慢性胰腺炎伴胰头部病变的外科手术处理

目的探讨慢性胰腺炎伴胰头病变患者的外科处理.方法回顾性总结分析了1998年10月至2001年12月收治27例慢性胰腺炎伴胰头病变患者的临床资料,其中:保留幽门的胰十二指肠切除(PPPD手术)14例(有2例慢性胰腺炎的患者术前已有门静脉栓塞),保留十二指肠胰头切除(Beger手术)2例,胰头部分切除、胰空肠侧侧吻合(Frey手术)2例.胰十二指肠切除(Whipple手术)9例.结果 2例慢性胰腺炎合并门静脉血栓的患者术前先行门静脉取栓,降低门静脉压力,然后再针对慢性胰腺炎实行外科手术,术后1例恢复顺利,另1例死于多器官脏器功能衰竭.总的院内并发症率25%,总院内死亡率4%,其中PPPD手术后院内并发症率21%,院内死亡率7%.结论慢性胰腺炎伴胰头肿大的患者的手术治疗应根据胰腺和邻近周围其它器官的形态学改变决定手术的方法,其结果不仅可以有效地治疗慢性胰腺炎,同时有助于提高胰头癌的诊治水平.     

24例慢性胰腺炎的外科治疗分析

目的回顾性的研究和探讨慢性胰腺炎的外科治疗方法。方法1999—10／2000—10共有24例慢性胰腺炎的病人接受了外科治疗。手术方法：保留幽门的胰十二指肠切除(PPW手术)14例，保留十二指肠胰头切除(Beger手术)2例，胰头部分切除、胰空肠侧侧吻合(Frey手术)2例，远端胰腺切除2例，胰十二指肠切除(Whipple手术)2例，胰腺假性囊肿侧侧空肠吻合2例。其中有2例慢性胰腺炎的病人术前已有门静脉栓塞。通常慢性胰腺炎的病人合并门静脉栓塞属手术禁忌，但我们术前将传统的用以治疗门脉高压的TIPPS(经颈内静脉干内门体分流)方法加以改进后先行门静脉取栓，然后再针对慢性胰腺炎实行外科手术。结果24例病人术后总并发症率17％，总死亡率4．2％，其中PPW手术后并发症率21％，病死率7％。术后并发症包括：胃排空障碍(8．3％)、肺炎(8．3％)、伤口感染(8．3％)、腹腔内脓肿(4．2％)、胰漏(4．2％)、术后胆管炎(4．2％)、糖尿病(4．2％)。其中2例慢性胰腺炎合并门静脉栓塞的病人术后1例恢复顺利，另1例死于多器官脏器功能衰竭。该方法迄今为止国内外尚无类似报道，该尝试或许可以为治疗慢性胰腺炎提供一种新的方法。结论掌握好慢性胰腺炎手术适应征，慢性胰腺炎的外科治疗是安全的，且近期内十分有效。     

19例胰管结石手术经验探析

目的：探讨胰管结石诊断和手术治疗方法的选择。方法回顾性分析重庆荣昌县中医院2006年1月－2014年9月收治的19例胰管结石患者的临床资料。所有患者均通过影像学检查（B 超、CT 及磁共振胰胆管造影）得到诊断。19例患者均伴有慢性胰腺炎，3例伴有糖尿病，2例伴有黄疸，1例伴有胆道出血，1例伴有胰头癌。结果19例患者均采取手术治疗，其中胰管切开取石、胰管空肠吻合5例，胰十二指肠切除9例，单纯行胰体尾部切除术3例，保留十二指肠的胰头切除2例。结论外科手术是治疗胰管结石最常用，也是重要和最终手段。应根据患者的的实际情况进行充分分析选择，制订个性化的手术方案，从而保证手术的成功率，改善患者的生存质量。     

