十二指肠乳头肿瘤局部切除术

十二指肠乳头肿瘤局部切除术具有维持人体正常的消化道通路、手术创伤小、并发症少等优点.但由于存在技术要求高、精细程度大、并发症处理困难、长期疗效有待循证医学的验证等问题,该手术未能普及.2000年1月至2012年6月上海交通大学医学院附属仁济医院实施了4例十二指肠乳头肿瘤局部切除术.患者术前均经ERCP检查确诊患有十二指肠乳头肿瘤,肿瘤直径＜1 cm,行十二指肠乳头活组织检查,3例为中至重度不典型增生,1例为腺癌,术前行CT、MRI检查均未见肿大淋巴结或远处转移,故选择行十二指肠乳头肿瘤局部切除术.术后病理检查示1例为十二指肠乳头腺瘤,3例为十二指肠乳头腺癌,切缘均为阴性,肝十二指肠韧带淋巴结无转移.术后除1例发生少量胰液漏外,其余均无并发症发生.术后随访3～24个月,4例患者均无肿瘤复发.严格掌握十二指肠乳头肿瘤局部切除术的手术适应证与手术操作规范是取得良好临床疗效的关键.     

十二指肠乳头肿瘤局部切除体会

目的 探讨十二指肠乳头肿瘤局部切除的可行性.方法 回顾性分析我院2000年1月至2007年1月8例十二指肠乳头肿瘤局部切除的资料.结果 切口感染1例,无胰漏,胆漏等并发症发生;随访2～5年无复发.结论 局部切除对于十二指肠乳头腺瘤或早期十二指肠乳头腺癌是一种切实可行的方法.     

十二指肠降段(含壶腹)切除术治疗早期十二指肠乳头癌

目的 探讨十二指肠降段（含壶腹）切除术治疗早期十二指肠乳头癌的临床疗效与安全性。方法 回顾性分析2015年8月至2016年9月期间同济大学附属杨浦医院普外科实施的3例十二指肠降段（含壶腹）切除术的临床资料。结果 3例手术均顺利完成,平均手术时间210 min。术后病理显示均为十二指肠乳头T1期腺癌,切缘阴性。患者术后恢复顺利,无胆、胰、肠吻合口瘘及出血等并发症发生。术后随访22～35个月,患者均健康生存,无肿瘤复发或转移,也无术后糖尿病、上行性感染、胆汁反流性胃炎等远期并发症。结论 对于早期十二指肠乳头癌,十二指肠降段（含壶腹）切除术是一种安全、可靠、有效的手术方式。     

十二指肠乳头肿瘤的CT诊断及治疗

目的 探讨十二指肠乳头肿瘤的CT表现及临床特征。方法 回顾性分析12例经病理学证实十二指肠乳头肿瘤的CT及临床资料。结果 12例中5例良性者均为腺瘤,7例恶性中5例腺癌,间质瘤及神经内分泌肿瘤各1例。5例腺瘤均呈边界较清楚的类圆形结节,CT平扫呈等或稍低密度,增强较均匀中等强化。5例腺癌中1例表现为十二指肠乳头不规则增厚,增强明显强化;4例表现为类圆形结节2例、不规则肿块2例,CT平扫呈等低密度,增强不均匀明显强化,3例见坏死囊变区,2例周边侵犯;1例间质瘤表现为类圆形肿块,CT平扫呈不均匀等、低密度,增强不均质强化;1例神经内分泌肿瘤表现类圆形等密度结节,增强明显均匀强化。12例均见程度不等的胆总管及主胰管梗阻,6例见程度不等的十二指肠不全梗阻,2例腺癌伴有胆总管结石及急性胰腺炎,其中1例伴有腹膜后单发淋巴结转移及腹腔积液。12例均以黄疸及右上腹痛为主要症状,并均接受手术治疗。3例腺瘤行内镜下肿瘤切除术,4例腺癌及1例间质瘤行 胰十二指肠切除术,其余行局部切除术,5例腺癌并行全身化疗6周期。术后随访6～18个月,1例腺瘤复发再次手术,其余均未见肿瘤复发及转移。结论 十二指肠乳头肿瘤以黄疸及右上腹痛为主要临床症状,往往早期出现胆胰管梗阻;CT对该类疾病的诊断有较大价值,早期手术切除预后较好。     

