慢性胰头肿块型胰腺炎合并胰管结石的外科治疗疗效比较

目的比较不同外科方法治疗慢性胰头肿块型胰腺炎合并胰管结石的疗效。方法回顾性分析哈尔滨医科大学附属第一医院胰胆外科2004年1月至2011年1月期间收治的、并经病理学检查确诊的19例慢性胰头肿块型胰腺炎合并胰管结石患者的临床资料,根据术式不同,分为Beger组(n=9)和Frey组(n=10)。结果Beger组患者的手术时间、术中失血量、总并发症发生率、B级胰瘘发生比例、腹腔感染发生比例、胃排空障碍发生比例、总住院时间及住院费用均长于(高于)Frey组(P0.05)。术后2组患者均无围手术期死亡,无C级胰瘘发生,腹痛及黄疸全部缓解。术后18例获访,随访率为94.7%。随访时间5~12年、(8.6±2.5)年。2组患者术后5年疼痛缓解比例均为7/9,2组比较差异无统计学意义(P0.05)。随访期间,新发糖尿病2例(Beger组和Frey组各1例),新发脂肪泻2例(Beger组和Frey组各1例),2组新发糖尿病及脂肪泻比例比较差异均无统计学意义(P0.05)。随访期间无死亡、胰管结石复发、癌变及再次手术病例。结论对于慢性胰头肿块性胰腺炎合并胰管结石患者,采用Frey术与Beger术的效果相当,但Frey术的术后恢复优于Beger术。     

Frey手术治疗慢性胰腺炎的临床疗效分析

目的探讨Frey手术治疗慢性胰腺炎(CP)的疗效。方法回顾性分析我院2000年6月至2009年10月期间32例行Frey手术的CP患者临床资料,观察围手术期并发症发生率和疼痛缓解率,着重了解胰腺内、外分泌功能。结果 32例患者术后无死亡病例。围手术期并发症发生率为9.4%(3/32)。其中2例患者出现伤口脂肪液化,经对症处理后痊愈;1例患者术后第4天出现胰瘘,经禁食、营养支持治疗康复出院。住院时间(11±2)d。术后患者均获随访,随访时间平均43个月,16例(50.0%)患者疼痛完全消失,14例(43.8%)患者疼痛明显缓解,2例无效,术后疼痛缓解率为93.8%。5例糖尿病患者术后病情无加重,术后新发糖尿病患者3例。3例术前伴消化不良、脂肪泻患者中,1例术后口服胰酶制剂后症状缓解,2例无变化;新增脂肪泻患者4例。结论在严格掌握手术指证的前提下,采用Frey手术治疗CP是一种安全、有效的方法。     

改良保留十二指肠胰头切除术治疗慢性胰腺炎的疗效分析

目的:观察改良保留十二指肠的胰头切除术(改良Beger手术)对伴胰头炎性肿块的慢性胰腺炎病人的治疗效果。方法:回顾性分析自2004年1月至2010年12月,在我院胰腺外科接受改良Beger手术治疗的51例伴胰头炎性肿块的慢性胰腺炎病人的临床资料,并对病人术后疼痛症状、生活质量及内分泌功能等进行随访。结果:无手术死亡病例,术后并发症发生率为15.7%,其中胰漏3例,胆漏2例,十二指肠漏1例,腹腔出血1例,切口裂开1例。术后6个月,病人疼痛得到明显缓解,EORTC QLQ-C30疼痛评分由(64.3±5.8)降至(12.5±3.7)(P<0.01),生活质量获显著提高,GLQI生活质量评分由(70.1±5.8)增至(86.4±6.6)(P<0.01);病人内分泌功能未受影响,无新增糖尿病病例。结论:采用改良Beger手术治疗伴胰头炎性肿块的慢性胰腺炎是安全、有效的。     

保留十二指肠的胰头切除治疗慢性胰腺炎(文献综述)

保留十二指肠的胰头切除术适用于治疗慢性胰腺炎引起的顽固性疼痛,解除肿大的胰头对邻近器官的压迫,畅通胰液引流.介绍了Beger、Frey和Warren三种术式,其中更以Frey术式操作简单,保留了足够的胰腺组织,手术死亡率、并发症和糖尿病发生率均较Whipple胰十二指肠切除术为低.     

