保留十二指肠胰头切除术与胰十二指肠切除术治疗慢性胰腺炎的比较研究

目的:比较保留十二指肠胰头切除术(duodenum-preserving pancreatic head resection,DPPHR)与胰十二指肠切除术(pancreaticoduodenectomy,PD)治疗慢性胰腺炎的安全性及临床疗效。方法:回顾分析我院2004年1月至2010年12月接受DPPHR与PD的59例慢性胰腺炎病人,比较两种术式的术前数据、手术情况、术后并发症率、死亡率和术后住院天数等,用EORTC(European Organization for Research and Treatment of Cancer)QLQ-C30(Quality-of-Life Questionnaire-C30)V3.0中文版生活质量评分量表评价术后病人的生活质量。结果:共59例病人纳入研究,PD组37例,DPPHR组22例。两组术前特征无统计学差异。PD组与DPPHR组相比,在术中失血[(332±103)mL比(241±74)mL,P<0.05]、手术时间[(310±91)min比(249±71)min,P<0.05)]和术后住院天数[(14.3±9.0)d比(9.4±8.4)d,P0.05)和生活质量评分两组无统计学差异,但DPPHR组评分略优于PD组。结论:DPPHR组与PD相比在缓解慢性胰腺炎病人疼痛方面有效。两组生活质量无统计学差异。两组病人在术后并发症发生率和术后死亡率上并无统计学差异,同样安全可行,在术后住院天数、术中失血和手术时间,DPPHR组优于PD组。     

Whipple's resection-proximal pancreaticoduodenectomy (PD)

Pancreatic resection offers the potential for long-term cure in 15% of patients with pancreatic cancer. This article describes the author's technique of pancreaticoduodenectomy (PD), together with guidelines for disease staging, pre-operative work-up and patient selection. The role of neo-adjuvant and adjuvant chemotherapy is currently under evaluation and all patients who have a curative resection should be considered for entry into the ESPAC 3 trial that aims to establish the definitive role of adjuvant chemotherapy in pancreatic cancer.     

保留十二指肠的胰头近全切除术治疗胰头部良性肿瘤

目的:探讨保留十二指肠的胰头近全切除术治疗胰头部良性肿瘤的价值。
方法:回顾性分析2004年1月—2009年12月4例施行保留十二指肠的胰头近全切除术患者的临床资料,均保留了胃肠道的完整性、肝外胆道、胆囊和Oddi括约肌的功能,仅在壶腹周围和胆管后方保留有少量胰腺组织。
结果:病理证实1例为导管内乳头状黏液瘤,1例为内分泌肿瘤,2例为实性假乳头状瘤。术后2例发生胰瘘,经过非手术治疗治愈。围手术期无死亡。随访8~20个月,均未发现复发征象。
结论:对于胰头部良性肿瘤,特别是摘除困难的,保留十二指肠的胰头近全切除术是合理的选择。

     

Prospective randomised comparison of organ-preserving pancreatic head resection with pylorus-preserving pancreaticoduodenectomy

Background and aims In a prospective, randomised, control trial organ-preserving pancreatic head resection (OPPHR) was compared with pylorus-preserving pancreaticoduodenectomy (PPPD) to assess the advantages and disadvantages of each type of operation.Patients and methods Forty patients were allocated randomly to either the OPPHR (n=20) or the PPPD (n=20) group. The surgical data, postoperative complications, induction of diabetes mellitus, postoperative pain and quality of life 1 year, postoperatively, were considered.Results The two study groups of 20 patients were well balanced with regard to sex, age, chronic pancreatitis history and indication for surgery. The duration of the operation for OPPHR and PPPD was 142.5±4.9 and 278±6.9 min, respectively (P<0.05). The postoperative mortality in each group was zero. After OPPHR and PPPD, the morbidity was 0 and 40%, respectively (P<0.05). The duration of hospital stay was also significantly different: 8.05±0.9 vs 13.8±3.9 days (P<0.05). After 1 year the pain relief was effective in both groups, but three patients acquired diabetes mellitus after PPPD; the body weight had increased by 7.8±0.9 and 3.2±0.3 kg after OPPHR and PPPD, respectively (P<0.05).Conclusion The two procedures are equally safe and effective with regard to pain relief, but OPPHR is superior to PPPD not only in the operation data and morbidity, but also in the quality of life 1 year postoperatively. OPPHR should be regarded as a recommended procedure in the treatment of chronic pancreatitis.Presented at the 6th Congress of the European Hepato–Pancreato–Biliary Association, 25–28 May 2005, Heidelberg, Germany and published in abstract form as HPB (2005) 7(Suppl. No. 1):73.     

