胆胰十二指肠结合部切除治疗壶腹部周围癌的疗效评价

目的探讨胆胰十二指肠结合部切除术治疗壶腹癌的临床疗效。方法18例壶腹癌患者,该术式切除范围：十二指肠降段,距胆胰管汇合部切除胰头1～2cm及胆总管至左右肝管汇合处下方。术中注意清扫区域淋巴结,术中冰冻病理证实各切缘无肿瘤残存。术后定期随访,统计并发症发生率、生存率、生存时间和肿瘤复发率等指标,进行临床疗效评价。结果全组手术成功率100％,术后未出现十二指肠漏、胆漏或明显胰漏等严重并发症,均痊愈出院。术后随访率为93．55％,随访时间为2个月～41个月不等,平均随访时间为13．6个月。本组目前共死亡5例：有2例因非手术并发症死亡,其中1例术后第8天出现急性心衰、肺水肿、严重肺部感染于术后1个月死亡;另1例死于术后2个月的应激性溃疡上消化道大出血;1例死因不明;2例死于肿瘤复发;其余26例均存活至今,其中有3例出现肝内或腹腔内淋巴结转移。结论胆胰十二指肠结合部切除术是治疗壶腹部癌的一种新术式,既比乳头局部切除术保证了相对足够的切除范围,又较常规胰十二指肠切除术明显降低手术难度和创伤程度。严格掌握手术适应证、彻底清扫区域淋巴结、保证各切缘无瘤残存和精细吻合是提高疗效的重要措施。     

改良Vater壶腹部切除的根治术治疗壶腹周围癌

目的：探讨行壶腹部改良切除术治疗Vater壶腹部周围癌,减少非肿瘤器官切除,提高疗效的手术方法。方法：总结1995－1998年13例壶腹周围癌行扩大壶腹部切除的根治术的经验,经十二指肠后外侧入路,整块切除肝外胆道,胆胰管汇合部,壶腹部及十二指肠乳头,十二指肠乳头封闭术,胆,胰,十二指肠间置空肠或胆,胰空肠Roux-en-y吻合术。结果：围手术期死亡1例,并发 1例经再手术治愈,随访术后半年以上9例,最长生存29个月,无并发症及转移征象。结论：（1）该术式符合胰十二指肠解剖关系;（2）按肿瘤治疗原则能达到广泛程度清扫;（3）初行该术式者应掌握胰十二指肠切除术。     

胆胰十二指肠结合部切除术术式介绍

1899年Halstea首次行壶馥癌局部切除术获得成功，但由于该术式切除范围有限、早期复发率高而一直未被广泛接受。1935年Whipple设计并实施胰十二指肠切除术（pancreaticoduodenectomy,PD），这是壶腹癌治疗的经典术式，但手术创伤大，不适用于高危患者及高龄难以耐受手术者。我们从2005年1月至今采用胆胰十二指肠结合部切除术治疗壶腹周围癌12例，手术成功率100%，术后未出现十二指肠漏、胆漏或胰漏等并发症。本文结合文献及我们的体会，就手术技巧、适应证及术后并发症等进行讨论。[编者按]     

胆胰结合部十二指肠部分切除术

1899年Halsted首次行壶腹癌局部切除术获得成功，但由于该术式切除范围有限、早期复发率高而一直未被广泛接受。1935年Whipple设计并实施胰头十二指肠切除术（pancreaticoduodenectomy，PD）成为壶腹癌治疗的经典术式。但该术式创伤大，高危及高龄患者难以耐受。为解决此难题，笔者自2005年1月至今采用胆胰结合部十二指肠部分切除术治疗壶腹周围癌等18例，     

胆胰十二指肠汇合部区域切除术治疗高龄患者壶腹部肿物

目的:探讨胆胰十二指肠汇合部区域切除术治疗高龄患者壶腹部肿物治疗经验。方法:回顾2008年1月—2010年12月采用胆胰十二指肠汇合部区域切除术治疗高龄壶腹部肿物患者12例临床资料。结果:术后病理诊断:十二指肠乳头癌6例,十二指肠乳头腺瘤恶变2例,胆管下段癌2例,胰头孤立纤维瘤1例,十二指肠降部癌1例,清扫淋巴结无转移。术后无胰瘘、胆瘘等并发症发生。术后随访1年无复发。结论:胆胰十二指肠汇合部区域切除术是治疗早期壶腹部肿物一种新方法。     