青少年慢性胰腺炎的诊断及外科治疗

目的探讨青少年慢性胰腺炎的临床特点、诊断及外科治疗.方法回顾性分析1993年3月～ 2001年3月手术治疗的7例青少年慢性胰腺炎患者的临床资料.结果青少年患者大多存在先天性胰胆管发育异常(胰腺分裂1例,胰胆管合流异常1例,胆总管囊肿2例).主要症状为反复上腹痛.B超、CT、ERCP和超声内镜(EUS)等影像学检查有助于早期诊断,其诊断阳性率分别为57.1%(4/7)、71.4%(5/7)、100%(5/5)和100%(4/4).7例患者均接受了手术治疗,其中行胰头部分切除、胰管空肠侧侧吻合术(Frey's)1例,胰管切开取石、胰管空肠侧侧吻合术3例(其中Partington's术式2例,Puestow's术式1例),Oddi括约肌切开成形术1例,胆总管囊肿切除、肝管空肠Roux-en-Y吻合术 + 保留十二指肠的胰头切除术(DPPHR)2例.术后近期腹痛均缓解.所有患者均获随访,随访时间2 ～ 9年,平均4.7年.1例于术后8个月症状复发,再次手术行胰尾切除,症状缓解.多数患者疗效满意.结论青少年慢性胰腺炎的病因不同于成人慢性胰腺炎,手术时机的掌握和手术方法的选择对患者的生活质量和疾病进程的控制至关重要.     

胰腺癌中孤立的门静脉受累是否为手术切除的反指征

为了评估接受门静脉切除(PVR)的胰腺癌 患者并发症发生率、死亡率和总体生存情况。本研究前瞻性地调查了1983年10月至1995年8月间332例组织学诊断为胰腺癌并接受胰腺切除的患者资料。其中58例(17%)合并孤立的门静脉受累,并接受了连同PVR的胰腺切除。以同期接受不需PVR的治愈性胰腺切除患者作为对照。 手术方式包括胰十二指肠切除、全胰切除或远侧胰腺次全切除。两组患者手术时年龄和性别比相似。PVR组中38例行门静脉直接端端吻     

缩小的胰切除术

该胰切除术是胰头十二指肠和胰尾部切除的术式,是为了减少术后机能障碍和不良主诉,确立保存邻近胃和脾的术式。作者在1981～1984年施行28例胰切除术,其中15例(胰岛癌2例、慢性胰腺炎13例)是保存脾的胰尾切除;13例(胰头癌4例、慢性胰腺炎9例)是保存胃幽门的胰头十二指肠切除术。前者从胰把脾动静脉剥离保存脾脏;后者保存右胃大网动静脉。距离幽门3cm肛侧切除十二指肠,再次建立胰空肠端端吻合,     

青少年慢性胰腺炎的诊断及外科治疗

目的探讨青少年慢性胰腺炎的临床特点、诊断及外科治疗。方法回顾性分析1993年3月～2001年3月手术治疗的7例青少年慢性胰腺炎患者的临床资料。结果青少年患者大多存在先天性胰胆管发育异常(胰腺分裂1例,胰胆管合流异常1例,胆总管囊肿2例)。主要症状为反复上腹痛。B超、CT、ERCP和超声内镜(EUS)等影像学检查有助于早期诊断,其诊断阳性率分别为57．1％(4／7)、71．4％(5／7)、100％(5／5)和100％(4／4)。7例患者均接受了手术治疗,其中行胰头部分切除、胰管空肠侧侧吻合术(Frey's)1例,胰管切开取石、胰管空肠侧侧吻合术3例(其中Partington's术式2例,Puestow's术式1例),Oddi括约肌切开成形术1例,胆总管囊肿切除、肝管空肠Roux-en-Y吻合术 保留十二指肠的胰头切除术(DPPHR)2例。术后近期腹痛均缓解。所有患者均获随访,随访时间2～9年,平均4．7年。1例于术后8个月症状复发,再次手术行胰尾切除,症状缓解。多数患者疗效满意。结论青少年慢性胰腺炎的病因不同于成人慢性胰腺炎,手术时机的掌握和手术方法的选择对患者的生活质量和疾病进程的控制至关重要。     