胰头癌联合门静脉区域切除的临床价值

目的探讨胰腺癌联合门静脉区域切除的临床价值，及评价区域切除术中肿瘤侵犯门静脉后以颈内静脉替代门静脉的效果。方法回顾性分析2000年1月-2003年1月间天津医科大学附属肿瘤医院6例行胰头癌联合门静脉切除并用颈内静脉替代门静脉修复的患者的临床资料。结果本组6例行胰头癌联合门静脉切除并用颈内静脉替代门静脉修复，术后病理均证实肿瘤侵犯累及门静脉和／或肠系膜上静脉，术后生存时间17～49个月，平均23．2个月，其中2例存活超过3年，最长的1例术后无瘤生存达4年1个月。结论对于胰头癌局部浸润肠系膜上静脉和／或门静脉，但无远处转移的患者，应积极行手术切除。胰腺癌联合门静脉切除后，行颈内静脉替代门静脉修复是一种有效的方法，可以提高手术切除率，减少术后并发症，延长患者生存期。     

Duodenum-preserving pancreatic head resection in patients with benign and borderline tumors of the pancreatic head

Background: Benign tumors of the pancreas are rare, accounting for only 1–2% of primary pancreatic lesions. Up to now, partial duodenopancreatectomy is still one of the established forms of treatment of benign tumors of the pancreas. We applied duodenum-preserving pancreatic head resection in 12 patients with benign pancreatic tumors to evaluate the feasibility, morbidity and recurrence rates after this less aggressive method. Methods: Between April 1984 and December 1999, 12 patients with benign and borderline tumors of the pancreatic head were operated on by duodenum-preserving pancreatic head resection. Results: All five patients with serous cystadenoma are free of recurrence 4.4 years after primary resection. One of two patients with mucinous cystadenoma and one of three patients with intraductal papillary mucinous tumor developed recurrent tumor within the former pancreatic head 5 years and 6 years, respectively, after the primary operation. Both patients were resected a second time. One of two patients with gastrinoma still has elevated serum gastrin levels. There was no hospital or long-term mortality. Conclusion: For a symptomatic serous cystadenoma, duodenum-preserving pancreatic head resection is a good alternative to partial duodenopancreatectomy. In borderline tumors with malignant potential, we would rather suggest a more radical duodenum-preserving segmental resection. A video clip (3 min) is attached demonstrating the basic steps of duodenum-preserving pancreatic head resection. Received: 1 March 2000 Accepted: 15 March 2000     

Portal vein resection during pancreaticoduodenectomy for pancreatic neuroendocrine tumors. An international multicenter comparative study

BackgroundThe role of portal vein resection for pancreatic cancer is well established but not for pancreatic neuroendocrine neoplasms. Evidence from studies providing information on long-term outcome after venous resection in pancreatic neuroendocrine neoplasms patients is lacking.MethodsThis is a multicenter retrospective cohort study comparing pancreaticoduodenectomy with vein resection with standard pancreaticoduodenectomy in patients with pancreatic neuroendocrine neoplasms. The primary endpoint was to evaluate the long-term survival in both groups. Progression-free survival and overall survival were calculated using the method of Kaplan and Meier, but a propensity score-matched cohort analysis was subsequently performed to remove selection bias and improve homogeneity. The secondary outcome was Clavien-Dindo ≥3.ResultsSixty-one (11%) patients underwent pancreaticoduodenectomy with vein resection and 480 patients pancreaticoduodenectomy. Five (1%) perioperative deaths were recorded in the pancreaticoduodenectomy group, and postoperative clinically relevant morbidity rates were similar in the 2 groups (pancreaticoduodenectomy with vein resection 48% vs pancreaticoduodenectomy 33%). In the initial survival analysis, pancreaticoduodenectomy with vein resection was associated with worse 3-year progression-free survival (48% pancreaticoduodenectomy with vein resection vs 83% pancreaticoduodenectomy; P < .01) and 5-year overall survival (67% pancreaticoduodenectomy with vein resection vs 91% pancreaticoduodenectomy). After propensity score matching, no significant difference was found in both 3-year progression-free survival (49% pancreaticoduodenectomy with vein resection vs 59% pancreaticoduodenectomy; P = .14) and 5-year overall survival (71% pancreaticoduodenectomy with vein resection vs 69% pancreaticoduodenectomy; P = .98).ConclusionThis study demonstrates no significant difference in perioperative risk with a similar overall survival between pancreaticoduodenectomy and pancreaticoduodenectomy with vein resection. Tumor involvement of the superior mesenteric/portal vein axis should not preclude surgical resection in patients with locally advanced pancreatic neuroendocrine neoplasms.     