十二指肠乳头癌局部切除术疗效分析及手助腹腔镜技巧探讨

目的总结十二指肠乳头癌局部切除术的手术经验及临床效果。方法4例十二指肠乳头癌患者,均为T1期高分化腺癌,1例行十二指肠乳头癌局部切除术,3例行手助腹腔镜十二指肠乳头癌局部切除术。结果手术经过均顺利,无术后并发症发生,平均住院时间为21.2(15~30)d。均获随访,平均14个月,均无瘤生存,无复发。结论十二指肠乳头癌局部切除术用于治疗T1期高分化腺癌是一种安全、可靠的术式。     

十二指肠乳头内生性腺瘤内镜下诊断与治疗（附8例报告）

目的探讨十二指肠乳头内生性腺瘤的内镜下诊治方法。方法2005年6月～2008年10月对8例B超、MRCP影像学检查提示胆总管及肝内胆管不同程度的扩张,乳头开口及下段狭窄,进一步行ERCP及IDUS检查,发现病变并予以治疗。结果2例绒毛管状腺瘤伴上皮中度不典型增生及1例管状腺瘤行胰十二指肠乳头切除术：1例绒毛管状腺瘤术后病理局部癌变,3个月后肝转移行介入化疗及栓塞2次,16个月全身复查未见异常;1例管状腺瘤伴上皮中度不典型增生者术后病理局部印戒细胞癌,术后6、14个月随访全身复查未见异常。1例管状乳头状腺瘤行十二指肠乳头内镜下切除术后置入胆管支架内引流,6个月后复发并癌变,术后10个月死亡;1例绒毛管状腺瘤伴上皮中度不典型增生行十二指肠乳头内镜下切除术后置入胆管支架内引流,术后6、12个月复查未见异常;1例绒毛管状腺瘤伴上皮中度不典型增生术后病理与术前相同,且切除干净,未随访。1例绒毛状管状腺瘤伴高级上皮内瘤变,胆道塑料支架置入术,术后4个月反复胆道感染,内镜下更换为金属支架。1例乳头状腺瘤置入胆管支架内引流,术后失访。1例管状腺瘤拒绝治疗,电话至12个月随访无异常不适。结论十二指肠乳头内生性腺瘤临床罕见,且易于癌变,对乳头切开后黏膜层及肌层增厚的患者尤其有增生性病变者应常规多点取活检,避免乳头内腺瘤及恶性变病灶的遗漏,并对相关病灶及时内镜下或手术治疗。     

肿瘤局部切除在高龄十二指肠乳头部癌患者治疗中的应用

目的 探讨高龄十二指肠乳头部肿瘤患者局部切除的可行性及合理性。方法 回顾性分析1998-2004年在我院行局部切除治疗的12例高龄十二指肠乳头部肿瘤患者的临床资料。结果 12例患者术前B超和CT均显示肝内外胆管扩张。全组均采用经十二指肠肿瘤局部切除术，无手术死亡。术后病理活检结果发现1例低分化、10例中、高分化腺癌。11例（91.6％）患者获1-3年随访。1例低分化腺癌患者术后10个月肿瘤复发死亡；7例存活时间分别达13、14、22、26、27、30、36个月，余3例患者仍存活至今。结论 肿瘤局部切除术对高龄十二指肠乳头部癌患者是一种安全、有效、合理的术式选择     