慢性胰腺炎的外科治疗及术式选择

目的 分析慢性胰腺炎（CP）外科治疗效果,探讨如何合理选择手术方式.方法 回顾性分析2007年1月至2011年12月哈尔滨医科大学第一附属医院手术治疗的54例CP患者的病例资料.结果 本组54例CP患者均行手术治疗,其中8例行单纯减压引流术（Partington术）;13例行切除术,包括7例胰十二指肠切除术（PD）、4例胰体尾部联合脾切除术、1例胰体尾部切除术（DP）及1例胰十二指肠联合胰体尾部切除术;12例行切除＋减压引流术,包括7例Beger术及5例Frey术;21例行其他手术（15例胰腺假性囊肿空肠吻合术,4例剖腹探查、胰腺组织活检术及2例胃空肠吻合、胆总管空肠吻合术）.术后病理证实4例CP已合并癌变.12例出现各种术后并发症,均经非手术治疗而治愈,无院内死亡病例.44例（81.5％）获得随访,随访时间2～ 67个月.42例术前明显腹痛者中36例（85.7％）获得持续缓解;术后新发糖尿病1例,无新发脂肪泻病例.结论 对于具备外科手术指征的CP患者,应以最大程度地保留胰腺内、外分泌功能为目的,遵循个体化治疗原则,合理选择手术方式,同时要兼顾手术的安全性及有效性.     

胰管结石的手术治疗

目的 探讨胰管结石的手术治疗方法。方法23例慢性胰腺炎伴胰管结石患者,14例行胰管切开取石、胰管空肠侧侧Roux-en—Y吻合术（2例有黄疸者加做胆管内引流术）,4例行胰体尾切除术（其中2例加做胰肠’吻合术）,1例行胰管成型取石术。4例因胰头肿大行胰十二指肠切除术（2例术后证实为胰头癌）。其中16例术中应用激光碎石。结果术中见23例主胰管直径0．8～2．0cm,多发结石17例、单发结石6例。手术均成功,行激光碎石者碎石率100％。无手术并发症。术后随访,20例术前有上腹痛者,17例术后腹痛消失,3例减轻;9例合并糖尿病者,4例血糖恢复正常,2例胰岛素用量减少,3例糖尿病未得到控制;术后第3年出现糖尿病1例;5例合并脂肪泻者,2例脂肪泻消失,1例减轻,2例无明显变化。2例合并胰头癌患者分别于术后1a2个月、1a8个月死亡。结论手术治疗胰管结石疗效较好,但应合理选择适应证和手术方式。     

括约肌切开术或括约肌成形术治疗病理改变较轻 的慢性胰腺炎

内外科医师对慢性胰腺炎的处理常感棘手。文献报告某些手术用于一定的病例是有效的,如胰管-空肠侧侧吻合术(胰管扩张或呈“串珠”状时)、内引流手术(胰腺假性囊肿)、胰十二指肠切除或胰远端切除术(如病变局限于胰头、钩突或体、尾部)。但对疼痛严重而病变较轻患者,不宜采用上述手术方法。本文旨在评价应用扩大性括约肌切开术或扩大性括约肌成形术对这类患者的治疗效果。     

Benign pancreatic tumor treated with duodenum-preserving resection of the head of the pancreas. Case report

Cystic neoplasms of the pancreas constitute about 9% of all cystic lesions of the pancreas and less than 1% of all pancreatic neoplasms. Authors report the case of a 70 year-old woman with microcystic cystadenoma. Computed tomography (CT) scan of the abdomen diagnosed a 5 cm multilocular septated cyst, with calcifications in the context, localized in the head-uncinate process of the pancreas. The mass was well separated by a sharp cleavage plane with portal vein and superior mesenteric vessels. An endoscopic retrograde cholangiopancreatography (ERCP) showed cephalic symmetrical stenosis (diameter: 3 mm) of the main pancreatic duct (MPD), mildly dilated in the remaining tract (diameter: 6 mm). An intra-operative biopsy of the cystic wall had been performed. Therefore, it was decided to proceed with a duodenum-preserving resection of the head of the pancreas (DPPHR), including stenosis tract of the MPD in the surgical specimen. The reconstructive procedure consisted, by i.v. jejunal loop transposition, of a side-to-side pancreatico-jejunostomy, including in the anastomosis both corpocaudal stump and the resection cavity of the pancreatic head, and an end-to-side Roux-en-Y jejuno-jejunostomy. With respect to long-lasting pain relief and preservation of the endocrine and exocrine functions of the pancreas, duodenum-preserving resection of the head of the pancreas is a highly effective surgical procedure with low early and late morbidity and mortality due to limited surgical resections. This technique, introduced into surgical practice in 1972 by Beger, is indicated in patients with chronic pancreatitis with an inflammatory mass in the head of the pancreas. The authors conclude that this procedure can also be performed in cases of pancreatic benign tumors, such as microcystic cystadenoma. Advantages of this technique make DPPHR an attractive alternative to pylorus-preserving pancreatico-duodenectomy (PPPD).     