扩大Vater壶腹部切除的根治术治疗壶腹部肿瘤

目的 探讨Vater壶腹部肿瘤行壶腹部扩大切除的根治性手术的方法,以减少非肿瘤器官切除,并符合肿瘤治疗原则。方法 总结1995-1998年手术切除的根治术的经验。经十二指肠后外侧入路,整块切除肝外胆道、胆胰管汇合部,壶腹部及十二指肠乳头,十二指肠乳头封闭术。胆、胰、十二指肠间置空肠或胆、胰空肠Roux-en-Y吻合术。结果 围手术期死亡1例。并发症1例经再手术治愈。随访术后半年以上病人9例,最长生存29个月,无并发症及转移征象。结论（1）该术式符合胰十二指肠解剖关系;（2）按肿瘤治疗原则能达到广泛程度清扫;（3）初行该术式者应掌握胰十二指肠切除术。     

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Ｈａｌｓｔｅｄ于 1899年行壶腹部肿瘤的局部切除。自 1935年Ｗｈｉｐｐｌｅ施行胰十二指肠切除术 (ＰＤ)成功以来 ,ＰＤ一直为壶腹部癌的经典术式。自 2 0世纪 80年代以来 ,重视术后生存质量 ,壶腹部肿瘤局部切除在国内外均有报告。1993年以来我们为 5例十二指肠乳头癌行局部切除。本文结合文献及我们的体会 ,就手术手技、术后并发症防治、适应证及疗效加以讨论。1　壶腹部局部解剖壶腹部包括十二指肠乳头、Ｖａｔｅｒ壶腹、胆总管第 4段(十二指肠壁内段 )、胰管终末段及围绕其周围的Ｏｄｄｉ括约肌 (图 1)。图 1　壶腹部范围及区分壶腹部…     

壶腹周围癌局部扩大切除术

目的：探讨壶腹周围癌的局部切除术的改进方法，方法：对4例壶腹腺癌和十二指肠乳头腺癌实施局部扩大切除术，将部分十二指肠降段，胆胰管远段，局部1cm厚度的胰腺组织连同壶腹周围癌一并切除，关闭十二指肠两断端，将近段空肠分别与胆胰管，胰头断面和十二指肠上部吻合，结果：标本切缘均无癌组织；术后胰瘘1例，经保守治疗后痊愈；术后4-24个月随访无复发及其他并发症发生。结论：该术式操作简单，对早期壶腹周围癌能够达到根治目的。     

扩大Vater壶腹部切除的根治术治疗壳腹部肿瘤

目的：探讨Vater壶腹部肿瘤行壶腹部扩大切除的根治性手术的方法，以减少非肿瘤器官切除，并符合肿瘤治疗原则。方法：总结1995-1998年手术切除的根治术的经验。经十二指肠后外侧入路，整块切除肝外胆道、胆胰管汇合部，壶腹部及十二指肠乳头，十二指肠乳头封闭术。胆、胰、十二指肠间置空肠或胆、胰空肠Roux-en-Y吻合术。结果：围手术期死亡1例。并发症1例经再手术治愈。随访术后半年以上病人9例，最长生存29个月，无并发症及转移征象。结论：（1）该术式符合胰十二指肠解剖关系；（2）按肿瘤治疗原则能达到广泛程度清扫；（3）初行该术式应掌握十二指肠切除术。     

胰十二指肠切除术治疗壶腹部癌和胰头癌临床分析

壶腹周围癌是指胆胰壶腹周围2cm范围内的恶性肿瘤，包括壶腹部癌（胆总管末端壶腹癌和十二指肠乳头癌）、胰头癌及十二指肠降段的恶性肿瘤．胰十二指肠切除术是治疗壶腹周围癌的主要方式，但该手术对于壶腹部癌和胰头癌的疗效有所差别．将我院近7年收治病例的情况报道并分析如下。     

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).     

Malignant papillomatosis of the common bile duct

Summary Bile duct papillomatosis is a rare entity with a high risk of malignant change. We report the case of a 60-year-old man with malignant papillomatosis of the distal common bile duct and a separate carcinoma of ampulla of Vater. The patient had previously undergone surgery for acute cholecystitis and common bile duct calculi. Three months later the patient developed jaundice and fever. An endoscopic retrograde cholangiopancreatography demonstrated multiple filling defects adherent to the wall of the distal common bile duct. Pancreatoduodenectomy was performed with complete resection of the extrahepatic bile duct. Histologic examination showed a multicentric papillary adenocarcinoma of the common bile duct associated with an adenocarcinoma of the ampulla of Vater. The resection margins were free of tumor.     