腹腔镜十二指肠乳头肿瘤局部切除术（附2例报告）

目的探讨腹腔镜十二指肠乳头肿瘤局部切除的安全性和可行性。方法我院2010年9月和2012年6月完成2例完全腹腔镜下十二指肠乳头肿瘤局部切除术。术中应用肠壁似“∫”形切ISl防止肠腔狭窄,边切除边缝合方式重建胆肠及胰肠通道,并放置胰管内支撑管。结果2例顺利完成。病例1：手术时间195min,出血量220ml。术后48h排气,无并发症。术后病理：十二指肠乳头绒毛管状腺瘤,伴重度不典型增生,基底部切缘阴性。病例2：手术时间300min,出血量400ml。术后72h排气。术后病理：十二指肠乳头腺癌伴黏液细胞癌,基底部切缘阴性。结论腹腔镜十二指肠乳头肿瘤局部切除术安全、可行。     

十二指肠乳头肿瘤局部切除术的临床病理分析

目的 探讨十二指肠乳头部肿瘤的定性诊断与分期，提高十二指肠乳头部肿瘤局部切除术的疗效。方法 回顾性分析29例行局部切除的十二指肠乳头肿瘤的临床、病理资料。结果 钳夹活检对十二指肠乳头癌的诊断符合率为55．6％。T1期腺癌的中位生存期显著性长于T2、T3期腺癌(分别为57个月和31个月)。结论 肿瘤局部切除术适用于良性十二指肠乳头肿瘤以及早期的十二指肠乳头癌；选用肿瘤局部切除术时，不能单纯依赖于十二指肠镜检查和钳夹病理结果，还需依据术中探查、冰冻病理结果以及术后病理结果采取相应的措施。     

经脐单切口腹腔镜十二指肠乳头肿瘤局部切除术的临床应用（附1例报告）

2012年12月完成1例经脐单切口腹腔镜十二指肠乳头局部切除术（transumbilical single-incision laparoscopic transduodenal papillectomy, SILTDP）。3个trocar呈倒三角形置入,利用十二指肠侧壁似“∫”形切口,完全单切口腹腔镜下完成十二指肠乳头切除及胆胰管重建。手术顺利。手术时间330min,出血量100ml。术后1天离床活动,3天排气进食,7天出院。术后诊断十二指肠黏膜高级别上皮内瘤变,局部不排除黏膜内高分化管状腺癌。随访6个月,无不适。我们认为SILTDP安全可行。     

Successful resection of posterior mediastinal thyroid cancer by partial sternotomy combined with video-assisted thoracoscopy.

We report on a rare case of substernal thyroid carcinoma extending into the posterior mediastinum of a 48-year-old man. The tumor was resected by partial sternotomy and a small anterior thoracotomy, combined with video-assisted thoracoscopy. The pathological diagnosis was of a well differentiated papillary adenocarcinoma of the thyroid with mediastinal extension. The patient had an uneventful postoperative course and no recurrence of tumor 6 months after surgical treatment. We describe this surgical approach and discuss the advantage for cervicothoracic tumors extending into the posterior mediastinum.     

Laparoscopic pancreaticoduodenectomy to treat cancer of the ampulla of Vater.

OBJECTIVES: We explored the feasibility, difficulty, and indications for laparoscopic pancreaticoduodenectomy. METHODS: Since November 11, 2002, we have successfully completed 5 laparoscopic pancreaticoduodenectomies. Patients included 4 males and 1 female, average age 43 years. Three patients had duodenal papillary cancer, one had cancer of the head of the pancreas, and one had pancreatic mixed cancer (duodenal papillary cancer, hepatobiliary ductal adenocarcinoma). The average mass size was 1.5/1.8 cm to 2.6/2.5 cm. RESULTS: The pathology diagnosis was well-differentiated duodenum papillary adenocarcinoma in 3 patients, head of pancreas endocrine small cell carcinoma in 1, and duodenum papillary adenoma with malignancy ductal intermediate differentiation adenocarcinoma in 1. During surgery, average blood loss was 770 mL. Operation time averaged 528 minutes. The main difficulties during surgery were estimation and identification of pancreatoduodenal tumor resection and hepatoduodenal ligament venation changes. After surgery, 1 patient had a small amount of pancreatic leakage, another developed stress ulcer bleeding; both patients became normal after appropriate treatment. The fourth patient developed severe recurrence of pancreatitis with pneumonia and on the 39th day after surgery developed stress ulcer bleeding. This patient died during the second operation. CONCLUSION: Laparoscopic pancreaticoduodenectomy is a very difficult and risky operation. It requires ample clinical experience in traditional pancreaticoduodenectomy, perfect laparoscopic surgery technique, consultation and cooperate with the surgical team, updated laparoscopy equipment, and very strict surgical indications. For hospitals that meet the above conditions and requirements, laparoscopic pancreaticoduodenectomy is very safe and feasible.     