Is a Whipple operation in chronic pancreatitis still a current procedure?

Until the eighties, the surgical procedure of choice in chronic pancreatitis with an inflammatory mass in the head of the pancreas has been partial duodenopancreatectomy (pDP). Since neither stomach, duodenum nor the common bile duct are directly involved in the inflammatory process of the pancreas, the Whipple's procedure (pDP) might lead to overtreatment. Therefore, duodenum-preserving pancreatic head resection (DPPHR), developed by Beger in 1972, has become in several centers the standard procedure for patients with an inflammatory enlargement of the head of the pancreas. We reviewed the literature of the last ten years and evaluated the different surgical procedures for pancreatic head resection. Comparing pDP and DPPHR. Whipple procedure has a higher hospital mortality (3.2% versus 0.6%), a higher late mortality (22% versus 8.4%), a higher morbidity and a higher incidence of a new "surgical" diabetes (17.6% versus 2%). With regard to relief of pain long-term investigations show totally pain-free patients after pDP in 72%, after pylorus-preserving duodenopancreatectomy (PPDP) in 82% and after DPPHR in 89%. Furthermore, other disadvantages of PPDP are the high rate of gastric outlet dysfunction (17% on average with a range of 4-32%) and the high rate of marginal ulcers (8.4% on average with a range of 5-11%). In summary, we conclude that in patients with chronic pancreatitis and an inflammatory enlargement of the pancreatic head. DPPHR is the procedure of choice. Whipple's procedure should only be performed if a suspicion of malignancy is suspected or, secondly, if a patient suffers from persistent pain (5%) after DPPHR.     

Duodenopancreatectomy versus duodenum-preserving pancreatic head excision for chronic pancreatitis.

BACKGROUND: The aim of this study was to compare two surgical procedures in the treatment for chronic pancreatitis (CP): pancreatoduodenectomy resection (classical Whipple - PD procedure, or pylorus-preserving - PPPD) to duodenum-preserving pancreatic head excision with longitudinal pancreatojejunoanastomosis (DPPHE/PJA), to define the advantages of each procedure with regard to postoperative complications, pain relief, and the quality of life. MATERIAL AND METHOD: 104 consecutive patients were included into this study. Duodenopancreatectomy was chosen when the head pancreatic mass was present or pancreatic cancer could not be ruled out (48 patients); otherwise DPPHE/PJA was performed (56 patients). Quality of life was measured prospectively on two occasions, before the procedure and during follow-up (median 39 months after surgery) using the European Organization for Research and Treatment of Cancer (EORTC) Quality-of-Life Questionnaire (QLQ-C30). The test was re-evaluated for patients suffering from CP. Pain intensity was quantified using a specially designed pain score. Early postoperative morbidity and mortality were assessed and evaluated in both groups of patients. RESULTS: Total pain score decreased significantly after surgery in both groups of patients. During the follow-up period, the global quality of life improved by 30.4% in the DPPHE/PJA group, and by 23.2% in the PD/PPPD group. Postoperative morbidity and mortality were higher in the resection group, but the differences were not significant. CONCLUSIONS: Both surgical procedures led to significant improvement in the quality of life and pain relief after surgery for CP. The EORTC QLQ-C30 was found to be a valid and readily available test for quality-of-life assessment in patients with CP.     

Duodenum-preserving head resection in chronic pancreatitis

A duodenum-preserving head resection was performed in 295 patients with chronic pancreatitis and an inflammatory mass in the head of the pancreas. Ninety-four percent of patients suffered severe pain syndrome, 48% had a common bile duct stenosis, 17% a vascular obstruction in the portal vein and splenic vein branches, and 6% had a severe stenosis of the duodenum. Surgical resection of the inflammatory mass in the head of the pancreas was indicated after a medical treatment of 4.1 years (median). Subtotal resection of the head of the pancreas, including the inflammatory mass, resulted in decompression of the narrowed common bile duct segment, decompression of the pancreatic main duct, and the relief of duodenum stenosis, as well as a relief of portal hypertension. The mean hospitalization time was 13 days, frequency of re-operation 5.8%, and hospital mortality 1.02%. Seventy-nine percent of patients experienced long-lasting pain relief and 11% reported a significant and long-lasting reduction of pain; late morbidity proved to be low. In comparison to the Whipple procedure the duodenum-preserving head resection has the advantage of preserving the stomach, duodenum and biliary tract.     