联合门静脉/肠系膜上静脉切除的胰十二指肠术治疗胰头癌的疗效

目的:分析联合门静脉(PV)/肠系膜上静脉(SMV)切除的胰十二指肠切除术(PD)治疗胰头癌的临床疗效。方法:回顾性分析2010年1月—2013年7月手术治疗的72例胰头癌患者的临床及术后随访资料,其中40例肿瘤未累及肝总动脉、SMV、PV也无转移的患者行单纯PD术(PD组),32例单纯性累及PV/SVM的患者行联合PV/SMV切除的PD术(PV/SMV组),比较两组患者的围手术期指标及术后情况。结果:与PD组比较,PV/SMV组的手术时间(357.4min vs.289.3min)、术中出血量(851.2m L vs.641.5m L)均明显增加(均P0.05),但输血量(700.0m L vs.650.5m L),手术并发症发生率(18.75%vs.20.00%),1、2、3年生存率(50.00%vs.57.50%、31.25%vs.37.50%、21.86%vs.25.00%)以及中位生存时间(15个月vs.18个月)差异均无统计学意义(均P0.05)。结论:对于胰头癌患者应根据患者的实际情况选择适宜的手术方式,联合PV/SMV切除的PD治疗单纯性累及PV/SVM的胰头癌临床效果可靠,术后远期预后与PD手术适应证者相当。     

保留十二指肠胰头切除术在胰头部肿块治疗中的应用价值

胰头部与十二指肠关系密切,既往行胰头切除时同时切除十二指肠,被认为是不可避免的。1972年Beger等首先为慢性胰腺炎施行保留十二指肠胰头切除术（DPPHR,Beger手术）,有较高长时间的疼痛缓解率。Imaizimi等于1990年报道改良的Beger手术,施行保留十二指肠胰头全切除术（DPTPHR）,主要用于无须行淋巴结清扫的胰头部低度恶性肿瘤。保留十二指肠胰头切除仅切除胰头病灶,不破坏消化道解剖连续性和生理功能,改善了术后生活质量。近年来,保留十二指肠胰头切除术在临床上得到比较广泛的应用,令人关注。     

胰头癌扩大切除在胰头癌根治术中的作用

目的 探讨后腹膜软组织和淋巴结扩大清扫在胰头癌根治术中的作用.同时合并肠系膜上-门静脉切除的安全性和对生存率的影响.方法 2001年6月至2004年12月共施行56例胰头癌扩大切除术,根据术后病理检查有无淋巴结转移分为两组,A组:存在淋巴结转移,B组:未发现淋巴结转移;根据有无合并门静脉-肠系膜上静脉切除分为两组,Ⅰ组:未合并门静脉切除,Ⅱ组:合并门静脉切除.比较各组术后生存率.结果 56例胰头癌扩大切除术并发症发生率为30%,死亡率2%,术后1年,3年、5年生存率分别为63%,29%和16%.术后病理检查发现淋巴结阳性(A组)40例(71%),其中腹主动脉旁淋巴结阳性(A1组)11例;淋巴结阴性(B组)16例(29%),A、B两组术后生存率无明显差别,但腹主动脉旁淋巴结阳性组生存率较A、B组降低.合并门静脉切除17例,Ⅰ、Ⅱ组术后生存率无明显差别.切缘阳性5例,中位生存时间9个月,切缘阴性51例,中位生存时间23个月.结论 胰头癌扩大切除以及合并门静脉切除可以安全施行,对部分淋巴结阳性的胰头癌有一定意义,但未能提高腹主动脉旁淋巴结阳性病人的长期生存率,门静脉侵犯并非预后不良的组织学指标.     