膀胱低度恶性潜能乳头状尿路上皮肿瘤的复发进展因素分析

目的探讨膀胱低度恶性潜能乳头状尿路上皮肿瘤(papillary urothelial neoplasms of low malignant potential,PUNLMP)的病理特点及复发进展因素。方法回顾性分析空军军医大学第一附属医院2009年2月至2019年2月收治的150例膀胱PUNLMP患者的病例资料。男118例,女32例。年龄57(20~93)岁。单发肿瘤112例,多发肿瘤38例。所有患者均行经尿道膀胱肿瘤切除术(transurethral resection of the bladder tumor,TURBT),术后136例行膀胱灌注化疗(吡柔比星方案61例、吉西他滨方案58例、表柔比星方案11例、丝裂霉素方案11例),14例未行膀胱灌注化疗。采用单因素和多因素logistic回归分析确定膀胱PUNLMP患者TURBT术后复发、病理进展的独立预测因素。结果本研究150例术后随访25.6(5.5~122.7)个月,21例复发(复发组),复发时间为23.1(2.2~108.3)个月;12例病理进展(进展组),分别进展为低级别非浸润性乳头状尿路上皮癌9例,高级别非浸润性乳头状尿路上皮癌1例,高级别浸润性尿路上皮癌1例,鳞癌1例,进展时间为21.5(2.2~56.3)个月。150例中,18例病理检查提示伴有内翻性生长模式的患者均未复发。复发组初发肿瘤数量1、2、≥3个者分别为7、4、10例,未复发组(129例)分别为105、10、14例,差异有统计学意义(P<0.05)。复发组和未复发组肿瘤长径分别为2.0(1.0~3.8)cm和1.6(0.3~5.0)cm,差异有统计学意义(P=0.040)。进展组初发肿瘤数量1、2、≥3个者分别为4、3、5例,未进展组(138例)分别为108、11、19例,差异有统计学意义(P=0.003)。进展组和未进展组肿瘤长径分别为2.3(1.0~3.8)cm和1.7(0.3~5.0)cm,差异有统计学意义(P=0.046)。单因素和多因素分析结果显示,肿瘤数量是膀胱PUNLMP患者TURBT术后肿瘤复发(OR=7.884,95%CI 2.815~22.082,P<0.05)和进展(OR=6.107,95%CI 1.659~22.473,P=0.006)的独立预测因素,而膀胱灌注化疗与术后复发(OR=1.026,95%CI 0.213~4.950,P=0.974)和进展(OR=2.100,95%CI 0.412~10.713,P=0.372)无相关性。结论膀胱PUNLMP患者TURBT术后肿瘤复发率约14%,其中约50%的患者发生病理进展,多进展为低级别非浸润性乳头状尿路上皮癌。初发肿瘤为多发是膀胱PUNLMP患者术后复发和进展的独立危险因素。膀胱灌注化疗不能降低膀胱PUNLMP患者复发和进展风险。     

