高龄患者胰十二指肠切除术分析

目的分析70岁以上老年人胰十二指肠切除术（PD）临床资料并探讨其安全性。方法回顾性分析老年人行PD的临床资料,将90例50岁以上PD手术病例分成≥70岁（高龄组,n＝27）和＜70岁（低龄组,n＝63）两组,分析两组术前Karnofsky功能状态（KPS）评分、入院时血红蛋白（Hb）、血细胞比容（Hct）、血浆白蛋白（ALB）、血清总胆红素（TBIL）、血浆前白蛋白（PALB）、血糖、血钾、手术时间、术中失血量、术后重症监护病房（ICU）入住率、术后住院日、术后并发症发生率及术后死亡率。结果高龄组与低龄组比较,术前KPS评分低[（71.11±6.98） vs （85.40±6.43）,P＜0.01]、血浆ALB低[（34.86±4.54） vs （37.02±4.13）g/L,P＜0.05]、PALB低（127.36±41.19） vs （160.27±57.11）g/L,P＜0.05）、血糖高[（8.47±3.68） vs （6.41±2.12）mmol/L,P＜0.05]、血钾低[（3.38±0.48） vs （3.81±0.45）mmol/L,P＜0.01]、术后ICU入住率高（81.48%vs 39.68%,P＜0.01）,两组间的差异均有统计学意义。两组并发症发生率差异无统计学意义（48.15% vs 39.42%,P＞0.05）。高龄组无住院期间手术死亡,低龄组有2例术后30d内死于并发症。结论严格掌握适应证,重视术前内环境调整,术后积极ICU治疗,≥70岁高龄患者行PD是安全可行的。     

Increased resectability of locally advanced pancreatic and periampullary carcinoma with neoadjuvant chemoradiotherapy

A prospective neoadjuvant trial utilizing chemotherapy (CTX) and radiotherapy (XRT) prior to pancreatectomy was established to determine the feasibility of resection after aggressive pretreatment and its effect on survival. Fifteen patients with pancreatic cancer (14 head, 1 body) and 1 patient with duodenal cancer, (with paraaortic adenopathy), were subjected to combination treatment with infusional 5-FU, bolus injection of mitomycin-C, and XRT (4 patients were treated off the protocol). Patients were restaged 3 wk after XRT, and those deemed resectable underwent a pancreatic resection. Three patients did not undergo exploration after the neoadjuvant therapy, although two of these were deemed resectable by CT scan. The remaining 13 patients underwent exploration and 10 underwent resection. Three did not undergo resection because of extrapancreatic disease, although their primary tumors were resectable. One patient had no residual tumor in the specimen. The others had residual tumor with evidence of necrosis and hyalinization, but all margins were free of tumor. There were two perioperative deaths from sepsis. Of the remaining patients who underwent resection, one died of a myocardial infarction at 9 mo. One patient died with recurrent disease at 19 mo. The remaining patients are alive 40, 32, 11, 11, 10, and 4 mo since diagnosis and are currently free of disease. Aggressive neoadjuvant chemoradiotherapy can be performed safely, allows successful resection, and may yield long-term survival or curve.     

术前影像学检查评估胰腺肿瘤可切除性的价值

目的 探讨胰腺癌可切除性的术前评估.方法 通过回顾性分析患者术前的CT、MRI、MRCP等影像学资料,对1990年6月至2006年6月间115例胰腺癌患者进行术前可切除性评估.结果 本组115例,有29例术前判断为无法切除,86例可切除;术中实际行胰十二指肠切除术的病例为78例,未能手术切除的病例为37例.CT等影像学检查术前判断肿瘤可切除的阳性预测值为87.2%(75/86),阴性预测值为89.7%(26/29),准确性为87.8%(101/115).结论 胰腺癌术前可切除性判断,既可提高手术切除率,降低手术风险,减少术后并发症及病死率;同时可避免不必要的手术给患者带来的侵害,提高患者的生活质量.     

术前影像学检查评估胰腺肿瘤可切除性的价值

目的探讨胰腺癌可切除性的术前评估。方法通过回顾性分析患者术前的CT、MRI、MRCP等影像学资料,对1990年6月至2006年6月间115例胰腺癌患者进行术前可切除性评估。结果本组115例,有29例术前判断为无法切除,86例可切除;术中实际行胰十二指肠切除术的病例为78例,未能手术切除的病例为37例。CT等影像学检查术前判断肿瘤可切除的阳性预测值为87.2%（75/86）,阴性预测值为89.7%（26/29）,准确性为87.8%（101/115）。结论胰腺癌术前可切除性判断,既可提高手术切除率,降低手术风险,减少术后并发症及病死率;同时可避免不必要的手术给患者带来的侵害,提高患者的生活质量。     

A new faecal chymotrypsin method for evaluating the exocrine pancreatic function in patients with different pancreatic diseases

Using a new colorimetric method we measured the faecal chymotrypsin in 407 subjects, divided as follows: 252 adult subjects with a normal exocrine pancreatic function as shown by duodenal intubation, 24 adult patients with a mild to moderate pancreatic insufficiency, and 26 adult patients with severe pancreatic insufficiency. In addition, 40 healthy children, 50 children with chronic diarrhoea, and 15 with cystic fibrosis were studied before and after substituting enzyme therapy. Faecal chymotrypsin was found to be useful in evaluating the degree of exocrine functional insufficiency in subjects with diseases of the pancreas that had already been clinically ascertained. The same cannot be said for its ability to provide an early diagnosis of subjects with a slight-moderate insufficiency in exocrine pancreatic function.     