Beger及Frey手术在胰腺良性疾病及低度恶性肿瘤治疗中的应用

目的 总结Beger及Frey手术的手术技巧及研究应用的新进展.方法 分析、评价近年来Beger及Frey手术在胰腺良性疾病及低度恶性肿瘤中的应用技巧,并对其临床疗效研究进展的文献进行综述.结果 随着器官保存观念被广泛接受,Beger及Frey手术被广泛应用,与传统标准术式比较,其具有保留消化道完整、切除胰腺组织少、手术创伤小、术后生存质量高及手术安全性好的优点,但是长期疗效优势随着时间延长而减弱.结论 Beger及Frey手术是相对安全、疗效确切的术式,可作为治疗胰腺良性疾病及低度恶性肿瘤特别是慢性胰腺炎的标准术式.但尚需进一步探索研究,降低术后并发症发生率及提高远期疗效.     

慢性胰腺炎病变类型与手术方式的选择

目的 探讨慢性胰腺炎手术治疗方案的选择.方法 回顾性分析华西医院2009年3月至2013年11月收治的慢性胰腺炎手术患者229例,总结其临床资料与随访信息,比较手术治疗疗效.结果 229例患者依据不同病变类型分别行引流术或切除术两类手术.57例行纵向胰管切开胰肠吻合术,118例行胰头部分切除胰肠吻合术(Frey法105例,Berne法6例,Beger法7例),7例行胰十二指肠切除术,21例行胰体尾切除术,26例行其他手术.术后疼痛缓解率89.3％,总并发症发生率19.6％.结论 慢性胰腺炎的不同术式有其特定适应证,应根据其病变类型选择手术方式以保证手术疗效.     

慢性胰腺炎伴胰管狭窄与扩张的外科治疗

目的：探讨慢性胰腺炎伴胰管狭窄与扩张的诊断和治疗方法。方法：回顾性分析27例慢性胰腺炎伴胰管狭窄与扩张的临床资料。结果：本组B超、CT、MRI及内窥镜胰胆管造影检查的诊断阳性率分别为89％、100％、100％和100％。27例均接受了手术治疗，其中Partington手术12例，胰尾切除3例，保留幽门的胰十二指肠切除4例，Beger手术4例，Frey手术2例，胰腺囊肿空肠吻合术2例。手术并发症发生率为11％。手术后24例(89％)疼痛获得缓解，体重增加18例(78％)，5例(33％)糖尿病症状显著缓解。结论：选择合理的诊断方法和适当的手术方法，采取综合治疗，对于改善患者的生活质量和控制病程的进展十分重要。     

慢性胰腺炎的手术方式选择

目的探讨慢性胰腺炎外科治疗的手术方式选择。方法回顾性分析2000年1月至2013年8月北京大学第一医院收治的80例慢性胰腺炎患者的临床资料,其中胰管扩张〉7mm、伴或不伴胰管结石者38例,胆总管扩张者44例,伴有胰头部炎性肿块者32例,脾大伴食管胃底静脉曲张3例。根据患者临床症状及影像学表现综合判断手术指征及选择手术方式。根据VAS疼痛分级标准评估患者术后疼痛缓解及复发。通过门诊复查、信件或电话访谈方式随访,随访时间截至2013年12月。结果胆肠吻合术27例,Partington—Rochelle术24例,Partington—Rochelle术＋胆肠吻合术6例,胰十二指肠切除术7例,胰体尾切除术4例,Beger术3例,脾切除术3例,Frey术＋胰头内胆管开窗术3例,Frey术2例,胆总管探查＋T管引流术1例。63例以腹痛为主要表现的患者术后腹痛缓解率达95．2％（60／63）。围手术期1例患者因腹腔感染并发MODS死亡。围手术期并发症7例,包括腹腔感染3例、胰瘘2例、胆瘘1例、腹腔出血1例,所有并发症经保守治疗治愈。79例患者获得随访,平均随访时间为58．6个月（4～156个月）。30例腹痛复发或出现新发腹痛症状,总复发率为38．O％（30／79）。32例胰头部炎性肿块患者中,17例因胆管扩张合并梗阻性黄疸仅行胆肠吻合术,术后腹痛复发率达9／17;另15例分别行胰十二指肠切除术、Beger术或Frey术,术后腹痛复发率为1／15。41例胰腺萎缩或弥漫炎性改变患者中,10例仅行胆肠吻合术者腹痛复发率达7／10;30例Partington-Rochelle术患者腹痛复发率为33．3％（10／30）。结论对胰管扩张的慢性胰腺炎患者,充分引流可有效缓解症状;对于胰头部炎性肿块慢性胰腺炎患者,应选择手术切除或联合术式。     

