４５．６５％;平均生存期１９６月;０．５．１,２,３,５年生存率分别为９５７％,７３８％,３６．３％,２０．６％,１１６％。Ｃｏｘ比例风险模型分析结果显示９例孤立性肝转移者较多发转移预后好,平均生存期为３１２个月,差异有显著性,Ｐ＜０．０５;综合治疗较单纯介人治疗疗效好,差异有非常显著性,Ｐ＜０．０１;其它因素对疗效的影响无统计学差异。全组无严重副作用或并发症。结论经肝动脉介人治疗是治疗消化道肿瘤不能手术切除肝转移瘤的较好方祛。单发肝转移、介人治疗前后的综合治疗是影响消化道肿瘤肝转移介人治疗疗效的重要因素。     

消化道肿瘤肝转移介入治疗的临床应用及预后分析

目的探讨介入治疗消化道肿瘤肝转移的治疗疗效。方法回顾性分析96例胃癌、结肠癌和胰腺癌肝转移患者的介入治疗,随访7个月～5年,评价其治疗效果和生存率。结果29例胃癌肝转移患者平均生存期为22.7个月,1年、3年、5年生存率分别为93.1%、31.4%、13.8%;55例结肠癌肝转移患者平均生存期为19.4个月,1年、3年、5年生存率分别为85.5%、34.5%、10.9%;12例胰腺癌肝转移患者平均生存期为13.2个月,1年、3年生存率分别为57.1%、14.2%;本组患者总的平均生存期为17.8个月,1年、3年、5年生存率分别为85.4%、33.3%、10.4%。结论介入治疗是不能根治性切除的肝转移瘤患者的有效治疗方法,鳞癌、胰腺癌肝转移的患者预后较差,而富血供肿瘤、原发肿瘤已切除的患者预后较好、生存期较长。     

Pancreatic carcinoid: transcatheter arterial chemoembolization of liver metastases

Carcinoid tumors are a common disease in the gastrointestinal tract, but are extremely rare in pancreas. To our knowledge, only 33 carcinoid tumors of pancreas have been reported in the English literature. Complete surgical resection of pancreatic carcinoid contributes to prolonged survival. But distant metastases, including liver metastasis, prevent long-term survival. We report here one resected case of pancreatic carcinoid tumor with liver metastases. Postoperatively, multiple liver metastases had arisen in the bilateral lobe of the liver and were treated with transcatheter arterial chemoembolization. In this case, transcatheter chemoembolization was effective for palliation for postoperative liver metastases.     

一起人体旋毛虫病群体感染调查及临床分析

本文报告西藏林芝地区10人集体食生或半生的猪肉后感染旋毛虫情况调查及患者临床特征。 10人中有9例患旋毛虫病, 其中2例因误诊、 误治死亡。3例嗜酸粒细胞升高, 3例血清旋毛虫抗体IgG阳性, 3例腓肠肌活检检出旋毛虫肌幼虫。7例经阿苯达唑驱虫治疗, 痊愈出院。 另1例无任何症状, 观察并口服阿苯达唑以作预防。     

骶前囊肿合并感染误诊误治一例

总结骶前囊肿合并感染误诊误治1例病人的病情发展及治疗过程,探讨如何避免骶前囊肿合并感染的误诊误治及其该病例的教训。     

CT-guided high-dose-rate brachytherapy in the interdisciplinary treatment of patients with liver metastases of pancreatic cancer

BACKGROUND: CT-guided high-dose-rate brachytherapy(CT-HDRBT) is an interventional radiologic technique for local ablation of primary and secondary malignomas applying a radiation source through a brachycatheter percutaneously into the targeted lesion. The aim of this study was to assess local tumor control, safety and efficacy of CT-HDRBT in the treatment of liver metastases of pancreatic cancer. METHODS: Twenty consecutive patients with 49 unresectable liver metastases of pancreatic cancer were included in this retrospective trial and treated with CT-HDRBT, applied as a single fraction high-dose irradiation(15-20 Gy) using a 192 Irsource. Primary endpoint was local tumor control and secondary endpoints were complications, progression-free survival and overall survival.RESULTS: The mean tumor diameter was 29 mm(range 10-73). The mean irradiation time was 20 minutes(range 7-42). The mean coverage of the clinical target volume was 98%(range 88%-100%). The mean D100 was 18.1 Gy and the median D100 was 19.78 Gy. Three major complications occurred with post-interventional abscesses, three of which were seen in 15 patients with biliodigestive anastomosis(20%)and overall 15%. The mean follow-up time was 13.7 months(range 1.4-55.0). The median progression-free survival was 4.9 months(range 1.4-42.9, mean 9.4). Local recurrence occurred in 5(10%) of 49 metastases treated. The median overall survival after CT-HDRBT was 8.6 months(range 1.5-55.3). Eleven patients received chemotherapy after ablation with a median progression-free survival of 4.9 months(mean 12.9). Nine patients did not receive chemotherapy after intervention with a median progression-free survival of 3.2 months(mean 5.0). The rate of local tumor control was 91% in both groups after 12 months.CONCLUSION: CT-HDRBT was safe and effective for the treatment of liver metastases of pancreatic cancer.     