Primary Malignant Duodenal Tumors

Fourteen patients with primary malignant duodenal tumors are studied. Twelve patients had adenocarcinomas and two patients had malignant lymphomas. Preoperative diagnostic procedures, such as radiographic study of duodenum with hypotonic duodenography, complete duodenoscopy with biopsy and artertiographic studies are discussed. Early diagnosis is the key for curative surgical treatment since these tumors seem to disseminate rather late. In patients with primary duodenal carcinoma the resectability rate was 66.7%-seven Whipple resections and one segmental resection. Only one patient in our series died after a Whipple resection. There was no mortality after other procedures. The five year survival rate was 14.2%. There is a definite correlation between regional lymph node involvement and survival time. The mean survival period after Whipple resection without lymph node invasion is 56.5 months in our series. The survival period after Whipple resection for adenocarcinoma with regional lymph node invasion (6 months) is identical to the survival after palliative internal derivations for duodenal adenocarcinoma (5.8 months). It is concluded that a positive peroperative frozen section of a regional lymph node should exclude resective procedures (except in patients who hemorrhage) because they have a higher mortality rate as derivative procedures. Fifty per cent of the patients treated for malignant duodenal lymphoma is tumor free two years after a radical surgical therapy combined with chemotherapeutical treatment from the early postoperative period.     

Long-term follow-up of patients with familial adenomatous polyposis undergoing pancreaticoduodenal surgery

Adenomatous polyps and adenocarcinomas of the periampullary region are the most common upper gastrointestinal neoplasms encountered in familial adenomatous polyposis (FAP) patients. Tumors arising from the liver, biliary tract, and pancreas have also been reported. The purpose of this study was to review the clinical outcome of FAP patients after pancreaticoduodenal surgery for periampullary neoplasms. Of the 61 individuals participating in our prospective FAP registry, 8 underwent surgical resection of periampullary neoplasms between 1987 and 1998. The charts of these individuals were reviewed for clinical indications, type of pancreaticoduodenal surgery, postoperative complications, and outcome. Of the 8 patients identified, 7 had pancreaticoduodenectomy and 1 had duodenotomy with ampullectomy. The indications for surgery were periampullary cancer (3), severe dysplasia within a duodenal villous tumor (4), and solid-pseudopapillary tumor of the pancreas (1). At the time of pancreaticoduodenal surgery, patients ranged in age from 29–65 years, and all but one had undergone colorectal surgery, on average 16 years beforehand. Pancreatic ascites after a pylorus-sparing pancreaticoduodenectomy was the only surgical complication. At a median follow-up of 70.5 months (range 37–162), 2 patients had died, neither from their periampullary neoplasm. The patient treated by local excision subsequently developed gastric cancer arising from a polyp and went on to gastrectomy. Another patient developed confluent benign jejunal adenomas just beyond the gastroenteric anastomosis almost 12 years after pancreaticoduodenectomy for severe dysplasia of a duodenal villous adenoma. Pancreaticoduodenectomy is a safe and appropriate surgical option for FAP patients with duodenal villous tumors containing severe dysplasia or carcinoma. Postoperative morbidity was minimal and there was no perioperative mortality. Good long-term prognosis can be expected in completely resected patients although subsequent proliferative and/or neoplastic lesions may still be detected in the gastrointestinal tract with prolonged follow-up. Presented at the Forty-Second Annual Meeting of The Society of the Alimentary Tract, Atlanta, Georgia, May 20–23, 2001 (poster presentation).     

Multicentric recurrence of intraductal papillary neoplasms of bile duct in the remnant intrahepatic bile duct after curative resection