慢性胰腺炎保留十二指肠的胰头切除术

以严重疼痛为特征的慢性胰腺炎的手术效果一直有争论.Beger介绍一种保留十二指肠的胰头切除术,这种手术保留胃、十二指肠和胆管,次全切除胰头.改良的Partington-Rochelle术式即切除大部分胰头同时保留十二指肠的术式.为了比较两种术式的术后疗效,设计了一个前瞻性随机研究.病人和方法从1992年1月起,连续收集46例慢性胰腺炎病人随机分配到Beger组(n=20)和Frey组(n=22).选择病人的标准是胰头炎性肿块,严重和反复发作的疼痛,疼痛史至少持续一年,同时存在并发症(胆管狭窄、十二指肠狭窄).所有病人由胃肠病专家和外科医师组成的专门小组决定手术指征.两组病人年龄、性别、病理类型均无显著性差异.     

慢性胰腺炎手术治疗的术式选择

慢性胰腺炎是公认的临床难治性疾病,疾病导致的顽固性疼痛和内外分泌功能不足或丧失及各种并发症严重影响了患者的生活质量,同时存在的增生性改变也是潜在的致癌因素。因此,慢性胰腺炎的手术治疗不仅应改善患者的生活质量和纠正产生的并发症,而且应去除癌变的危险因素。我们知道,任何治疗包括手术并不能恢复胰腺功能或中断胰腺病变的进程,因此疗效的评价标志是疼痛的缓解和／或各种外科性并发症如梗阻性黄疸等能否解决。除了各种外科性并发症外,对具体的患者选用何种术式才能达到好的治疗效果,目前尚无可靠的数据或设计良好的随机对照试验研究来帮助外科医师做出抉择。因此,在外科治疗中找到合理选择手术术式的依据是急需解决的问题。现根据我们的经验和研究对慢性胰腺炎手术治疗中手术术式的选择作一讨论,供同道参考。     

Duodenum-preserving resection of the head of the pancreas in chronic pancreatitis. A prospective, randomized trial.

OBJECTIVE: Two techniques of duodenum-preserving resection of the head of the pancreas were compared in a prospective, randomized trial. The technical feasibility and effects on quality of life were assessed. SUMMARY BACKGROUND DATA: Drainage and resection are the principles of surgery in chronic pancreatitis. The techniques of duodenum-preserving resection of the head of the pancreas as described by Berger and Frey combine both to different degrees. The efficacy of both procedures has not been compared thus far. METHODS: Forty-two patients were allocated randomly to either Beger's (n = 20) or Frey's (n = 22) group. In addition to routine pancreatic diagnostic work-up, a multidimensional psychometric quality-of-life questionnaire and and a pain score were used. Assessment of endocrine and exocrine function included oral glucose tolerance test, serum concentrations of insulin, C-peptide, and HbA1c, as well as fecal chymotrypsin and pancreolauryl test. The interval between symptoms and surgery ranged from 12 months to 12 years, with a mean of 5.7 years. The mean follow-up was 1.5 years. RESULTS: There was no mortality. Overall morbidity was 14% (20% Beger, 9% Frey). Complications from adjacent organs were resolved definitively in 94% (90% Beger, 100% Frey). A decrease of 95% and 94% of the pain score after Beger's and Frey's procedure, respectively, and an increase of 67% of the overall quality-of-life index in both groups were observed. Endocrine and exocrine function did not differ between both groups. CONCLUSIONS: Both techniques of duodenum-preserving resection of the head of the pancreas are equally safe and effective with regard to pain relief, improvement of quality of life, and definitive control of complications affecting adjacent organs. Neither procedure leads to further deterioration of endocrine and exocrine pancreatic function.     