Results of surgical treatment of periampullary tumors: a thirty-five-year experience

Data on 126 consecutive patients with periampullary tumors resected at the Cleveland Clinic between January 1950 and December 1984 were reviewed. One hundred five patients underwent pancreatoduodenal resection, 10 patients total pancreatectomy, and 11 patients local resection of the tumor. The site of tumor was ampulla of Vater (59), head of the pancreas (30), duodenum (20), and distal common bile duct (11). Six patients had benign disease. The operative mortality rate for radical resection for the entire period was 7.8%; it has declined to 5.4% since 1974. The operative mortality rate for local resection was 9.1% (one patient). The overall 5-year survival rate for all malignant tumors of the periampullary area was 28% and 25.5% for invasive adenocarcinoma. Survival was affected primarily by location and histologic findings. The 5-year survival rate for adenocarcinoma of the ampulla of Vater was 37.2%, 27.5% for the duodenum, 16.7% for the distal common bile, and 4.3% for the pancreas (p = 0.0001). Papillary adenocarcinoma had a 5-year survival rate of 49.2% in contrast to 18.4% for nonpapillary ductal adenocarcinoma (p = 0.002). Patients with ampullary adenocarcinoma treated by local resection had a 5-year survival rate of 40.9%. These data justify continued use of a selective radical approach in the resection of most periampullary tumors with local resection for small tumors in high-risk patients.     

Surgical treatment of cancer of the pancreas and the periampullary region: cumulative results in 57 institutions in Japan.

In this study the experiences with carcinomas of the pancreas, ampulla of Vater, terminal comma bile duct, and duodenum found in a series of 3,610 patients collected from 57 major Japanese institutions was compiled over a 26 year period. The results were analyzed as to the success of resectional and palliative surgery for the various lesions. The most common lesion was carcinoma of the head of the pancreas. Unifortunately, only 18.3% of these patients were resectable with a 25.3% mortality. Carcinoma of the body and the tail was the second most frequent lesion, and it also exhibited a low resection rate. Carcinomas of the ampulla and the terminal common bile duct and duodenal regions were the most favorable for resection; usually pancreatoduodenectomy with an overall mortality of 20.8%. As a result of the large number of pancreatectomies performed, there was also a large number of postoperative complications, the most frequent being leakage at an anastomotic line. Hemorrhage also occurred frequently. Distal pancreatectomies were reserved for carcinoma of the body and the tail of the pancreas, and the most common postoperative complication of this procedure was hemorrhage. There were only 45 total pancreatectomies among the 973 resections being performed most frequently in patients with carcinoma of the head of the pancreas. Again, the most frequent postoperative complication was hemorrhage, followed by anastomotic leakage. The long term survivals following resection for these lesions were each poor. The best mean survival time was 22.7 months for carcinoma of the ampulla of Vater. Patients having resections for carcinoma of the head of the pancreas had a mean survival time of 12.3 months. At 5 years there were few survivors and most of them were patients who had undergone resections for carcinoma of the ampulla of Vater.     

Results of radical resection for periampullary cancer.

This report concerns 348 pancreatoduodenectomies, including 13 total pancreatectomies. Operative mortality over 30 years was 15%, operative mortality since 1962, 10%. Precise factors influencing operability, mortality, morbidity, and long-term palliation or cure are emphasized. The necessity for making a distinction among tumors arising in the ampulla of Vater, the intrapancreatic portion of the common bile duct, and the duodenum surrounding the papilla of Vater and carcinomas arising in the head of the pancreas is the most important factor in the approach to periampullary malignant tumors. Even with this large experience, the impression of the operating surgeon at the time of resection was incorrect in 10% of the patients in whom a reons who do not resect carcinomas arising in the head of the pancreas and who may have had less experience in this specialized field may be rejecting an even larger per cent of patients with more favorable periampullary malignant tumors. The influence of previous exploration, manipulation, and biopsy on morbidity, mortality, and survival is discussed. The significance of nodal involvement and residual tumor at the neck of the pancreas and the point of division of the common bile duct and the uncinate process is discussed. These data justify continued selective application of pancreatoduodenectomy for periampullary cancer and identify areas where further improvement can be made.     