Appraisal of the Imaizumi modification of the Beger procedure: the TWMU experience

Background/purpose

We developed the Imaizumi modification of the Beger procedure, a duodenum-preserving pancreatic head resection. The Imaizumi modification allows for removal of more of the subtotal pancreatic head than in the conventional Beger procedure, including the intrapancreatic bile duct, for chronic pancreatitis with common bile duct stenosis. A retrospective study was performed to evaluate the efficacy of the Imaizumi modification compared to a pylorus-preserving pancreaticoduodenectomy (PPPD), based on the early and late postoperative results.

Methods

A group of 14 patients who underwent the Beger procedure with the Imaizumi modification to treat chronic pancreatitis from November 1997 to December 2005 was investigated retrospectively. This group was compared to a group of 21 patients who underwent PPPD from November 1997 to December 2003. The median follow-up period was 3.6 years (range 3.1–5.7 years) for the Imaizumi modification group and 4.0 years (range 3.0–8.3 years) for the PPPD group.

Results

A pancreatic fistula formed in 7% of the Imaizumi modification patients (PPPD 5%), pain relief was achieved in 92% (PPPD 94%), complete professional rehabilitation was achieved in 71% (PPPD 67%), insulin-dependent diabetes mellitus was present in 43 versus 36% before the procedure (PPPD 62 versus 38% before the procedure), and body weight improved in 79% (PPPD 48%). No significant differences were found between the two groups for the early postoperative complications and the late postoperative outcome 3 years after the procedure. However, the Imaizumi modification group exhibited an encouraging tendency to have a lower rate of new-onset exocrine and endocrine insufficiency than the PPPD group.

Conclusions

Our Imaizumi modification of the Beger procedure, including intrapancreatic bile duct resection, represents a useful alternative for the treatment of chronic pancreatitis with an inflammatory mass and bile duct stenosis in the pancreatic head.     

The anatomy of the parapancreaticoduodenal vessels and the introduction of a new pylorus-preserving pancreatoduodenectomy with increased vessel preservation

Classical pancreaticoduodenectomy for malignant tumors of the pancreatoduodenal region or chronic pancreatitis has recently been discussed in terms of the quality of life, associated with long-term postoperative morbidity. Pylorus-preserving pancreatoduodenectomy (PPPD) for the patient with chronic pancreatitis was first reported by Traverso and Longmire. Since that time, PPPD has become an accepted surgical procedure that is being increasingly indicated for certain malignancies. Herein, we report a PPPD that also preserves the parapancreatoduodenal vessels. The reasons why PPPD with the preservation of these vessels is significant are related to the length of the preserved duodenum and the reactions of gastrointestinal hormones. However, it may appear that this new PPPD poses a little greater risk of cancer recurrence, since the surgery is less radical than the usual PD. If the indications listed below are strictly observed, this operation should enable. The indications are: (1) chronic pancreatitis with tumor formation in the pancreatic head, (2) ampullary carcinoma, (3) inferion biliary duct carcinoma, (4) early duodenal carcinoma (all without pancreatic invasion), and (5) certain benign cystic tumors. Whether this operation should also be recommended for patients with small carcinomas or islet cell tumors arising in the head of the pancreas is now being investigated.     

Pancreaticoduodenectomy for chronic pancreatitis: a case report and literature review.

This is a case report of a patient with chronic pancreatitis who presented with biliary, duodenal and portal vein obstruction, a mass in the head of the pancreas, and a CA 19-9 level of 372 U/ml. Thus, the concern was raised as to the possibility of pancreatic cancer in this patient. We discuss the difficulties in the diagnosis of pancreatic cancer in patients with chronic pancreatitis and the treatment options available for patients with chronic pancreatitis where the significant findings involve the head of the pancreas. Finally, a brief review is given describing the pertinent literature on the surgical treatment of chronic pancreatitis and the current indications of pancreaticoduodenectomy for chronic pancreatitis.     