Comparison of Local Resection of the Head of the Pancreas Combined with Longitudinal Pancreaticojejunostomy (Frey Procedure) and Duodenum-Preserving Resection of the Pancreatic Head (Beger Procedure)

The etiology of pain in chronic pancreatitis may be ductal hypertension, increased parenchymal pressure, or neural damage. It is difficult to assess the severity of pain in this patient population, a problem made more challenging by the frequency of narcotic dependency. Therapeutic interventions developed to relieve the pain of chronic pancreatitis include denervation of the pancreas, decompression of the main duct of the pancreas, resection of part or all of the diseased pancreas, and reduction of pancreatic secretion. Operative intervention for patients with chronic pain is indicated when severe pain, complications of pain, or potential malignancy are present. The operations that consistently provide long-lasting pain relief all have in common resection of all or a portion of the head of the pancreas. Adverse effects on exocrine and endocrine function, nutrition, and quality of life are related to the amount of pancreas resected. The ideal procedure should be easy to perform, have a low morbidity and mortality rate, provide long-lasting pain relief, and not augment endocrine and exocrine insufficiency. No single operation fulfills this ideal. The local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy (LR-LPJ) proposed by Frey and the duodenum-preserving resection of the head of the pancreas (DPHR) proposed by Beger are discussed. The conceptualization, development, and technique of LR-LPJ are discussed, and comparisons of patient outcomes are made with the outcomes of other procedures for chronic pancreatitis.     

Long-term follow-up of a randomized trial comparing the beger and frey procedures for patients suffering from chronic pancreatitis

OBJECTIVE: To report on the long-term follow-up of a randomized clinical trial comparing pancreatic head resection according to Beger and limited pancreatic head excision combined with longitudinal pancreatico-jejunostomy according to Frey for surgical treatment of chronic pancreatitis. SUMMARY BACKGROUND DATA: Resection and drainage are the 2 basic surgical principles in surgical treatment of chronic pancreatitis. They are combined to various degrees by the classic duodenum preserving pancreatic head resection (Beger) and limited pancreatic head excision combined with longitudinal pancreatico-jejunostomy (Frey). These procedures have been evaluated in a randomized controlled trial by our group. Long-term follow up has not been reported so far. METHODS: Seventy-four patients suffering from chronic pancreatitis were initially allocated to DPHR (n = 38) or LE (n = 36). This postoperative follow-up included the following parameters: mortality, quality of life (QL), pain (validated pain score), and exocrine and endocrine function. RESULTS: Median follow-up was 104 months (72-144). Seven patients were not available for follow-up (Beger = 4; Frey = 3). There was no significant difference in late mortality (31% [8/26] versus 32% [8/25]). No significant differences were found regarding QL (global QL 66.7 [0-100] versus 58.35 [0-100]), pain score (11.25 [0-75] versus 11.25 [0-99.75]), exocrine (88% versus 78%) or endocrine insufficiency (56% versus 60%). CONCLUSIONS: After almost 9 years' long-term follow-up, there was no difference regarding mortality, quality of life, pain, or exocrine or endocrine insufficiency within the 2 groups. The decision which procedure to choose should be based on the surgeon's experience.     