影像学检查技术在壶腹周围癌诊断上的合理应用

目的：探讨影像学检查技术在壶腹周围诊断上的合理应用。方法：对我院185例壶腹周围癌（包括胰头癌119例、十二指肠乳头癌41例、Vater壶腹癌13例、胆总管下段癌12例）的临床特点和各种影像学检查资料进行回顾性分析。结果：本组CT诊断胰头癌的准确率为90．9％；ERCP对十二指肠乳头癌的确诊率为100％；ERCP和MRCP对壶腹癌和胆总管下段癌的诊断价值优于其他检查。78％的病人上腹饱胀／隐痛出现时间早于黄疸1－3月。血清CA19－9值在3／4以上的胰头癌、壶腹癌和胆总管下段癌病人超过正常值。结论：凡有中上腹部饱胀、隐痛、血清CA19－9值升高、胆总管和（或）胰管扩张的病人应有步骤地进行各种影像学检查。超声检查发现胰头部有肿块，宜行CT检查。如未发现肿块，则行ERCP。凡ERCP检查时观察到有肿瘤征象的病人，不宜作胰胆管造影而仅作活检。MRCP可用于胰胆管造影失败的壶腹癌和胆总管下段癌。超声内镜对壶腹周围癌的诊断和鉴别诊断也起重要作用。     

Vater壶腹部扩大的局部切除术治疗壶腹部肿瘤

目的 探讨探讨对Vater壶腹部肿瘤行壶腹部扩大切除的手术方法。方法 1995-1998年行壶腹部癌扩大的局部切除术8例。切除范围包括肝外胆道,胆胰管汇合部,壶腹部及十二指肠降部后外侧壁乳头区。结果 围手术期死亡1例,术后外压性十二指肠梗阻1例,经再手术治愈,术后随访半年以上7例,最长生存29个月,无并发症及转移征象。结论 该术式虽为局部切除但可达到广泛淋巴清扫的目的,符合肿瘤的治疗原则。     

多种肿瘤成分并存的胰腺及壶腹部恶性肿瘤生存分析

目的 探讨多种肿瘤成分并存的胰腺及壶腹部恶性肿瘤的生物学特点及临床治疗方 法.方法 回顾性分析复旦大学附属中山医院2005年1月至2007年5月收治的18例多种肿瘤成分并存的胰腺及壶腹部恶性肿瘤的临床特点、影像学改变、病理特征、治疗过程及随访资料并结合文献讨论.结果 该组18例病人,男11例,女7例;平均年龄62.4±11.7(36～80)岁.其中碰撞癌11例,即肿瘤成分间无混合及移行状态;其余7例为混合癌,即肿瘤成分相互掺杂.肿瘤分别位于胰腺、胆总管下端及十二指肠壶腹部14例,其余4例则分别位于胰头+胆囊(双碰撞癌)、胰头+胆总管下端、十二指肠壶腹部+胆总管下端以及十二指肠乳头+十二指肠近幽门部.组织学类型以导管内乳头状黏液腺癌(intraductal papillary mucinous carcinoma,IPMC)合并导管腺癌/神经内分泌癌以及导管腺癌合并其它壶腹部少见类型恶性肿瘤为主.pT分期以2、3期多见,而病理分期则以早、中期为主.行胰十二指肠切除术15例,胰体尾+脾切除术2例,全胰切除术1例.所有病人均无围手术期死亡,术后均未出现严重并发症.随访18例,术后均辅以化疗或加中医治疗,其中10例死亡,多死于肿瘤复发或肝脏转移.全部病人中位生存期仅13.2个月,较同期实施的胰腺导管腺癌根治性切除者(中位生存期27个月)、胰腺及壶腹部恶性肿瘤姑息性手术者(中位生存期20.9个月)更差.结论 多种成分并存的胰腺及壶腹部恶性肿瘤多发生在胰头及胆总管下端,以导管内乳头状黏液腺癌或导管腺癌合并其它少见类型恶性肿瘤为主,pT分期以2、3期多见,而病理分期则以早、中期为主,预后极差.     

Follow-up studies of radical resection for pancreaticoduodenal cancer.

In a study of 66 patients with pancreaticoduodenal cancer with pancreaticoduodenectomy, there were five (7.5%) hospital deaths. Five-year survival rates were 7.8% in 20 patients with carcinoma of the head of the pancreas, 16.7% in 31 patients with carcinoma of the bile duct, and 38.5% in 15 patients with carcinoma of the ampulla of Vater. Fecal fat loss measured was 10 g or less per day in nine of 12 patients. Of the 19 patients having glucose tolerance tests, 13 showed abnormalities including the two who were diabetic. Operative findings which were indicative of a poor prognosis included lymph node metastases, macroscopic invasion of the tumor into the pancreatic capsule in patients with carcinoma of the head of the pancreas, the size of the tumor in those with carcinoma of the common bile duct, and direct invasion of the lesion into the pancreas in patients with carcinoma of the ampulla of Vater.