Outcome after duodenum-preserving pancreatic head resection is improved compared with classic Whipple procedure in the treatment of chronic pancreatitis

BACKGROUND: There is no consensus in the surgical management of chronic pancreatitis (cP) as to whether techniques preserving the duodenum are superior to pancreatoduodenectomy. This prospective study compared the outcome of standard pancreatoduodenectomy (PD) and duodenum-preserving pancreatic head resection (DPPHR) in treatment of selected patients with cP. METHODS: Inclusion criteria for this prospective controlled, nonrandomized study were patients suffering from cP centered in the head and with severe pain. Seventy consecutive patients underwent DPPHR (n = 38) or, if there was suspicion of malignancy, classic PD (n = 32). A multidimensional, psychometric questionnaire was used to measure the quality of life (QoL). QoL was compared with that of the general German population. Pain intensity was evaluated on the basis of the frequency of pain attacks, analgesic medication, and self-assessed pain score. Assessment of endocrine and exocrine function as well as nutritional status included oral glucose tolerance test, fecal elastase, stool frequency, and body mass index. The median follow-up was 34 months. RESULTS: Multiple clinical characteristics did not differ between the two groups except for age (P =.04), the tumor marker carbohydrate antigen 19-9 (P =.02), and the parameter suspicion of malignancy. There was no hospital mortality. Surgical morbidity was 19% in the PD group and 8% in the DPPHR group (P =.60). PD resulted in a longer median hospital stay than DPPHR (19 vs 15 days, P =.04). Complications of adjacent organs were definitively treated in 100% after PD and in 97% after DPPHR. Postoperative pain intensity as self-assessed by the patients was significantly less in the DPPHR group (P <.001), whereas the frequency of acute episodes (P =.27) and analgesic medication (P =.43) did not differ between the two groups. After surgery, symptom and functional scales of the DPPHR group were significantly better than those in the PD group and were similar to those of the overall German population. No significant difference was found between the two groups with regard to endocrine and exocrine function. Postoperative increase of body mass index was significantly higher in the DPPHR group (P <.001). CONCLUSIONS: DPPHR provides better results in the treatment of cP than PD in terms of QoL, pain intensity as self-assessed by the patients, nutritional status, and length of hospital stay.     

保留胰腺功能的局部切除治疗胰头部良性肿瘤：附11例报告

目的　探讨对胰头部较大的良性肿瘤采用局部切除的可行性及手术方法。方法　通过对一组１１ 例胰头部良性占位性病变病例治疗的回顾性分析,说明局部切除术治疗该病例的优点及术中应注意的问题。结果　（１）该术式是可行的,与以往通常采用的Ｗｈｉｐｐｌｅ 手术相比,该术式操作简单对机体的侵袭性小,术后并发症发生率低,恢复快,消化功能保持良好;（２）对肿瘤与胆管关系密切者,先行胆管切开探查放置指引管可防止误伤胆管;（３） 采用胰腺创面与空肠行侧侧吻合术可有助于降低术后胰漏的发生。结论　该方法可作为治疗胰头部良性肿瘤的首选术式。     

Evidence-based pancreatic head resection for pancreatic cancer and chronic pancreatitis

OBJECTIVE: To review the current status of pancreatoduodenectomy for pancreatic cancer and chronic pancreatitis using evidence-based methodology. SUMMARY BACKGROUND DATA: Despite improved results of pancreatoduodenectomy over the recent years, the reputation of the Whipple procedure and its main modifications has remained poor. In addition, the current status of newer modifications of standard pancreatoduodenectomy is still under debate. METHODS: Medline search and manual cross-referencing were performed to identify all relevant articles for classification and analysis according to their quality of evidence. The search was limited to articles published between 1990 and 2001. RESULTS: The mortality rate of pancreatoduodenectomy has declined to less than 5% for chronic pancreatitis and 3% to 8% for pancreatic cancer. In contrast, overall morbidity rates remain high, ranging between 20% and 70%. Delayed gastric emptying represents almost half of all complications. The overall 5-year survival rate for patients with pancreatic cancer remains poor, ranging between 5% and 15%, with a median survival of 13 to 17 months. Mortality and morbidity are not related to the type of pancreatoduodenectomy; however, patients with pancreatic cancer tend to be at increased risk for complications. Extended lymph node dissection and portal vein resection can be performed with similar mortality and morbidity rates as standard procedures, but without apparent survival benefits in the long term. Major relief of pain is achieved in 70% to 100% of patients with chronic pancreatitis. CONCLUSIONS: Pancreatoduodenectomy and its main modifications are safe and effective treatment modalities, especially in experienced centers with a high patient volume. For chronic pancreatitis, surgical resection provides major relief of pain and thus increased quality of life. Overall survival for patients with pancreatic cancer is determined predominantly by the pathology within the resected specimen.     