Surgical treatment of chronic pancreatitis

Debilitating abdominal or back pain remains the most common indication for surgery in patients with chronic pancreatitis. The surgical approach to chronic pancreatitis should be individualized based on pancreatic and ductal anatomy, pain characteristics, baseline exocrine and endocrine function, and medical co-morbidity. No single approach is ideal for all patients with chronic pancreatitis. Pancreatic ductal drainage with pancreaticojejunostomy targets patients with a dilated pancreatic duct and produces good early postoperative pain relief; however, 30%–50% of patients experience recurrent symptoms at 5 years. Resection for chronic pancreatitis should be considered (1) when the main pancreatic duct is not dilated, (2) when the pancreatic head is enlarged, (3) when there is suspicion of a malignancy, or (4) when previous pancreaticojejunostomy has failed. Re-sectional strategies include pancreaticoduodenectomy, distal pancreatectomy, total pancreatectomy, duodenum-preserving pancreatic head resection (Beger procedure), or local resection of the pancreatic head with longitudinal pancreaticojejunostomy (Frey procedure). Superior results are obtained when the pancreatic head is resected, either completely (pancreaticoduodenectomy) or partially (Beger or Frey procedure). Although pylorus-preserving pancreaticoduodenectomy remains the gold standard resection procedure, there is evidence that newer operations, such as the Beger resection, may be as effective in regard to pain relief and better in respect to nutritional repletion and preservation of endocrine and exocrine function. Received: April 20, 2002 / Accepted: May 13, 2002 Offprint requests to: H.A. Reber     

Laterale Anastomosentechniken

Characteristic symptoms of chronic pancreatitis are difficult to manage conservatively. They include severe pain and endocrine and exocrine insufficiency. Surgical treatment with simple and extended draining procedures addresses pain relief and the management of chronic pancreatitis-associated complications of adjacent organs. Following the assumption that pancreatic duct changes with intraductal hypertension are the reason for pain, simple drainage procedures have reduced pain in up to 80% of patients, with low morbidity and mortality. In case of complications involving adjacent organs with inflammatory pancreatic head tumor and stenosis of the distal bile duct, extended drainage procedures with limited pancreatic head resection according to Frey and V-shaped excision of the ventral aspect of the pancreas have been performed successfully.     

Die duodenumerhaltende Pankreaskopfresektion

Chronic pancreatitis is an inflammatory disease characterized by the progressive conversion of pancreatic parenchyma to fibrous tissue. The most frequent causes are alcohol overconsumption and anatomic variants such as pancreas divisum, cholelithiasis, and individual genetic predisposition. The process of fibrosis with consecutive loss of pancreatic parenchyma leads to exocrine insufficiency and maldigestion and, in advanced stages of the disease, to diabetes mellitus. Beside exocrine and endocrine malfunction, mechanical complications occur such as the formation of pancreatic pseudocysts and duodenal and common bile duct obstruction. About 50% of patients with chronic pancreatitis need surgical intervention due to untreatable chronic pain. As recent investigations suggest that the head of the pancreas triggers the chronic inflammatory process, resection of this inflammatory mass must be regarded as pivotal in any surgical intervention. Radical techniques such as the Whipple procedure are undoubtedly successful regarding pain reduction but, even in its pylorus-preserving variant, associated with high postoperative morbidity due to a large loss of pancreatic parenchyma and the absence of duodenal passage. Thirty years ago, H.G. Beger described for the first time the technique of duodenum-preserving pancreatectomy, which better combines resection of the pancreatic head with low morbidity. Over the years, different variations of the original Beger technique (Frey, Izbicky, Berne modification) have been developed, and the excellent results obtained with these methods underline that organ-sparing techniques should be preferred in the surgical treatment of chronic pancreatitis.     