Prognostic Implications of the Localization of Carcinoma in the Head of the Pancreas

Between 1974 and 1989, 411 patients with pathologically and anatomically proven carcinoma of the head of the pancreas underwent endoscopic retrograde cholangiopancreatography (ERCP). According to the localization of the tumor, these patients were divided into those with a cranially, centrally (periductally), caudally, or indeterminately localized tumor. In cranially localized tumors, extrahepatic metastases and vessel invasion were absent or resectable in 53% and 46%, respectively. The tumor was resectable in 41% of cases. If a patient with a cranially localized tumor could not be operated curatively for secondary reasons, the prognosis was better than for tumors with another localization. If there was unresectable vessel invasion and the tumor was not resectable, the 0% survival rate was reached at 33 months. Of the curatively operated patients, 26% were alive at 36 months after the start of complaints. Of the centrally or periductally localized tumors, there were no liver metastases in 73%. Extrahepatic metastases and vessel invasion were absent or resectable in 57% and 53%, respectively. The tumor was resectable in 48% of cases. If there was unresectable vessel invasion or the tumor was unresectable, the 0% survival rate was reached after 18 months. These tumors have maximal chances at curative resection. Of the curatively operated patients, 31% were alive at 36 months after the start of complaints. In caudally localized tumors, there were liver metastases in 59%, unresectable other abdominal metastases in 93%, unresectable vessel invasion in 91%, and the tumor was unresectable in 96%. In patients with an unresectable vessel invasion or an unresectable tumor, the 0% survival rate was reached after 33 months; 3% of these patients were operated curatively. Indeterminately localized tumors had liver metastases in 77%, unresectable extrahepatic metastases in 90%, unresectable vessel invasion in 95%, and the tumor was unresectable in 91%. Only one of the 44 patients (2%) could be operated curatively.     

Surgical treatment of carcinoid tumours of the stomach and small intestine

Gastric carcinoid tumours can be divided into subtypes with a different pathogenesis and biological behaviour. Individualized surgical treatment of these tumour types is discussed. Liver metastases imply a major problem in patients with carcinoid tumours. Patients with distant metastases can undergo resection for potential cure, or for symptom palliation, due to the slow growth rate of many carcinoid tumours. In patients with the midgut carcinoid syndrome and bilobar liver metastases, interventional treatment by tumour removal and liver embolization followed by medical therapy (octreotide and/or interferon) seem to prolong survival and reduce hormonal symptoms. Patients with the foregut carcinoid syndrome may present special problems with life-threatening release of histamine during interventional treatment.     

A new index for resection of meckel diverticula in children

Background: Mid-gut carcinoid tumours often present with liver metastases, and survival has then been less than 2 years in earlier reports. We have evaluated the effects of interferon therapy on clinical response and survival, with or without hepatic artery embolization in these patients.

Methods: In a prospective study 30 female and 12 male patients, aged 23 to 75 years, with mid-gut carcinoid tumours and liver metastases underwent surgery with removal of as much as possible of their primary tumour. If technically feasible, embolization of hepatic arteries was performed in the absence of contraindications. Seventeen patients were embolized, and all patients received interferon-α2b treatment for 1 year. Response factors were computer tomography (CT) measurement of the largest liver metastasis and the 24-h urinary excretion of 5-hydroxyindoleacetic acid (5-HIAA). After 12 months patients with objective response or stable disease either continued or withdrew from interferon therapy. Survival was estimated when all patients had been observed for at least 36 months.

Results: Nine patients reduced the dose, and five withdrew from interferon treatment owing to side-effects the 1st year. Three patients died. Fifteen patients (39%) showed objective response 12 months after inclusion. Cumulative 5–year survival estimated from inclusion was 37.5% in all 42 patients but 71.4% in those who continued interferon therapy. The difference in survival between the interferon-treated and those who withdrew from interferon therapy at 12 months was significant when embolization was corrected for in a Cox model (p < 0.0125). The seemingly increased survival in embolized versus non-embolized patients did not reach statistical signifiance (p = 0.07).

Conclusion: Interferon induced an objective response in mid-gut carcinoid patients as judged by the 24-h urinary S-HIAA excretion. Patients receiving continuous interferon therapy showed improved response and survival compared with patients who stopped the treatment. Regardless of medical therapy, more survivors and more responders, as evaluated from (JT measurements, were found among the embolized patients than among the non-embolized. Embolization could, however, not be shown to have a significant effect on survival.     

结直肠癌肝转移的综合治疗策略

结直肠癌(colorectal cancer,CRC)是世界上常见的消化道肿瘤之一,约有50%的患者最终出现肝转移。对于发生肝转移的患者,若不经治疗,中位生存期仅为6.9个月,5年生存率为0。若肝脏转移灶行根治性手术,则中位生存期为35个月,5年生存率为30～50%,因此手术切除仍是结直肠癌肝转移治疗的首选。对于同时性肝转移的患者,若无肠道梗阻、穿孔、出血等症状,笔者倾向于同时性切除原发灶和转移灶,术中联合应用B超探查、微波、射频等新技术来提高切除率,降低复发率。而临床上只有少部分患者(10%～15%)可以行手术治疗。对于不可切除的肝转移灶,需通过多学科讨论,针对疾病某一时期,制定出详细的个体化综合性治疗方案,如术前新辅助化疗、联合靶向药物治疗、门静脉栓塞术的应用、局部治疗、放疗等,使得一些不可切除的病灶转化为可切除病灶。因此癌肿作为一项全身性疾病,单纯依靠一种治疗手段很难取得理想的效果,需要多学科的合作,通过对疾病的不同时期进行认识、讨论,以便找到针对某一时间段疾病的最佳治疗方法。同时术后需要定期复查及时发现复发和转移以及制定进一步治疗计划,从而提高患者的长期生存率及生活质量。