胰头癌根治性胰十二指肠切除术若干问题的思考

作者在为胰头癌施行根治性胰十二指肠切除术的过程中,依据实践,结合文献复习,针对目前的某些热点问题,提出应避免主动性姑息性胰十二指肠切除术.提倡淋巴结廓清至少应达二站淋巴结,建议将肝十二指肠韧带骨骼化清扫和腹膜后组织切除作为根治性胰十二指肠切除术的常规手术步骤,无论有无证据支持第13组淋巴结(胰头后淋巴结)已发生转移,均应对可切除胰头癌进行限制性腹膜后组织切除.显露肠系膜上动脉并辨清钩突下缘和左侧缘与动脉的关系,是保证钩突切除完整性的技术要点.术前评估血管成像等影像学资料,可提高主动性联合血管切除的手术比例.胰肠吻合方式的选择,手术者的经验非常重要,从自己熟悉和熟练的二三种方法中选择最适合患者的方式,作者更偏向于胰肠端侧双层套入吻合法.并认为能量外科技术平台(电外科工作站)应用应慎重,仍须积累更多的经验再做评价.

Abstract：

According our practice of raical pancreaticoduodenectomy for pancretic head carcinoma and combined with these reviews, we suggested the active and palliative pancreaticoduodenectomy should be aviod. Skeletonization of hepatoduodenal ligament and the retroperitoneal resection should be the routine procedure in pancreticoduodenectomy, and at least invovle two regional lymph nodes. In addition, regardless of the metastase of No 13 lymph node, ristricted retroperitoneal resection for resectable pancretic carcinoma was needed. Exposured the superior mesenteric artery and distinguished inferior of uncinate process of pancrease with the artery, were the key point of the uncinate process of pancrease resection. Preoperative evaluation of angiography and other images, the ratio of activeness and combination with vessel resection would be improved. The style of pancreaticojejunostomy could be selected by the experience of the operator, we are apt to the double-deck invaginated pancreaticojejunostomy. Additionally, utilization of the electronic surgical workstation, should be careful and also need to accumulate more experience.     

Quality of life after pancreaticoduodenectomy for ductal adenocarcinoma of the pancreatic head

BACKGROUND: This study examined quality of life (QoL) after classical partial pancreaticoduodenectomy (PPD) and pylorus-preserving pancreaticoduodenectomy (PPPD) in patients with adenocarcinoma of the pancreatic head, and also evaluated the influence of extended lymphadenectomy (ELA). METHODS: Between January 1993 and March 2004, QoL was analysed in a prospective single-centre study that included 91 patients. Thirty-four patients underwent PPD and 57 had a PPPD. Seventy patients had an ELA and 21 underwent regional lymphadenectomy (RLA). QoL was assessed using the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire and a pancreatic cancer-specific module. Data were collected before operation and for 24 months after surgery. RESULTS: The overall 5-year survival rate was 18 percent for all patients and 21 percent in those who had an R0 resection. QoL was impaired for 3-6 months after surgery and then recovered to preoperative levels. There was no significant difference in long-term survival after PPD versus PPPD and ELA versus RLA. Patients who had ELA reported clinically significant higher levels of diarrhoea and pain. PPPD showed a disadvantage in terms of pain. CONCLUSION: The surgical techniques of resection and reconstruction did not affect QoL, but extended lymphadenectomy was associated with an impairment in QoL.     

胰头癌根治性胰十二指肠切除术后肿瘤早期复发的影响因素分析

目的:探讨胰头癌根治性胰十二指肠切除术后肿瘤早期复发的影响因素。方法:采用回顾性病例对照研究方法。收集2014年5月至2015年5月复旦大学附属肿瘤医院收治104例胰头癌行根治性切除术病人的临床病理资料;男62例,女42例;年龄为（61±10）岁。病人均行根治性胰十二指肠切除术。观察指标：（1）手术情况。（2）随访情况...