Duodenumerhaltende Pankreaskopfresektion

In chronic pancreatitis chronic pain is the most frequent indication for surgery. Because symptoms are often caused or maintained by an inflammatory mass in the head of the pancreas, resection procedures are superior to pure surgical drainage. The pancreatoduodenectomy (PD) and the duodenum-preserving pancreatic head resection (DPPHR) are safe and effective techniques resulting in long-lasting pain relief in about 80% of patients. Randomized controlled trials (RCTs) show initial functional advantages for the organ-preserving DPPHR compared to PD, but these advantages are lost during follow-up, most likely because neither operation prevents a progressive loss of exocrine and endocrine function. Nevertheless the less invasive DPPHR should be regarded as the procedure of choice. The technique of DPPHR described by Beger was modified by Frey to an extended drainage procedure with local head excision; the Berne modification offers a technically less demanding option with comparable extent of resection. While results in terms of pain relief, quality of life and organ function are comparable between the three DPPHR techniques, the technical aspect of a simpler procedure favors the Berne modification.     

Longitudinal V-shaped excision of the ventral pancreas for small duct disease in severe chronic pancreatitis: prospective evaluation of a new surgical procedure.

OBJECTIVE: The technique of longitudinal V-shaped excision of the ventral pancreas for small duct chronic pancreatitis is presented and its efficacy in terms of pain relief and improvement of quality of life is evaluated. SUMMARY BACKGROUND DATA: Small duct chronic pancreatitis has been regarded as a classical indication for more or less extensive resection, in which the therapeutic success of pain relief is offset by the considerable risk of significant perioperative mortality and morbidity and the burden of substantial loss of pancreatic function. METHODS: Thirteen patients with severe pain who were diagnosed with small duct pancreatitis (defined as maximal Wirsungian ductal diameter of 2 mm) underwent longitudinal V-shaped excision of the ventral pancreas. In addition to routine pancreatic workup, a multidimensional psychometric quality-of-life questionnaire and a pain score were used. Assessment of exocrine and endocrine function included fecal chymotrypsin and the pancreolauryl test as well as oral glucose tolerance, serum concentrations of insulin, C-peptide, and hemoglobin A1c. The interval between symptoms and surgery ranged from 12 months to 10 years (mean, 5.4 years). Median follow-up was 30 months (range, 12-48 months). RESULTS: There were no deaths. Overall morbidity was 15.4%. In 92% of patients, complete relief of symptoms was obtained. Median pain score decreased by 95%. Physical status, working ability, and emotional and social functioning scores improved by 40%, 50%, 67%,, and 75%, respectively. Global quality-of-life index increased by 67%. Occupational rehabilitation was achieved in 69% of patients. Exocrine and endocrine pancreatic function was well preserved. CONCLUSIONS: In small duct chronic pancreatitis, longitudinal V-shaped excision of the ventral pancreas is a safe and effective alternative to resection procedures. The new technique provides pain relief and improvement of quality of life, thus offering the benefit of a resection procedure without its burden.     

慢性胰腺炎的分型与术式选择

目的 探讨慢性胰腺炎的分型与术式选择及其外科治疗效果。方法 回顾性分析我院外科1983-2004年收治的54例慢性胰腺炎患者的临床资料,并将其分为慢性钙化性胰腺炎及慢性梗阻性胰腺炎两组。结果男性41例(76％),女性13例(24％),平均年龄53．7岁。嗜酒者25例(46％),合并胆石症者21例(39％),原因不明特发性者2例(4％),既往有急性胰腺炎发作者18例(33％)。主诉腹痛者38例(70％),合并黄疸者27例(50％)。慢性钙化性胰腺炎与慢性梗阻性胰腺炎在某些临床表现问存在显著性差异,后者临床表现更趋复杂多样。34例患者分别采用9种不同的手术方式,无围手术期死亡。Puestow手术及胰十二指肠切除可有效地缓解疼痛,并可改善胰外分泌功能,对胰内分泌的影响不大。Puestow手术并行胆肠吻合适于合并胆道狭窄的慢性胰腺炎患者;胰头肿块型胰腺炎以黄疸为主要表现,应行胰十二指肠切除等切除术式,仅行胆道引流减黄效果良好,但胰头病变的演变尚待进一步观察。结论慢性梗阻性胰腺炎临床表现复杂,外科治疗应采用个体化原则。