The impact of pylorus-preserving pancreatoduodenectomy on surgical treatment for cancer of the pancreatic head

Pylorus‐preserving pancreatoduodenectomy (PPPD) was reintroduced in 1978. This pylorus‐preserving modification was designed to minimize complications related to gastric resection, such as early satiety, marginal ulceration, and bile reflux gastritis, as well as diarrhea and dumping. Since 1978, PPPD has been performed preferentially for benign and malignant diseases of the periampullary region and pancreatic head. Some groups have argued against PPPD for cancer of the pancreatic head, because the pylorus‐preserving procedure is likely to compromise the field of resection and does not allow lymph node dissection of the peripyloric and perigastric groups. However, comparative survival rates after PPPD have been the same as, or better than, those with classic pancreatoduodenectomy, showing the rationale for PPPD as a radical resection procedure for cancer of the pancreatic head. PPPD can be performed with low mortality. Delayed gastric emptying, which is the most common complication in the immediate postoperative period after PPPD, is always transient. Many investigators have shown that body weight and the majority of nutritional parameters are better than after PD. PPPD does not appear to cause any negative outcomes. We conclude that PPPD is the surgical procedure of choice for cancer of the head of the pancreas.     

Carcinoma of the head of the pancreas

BACKGROUND/AIMS: Extended radical surgery might provide a survival advantage for patients with carcinoma of the head of the pancreas. METHODOLOGY: Between January 1980 and December 1999, 144 patients with carcinoma of the head of the pancreas were treated in a community hospital setting, of whom 69 patients who underwent radical surgery were retrospectively reviewed. Surgical procedures included standard pancreaticoduodenectomy (27 patients), pylorus-preserving pancreaticoduodenectomy (27 patients), and total pancreatectomy (15 patients). Portal vein resection was performed for 15 patients. Retroperitoneal lymphadenectomy was performed for 35 patients. No patients received adjuvant chemotherapy or radiotherapy. RESULTS: The surgical resection rate was 47.9% with a surgical mortality rate of 4.3% during this period. The overall 5-year survival rate after radical surgery was 16.1% with a median survival of 12 months. Seven patients survived five years, making 16.3% of the patients available for a more than 5-year follow-up. Long-term survivors had less than two positive lymph nodes in the posterior pancreatic head. Fourteen of 15 patients undergoing portal vein resection died within 21 months. One patient having no portal vein invasion microscopically survived 27 months without recurrence. CONCLUSIONS: Extended radical surgery did not prolong survival for patients with carcinoma of the head of the pancreas.     

Long-term follow-up study of surgical treatment for pancreatic stones

BACKGROUND/AIMS: With rare incidence and lack of extensive study for pancreatic stones, some issues in this area remain to be clarified. Surgical experience for pancreatic stones was presented, particularly focusing on the surgical risk and long-term outcome. We also evaluated the role of the pancreatic stone in pancreatitis and pancreatic cancer. METHODOLOGY: Data of patients with pancreatic stones are analyzed between 1984 and 2002, with a median follow-up period of 67 months. Clinical features and characteristics of pancreas and pancreatic stone are evaluated. Diagnostic image studies are compared. Outcome measures are surgical risks including surgical morbidity and mortality, and degree of long-term symptom control. RESULTS: There were 18 patients with pancreatic stones. The etiology was idiopathic in 50% of cases, and alcoholism in 33.3%. Abdominal pain was the most common (100%) clinical presentation. Pancreatic cancer was found in 4 (22.2%) patients. Most (61.1%) of the pancreatic stones were located in the pancreatic head. Only 1 patient had a single pancreatic stone, and 12 (66.7%) patients had more than 3 pancreatic stones. All the patients except one (94.4%) presented pictures of chronic pancreatitis. Surgical complication occurred in 2 (11.8%) patients, and surgical mortality in 1 (5.9%) resulting from pneumonia. Improvement of clinical symptoms after surgery was achieved in nearly all (93.8%) patients, including 56.3% free of symptoms, 25.0% much improvement and 12.5% mild improvement. CONCLUSIONS: Removal of pancreatic stones combined with surgical drainage of pancreatic duct or resection of pancreas might have symptomatic benefits. Surgical intervention is recommended for all patients with pancreatic stones, in terms of symptom relief, cancer risk and low surgical risk.