IntroductionThere have been few reports on the prognosis of patients with intraductal papillary neoplasms of the bile duct (IPNB). Here we report a case of IPNB in a patient with early-stage carcinoma who had multicentric recurrence in the remnant hepatic bile duct after curative resection.Case presentationA 78-year-old man with hepatic dysfunction and cholestasis was referred to our hospital. Preoperative imaging studies revealed the presence of papillary tumors in the left hepatic duct and common hepatic duct, while no tumor lesions were detected in the right hepatic duct. This patient underwent left hepatectomy, extra-hepatic bile duct resection with biliary reconstruction, and regional lymphnode dissection. On the basis of pathological examination, this patient was diagnosed with multiple IPNB with early-stage adenocarcinoma with negative surgical margin. Postoperative work-up was periodically performed, indicating no evidence of recurrence, while the patient had sustained hepatic dysfunction, cholestasis, and repetitive cholangitis since the early postoperative period. Finally, recurrence in the remnant intrahepatic bile duct of the posterior segment was revealed by double balloon enteroscopy at 29 months after surgery. At 34 months after surgery, internal drainage stents were replaced in both endoscopic and percutaneous manners within the relapsed intrahepatic bile ducts to address repetitive cholangitis. These procedures enabled the patient to remain asymptomatic until death at 41 months after surgery.DiscussionMulticentric recurrence in the remnant intrahepatic bile duct after surgery may occur in IPNB patients with multiple lesions. An endoscopic approach may be useful in such cases, not only in the diagnosis of remnant intrahepatic bile duct recurrence but also for palliation of symptoms.     

原发性左心室肿瘤的病理特点分析

目的 总结原发性左心室肿瘤病理特点及其对外科治疗的影响.方法 回顾性分析中国医学科学院阜外医院2008年1月至2019年3月32例原发性左心室肿瘤患者的临床资料,其中男17例、女15例,平均年龄(33.88±17.89)岁.分析不同的左心室肿瘤病理类型对手术结果的影响.结果 32例左心室原发性肿瘤患者接受外科手术,术后...     

腹腔镜肾部分切除术（附160例报告）

目的：介绍我院行腹腔镜肾部分切除术（LPN）的体会。方法：2004年1月～2009年11月采用腹腔镜经腹腔或后腹腔途径对160例肾肿瘤患者行LPN。局限性肾透明细胞癌135例,乳头状肾细胞癌6例,嫌色细胞癌2例,嗜酸细胞腺瘤2例,肾血管平滑肌脂肪瘤15例,肿瘤直径4．1cm（2．0～6．0cm）。左侧86例,右侧74例。观察手术时间、术中出血量、住院大数、并发症及手术效果。结果：160例手术均顺利完成。平均手术时间70min（40～150min）,152例患者平均血管阻断时间26min（20～55min）,8例患者未阻断肾血管。术中平均出血量75ml（10～300m1）。4例术后出现迟发出血,予以保守治疗。2例术后出现漏尿。平均住院时间7．5天（6～15天）。随访2～70个月肿瘤无复发。结论：LPN安全、有效,对肿瘤压迫集合系统的,腔镜下缝合也是安全有效的,随着手术技术的熟练,对复杂肾肿瘤行LPN,肾脏功能保留和肿瘤控制效果逐渐提高。     

Partial nephrectomy: the rationale for expanding the indications

Background We report preliminary results of partial nephrectomy for renal tumors of ≥4 cm in 39 patients with the intent of extending the indications for kidney-sparing surgery. Methods From July 1989 to October 2001, 39 patients underwent a partial nephrectomy for renal cortical tumors >4 cm in maximum diameter. Fourteen (36%) had the procedure performed for essential reasons, and 25 (64%) had an elective kidney-sparing operation. We evaluated tumor location and histology, perioperative renal function, and postoperative complications. Results There were 20 conventional clear-cell (51%), 13 papillary (33%), 4 chromophobe (10%), and 3 oncocytomas (8%) with a median tumor size of 5 cm. After a median follow-up of 13 months, 36 patients had no evidence of disease, 1 patient had died as a result of other causes, and 2 patients who had essential operations were alive with disease. Twenty-three patients (70%) maintained normal postoperative renal function. Of six patients with moderate preoperative renal dysfunction, five (83%) had no change in postoperative renal function and only one patient required short-term dialysis. Conclusions With careful patient selection, partial nephrectomy can be effectively used to treat patients with renal cortical tumors >4 cm in diameter. The benefits of this approach include the effective local tumor control while at the same time preserving maximum renal function. Presented at the Society of Surgical Oncology Meeting, Washington, DC, March 17, 2001.