A new faecal chymotrypsin method for evaluating the exocrine pancreatic function in patients with different pancreatic diseases

Summary Using a new colorimetric method we measured the faecal chymotrypsin in 407 subjects, divided as follows: 252 adult subjects with a normal exocrine pancreatic function as shown by duodenal intubation, 24 adult patients with a mild to moderate pancreatic insufficiency, and 26 adult patients with severe pancreatic insufficiency. In addition, 40 healthy children, 50 children with chronic diarrhoea, and 15 with cystic fibrosis were studied before and after substituting enzyme therapy. Faecal chymotrypsin was found to be useful in evaluating the degree of exocrine functional insufficiency in subjects with diseases of the pancreas that had, already been clinically ascertained. The same cannot be said for its ability to provide an early diagnosis of subjects with a slight-moderate insufficiency in exocrine pancreatic function.     

Clinical value of serum CA19-9 levels in evaluating resectability of pancreatic carcinoma

AIM： To evaluate the clinical value of serum CA19-9 levels in predicting the respectability of pancreatic carcinoma according to receiver operating characteristic （ROC） curve analysis.
METHODS： Serum CA19-9 levels were measured in 104 patients with pancreatic cancer which were possible to be resected according to the imaging. ROC curve was plotted for the CA19-9 levels. The point closest to the upper left-hand corner of the graph were chosen as the cut-off point. The sensitivity, specificity, positive and negative predictive values of CA19-9 at this cut-off point were calculated.
RESULTS： Resectable pancreatic cancer was detected in 58 （55.77%） patients and unresectable pancreatic cancer was detected in 46 （44.23%） patients. The area under the ROC curve was 0.918 and 95% CI was 0.843-0.992. The CA19-9 level was 353.15 U/mL, and the sensitivity and specificity of CA19-9 at this cutoff point were 93.1% and 78.3%, respectively. The positive and negative predictive value was 84.38% and 90%, respectively.
CONCLUSION： Preoperative serum CA19-9 level is a useful marker for further evaluating the resectability of pancreatic cancer. Obviously increased serum levels of CA19-9 （〉 353.15 U/mL） can be regarded as an ancillary parameter for unresectable pancreatic cancer.     

A new approach to evaluating carcinogenic risk.

Carcinogenic risk assessments are based on extrapolating from high-dose chronic rodent-feeding studies to human-exposure levels. A serious problem is that about half of all substances tested at their respective maximum tolerated dose (MTD) are found to induce cancer. The MTD as currently defined has been criticized because it may stimulate cell proliferation in susceptible tissues. Such chemically induced mitogenesis is postulated to increase the probability that neoplasia will develop at the affected site. It is proposed that, in the development of an MTD for a given substance, chemically induced mitogenesis be considered an undesirable toxic manifestation. Hence, mitogenesis should not be induced by a substance fed at its true MTD. Since MTDs determined in this fashion are likely to be lower than those developed using current criteria, an added level of protection is introduced by employing a safety factor similar to that used now in determining acceptable daily intakes for noncarcinogenic food additives. In calculating acceptable daily intakes, the usual safety factor is 100; i.e., the acceptable daily intake is set at 1% of the no-observed-effect level. Hence it is proposed that the acceptable daily level of exposure to a substance that does not induce cancer at its MTD as defined herein be set at 1% of that MTD. On the other hand, a chemical that induces cancer at its MTD as defined herein would continue to be regulated as is customary now.     

Palliation of unresectable periampullary neoplasms. "surgical" versus "non-surgical" approach

BACKGROUND/AIMS: A series of 84 patients with unresectable periampullary neoplasms, observed during an eight-year period (1992-1999), is reviewed for a critical analysis of modalities of treatment and clinical outcome. Two different approaches, a preference for "non-surgical" palliation and a preference for "surgical" palliation, in two consecutive periods, are compared. METHODOLOGY: In the first period (1992-1995) endoscopic retrograde cholangiopancreatography with endoprosthesis insertion was performed routinely and, after diagnostic assessment, patients were divided into two groups: those with apparently resectable neoplasms, candidates for surgery, in whom the decision to perform a surgical palliation by biliary bypass was taken intraoperatively, and those with unresectable neoplasms, in whom the endoprosthesis insertion was considered as definitive palliation. Since January 1996, a different approach was started; surgical bypass was considered the palliation of choice and only patients unfit for surgery underwent endoscopic stenting. RESULTS: Evaluation of the results showed that the first strategy was associated with a high incidence of complications and unsatisfactory long-term results, with frequent hospital readmissions, poor quality of residual life and therefore failure of palliation. On the contrary, the latter approach with preference for surgical palliation was associated with lower morbidity and mortality, with persistent relief of symptoms and better quality of life in a larger percentage of patients. CONCLUSIONS: This study provides evidence that, in patients with unresectable periampullary carcinoma, surgical palliation provides better long-term results than endoscopic palliation. The results were also consistent with the advantage of associating a gastric bypass to the biliary bypass, also in the absence of gastric outlet obstruction.     

A new approach for evaluating bone turnover in chronic kidney disease

BackgroundThe validity of serum parathyroid hormone (PTH) as a surrogate marker of bone turnover in chronic kidney disease (CKD) is limited by several factors such as relative resistance of bone to PTH, hyperphosphatemia, diabetes, gender, age, race and vitamin D analog action on the PTH-bone axis. Urinary collagen N-terminal telopeptide X (NTx), a bone collagen degradation product, expressed as bone collagen equivalents (BCE) per mM of creatinine (NTx/Cr ratio), is routinely used to estimate bone turnover in osteoporosis. The purpose of this study is to evaluate NTx as a marker of bone turnover in CKD.MethodsWe studied the relationship between bone-specific alkaline phosphatase (BSAP), PTH and urine NTx/Cr in 37 CKD out-patients.ResultsIn a multivariate model, PTH had a positive correlation with BSAP (r = 0.44, P < 0.19) and U-NTx/Cr (r = 0.55, P < 0.30), after adjusting for age, gender, estimated glomerular filtration rate (GFR), serum phosphorus, corrected calcium, and race. However, the strongest correlation was found between the two direct markers of bone resorption and formation (U-NTx vs. BSAP; r = 0.80; P < 0.0001), suggesting a tight coupling of bone resorption and formation in CKD. The effect of gender on U-NTx/Cr was studied in a multivariate model after adjusting for age, race, GFR, serum calcium, phosphorus and PTH. Females had a higher U-NTx/Cr than males.ConclusionOur findings indicate that urinary NTx, a promising marker of bone resorption in CKD patients, exhibits a strong positive correlation with other markers used to assess renal osteodystrophy i.e. PTH and BSAP. Unlike PTH and BSAP, urine NTx also measures bone loss secondary to osteoporosis.     

Functional MRCP in pancreatic and periampullary disease

Summary Background. The magnetic resonance (MR) evaluation of the pancreatic and biliary tree has undergone an important evolution because the introduction of the technique of MR cholangiopancreatography (MRCP). Aim. To describe and illustrate the technique of secretin-enhanced MRCP (S-MRCP) and discuss its use in pancreatic and periampullary disease. Methods. Results are based on 6 years experience using MRCP with secretin infusion in hundreds of patients in a tertiary referral center. Results. Secretin improves pancreatic duct and side-branch delineation and the detection of anatomic variants such as pancreas divisum and abnormal common bilio-pancreatic channel. It allows monitoring of pancreatic flow dynamics and evaluation of pancreatic exocrine function that has been previously unavailable. In advanced inflammatory disease, it is useful in monitoring the course of the disease, for planning therapy and for follow-up studies after therapeutic endoscopy. Conclusion. Combining morphology and function into one non-invasive and comprehensive diagnostic modality has expanded the clinical applications of MRCP beyond the diagnostic ERCP that it replaces.     

A new approach to diagnosing and evaluating the efficiency of dehelmintization in ascariasis

The results of dehelmintization were studied in 127 patients with the intestinal stage of ascariasis. Its diagnosis was established by the Kato test. The ovoscopic technique was combined with the trend of proinflammatory cytokines and the grade of dysbacteriosis. There was a strong direct correlation of the high levels of proinflammatory cytokines and the high-grade dysbacteriosis with the inefficiency of expulsion of the parasite.     

Survival analysis of pancreatic and periampullary collision cancers

OBJECTIVE: Collision cancers are malignancies in the same organ or anatomical site that comprises at least two different tumor components, with no mixed or transitional area between two components. Collision cancers are very rare in the pancreas and periampullary region. The aim of this study was to analyze the clinical and pathological features and prognosis of collision cancer in the pancreas and periampullary region. METHODS: Patients with collision cancers of the pancreas and periampullary region (n= 10) who had undergone radical surgery were retrospectively studied. Their clinical and pathological features were summarized and the prognostic data were compared with patients with pancreatic adenocarcinomas who underwent radical surgery (n= 87) and with patients with pancreatic or periampullary malignancies who underwent palliative surgery (n= 89). RESULTS: Compared with other cancers at these sites, collision cancer presents no specific clinical features. However, the median survival period of patients with such malignancies was only 10.0 months, which was much less than those with pancreatic adenocarcinomas who underwent radical surgery (27.0 months) and those who received a palliative operation (20.9 months) only. CONCLUSION: Collision cancers of the pancreas and periampullary region are difficult to diagnose preoperatively. Their prognosis is poor even after radical resection and adjuvant chemotherapy were given.